PAGENO="0001" .GOV Deo, HEALTH MANPOWER ACT ~F~' 1968 C~t~zoc~ HEARINGS BEFORE THE SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE OFTHE COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE HOUSE OF REPRESENTATIVES NINETIETH CONGRESS SECOND SESSION ON H.R. 15757 A BILL TO AMEND THE PUBLIC HEALTH SERVICE ACT TO EXTEND AND IMPROVE THE PROGRAMS RELATING TO TH~ Tt~AINING OF NURSING AND OTHER HEALTH ?ROFES SIONS AND ALLIED HEALTH PROFESSIONS PERSONNEL, THE PROGRA1\4S RELATING TO STUDENT AID FOR SUCH PERSONNEL AND THE PROGRAM RELATING TO HEALTH RESEARCH FACILITIES, AND FOR OTHER PURPOSES JUNE 11, 12, 13, 1968 Serial No. 9O~-41 1.~rinted for the use of the Committee on Interstate and Fc~reign Conimerce 4 I Y `~ I U.S. GOVERNMENT PRINTING OFFICE 95-540 WASHINGTON : 1968 PAGENO="0002" SUECO~LMITPEE ON PUJ~LIC JO]1~ JARMAN, Oklaj COMMjTpj~ ON ~IARLEy o~ PATJI4 0. ROGERS, F'lorida IMVID E. SATPEIu~'IELD 111, Vlrg1nj~ PETER N. I~YROS, Maine (II) PAGENO="0003" CONTENTS Hearings held on- Page June 11, 1968 I June 12, 1968 91 June 13, l968~~~. 165 Text of H.R. 15757 2 Report of- BureauoftheBnwdget 14 Defense DepartmeuL~ 14 General Accounting Office - - 15 Health, Education, and IA? elfare Department 14 Veterans' Administration Statement of- Berry, Hon. K. Y., a Representative in Congress from the State of South Dakota 94 Berson, Dr. Rabert C.., executive director, Association of American Medical Colleges 127, 144 Blair, Lewis, superintendent, St. Luke's Methodist Hospital, Cedar Rapids, Iowa, representing the American Hospital Association_ - 177 Bliven, Charles `NA?., executive secretary, American Association of Colleges of.Pharmacy 216 Bolton, Hon. Frances P., a Representative in Congress from the State of Ohio 92 Cahill, Hon. William T., a Representative in Congress from the State of New Jersey 110 Cohelan, Dr. Evelyn, chairman, Committee on Legislation, American Nurses Association 165 Conley, L. Ann, president, National League for Nursing 196, 214 Connors, Helen, representing the New York office of the American Nurses Association 165 Dulski, Hon. Thaddeus J., a Representative in Congress from the State of New York 91 Fenninger, Dr. Leonard D., Director, Bureau of Health Manpower, National Institutes of Health, Public Health Service 19 Filerman, Gary, executive director, Association of University Pro- grams in Hospital Administration 261 Harty, Dr. Margaret, director of Nursing Education, National League for Nursing 196, 214 Heil, Nicholas D., legislative assistant to Congressman William T. Cahill 110 Huitt, Dr. Ralph K., Assistant Secretary for Legislation, Department of Health, Education, and Welfare 19 Kennedy, Dr. Thomas J., Jr., Director, Division of Research Fa- cilities and Resources, National Institutes of Health, Public Health Service 19 Lee, Dr. Philip R., Assistant Secretary for Health and Scientific Affairs, Department of Health, Education, and Welfare 19 Martin, Dr. Samuel P., provost of the University of Florida, repre- senting the Association of American Medical Colleges 127, 144 Morse, Dr. Erskine V., dean, School of Veterinary Science and Med- icine, Purdue University - 256 Ostrander, Dr. F. Dan, president, American Dental Association, representing also the American Association of Dental Schools - - - 154 Peterson, Harry N., attorney, Legislative Department, American Medical Association 95 Pritchard, Dr. W. R., dean, School of Veterinary Medicine, University of California, Davis, CaliL. - - 249 (fix) PAGENO="0004" lv statement of-Continued Page Rosenthal, Hon. Benjamin S., a Representative in Congress from the State of New York 86 Ross, Dr. Doris Laune, American Society of Medical Technologists. - 88 Ruhe, Dr. C. H. William, director, Division of Medical Education, American Medical Association 95 Smith, Hon. Neal, a Representative in Congress from the State of Iowa Sodeman, Dr. William A., member, Executive Committee on Medical Education, American Medical Association 95 Sullens, Reginald, assistant secretary for educational affairs, American Dental Association, representing also the American Association of Dental Schools 154 Thompson, John D., president, Association of University Programs in Hospital Administration 261 Thompson, Julia, director, Washington (D.C.) office, American Nurses Association 165 Thorp, Dr. W. T. S., chairman, Joint Committee on Education, Veterinary Medical Association 228 Weaver, Dr. Warren E., president, American Association of Colleges of Pharmacy 216 Williamson, Kenneth, associate director, American Hospital Associa- tion 177 Additional material submitted for the record by- American Association of Colleges of Podiat~ric Medicine, letter from Dr. Max M. Pomerantz, president 271 American Ass9ciation of Schools of Pharmacy: Reply to q~ueatiOfls posed by Coiogressman Rogers as to: Present student Fcapacity of schools Of pharmacy; projection of needs for additional schools of pharmacy; and feasibility of requiring schools `&f pharmacy to increase student body by 10 percent as prerequisite for obtaining Federal funds 225 Table A-Undergraduate enrollment in continental U.S. schools of pharmacy, 1964-67 223 Table B-Graduates from undergraduate curriculums of conti- nental U.S. schools of pharmacy, 1958-67 223 Table C-Average annual number of pharmacists, and require- ments for replacements, new entrants, and total needs for pharmacists in the United State~, 1965-80 223 Table D-Enrollment by classes in schools of pharmacy, 1967-68, and estimated enrollments and number of graduates, 1968-7&. 224 American Dental Association: Career plans of senior dental students (table) 162 Dental schools, projected need for new 163 Number of dentists needed through 1975 to maintain present dentist-population ratio 160 States without dental schools (table) 159 American Hospital Association: Army recruitment material, as example of solicitation of nurses by military 179-181 Response to AHA questionnaire to medical schools on acceptance of Federal subsidy and increasing size of classes 190 American Medical Association: Letter dated July 9, 1968, from Dr. F, J. L. Blasingame, executive vice president, replying to questions posed during hearings by Congressmen Rogers and Skubita 303 American Nurses Association, Inc., letter dated June 19, 1968, re estimated needs for nurses and new schools 174 American Optometric Association: Comments by officials of schools and colleges of optometry, re S. 3095: Illinois College of Optometry, Chicago, Dr. Alfred A. Rosenbloom, dean 307 Indiana University, Division of Optometry, Bloomington, lad., Dr. Henry W. Hofstetter, director 307 Ohio State University, School o~ Optometry, Columbus, Ohio, Dr. Fred Mi. Hebbard, director 307 PAGENO="0005" V Additional material submitted fo~ the Fe~ord by---Contlnued American Optome1rh~ Aisisoci'ation-~Continued Comments by officials of schools and colleges of optometry, re S. 3095-~Continued Los Angeles College of Optometry, Charles A. Abel, O.D., Page dean 307 Pennsylvania College of Optometry, Philadelphia, Stt1~nlOy S. Willing, Ed. D., dean 308 Mas~achusetts College of Optometry, Boston, Hyman it. Kamens, O.D., dean 309 tlriiversity of Houston, Houston, Tex., Chester H. Pheiffer, dean 309 Statement of Henry B. Peters~ O.D., member, Committee on Public Health and Optometrio Care 305 American Osteopathic Association, letter from Dr. Roy J. Harvey, director 269 American Public Health Association, Inc., letter from Dr. Berwyn F. Mattison, executive director 268 American Veterinary Medical Association: Statement of- Allam, Dr. Mark W., dean, School of Veterinary Medicine, Uniik~rsity of Pennsylvania - 245 Armistead, W. W., dean, College of Veterinary Medicine, Michigan State University 244 Booth, Nicholas H., dean, College of Veterinary Medicine and Biomedical Sciences, Colorado State University 243 Clarkson, Dr. M. R., executive secretary, American Veteri- nary Medical Association 238 Greene, Dr. James E., dean, School of Veterinary Medicine, Auburn University 247 Kingrey, Dr. B. W., dean, School of Veterinary Medicine, University of Missouri 248 McRibben, Dr. John S., professor, Department of Anatomy, College of Veterinary Medicine, Iowa State University - - 241. Price, Alvin A., dean, College of Veterinary Medicine~ Texas A. & M. University 237 Williams, T. S., dean, School of Veterinary Medicine, Tuskegee Institute 245 Animal Welfare Institute, New York, statement of Christine Stevens, president 301. Area Ten Community College, Cedar Rapids, Iowa, statement by Dr. S. A. Ballantyne, superintendent, and Elizabeth Kerr, director of health occupations education, Divisioh of MediCal Services, Uni~ versity of Iowa 284 Association of American Medical Colleges: Letter dated June 24, 1968, from Dr. Berson, re need for new medical schools 142 Proposed amendments to H.R. 15757 130 Statement of William N. Hubbard, Jr~, before the Senate Com- mittee on Labor and Public Welfare, March 20, 1968 134 Table 1.-Medical schools-Relation of total expenditures to expenditures for sponsored programs, 1958-59 and 1965-6& - - 127 Table 2.-Medical school productivity, 1950-66 128 Table 3.-Medical school productivity of service, 1955-67 129 Association of Schools and Colleges of Optometry, statement of Henry B. Peters, O.D., president 305 Besch, Everett D., dean, School of Veterinary Medicine, Louisiana State University and Agricultural and Mechanical College, Baton Rouge, La., letter 280 Bolton, Hon. Frances P., excerpts from newspaper items, pointing up the nurse shortage and effects on patient care 93 Coker, Dr. Samuel T., dean, Auburn University School of Pharmacy, Auburn, Ga., letter - 279 Cole, Dr. Clarence R., dean, College of Veterinary Medicine, Ohio State University, statement 290 PAGENO="0006" VI Additional material sub~jtted for the recç~rd b7-~-~Jontjnued Cornelius, Dr. C. B., dean, College of Veterinary Medicine, 1~ansas Page State University, statement of_ - 251 Daniel, David E., director of college relations, Louisburg College, Louisburg, N.C., statement 297 Davison, Fred C., president, University of Georgia, statement 302 `Georgia Veterinary Medical Association, statement of Dr. Jesse D. Derrick, president - 283 Gershon~Cohen? Dr. J., Professor of Research Radiology, Temple University School of Medicine, statement of 119 ll~rris, Dr. George P., de~tn, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, letter 275 Harris, Rufus C., president, Mercer University, Macon, Ga., letter. - 278 Health, Education, and Welfare Department: Admissions and graduations frQm schools of nursing, 19~7-67_ - 62 Construction projects, approved but not funded, under- Health' Professions Educational Assistance Act 79 Nurse Training Act 80 Health research facilities program 82 Diversity of medical schools, and Federal financial participation in construction and institutional support 77 Estimated new obligational authority required for fiscal years 1970-73, under "Health Manpower Act of 1968" (table) 56 Institutional support for schools of nursing, statement on 69 Nursing school graduates, estimated cost to increase by 30 and 50 percent 66 Personnel shortages in the health professions over tl~e next 5 years, projection of 57 Placements in schools of medicine, osteopathy, and dentistry, estimated cost to increase by 30 and 50 percent 65 Practical nurse training, statement on 71 Section-by-section analysis of H.R. 15757 32 Special improvement grants, examples of need for and estimated cost of - Summary of accomplishments under existing programs: I. Health Professions Educational Assistance Act 22 II. Nurse Training Act. 25 III. Allied Health Professions Personnel Training Act~ - - - 29 IV. Public health training program 30 V. Health research facilities programs 31 Veterinarians, statement on shortage of 73 Xibrick, Anne, dean, Boston University School of Nursing, letter - - 277 Littlejohn, Dr. Oliver M., dean, Southern School of Pharmacy, Mercer University, Atlanta, Ga., letter 279 Medical Society of the State of New York, letter and resolution from Dr. Henry I. Fineberg, executive vice president 278 Melby, Dr. Edward C., Jr., associate professor and head, Division of Animal Medicine, Johns Hopkins University School of Medicine, letter 273 Mississippi Nurses' Association, letter from Oneita Dongieux, execu- tivedirector 278 Missouri Veterinary Medical Association, letter from Dr. D. R. Haney, chairman, Legislative Committee 276 National Association of Retail Druggists, letter from Willard B. Simmons, executive secretary 271 National Association of State Universities and Land-Grant Colleges, statement 282 National League for Nursing: Exhibit I-Role and functions of the National League for Nursing 200 Exhibit IJ-A-Admissio~s and graduations for baccalaureate programs, 1962-67, by accreditation status (table) 201 Exhibit Il-B--Admissions and graduations for diploma programs in nursing, 1962-67, by accreditation status (table) 201 Exhibit Il-C-Admissions and graduations for associate degree programs, 1962-67, by accreditation status (table) 202 PAGENO="0007" VII Additional material submitted for the record by-Continued National League for Nursing-Continued Exhibit II-D-Admissions, graduations, and enrollments in baccalaureate, associate degree, and diploma programs, by Page accreditation status, as of January 1968 (table) 202 Exhibit III-Educational programs in ntirsing, 1967, associate degree, baccalaureate, diploma, masters degree, by States and accreditation status (table) 203 Exhibit IV-Data on NLN reasonable assurance of accreditation under Nurse Training Act of 1964 (table) 204 Exhibit V-Full-time faculty teaching in nursing departments, schools, or programs, as of January 1968, by type of program and highest earned credential (table) 205 Exhibit VI-Number of candidates failing State board test pool exams for licensure of registered nurses (table) 206 Exhibit VJ1-NLN accrediting practices and charges for asso- ciate degree, baccalaureate, masters, and diploma nursing programs (table) 206 Exhibit VIII-A-NLN procedures-Reasonable assurance of accreditation under the Nurse Training Act of 1964-New nursing programs 206 Exhibit VIII-B--NLN procedures-Reasonable assurance of accreditation under the Nurse Training Act of 1964-Estab- lished nursing programs 207 Pamphlet entitled "Nursing Education Accreditation, a Service of the National League for Nursing" 208 National Student Nurses Association, Inc., telegram from Frances Tompkins, executive director 282 Oklahoma Board of Nurse Registration and Nursing Education, letter from Frances I. Waddle, R.N., executive director 277 Pharmaceutical Manufacturers Association, letter from C. Joseph Stetler, president 270 Reinhard, Dr. Karl R., dean, College of Veterinary Medicine, Okla- homa State University, statement 299 Schlotfeldt, Rozella M., dean, Frances Payne Bolton School of Nursing, Case Western Reserve University, letter 276 Smith, Hon. Neal, proposed amendments to H.R. 15757 18 Squire, Dr. Robert A., director, Comparative Pathology, Johns Hopkins University School of Medicine, Department of Pathology, letter 273 Terry, Dr. Luther L., vice president for medical affairs, University of Pennsylvania, letter - 266 *Webster, George L., dean, College of Pharmacy, University of Illinois, letter 281 ~Wolf, Dr. George A., Jr., dean and provost, University of Kansas Medical Center, letter 274 PAGENO="0008" PAGENO="0009" HEALTH MANPOWER ACT OF 1968 TtEESDAY, IUNE 11, 1968 HOUSE oi~ REPRESENTATIVES, SUBCO~EUTBB ON PUBLIC HJ~ALTU AND WELFARE, COMMIPrEE ON INTERSTATE AND FOREIGN COMMERCE,~ Washington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. John Jarman (chairman of the subcommittee) presiding. Mr. JARMAN. The subcommittee this morning is meeting to receive testimony on H.R. 15757, introduced by Chairman Staggers at the request of the administration, to extend the Health Professions Edu- cational Assistance Act, the Nurse Training Act, the Allied Health Professions Personnel Training Act, the Health Research Facilities Act, and the authorities for traineeships and training grants in public health. Each of these programs is proposed to be extended for 4 years, with the exception of the Allied Health Professions Personnel Training Act, which is proposed to be extended for 1 year so as to enable the Department to gain additional experience with this program before proposing a major extension. The proportion of the gross national product spent on medic~l care and services has increased in recent years to over 6 percent, with an estimated $45 billion a year spent for this purpose. All indications are that these expenditures, both in absolute and in relative terms, will increase in future years. This will require a substantial expansion in the numbers of persons in the health professions to meet the needs of the American people in future years. There are today about 3 million people in the health occupations. By 1975, at least another million will be needed. Yet, as the President pointed out in his March 4 health message, "We lack the capacity to train today those who must serve us tomorrow." This legislation will help provide the increased training capacity needed to meet our future needs for health manpower, both through providing construction assistance for new facilities, and through pro- viding operational assistance to enable more people to be trained in existing facilities and to improve the quality of the training they receive. Hearings have been completed on the companion legislation to H.R. 15757 before the Senate Committee on Labor and Public Welfare, and it is anticipated that the Senate bill, S. 3095, will be reported to the Senate in the near future. We hope to be able to complete early action on the measure before us today, so that we can get the legisia- (1) PAGENO="0010" 2 tion needed in this field to the President's desk for signature as soon as practicable. At this point there will be included in the record the text of the bill, together with the agency reports thereon. (H.R. 15757 and departmental reports thereon, follow:) [HR. 15757, 90th Cong., second sess.] A BILL To amend the Public Health Service Act to extend and improve the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to student aid for su~h personnel, and the progra~n relating to health research facilities, and for other purposes Be it enacted by. tive senate and Honse of Representatives Of the 7J4~ited ~tcaei~ of America in Congress ct~sembled, That this Act may be cited as the "Health Manpower Act of 1968". Snc~. 2. As used in the amendments made by this Act, the term "Secretary", unless the context otherwise requires, means the Secretary of Health, Education, and Welfare. TITLE I-HEALTH PROFESSIONS TRAINING PAirr A-CoNsTRUcTIoN GRANTS EXTENSION OF cONSTgUOTI0N AUTHORIZATIONS Snö. 101. (a) Section 720 of the Public Health Service Act (42 U.S.C. 203) is amended by inserting after and below clause (3) of tl~e first sen~tence thereof the following new sentence: "For such grants there are also authorized to be appropriated such Sums as may be necessary for the fiscal year ending June 30, 1070, and each of the next three fiscal years." FEDERAL SHARE SEc; 102. (a) Subsection (a) (1) of section 722 of the Pttblic Health, ~ercrice Act (42 U.S.C. 293b) is amended by striking out "such amount may not exceed 50 per centupi" and inserting in lieu thereof "such amount may ndt, ~xcept Where the S~oretary determines that unusual circumstances make a larger per- centage (which in no case may exceed 662/3 per centum) necessary in order to effectuate the purposes of this part, exceed 50 per centum." (b) The amendments made by this section shall apply In the case of projects for which grants are made from appropriations for fiscal years ending after June 30, ,1969. LENGTH AND CHARACTER OF FEDERAL RECOVi~R~ INTEREST IN FACILITIES SEC. 103. (a) (1) Clause (b) of section 723 of the Public Health Service. Act (42 U.S.C. 293c) is amended to read as follows: "(b) the facility shall cease to be used for the teaching purposes (and the other purposes permitted under section 722) for which it was con- structed, unless the Secretary determines that it is being and will be used for- "(1) any teaching purposes for which a grant was authorized to be made under this part, "(2) research purposes, or research and related purposes, in the sd- ences related to health (within the meaning of part A); or "(3) medical library purposes (within the meaning of part I of title [II), or the Secretary determines, in accordance with regulations, that there is good cause for releasing the applicant or other owner from the obliga- tion to do so,". (2) Clause (A) of section 721 (c) (2) of such Act (42 U.S.C. 293a) is amended to read: "(A) the facility is intended to be used for the purposes for whichthe application has been made,". (b) The amendment made by subsection (a). (1) shall apply in the ease of facilities for which a grant has been or is in the future made under part PAGENO="0011" 3 B of title VII of the Public Health Service Act. The amendment made by subsection (a) (2) shall apply ifl the case of assurances given after the date of enactment of this Act under such part B. GRANTS FOR MULTIPURPOSE FACILITIES SEe. 104. (a) Section 722 of the Public Health Service Act (42 U.S.C. 293by is further amended by adding at the end thereof the following new subsection "(d) In the case of a project for construction of facilities which are to a substantial extent (as determined in accordance with regulations of the Sec~ retary) for teaching purposes and for which a grant may be made under this part, but which also are for research purposes, or research and related purposes~ in the sciences related to health (within the meaning of part A of this title) or for medical library purposes (within the meaning of part I of title [II), the project shall, insofar as all such purposes are involved, be regarded as a project for facilities with respect to which a grant may be made under this part." (b) The amendment made by subsection (a) shall apply in the case of projects for which grants are made under part B of title VII of the Public Health Service Act from appropriations for fiscal years ending after June 30, 1969. GRANTS FOR CONTINUING AND ADVANCED EDUCATION FACILITIES Sue. 105. (a) Paragraph (3) of section 721(c) of the Public Health Service Act (42 U.S.C. 293a) is amended by inserting before the semicolon at the end thereof the following: "(and, for purposes of this part, expansion or curtail- ment of capacity for continuing education shall also be considered expansion and curtailment, respectively, of training capacity) ". (b) Subsection (d) of section 721 of such Act is amended by inserting "(other than a project for facilities for continuing education)" after "an existing school" in paragraph (1) (A) and after "a school" in paragraph (1) (B). (c) Section 724(4) of such Act is amended by inserting before the semicolon at the end thereof: ", and including advanced training related to such training provided by any such school". (d) The amendments made by this section shall apply in the case of projects for which grants are made under part B of title VII of the Public Health Service Act from apj~ropriations for fiscal years ending after June 30, 1960. PART B-INSTITUTIONAL A1~D SPECIAl Pno~ucr GRANTS FOR TRAINING OF HEALTH PROFESSIONS PERSONNEL SEe. 111. (a) Sections 770, 771, and 772 of the Public Health Service Act (42 U.S.C. 29Sf, 29Sf-i, 295f-2) are amended to read as follows: "AUTHO1HEATION FOR APPROPRtAPIONS "SEc. 770. (a) There are authorized to be appropriated for the fiscal year ending June 30, 1970, and each of the next three fiscal years such sums as may be necessary for institutional grants under section 771 and special project grants under section 772. "(b) The portion of the sums so appropriated for each fiscal year which shall be available for grants under each such section shall be determined by the Secretary unless otheri~vise provided in the Act or Acts appropriating such sums for such year. "INSTITUTIONAL GRANTS "Sue. 771. (a) (1) The sums available for grants under this section from appro- priations under section 770 for the fiscal year ending June 30, 1970, or any of the next three fiscal years shall be distributed to the schools of medicine, den- tistry, osteopathy, optometry, and podiatry with approved applications as follows: Each school shall receive $25,000; and of the remainder- "(A) 75 per centum shall be distributed on the basis of- "(i) the relative enrollment of full-time students for such year, and "(ii) the relative increase in enrollment of such students for such year over the average enrollment of such school for the five school years pre- ceding the year for which the application is made; PAGENO="0012" 4 with the amount per full-time student so computed that a achool receives twice as much for each such student in the increase as for other full-time students, and "(B) 25 per centum shall be distributed ~n the basis of the relative number of graduates for such year. "(2) The sum ~omputed under paragraph (1) for any school which is less than the amount sui~h school received under this section for the fiscal year ending June 30, 1969, shall be increased to that amount, the tofal of the increa~es thereby required being derived by proporrions~te1y reducing the sums computed under such paragraph (1) for the remaining schools, but with such adjustments as may be necessary to prevent the sums computed for any of such remaining schools from being reduced to less than the amount it received for such fis~da1 year ending June 30, 1969, under this seCtion. "(b) (1) Phe Secretary shall not make a grant under this seCtion to any school unless the application for such grant contains or is supported by reasonable assurances that for the first school yehr beginning after the fiscal year for which such grant is made and each school year thereafter during which such a grant is made the fir~t-year enrollment of full-time Students in such school will exceed the average first-year enrollment of such students in such school for the five schOol years during the period of July 1, 1963, through June 30, 1968, by at least 21/2 per centum of such average first-year enrollment, or by five students, which- ever is greater. The requirements of this paragraph shall be in addition to the requirements of section 721 (c(2) (D) Of this Act, where applicable. The Secretary is authorized to Waive (in wbQle or in part) the provisions of this paragraph If he determines, after consultation with the National Advisory Council on health Professions 1~kjucational Assistance that the required incre~se i~ first-year ep- rohiment of fu1l~time students in a school cannot be accompli~hed without lowering the quality of training provided thereiri~ or if he determines, after such con- sultation, that to do so would dtherwise be in the public interest and consistent with the purposes of this part. "(2) Notwitb~tar~ding the preceding j~rovisions of this section, no grant under this sqetion to any school for any fiscal year may exceed the total of the funds from non-Federal s'ources expended (ex'c'Lu~ing expendit~res of a non- recurring nature) by the school during the preceding year f~r teaching purpose~ (as determined in accordance, with criteria prescribe4 by the Secretary), except that this paragraph ~ball not ap~1y in the case of a s~bo'o1 which has for such year a particular year-class which it did not have for `the proceeding year~ "(c) (1) For purposes of this part and part F, regulations of the Secretary ~ball hncl'ude provisions relating to determiimtion of the number of students enrolled in a school, or in a particular year~clasis to a schoOl, or the number of graduate's, as the cas'e may be, on the biasis of estimates, or on the basis of the number of students whQ were enroijed in a school, or in a particular year~cla'ss in a school, or were graduates, in an cantor year,, as the ease may be, or on such basis as he deems appropriate for mhking s~tcb determination, an'd shall include methods of making such determinations when a school or a year-class wa's not in existence in an earlier year at a school. "(2) For purposes of this part and ~ar't F, the term `full-time students' (whether such term is used by itself or in cOnnection with a particnlar year-class) means students pursuing a full-time co~irse of study leading to a degree of doctor of medicine, doctor of dentistry, or an equivalent degree, doctor of osteopathy, bachelor of Science in pharmacy or doctor of ~harmhcy, doctor of optometry or an equivalent degree, doctor of veterinary medicine or an equivalent degree, or doctor of podiatry or an equivalent degree. "SPECIAL PROJECT GRANTS "Snc. 772. Grants may be made, from sums available therefor from appropria- tions under section 770 for the fiscal year ending June 30, 1970, and for each of. the next three fiscal years, to assist schools of medicine, dentistry, osteopathy, phar- macy, optometry, podiatry, and veterinary medicine in meeting the cost of special projects to plan, develop, or establish new programs or modifications of existing programs of education in such health professions or to effect significant im- provements in curriculums of any such schools or for research In the various fields' related to education in such health professions, or to develop training for new levels or types of health professions personnel, or to assist any such schools which are in serious financial straits to meet their costs of operation or which have special need for financial assistance to meet the accreditation requirements, PAGENO="0013" 5 or to a~sl~t any such schools to meet the costs of planning experimental teach- ing facilities or experimental design thereof, or which will otherwise strengthen, improve, or expand programs to train personnel in such health professions or help to increase the supply of adequately trained personnel in such health professions needed to meet the health needs of the Nation. (b) (1) Subsection (a) of section 773 of such Act (42 U.S.C. 295f-3) is amended b~ striking out "basic or special grants under section 771 or 772" and inserting in lieu thereof "grants under section 771 or 772". (2) Subsection (b) (1) of such section is amended by inserting after "or p0- diatr~r" the following: "or (In the case of section 772) pharmacy, or veterinary medicine'. (3) Subsection (c) of such section is amended by striking out "National Ad- visory Council oh Medical; Dental, Optometric, and Podiatric E'dttcation" and inserting in lieu thereof "National AdvisOry Council on Health ProfessiOns Educational Assistance". (4) Subsection (d) (2) of such section is amended by inserting "(excluding expenditures of a nonrecurring nature)" after "for such purpose". (5) Subsection (e) of such section is amended to read as follows: "(e) In determining priority of projects applications for which are filed under section 772, the Secretary shall give consideration to- "(1) the extent to which the project will increase enrollment of full-time students receiving the training for which grants are authorised under this part; "(2) the relative need of the applicant for financial assistance to maintain or provide for accreditation or to avoid curtailing enrollment or reduction in the quality of training provided; and "(3) the extent to which the project may result In curriculum improvement or improved methods of training or will help to reduce the period of required training without adversely affecting the quality thereof." (c) (1) Section 774 (a) of such Act is amended by striking out "or podiatric Odtication" and inserting in lieu thereof "podiatric, pharmaceutical, or veterinary education". (2) Such section 774 (a) is further amended by striking out "twelve" and in- serting in lieu thereof "fourteen" and by strlkin~ out "National Advisory Coun- cil oh Medical, Dental, Optometric, and Podiatric Education" and inserting in lieu thereof "National Advisory Council on Health Profess1on~ Educational Assistance". (3) The beading of section 774 is amended to read: "NATTONAL ADvISoRY COUNCIL ON HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE" (d) The amendments made by this section shall apply with respect to appro- priations for fiscal years ending after June 30, 1969. (e) Effective only with respect to appropriations for the fiscal year ending JunO 30, 1969, section 772(b) of such Act Is amended by inserting before the perIod at the end thereof ", or (3) to plan for special pro~jects for which grants are authorized under this section as amended by the Health Manpower Act of 1968". (f) Effective with respect to appropriations for the fiscal year ending June 30, 1968, and the next fiscal year, the third sentence of section 771(b) of such Act is amended by inserting before the period at the end thereof ", or if he determines, after such consultation, that to do so would otherwise be in the public interest and consistent with the purposes of this part". PART C-STUDENT AID STUDENT LOANS SEc. 121. (a) (1) Clauses (2) and (3) of section 740(b) of the Public Health Service Act (42 U.S.C. 294) are each amended by inserting ", except as pro- vided in section 746," after "fund" the first time it appears therein. (2) Section 740(b) (4) of such Act is amended by striking out "1969" and in- serting in lieu thereof "1973". (3) Section 741 (c) of such Act (42 U.S.C. 294a) is amended by adding before the period at the end thereof ", or (3) service as a full-time volunteer in the Volunteers in Sertice to America program under the Economic Opportunity Act of 1964; and periods (up to five years) of advanced professional training (in- eluding residencies) ". PAGENO="0014" 6 (4) (A) Section 741 of such Act is further amended by adding at the end thereof the following new subsection: "(j) Subject to regulations of the Secretary, a school may assess a charge with respect to a loan made under this part for failure of the borrower to pay all or any ~sart of an installment when it is due and, in the case of a borrower who is entitled to deferment of the loan under subsection (c) or canc~llation of part or all of the loan under subsection (f), for any failure to file timely and satisfactory evidence of such entitlement. The amount of any such charge may not exceed $1 for the first month or part of a month by which such, installment or evidence is late and $2 for each such month or part of a month thereafter, The school may ele~t to add the amount of any such charge to the principal amount of the loan as of the first day after the day on which such ip'stallment or evidence was due, or to make the amount of the charge payable to the school not later than the clue date of the ReNt installment after receipt by the borrower of notice of the assessment of the charge." (B) Subsection (b) (2) of section 740 of such Act is further amended by striking out "and (D)" and inserting in lieu thereof "(D) collections pursuant to section 741 (j), and (l~) ". (`b) (1) The first sentence of subsection (a) of section 742 of such Act (42 IIJ.S.O. 294b) is amended by striking out "and" before "$25,000,000" and by inserting before the period at the end thereof ", and such sums as may be neces~ ary for the fiscal year ending June 30, 1970, and each of the next three fiscal yOars". (2) The third `sentence of such subsection is amended by striking out "1970" and "1909" and inserting in lieu thereof "1974" and "1973", respectively. (3) The fourth sentence of such subsection is amended by striking out "and" before "(2)" and by inserting before the period at the end thereof ", and (3) for transfers pursuant to `sectIon 746", (c) Section 743 of such Art (42, ~J.S.e. 294c) is amended by striking out "1972" each place it appears therein and inserting in lieu thereof "1976". (d) (1) Section 744(a) (1) of such Act (42 U~S.C. 294d) is amended by insert~ ing "and each of the next five fiscal years" after "1908,". (2) Section 744(e) of such Act is amended by striking out "$35,000,000" and inserting in lieu thereof "$45~000,000". (e) Part 0 of title VII of such Act (42 U.S.0~ 294, et seq.) is futher amended by adding at the end thereof the following new section: "TRANSFER or FUNDS TO SCHOLARSHIPs "SEC. 746. Not to exceed 20 per centum of the amount paid to a school from the appropriations for any fiscal year for Federal capital contributions under an agreement under this part, or such larger percentage thereof as the Secretary may approve, may be transferred to the sums available to the school under part F of this title to be used for the same purpose as such sums. In the case of any such transfer, the amount of any funds which the school deposited in its student loan fund pursuant to section 740(b) (2) (B) may be withdrawn by the school from such fund." (f) The amendments made `by subsection (a) (1), (b) (3), and (e) shall apply with respect to appropriations for fiscal years ending after June 30, 1909. The amendment made by subsection (a) (3) shall apply (1) with respect to all loans made under an agreement under part (C) of title VII of the Public Health Service Act after June 30, 1969, and (2) with respect to loans made thereunder before July 1, 1909, to the extent agreed to by the school which made the loans and the Secretary (but, then, only as to years beginning after June 30, 1969'). The amendment made by subsection (a) (4) shall apply with respect to loans made after June 30, 1969. SCHOLARsHIps SEc. 122. (a) Subsection (a) of section 780 `of the Public Health Service Act (42 U.S.C. 295g) is amended by striking out "or pharmacy" and inserting in lieu thereof "pharmacy, or veterinary medicine". The heading of such section is amended by striking out "on PHARMACY" and inserting in lieu thereof "PHARMACY, OR VETERINARY MEDICINE". (b) Subsection (b) of such section is amended by inserting "and each of the next four fiscal years" after "1969," in the first sentence and by striking out ~`197O" and "1969" and inserting in lieu thereof "1974" and "1973", respectively, in the second sentence. PAGENO="0015" 7 (c) (1) Paragraph (1) of subsection (c) of such section is amended by Insert- ing "and each of the next four fiscal years" after "1969" and clause (D) and by ~tr1king out "1969" and "1970" in clause (B) a~id ins~rthig in lieu thereof "1973" and "1974", respectively. (2) The first sentence of paragraph (2) of such subsection (c) is amended by striking out "from low-income families who, without such financial assistance could not" and inserting in lieu thereof "of exceptional financial need who need such financial assistance to". (d) Part F of title VII of the Public Health Service Act is further amended by inserting after section 780 the following new section: "TRANSFER TO STUDENT LOAN FUNDS "SEc. 781. Not to exceed 20 per centum of the amount paid to a school from tl~e appropriations for any fiscal year for scholarships under this part, or such larger percentage thereof as the Secretary may approve, may be transferred to the sums available to the school under part 0 for (and to be regarded as) Federal capital contributions, to be used for the same purpose as such sums." (e) The amendment made by subsections (a), (b), (c) (1), and (d) shall apply with respedt to appropriations for fiscal years ending June 30, 1969. The amendments made by subsection (c) (2) shall apply with respect to schtilarships from appropriations for fiscal years ending after June 30, 1969. Panv P-MISCELLANEOUS STUDY OF SCHOOL AID AND STUDENT AID PROGRAMS SEC. 131. The Secretary shall, in consultation with the Advisory Councils established by sections 725 and 774, prepare, and submit to the President and the Oongress prior to July 1, 1972, a report on the administration of parts B, 0, B, and F of title VII of the Public Health Service Act, an appraisal of the programs under such parts in the light of their adequacy to meet the 1ong~term needs for health professionals, and his recommendations as a result thereof. TITLE Il-NURSE TRAINING PAnT A-CONSTRUCPION GRANTS EXTENSION OF CONSTRUCTION AUTHORIZATION SEC. 201. (a) Section 801 of the Public Health Service Act (42 U.S.C. 296) is amended to read as follows: "SEC. 801. (a) There are authorized to be appropriated, for grants to assist in the construction of new facilities for collegiate, assfociate degree, or diploma schools of nursing, or replacement or rehabilitation of existing facilities for such schOols, such sums as may be necessary for the fiscal year ending June 30, 1970, and each of the next three fiscal years. "(b) Sums appropriated pursuant to subsection (a) for a fiscal year shall remain available until expended." (b) Section 802(a) of such Act (42 U.S.C. 296a) is amended by striking out "July 1, 1968" and inserting in lieu thereof "July 1, 1972"~ LENGTH OF FEDERAL RECOVERY INTEREST SEC. 202. (a) Section 802(b) (2) of the Public Health Service Act is amended by striking out "twenty" in clause (A) and inserting in lieu thereof "ten". (b) Section 804 of such Act (42 U.S.C. 296c) is amended by striking out "twenty" and inserting in lieu thereof "ten". FEDERAL SHARE SEC. 203. Section 803 (a) of the Public Health Service Act (42 U.S.C. 296b) is amended by striking out "may not exceed 50 per centum" in clause (B) and inserting in lieu thereof "may not, except where the Secretary determines that unusual circumstances make a larger percentage (which may in no case exceed 662/s per centum) necessary in order to effectuate the purposes of this part, exceed 50 per centum". PAGENO="0016" S INCLUSION OF TRUST TERRITORT S~c. 204. Section 843 (a) of the Public H~alth service A~t (42 U.S~C. 298b) is amended by striking ont "or the Virgin Islands" and inserting in lieu thereof "the Virgin Island, or the Trust Territory of the Pacific Islands". AMENDMENT OF DEI?INIPION OF COLLEGIATE SChOOL OF NURSING SEC. 205. Section 843(e) of the Public Health Ser~,rice Act is amended by In- serting before the'period at the end thereof `~, and includi~ig advanced trailhlng related to such program of ~slReation". EFFECTIVE DATE SEC. 206. The amendments made by sections 201, 202, and 205 shall apply with respect to appropriations for fiscal years ending after June 80, 1969, except that (1) section 804 of the Public Health Service Act as amended by this Act shall apply In the case of any projects for which grants have been made or are in the future made under section 803 of such Act; and (2) the amendment made In section 802(b) (2) of such Act by section 202(a) of this Act shall apply in the case of any projects for which grants are made under section 803 of the Public Health Service Act after the enactment of this Act. PART B-SPECIAL PROJECT AND IIVSTITUTIONAL GRANTS TO SCHOOLS OF NURSING SPECIAL PROJECT AND INSTITUTIONAL GRANTS SEC. 211. Sections 805 and 806 of the Public Health Service Act (42 U.S.C. 296d, 296e) are amended to read as follow's; "IMPROVEMENT IN NURSE TRAINING "SEC. 805. From the sums available therefor from appropriations under sec- tion 808 for the fiscal year ending June 30, 1970, and each of the next three fiscal years, grants may be made to assist any public or nonprofit private agency, or- ganization, or institution to meet the cost of special projects to plan, develop, or establish new programs or modifications of existing programs of nursing educa- tion or to effect significant improvements in curriculums of schools of nursing or for research in the various fields of nursing education, or to assist schools of nursing which are in serious financial straits to meet their costs of operation or to assist schools of nursing which have special need for financial assistance to meet ac~reditation requirements, or to assist in otherwise strengthening, im- proving, or expanding programs of nursing education, or to assist any such agency, organization, or institution to meet the costs of other special prQjects which will help to increase the supply of adequately trained nursing personnel needed to meet the health needs of the Nation. "INSTITUTIONAL GBANTS "SEC. 806. (a) The sums available for grants under this section from appropria- tions under section 808 for the fiscal year ending June 30, 1970, or any of the next three fiscal years shall be distributed to the sch6ol~ with approved applica- tions as follows: Each school shall receive $15,000; and of the remainder- "(A) 75 per centum shall h~ distributed on the basis of the relative en- roillment of fuTh4ime student's for such year and the relative increase in en- `ro1lm'en~t of such students for such year over the average enrollment of such school for the five school years preceding the yetr for which the applh~a?tThn is made, with the amount per full-time student so computed that a school receives twice as much for each such student in the `increase as for otheT full- time students, and "(B) 25 per centum shall be distributed on the basis of the relbtive num- ber of graduates for such year. "(b) (1) For purposes of `this part `and part D, regulations of the Secretary shall include provisions relating to determination of the number of students enrolled in a scho~ol, or in a particular year-class in a school, or the number of graduates from a school, as the ease may be, on the basis of estimates, or `on the basis of the' number of sltu'den~ts who were enrolled in a school, or in a ~articuiar year-class in a sc'hsol, or were gradu/aites from a schont in earlier years, as the case may be, or on such basis sh he deems appropriate for making such determination, and shall include PAGENO="0017" 9 methods of mtaking such dfetertmin~ation1s When a school or a ~ear~e1as's was net in existence in an earlier yehr at a `~eboo1. "(2) For purposes of this part and part D, the term `full-time students' (whether such term is used by itself or in con'nedt'ion with a particular year-class) means students pursuing a full-time course of study in an accredited program in a schOol of nursing." CONDITIONS OF ELIGIBILITY Sac. 212. Part A of title VIII of the Public tle'alth Ser~ice Act is amended by adthn'g at the end thereof the following new sections: "APPLICATIONS FOR GRANTS "Sac. 807. (a) The Secretary may from time to time set dates (not earlier than in the fisCal year precee'dinig the yCar for which a grant Is sought) by which appli- cations under section 805 or 806 for any fiscal year must be filed. "(b) The Secretary shall not approve or dislapprosre any application for a grbn't under this part except afer cousultation with the National AdvisOry Council on Nurse Training. "(c) A grant under section 805 or 806 Iniay be made only if the application therefor- "(1) is from a public or nonprofit privhte school of nursing, or in the case of grants under section 805, a public or nonprofit private agency, organizhtio'n, or institution; "C2) contains or is supported by assurances s)atisfactbory to the Secretary that the applicant will expend in carrying out Its functions as a school of nurs- lug, during the fisOal year for which such grant is sought, an amount of funds (`ether than funds for con'stru~tion ais determined by the Secretary) from non~ Federal sources which are `at least `a~ great as `the average amount of funds expCnded by such applicant for such pu'r~ose (excluding expenditures of a nonrecurring nature) in the three fiscal years immediately preceding the fis~al year for which such grant is sOught; "(3) contains such additional information as the Secretary may require to make the determinaltions required of him under this part and such as- surances as he may find necessary to carry Out the purposes of this part; and "(4) provides for such fiscal-control and accounting procedures and re- ports, and access to the records of the applicant, as the Secretary may require to assure proper disbursement of and accounting for Federal funds paid to the applicant under this part. "AUTHORIZATION FOR APPROPRTATIONS "SEC. 808. (a) There are authorized to be `appropriated for the fiscal year end- ing June 30, 1970, and each of the next tb~ee fistal years such sums a's may be neceSsary for improvement grants under section 805 and ini~titutiOnal grants under section 806. "(b) Phe portion of the sums' so appropriated for each fiscal year which shall be available for grants under each such section shall be determined by the, Sec- retary unless otherwise provided in the Act or Acts appropriating such sums for such year." CONFORMING CHANGE SEC. 213. Clause (2) of section 843(f) of the Public Health Service Act (42 U.S.C. 298b) is amended to read: "(2) in the case of a school applying for a grant under section 806 for any fiscal year, prior to the beginning of the first academic year following the normal graduation date of the class which is the entering class for such fiscal year (or is the first such class in such year if there is more than one) ;". EFFECTIVE DATE SaC. 214. The amendments made by the preceding provisions of this part shall apply with respect to appropriations for fiscal years ending after June 30, 1969. PLANNING FOR FISCAL YEAR 1969 SEC. 215. Effective only with respect to appropriations for the fiscal year end- ing June 30, 1969, seCtion 805 (a) of the Puiblic Health Service Act is amended 95-54O-68---2 PAGENO="0018" 10 by inser~ting ait the end thereof the following new sentence: "Appropriations under this section shkll also be available for grants for planning sperial projects for which grants are authorized under this ~eOtion as amended by the Health Manpower Act of 1068" PART C-~STTJDENT AID ADVANCED TRAINING Suc. 221. Section 821 (a) of the Public Health Service Act (42 U~S.C, 297) is amended by striking out "and". before "$12,000,000" and by inserting "and such sums as may be necessary for the next four fiscal years," after "1969,". STUDENT LOANS SEc. 222. (a) (1) Clauses (2) and (3) of section 822(b) of the Public Health Service Act (42 U.S.C. 297a) are each amended by inserting ", except as provided in section 82~," after "fund" the first time it app~ars therein. (2) Section 822(b) (4) of such Act is amended by striking out "1969" and in- serting in lieu thereof "1973". (b) (1) Section 823(a) of such Act (42 U.S.C. 207b) is amended by striking out "$1,000" and inserting in lieu thereof "$1,500". (2) Section 823(b) (2) of such Act is amended by striking "except that" and all that follows down to but not including the semicolon and inserting in lieu thereof "excluding from such 10-year period all (A) periods (up to three years) of (i) active duty perfomned by the borrower as a member o1~ a uniformed service, (ii) service as a volunteer under the Peace Corps Act, or (iii) service as a full- time volunteer under the Volunteers in Service to America program under the Economic Opportunity Act of 1964, and (B) periods (up to five years) during which the borrower is pursuing a full-time course of study at a collegiate school of nursing leading to a baccalaureate degree in nursing. or an equivalent degree, or to a graduate degree in pursing, or is otherwise pursuing advanced profes- sional training in nursing." (3) Section 823(b) (3) of such Act is amended by inserting before the semi- colon at the end thereof the following: ", except that such rate shall be 15 per- centum for each complete year of service as such a nurse in a public hospital in any area which is determined, in accordance with regulations of the Secretary, to be an area with substantial population which has a substantial shortage of such nurses at such hospitals, and for the purpose of any cancellation at such higher rate, an amount equal to an additional 50 per centum of the total amount of such loans plus interest may be cancelled". (c) (1) Section 823 of such Act is further amended by adding at the end thereof the following new subsection: `(f) Subject to regulations of the Secretary, a school may assess a charge with respect to a loan from the loan fund established pursuant to an agreement under this part for failure of the borrower to pay all or any part of an installment when it is due and, in the case of a borrower who is entitled to deferment of the loan under subsection (b) (2) or cancellation of part or all of the loan under subsection (b) (3), for any failure to file timely and satisfactory evidence of such entitlement. The amount of any such charge may not exceed $1 for the first month or part of a month by which such installment or evidence is late and $2 for each such month or part of a month thereafter. The school may elect to add the amount of any such charge to the principal amount of the loan as of the first day after the day on which such installment or evidence was due, or to make the amount of the charge payable to the school not later than the due date of the next installment after receipt by the borrower of notice of the assessment of the ch~r.Subsection (b) (2) of sectiOn 822 of such Act is' further amended by strik- ing out "and (D)" and inserting in lieu thereof "(D) collections pursuant to secition823(f), and (B)". (d)(1) Section 824 of such Act (42 U.S.C. 297c) is amended by inserting "such sums as may be necessary for each of the next four fiscal years" after "1969," the first time it appears therein, by striking out "1970" and inserting in lieu thereof "1974", and by striking out "1969," the second time it appears therein and In- serting in lieu thereof "1973,". (2) The second sentence of such section is amended by inserting before the period at the end thereof ", and (3) for transfers pursuant to section 829". (e) The first two sentences of section 825 of such Act (42 U.S.C. 297d) are amended to read as follows: "From the sums appropriated pursuant to section PAGENO="0019" 11 824 for any fiscal year, the Secretary ~haU allot to each school an amount which bears the same ratio to the amount so appropriated as the number of persons enrolled on a full~time basis in such school bears to the total number of persons enrolled on a full-time basis ifi all schools of nursing in all the States. The number of persons enrolled on a full-time basis in schools of nursing for purposes of this section shall be del~ermined by the Secretary for the most recent year for which satisfactory data are available `to hIm." (f) Section 826 of such Act (42 U.S.C. 297e) is amended by striking out "1972" each place it appears therein and inserting in lieu thereof "1976". (g) Section 827(a) (1) of such Act (42 U.S.C. 297f) is amended by inserting "and each of the next five fiscal years" after "1968,". (h) Part B of `title VIII of such Act (42 U.S.C. 297 et seq.) is further amended by adding at the end thereof the following new section: "TRANSFERS TO SCHOLARSHIP PROGRAM "SEC. 829. Not to exceed 20 per centum of the amount paid to a school from the `appropriation for any fiscal year for Federal capital contributions under an agreement under this part, or such larger percentage thereof as the Secretary may approve, may be transferred to the SUmS available to th~ school under Part D to be used for the same purpose as such sums. In the case of any such trans- fer, the amount of `any funds which the school deposited in its student loan fund pursuant `to Section 822(b) (2) (B) may be withdrawn by the school from such fund." (i) The amendments made by subsection (b) (1) and (2) shall apply with respect to all loans made after June 30, 1969, and with respect to loans made from a student loan fund established under an agreement pursuant to section 822, before July 1, 1969, to the extent agreed to by the school which made the loans sand the Secretary (`but then only `for years beginning after June 30, 1968). The amendment made `by subsection (c) shall apply with respect to loans made after June 30, 1969. The amendment made `by subsection (h) shall apply with respect to appropriations for fiscal years `beginning after Jhne 30, 1969. The amendment made by subsection (b) (3) shall apply with respect to service, specified in see- tion 823(b) (3) of such Act, performed during academic years beginning after the enactment of this Act, whether the loan was made before or after such enactment. SCHOLARSHIPS Suc. 223. (a) So much of part D of title VIII of the Public Health `Service Act (42 U.S.C. 298c et seq.) as precedes section 868 is amended to read as follows: `PART D-~SCHOLAR5HIP GRANTS TO SCHOOLS OF NUI~sING "SCHOLARSHIP GRANTS .~, 860. (a) The Secretary shall make grants as provided in this `part to each public or other nonprofit school of nursing for scholarships to be awarded annually `by such school to students thereof. "(b) The amount of the grant under subsection (a) for the fiscal year ending June 30, 1970, and each of the next three fiscal years to each such school shall be equal to $2,000 multiplied `by one-tenth of the number of full-time students of such school. For the fiscal year ending June 30, `1974, and for each of the three succeeding fiscal years, the grant under subsection (a) shall be such amount as may be necessary to enable such school to continue making payments under scholarship awards to students who initially received such awards out of grants made to the school for fiscal years ending prior to July 1, 1973. "(c)(1) Scholarships `may be awarded by schools from grants under subsec- tion (a)- "(A) only to individuals who have been accepted `by them for enrollment, and individuals enrolled and in good standing, as full-time students, in the case of awards from such grants for the fiscal year ending June 30, 1970, and each of the next three fiscal years; and "(B) only to `individuals enrolled and in good standing as full-time stu~ dents who initially received scholarship awards out of such grants ~or a fiscal year ending prior to July 1. 1973, in the case of awards from such grants for the fiscal year ending June 30, 1974, and each of the three succeeding fisóal years. PAGENO="0020" 12 "(2) Scholarsifips from grants under subsectton (a) for any school year shall be awarded only to students of exceptional finan4~lal need wb.o need such financial assistance to pursne a course of study at the school for sm~b year. Any such sclioI-~ arship awarded for a school year shall cover such portion of the student's tuition, fees, books, equipment, and living expenses at the school making the award, but not to exceed $1,500 for any year in ~the cfise of any student a~ such sthool thay determine the student needs for such year on the basis of his requirements and financial resources. "(d) Grants tinder subsection (a) sl~all be i~uadeifl accordance with regulations prescribed by the Secretary after consultation with the National Advisory Coun- cii on Nurse Training. "(e) Grants under subsection (a) may be paid iii advance or by way of re- imbursement, and at such Interrals as the Secretary may find necessary; and with appropriate adjustments on account of overpayments of underpayments pre- viously made. "TRANSFERS TO STUDENT LOAN PROGRAM "SEC. 861. (a) Not to exceed 20 per centum of the amount paid to a school from the appropriation for any fiscal year for scholarships under this part, or such. larger percentage thereof as the Secretary may approve for such school for such year, may be transferred to the sums available to the school under this part for (and to be regarded as) Federal capital contributions, to be used for. the same~ purpose as such sums." (b) The amendment made by subsection (a) shall apply with respect to appro-~ priations for fiscal years ending after June 30, 1969, PART fl-MISCELLANEOUS DEFINITION OF ACCuRDITArION SEa. 231. So much of section 843(f) of the Public Health Service Act (42 U.S.C.. 298b), as precedes clause (1) is amended by Inserting ", or by a State agency," after a recognized body or bodies" the first time it appears therein, by inserting "or State agency" after "a recognized body or bodies" the second and third time is appears therein, and by striking out "or a program accredited for the purpose~ of this Act by the Commissioner of Education,". Clause (1) of such section 834(f) is amended by striking out "for a project for construction of a new school (which shall include a school that has not had a sufficient period of operation to be eli- gible for accreditation)" and inserting in lieu thereof "for a construction proj- ect". Such section 843(f) is further amended by adding at the end thereof the following new sentence: "For the purpose of this paragraph, the Commissioner of Education shall publish a list of nationally reebgnised aecrediting bodies, and of State agencies, which he determines to be reliable authority as to the quality of training offered." STUDY OF SCHOOL AID AI~D STUDENT AID PROGRAMS SEn. 282. The Secretary shall, in consult~tion with the Advisory Council estab- llshed by section 841, prepare, and submit to the President and the Congress ~rior to July 1, 1972, a report on the administration of title VIII of the Public Health Service Act, as appraisal of the programs under such title in the light of their adequacy to meet the long-term needs for nurses, and his recommendations as a result thereof. TITLE Ill-ALLIED HEALTH PROFESSIONS AND PUBLIC H~EALTH ThA1NIN~ EXTENSION AND IMPROVEMENT OF ALLIED HEALTH PROFESSIONS PROGRAM SEC. 301. (a) (1) (A) Section 791(a) (1) of the Pu~biic Health Service Act (42 U.S.C. 295h) is amended by striking out "and $13,500,000 for the fiscal year end- ing June 30, 1969" and inserting in lieu thereof "$13,500,000 for the fiscal year ending June 30, 1969, and such sums as may be necessary for the fiscal year end- ing June 30, 1970". (B) Section 791(b) (1) of such Act Is amended by striking out "1968" and inserting in lieu thereof "1969". (2) (A) Section 792(a) of such Act (42 U.S.C. 2~5h-1) is amended by striking out "and $17,000,000 for the fiscal year ending June 30, 1969" and inserting in PAGENO="0021" 13 ~lieu thereof "$17,000,000 for the fiscal year ending June 30, 1969; and such sums as may be necessary for the fiscal year ending June 30, 1970". (B) Section 792(b) (1) of such Act is amended by striking out "1969" and inserting in lieu thereof "1970". (3) Section 793(a) of such Act (42 U.S.C. 295h-2) is amended by striking out "and $3,500,000 for the fiscal year ending June 30, 1969" and inserting in lieu thereof "$3,500,000 for the fiscal year ending June 30, 1969; and such sums as may be necessary for the fiscal year ending June 30, 1970". (4) Section 794 of such Act (42 U.S.C. 295h-3) is amended by striking out "anti $3,000,000 for the fiscal year ending June 30, 1969" and inserting in lieu thereof "$3,000,000 for the fiscal year ending June 30, 19~9; and suc~i sums as ~may be necessary for the fiscal year ending June 30, 1970", (b) Such section 794 is further amended by- (1) striking out "training centers for allied health professions" and Juserting in lieu `thereof "agencies, institutiens, and organizations"; (2) inserting "and methods" after "curriculums"; (3) `striking out "new types of". (c) Part 0 of title VII of such Act is further amended ~y adding at the end `thereof the following new section: "Sue. 797. Such portion of any appropriation pursuant to sections 791, 792, 793, or 794, for any fiscal `year ending after June 80, 1969, as the Secretary may determine, but not exceeding one-half of 1 `per centum thereof, shall be availa~e ito the Secretary for evaluation (directly or by grants or contracts) of the pro- ~grams authorized by this part." PUBLIC HEALTH TRAINING SEc. 302. (a) Section 309(a) of the Public Health Service Act (42 LT.S.C. 242g) is amended by striking out "and" before "$9,000,000" and by inserting "and such sums as may be necessary for each of the next four fiscal years" after "1969". (b) (1) Section 306(a) of the Public Health Service Act (42 U.S.C. 242d) is amended by striking out "and" before "$10,000,000" and by inserting "and such sums as may be necessary for each of the next four fiscal years," after "the suc- ceeding fiscal year,". (2) Section 306(d) of such Act is amended by striking out "$50" and insert- ing in lieu thereof "$100". TITLE IV-IJEALTH RESEARCH FACILITIES EXPEN5ION OF CONsTRUCTION AUTHORIZATION SEC. 401. (a) Section 704 of the Public Health Service Act (42 U.S.C. 292c) is amended by striking out "and" after "$50,000,000"; and by inserting "and for the fiscal year ending June 30, 1970, and each of the next three fiscal years such sums as may be necessary," after "$280,000,900,". (b) Section 705(a) of such Act (42 U.S.C. 293) is amended by striking out "1968" and inserting in lieu thereof "1972". FEDERAL SHARE SEC. 402. (a) Subsection (a) of section 706 of the Public Health Service Act (42 U.S.C. 292e) is amended by striking out "except that in no event may such `amount exceed 50 per centum" and inserting in lieu thereof "but such amount may not, except as provided in paragraph (2), exceed 50 per centum". (b) Such subsection (a) of section 706 is further amended by inserting "(1)" rafter "(a)" and adding at the end thereof the following new paragraph: "(2) The maximum amount of any grant sha1l be 6~i2/~ per centum instead of the maximum under paragraph (1) in the case of any class or classes of projects `which the Secretary determines have such special national or regional signifi- cance as to warrant a larger grant than is permitted nuder paragraph (1); but not more than 25 per centum of the funds appropriated pursuant to section 704 for any fiscal year shall be available for grants in excess of 50 per centum with respect to such class or classes of projects." ADVISORY COUNCIL COMPENSATION SEC: 403. Section 703(d) of the Public Health Service Act (42 USC. 292b) is `amended by striking out "$50" and Inserting in lieu thereof "$100". PAGENO="0022" 14 E~?FECPIVE DATE Ssc, 404. The amendments made by section 402 shall apply in the case of proj- ects for which grants are made from appropriations for fiscal years ending after ruue 30, 1969. ______ ExECUTIvE OFFICE OF THE ?I~ESIDENT, Bu~mAu or THE BUDGET, Washington, D.C~, June 14, 1968. lion. HARLEY 0. STAGGERS, Chairman, Comm4ttee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEA1~ MiL `CHAIRMAN; This is in response to your request for our views on H.R. 15757, a bill "To amend the Public Health Service Act to eNtend and ~mprOve the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to student aid for such personnel, and the program relating to health research facilities, and for other purposes." President Johnson stated in his health, message to the Congress of March 4,. 1968, that "our increasing population and the demand for more and better health care swell the need for doctors, health professionals and other medical workers." To meet the need to train more health workers and to train them better and faster, he proposed the Health Manpower Act of 1968. Enactment of H.R. 15757 would be in accord with the program of the President. Accordingly, the Bureau of the Budget recommends favorable consideration of' H.R. 15757. Sincerely yours, WILFRED H. ROMMEL, Assistant Director for Legislative Reference. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE, Washington, D.C., March20, 1968. Hon. HARLEY 0. STAGGERS, Cha4rman, Com4n4ttee on Interstate and Foreign Commerce, House of Rcpresen~atives, Washington, DXI. DEAR MR. CHAIRMAN: This letter is in response to your request of March 7, 1968, for a report on H.R. 15757, a bill "To amend the Public Health Service Act to extend and improve the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to student aid for such personnel, and the program relating to Jaealtk research facilities, and for other purposes." This bill embodies the legislative proposals contained in a draft bill submitted by this Department to the Congress on March 4, 1968, to implement the recom-~ mendations on the training of health workers contained in the President's March 4, 1968 Message on Health. We urge early enactment of this proposed legislation. The Bureau of the Budget advises that enactment of this proposed legislation would be in accord with the program of the President. Sincerely, WILBUR J. COHEN, Acting secretary. DEPARTMENT OF DEFENSE, OFFICE OF THE GENERAL COUNSEL, Washington, D.C., June 11, 1698. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, House of Repre- sentatives, Washington, D.C. DEAR MR. CHAIRMAN: Reference is made to your request for the views of the Department of Defense on H.R. 15757, 90th Congress, a bill "To amend the Pub- lic Health Service Act to extend and improve the programs relating to the train- ing of nursing and other health prOfessions and allied health professions person- nel, the program relating to student aid for such personnel, and the program relating to health research facilities, and for other purposes." PAGENO="0023" 15 The title of the bill generallystates its purpose. The Department of Defense has considered the bill. The need for extending and improving the programs in question is recognized. It is also manifest that such extensions and improvements would indirectly improve the availability of health services for beneficiaries of the Department of Defense. Accordingly, the Department of Defense favors in principle legislation which would accomplish the purpose of H.R. 15757. The Department of Defense defers, however, to the Department of Health, Education, and Welfare on the details of this legislation. The Bureau of the Budget advises that the enactment of H.R. 15757 would be in accord with the Program of the President. Sincerely, L. NIEDERLEHNER, Acting Generai Counsel. C0MPrn0ILRR GENERAL OF vrm UNITED STATES, Washington, D.C., April 17, 196& Hon. HARLEY 0. STAGGERs, Clra,irman, Committee on Interstate and Foreign Commerce, House of Repre- sent atives, Washington, D.C. DEAR Mn. CHAIRMAN: The proposed "Health Manpower Act of 1968," ILR. 15757 which has been referred to your Committee proposes a number of amend- ments to the Public Health Service Act to extend and improve several programs provided for in that act. While we have no comments on the merits of this pro- posed legislation, we are concerned over the records maintained by recipients of grants under that act and our access thereto for audit and examination purposes. *A number of programs authorized by the Public Health Service Act provide for the making of grants of public funds to individuals, schools, hospitals, public institutions, etc., in furtherance of the purposes of the Act. However, only a few of the recipients of such gr~uts are required by the Public Health Service Act to keep records concerning the disposition of the grant funds and to make them available for audit purposes. Consequently neither the Department of Health, Education, and Welfare, nor the General Accounting Office may be able to a~cer- tam that the recipieuts of those grants have expended them solely for the pur- poses for which the grants were made. As indicated above the provisions of law pertaining to several of these grant programs require the recipients of grants to keep records pertaining to those grants and provide that the Secretary of Health, Education, and Welfare and the Comptroller General or their representatives may examine and audit those records. See section 909 of the Public Health Service Act as added by Public Law 89-239, approved October 6, 1965, 79 Stat. 930, 42 U.S.C. 299i; section 399b(a) of the Public Health Service Act as added by the Medical Library As- sistance Act of 1965, approved October 22, 1965, 79 Stat. 1066, 42 U.S.C. 280b-11; and section 796 of the Public Health Service Act as added by the Allied Health Professions Personnel Training Act of 1966, appproved November 3, 1966, 80 Stat. 1230, 42 11.S.C. 295b-5. Title III of H.R. 15757 provides for the extension of the grant program authorized by the Allied Health Professions Personnel Training Act of 1966 referred to above. In view of the large number of programs providing grants for various purposes, the General Accounting Office, in an effort to protect against waste or improper use of grant funds, has recommended to the appropriate Congressional commit- tees that there be Inserted in all such legislation similar "access to records" pro- visions. However, rather than to enact such records requirements with respect to Public Health Service programs on a program by program basis, we recommend that HR. 15757 be amended to include a records clause that would be applicable to all grant programs covered by the Public Health Service Act. This could be accomplished by adding a new section 405 to HR. 15757 which would read as follows: "SEc. 405. The Public Health Service Act (42 U.S.C., ch. 6A) is amended by adding at the end thereof the following new title: "TITLE X-RECORDS AND AUDIT "SEc. 1000. (a) Each recipient of a grant under this Act shall keep such rec- orcis as the Secretary may prescribe, including, records which fully disclose the PAGENO="0024" 16 amount and disposition by such recipient of the prpceeds of such grant, the total cost of the project or undertaking in ~connection with which such grant is made or used, and the amount of that portion of the cost of the project or undertaking supplied by other sources, and such records as will facilitate an effective audit. "(b) The Secretary and the Comptroller General of the United States, or any of their duly authorized representatives, shall have access for the purpose of audit and examination to any books, documents, papers, and records of the re- cipient of any grant under this Act which are pertinent to any such grant." The primary purpose of audits by the General Accounting OfJIee is to make for the Congress independent examinations of the manner in which Government agencies are discharging their finahciai responsibilities. Financial responsibilities of Government agencies are construed as including the administration of funds and the utilization of property and personnel only for authorized programs, ac- tivities, or purposes, and the conduct of programs or activities in an effective, efficient, and economical manner. Full and complete access to all records pertain- ing to the subject matter of an audit or investigation is necessary in order that the ~l~neral Accounting Offlce can fully carry out its duties and responsibilities. If the amendment proposed above is adopted it is not contemplated that the General Accounting Omce will make a detailed examination of the books and records of every recipient of a loan or grant, ~or ~even a i~ajor part of them. however, selective checks will b~ made to prOvide reasonable assurance that assistance funds are being properly applied or expended. Als6, if the Public Health Service Act is amended in the manner suggested above, a new section 406 should be `added lo ~R. 15757 which would provide fbi~ the' repeal of the "records and audit" provisions preseutly applicable to sevetal programs authorized by the Public Health Service Act. The following language is suggested for that ptirpose: "Sue. 406. Section 399b (42 U.S.C. 250b-11); section 796 (42 U.S.C. 29'5h-5); and section 909 (42 U.S.C. 2991), of the Pttblic health Service Act are hereby repealed." And a new section 407 should be added to the bill which woi,ild read as follows: "Sue. 407. Section 1 of the Public Health Service Act Is athended to read as follows: "SECTION 1. (a) Titles I to X, inclusive, of this Act may be cited as the `Public flealtb Service Act.' "(b) The Act of July 1, 1944 (58 Stat. 682), as amefided, is further amended by renumbering title X (as in effect prior to the enactment of this Act) as title XI, and by renumbering sections 1001 through 1014 (aS in effect prior to the enactment of this Act), and re~erence~ thereto, as sections 1101 through 1114 respectively." Sincerely yours, FRANK 11. WEITZEL, Assistant Comptrolter Genera' of the United States. VETERANS' AimuxIsruArIox, Orrreu or rim APMINI5r5AT0E or VETERANS' ATTAInS, WasMnŘon, D.C., ,Tune 10, 1968. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreiqn Commer~oe, House of Representativer, Wash ington, D.C. DEAR Mn. CHAIRMAN: The following comments are submitted in response to your request for a report by the Veterans Administration on H.R. 15757, 90th Congress. The bill would amend the Public Health Service Act to extend and improve programs relating to the training of nursing and other health professions and allied health professions personnel, student aid for such personnel, and health research facilities. The proposed legislation applies to programs administered by the Department of Health, Education, and Welfare, and would appear to impose no additional administrative responsibility on the Veterans Administration. We, therefore, defer to the views of that Department with respect to detailed analysis of the separate provisions of the bill. The Veterans Administration has an extensive hospital and medical program to provide care for sick and disabled veterans. In carrying out this program we employ a large number of physicians, dentists, nurses, and other professional PAGENO="0025" 17 and allied health professions personnel. Consequent'y, any reasonable steps which would enhance the opportunities of the better students to enter medical, ~Iental, and nursing schools, regardless of income, and attract more qualified persdns into the health professionsare~ of interest to us. We mahe availabJ~ to iu~ veteran patient's the latest technology in the diagnosis and treatment of diseases. New knowledge and tecJ~i~ues ,are deye1oped~tl~ropg1j greater emphasis on research. We are interested therefOre in any reasOnable program which will increase health research facilities. Iii his Health Message to the Congress on March 4, 1968, the President reconi- mended legislation to meet the urgent need for more doctors, nurses and other health workers, and for greater emphasis on the development of research facilities meeting critical regional or national needs. We are advised that JIlL 15757 is designed to carry out these recommendations of the President. We recommend favorable consideration of ll.IL 15757 by your Committee. We are advised by the Bureau of the Budget that there is no objection to the presentation of this report from the standpoint of the Administration's program. Sincerely, W. J, DRIVER, Administrator. Mr. JARMAN, Our first witness today is our lo~ngtime friend and coi~ league from Iowa, the Honorable Neal Smith. We are pleased that you could take the time to be with the subcom- mittee and give us the benefit of your good counsel. Mr. ROGERS. May I say, Mr. Chairman, how delighted we are to have our distinguished colleague here. STATEMENT OP HON. NEAL SMITH, A REPRESENTATIVE IN CONGRESS PROM THE STATE OF IOWA Mr. SMITH. Thank you. While I was. waiting, I saw this nice crowd sitting in the room with no one talking to them, and it Was an awful temptation. [Laughter.] Anyway, Mr. Chairman and Mr. Rogers, I am happy to be here to suggest that the bill you have under consideration provide an alterna.. the method or schedule for repaying loans. I think a rigid repayment schedule has two great shortcomings: (1) Some loan recipients are bound to have years in which they do not make enough money so that they can repay on schedule; and (2) fear that they cannot repay on schedule will cause some applicants who are needed in the healtl~ professions to not develop their skills as a nurse or in one of the fields where they are so badly needed. I am proposing that a, loan recipient be permitted, as an alternative, to become obligated to repay the loan at the rate of 5 percent of their net taxable income per year rather than on a fixed or inflexible basis. The vast majority of nurses have been, and I assume will be, women. Young women `hestiate to~ restrict their married life in advance ~y signing up for a loan whiph' requires a fixed payment per year. To secure money with this kind of an obligation meanč that they will be over 30 years of age before the loan is paid ofF; and, until that time, they have a fixed indebtedness to meet each year. When ~they are considering going to nursing school, these girls do not know if they will be marrieçl, what the obligations of their husband' and family may be, if they' wifi be out of work due to pregnancy or caring for a child, or the family moving. They simply hesitate to introduce such a fhced obligation' into such an uncertain future schedule. Understandably, many of them areso afraid it will interfere with what they decide to do in the way of marriage, that they would rather not go to school than run the risk of such interference. PAGENO="0026" 18 They would not have the same fear, nor the same problems, in meet- ing an obligation wherein they pay 5 percent of their net taxable income, whatever that may be, per year. In the years that they are working, they may pay more than they would otherwise, but it all depends upon their income. In any event, since the average graduate will make 20 percent more than they would have had they not gone to school, they have about one- fourth of the extra income to repay the loan, which makes it a good investment for them. In the long run, they will have repaid the money, paid a great deal more in incom~ tax as a result of the increased income, and they will have provided, services that are going to be badly needed for this Nation many years to come. It would not involve any additional paperwork for the nursing school which collects the money and remits it to the Government. The borrower would merely file a certificate stating what her income i~mounted to, and pay 5 percent of that amount each year. Since 1961, I have been pushing this approach as a method of repay- ment for NDEA and other college loans. Although it was at one time accepted by the Education and Labor Committee in a proposed bill, that bill was later revised, and some people were still saying that the inflexible loan provisions would work well. The repayment record of the last few years shows conclusively that some who have received loans do have a problem with an inflexible schedule that they would not have under this proposal. I am confident that almost every one of the loans that are in default now would not be in default if this kind of a repayment schedule had been iermitted. This idea that I am proposing has been heartily endorsed by persons I have talked with, such as Sister Mary Brigid, head of the School of Nursing at Marycrest College in Davenport, Iowa. And while she said her organization had not studied it so they could endorse it for the organization, Miss ,Juiia C. Thompson, the Washington representative of the American Nurses Association, in testimony before the HEW appropriations subcommittee last year, said as follows: Miss THOMPSON. This is one area we have found to be somewhat of a problem, that generally female students aren't as apt to take loans as men students be- cause of the repayment and other responsibilities that they have in our society. Mr. SMITH. Because they are on a rigid repayment schedule? Miss THOMPSON. Yes. Mr. SMITH. But if they were on a flexible schedule, they wouldn't have that kind of reluctance, would they? Miss THOMPSON. Probably tiot. Mr. Chairman and gentlemen of the committee, I sincerely urge you to include an amendment of this type in the bill. I have prepared such an amendment, which I will leave with you. That is all I have. (The document referred to follows:) AMENDMENTS TO H.R. 15757, PROPOSED BY CONGRESSMAN NEAL SMITH On page 14, after line 3, add the following and renumber the following para- graph accordingly: (4) Section 741(c) of such Act (42 U.S.C. 294a) is further amended by add- ing thereto the following paragraph: "In lieu of payments required under this Act, an institution may enter into an agreement with a student providing that, beginning with the student's second taxable year which begins after the student ceases to pursue such full-time course of study, repayments shall be made at a PAGENO="0027" 19 rate for each taxable year equal to five per centum of his personal net taxable income for such year, as defined or determined by section 63 of the Infernal Revenue Code of 1954, for each year payments would be made and until such loan Is repaid, but no interest shall be charged for any such loan which is repaid in this manner." On page 32, after line 3, add the following: (I) Section 823(b) of such Act (42 15.8.0. 297b) is further amended by adding thereto the following paragraph: "In lieu of payments required under this Act, an institution may enter into an agreement With a student providing that be ginning with the student's second taxable year which begins after the student ceases to pursue such full-time course of study, repayments shall be made at a rate for each taxable year equal to five per centum of his personal net taxable income for such year, as defined or determined by section 63 of the Internal Ilevenue Code of 1954, for each year payments would be made and until such loan is repaid, but no interest shall be charged for any such loan which is repaid in ~this manner." Mr. JAEMAN. Then if Would be on a flexible, open end basis as to the number of years in which repayment would be made, simply based ~on the amount' of income, 5 percent of the net income received in each year? Mr. SMITH. Yes. As you know, the loans are made through the `college, and when the applicant came before the college personnel, he would be told that there are two methods of repayment and that he could choose which one he wanted. From what the people who run nursing schools tell me, they have many good applicants, and if they ~had this alternate method to use in talking to them, they would decide to go to nursing school, whereas now they don't see some of them :agam. Mr. JARMAN. It is an interesting approach to the problem, and we ~will bring it before the subcommittee in executive session. Mr. SMITH. Thank you very much. Mr. JARMAN. Our next witness is Dr. Philip II. Lee, Assistant Sec- retary for Health and Scientific Affairs. Dr. Lee, it is fine to have you with the subcommittee again. ~STATEMENT OF DR. PHILIP R. LEE, ASSISTANT SECRETARY FOR :HEALTH AND SCIENTIFIC APPAIRS~ DEPARTMENT OP HEALTH, EDUCATION, AND WELFARE, ACCOMP~.NIED BY DR RALPH K HUITT, ASSISTANT SECRETARY FOR LEaISLATION; DR. LEONARD D. ~NNINGER, DIRECTOR, BUREAU OP HEALTH MANPOWER, NATIONAL INSTITUTES OF HEALTH, PUBLIC HEALTH SERVIcE; AND DR. THOMAS J~. KENNEDY, JR., DIRECTOR, DIVISION OP RE~ SEARCH FACILITIES AND RESOURcES, NATIONAL INSTITUTES ~OE HEALTH Dr. LEE. Thank you very much again. With me are Dr. Huitt, Assistant Secretary for Legislation, Dr. Fenninger, Director, Bureau of Health Manpower, and Dr. Thomas Kennedy, Jr., Director of the Division of Research Facilities and Re- sources, National Institutes of Health. This reflects in part `the reorganization that has occurred. rfhe Bureau of Health Manpower, the National Library of Medicine, and the National Institutes of Health now comprise a new agency within the Department. PAGENO="0028" 20 Mr. JAEMAN. It is good to have you with us. Dr LEE Mr Chairman, it is a pleasure to testify on, and give our full stipport to, the Health ManpowerAct of 1968, H.R. 15757, intro- duced, as you noted, by the distinguished chairman of this committee. Health manpower is vital to all our health endeavors fhe N'ition cannot afford any interruption or loss of friomentum in th~ efforts we are now making to provide the people trained to meet its health needs. For that reason we strongly urge enactment of the bill this year. The Health Manpower AÔt of 1968 will continue and strengthen five n~ajor health progranis authorjzed by the Health Professions Educational Assistance Act of 1963, the Nurse Training Act of 1964, the Allied Health Professions Personnel Training Act of 1966, and the Health Research Facilities Act of 1956, as well as the Public Health Service Act authority for public health traineeships and proj- ect grants to schools for graduate or specialized training in public health. This committee has played a very important role in the devel- opment of these programs. These laws have provided the foundation and the framework with- in which the Federal Government has become a partner witiTi educa- tional institutions in pioviding the facilities and the faculty for the difficult but essential task of preparing the large numbers of skilled personnel necessary to translate the Nation's expectations for health care into reality. Under these laws new schools have opened their doors and others have significantly expanded and updated their training facilities.. Schools have been assisted in strengthening their curriculums so that those who are trained are realistically equipped to serve the health needs of the people of this Nation. Students in the health professions have received loans and other financial assistance enabling them to undertake health *careers in which they could not otherwise have become engaged. The programs authorized under the existing laws have . involved a variety of institutions and agencies, varied in their organizational patterns and their social settings. S~nie are free standing, some are relatively independent members within a university system, some are integral parts of universities and colleges, and some are product~ of the community and close to the community. Throughout our society we are experiencing shortag~s of trained people, and inadequacies in social arrangements~ to deal with the vast, complex, and frequently long neglected problems with which we are now confronted. The problems associated with the prevention of ill- ness and with the care of those who become ill are related to all other aspects of contemporary society and must be viewed in that context. We are all concerned with the quality and availability of health services. Among the large number of factors involved, the most signif- icant include public education which has led to a greater understand- ing of the significance of individual and community health; a rising, and sometimes unrealistic, expectation of what the . medical sci~nces can offer; rapidly increasing medical knowledge an.d technology which have profoundly altered health care; increases in the population, its geographic and age distribution; and an emerging social policy that adequate high-quality health care should be available to all ~who need it. PAGENO="0029" 21 The essential ingredient in the provision of health services ~is~ of course, the people who are engaged in it. People who contribute to our health-as individuals and as a na- tion-are needed in large numbers at every level of education and skill. They must be encouraged to enter the health field. They must work in settings which allow them to use their abilities most effectively. Our most important task in the field of health is tQ prepare enough people with adequate knowledge and skill so that the right and expectation of every individual to have good health and tc~ fulfill himself as an individual being can be realized. The supply and quality of Americ&s health professionals is at the very heart of our success in achieving and maintaining the oppor- tunity for good health services for all Americans. The great break- throughs in medical research will be of little value if patients in need cannot have access to physicians, dentists, nurses, and other important practitioners of the health professions. Our continuing rising pros- perity ~s a nation will not bring about better health if essential health services are not available when and where they are needed. When these laws were first enacted, attention was directed to the critical needs for different kinds of skills in the respective areas of health manpower. It was pointed out at that time that there were often long waiting periods for medical and dental care, that hospital beds were closed for lack of staff, and that desperately overcrowded hos-: pital emergency rooms were unable to meet urgent community needs. The removal of financial barriers to the receipt of health care through private health insurance, medicare, and medicaid is increas- ing the demand for services. Costs of providing services have risen rapidly, as have the costs of education and training, The science base that is the foundation for allof our education programs for the health professions, aud for the services they prpvide, cont~uues to expand and provide new opportunities, for service. When these laws were first enacted, we all recognized that there was no such thing as "instant manpower" and we recognized that we were already late in meeting the need. But the commitment was made, the tasks were begun, and we are beginning to see the results. When one stops to think that the first construction pro ject under the Health Professions Educational Assistance Act;w~s funded in 1965, only 3 years ago, we can se~ that we are making good progress. We are also aware that, as we tool up to train increasing numbers of stu- dents, the demand for health services is also increasing. W~ cannot afford to stand still; we must run simply to keep up. Under the Health Professions Educational Assistance Act, first au- thorized in 1963, 114 schools have received $365 million for construc- tion of teaching facilities. These dollars have assisted in the construc- tion of 17 new schools and the expansion, renovation, or remodeling of 97 other schools. Approximately 4,000 ~new first-year places are at~ tributabl~ to such construction. Health professions basic improvement grants will aid 170 schools this year. Construction grants under the Nurse Training Act h~v~ aided 84 schools, adding over 3,300 new first-year places. There is much more progress to reports Mr. Chairman, and in the interest of time I will submit for the record, with your permission, a detailed description of accomplishments und~r t1i~se programs; PAGENO="0030" 22 Mr. JARMAN. The committee will be glad to receive it. Dr. LEE. Thank you, sir. (The document referred to follows:) SUMMARY BY THE DEPARTMENT OF HEALTH, EDUcATION, AND WELFARE OF ACCOMPLISHMENTS UNDER ExISTING PROGRAMS L ACCOMPLISHMENTS UNDER HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE ACT A. Construction of teaching facilities Since the Health Professions Construction Program was first authorized in 1963, 114 schools have received $365 million for constructiOn of teaching facilities. These dollars have assisted in the construction of 17 new schools, and the ex- pansion, renovation, or remodeling of 97 other schools. HEALTH PROFESSIONS EDUCATIONAL FACILITIES CONSTRUCTION, FISCAL YEAR 1965-MAR. 1, 1968 IDollar amounts in thousands) Type of construction Number T of schools otal teaching cost Federal share Increase in 1st-year places 1st year places main- tained Total New schools Existing schools -- -- -- Included in the above: Affiliated teaching hospitals University hospitals 114 $670,994 $365,241 3,974 8,655 17 97 188 039 482,955 114 000 251,241 1 067 2,907 - 8,655 (8) (9) (62,003) (105,492) (35, 054) (48,420) (1) (1) 1 These projects are in most cases 2d phases of institutional expansion prograns. The 1st-year place increase has been dentified with the school. Approximately 4,000 new first year places are attributable to such construc- tion-some are already open and occupied-others will be occupied in later years as construction progresses. In addition, more than 8,600 first year places have been maintained through renovation and replacement of obsolete facilities. While increases in enrollment are identified, in keeping with the legislative requirements, in terms of first-year students, this number does not reflect either the full effect on the teaching load of the school, or on the value derived from the expansion. As each additional first-year student progresses through the program, the school must add second, third, and fourth year student places. Thus an increase of five first year students means in the fourth year, a total teaching load of 20 students, with the necessary facilities, faculty, and equipment. As to the effect of the increase, it can be most adequately measured in terms of the school's added production of five graduates a year, or 100 graduates over a 20-year period. These, at an estimated professional life of 40 years-for ex- ample, for a physician or dentist-will give 4,000 professIonal years of service to the nation, extending well into the next century. B. Health pv~ofessions improvement grants Basic improvement grants The 1965 amendments to the Health Professions Educational Assistance Act, authorized basic improvement grants, on a formula basis, to eligible schools of medicine, dentistry, osteopathy, optometry, or podiatry. In fiscal year 1966, this grant was computed on the basis of a statutory formula of $12,500 plus $250 times the number of full-time students; for the fiscal years 1967, 1968, and 1969, the formula provided for $25,000 plus $500 times the number of full-time students. In fiscal year 1966, basic improvement grants, totaling $10,482,000, were awarded to 159 eligible schools. This provided grants at 70 percent of the statu- tory formula. In fiscal year 1967, basic improvement grants, totaling $30 million and representing 95 percent of the formula amount, were made to 172 schools. In fiscal year 1968, full funding at the statutory formula level occurred for the first time with over $32 million awarded for these grants. The number of schools PAGENO="0031" 23 receiving support and the amouiits of awards by discipline for each fiscal year are shown in Table I. TABLE 1.-HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE ACT, BASIC IMPROVEMENT GRANTS, FISCAL YEARS 1966-68 Fiscal y ear 1966 Fiscal y ear 1967 Fiscal year 1968 Discipline ~ Number of participating schools Amount Number of participating schools Amount Number of participating Amount schools Medicine Dentistry Optometry Osteopathy Podiatry Total 91 49 9 5 5 $6, 566,249 2,975,283 398,119 355, 834 186, 515 99 53 10 5 5 $18, 780, 518 8, 440, 653 1,231,266 983, 293 564; 270 99 $20, 242, 500 51 8,859, 500 10 1 360 500 5 1 063 000 5 ~35, 000 170 32, 160, 500 159 ~--:~.- 10,482, 000 .~ 172 30, 000, 000 With basic improvement grant funds, schools are improving and expanding their educational capabilities. The majority of the funds are being used for support of teaching faculty. With these grants schools are developing new courses, improving teaching methods (including use of visual ohids), expanding curriculum areas, improving library resources, and otherwise supporting and strengthening their teaching programs. For example, dental schools have added courses in community dentistry, preventive dentistry, human behavior, pathology and hospital dentistry. Schools of medicine and osteopathy have strengthened and expanded both basic science courses and clinical instruction and are experi- menting. wjth innovations in education. For example, one school designed courses to introduce students to the clinical aspects of medicine earlier than in the traditional curriculum. Students are now introduced to pediatrics and obstetrics in the sophomore year. special improvement grants - Special improvement grants, are to be used to overcome educational weaknesses related to accreditation problems and to carry out the specialize functions which the school serves. Funds for these grants are available for the first time in fiscal year 1968, with approximately $17.5 million available for these purposes. For this year, the statutory maximum amount of any grant to a- school is $300,000. Requests totaling $34.3 million from 136 schools were received. The National Advisory Council on Medical, Dental, Optometric, and Podiatric Education has recommended approval of 124 applications totaling $29 million. In awarding these grants, priority will be given to schools which plan to use special improvement funds to improve further these aspects of their educa- tional program which have placed the school's accreditation status in jeopardy. The applications from schools whose accreditation is in jeopardy show a determination to solve those accreditation problems which, indeed, can be solved primarily with additional funds. These and other schools in serious fi- nancial straits have reflected in their applications careful planning to over- come their most critical weaknesses. Other schools have given careful thought to using their funds to add breadth and depth to their curricula by filling in gaps in instructional areas, by the addition of new courses, and by improving student-faculty ratios. U. health professions student loans The Health Professions Student Loan Program began in 1965 with 147 schools of medicine, dentistry, osteopathy and optometry participating. Schools of pharmacy and podiatry participated in the program for the first time in 1967 and schools of veterinary medicine, in 1968. Participating schools numbered 217 in 1968-an increase of 48 percent in four years. Similarly, the number of stu- dents enrolled in participating schools rose from 47,430 in 1965 to about 64,470 in 1968-an increase of 36 percent. In 1965, 11,554 students received loans averaging $817. In 1968, an estimated 25,383 students in health professions schools, representing 39 percent of the total enrollment, received loans averaging about $1,050. The number of par- ticipating schools, students enrolled therein, students assisted, amounts allocated and average loan for each discipline for each fiscal year are shown in Table IL PAGENO="0032" Fiscal year 1965: Medicine Dentistry Osteopathy Optometry ____________ Total ________ Fiscal year 1966: - Medicine Dentistry Osteqpathy Optometry Total Fispal yçar 1967: - Medicine Dentistry O~teopathy~ Optom~try_, Pharmacy Podlatry.~ _______ Total Fiscal year 1968: - Medicine DentIstry Osteopathy Optometry Pharmacy Podiatry Veterinary medicine ________________ ____,_.. __,._. ___~.*. ,_, _,-_ D. Hoalth profe8~Ofl8 sohoZar8h1~p8~p?O9raflt/' The flealth Professions Scholarship Program pro~1des scholarship assistance to students from low-income familieS eitrolled In schools of medicine, dentistry, osteopathy, optometry, pharmacy and podiatry. In fiscal ~~ear 19E17, 227 health professions schools partic1p~tted in the program. Scholarships averaging $805 were awarded to 3,824 first-year students. lit fiscal year 1968, an estimated 7,964 first- and second-year students in 238 schools Will receive scholarship assistance, representing 20 percent of the estimated first- and second-year enrollment of 38,872 students. The average scholarship award in fiscal year 1968 Is an estimated $903. The numbers of participating schools, enrollments, students assisted, amounts allocated and the average scholarship awards for each type of school for fiscal years 1967 and 1968 are shown in Table III. 24 TABLE li~HEALTH PROFESSIONS STUDEN1' LOAN PROGRAM ` ` ~- ~- Amount' Average allocated loan Type of school Number of participating schools Number of students enrolled ~n participating schools Nutnberof students assisted Percentage of students assisted 87 ` 31,416. 7,186 46 12,954 3,367 5 1,651 614 9 1,409 387 7 47, 430~ 11,554 23 $6,628,787 $839 26 2,870,963 815 31 398, 088 646 27 302, 162 706 24 10,200,000 817 87 32,040 9,475 30 9,834,258 1,011 46 13,434 4,472 33 4,623,920 990 5 1,710 716 42 648,458 893 9 1,489 564 38 493,364 871 147 48,673 15,237 31 15,600,000 941 88 32,883 11,303 34 14,217,791 1,094 46 13,720 `5,530 40 7,132,000 1,178 5 - 1,781 937 53 1,2~2,634 1,215 - 2,016 656 33 869,782 1 040 45 8 139 1584 ` 19 1,638,887 704 2 `338 .1~8' 47 203,906 1,288 34 25,325,000 ` 1,092 i~T'TI6~14?, 2o,16~ 93 33,749, 13,073 47 14,114 6,634 5 1,838' 1,266 10 2113 748 48 9,291 2,311 2 413 208 12 2,955 1,14~, Total 217 -- 64,473 1 Estimated. 39 14,736,356 1,127 47 6822,117 1,028 69 1;044,947 825 35 856,113 1,145 75 1,810,357 , 783 50 234,800 1,128 39 1,154,786 - 1,010 1 39 26,659,476 11,050 125,383 PAGENO="0033" 25 TABLE 111.-HEALTH PROFESSIONS SCHOLARSHIP PROGRAM Type of school Number of participating schools First-year enrollment in participating schools Number of students assisted Percentage of students assisted Amount allocated Average scholarship Fiscal year 1967: Medicine Dentistry Osteopathy Optometry Pharmacy Podiatry Total Fiscal year 1968: Medicine Dentistry Osteopathy Optometry Pharmacy Podiatry Total 88 49 5 10 70 5 8,754 3,824 469 695 5,373 288 1,635 799 147 144 1,040 59 18 20 31 21 19 21 $1,769,200 808,200 91,800 145,800 1,003,200 51,000 1 $891 1 831 1 650 1 932 1655 1 760 227 19,403 3,824 19 3,875,200 1805 95 50 5 10 73 5 17,514 7,785 971 1,363 10,642 597 3,356 1,585 306 303 2,280 134 19 20 32 22 21 22 3,293,009 1,475,826 177,049 248, 526 1,894,910 108,856 2 981 2 931 2578 2 820 2831 2812 238 38,872 7,964 20 7,198,176 2903 I Based on expenditures by the schools. 2 Estimated. II. ACCOMPLISHMENTS UNDER NURSE TRAINX1~G ACT By January 1, 1968, more than $100 million had been awarded, under the Nurse Training Act to `schools of nursing for institutional `and student assistance. Dur- ing these first three and one-half years, over 3,300 grants were awarded for con- struction projects `and payments for `school improvement, `and loan's and trainee- ships-2,113 to diploma programis, 144 to associate degree programs and 1,051 to baccalaureate and higher degree programs. Seven hun'dred and twenty `schools partAcij~ated in one or more provision's of the Act; `of these 490 were diploma programs, 55 were associate degree, and 175 were baccalaureate and higher degree. Because the quality of care nurses give is dependent upon the quality of their preparation, the Nurse Training Act of 1964 ~as developed to provide assistance that would `bear `directly on the improvement of this preparation `and make it more `accessible to `student's. The Nurse Training Act was designed as a balanced program of ~asistance to all types of nursing education programs through financial aid to schools and students of professional nursing. Although this `assistance has been avail'at~Ie l~ss than four years, results for this s'hort period are encourag- ing. Each year, the participation has increased, and more students are benefiting. Faculty `and administrators of schools of nursing h'ave shown imagination and ingenuity in developing teaching facilities, course content, `and teaching methods which are providing more students with higher quality preliaration for nursing care of patients. A. Construction of teaching faciZities Construction grant `assistance to schools of nursing first bec'ame available when `baccalaureate programs of nursing education were eligible `to apply for construction grant funds with the other disciplines under the Health Profes- sions Educational Assistance Act of 1963. Under that authority, grants totaling $8.8 million were made to 16 sdhools in 13 States. Two grants were made to new schools. The 14 other grants were tuade to rep~Faee existing obsolete facilities and to provide additional facilities to accommodate enrollment increases. Two of these projects involved renovation, `and t'he remaining projects were for new construction. A total of 786 additional first-year `student places will be av'aithble upon co~mpict&on of the 16 projects. The Nurse Training Act of 1964 `authorized matching grants to eligible colle- giate, ass'ociate degree and diploma programs for new construction, expansion or reno~ation of educational facilities for four years, 1966 through 1969. Tl~e construction grants awarded to 84 `school's of nursing `as of April 30, 1968, will enable these programs to accommodate `approximately 11,000 additional students. Quality of education will be `maintained and enhanced hs teaching facilities are added, replaced or renovated and, in addition to the increased places, t'he original enrollment of `approximately 14,500 nursing students will benefit. 95-5400-68-3' PAGENO="0034" 26 This construction is characterized by a flexibility of plans that promotes effi- cient and economical use of space and specific innovations in design reflecting innovations In curricula. The majority of ~cnistruetion grants have gone for replacement of obsolete buildings rather than for expansion; most schools conld not consider increasing enrollments until a~ter facilities are improved to accommodate present students. Experience with existing schools has uhown that, in most cases, replacement or rehabilitation must of necessity take priority over expansion. CONSTRUCTION GRANTS AWARDED UNDER THE NURSE TRAINING ACT, COSTS, INCREASE IN FIRST-YEAR PLACES AND PLACES MAINTAINED, BY TYPE OF PROGRAM, SEPT, 7, 1965, TO APR. 15, 1968 Type of program Number of schools Total eligible I Federal share Increase in 1st-year places Student places maintaIned Total Baccalaureate and graduate Associate degree Diploma 84 28 15 41 $84,962, 160 42,368,924 6,619,980 35,973,256 $47, 976,993 24, 304,493 4,242,754 19,429,746 3,312 1,812 787 713 14, 391 7,472 865 6,054 1 Portion of total construction costs to which form ula for Fed eral funds is ap plied. B. Project grants for improvement of nurse training As of April 30, 1968, 139 project grants bad been awarded to 108 sponsoring schools of nursing-diploma, associate degree, baccalaureate and higher degree. An additional 177 schools, including 68 unaccredlted programs, are participating in these `projects with the benefits reaching a combined enrollment of over 38,000 students. The amount of funds awarded totaled $8,965,447; funds approved for duration of the projects totaled $14.5 million. Participation to date and the funds awarded for the first three years of the program are shown in the following tables. Final figures for FY 1968 are not yet available, It is anticipated that the total a~propri'ation of $4 million will be awarded. PARTICIPATION IN PROJECTS FOR THE IMPROVEMENT OF NURSE Number of Number of Type of program schools nonapplying awarded participatng grants schools Total partici- pating schools Total 108 177 285 Diploma 49 35 Associate degree 6 77 Baccalaureateandhigherdegree 53 65 88 84 113 FUNDS AWARDED FOR PROJECTS FOR IMPROVEMENT OF NURSE TRAINING Type of program 1965 1966 1967 1968 Total $1,989, 564 $1,927,620 $3, 518,833 1 $4,000, 000 Diploma 553,216 532,814 945,144 (2) Associate degree 236,952 199,904 Baccalaureateandhigherdegree_. 1,436,348 1,157,854 2,373,785 1 Appropriation. 2 Awards incomplete. A simple accounting of the number of grants, dollars awarded or enumeration of the project titles cannot indicate the impact of this assistance on the quality of nursing education during this short time. One of the significant accomplishments of the project grants program is the collaboration among several scbools to achieve maximum results with these teaching improvement grants. The Project Grants Program is also fostering a faculty commitment to good nursing education that surpasses commitment to a PAGENO="0035" 27 particular school. For example, in Southern California, faculty in 9 diploma schools are taking part in a single project making possible expert teaching assistance that the schools cou~1d not afford alone. On a mid-west campus, the baccalaureate and graduate nursing programs are sharing their resources with 12 associate degree and diploma programs in a project both to prepare teachers and to master teachers available through the use of new media. These schools could have applied for and received, individual grants. This would have increased the number of projects but would have defeated the purpose. The projects are also helping individual schools to strengthen their own programs. For example, one project has assisted a diplom.a program to increase enrollment by developing a more academically sound educational program and simultaneously reducing the length of time needed to prepare a bedside nurse. Other examples of specific projects follow. One project involving 18 diploma schools has produced educational materials' presently being used to improve this type of education by at least 40 schools in several States. Several schools in Florida are extending the short supply of teachers by cooperating in the development of a series of television courses that will bring the few expert teachers to large numbers of students in schools throughout this State as well as others in the Southern region. In 13 western States, 43 associate degree, 35 baccalaureate, and 10 graduate schools of nursing are working together to improve the preparation and increase the numbers of the types of nurses needed in this geographic area. With the accomplishments of the project grants program to date are im- portant, a full realization of the program's potential for far reaching, long range results is yet to come. As more and more schools incorporate the educa- tional improvements into curriculum and use the techniques and materials developed under these projects, the improved quality of students' preparation will be reflected in the care they give as practitioners. (1. Payments to diploma schools Under this program of partial reimbursements of diploma schools, 1292 pay- ments, through Fiscal Year 168, were made to the 447 eligible diploma schools that applied. Awards totaled $9 million. Payments ranged from $250 to $40,000; the average amount of the entitlement was $8,000. Substantial improvements were not possible with average payments at this level. However, schools used the payments to improve library resources, pur- chase up-to-date equipment and to make other educational improvements. The formula itself, being dependent upon increased enrollment and Federally-spon- sored students, prevented extensive participation. Many schools were already operating at full capacity and could not increase enrollments; others had not chosen to participate in the loan program and therefore had no Federally- sponsored students. D. Prolessional nurse traineeship proyram The Professional Nurse Traineeship Program has increased by 20,000 the number of professional nurses qualified for positions as teachers, administrators and supervisors since it was initieted in 1956. Another 36,000 nurses, in or com- mitted to key positions, have received traineeships for short-term intensive courses since these began in 1960. This program is crucial to the preparation of enough teachers to expand all types of nurse training and enough nu~rses to direct and give expert care as well as supervise the many people providing nursing care in all settings. During the four years that this program has been one of the provisions of the Nurse Training Act of 1964, the awards totaled $47 million. Over 8,000 nurses received long-term traineeships and almost 18,000 received short-term trainee- ships, including some for study in the clinical nursing specialties made possible under the extended authority. Quality and effectiveness of nursing education and nursing services depend directly on leadership available. The program is making significant contribution toward meeting the urgent need of teachers to train more students; for super- visors and administrators to improve and maintain patient care and to improve the utilization of nursing personnel; and for clinical specialists to give and to demonstrate expert direct patient care. E. Nursing student loan program The Nursing Student Loan Program assists students enrolled in diploma, associate degree, baccalaureate and graduate programs of nurse education. The program began in 1965 with 426 programs of nursing education participating. In PAGENO="0036" 28 1968, 687 programs are participating, an increase of 61 percent in four years. In the same period the number of stwlents enrolled in participating schools rose from 67,037 In 1965 to 104,796 in 1968. The number of loans made to students has grown from 3,645 In 1965 to an estimated 24,500 in 1968, about 23 percent of the enrollment in participating schools. The average loan in 1965 was $395; in 1968 the estimated average loan is $664. The numbers of partici- pating programs, enrollments, students assisted, amounts allocated and the average loan are shown in table IV. TABLE IV.-NURSING STUDENT LOAN PROGRAM Number of nursing programs participating in program: Graduate Baccalaureate Associate degree Diploma Total Enrollment of participating programs: - Graduate Baccalaureate Associate degree Diploma Total Number of students assisted: Graduate Baccalaureate Associate degree Diploma Total Percentage of students assisted: Graduate Baccalaureate Associate degree Diploma Total Average amount of student loan 23 31 37 106 141 149 8 29 56 289 391 414 426 592 656 1,210 1,195 2,383 2,796 23,203 30,080 32,415 38,726 1,112 3,145 4,092 6,625 41,512 54,589 54,620 56,649 67,037 89,009 - 93, 510 104,796 32 28 65 `102 1,707 4,930 6,426 19,805 38 375 1,060 `2,334 1,868 6,407 9,667 112,291 3,645 11,740 17,218 124,532 3 2 3 14 7 16 20 125 3 12 26 135 5 12 18 `22 5 13 18 `23 $395 $534 $567 `$664 I Estimated. 2 Graduate and baccalaureate. Despite the increase in numbers of nurses and the improvements in quality of service, the demand for professional nurses continues to be greater than the increasing supply. Educational costs are increasing in all types of nursing education programs beyond the ability of students to meet them from their own or from their family's resources. Phe availability of this financial assistance is making it possible for more individuals to enter and remain in nursing school. F. Nursing eduoatioaa~ opportunity grants The Nursing Educational Opportunity Grants were authorized by amendment in 1966 and were initiated in the summer of 1967. During the first full year of the program, Fiscal Year 1968, 248 programs of nursing have awarded these grants to an estimated 7,000 students who could not otherwise attend the school of nursing. The individual grants ranged from $200 to $800; the average grant was $535. The awards to date total $4.1 million. The fact that these grants had to be matched by at least equal amounts of aid from other sources presented hardships in* many cases. Experience has Fiscal year- 1965 1966 1967 1968 41 164 71 411 687 Amount of funds allocated, fiscal years 1965-68: Graduate Baccalaureate 2 $1,461, 114 Associate degree 31,023 Diploma 1, 597, 767 Total 3,089,904 $166,723 $306,448 $351,840 3,627,624 4,691,385 5,725,388 343,258 813,296 1,494,859 4,732,963 6,865, 560 8,817,798 8,870, 568 12,676,689 16, 389,885 PAGENO="0037" 29 shown that student aid must more closely approximate the costs of education to the student which range from minimal in public institutions to many hundreds of dollars for tuition and fees alone each year. Cost should not be the determining factor in the selection of a nursing program. G. Accreditation In the interests of quality of patient care and of the students undertaking study with Federal support, quality factors were included in the Nurse Train- ing Act of 1964. To be eligible for participation, nursing programs had to meet standards of accreditation a't the time of application or to show that these stand- ards would be met within periods of time specified for the various provisions of the Act. In the case of projects for the improvement of nurse training, the stand- ards would have to be met by the end of the project. Schools with reasonable assurance participating in the loan program had to meet accreditation standards after graduation of the first class receiving loans. The Nurse Training Act has been a major factor in stimulating and assisting schools to improve and meet accreditation standards. The progress in accredita- tion of all types of nursing programs since enactment of the Nurse Training Act is significant. In January 1965, soon after passage of the Nurse Training Act of 1964, 776, or 67 percent of the 1,158 nursing education programs were accredited or had reasonable assurance of accreditation and were thereby eligible to participate in the provisions of the Act. By January 1968, when the total number of nursing programs had increased by over 100, the number of eligible programs increased to 917, 72 percent of the total 1,269 programs. These eligible programs enrolled 83 percent of the total students in nursing education programs. The importance of quality programs to the students themselves were evidenced recently when the National Student Nurses' Association passed a resolution urg- ing that "n' * * NLN accreditation be a primary criterion in the allocation of Federal, State or local funds to schools of nursing." III. ACCOMPLISHMENTS UNDER ALLIED HEALTH PROFESSIONS PERSONNEL TRAINING ACT The Allied Health Professions Personnel Training Act of 1966 was implemented in Fiscal Year 1967. Therefore, there has been only one full year of experience with the programs under it. A. Constrnotion of teaching facilities. The Act authorizes grants for construction of allied health educational facili- ties; however, no construction grants have been made. No funds were appro- priateci for this program in 1967. $2,000,000 is available in Fiscal Year 1968, and applications for construction grants are now being received. B. Allied health improvement grants In Fiscal Year 1967, a total of $3,285,000 was available for basic improvement formula grants for the purpose of improving the quality of curricula for the eligible allied health professions. This amount provided 41% of the total statutory entitlement amount for eligible institutions. Basic improvement grants were awarded to 192 junior colleges, colleges and universities. The following curricula have been designated eligible for support under the program: Baccctlanreate or Higher Degree Medical Technologist Optometric Technologist Dental Hygienist Radiologic Technologist Medical Records Librarian Dietitian Occupational Therapist Physical Therapist PAGENO="0038" 30 Associate Degree or Equivalent Degree X-ray Technician Medical Records Technician Inhalation Therapy Technician Dental Laboratory Technician Dental Hygienist Dental Assistant Ophthalmic Assistant Occupational Therapy Technician Food Service Assistant Medical Technologist1 Optometric Technologist In Fiscal Year 1968, $9,750,000 was awarded to 230 schools for basic improve- ment grants. Allied health professions special improvement grants are made available on a project basis from funds remaining after fulfilling the basic improvement en- titlements. No funds have as yet been available for funding special improvem;e'nt grants. C. Advanced trainees hips In Fiscal Year 1967, with the $250,000 available for that year, sixty-four advanced `traineeships were awarded for support of students being prepared to serve as teachers, administrators, supervisors, and specialists' in the eligible allied health professions. In Fiscal Year 1968, $1,500,000 is available for this pro- gram, and 257 traineeships have been awarded this year. D. Development of new methods Six grants for development of new methods were funded with the $200,000 made available in Fiscal Year 1967. These projects are designed to' develop, demonstrate or evaluate curriculums for the training of new `types of health technologists In Fiscal Year 1968, $1,000,000 is available for this program. iv. ACCOMPLISHMENTS TINDER PUBLIC HEALTH TRAINING PROGRAM (PUBLIC HEALTH SERVICE ACT, SECTIONS 306 AND 309) A. Traineeships for professional public health personnel Section 306 of the Public Health Service Act authorizes grants fo'r tr'aineeships for support of graduate or specialized training in public health for physicians, engineers, nurses, and other professional health personnel. Federal support for traineeships for professional public health personnel was first authorized by the Congress in 1956. Currently more than 1300 academic traineeships are supported annually. Since the program was initiated, it has been expanded to provide short-term training to upgrade professional an'd special skills for 12,000 annual trainees, 60 residencies in preventive medicine and dentistry an'd 500 medical and dental public health apprenticeships each year. By the end of Fiscal Year 1968, more than 10,000 individuals will have received lo'ng-term academic training, 42,000 short-term training, 150 residency awards, and 1500 apprenticeships awards. The 1967 and 1968 funding level for the public health traiineeship program has been $8,000,000 each year. B. Project grants for strengthening public health trainSug Section 309 of the Public Health Service Act authorizes project grants to schools of public health and to other public or nonprofit institutions providing graduate or specialized training in public health for the purpose of strengthening or expanding such public health tra'ining. This project grant program, established by the Congress in 1960, was designed to provide special institutional support to schools of public health, nursing, and engineering to initiate, strengthen, and expand specialized public health curriculum offerings at the graduate level. In 1964 `the program was broadened to include other institu'tions offering such training. Since the program was initiated in Fiscal Year 1961, 218 project grant awards have been made. Curriculum areas supported have included preventive medicine, medical care economics and administration, health ad- ministration, environmental public health, public health nursing and preventive dentistry. The benefits derived from support of public health curricula through 1 Regulations are currently being mod~lfied to change "Medical Technologist" to "Medical Laboratory Technician" at the associate degree level, in accordance with SectIon 12(e) of the "Partnership for Health Amendments of 1967" (P.L. 90-174). PAGENO="0039" 31 these grants include incorporation of newly developed curriculum offerings into the regular offerings of the schools, addition of new faculty positions not previously included in the schools' offerings, and revision and reorientations of curriculums in recognition of the school's role as a community resource to further community health needs. In 1967, $5,000,000 was appropriated for the public health project grant pro- gram authorized under Section 309 of the Act. In 1968, $4,500,000 is available for this program. V. ACCOMPLISHMENTS UNDEII THE HEALTH BESEARCH FACILrnE5 PR0GnAM5 The Health Research Facilities Construction Program (Title VIIA of the Public Health Act) has been in continuous operation for 11 years. During that period $452,000,000 has been awarded to 406 institutions in every state in the Union as well as the District of Columbia and Puerto Rico. The funds have been used to construct or remodel over 18 million net square feet of space for the conduct of research and research training in the sciences related to health. The awards have been distributed to the following types of institutions: Amount Percentage Medical schools $250,729,392 55.4 Dental schools 9,328,760 2.1 Schools of public health 9, 749, 889 2. 2 Schools of osteopathy 5,469 0 Schools of nursing 500,000 0.1 Schools of pharmacy 4,976,408 1. 1 Other schools 87, 522,930 19. 4 Private nonprofit institutions 69, 945, 063 15. 4 Nonacademic public institutions 19, 469, 064 4. 3 Total 452,226,975 ~ Since the inception of the program in fiscal year 1957, 1944 applications re- questing $832,026,455 have been received (as of June 1, 1968). Of this total, applications requesting $268,277,550 have been disapproved. Grants awarded total $452,226,975. Grants recommended for approval, but not awarded (due to lack of funds) currently total $54,019,872. The National Advisory Council on Health Research Facilities is scheduled to review applications requesting $42,- 943,133 at its June 1968 meeting. Thus, by July 1, 1968 the total of apprźwed but unfunded appllcation.s probably will be about $80 million. The funds awarded were for 1151 construction projects, 913 of which have been completed and 240 of which are either under construction or pending initia- tion of construction. The present legislative authorization expires on June 30, 1969 and applications for grants under the program cannot he accepted after June 30, 1968 unless the authority is extended by Congress prior to that date. That continuation of the Health Research Facilities Program is essential is evident from, the application iressure still being experienced-notjces of intent to file currently total over $150 million. The Nation's heailth research community still needs substantial federal support for expansion and renovation of its inventory of health-related research facilities. Dr. LEE. The main purpose of the legislation before you today is to sustain the Federal commitment to health manpower development, to continue, expand and improve the Federal partnership role in assist- ing training and educational institutions across the country in meet- ing these critical needs to expand programs of student aid in order to improve educational opportunity for talented youth of limited means. The Health Manpower Act of 1968 (H.R. 15757) makes some sig- nificant improvements in the five legislative acts it amends. In the interest of time, I would like to call particular attention to some major changes made by the present bill and submit to you for the record a more detailed analysis of each amendment and justification. Mr. JARMAN. We will be glad to have that. (The document referred to follows:) PAGENO="0040" 32 Department of Health, Education, and Welfare Section-by- Section Analysis of H.R. 15757 TITLE I-HEALTH PROFESSIONS TRAINING PART A-CONSTRUCTION GRANTS Section 101.-The program of construction grants would be extended for 4 years (fiscal year 1970 through fiscal year 1973). "Such sums as may be necessary" would be authorized to be appro- priated for each of the 4 years. This program authorizes grants to assist in the construction, ex- pansion, or renovation of schools of medicine, dentistry, osteopathy, optometry, podiatry, pharmacy, veterinary medicine, and public health. Section 102.-The Federal share authorized under present law-i.e., a maximum of 66% percent for new or major expansion, and up to 50 percent for other construction-would be amended to authorize the Secretary to increase the 50-percent maximum Federal share where he determines thut "unusual circumstances" make a larger percentage (in no case to exceed 662/3 percent) necessary in order to effectuate the purposes of the program. In many established schools producino~ health professionals there are weaknesses of program, faculty, or ~aci1ities which are directly related to financial weakness. These institutions, beset by increasing demands on inadequate and obsolete facilities, have great difficulty in providing the institutional share of matching funds for construc- tion projects and, therefore, have been unable to make use of Federal financial assistance toward rehabilitation of school plant. Financial weakness in health professions schools stems from infla- tionary pressures and inability to secure adequate private or public State and local support. In general, the schools not able to meet the matching requirement are institutions which are privately supported, schools without a tax base for operating and capital funds, or public schools in States with limited matching funds. These institutions are important in the pro- duction of health manpower and deserve support to prevent decline in both quality and capacity of training. Section 103.-This permits facilities constructed for teaching pur- poses (and federally assisted by reason thereof) to be used for teaching purposes, or research purposes, or medical library purposes for which construction grants may be made-thus the provision for Federal re- covery within 10 years of completion fOr failure to use the facilities for the teaching purposes for which they were constructed would not apply. Section 104.-The present program has been limited to the construc- tion of teaching facilities in the respective health professions schools. A school planning to construct a `facility to include a medical library PAGENO="0041" 33 and/or a health research facility has been required to make separate applications to the medical library construction program and the health research facilities construction program as well as to the health professions educational assistance construction program. Applications have been reviewed by three separate councils on three separate sets of criteria. The bill would authorize a school to make one application to and to receive funds under the health professions educational assistance con- struction program if the project is for the construction of facilities which are to a substantial extent for teaching purposes but are also for health research purposes or medical library purposes. Section 105.-Under the present program, work area in a medical, dental, or other health professions school can be constructed with pro- gram funds only if it is space attributable to the teaching program leading to the degree of doctor of medicine, doctor of dentistry, or other first health professional degree. This has proven to be a most un- desirable barrier to sound planning and construction of the school as an entity. The bill would allow the inclusion in the construction project of space for graduate, continuation, and other advanced training activi- ties as well as that attributable specifically to the training of persons in the first health professional degree curriculums. This would allow for sound, coordinated planning and construction of the total school. In the present educational system where advanced and undergrad- uate education arrangements for health professionals are largely in- terdependent, and the inability to support advanced training space has resulted in `considerable difficulties for all of our applicant insti- tutions, the institutions have been forced to pay for the entire cost of advanced training space, limit it, or eliminate it from its plan. PART B-INSTITUTIONAL AND. SPECIAL PROJECT GRANTS TO HEALTH PROFESSIONS PERSONNEL Section 111 (amends secs. 770-77~ of the PHS Act) .-Under present law, grants may be made to improve the quality of schools of medicine, dentistry, osteopathy, optometry, and podiatry. Improvement grants are of two kinds.: (a) basic grants made on the basis of a fommula of $25,000 per school and $500 per enrolled student, (b) special grants made on a project basis. There~ is a single appropriation authorization for both types of grants. Special improvement grants are awarded from the sums appropriated and not required for making the formula grants. This program became effective in fiscal year 1966. It has provided a source of continuing s~xpport for the teaching curriculums of the respec- tive schools. Appropriations were not sufficient to fund the basic im- provement grants under the statutory formula in fiscal years 1966 and 1967. Therefore, no special projects were funded in those years. The bill would authorize a 4-year extension (fiscal year 1970 through fiscal year 1973) of both the institutional (formula) (sec. 771) and special project (sec. 772) grant authorities with significant modifica- tions. The 4-year period represents the recommended time to assure these schools of the continued support necessary for sound curriculum devel- PAGENO="0042" 34 opment and stability. In addition, the assurance of 4 years of legisla- tive authority for support of curriculum improvements can do much to encourage these institutions to plan for significant modifications, to recruit and retain faculty necessary for implementation of these modifications, and to risk venture into some of the areas which could contribute most to curriculum improvement. Equally important for the schools which are in serious financial difficulties, the 4-year period of time for the continued, assured support under the formula grants, and the special assistance in meeting their operating costs through the special project grants can be a vital incen- tive to their marshaling of resources to upgrade their programs, or even to remain in existence. The bill would authorize appropriations of such sums as may be necessary for both the improvement grants and the institutional grants. The portion of the moneys appropriated for each fiscal year which would be available for special project improvement grants on the one hand, and formula institutional grants on the other, shall be deter- mined by the Secretary unless otherwise provided in the Appropriation Acts for that year. New section 771 (a) (1) .-The formula would be revised as follows: The base grant per institution would remain at $25,000. Of the sums remaining from the available appropriations: (a) 75 percei~t would be distributed on the basis of (i) the relatice enrollment of full-time students, (ii) the relative increase in enroll- ment of such students (over the average enrollment of the school for the 5 preceding school years) with the amount per student computed so that a school receives twice as much for each student in the increase as for other full-time students, and (b) 2.5 percent would be distributed on the basis of the relative number of graduates. Under present law, the formula for determining the amount of in- stitutional support takes into account only one variable: the number of students enrolled. A school receives $500 for each full-time student. The new formula takes into account two additional factors: (a) in- creases in number of students, and (b) the number of graduates. Under the bill, a school would receive twice as much for each stu- dent added to its enrollment in a given year over the average enroll- ment of the school for the 5 preceding years. Consequently, the schools w-ould be assisted to a greater extent by the new formula than the old. The increased funding for increased enrollment will encourage the schools to enlarge their enrollment while at the same time helping them with the cost of educating the additional students. The new formula would provide that 25 percent of the sums remain- ing from appropriations after the base grant ($25,000 per school) would be distributed on the basis of the relative number of graduates. This would provide a further incentive for the schools to increase and retain their enrollments, since at graduation the student would again be counted. This would also provide an incentive for schools to experiment with shortening the length of the training period without diminishing the quality of training, and to try to develop practical means for accepting students at advanced standing-for example, admitting a first-year student with advanced standing in courses for which he had demon- PAGENO="0043" 35 strated competency. This would assist schools in maintaining a full enrollment and help to counteract the attrition which inevitably occurs. New section 771 (a) (2) .-No school could receive less than it receives in fiscal year 1969 as a basic improvement formula grant. New section 771 (b) (2) .-However, without regard to any other provision relating to the new formula, no school could receive more in any year than it expended from non-Federal sources during the pre- vious year for teaching purposes (except that this proviso would not apply in the case of a school which has for such year a particular year- class which it did not have for the preceding year.) New section 771 (b) (1) .-As in the present law, the bill would re- quire, as a condition for receiving a formula grant, assurances from the school that the school would increase its enrollment by 21/2 percent or five students (whichever is greater) over the average first-year en- rollment of full-time students of the school over a 5-year period. How- ever, three changes have been made in this provision. (a) The 5-year average period would be changed from July 1, 1960, through July 1, 1965, to the period July L 1963, through June 30, 1968. Thus, the 5-year base period against which the expansion of enroll- ment is to be computed would be moved up to July 1, 1963, through June 30, 1968. The effect of this is to advance the fixed period of time against which the computation is made 3 years beyond that provided for in the present law. (b) The expansion would relate to the a?'erage first-year enrollment in lieu of the existing law's highest first-year enrollment. The number of additional students which a school can reasonably be expected to enroll is limited. Since the beginning of the im~ro'~ernent grant program in fiscal year 1966, most schools have already increased their number of first-year students by at least five. To make the in- crease cumulative, i.e., to require that the school take five more stu- dents in addition to the five which it had so recently taken, would constitLte an unreasonable burden: for example, a medical school which enrolled 100 first-year students each year during the period July 1, 1960 through July 1, 1965, made the effort and expanded to 105 students during fiscal year 1968. If the bill were to require the highest enrollment to be used as the base, the cumulative impact would mean a 10-percent increase in enrollment, i.e., an additional five first- year students with the responsibility on the school to assure that places are available for these students in each of their succeeding years- second, third, and fourth, as well as the first, or the equivalent of 20 school places. If the formula were structured so that the school re- ceived approximately the full cost of education for such students, such as required increase might be justifiable. However, it is not reasonable to place such a cumulative requirement of this nature on all schools. The requirement has therefore been changed so that the increases which schools have already made can be averaged over the new 5-year period. This will retain the stimulus for increase without undue, or even unjust, burdens on the schools. Effective in fiscal year 1970, the bill would authorize the Secretary to waive the required first-year enrollment if he determines, after consultation with the Advisory Council, that it cannot be accomplished without lowering the quality and training provided or that a waiver PAGENO="0044" 36 would otherwise be in the public interest and consistent with the purposes of this program. (Sec. 111(f) of the bill would also provide similar waiver authority under present law for fiscal years 1968 and 1969.) (c) Experience under the expansion of enrollment requirement of the present law has demonstrated that the purposes of the health professions educational assistance program cannot be fully achieved with a rigid and inflexible enforcement of this requirement. Under present law, the Secretary may waive the expansion of enrollment, in whole or in part, if he determines, after consultation with his Ad- visory Council, that si~ch an increase cannot be accomplished because of limitation of physical facilities available to the school without lowering the quality of training. * Under present law, a school must have had an approved application for a basic grant to be eligible for a special improvement grant. Therefore, sc~hools which are ineligible for basic improvement grants are also ineligible to receive assistance under the special project authority; thus no Federal assistance is available to them through the improvement grant mechanism. The expansion of enrollment requirement has presented a serious problem to schools which by merely maintaining or cutting back on enrollments could maintain or improve the quality of education pro- vided for students. The dilemma of the school is particularly great when the financial resources of the school are limited. The school has the choice of further reducing the quality of its educational program by taking in more students in an already weak curriculum or going without the funds and undertaking the curriculum improvement en- tirely at its own cost. The bill would authorize the Secretary effective in fiscal year 1968, to waive the expansion of enrollment requirement if he determines, after consultation with the Advisory Council, that the waiver is in the public interest and consistent. with the purposes of the law. This amendment would make it possible for the Secretary and the Advisory Council to weigh the many complex factors in the individual situations which the schools are confronting and to deter- mine whether it is in the public interest to grant such a waiver and the degree to which Federal assistance would or would not be warranted in terms of the objectives of the act. New $ectwn 772.-Under existing law, special project grants may be made to schools of medicine, dentistry, osteopathy, optometry and podiatry to improve their curricula, to contribute toward the main- tenance of or provide for accreditation, or to contribute toward the maintenance of or provide for specialized functions which the school serves. In order to receive a special improvemetit grant, a school must have had an approved application for a basic improvement grant. There is a statutory ceiling on the amount of grant to any school: $300,000 for fiscal year 1968 and $400,000 for fiscal year 1969. In addition to the schools presently eligible to receive special improvement grants, schools of pharmacy and veterinary medicine would be eligible for special project grants under the bill. A school would not be required to have an approved application for an institutional (formula) grant in order to be eligible for a special project grant. PAGENO="0045" 37 Effective for fiscal year 1969, the present authority for special im~. provement grants would be amended to authorize support of plannin of special projects for which grants could be made under the amende law which would go into effect in fiscal year 1970. The purposes of the special project grants would be- (1) To plan, develop or establish new programs or modifica- tions of existing programs of education in the respective health professions. (2) To effect significant improvements in curricula of health professions schools. (3) To conduct research in the various fields related to educa- tion in the respective health professions. (4) To develop training for new levels or types of health professions personnel. (5) To assist any school which is in serious financial straits to meet the costs of operation or to meet accreditation requirements. (6) To plan experimental teaching facilities or experimental design thereof. (7) Or otherwise strengthen, improve, or expand programs to train the personnel in the respective health professions or help to increase the supply of adequately trained personnel in such professions. These are designed to stimulate schools to undertake and carry out projects such as increasing enrollment, improving the quality of educa- tional programs, modernizing and improving the overall approach to health professions education, carrying out educational research, and training new kinds of intermediate health personnel to extend the resources and skills of highly trained professionals. Further stimulus is given to the development of meaningful projects by the inclusion in the bill of authority, effective in fiscal year 1969, for special improvement grants for planning projects under the new special project authority which becomes effective in fiscal year 1970. New section 773(e) .-In determining the priority of projects under the amended authority, the Secretary would be required to give con- sideration to the following: (a) The extent to which the project will increase enrollment. (b) The relat.ive need of the applicant for financial assistance to maintain or provide accreditation or to avoid curtailing enroll- ment or reduction in quality of training. (c) The extent to which the project would result in curriculum improvement, improved methods of training or help to reduce the period of required training without adversely affecting the quality thereof. Projects of the magnitude and of the nature envisioned for these grants require careful and time-consuming study. The availability of funds to help meet the costs of preparatory analyses of the needs of the schools and their correction should result in major improvements of the schools. Section 111(b) (3) .-This amendment makes a conforming change in the title of the Advisory Council. Section 111(b) (4) .-This amendment excludes nonrecurring ex- penditures from the average non-Federal expenditure of the applicant PAGENO="0046" 38 during the last 3 years when determining how much non-Federal nionev the applicant must spend to get a grant. Section 111(c) .-This amendment would authorize additions to the Advisory Council of members from the fields of pharmaceutical and veterinary medical education; and change the name of the Advisory Council to the National Advisory Council on Health Professions Educational Assistance. The role of the Council is to advise the Secre- tary on regulations and policy with respect to institutional, special project and scholarship grants. The Secretary may not award an insti- tutional grant nor can he grant a waiver of the expansion of enrollment requirement, nor make a special project grant, until he has consulted with the Council. It is important that the Secretary should be author- ized to have the advice of persons who have expert knowledge in the fields of pharmaceutical and veterinary medical education, if schools of veterinary medicine and pharmacy are to be eligible for these grants. Section 111(d) .-Provides effective date for the amendments made by section 111. Section 111(e) .-For fiscal year 1969, special improvement grants will be authorized to support planning for special projects for which grants are authorized by the bill beginning in fiscal year 1970. Section 111(f) .-~-For fiscal years 1968 and 1969, the Secretary may waive the condition of eligibility for formula institutional grants that enrollment must increase if he determines it is in the public interest and consistent with the purposes of the program to waive it. PART ~J-HEALTII PROFESSIONS STUDENT Am Section 1~1.-Under present law, grants may be made to schools of medicine, dentistry, osteopathy, pharmacy, podiatry, or optometry for two types of student aid programs: loans and scholarships. SchooTh of veterinary medicine have also been eligible to receive grants for loans, but not for scholarships. These two programs have provided vital resources for support of students in the respective health professions. The bill would extend the authorization for appropriations of Federal capital contributions to student loan funds for 4 years (fiscal years 1970-73) and extend the authorization for making loans (to such funds) from the revolving fund for 5 years (fiscal years 1969-73). Existing authorization for the Federal capital contribution to student loan funds expires on June 30, 1969, and the authorization which enables the schools to borrow capital from the revolving fund expires on June 30, 1968. The proposed extensions of 4 and 5 years, respectively, for the two methods of capitalization of student loan funds would provide for coterminous expiration of authority on June 30, 1973. Authority would be extended for three additional years for appropriations for Federal capital contributions to enable students who received a loan for any academic year ending before July 1, 1973, to complete their education. Section fldl (a) (3) .-TJnder present law, repayment of a loan must be accomplished within a 10-year period which begins 3 years after PAGENO="0047" 39 a student ceases to pursue a full-time course of study. However, if he is serving as a member of the uniformed services or as a Peace Corps volunteer during the period of repayment, he is entitled to an additional year of postponement for repayments for each full year of such service (but not to exceed 3 years). The bill would include service as a VISTA volunteer as a basis for such postponement. Up to 5 years of advanced professional training (including residencies) would also be a basis for such postponement. This amendment provides (1) an inducement for health professional personnel to serve in the Volunteers in Service to America program similar to the existing provision under section 741 (c) of the act which provides for postponement of repayment for borrowers serving in the Peace Corps, and (2) for lengthy advanced professional training required in fields of specialization which might otherwise be deferred because of financial.burden. Section 121 (a) (4) (A) .-The bill would authorize a school to charge a `borrower for failure to pay all or any part of an installment when it is due or, if the borrower is entitled to postpone his repayments, or to cancel his repayment, for his failure to file timely evidence of such entitlement ($1 first month; $2 each month thereafter). The proposed amendment would permit participating schools to place greater emphasis on terms and conditions of repayment. Section 121 (c) .-This would postpone for 4 years through Septem- ber 30, 1976, the date of the capital distribution of the balance of any student loan fund. Section 121(d) (1).-This would extend for 5 years through fiscal year 1973 the authorization of loans to schools. Section 121 (d) (2) .-This would increase from $35 million to $45 million the total amount of loans which may be made to student loan funds from the revolving fund. Section 121 (e) (new sec. 746) .-The bill would authorize a school to transfer to its scholarship funds up to 20 percent (or a higher percentage with the approval of the Secretary) of the Federal funds paid to it for its loan fund. (There is a similar provision for transfer from its scholarship program into its loan fund.) This transfer au- thority will provide a most desirable flexibility to the school in tail- oring its financial assistance programs to meet the needs of its indi- vidual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 121 (/) .-This provides effective dates for the amendments made by this section. Section 122.-This would extend the health professions scholarship program for 4 years (fiscal year 1970 through fiscal year 1973). It would add veterinary medicine students to the eligible partici- pants. Veterinary medicine makes significant contributions to the field of human medicine, to medical research, and to the maintenance of an abundant and safe food supply. Section 122(d) (new sec. 781) .-The bill would authorize a school to transfer to its student loan program up to 20 percent of the amount paid to it for scholarships (or a higher percentage with the approval of the Secretary). (There is a similar provision for transfer from PAGENO="0048" 40 its scholarship program into its loan program.) This transfer authority will provide a most desirable flexibility to the school in tailoring its financial assistance programs to meet the needs of its individual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 122(c) (2) .-"Students from low-income families who, with- out such financial assistance could not pursue a course of study at the school for such year." Change to "students of exceptional financial need who need such assistance to pursue a course of study." This change makes the program comparable in this respect to the higher education scholarship program. Section 131.-The Secretary would be required, in consultation with the Advisory Council to prepare and submit to the President and Congress before July 1, 1972, a report on the administration of parts B, C, E, and F of title VII of the Public Health Service Act TITLE Il-NURSE TRAINING PART A-CONSTRUCTION GRANTS Under the Nurse Training Act of 1964, Federal grants were au- thorized to assist in the construction, expansion or renovation of di- ploma, associate degree, and collegiate schools of nursing. Section 201.-The program would be extended for 4 years (fiscal year 1970 through fiscal year 1973). Such sums as may be necessary would be authorized to be appropri- ated for each of the 4 years. Section 202.-The period that a Federally assisted project would be required to be used as a school of nursing would be reduced from 20 to 10 years. (Failure to comply entitles the United States to recover present value of the Federal share.) Section 203.-The Federal share authorized under present law would remain the same. However, a new exception would be added: It would authorize the Secretary to increase the maximum 50 percent Federal share (for construction other than new facilities or major expansion) where he determines that "unusual circumstances" make a larger percentage (in no case to exceed 66% percent) necessary in order to effectuate the purposes of the program. Section 204.-Adds the Trust Territory of the Pacific Island's to the definition of a State. Section 205.-Under the present program space in a collegiate school of nursing can be constructed only if the space is attributable to the teaching program leading to a degree in nursing. * Extension of the program of construction grants was recommended by the Program Review Committee provided for under the nurse train- ing program. Approximately 49,000 new places for first-year students will be needed if schools are to prepare the numbers of nurses needed by 1975. Grants for construction of teaching facilities can help to increase the number of first-year places in three ways: 1. Construction funds to replace and renovate obsolete facilities in order to retain current enrollments. Many nursing education programs occupy makeshift buildings such as barracks, dormitor- ies, and basement areas; many are unsafe, poorly ventilated, noisy, PAGENO="0049" 41 and mt conducive to learning. These schools can scarcely main- tain their present enrollments much less con~dder increasing their student body. The contribution which these schools can make to- ward maintaining the nurse manpower supply warrants the same favorable Federal share as new schools or schools which can ex- pand enrollments substantially. 2. Construction funds for existing schools which can undertake major expansion of enrollments. Many well-established schools turn away qualified applicants due to lack of space. Given addi- tional facilities, these schools could expand einrollrnents without jeopardizing the quality of their teaching programs. 3. Construction funds for new schools in areas where there is a demonstrated potential for recruitment, faculty improvement and community interest but no physical facilities for a new nursing educational program. Schools which do not attract sufficient applicants to fill their spaces do not always provide a reservoir of unused capacity for use by a~pli- cants turned away at other schools which are filled to capacity. Ihis might be the case if undersubscribed and oversubscribed schools were located in the same areas, and were almost equally acceptable as regards accreditation, quality of faculty, adequacy of facilities, and similar criteria which guide applicants in choosing schools. Under the provision of the nurse training program new schools of nursing and those making a major expansion of enrollment are entitled to Federal participation not to exceed 66% percent of necessary cony struction costs. Schools replacing, renovating, or making minor expan- sion of capacity may receive up to 50 percent Federal participation. The bill would allow the inclusion in the construction project of space for advanced training activities that are not degree-oriented. This would allow for sound, coordinated planning and construction of The school as a whole, taking into consideration the several interrelated teaching mission that the school fulfills. PART B.-SPECIAL PROJECT AN!) INSTITUTIONAL GRANTS TO SCHOOLS OF NURSING Under the Nurse Training program, special project grants are made to diploma, associate degree and collegiate schools of nursing to assist them in meeting the costs of projects of limited duration to strengthen, improve, and expand their programs to train nurses. Section ~ (new 8ec. 805).-The program would be extended for 4 years (fiscal year 1970 through fiscal year 1975). The definition of institutions eligible to receive improvement grants would be broadened. Schools of nursing would continue to be eligible, `but broadened authority would also permit grants to be made to in- stitutions or agencies which do not have programs of nurse education but which could plan or develop such programs or could contribute to the strengthening and improvement of nursing education. In addition to the general purposes of the project improvement grant authority-i.e., to strengthen, improve, or expand programs of nurse training-the bill would specifically clarify these purposes and would also add new authority to develop, or establish new or modified, programs of nursing education. The specific clarification of purposes 95-540 0 - 68 - 4 PAGENO="0050" 42 gives special emphasis to the assistance of schools which are in serious financial straits to meet their costs of operation or to meet accreditation requirements. It also emphasizes assistance to projects for the modifi- cation of existing programs, an emphasis which is particularly vital at this time of transition in nursing education. Present section 805 (improvement grant) authority would also be amended, effective fiscal year~ 1969, to include support for planning special projects to be funded under new authority coming into the law in 1970. Content of nursing education must be improved, updated, and ex- panded to prepare students for present-day complexities of nursing practice and the variety of pa~tient care setting in which they will function. Curriculum improvement is a continuous process to use new teaching methods to incorporate new knowledge and nursing skills into the student's educational experience. Many schools are in such difficult financial straits that they cannot undertake the fundamental curricu- lum changes and improvements necessary for quality programs which will meet accreditation standards. Because of increasing specialization and complexity of present-day care, new ways must be found to train nursing students in shorter periods of time and to train a larger number of students with a short supply of qualified teachers. Improved utilization of qualified faculty members in all types of educational programs for nursing is one ap- proach which is effective for expanding the present teacher supply. These activities are costly since they require the use of expensive corn- inunications equipment for large numbers of students. However, these systems can conserve the time required for teaching students and make the most effective use of the short supply of well-qualified teachers. Recent developments in nursing education indicate the need for Federal funds to assist and insure development of the numbers and types of programs needed, and orderly transition from present pat- terns. These developments-the closing of hospital programs, the pro- liferation of associate degree programs, the enlargement and establish- ment of new baccalaureate and graduate programs, the increasing de- mand for clinical facilities for student experience, and the appropriate interlocking of education for nursing with that for other health pro- fessions-are strarnrng the resources of the institutions and agencies which have responsibility for providing services as well as learning experiences, and of the educational institutions faced with enlarging and adding new programs. New section 806.-Under the Nurse Training Act program, grants are authorized for payments to diploma schools of nursing to defray a portion of the cost of training federally sponsored students. Grants are made on a formula of $250 times the sum of the number of federally sponsored students and the number of students attributable to an in- crease in enrollment. No school could receive more than $100 times its full-time enrollment. An entirely new program of institutional (formula) grants to all three types of schools of nursing would be authorized under this bill. The bill would authorize a new 4-year program, beginning in fiscal year 1970 through fiscal year 1973. New section 806.-The statutory formula provides for: A basic grant to each school of $15,000 and of the remainder: PAGENO="0051" 43 (a) Seventy-five percent of the `basis of the relative enrollment of full-time students and the relative increase in enrollment of such students over the average enrollment of the 5 preceding years (with the amount per student computed so that a school would re- ceive twice as much for each student in the increase as for other students), and (b) Twenty-five percent on the `basis of the relative numbers of graduates. Institutional support grants would enable all schools to improve student-faculty ratios, attract more highly qualified faculty and strengthen and enrich basic curricula. It would also permit schools to apply new educational methods and innovations to professional nurs- ing education. Costs of the educational institutions have risen rapidly because of increasing costs of supplies, equipment, maintenance. Salaries of academic and nonacademic personnel have accelerated rapidly without commensurate increase of income. Income from tuition and fees has never approximated costs. There has always been a deficit met through other sources. As academic costs have risen, the percentage of the cost paid .by tuition has been less and the gap has widened. Income from endowments and gifts has be- come a very limited source of support; Federal funds `are also limited. For the public institutions, increase in State appropriations is the only significant source `of increased support. Privately supported in- stitutions must look to Federal financing to assist in closing the gap between income and costs. The private institutions particularly are reluctant to increase enrollment in existing programs. Graduate pro- grams (master's and doctoral level) incur higher deficits than those at the baccalaureate level. This is due to the need for highly specialized faculties, the need to support faculty research as well `as instructional costs, and the desirability of low student-faculty ratio in practicum. Basic support grants would make the vital difference in the decision to open or continue a nursing program. The low faculty student ratio makes a nursing major costly to the school; and there are other costs connected with the clinical practice courses. Broadening the `base of the formula grants `to include associate degree, baccalaureate degree and graduate programs, and application of a formula which guarantees a basic payment of no less than $15,000 to all schools would permit employment of at least one `additional faculty members and supporting services. B'asin~ the remainder of grant on enrollments and graduations would provide a total grant re- lated to size of the programs. These institutional grants would con- tribute directly to high-quality education. These funds could make the difference between an excellent instructional program and a medi- ocre one by making it possible to attract more highly qualified faculty and improve student-faculty ratios. Such grants could make it possible and feasible for the school to allocate a certain proportion of faculty time to research activities and to programs designed to foster faculty growth and development. Basic support grants could place the school in a position to better obtain essential teaching aids to enrich the in- structional program. New $ection 806(b) (1) .-The Secretary's regulations shall provide for determination of number of students enrolled in a school or num- ber of graduates. PAGENO="0052" 44 New section 806(b) (2) .-"Full-time students" means students pur- suing a full-time course of study in an accredited program in a school of nursing. Costs for educating nurses, particularly in collegiate and graduate programs, have increased as for all health professions. Schools cannot attract qualified faculties, provide comprehensive and supervised clini- cal practice, and increase enrollments, without financial assistance. It is essential that continuing basic support be provided for all health curricula to maintain the necessary level of quality. Our Consultant Group on Nursing recommended that Federal funds be made available to help schools meet the costs of nursing education. The Program Re- view Committee endorsed the principle of basic support grants Icr schools of nursing, but they took serious exceptions to supporting a single segment of nursing education. The Committee recommended that basic support grants be given to all types of accredited nursing programs: diploma, associate degree, baccalaureate and graduate degree. Section 212 (new sec. 807(a)) .-The Secretary may set the date by which applications for improvement or institutional gi'ants must be filed. New section 807 ( b) .-The Secretary must consult with the National Advisory Council on Nurse Training before acting on aiiy application. New section 807(c) .-An improvement or institutional grant may be made only: (1) to a public or nonprofit private school of nursing or (in the case of an improvement grant) public or nonprofit private agency, organization, or institution; (2) if recipient assures the Sec- retary that it will expend an amount of non-Federal funds which are at least as great as the average amount of funds expended by applicant in the 3 fiscal years preceding year for which the grant is sought; (3) if applicant provides information and gives assurance that Secre- tary requires; and (4) if applicant provides fiscal control and access to records as Secretary may require. Section 212 (new sec. 808) .-The bill would authorize appropria- tions of such sums as may be necessary for both the improvement grants and the institutional grants. The portion of the moneys appro- priated for each fiscal year which would be available for special project improvement grants on the one hand, and formula institutional grants on the other, shall be determined by the Secretary unless otherwi~e provided in the appropriation acts for that year. Section 213.-This makes a conforming change specifying the time that schools with reasonable assurance of accreditation applying for institutional grants under section 806 will become accredited. Section 214.-This provides the effective date for these amendments. Section 215.-With respect to fiscal year 1969, appropriations (un- der old sec. 805(a)) shall be available for planning special projects for which grants are authorized under the amended section beginning with fiscal year 1970. PART C-STUDENT AID Section 221.-The program of traineeships of professional nurses would be extended for 4 years (fiscal year 1970 through fiscal year 1973). Such sums as may be necessary would be authorized to be appropriated for each of the 4 years. PAGENO="0053" 45 With the incentives to expansions of enrollment and the encourage- ment of the planning and establishment of new programs of nursing education, it is particularly vital to extend the present authority for advanced traineeships for the preparation of teachers in the various fields of nurse training. These advanced traineeships are also a source of support for the training of nurses to serve in administrative or supervisory capacities and to serve in the various professional nursing specialties which have become increasingly important with the ad- vanced technology in medicine. Section 222(a) (1) .-This would amend the existing Public Health Service Act to make it conform with the new section 829 (transfer of funds to scholarship program). Section 222(a) (2).-This would extend the deadline for loan appli- cations to 1973. Section 222(b) (1) .-This would revise the maximum limit for loans per academic year from $1,000 to $1,500. Section 222(b) (2) .-This would authorize postponement of the 10-year period for repayment of nursing student loans by~ addin postponement during service (not to exceed 3 years) in the uniforme services, the Peace Corps or VISTA. It would further authorize post- ponement (up to 5 years) for advanced professional training. Section 222(b) (3) .-This would authorize up to 100 percent can- cellation of nursing student loans at the rate of 15 percent per year for service as a professional nurse in a public hospital in an area with a substantial population and a substantial shortage of nurses in public hospitals. (Retains 50 percent cancellation at 10 percent per year rate for fuiltime service in public or nonprofit institutions or agencies.) Section 222(c) .-This would allow a school to charge a borrower for failure to pay all or any part of an installment. When or if a borrower is entitled to postpone repayment or cancel part or all of the loan, lie may be similarly charged for failure to file timely evidence of entitlement. The charge may not exceed $1 for the first month, and $2 for each subsequent month. Section 222(d) (1) .-This would extend the authorization of appro- priations for payments to student loan funds. Section 222(d) (2).-This would make the existing Public Health Service Act conform to new section 829. Section 222(e) .-This would change the allotment formula for dis- tribution of funds for Federal Capital contributions to student loan * funds. The existing formula allocates the money among the States, 50 percent on the basis of the relative number of high school graduates, and 50 percent* on the relative number of students enrolled in schools of nursing. The new formula would allow for a more equitable dis- tribiition of funds among schools of nursing by providing for allotment of the funds among the schools on the basis of the relative school enrollment. Section 9322(g) .-This would extend the time that the Secretary can make loans from the rev~1ving fund for 5 fiscal years to fiscal year 1973. Section 222(h) .-This would add a new section (sec. 829) to the Public Health Service Act providing for "Transfers to Scholarship Program." This would authorize the transfer to the school's scholar- PAGENO="0054" 46 ship program of up to 20 percent (or higher on approval of Secretary) of Federal funds paid to a school for its student loan program. This transfer authority will provide a most desirable flexibility to the school in tailoring its financial assistance programs to meet the needs of its individual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 2~2(i) .-Provides effective dates for amendments made by the preceding provisions of section 222. Section ~23.-This provides two new sections, section 860 and sec- tion 861. Section 860 replaces the existing educational opportunity grants with a scholarship program patterned generally after the schol- arship provisions for the health professions. &ction 860(a) .-This would authorize the Secretary to make grants to public or nonprofit schools of nursing for scholarships. `5eetoii 860(b) .-This would authorize scholarship aid for students in all three types of nursing schools: diploma, associate degree, and collegiate. This program would begin in fiscal year 1970 and would go through fiscal year 1973. It would further provide that appropriated funds be allocated among the participating schools on the basis of $2,000 times one-tenth the number of full-time students. Many nursing students come from low-income families who cannot help finance their educations; they will enter a profession where sal- aries are very low, particularly compared with the high remuneration of physicians and dentists. Consequently, proportionately more nurs- ing students will require scholarship support. The increasing costs of education to students are discouraging tal- ented and interested young people from pursuing nursing careers. Availability of scholarship support would relieve financial pressure on students in school and give greater quality of opportunity to those who could not otherwise pursue a nursing career. One-fifth of all nursing students are from families which have less than $5,000 annual income. An additional fifth come from families in the $5,000 to $7,500 income bracket. All of the students in the first category and a substantial number in the second would require finan- cial assistance for their nursing education. Section 860(c) (1) .-To be eligible for a scholarship, a student must be enrolled as a full-time student in good standing and must be of exceptional financial need and must need the financial assistance to pursue the course of study. Section 860(c) (~) .-This would provide that students could not re- ceive more than $1,500 per academic year. rfhe present scarcity of financial aid, particularly nursing scholar- ships, forces students from low-income families to select, on the basis of its cost iriespective of the students' ability or career goals. The in- creasing costs of eduaction to students will discourage talented and iiiterestcd youth from pursuing nursing careers unless the amount of a scholarship approximates the cost of the nursing education program. Costs of nursing education vary widely among and within diflerent types of programs-diploma, associate degree and baccalaureate. They can range from minimal in State-supported schools to over $2,000 per year in private institutions. In many nursing programs, :tuitioli alone is over $1,000 per year. A maximum `scholarship of $1,500 will permit students more realistic planning of their educational programs. PAGENO="0055" 47 Section 860~ (d)-This would provide that regulations for nursing' student loans be prescribed by the Secretary after consultation with the National Advisory Council on Nurse Training. Section 860 (e)-This would provide that scholarship grants may be made in advance or at such intervals as the Secretary finds neces~ sary. Section 861-This would authorize up to 20 percent of the amount paid to the school for scholarships (or a higher percentage with the approval of the Secretary) to be transferred to its student loan pro- gram. This transfer authority will provide a most desirable flexibility to the school in tailoring its financial assistance programs to meet the needs of its individual students and will improve the effectiveness of the utilization of both the scholarship and loan funds. Section 231-It would del~te the authority of the Commissioner of Education directly to accredit programs of nurse education. This sec- tion would take effect on enactment of this act and would add State agencies to the body or bodies which the Commissioner of Education could approve for purposes of accrediting programs of nurse educa- tion. It would require the Commissioner of Education to publish a list of nationally recognized accrediting bodies and State agencies which he determines to be reliable authority as to the quality of training offered. It would authorize the reasonable assurance (of accreditation within a specified period) provision to apply, in the case of a construc- tion project, to an existing school. (Present law relates solely to new schools.) Section 232-This would direct the National Advisory Council on Nurse Training to submit a report to the President and Congress be- fore July 1, 1972, on the administration of the nurse training pro- gram and recommendations with respect thereto. TITLE Ill-ALLIED HEALTH PROFESSIONS AND PUBLIC HEALTH TRAINING ALLIED HEALTH Stimulated by the advances is medical knowledge, the population ex- plosion, lowered financial barriers to medical care, and an emerging social concept that medical care should be related to medical need, the demand for health manpower is approaching crisis proportions. Less generally recognized than the shortages of physicians and nurses has been the need for a. complex of some 85 allied health professions and occupations without. which modern medical practice and total health services cannot be delivered. The adequate numbers and quality of education of these professional and technical personnel are critical to maintenance of quality community and personal health services. All allied health occupations present manpower problems to the degree that. lack and/or inefficient utilization of such personnel pre- vent our reaching reasonable objectives for health programs. The allied health professions personnel training program was en- acted in November, 196f. It. authorizes grants for the construction of teaching facilities for allied health training centers, grants for train- eeships for advanced training of allied health professions personnel to become teachers, supervisors. administrators or specialists, grants (both formula and special project) to improve the curriculums for PAGENO="0056" 48 training allied health professions personnel, and project grants to de- velop, demonstrate, or evaluate curricula for the training of new types of health technologists. There has been 1 year of experience under the program. Section 301 (a) .-This section would extend the allied health pro- fessions program for 1 year (through fiscal year 1970), authorizing such sums as may be necessary. This would make it possible to gain additional experience before proposing a major extension, since there has been only 1 year of experience. Section 301(b) .-This would clarify the provisions for projects to develop, demonstrate, or evaluate curricula for the training of new types of health technologists. It would make the following clarifying amendments to those provisions. Section 301(b) (1) .-At the present time only training centers for the allied health professions are eligible to apply for project support under this section. The bill would extend the present authority to in- clude agencies, institutions, and organizations. Thus, institutions which do not qualify as training centers, but which have the competency to de- velop, demonstrate, or evaluate curricula, would be eligible to partici- pate. Section 301 (b) (2) .-This would make it clear that among the au- thorized purposes of the projects is the development, demonstration, or evaluation of curricula and methods of training health technolo- gists. This would prevent an unduly restrictive interpretation limited only to curricula. / Sect km 301 (b) (3) .-This would delete the phrase "new types" as it relates to health technologists. Thus, projects to develop, demon- strate, or evaluate curricula and methods may be directed toward known types of health technologists as well as new types. Section 301 (c) .-This would authorize a new section 797 of the Public Health Service Act. rihis section would authorize the use of up to one-half of 1 percent of the amounts appropriated under the allied health professions training program for any fiscal year beginning with fiscal year 1970 for evaluation of the program. PUBLIC HEALTH TRAINING Project grants for graduate training of schools of public health for professional public health personnel have made a significant contribu- tion to the expansion and improvement of public and community health training throughout the country and in increasing the numbers of trained public health specialists so badly needed in today's society. it has made possible special innovative programs in schools of public health to provide them with the capacity to become balanced centers of public health training and major public health consultative and investigative resources for the Federal, State, and local governments. Under the present law, the Secretary may make project grants to schools of public health, to other public or nonprofit institutions pro- viding graduate or specialized training in public health, for the pur- pose of strengthening or expanding such public health training. The present law further provides for traineeships for graduate or special- ized public health training for physicians, engineers, nurses, and other professional health personnel. PAGENO="0057" 49 Section 302.-This section would extend the above described pro- visions for 4 years (through fiscal year 1973). It would also raise the per diem limit for members of the expert advisory committee to $100 from the current limit of $50 to conform with the statutory authoriza- tion for compensation for members of other health manpower councils. This expert advisory committee, composed of persons representative of the principal health specialties in the field of public health admini~tra- tion and training, advises the Secretary on both the above programs. TITLE IV-HEALTH RESEARCH FACILITIES Under present law, project grants may be made for the construction of facilities for research, or research and related purposes, in the sciences related to health. Grants may be made to pubhc or nonprofit institutions determined by the Surgeon General to be competent to engage in the type of research for which the facility is to be con- structed. Section 401.-This would extend the program for 4 years through fiscal year 1973, authorizing "such sums as may be necessary." Section 402.-This would allow construction grants of up to 662/3 percent for a class or classes of projects determined by the Secretary to have special national or regional significance. Not more than 25 percent of the moneys appropriated could be made available for these projects. This modifies the existing provision of the law which provides that the Federal share in the construction of health research facilities may not exceed 50 percent. An appropriate analogy to this proposal was the special grant pro- gram to construct research centers investigating mental retardation causes and cures. Mental retardation is clearly a national problem, not restricted to a particular area of the Nation. Program needs pro- jected a limited number of research centers distributed throughout the Nation. Given pressing local health priorities, no single university or medical school could reasonably be expected to take on the task of establishing mental retardation research centers without increased Federal sharing in the cost. A richer sharing was provided by law (75 percent) and the centers were planned, funded, and are now under construction. The special construction authority has been allowed to elapse. The authority proposed in this section would remove the need for a series of individual, categorical authorities for such construction and allow the Department to respond to situations and problems as they afls~ Section 403.-This would raise the maximum per diem for members of the National Advisory Council on Health Research Facilities from $50 to $100 to conform with the statutory compensation for other Public Health Service advisory councils. As indicated earlier in this document, the bill would authorize a school to make an application to the health professions educational assistance construction program if the project is for the construction of facilities which are to a substantial extent for teaching purposes but also for health research purposes or medical library purposes. PAGENO="0058" 50 Dr. LEE. The Health Manpower Act of 1968 would extend all but one of the these laws for 4 years (fiscal year 1970 through fiscal year 1973). Since we have had only 1 year of experience under the Allied Health Professions Personnel Training Act, H.R.. .15757 would pro- vide for a 1-year extension of that act in order to gain more experi- ence and evaluate the needs for modification or revision. We believe that 4 years is the minimum period of assured continua- tion of this fundamental legislative authority if we are to ask schools to undertake maj or expansion of their teaching capacities or signifi- cant modifications of curricula. We therefore strongly urge that the extension of these laws be for the full 4-year period authorized in the bill. HEALTH PROFESSIONS TRAINIING Construction The first major amendment under title I of the bill relates to con- struction grants for health professions training. This amendment is aimed at simplifying and making more efficient the authorities related to the support of construction so that schools planning to construct facilities to serve a variety of functions will not be forced to deal with several authorities and several different review procedures and priorities. Under present law, a medical or dental school applies under the health professions educational assistance construction program for funds to construct teaching facilities. But if a school is planning to construct a medical library or a research facility, the school must make separate application under those respective programs. Each applica- tion must be separately reviewed and must meet separate sets of criteria. Moreover, under the present program, teaching space in a school can be constructed only if the space will be used for teaching pro- grams leading to degrees as doctor of medicine, doctor of dentistry, or other first health professional degree. The amendment we are propos- ing would allow the inclusion in the construction grant of space for graduate, continuation or other advanced training activities, as well as training directly related to the first professional degree. Our amendment would also authorize a school to make one applica- tion under the health professions educational assistance construction program if the project is for the construction of facilities which are used to a substantial extent for teaching purposes, but which will also be used for health research purposes or medical library purposes. In short, we hope to bring about a more efficient and better coordi- nated support of a teaching facility. This bill would authorize the Secretary of Health, Education, and Welfare to increase the Federal share of construction costs in "unusual circumstances." In addition to these proposed changes relating to construction grants, the bill includes several significant revisions with respect to grants to schools for support or improvement of their teaching programs. Iii~titutional and special~ project grants The law now provides for two classes of grants: Basic improvement grant and special improvement grants. The former are distributed PAGENO="0059" 51 among the eligible schools on the basis of a statutory formula which now provides $25,000 to each school plus $500 for each full-time student enrolled. To be eligible for such a grant, the school must have an increase in first-year student enrollment over the highest enrollment n any of the preceding 5 school years-except that the Secretary may waive this requirement if he finds that the facilities of the school are too limited to permit an enrollment expansion without deterioration of quality of training. Special project grants are awarded on the basis of individual proj- ect applications, but grants may be made only to schools which have been awarded a basic improvement grant, and there is a specific dollar limitation on the amount of any project grant. In addition, there is a combined appropriation authorization covering both basic and special improvement grants, with the specific condition that funds are to be available for project grants only after the requirements of the formula grants have been met. Several key amendments to these provisions are proposed in H.R. 15757. First, the appropriation authorization would be modified so that the availability of project grant funds would not be subordinated to the formula grant requirements. Second, the basis for distributing formula grants would be different. Each school would still receive a ~asic $25,000, but of the remaining funds appropriated for these grants, 75 percent would be distributed on the basis of full-time student enrollments and 25 percent on the basis of the number of graduates. In the distribution of funds for full- time student enrollment, the schools would receive twice the per capita amount for enrollment in excess of the average enrollment during the 5-year base period. In addition, effective with fiscal year 1968, the authority of the Secretary to waive the enrollment expansion requirement would be broadened to apply to cases in which such waiver would be in the public interest and would be consistent with the purposes of this program. Third, the special project grant provisions would be amended to broaden the purposes for which such grants can be made. New authority is proposed, for example, for projects to strengthen the progam planning competencies of the schools-including the planning, devel- opment, or establishment of new programs, as well as modifications of existing programs. Projects for planning experimental teaching facilities, including experimental designs, would also be authorized. Special emphasis would, of course, continue to be given to assisting schools in serious financial straits. Fourth, the proposed amendments would eliminate the dollar ceilings on individual project grants, as well as the provision limiting such grants to schools that are recipients of formula grants. Finally, the eligibility for special project grants would be expanded to include schools of pharmacy and schools of veterinary medicine. We believe these proposed amendments will provide a more flexible basis for institutional assistance and a more realistic approach to in- centives for enrollment expansion. We propose to increase from 12 to 14 the membership of the Na- tional Advisory Council-on medical, dental, optometric, and podi- PAGENO="0060" 52 atric education-and change its name to National Advisory Council on Health Professions Educational Assistance. Student aid There are a number of amendments in the bill which would adjust the health professions student loan program to provide greater incen- tives for participation in such programs as VISTA, and to encourage prompt repayment of loans as well as to increase to $45 million the total amount of loans which may be made from the revolving fund to student loan funds. We are also asking for greater flexibility in the administration of student assistance programs by the schools by permitting transfer of a percentage of the student capital contribution loan funds to the scholarship program and vice versa. NURSE TRAINING Title II of the bill would extend for 4 additional years the several authorizations contained in the Nurse Training Act-including grants for the construction of teaching facilities, institutional improvement grants, traineeships for advanced training of professional nurses, and the provision of loans and other forms of financial aid for nursing students. In addition, several significant program additions or modi- fications are proposed. Construction `First, the construction grant authorizations would be modified in several ways. The bill would authorize the Secretary of Health, Edu- cation, and Welfare to increase the Federal share of construction costs in "unusual circumstances." The period during which the facilities must be used for the purposes for which the grant was made would be reduced from 20 to 10 years. Because of the ongoing transition in nursing education and the factors of obsolescence and maintenance costs, many schools today are reluctant to undertake the longtime commitment of space required under the Nurse Training Act. Ten years would be consistent with construction grants for teaching facilities for the other health professions. The bill would allow the inclusion in the construction project of space for advanced training that is not degree oriented. The present definition of programs has prevented the awarding of construction grants for advanced training space. Institutional and special project grants Second, the present authority for partial reimbursement of diploma schools would be replaced with a broader authority for institutional- formula grants to all three categories of nursing schools-diploma schools, associate degree schools, and collegiate schools. The statutory program review committee on the Nurse Training Act recommended that this kind of support be provided to all types of nursing schools as it has been for educational programs of the other health professions. Costs of educating nurses have increased as for all health professions where the existence of a high faculty-student ratio is essential. All types of schools are finding it increasingly difficult to operate their expensive nursing programs and often impossible to ex- pand enrollments, attract more highly qualified faculty or to strength- PAGENO="0061" 53 en the educational programs so as to produce better prepared nurses. In many cases, particularly in hospital-based schools, the deficits are passed along to patients through higher fees for hospital care. Under this proposed formula grant, each school would receive $15,- 000, and the remaining funds appropriated would then be distributed in the same manner as proposed for the health professions schools- 75 percent on the basis of enrollment and 25 percent on the basis of the number of graduates. In the distribution of funds on the basis of the enrollment, the schools would receive twice the per capita amount for enrollment in excess of the average enrollment during the 5-year base period. Third, the present special project grant authorization would be some- what broadened with respect to the purposes for which grants may be made, and eligibility for these grants would be extended to cover in- stitutions in addition to nursing schools. Planning groups are now studying local needs and resources for nursing education, yet their progress toward developing formal and continuing education pro- grams to meet their requirements for nursing services is deterred by lack of support. The broadened authority would permit grants to be made to institu- tions or agencies which do not have programs of nurse education but which could plan or develop such programs or could make major con- tributions to the improvement of programs of nurse education, as well as permitting, in this period of transition in nursing education, grants to junior colleges and colleges which are planning and developing ar- rangements with diploma programs. It would also assist the hospital schools with ongoing planning and phasing processes so that this period of transition in nursing education would be orderly. Graduations from associate degree and baccalau- reate programs are increasing and will continue to increase as more and more students select academically based preparation. Graduations from diploma programs, which are the predominant producers of practicing professional nurses, must also increase to insure production of the number of nurses needed. Hospitals will continue to provide the setting where students learn and practice patient care. Student aid Fourth, the student aid provisions of the act would be strengthened in several important respects. The present limited authority for "op- portunity grants" for nursing education would be replaced with a broad program of scholarship grants patterned after the scholarship program for students in health professions schools, with a maximum scholarship of $1,500. Coupled with the loan program, the scholar- ships would allow institutions greater flexibility in meeting individual students' financial requirements and provide more realistic support to meet educational costs. In addition, the student loan provisions would be amended to in- crease the maximum loan to individual students from $1,000 to $1,500; to postpone loan repayments during periods of service with VISTA or the Peace Corps; and to liberalize the loan cancellation or "forgive- ness" provisions by increasing the annual cancellation rate for service as a professional nurse in publicly owned hospitals in substantially populated, nurse-shortage areas, and by eliminating the present 50- PAGENO="0062" 54 percent limit on the portion of the loan that may be canceled because of such service. Coupled with the loan program, the scholarships would allow insti- tutions greater flexibility in meeting individual students' financial requirements and provide more realistic support to meet their edu- cational costs. Finally, the accreditation provision would be amended to delete the authority of the Commissioner of Education to accredit the schools directly. It would also authorize the Commissioner to utilize the services of State agencies, as well as professional accrediting agencies, in evaluating the quality of training offered by nursing schools apply- ing for Federal assistance. ALLIED HEALTH AND PUBLIC HEALTH Allied health As mentioned earlier, under title III of the bill the allied health professions program would be extended for 1 year, with a few clari- fying amendments. We have been operating only a year under this authority, and we have not had sufficient experience to recommend either piecemeal amendments or major changes in the act. `We feel there should be a thorough review of the program, careful analysis of its strengths and weaknesses prior to any significant modification or extension. Public health The program of traineeships for graduate or specialized training in public health and the program of grants to institutions for strength- ening or expanding public health training would be extended for 4 yea.rs. HEALTH RESEARCH FACILITIES I want to turn now to title IV of H.R. 1~5757. The health research facilities construction program has played a major role in improving the quality and quantity of the Nation's health research over the past decade. Since first authorized in 1956, 406 medical schools, universities, graduate schools in the healing arts, and other nonprofit institutions have received $452 million in project funds. These dollars have remodeled or constructed hundreds of labora- tories and research facilities and provided equipment for difficult and increasingly complex research into the causes and cures of disease and the basic elements of life itself. There have been more than 1,100 project awards, involving every State plus the District of Columbia and Puerto Rico; 913 of these projects are completed. Construction has begun on an additional 185. And 53 more are preparing for construction. In many cases these construction grants have enabled new medical schools to incorporate research facilities into their basic design. In other cases, existing schools and other institutions have been able to expand greatly their research capacity and enhance their training programs by attracting and utilizing researchers and their findings. PAGENO="0063" 55 In all cases the facilities and equipment have contributed signifi- cantly to the astonishing expansion of our knowledge about disease and disability and what can be done about them. But this is a growing program. So long as the quest for new knowl- edge in the health sciences continues to challenge the country's best minds there will be a continuing need for expansion of research facilities. So long as technological progress offers new research opportunities and new avenues of exploration, we will need to modernize, expand, and remodel existing research facilities. We are recommending an amendment which would authorize a Federal share of up to 662/3 percent for the construction of facilities of special regional or national significance. Not more than 25 per- cent of the funds appropriated in any fiscal year could be used for this purpose. The health research facilities construction program expires June 30, 1969. We ask you to extend it for another 4 years-until June 30, 1973-so that the momentum gained over the past decade will not be lost. Mr. Chairman, I have given you only a brief description of the most significant provisions in this legislation. Such a statement can hardly convey the urgent need for early enactment of this legislation and continuing support of these programs. Nor can I, in this limited time, fully describe the impact H.R. 15757 will have on the educational opportunities for thousands of Americans and the health of all our citizens. I and my associates will be happy to answer your questions and add whatever we can to the committee's understanding of this bill. Thank you. Mr. JARMAN. Thank you, Dr. Lee. I think it is an excellent presenta- tion-succinct, and containing exactly the kind of information that we need to have as we begin hearings on this tremendously important bill. The committee is well aware of the need for support of the gen- eral objectives of the bill, and is conscious of how much has been achieved in a short period of time in these programs. One thing I will ask at the beginning of the questioning is this. All of the authorizations in the bill are open ended. Are you in a position to give us cost estimates? Dr. LEE. Yes, sir, and I will submit that for the record at this time, if you wish, Mr. Chairman. Mr. JARMAN. All right. PAGENO="0064" 56 (The information referred to follows:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ESTIMATED NEW OBLIGATIONAL AUTHORITY REQUIRED FOR FISCAL YEARS 1970-73 UNDER "HEALTH MANPOWER ACT OF 1968" fin millions of dollarsf New obligational authority Fiscal year- 1970 1971 1972 1973 A. Health professions educafional assistance: 1. Construction grants 2. lnstutltional support 3. Scholarships 4. Student loans 170.0 225.0 225. 0 225. 0 100.0 150.0 190. 0 220. 0 16.0 16.8 17.4 18. 0 35.0 35.0 35.0 35. 0 B. Nursing: 1. Construction grants 2. lnstitutional support 3. Traineeships 4. Scholarships 5. Student loans 25.0 35. 0 40.0 50. 0 30.0 45.0 70. 0 100. 0 15.0 19.0 23. 0 28. 0 20.0 30. 0 33. 0 34. 0 20.0 21. 0 22. 0 23. 0 C. Allied health: 1. Construction grants 2. Institutional support 3.Traineeships 4. New methods grants D. Public health: 1. Project grants 2. Traineeships E. Health research facilities-construction grants 10. 0 20.0 5.0 4. 5 8. 5 12.0 14. 0 15. 0 10.0 14.0 17.0 20. 0 35.0 50. 0 50.0 50. 0 The projections contained in this table represent departmental predictions and do not represent the administration position on the future program or budget requirements. Personnel requirements will be dependent on program develop- ments and budget factors which atthis time cannot be fully predicted. Mr. JARMAN. Mr. Rogers? Mr. ROGERS. Thank you, Mr. Chairman. I think your statement is comprehensive. There is a great deal in it. It is going to take the committee a long time to analyze it in great detail. Perhaps we will have to have you come back to explain some things. I am not sure. - How many new students would be provided by this bill? Dr. LEE. Well, the number of new students will, of course, be de- pendent eventually on the funding, both for construction and for the institutional support grants, formula and project grants. And it will also be dependent on the changes that occur in the health profession schools during the years ahead. There is a great deal of ferment at the present time in these insti- tions. There is much change in the wind, and significant reforms have been undertaken in a number of schools. One of the purposes of this kind of authority we are asking for is to permit and to encourage this kind of innovation and change. Such as experimentation with shortening of the curriculum, and develop- ment of new courses or new curricula which may decrease the costs. We know the costs of construction are rising, that salaries are in- creasing. And these things make it difficult to give any exact projec- tion of any number of new students, particularly the graduates that will result from this legislation. But the purposes, I think, are clear: to sustain the institutions and to provide them with the stability and support they need to meet the challenges ahead. There are significant incentives to help them, when they feel it is feasible to `expand enrollment. The number of graduates PAGENO="0065" 57 may be increased by two methods: by increasing enrollment, and in some cases, shortening the period of the educational process. Mr. ROGERS. What is the shortage of physicians presently, would you say? Dr. Lion. We estimate 50,000. It is, of course, difficult to be exact about these things. Mr. ROGERS. This is based on how many per how many of population? Dr. LEE. This is based on a variety of factors. There has been an improvement in the ratio of physicians to population since 1963, and I think that the present ratio has been 142 per hundred thousand. I am informed that is correct, 142 per hundred thousand. Needs change with the shifts in population, with the shifts in the disease patterns-the increased number of people with chronic disease, for example, who require more care-and as we eliminate certain diseases in youth and childhood, people live longer, and they require more care, more physicians' services and nursing services. Mr. ROGERS. Could you give us a projection of the next 5 years on the shortages? Dr. LEE. We can do that for the record, Mr. Rogers. Mr. ROGERS. Yes, I realize you may not have it. I think that would be helpful, and for dentists as well. (The information requested appears in statement below.) Mr. ROGERS. What is the shortage in nurses? Dr. LEE. About 145,000, Dr. Fenninger tells me, and there are ap- proximately 660,000 nurses in active practice. So with a shortage of 100,000 to 150,000, we have a serious problem. We are making a major effort, as you know, at the present time to bring back into active practice nurses who are licensed but who are married or for one reason or another have become inactive, and to pro- vide them with the refresher training and the educational opportuni- ties that they need to reenter practice. There is a large pool of nurses in this category, and a number of them in the last several years have in fact returned to practice. Mr. ROGERS. Could you give us a projection of your nurse shortage in the 5-year period, too? Dr. LEE. Yes, sir. (The information requested follows:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON PROJECTION OF PERSONNEL SHORTAGES IN THR HEALTH PROFESSIONS OVER THE NExT 5 YEARS Among the many factors involved in the projection of numbers of people needed in the health professions over the next 5 years are: (1) The rate at which the demand for services increases; (2) the rate of change in the age and geographical distribution of the population; (3) the rate at which medical knowledge and technology change; (4) the ways in which health services are organized and pro- fessional and technical skills are utilized; (5) the rate at which educational and training institutions can develop and acquire faculties and facilities to accom- modate an increased student body and provide the students with sound educa- tional and training experiences; (6) the recruitment of students to the health professions; (7) the length of the educational period; (8) the rate at which inactive practitioners return to work and can acquire knowledge and techniques which are current. These variables are all related to one another and must be considered in making projections. The provisions of Title 18 of the Social Security Act involving a segment of the population (the older age group) which requires considerably more personal health care than people who are between ages 15 and 65, have increased the de- 95-540 0 - 68 - 5 PAGENO="0066" 58 mand for health services not only in institutions but also in ambulatory facilities and in the home. Particular demands are placed not only on physicians and nurses, but also on other health professions who deal with the problems related to chronic diseases and on those who administer health care institutions and programs. The experience with Title 18 has been brief. Its full implications for health manpower are not yet clear but it is evident that all health professions and occupations have been affected by it as well as the institutions providing care. *Since Title 19 of the Social Security Act has not been fully implemented in all States, its implications for health manpower needs are even less well defined than those of Title 18. We do know from previous experience, however, that the in- cidence and prevalence of illness, particularly chronic illness, among the poor and the disadvantaged is higher than that of people whose income and education have been greater. There is clear evidence also that infants and young children who are provided for under Title 19 make greater use of health services than those in the middle years, and that there is undetected illness among the group provided for under Title 19. We can, therefore, estimate that there will be an in- creased demand for health services, with a concomitant increase in the need for health manpower, over the next 5 years although the extent of the need cannot be predicted with certainty since health services are used only if those who need them know how to avail themselves of the services. Medical knowledge and technology have undergone very rapid changes in the last two decades and we can predict that the rate of change will increase over the next five years. Most of the changes have required higher levels of skill and knowledge on the part of those who are providing the care. The advancement of knowledge and technology have also led to survival of people whose convalescence may be longer and who need care for a prolonged period during their recovery. While improvements in the prevention of certain illnesses, such as poliomyelitis, has decreased the need for medical care and decreased the demand for certain kinds of health services, the ability to treat other illnesses which previously could not be treated, the increase in the population and their need for care, and the in- creased ability to pay for care through Title 18 and Title 19 as well as through other public and private programs has more than offset the gains which have been made in the prevention of certain diseases. Organization for the delivery of health services and in utilization of the skills and knowledge of practitioners has undergone continual change in the last two decades but these changes have not been sufilciently rapid to meet the increased demand for health services nor has it kept pace with the rapid changes in medical knowledge. We can anticipate that changes in organization and utilization of health professionals will accelerate and will alter the needs, both qualitatively and quantitatively, for those in the health professions and occupations. The extent to which these changes will take place over the next five years involves so many dependent variables that precise prediction of shortages cannot be made but can only be approximated. Preparation of teachers in the basic sciences and the clinical disciplines of the health professions requires several years beyond the initial basic education. The capacity of existing institutions to prepare teachers is limited as is the num- ber of candidates who wish to undertake such preparation. Schools of the health professions cannot undertake substantial expansion of their enrollments without increasing their faculties if the quality of professional education is to be main- tained. In certain fields essential to the preparation of students in the health professions shortages of faculty now exist; in others there are barely enough teachers to maintain present enrollments. The lack of teachers therefore becomes a limiting factor in the increasing production of increased numbers of qualified health professionals and in the alleviation of shortages of personnel. A number of schools are experimenting with ways of shortening the time required for professional education. It should be recognized, however, that the body of knowledge in the health professions is vast, that time is required to develop mature judgment so essential to professional practice and that profes- sional education can only be undertaken by students who have completed their general education and the subjects requisite to an understanding of the medical sciences. Shortening of the educational period requires shortening of the entire period of education, not necessarily the shortening of professional education alone. It will take a number of years before changes in educational programs will have an appreciable effect on the production of health professionals. The planning and construction of facilities in existing schools and for new schools are lengthy processes because of their great complexity. Federal pro- grams for the support of the construction of facilities for education in the health PAGENO="0067" 59 professions have been effectively in existence for little more than three years. Appreciable effects and benefits derived from these programs will not be felt before 1973. Their major impact will occur in the mid and late 1970's and 1980's. These programs are, by their very nature, long term investments as are the programs of student aid and institutional support. Today there is essential universal agreement as to the existence of very large unmet needs for health workers. There is also agreement that the present educational capacity is inadequate to meet these needs and that production must be increased as rapidly as educational capability will permit. The shortages today are so great as to make it apparent that the greatest effort is needed even if we are to keep up with the growing demand. The statistics which are given here are to be considered not as exact measurements but as orders of magnitude. They are given in full realization that increasing demands, changing patterns of utilization, technological developments, population growth, and many other factors are constantly changing the picture, but the growing potential of medicine in this country can be expected to require a continually growing and better prepared health manpower force. The projections of shortages prior to the enactment of the HPEA Act have, as a result of the Act, and a variety of factors relating to demand, been altered in varying degrees in the respective professions. Current projections of shortages of physicians indicate a reduction in the shortage of 10,000 (from 52,000 in 1968 to 42,000 in 1973). On the other hand, the projected shortages of dentists is increasing over the same period, for, although the supply is estimated to increase by 6,000 between 1968 and 1973, the estimated demand for dental services will result in a need for 12,000 dentists in addition to the 6,000 who are estimated to be added be- tween 1968 and 1973. The supply of nurses is estimated to increase by 95,000 between 1968 and 1973. However, the demand for nursing services is likely to rise precipitously. It is estimated that by 1973, despite the increase in the numbers of nurses trained and returning to practice, there will be a shortage of 186,000 as compared with a shortage of 141,000 in 1968. The fields of nursing and dentistry demonstrate increasing shortages over this time period, as the growth of need will continue to outrun the growth in supply. The long lead-time in the educational process at the advanced levels of medicine, dentistry, nursing, and other health professions means that the effect. of health manpower programs in increasing the health manpower force must be judged over a relatively long time period. PROJECTION OF SHORTAGES IN THE HEALTH PROFESSIONS, 1968-73 Medical doctor and doctor of osteopathy tact or of dental science Registered' nurse 1968 1973 1968 1973 1968 1973 Need 353, 000 387, 000 109, 000 127, 000 800, 000 940, 000 Supply 311,000 345,000 100,000 106,000 659,000 754,000 Shortage 52, 000 42, 000 9, 000 21, 000 141, 000 186,000 Mr. ROGERS. The proposed legislation, then, has no required number of new students to be accepted by universities if they accept aid? Dr. LEE. The proposed legislation does include an expansion-of-en- rollment requirement, Mr. Rogers. It refers to the average enrollment in the preceding 5 years, and the schools will have to meet that requirement. Mr. ROGERS. I didn't see anything in your discussion requiring an increase, that if they do, they have an incentive to double the amount instead of the amount for one student. They get the amount for two students for every new one taken over a 5-year period? Dr. LEE. They have an increased incentive for the added enrollment. Mr. ROGERS. It is double the amount of what they would get for one student. PAGENO="0068" 60 Dr. LE]~. That is right. Mr. Rooi~s. Why is it you don't have a requirement that they should increase 5 percent or 10 percent of their student body? Dr. LEE. There is a requirement in the legislation at the present time. Mr. ROGERS. It is very modest. Dr. LEE. We have not eliminated that requirement. Mr. Rogers, we gave serious consideration to the effect of increased expansion of enrollment requirements. It is a complicated matter. As you know, most medical and dental schools have been full to overflowing for many years. Our experience has shown that, at base, the single most important factor in increasing enrollments, is construction of addi- tional space. Next is the availability of operating moneys. Every time a medical school adds one first-year place, it assumes the responsi- bility for providing that place in each of the succeeding years until the student graduates. It must provide the faculty, the space, and the clinical experiences. In the proposed legislation, we have tried to give a greater incentive to increase enrollment. And one of the pur- poses of removing the ceilings on the project grants is that when construction expands the capacity of a school and makes it possible to expand enrollment rapidly, project grants could be used for purposes related to teaching the enlarged student body. Mr. ROGERS. Just looking at some figures furnished by the American Medical Association, it said in 1937 medical schools graduated over 5,400; and in 1947, 6,400; in 1957, 6,800; and in 1967, 7,700; that total expenditures on medical schools, 1940~-41, $32 million; 1965-66, $882 million. And yet we only have an increase of about, at the most, 1,500 to 2,000 graduates. The money expenditure has gone up from $32 to $882 million. Dr. LEE. I think there are several factors involved. I think if we look back at the total expenditures on health and medical care in 1941 and compare that with the total figures this year, and we can provide that for the record, we will see not comparable increases, but very great increases in dollar costs- Mr. ROGERS. I am talking about medical schools. Dr. LEE. I realize that, but I am trying to relate the two. There have been very great increases in costs. There have been sig- nificant increases in salaries for teachers. In 1941 many of the teachers in our medical schools were not salaried. They were volunteers. They were not full-time, and there was little research in our schools at that time. We have dramatically altered the research base in our schools. I think we have markedly improved the quality of instruction. We have markedly improved the knowledge base of professional educa- tion. And all these things do increase the cost of medical education and the education in the other health professions. Mr. ROGERS. Look at this-medical school graduates, 1958-59, 6,860; from 1965-66, 7,574. The percentage of increase is 10.4 percent. Full-time faculty, 1958-59, 10,350; and 1965-66, 17,149-a percent- age increase of 65.7 percent. There is a percentage increase in expendi- tures of 176.5 percent in a comparison of those same years. PAGENO="0069" 61 There, it seems to me, with 10,350 instructors and 6~860 graduates, in 1958-59, we find that in 1965-66, 17,149 instructors are only putting out 7,574 graduates. Dr. LEE. I think we have to realize that the teachers in the medical schools are teaching not only medical students; they are teaching interns, residents- * Mr. ROGERS. Didn't they always do this? Dr. LEE. There has been a marked increase in specialization. We have more specialties. We have more probing research in areas so that it takes more teachers because of the more specialized nature of medi- cine. And I think this is true in graduate education generally, whether it is medicine, engineering or other areas. You will find significant increases in faculty. You will find a longer period of not only medical education but the internship, residency period in a variety of areas. The other doctoral and graduate students who are being trained in the university medical centers and the participation of the medical school faculty in these activities- Mr. ROGERS. But this is seven instructors for seven graduates increased. Dr. LEE. If you said their only activity was related to teaching undergraduate medical students, but they are involved in a number of other activities. Mr. ROGERS. This was so all the time, wasn't it? We haven't had that much of a dramatic change from 1958 or 1959. That is only 10 years ago. Dr. LEE. There is a change- Mr. ROGERS. These are full-time instructors in medical schools? Dr. LEE. We are just beginning to provide an adequate faculty base in our schools so that we can provide the kind of quality instruction necessary. We still have major shortages within areas in the schools and needs that must still be met. Mr. ROGERS. It seems to me we are getting completely out of balance when we can't produce, with the shortages existing in this nature, with all the money we are now putting into medical schools, to the faculties, and we are not turning out any more graduates than we are. There is something wrong. I hope your department will begin to look into this, and I hope this committee will do it, Mr. Chairman, to see what has happened to this ratio. Why does it take seven more instructors? At least these figures would signal something needs to be done. Somebody is just not using their talents somewhere if you have got to have seven more instructors for every college graduate. No wonder we are having shortages. Dr. LEE. I think that obviously we are examining the needs of each of the schools. We are examining the needs necessary to begin to tool up to meet the manpower requirements for health services. Certainly, the schools, with fewer teachers, could turn out a much inferior product. Mr. ROGERS. I don't know that that has to be the conclusion drawn. I am not sure it takes seven new instructors for every graduate over and above what the base is to put out a competent doctor. I am not sure that that is necessary. Rather, I would think, we are not properly utilizing the talents we have in the instruction field. PAGENO="0070" 62 Dr. Lra~. If we look at the time of the faculty member, how he spends his time, we find that he does not spend his full time teaching the student. Mr. ROGERS. This may be our difficulty today. He is doing too much research, perhaps? Dr. LEE. Taking care of very sick patients. The university medical centers have increasingly become the referral centers for patients with special problems. I have visited many hos- pitals, and I don't think we will find many of the faculty under- employed. Mr. ROGERS. Perhaps we are not using them in the right way, then. These are supposed to be full-time instructors, according to the fig- ures given by AMA. Dr. LEE. They are full-time faculty members. But that doesn't mean they are spending full time just in teaching. They do research, they take care of patients- Mr. ROGERS. They have interns going with them. Dr. LEE. The highest cost programs are the fellowships, I think. In these advanced training programs you will have a lower ratio, almost a 1-to-i ratio in some cases, of a graduate student or fellow with an individual faculty member in a specialized area, such as cardi- ovascular research, heart surgery, and this sort of thing. Mr. ROGERS. Look at this: University of Kansas School of Medicine, graduates, 1957-107. In 1967 it had 103. They graduated less. The University of Pennsylvania School of Medicine, 126 in 1957 and 122 in 1967. This is a downward trend. Let me ask you this: How many less nurses graduated this year than last? Dr. LEE. Total number of nurses? Mr. ROGERS. Yes. It seems to me we are going down. We are puttlng money into building up faculty, but we are not getting results. I understand there are 2,000 less graduates this year in nurse train- ing programs than there were last year. Dr. LEE. We can provide those figures for the record. Dr. Fennmger and I don't have them right here. (The information requested follows:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE DATA ON ADMISSIONS AND GRADUATIONS FROM SCHOOLS OF NURSING, 1957-67 Graduation figures for this year (1967-68) are not yet available. The following table shows that graduations have increased over the last decade. In the last academic year for which figures are available (1966-67), there was an increase of 3,112 over the previous year. Graduation figures for 1967-68 are expected to be still higher. A drop in admissions in 1966-67 (2,000 below 1965-66) will be reflected in later graduations, but estimates from the 1967-68 fall admissionsJndicate they will be up again. PAGENO="0071" 63 ADMISSIONS TO SCHOOLS OFFERING INITIAL PROGRAMS IN PROFESSIONAL NURSING, BY TYPE OF PROGRAM, 1957-67 1 Total Type of program ad*mis- Baccalau- Associate Diploma 510fl5 reate degree AcademiC year: 1957-58 44,221 6,866 953 36, 402 1958-59 46,263 7,275 1,266 37,722 1959-60 49,166 7,555 1,598 40,013 1960-61 49,487 8,700 2,085 38,702 1961-62 49,805 9,044 2,504 38,257 1962-63 49,521 9,597 3,490 36, 434 1963-64 52,667 10,270 4,461 37,936 1964-65 57,604 11,835 6,160 39,609 1965-66 60,701 13,159 8,638 38,904 1966-67 58,700 14,070 11,347 33,283 1 Includes 49 States and Puerto Rico for all years, Virgin Islands beginning 1965-66, and Guam in 1966-67. Alaska has no registered-nurse program. Source: National League for Nursing, State-approved schools of nursing, RN. annual editions. GRADUATIONS FROM SCHOOLS OFFERING INITIAL PROGRAMS IN PROFESSIONAL NURSING, BY TYPE OF PROGRAM, 1957-67 1 Type of program Total Baccalau- Associate Diploma reate degree Academic year: 1957-58 30,410 3,671 425 26,314 1958-59 30,312 3,943 462 25,907 1959-60 30,113 4,136 789 25,188 1960-61 30,267 4,039 917 25,311 1961-62 31,186 4,300 1,159 25,727 1962-63 32,398 4,481 1,479 26,438 1963-64 35,259 5,059 1,962 28,238 1964-65 34,686 5,381 2, 510 26,795 1965-66 35, 125 5,498 3, 349 26,278 1966-67 38,237 6, 131 4,654 27, 452 1 Includes 49 States and Puerto Rico for all years, Virgin Islands beginning 1965-66, and Guam in 1966-67. Alaska has no registered-nurse program. Source: National League for Nursing, State-approved schools of nursing, R.N. annual editicns. Mr. ROGERS. To me, this signals great mismanagement in the medi- cal colleges, and we cannot continue to put vast sums of money build- ing up professional pay without results. Now, if we get results, that is different. But here we have increased 176 percent in the money, the full-time faculty has increased 7,000 over this same period of time, and the graduates have increased about 700. Dr. LEE. I think we have to look at the timing of Federal aid and the purposes of Federal funds flowing into the medical schools. Mr. ROGERS. It seems we are hurting it rather than helping it, ac- cording to the figures. Dr. LEE. For a number of years the faculty of the medical schools were serving a national purpose in research, and faculties were added for this purpose. And I think that we have seen brilliant results from this effort. We have seen, also, more knowledge and an increasing demand for services. Mr. ROGERS. We have ongoing programs with the National Insti- tutes of Health. That is not what I am talking about. I am talking PAGENO="0072" 64 about medical schools whose purpose is to turn out doctors and den- tists and nurses, manpower for health needs of this Nation. Dr. LEE. Their purpose is also to advance knowledge. Mr. ROGERS. I guess all education has to do that. Dr. LEE. They are a national resource, and have accepted major national responsibilities in this regard. Mr. ROGERS. Here is what I am trying to get at-what we need is manppwer to minister to people even with present knowledge. Now, the point I am trying to make is that if we can do something on manpower, and that is the thrust of what this legislation will bring about, to get the manpower out, to treat somebody who is sick, with- out doing so much research-all I want to do is get doctors and nurses out to treat people who are now sick, with present knowledge where they can be helped. If we are having fewer nurses turned out, a very small increase in doctors, something is wrong with the way we are running the pro- gram. We are putting too much into fancy buildings, too much into high-paid salaries where they are not really instructing. And I think we need to review this. I hope you will try to encourage your medical schools to look at the way they are using their teaching staff, because I want this committee to do this if the chairman and the other committees agree. These figures signal to me that a great deal needs to be done, but we will pursue this later. Dr. LEE. We have a common goal, without any question, Mr. Rogers. Mr. ROGERS. I am sure we do. Dr. LEE. On the nursing figures, the figures I have given, in 1965-66, the total graduates were 35,125; in 1966-67, 38,237. That is an increase of a little more than 3,000 in that year. We don't have the 1968 figures. Mr. Romis. I don't know. Is Miss Thomas here? Maybe you could straighten me out. Could we go off the record a minute. (Discussion off the record.) Mr. Rooi~a~s. If you could, verify this for us. Dr. LEE. We will, most certainly. (See p. 63.) Mr. ROGERS. I think we do need to look into this whole matter. You mentioned the Secretary could do certain things under "unusual circumstances." What do you mean by "unusual circumstances"? Dr. LEE. In a situation where a school, for example, might have to close because it simply does not have the resources available to build the facilities which are essential if they are to continue their programs. A school moving to a new location would be another example of an "unusual circumstance." Dr. Fenninger might have other examples. Dr. FENNINGER. There might be a school that is revamping its curric- ulum, where it would require a different kind of facility than the school had had in the past, and where the increase in enrollment at the time of this transition would seriously jeopardize the educational pro- gram, yet where new facilities would be needed to launch the next step. This might be an "unusual circumstance" also. In other instances, schools having obsolete facilities and desperately needing to modernize or replace these facilities if they are to maintain PAGENO="0073" 65 the quality necessary to attract and retain their students, are unable to raise the required 50 percent matching moneys from non-Federal sources. Mr. Roajirts. Let me ask you two or three more questions. The number of new students that would be required under present law is how many? Dr. LEE. Present law requires 21/2 percent of the highest first year enrollment in the school for the 5 school years July 1, 1960, through July 1, 1965, or five students, whichever is higher. Mr. ROGERS. What would it cost, could you estimate, to have a 30- percent increase in a beginning class, or, eventually, a graduate class, if we start now? Could you give me those figures? If you could, let us have those figures. Dr. LEE. For each of the professional schools? Mr. ROGERS. Yes, including nursing. (The information requested follows:) DEPARTMENT OF HEALTH, EDUCATION, AND WELE'ABE STATEMENT ON ESTIMATEs OF COST OF 30-PERCENT AND 50-PERCENT INCREASE IN THE NUMBER OF PLACE- MENTS IN SCHOOLS OF MEoXCTNE, OSTEOPATHY, AND DENTISTRY Enrollment increases of these orders of magnitude are possible under proper conditions of availability of facilities, operating resources, and student support. These will require both time and money. Because of the time required to prepare and acquire faculty, to construct facilities, and to develop teaching programs, the earliest realistic goal for the achievement of a 30% increase in first-year places (over school year 1968 base) will be FY 1975 (which is the school year beginning in the fall of 1974); and for a 50% increase, FY 1980 (the fall of 1979). The following tables are based on the assumption that non-Federal support for education will increase at rates proportional to Federal support, that serv- ices rendered by primary teaching hospitals and clinical facilities of the health professions schools will be reimbursed at full cost and that research carried out by the health professions schools will also be fully funded. If there is not a proportional increase in non-Federal funds, then the Federal share would have to be increased by that difference. The projections of Federal expenditures shown in the tables would be inadequate to meet the educational expenditures of the schools under that circumstance. ConstrRction Substantial increases in facilities will be required. The achievement of the proposed goal would require (in millions of 1968 dollars) Estimates of Federal share (30-percent in- crease in 1st-year en- roilments by fiscal year 1975 and a 50-percent increase by 1980) Estimates of Federal share submitted with proposed legislation 1970 1971 $170 225 $170 225 1972 225 225 1973 225 225 1974 250 1975 250 1976 250 1977 250 1978 250 This is the Federal share alone. The needed matching funds would be of the same order of magnitude. PAGENO="0074" 86 InstitnticmaZ and project grants The development of the necessary faculties and operating resources will also require both time and money. The following table is based on the same time scale as that for Construction. The Federal contribution would be represented by extension and expansion of the institutional and special project grants as follows (in millions of 1968 dollars) Estimates of Federal share (30 percent in- Estimates of Federal crease in 1st-year en- share submitted with rollments by fiscal year proposed legislation 1975 and a 50 percent increase by 1980) 1970 1971 $100 150 $100 150 1972 190 190 1973 220 220 1974 1975 250 275 - 1976 300 1977 325 1978 350 1979 400 1980 450 - $tndent aid The requirement for student support would also increase substantially, re- flecting increased numbers of students, cost to the student for his education, and the increase in students from lower income families. An expanded traineeship and fellowship program would be a part of the cost of meeting faculty expansion (In millions of 1968 dollars): Estimates of Federal share (30 percent in- Estimates of Federal crease in 1st-year en- share submitted with rollments by fiscal year proposed legislation 1975 and a 50 percent increase by 1980) 1970 1971 $51.0 51.8 $51.0 51.8 1972 52.4 52.4 1973 53.0 53.0 1974 70 1975 75 1976 80 1977 85 1978 90 1979 95 1980 100 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON ESTIMATEs OF Cosr OF 30 PERCENT AND 50 PEROENT INCREAsE IN THE NUMBER OF GRADUATES OF SCHOOLS OF NURsING Substantial expansion of nursing schools will require tremendous effort by the schools themselves, the communities, and State and Federal governments. En- rollment increases of 30% and 50% are feasible under proper conditions of adequate facilities, sufficient numbers of well prepared teachers, operating re- sources, an increased proportion of high school graduates who wish to undertake careers in nursing and support for students to enable them to complete their studies. Because of the time required to prepare teachers, to construct facilities, to develop teaching programs and to recruit students, the earliest realistic goal for a 30% increase in first-year nursing students is FY 1975 and for a 50% increase by FY 1980. The corresponding increases in graduates would come in FY 1977 and FY 1982 Although levels of funding influence the rate at which schools can increase their enrollments they are by no means the only factor. PAGENO="0075" 6'7 Nursing education and training, unlike medicine and dentistry, follows three paths : (1) the diploma program which is 3 years in length and is provided by hospitals ; (2) the associate degree program (requiring two years), which is based in junior and community colleges with the clinical experience being provided in hospitals affiliated with the community or junior college; and (3) the baccalaureate program in colleges and universities, which is usually 4 years in length-the clinical instruction being given in hospitals, owned or affiliated with the college or university. All three programs prepare students to become registered nurses. In addition to the programs described above, there are graduate programs in nursing. These are of the utmost importance in preparing the teachers, the administrators, and the clinical specialists who are so essential to any expansion of enrollment in nursing programs and to high quality patient care which is fundamental to nursing education. These graduate programs have a limited capacity and limited resources. They must be strengthened and expanded before enrollments of nursing students in- crease so that teachers may be available to fill the many vacancies in existing schools and to staff the faculties required for maintenance and expansion of exist- ing schools and the new schools which must be established if the number of nursing graduates is to be substantially increased. Nursing education is in a period of transition. An increasing number of young people who wish to become registered nurses are seeking their training in educa- tional institutions, that is, junior and community colleges and 4 year colleges and universities. These junior colleges and 4 year colleges are seeking affiliations with hospitals to provide sound clinical training for their students. Some hos- pitals which have heretofore had diploma programs are affiliating with educa- tional institutions, discontinuing their diploma programs and providing the resources for the clinical experience for students in associate degree or bacca- laureate programs. During this period of transition, expansion of enrollment may be quite difficult and can take place only after the transition is completed. Orderly development of nursing programs in educational institutions, and strengthening the hospitals as clinical components of nursing programs are es- sential if quality of nursing education is to be maintained and the number of nurse practitioners, teachers and administrators are to be maintained and in- creased in the future. All three programs, diploma, associate degree and bac- calaureate, must be maintained and strengthened in this transition. Planning and cooperative efforts among institutions, their faculties and staffs and the com- munity are essential. The recent developments in nursing education have indi- cated the need for Federal funds to assist and insure development of the num- bers and types of programs needed. These developments, the changes in hospital based programs, the proliferation of associate degree programs, the enlargement and establishment of baccalaureate and graduate programs, the concomitant in- creasing demand for clinical facilities for student experience and the appro- priate interlocking of education for nursing with that for other health disci- plines-~are straining the resources of the institutions and the `agencies that have responsibilities for serving patients as well as providing learning experiences, and of the educational institutions faced with enlarging their present programs and adding new ones. Institutions, communities, States and regional groups are looking to the Federal government to support and share in their efforts to assess needs and to pool resources. The following discussion of the resources required to increase the number of graduates in nursing by 30% and 50% is based on the assumption that non- Federal support for nursing education will increase at rates proportional to Fed- eral support and that non-Federal matching funds for construction of facilities can be acquired by `the institutions in sufficient amounts to provide the very large sums that will be necessary for increases of this magnitude. Coastructioi~ of additiona~ teachieg spaces A 30% increase over the 1966-67 graduates (38,000) from schools of nursing would require 11,500 more graduates or a total of 49,500 per year. If this number were achieved by FY `1977, the cost of constructing `the necessary additional teaching space would require an estimated $500 million (1968 dollars) Federal share and non-Federal matching funds of $300-$400 million. A 50% increase in graduates by 1982 would require an estimated additional $175 million as the Federal share between FY 1977 and FY 1979 with non-Federal matching funds of $120-$160 million. PAGENO="0076" 68 Institutional and project grants Expansion `of enrollment of existing schools and the creation of new schools requires the recruitment of many more students, the development and recruit- ment of faculties, and the provision of major operating resources to support fac- ulties and educational programs. In order to achieve a 30% increase in nursing graduates by FY 1977 approximately $870 million total Federal funds from FY 1970 through FY 1977 would be required for institutional and project grants. A 50% increase by FY 1982 would require Federal grants of approximately $600 iiiillion from FY 1978 through FY 1982. (All estimates are in terms of 1968 dollars.) student scholarships and loans If able young people are to be recruited into nursing from all portions of our society, many of them will need substantial financial aid in the form of scholar- ships and loans. Greatest emphasis will indubitably be on scholarships as most young women are not willing to take on a major indebtedness that will be a responsibility of her future husband. Tr~neeshi'ps Funds for traineeships are of the utmost importance to enable nurses to pre- pare themselves as teachers, clinical specialists who participate in teaching and patient care and administrators. The rate at which traineeships can be taken depends on several factors including: (1) the capacity of collegiate and gradu- ate schools of nursing to accept students; (2) the number of nurses prepared to undertake advanced education; (3) the rate at which nurses can leave the work force where patient care is given to return school as full-time students without ad- versely affecting health services; (4) the availability of funds for the support of nurses during their advanced training; (5) the availability of resources to the collegiate and university schools of nursing where advanced education is provided. Many more nurses must have advanced preparation if schools are to expand their graduations. This advanced educational experience must be provided before faculties can be increased to take increased numbers of students. When the various factors which affect advanced training have been weighed, our best estimate is that by FY 1974, $35 million will be needed annually for nurse traineeships. Mr. ROGERS. How much emphasis are you going to put on diploma schools in nursing? Dr. LEE. I think there is no question that they constitute the major source of graduates. We feel there is an increasing interest among the diploma schools and associate degree schools and the baccalaureate schools in working together to develop stronger programs. These closer interrelationships are emerging between the academic institu- tions and the hospital programs because of the desire on t1~ie part of the students to enter academically based programs, and the necessity for the strong and meaningful clinical hospital experience necessary for quality patient care. We will see a great deal more of this in the next 5 years. Mr. Roorms. I would like to see some specifics on what you are plan- ning on diploma schools, how many you expect to try to get going, what your projections would be, how you will tie in a junior college associate degree program with a diploma and, of course, the bacca- laureate degree. I would like to see some specifics. Dr. LEE. On both construction and the institutional support grants? Mr. ROGERS. Yes. Dr. LEE. Yes. (The information requested follows:) PAGENO="0077" 69 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON INSTITUTIONAL SUPPORT FOR ScHooLs OF NURSING Grants are needed for planning, development and establishment of new pro- grams of nurse training, including combinations of programs for sharing faculty and facilities, and coperative arrangements among institutions and agencies for the orderly transition from one type of nursing education program to another. New ways are being found to train nursing students in shorter periods of time and to train a larger number of students with the same short supply of qualified teachers. These would assist greatly in maintaining continuity in numbers of nurses produced and in improving the quality of nursing education in a period of transition. They would also make possible establishment of graduate programs to meet emerging urgent needs in specific areas. Existing programs are not ade- quate to accommodate either the initial or graduate preparation of the numbers that will be needed for quality nursing services. The planning of new schools and programs (considering the needs and resources for an area or region) and coordinating this preparation to assure balance in numbers and types of person- nel for practice, are as important as the actual establishment of the program and usually requires funds In excess of those locally available. specifics on dipZoma ,whools This bill will help maintain the supply of graduates from hospital schools. Today, hospital-based diploma programs produce 72% of nurse supply and it is essential that these graduations be maintained. Many of these schools are out- standing and should be continued, strengthened and expanded as a major re- source of nurse manpower. Graduations from associate degree and baccalaureate programs are increasing and will continue to increase as more and more students select academically based preparation. Graduations from diploma programs must also increase to insure production of the numbers of nurses needed. Project grants will help schools with planning and the phasing or "orderly transition" processes so that preparation of sufficient numbers of nurses is continued. Special project grants could assist hospitals in several ways depending on the individual situation: Where diploma schools are to be continued, grants can help strengthen and expand educational programs. (Programs will also be eligible for institu- tional formula grants.) Where hospital-based schools are becoming an integral part of an academic institution-a junior (two year) or senior (four year) college-grants will help to plan for the transition and to develop and establish the new program. The hospitals will continue to provide the students' clinical experience and will work with these institutions to develop the appropriate learning and practice setting for the new associate degree and baccalaureate programs. Therefore improving the hospital's facilities and the faculty will strengthen these new programs. Where diploma schools are to be discontinued, the hospitals could continue to provide the clinical practice setting for several programs of nursing educa- tion of all types, including the training of clinical nursing specialists. This bill provides assistance for those hospitals and hospital-based diploma schools which choose to plan with a junior college for an associate degree program of nursing education. Authorization of special project grants to the hospital (or the junior college, or senior college which wants to establish a relationship with the hospital) would provide for the necessary planning, development, and estab- lishment of the different curricula, faculty preparation, and clinical experiences required if students are to be preps~red in two years rather than three, and if education is to be based in an academic rather than a service institution. The transition of diploma schools into institutions of higher education requires the establishment of a different type of educational program. Arrangements must be made for the different curriculum and different faculty of associate and baccalaureate degree programs and for the phasing of classes from old to new. Concurrently arrangements must be made to maintain, develop, or even increase, the clinical facilities for the needs of the new program. Hospitals will continue to provide the setting where students learn and practice patient care as part of a different kind of educational program related to changes in medical knowledge and to the interests of students. Hospital train- PAGENO="0078" 70 ing is an essential component of all nursing education programs. The affiliating hospitals need support for improving and expanding the situations where nurs- ing students receive their clinical experience. As classes are phased from diploma to associate degree of baccalaureate programs, the institutions in which all aspects of nursing education take place will need assistance. There is nationwide recognition of and planning for the changes in nursing education ("States Plans for Transition in Nursing Education," American Journal of Nursing, 67:1215-16, June 1967). The majority of States already have definite plans for the ultimate transition of nursing education into institutions of higher education. Of the diploma schools of nursing that closed during 1967, more than half coincides with the opening of associate degree and baccalaureate programs.. This trend is reflected in the construction grants awarded and in the applica- tions pening. There were fewer new first year places constructed for diploma programs than other types. (713 diploma, 787 associate degree and 1812 baccalau- reate. See table under Accomplishments.) The essential construction has been for and must continue for replacement and renovation to maintain quality of existing diploma programs as well as to provide better clinical practice areas for utilization by other programs during and after the transition. Planning by hospitals and educational institutions is increasingly for teaching facilities to accommodate the essential clinical experience of programs based in educational institutions. This trend is expected to continue. There are 46 anticipated applica- tions from existing diploma schools and three for new diploma schools. Applica- tions from schools of all types total 130 for existing schools and 68 for new schools. Needs for other programs Present authority does not provide for establishment of new schools or pro- grams; funds can go only to established and eligible nursing education programs and only for projects for the improvement of nurse training. The broadened authority and broadened eligibility would permit establishment of new and modi- fied programs. The Program Review Committee for the Nurse Training Act recommended establishment of programs in colleges and universities as well as in medical and health science education centers without nursing programs. The latter must be encouraged to establish both initial and graduate programs where the educa- tional climate and clinical resources of such centers should be utilized for nursing education. Members of the health team function and work better together when they learn together. Many senior colleges and universities are unable, or are unwilling without additional support, to commit funds to the establishment of baccalaureate or higher degree programs which are very costly relative to other programs. If colleges and universities could be helped with the direct costs of nursing edu- cation, they might be encouraged to establish new or expand existing programs. Including "other institutions and agencies" among the authorized grantee insti- tutions will increase .the opportunities to use the competency in a variety of educational and clinical institutions in the improvement of quality of training programs. It will permit grants to go to institutions, and agencies providing a variety of clinical experience for nursing students as well as to educational insti- tutions which do not, at the present time, have nurse training programs but which could make a major contribution to the improvement of nursing education and which might become the situs for new nurse training programs.. States and regional organizations and associations could, if financially assisted, combine the educational and health care competencies and resources of the com- munity for planning for nurse manpower. They could also carry out demon- strations, and assist in the preparation ~nd dissemination of materials and information from the various projects beyond the individual schools or local situation. Such comprehensive projects could have great impact and could move the educational community, the profession, and the service institutions and agen- cies toward better nursing care of patients. Mr. ROGERS. Why do you think it is essential, if we are going to con- struct a building, to only require that that be used for this purpose for 10 years? Dr. LEE.. In the nursing area, it is our belief that with the problems that the schools are having, and with the information that we have PAGENO="0079" `71 frc~m them, a requirement of this type would make it more possible in the future-when an institution is undertaking such a program-for there to be modification or other uses for the facility in training other kinds of personnel, and that this is a more realistic time than a 20-year commitment on the part of the school. Mr. ROGERS. Suppose you build a medical school. Are you only go- ing to require it to exist 10 years ~ Dr. LEE. That is a requirement, but, of course, they do use the facil- ities for much longer. And in most cases we anticipate they will use the facilities much longer. Some of our nursing school facilities today are 50 years old, and older. Mr. ROGERS. You won't have the building changed by the time he graduates, because it takes 10 years. I think we need to look at the law again on that. I will yield, Mr. Chairman. Mr. JARMAN. Mr. Nelsen ~ Mr. NELSEN. Usually on the floor of the House, when this kind of bill reaches us, Representatives Cahill and Bolton ask questions con- cerning care for bedside nursing. Maybe a young lady would not have the resources to go ahead for a nursing degree, but her training could emphasize bedside nursing. Every time we report a bill concerned with nursing, this question comes up on the floor. Do you have any comment about the possibility of expansion in the area of bedside nursing ~ Dr. LEE. If I understand the question correctly, it relates to prac- tical nurses, and we do have a program in the Office of Education which is supporting the training of practical nurses. We can provide for the record the numbers of students trained each year in this pro- gram in the last 5 years. It is a very significant number. But I don't have the exact figures. (The information requested follows:) DEPARTMENT OF HEALTH, EDUcATION, AND WELFARE STATEMENT ON PRACTICAL NURSE TRAINING Advances in medical science and nursing practice coupled with the growing demand for health care have made it impossible for the registered nurse to pro- vide all of the nursing services patients require. The registered nurse is now assisted by licensed practical nurses, who receive one year of formal training, generally in public vocational school systems with clinical instruction in a hos- pital setting, and by nurses' aides who usually receive informal, one-the-job instruction. Registered nurses continue to give patients the nursing care which they alone are prepared to give. They have responsibility for assessing the patient's nurs- ing needs and making decisions regarding his nursing care. The registered nurse determines and assigns to licensed practical nurses aspects of care for which she is trained. Nurses' aides relieve the registered nurse and the licensed practical nurse from the more routine tasks which are important to the patient's personal comfort. Both licensed practical nurses and nursing aides are super- vised and taught by the registered nurse. The Nurse Training Act of 164 provides financial assistance for the educa- tion of registered nurses only. Federal aid for practical nurse education is pro- vided under the Manpower Development and Training Act and the Vocational Education Act. The following table shows the number of practical nurse educa- tion programs and graduations for the years 1954 to 1967. PAGENO="0080" 72 PRACTICAL NURSE1 TRAINING IN THE UNITED STATES,~ 1953-1967 Academic year Approved pro- grams (3) Reporting pro- grams Admissions Graduations 1953-54 1954-55 1955-56 1956-57 1957-58 1958-59 1959-60 1960-61 1961-62 1962-63 1963-64 1964-65 1965-66 1966-67 296 395 396 439 520 607 661 693 739 851 913 984 1,081 1,149 290 361 396 432 511 595 632 660 707 810 881 941 1,018 1,111 12,075 15,440 15,526 16,843 20,531 23,116 23,060 24,955 26,660 30,585 34,131 36,489 38,755 41,269 7,109 9,694 10,641 10,666 12,407 14,573 16,491 16,635 18,106 19,621 22,761 24,331 25,688 27,644 1 Includes attendant nursing 1954-1957, and vocational nursing 1956-1967. 2 Alaska, Hawaii and Puerto Rico were included for all years, American Samoa and Virgin Islands for 1962 and later. 3 Accredited by State agencies where licensure provisions were in force, and by the National Association for Practical Nursing Education where no licensure provisions existed. Sources: American Nurses' Association. Facts About Nursing: A Statistical Summary, New York, The Association Annual eds.: 1955-56, pp. 147-8: 1960, pp. 171 and 173: 1965, p. 185; and 1967, pp. 177 and 181. State-approved schools of nursing-LPN/LVN, 1968. New York, The League, 1968, p. 71. Mr. NELSEN. I think it would be very helpful if we had that infor- mation, because I am sure the question will come up again. One of the criticisms that I have noted is that the hospital school approach has not really been developed. It was our feeling that where you have a hospital, you have the bricks and mortar, and if we could stimulate a program at that level to a greater degree, there would be a greater production of nurses, which we badly need. Dr. LEE. One of the problems in the hospital schools-the recruit- ment of faculty, the difficulty of expanding enrollment, and assuming the responsibilities in terms of the increased operating costs, because we don't provide all of those costs. This has made it more difficult for these hospital-based schools to expand their enrollment and to achieve some of these objectives. Mr. NELSEN. It is possible the level of Federal assistance in this pro- gram is too low according to present costs? Dr. LEE. Yes, I think that is an accurate assumption. The other point that I should make is that under the present law we provide assistance to the diploma schools on the basis of the num- ber of their students who get Federal aid. In other words, it is only in relation to the federally aided students and not to all the students in the school, so there are limitations in the existing law on our support for those schools. That is why we are proposing a formula grant which includes a specific dollar amount per school-$15,000-and also relates to total enrollments. Mr. NELSEN. I see. I was interested in the observation made relative to costs and that a relatively great amount goes into research. Now, is it possible that the vast amount of research at NIH is not adequately communicated to the medical schools? As I recall, in a hearing we had a number of years ago we found a tremendous duplica- tion of research in the same areas. Is it possible perhaps some of the research manpower that is presently used here and there over the country, could be moved into more effective turning out of doctors which we so badly need. Is that possible? PAGENO="0081" 73 Dr. LEE. Well, you can take an example of a research area which is in the forefront now, and that is the area of cardiovascular surgery, the development of artificial hearts and heart transplants. You find a number of university `centers where these programs are ongoing. We will promote, we believe, the advance of knowledge, which then, of course, is disseminated to the students and to many practitioners and actually much of it to the public as well, more rapidly, more effec- tively, if we don't put ati of our eggs, you might say, into one basket. There are a variety of people working in basic research in genetics, for better understanding of a variety of diseases related to heredity. These programs are `supported in a number of institutions, and it would be hard, I think, to say that we should divert people from those activities. I wouldn't really describe this as overlap. I think these are com- plementary research activities. We have an extensive information exchange program, not only through scientific journals, but through our own program, and through the library of medicine, which is very helpful to investigators to know what other people are doing. And through their participation with the `scientists at NIH and through a variety of other activities in communication, I think that there is little-there may be some, I think it is unavoidable-when we are supporting a kind of broad base vital research program that we are now supporting. But I think it is more of a complementary nature. Mr. NELSEN. Congressman Rogers asked about nurses and doctors, and I want to know about the shortage of veterinarians. Being a farmer, I need to know that. Dr. LEE. We can give you some projections on this. I don't have those immediately available. There are a variety or roles that are played by the veterinarian in public health, and not only in terms of animal health, but also in terms of domestic public health and preven- tion of transmission of disease to human beings and the improvement of animal health to improve our food supply, as well as the world's food supply. And, of course, this is one of the most critical problems in the world today, and veterinarians are playing an increasingly im- portant role. So the shortage really would depend on how narrowly, or how broadly, you define their role. (The information requested follows:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON SHORTAGE OF VETERINAEIANS Veterinary science makes significant contributions to human health in the maintenance of a safe and abundant food supply, in the testing of biologicals and pharmaceuticals used in both human and animal medicine, in safeguarding humans against the diseases of animals which are transmissible to man, and in protecting American livestock and poultry against foreign animal disease. We are aware, however, of no evidence of a shortage of veterinarians com- parable in terms of a negative impact on human health to the shortages we are facing in those health professions which provide human patient care. Shortages of veterinarians in areas most directly affecting human health may be more directly related to distribution of veterinary practice than a total shortage in the profession. Of the 26,000 veterinarians in the United States, only a fraction are employed directly in regulatory or public health aspects of veterinary medicine. Some 95-540 O-68----6 PAGENO="0082" 74 5(X) are in veterinary public health and about 1,800 in regulatory activities. Combined, these are less than 10% of veterinarian manpower. Shortages of veterinarians in these activities exist, as evidenced by a 12% vacancy rate in State and local health agencies. These vacancies, however, are best explained by the fact that, while the average salary of veterinarians in State employ is $11,500, the net income in private practice varies from $16,000 (in solo large animal practice) to $39,000 (in group small animal practice). It seems apparent that more attractive salaries will be required to attract larger numbers to public service, rather than merely more graduates. Of veterinarians not in public health regulatory activities, most are in small animal practice, with minimal impact on public health. About 1,800 veterinarians are exclusively, and 4,800 partially in large animal practice. Their efforts may be regarded as primarily directed toward livestock production. While in the course of this they undoubtedly suppress animal diseases transmissible to man, determination of a shortage in this type of practice must be approached from the point of view of livestock management. The challenges of public health to veterinary medicine can best be met, we feel, through our project grant authority. With this we can direct our resources specifically to strengthening those segments of educational programs in schools of veterinary medicine which relate most directly to human health. Mr. NELSEN. I understand. Our problem is that so many of the veterinarians are taking care of the lady's dog, and we can't get them on the farm. Dr. LEE. We have the same problem with physicians. They are in the suburb taking care of that lady, and not where some of us think they should be. Mr. NELSEN. No more questions. Mr. JARMAN. Mr. Rogers? Mr. ROGERS. How much money is contemplated for the institutional grants? Dr. LEE. The projected institutional formula and special project grants would be $100 million in fiscal year 1970. Mr. ROGERS. $100 million? Dr. LEE. 150 million in 1971, up to 220 million in 1973. Under nurse training, 30 million in 1970, fiscal year 1970, 45 million in fiscal year 1971, 70 million in fiscal year 1972, and 100 million in fiscal year 1973. As to allied health, of course, we only have the projections for the fiscal year 1970, and those are 20 million. Mr. ROGERS. These institutional grants go to pay faculty? Is that basically what it does? Dr. LEE. Yes. There are other things that are re] ated to their teach- ing activities, such as the equipment that may be needed, teaching equipment, and the supplies that would be needed. But fundamentally, it is to support faculty and their related-- Mr. ROGERS. That is the project grants? Dr. LEE. Both the formula grant and the project grant would be for those purposes, and the project grant could be for a variety of other things. Mr. ROGERS. Are both included in these amounts? Dr. LEE. Yes. Mr. ROGERS. And, as I understand it, you can use this money either as a project grant or a formula grant in this new legislation. Dr. LEE. We would propose that; yes. Mr. ROGERS. Is there any break on that that you anticipate? Dr. LEE. Around 45 percent formula grants and 55 percent project grants in the first year of this bill, because of the more rapid change PAGENO="0083" 75 that can be supported with the project grants A large project grant can be used to support significant enrollment increase, significant change in curriculum, and other very important objectives, such as assisting or even salvaging a weak school in a very serious financial condition. A project grant of significant size could be used to sustain that school until it got back on its feet. Mr. ROGERS. The formula is what, 25,000 base and then so much per student? Dr. Lj~. Right. Mr. ROGERS. Project has no requirement as to- Dr. LEE. Project grants would be awarded on a competitive basis, and we would remove the ceiling, which is presently 400,000 for next year. Mr. ROGERS. What would be the ceiling? You would have no ceiling? Dr. LEE. There obviously is not going to be an infinite amount of money, but I could envision a project grant of $1 million, for example, to aid a school making a major expansion in enrollment, so that they would have to add faculty to achieve that objective. For a school in serious financial trouble large grants would be needed to tide it through a period of 2 or 3 years, and funds at that level, I think, could easily be required. Mr. ROGERS. Should there be a ceiling of $1 million? Dr. LEE. Well, I think that you could give this careful consideration. We could perhaps submit some other examples of estimated costs of projects so that you could better weigh that question. (The data referred to follows:) EXAMPLES OF NEED FOR AND ESTIMATED COSTS OF SPECIAL IMPROVEMENT GRANTS, AS VIEwED BY HEW The need for more physicians and other health professional personnel to meet the spiralling demand for health services is well recognized. The serious financial plight of medical schools is less well known. Traditionally these schools have not disclosed their weaknesses nor the financial problems responsibk~ for them. They have been concerned that in doing so there might be difficulty in recruiting top quality faculty, loss of prestige, and, in some cases, inability to compete successfully for Federal grants. The dire situation which confronts these schools is now reversing tradition and some schools are speaking out about their needs. Dr. Robert Berson, Executive Director of AAMO (Association of American Medical Colleges) made the following statements before the Subcommittee on Labor, HEW, of the House Appropriations Committee: "University after university is finding it necessary to sever all fiscal relation- ships with its medical school because of the financial drain on university funds and the damage that drain has done to other components of the university. There is grave concern that some medical schools will be forced to close for lack of funds. "Those schools in imminent danger of closing may find (basic and special improvement grants) to be lifesaving. A second group to which they might mean everything would be those in danger of losing their accreditation because of serious weaknesses in one or two departments." Dean Franklin Ebaugh, Jr., described the plight of the Boston University School of Medicine to the same subcommittee. He said flatly that the school will close unless more Federal funds' are soon made available. He predicted that the annual operating deficit will increase from the half million dollar level over the past three years to $1,700,000 by 1972-73. Dr. Ebaugh testified further that the Schools' incomes cannot keep pace with rising costs of operation. Marquette, Tufts, and St. Louis University Schools of Medicine were described as having needs as great as, and, in some instances, larger than, those which confront Boston University. PAGENO="0084" 76 Dr. Robert Felix, Dean of St. Louis University, said, "I cannot emphasize too strongly that the very life of my school and a number of others hangs in the balance. If assistance is not forthcoming soon, we will disappear from the scene. It is not a question of how many more students we can accept, but if we can accept any at all." A principal aim of institutional and project grants is to salvage these impor- tant National resources. This is predicated on the fact that it is less costly, par- ticularly with respect to time, to assist a school to continue its operation than to permit it to close and replace it with a new school at a cost of many millions of dollars, and a loss of as many as ten years of output of graduates. To say that it is "less costly" should not, however, be interpreted as being "inexpensive". Considerable sums will be needed annually for at least several years by these and other schools which have equally grave but unpublicized problems. Evidence was presented to the Congress that annual operating deficits ap- proaching $2 million will be experienced by some schools. It is not enough, how- ever, to aid a weak school in keeping its doors open. If such schools are to continue to operate, the quality of their educational programs will, in many cases, require improvement at added costs. Before public funds were committed in the amounts which would be required an exhaustive study would be made of the school. It is envisioned that a special site visit `team or task force would be estab- lished to seek information about the school's situation and its prospects. The group would probably include representatives of the appropriate review com- mittee (study section), officials responsible for administering the grant pro- gram, the appropriate school association (such as AAMC), and perhaps fiscal and management experts. It would also be helpful if members of the accrediting body would serve as members of, or consultants to, the group. Information would be sought concerning such matters as the following: 1. The immediate problems confronting the school, the factors responsible for the situation, and the probability of their continuation. 2. The size of the annual deficit over the past several years, and the reasons therefor. 3. The efforts that the school has made to obtain support from non-Federal sources; its plan for and probability of success of continuation of such efforts. 4. The school's proposals with respect to its continued operations, includ- ing its plans to increase the quality of its educational program to acceptable standards, and to improve its business and fiscal management, if indicated. 5. The immediate and longer-range probable cost to the Federal Govern- ment of underwriting the school's operation. The group's report and recommendation would be given thorough study by the review committee which, in turn, would make recommendations to the Council for its further consideration. The Surgeon General could not approve the application without favorable action and recommendation by the Council. One of the most important objectives of this bill is to provide a mechanism for preserving and strengthening health professions schools which are dying from financial starvation. The legislation must be sufficiently flexible to permit the Secretary to make judgments about the needs of the school and whether it would be in the public interest to underwrite its deficit. It is not possible at this time to foresee the magnitude of grants which will need to be made for this purpose, and it is for this reason that it is proposed to delete the statutory ceiling on project grants. Such ceilings could jeopardize or thwart achievement of goals which are necessary for amelioration of existing critical health manpower shortages. Mr. ROGERS. This would be in addition to an institutional grant? Dr. LEE. In addition to a formula grant. Mr. ROGERS. We could go out and build a medical school, then? Dr. LEE. You can't use this money for construction of new buildings. Mr. ROGERS. There are other moneys for construction? Dr. Li~i. Yes, but- Mr. ROGERS. You could go in and staff it. Dr. LEE. You could assist in staffing it if faculty could be recruited. Mr. ROGERS. Should we build medical schools? PAGENO="0085" 77 Dr. LEE. I believe we should. Mr. ROGERS. Are we doing it in effect now? Dr. LEE. We are. We are supporting the building of medical schools, and I see the Federal role as important in this. Take Florida as an example. The students who graduate often go to other States to practice, so it is, I think, difficult to be able to say to the taxpayers of Florida that they should support fully the training of medical students who are going to practice in California. The same thing is true in Illinois and practically every other State in the Union, so that I think this is one of the major reasons that the Federal role should be a significant one. Mr. ROGERS. Could you let us have a breakdown of the medical schools in this country and the amount of Federal participation in their construction and in their institutional support, or whatever moneys may come? I would like to get that for the record. Dr. LEE. Yes. (The information requested follows:) DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE STATEMENT ON DIVERSITY OF MEDICAL SCHOOLS, AND FEDERAL FINANCIAL PARTICIPATION IN CONSTRUCTION AND INSTITUTIONAL SUPPORT The question of the sources of support for operation and construction of the medical schools of the United States is of the utmost importance. It is one that is difficult to answer because of the great diversity among the medical schools, their organizational relationships and their missions. Some schools are divisions of universities. Others are independently chartered. Some are parts of State educational systems. Others are private. Some are in urban settings. Others are in smaller communities. There are two-year schools and four-year schools. In some instances, the major teaching hospitals are integral parts of the schools, owned and operated by the medical school or the university. In others, the major teaching hospitals are independent Institutions with their own boards of trustees and affiliated with the medical school through an agreement. Some medical schools have nursing education as a formal part or department of the medical school. In many medical schools, members of the medical faculty par- ticipate in the teaching of graduate students from other divisions of the univer- sity. Faculty may also participate in the teaching of pre-baccalaureate students of the parent university, in the teaching of students of the allied health profes- sions and technologies, students of nursing and students of dentistry as well as medical students and graduate students studying with the medical faculty. In all medical schools, members of the faculty are involved in teaching interns and residents and in `teaching post doctoral fellows. They are engaged in research and in rendering care to patients who may come from the local community or be referred from considerable distance to take advantage of the enormous re- sources, the high level of knowledge and specialized skills and the new tech- nologies which are available through the faculty of `the medical schools in the hospitals where clinical teaching is conducted. `The sources of funds are as diverse as the functions and activities which re- quire their expenditure. Medical schools receive funds from both public (Federal, State and local) and, private sources for services rendered to patients and to the community. They also receive them from individuals in the form of gifts and bequests as well as grants from private foundations or organizations. These gifts, bequests and grants may be for general purposes as determined by the schools themselves or they may be given for narrowly restricted purposes determined by the donor. They may be for the support of education, for the support of re- search, for student aid, or for the care of patients who cannot pay for their own care. Gifts and grants may also be provided for studies of community problems or for provision of services to the community. Federal, State and local public funds are also granted to medical schools and their teaching hospitals for educa- tion, for research and for direct health services or for participation in community or regional planning for health services. They are provided from. a variety of agencies and departments of Federal and State governments. The terms of the PAGENO="0086" 78 grants may be quite general or highly specific. The determination of allowable items of expense varies considerably from one agency to another, from one foun- dation to another and from one bequest to another. Where the medical school or the university owns and operates its teaching hospitals, the sources of funds and the `basis on which payment is made increase the diversity and complexity of funding, of accountability and of general man- agement. Members of the faculty and students are intimately engaged in the care of patients as an inevitable part of clinical medical education. Determining the costs associated with patient care and those associated with education are difficult at best. The difficulty is greatly enhanced by the multiplicity of methods of payment (payment by the patient himself, by private Insurance carriers which may provide reimbursement or indemnity plans, by local, State and Federal agen- cies under the many programs which pay for patient care, by voluntary health agencies or combinations of several or in some instances all of these). Yet the very complexity and scope of the purposes of the medical schools, the many functions of their faculties, their many kinds of students, the great de- mands being placed on them to serve society, and the diversity of the sources of funds to meet their expenditures makes it essential to devise sound means of al- locating costs incurred by the medical schools in carrying out their programs. For this reason, the Association of American Medical Colleges with its Council of Teaching Hospitals has undertaken with the support of the Department of Health, Education, and Welfare a study in depth of several medical schools which have different organizational patterns in different university or other settings and in which, in some cases, there are other schools of the health professions and nursing in the same university. The aims of the study include the development of clear and common `definitions of elements of cost, of sources of income, and of the financial status of the institutions. Educational and fiscal officers of the univer- sity, the medical schools and their teaching hospitals are participating in this study as well as schools of other health and allied health professions and nursing where they exist within the same university. It is hoped that this study will pro- vide a sound and reliable instrument for cost allocation and fiscal management of medical schools when it is completed, the results have been analyzed and the instrument has been tested in other settings. Accurate information on medical school financing is critically needed in the operation of the individual educational facility `and in the national effort to al- leviate our health manpower shortages. The Bureau of Health Manpower con- siders this problem to be one of its major objectives and will be able to expand its activities in this direction under the "Health Manpower Act of 1968." We can, however, speak to the amount of Federal participation in the con- struction of medical schools under the Health Professions Educational Assistance Act, and to the institutional support under the Health Professions Basic and Special Improvement Grant authority. The following table summarizes the obligations to medical schools since the implementation of these respective authorities, together with the student aid provisions of the Health Professions Educational Assistance Act. Fiscal 1965 1966 year- 1967 1968 Construction $54, 376,700' $42,705,626 $90,773,845 $79, 702,811 Institutional support: Basic 6,566,249 18 780 518 20,242,500 Special 10,131,500 Scholarships 3,875,200 7, 198, 176 Student loans 9,834,258 14,217,791 26,659,476 Total 54,376,700 59, 106, 133 127,647,354 143,934. 463 Mr. ROGERS. What moneys are contemplated for construction? Dr. Liii~. We will request for construction $170 million in 1970. Mr. ROGERS. $170 million? - Dr. Lr~. Yes, and $225 million in 1971, in 1972, and 1973. On that, Mr. Fenninger might say a word about the backlog of construction. If you would, Len, I think that could help to put these figures in perspective. PAGENO="0087" 79 Dr. FENNINGER. At the present time, the approved but not funded projects as of April 3 under the Health Professions Educational As- sistance Act was $106 million- Mr. ROGERS. This is a backlog? Dr. FENNINGER. Yes. Dr. LEE. Our appropriation requestthis year is $75 million for fiscal year 1969. Mr. ROGERS. Will that reduce the $100 million backlog by three- quarters? Dr. FENNINGER. No, sir, because there will be other applications coming in within the next 12 months, which also will be eligible for funding. Mr. ROGERS. Do we have any idea what they should amount to? Dr. FENNINGER. For 1969, the amount is currently anticipated at about $225 million, in addition to the $106 million backlog I mentioned. Mr. ROGERS. How many new schools are there in that? Dr. FENNINGER. I don't know that, but I could furnish it. Mr. ROGERS. Would you do that? Dr. LEE. Would you want that also under the nurse training? Mr. ROGERS. Yes, if we could, please. (The information requested follows:) HEALTH PROFESSIONS EDUCATIONAL ASSISTANCE CONSTRUCTION PROJECTS Approved but not funded as of Apr. 1, 1968: Medical Dental Pharmacy Podiatry Veterinary medicine Total - Pending Council as of Apr. 1,1968: - Medical Dental Pharmacy Total Anticipated for Council review in fiscal year 1969: Medical Osteopathy Dental Pharmacy Podiatry Veterinary medicine Public health 10 89 153 4 99 195 3 96 96 1 46 46 2 121 121 9 198 298 2 62 62 1 49 49 Federal share Numberof new schools Numberof 1st year places Numberof existing schools Numberof additional 1st year places Total additional places $65,410,759 2 64 31,591,609 2 96 2,508,973 1,436,006 5, 755, 245 106, 702, 592 4 160 20 451 611 102,135,399 2 100 16,178,952 2, 919, 302 253,300,000 8 5, 000, 000 1 84,763,000 4 14,000,000 1 2,000,000 7; 500, 000 6, 500, 000 Total 373,063,000 121 233 653 2 100 12 309 409 350 27 443 793 60 60 258 15 305 563 60 6 155 215 1 20 20 3 71 71 2 10 10 14 728 54 1,004 1,732 12 654 26 310 964 Letters of intent, fiscal year 1970-73: Medical 258,700,000 3 264 12 80 344 Osteopathy Optometry 2, 100, 000 3 20 20 Dental 51, 000, 000 8 390 3 90 480 Pharmacy 7,700,000 4 45 45 Podiatry 1,600, 000 1 Veterinary medicine 3, 100, 000 2 25 25 Public health 4,800,000 1 1 50 50 Total 329,000,000 PAGENO="0088" Number of Number of Number of Federal new 1st year existing share schools places schools Number of additional 1st year places Total additional places Approved but not funded as of June 1, 1968: Baccalaureate $9, 136,401 3 95 7 Associate degree 402, 092 1 80 Diploma 5,397,670 10 Total 14,936,163 4 175 17 Pending Council as of June 1, 1968: Baccalaureate 2,483,626 1 115 3 Associate degree 1, 369,517 2 175 2 Diploma 2,482,160 4 Total 6,335,303 3 290 9 Anticipated for Council review in fiscal year 1969:1 Baccalaureate 6 390 13 Associate Degree 12 720 20 Diploma 2 50 7 Total 20 1,160 40 Letters of intent, fiscal year 1970-73: 2 Baccalaureate 12 514 33 Associate degree 35 1, 328 18 Diploma 1 40 39 . 379 82 474 80 82 * 461 636 116 50 41 231 225 41 207 497 806 500 140 1,196 1,220 190 1,446 2,606 1,024 597 860 1,538 1, 925 900 Total 48 1, 882 90 2,481 4, 363 1 Federal share: Estimated $45 million for 60 projects. 2 Federal share: Estimated $101 million for 138 projects. Mr. ROGERS. Is it your intention to phase out allied health programs? Dr. LEE. No, sir. We believe the additional year of experience and a very careful review of the program in the next 6 to 9 months will help us to develop programs-perhaps the present program is ~just what we need. We are not at all sure about that. There are disciplines not now covered. There are a variety of complex problems coming to light that make it more difficult, and one of the reasons we did not pro- pose a long extension at this, time was because of these problems and because we believe it is necessary to give it a more thorough compre- hensive review before proposing anything but a 1-year extension. Mr. ROGERS. Have you given us a rundown of what has been done under the allied health program, how many institutions? Dr. LEE. Yes, sir. Mr. ROGERS. I notice health research facilities-a construction grant there. How would these be operated? Dr. Liz. Tom, do you want to say a word about that? Of these programs, it is one of the longest and most successful, and I would like Dr. Kennedy, who is director of that program, to speak to that question. Dr. KENNEDY. What kind of information can I give you about them, Mr. Rogers? Mr. ROGERS. Well, I want to know about your program. How does it operate? Do you build these resear'~h facilities at universities, or is it just nonprofit institutions? Or how do you decide? 80 NURSE TRA~NING~ACT CONSTRUCTION PROJ ECTS PAGENO="0089" 81 Dr. KENNEDY. We have built over the last 12 years through about 1,150 projects in some 406 institutions, a total of some 18 million net square feet of space. Mr. ROGERS. How much money over those 12 years? Dr. KENNEDY. $452 million in Federal funds. That has been matched by about $600 million of private funds. The ratio, by law, is 50-50. Actual funding is about 57 percent private and 43 percent Federal. The total projects, of course, include much more than the research facilities, and there is something like $2.5 billion worth of space that has emerged from this $452 million investment of health research f a- cilities funds. We are in the third year of a $280 million authorization. Dr. LEE. We should point out, I think, Tom, that we asked for only $8 million in fiscal 1969. Is that correct? Dr. KENNEDY. Yes. This program has been hard struck in the appro- priations process. About a third of the authorizations will have been requested in appropriations by the end of the year. Mr. ROGERS. In 1968? Dr. KENNEDY. In total for the 3 fiscal years, 1967, 1968, and 1969. Mr. ROGERS. I see. One-third of the $280 million would have been requested? Dr. KENNEDY. Yes. Dr. LEE. One other point: The priorities established by Secretary Gardner required a special priority be given to new medical schools or schools that were expanding, so that he tried, even though the re- search facilities program is to achieve a national research objective, to relate these as best as could possibly be done to the development of new medical schools. And this, I think, put a further crimp in the objectives- Dr. KENNEDY. We have a substantial backlog, Mr. Rogers, of $54 million- Mr. ROGERS. How many schools are involved in that? Dr. KENNEDY. Fifty-four approved projects at the moment. Mr. ROGERS. Would you let us have a list of those? Dr. KENNEDY. We will indeed., sir. We have something like $165 mil- lion worth of construction in our "intention to file" roster of informa- tion. (The information requested follows:) PAGENO="0090" 82 HEALTH RESEARCH FACILITIES APPROVED APPLICATIONS-NOT FUNDED (AS OF JUNE 21, 1968) Council Institution Description recommen- dation Alabama: Southern Research Institute, Construction of a building to house animals, chiefly dogs and $272,600 Birmingham. primates for research laboratories for pharmacological research. California: University of California, San Diego - Research space in a new building for the department of biology~_ 1, 292, 000 University of California, Los Angeles Research space in a molecular biology institute for development 1, 000, 000 of eftective multidisciplinary approaches to molecular biology. Colorado: Colorado State University, Construction of two separate buildings for the departments of 1,002, 000 School of Veterinary Medicine, Fort anatomy and pathology. Collins. Connecticut: Yale University School of Construction of a research building to house the departments of 2, 578, 000 Medicine, New Haven. surgery, obstetrics, and gynecology. District of Columbia: George Washington Research space in a new basic science building for the basic 2, 578,000 University School of Medicine, Wash- science departments. ington, D.C. Florida: University of Florida, Gaines- Construction of a new research building for the Department of 541, 000 ville. Psychology. Georgia: Medical College of Georgia, Research space In a new research and education building for 1,786, 180 Augusta. basic medical sciences. Illinois: Northwestern University Evanston_ A new facility for research In communicative disorders 1,828, 000 Presbyterian-St. Luke's Hospital, Completion of space in the southcenter building for portions of 601, 000 Chicago. the departments of biochemistry, pathology, and surgery. University of Chicago, Chicago A new basic biological sciences research building for the de- 3,621, 000 partments of biochemistry, biophysics, and microbiology. University of Chicago School of Remodeling of the central animal quarters of Billings Hospital 146, 000 Medicine, Chicago. for the department of pathology's research programs. University of Illinois College of Medical research laboratory addition to house animals and 1, 566, 000 Medicine, laboratory facilities. Indiana: Indiana University School of Space in a new addition to the Indiana University Hospital for 539,000 Medicine, Indianapolis. OB-Gyn research laboratories and clinical research center. Massachusetts: Boston University School of Dental Facilities for dental research 325,000 Medicine Boston. Harvard lVledlcal School, Boston, Remodeling research facilities for the physiology departmeflt - - 185~ 000 Do Remodeling research space fOr the laboratory of psychobiology - 130 000 Harvard University, Cambridge Research space in a new center for environmental and behavIoraL 660 000 biology. Massachusetts General Hospital, Remodeling the hospital research building 736,000 Boston. Massachusetts Institute of Technol- A new electrical engineering and communications research fa~ 1, 593 000 ogy, Cambridge. cility for conducting health-related research, Michigan: Michigan State University College of Research facilities in a new life sciences building of the new 1931 006 Medicine, East Lansing. medical school. University of Michigan, Ann Arbor.. Research facilities in the University of Michigan Center fOr 1, 811, 000 Human Growth and Development. Minnesota: Mayo Foundation-St Mary's Hospital Space in the Alfred addition to St Mary's Hospital for animal 183,000 Rochester facilities and small areas for nutrition, gastroenterology, cardiovascular, and surgical research. University of Minnesota, School of Construction of a laboratory in the veterinary school for re- 382,000 Medicine, St Paul. search in leukemia, toxicology, and mycotoxin. Missouri: Washington University, School Addition of a floor to the west building for animal facilities for 442, 500 of Medicine, research use by the departments of pathology and preventive medicine. New Hampshire: University of New Research space in a new animal sciences building 204,000 Hampshire, Durham. New York: Albany Medical College and Health Research space in a new toxicology center 726,000 Res. Inc., Albany (facility at Guilderland). Columbia University College of Research space in a new facility for the study of human reproduc- 3,937, 000 Physicians and Surgeons, New tion. York. Cornell University, Ithaca Remodeling of research facilities for biological sciences 66, 400 Cornell University, Ithaca A new animal facility for research In nutrition 321,000 Hillside Hospital, Glen Oaks Construction of a new facility for research in psychiatry 158, 000 Maimonides Hospital of Brooklyn A new medical research building on the grounds of Coney Island 765, 002 and the City of New York, Depart- Hospital. ment of Hospitals, Brooklyn. Yeshiva University, Albert Einstein Participation in space to house the computer centers and the 366, 384 College of Medicine, New York. division of blomathematics, both of which support health- related research. Duke University School of Medicine, A new research building for the departments of anatomy, med- 2, 843, 000 Durham. icine, pediatrics, psychiatry, and surgery. North Carolina: North Carolina Baptist Hospitals, Remodeling and new construction of research facilities for the 88, 000 lnc., Winston Salem. departments of radiology and surgery. North Carolina State University, Animal facility and laboratories for biological research 221, 000 Raleigh. PAGENO="0091" 83 HEALTH RESEARCH FACILITIES APPROVED APPLICATIONS-NOT FUNDED (AS OF JUNE 21, 1968) Expansion of the hospital research areas for medicine, pedi- atrics, and surgery, A new addition and some remodeling of the hospital for medical research, A new research facility for comparative medical research A new science building for the department of biology A new structure for a clinical radiation therapy research center. A new research facility for the department of pediatrics Construction of a central animal facility to serve the research needs of the University Park campus. Remodeling and new construction for an animal research facility Remodeling of space for the department of anatomy and mak- ing provisions for animal quarters also. An addition to existing medical facilities to expand research in medicine, clinical Pharmacology, and psychiatry. Remodeling first floor of masters hall for research in chemistry - An animal research farm Expansion and improvement of vivarium Zoology research building A new comparative behavior laboratory A new research structure for the department of psychiatry Expansion of the Lyons-Harrison Building for cardiovascular research. A laboratory for research in behavioral biology An additional to the surgical wing for a surgical and metabolic research laboratory. Expansion of the medical science building for research in basic and clinical sciences. Completion of shell space for medical research laboratories. - - - Completion of shell space for ophthalmology, medicine, and surgery research laboratories. Research facilities in a new medical science building of the new medical school. Remodeling space in Polk Hall for biochemistry and animal science departments. Remodeling the 2d floor of the Bell Building for the departments of microbiology and medicine. Also, remodeling the 2d floor of the Davison Building for the department of pathology. A new animal facility and research laboratories for reproductive biology of subhuman primates. Remodel and renovate part of the existing medical school building for the departments of anatomy, microbiology, bio- chemistry, pharmacology, pathology and medicine. A new medical research wing Council Institution Description recommen- dation Texas Dental Branch, Dental science institute Ohio: Cleveland Metropolitan General Hospital, Cleveland. Mount Sinai Hospital of Cleveland, Cleveland. Ohio State University School of Medicine, Columbus. Oregon: University of Oregon, Eugene - * Pennsylvania: Allegheny General Hospital, Pitts- burgh. Children's Hospital of Philadelphia, Philadelphia. Pennsylvania State University, Uni- versity Park. Philadelphia General Hospital, Phil- adelphia. University of Pennsylvania School of Medicine, Philadelphia. Tennessee: Vanderbilt University School of Medicine, Nashville. Texas: North Texas State University, Denton. University of Houston. Virginia: Medical College of Virginia, Rich- mond. University of Virginia Medical School, Charlottesville. Washin?ton: University of Washington, Seattle_ - - Washington State University, Pull- man Wisconsin: University of Wisconsin Med- ical School. Alabama: University of Alabama Medical School, Birmingham. California: California Institute of Tech- nology, Pasadena. Colorado: Colorado State University, School of Veterinary Medicine, Fort Collins. Indiana: Indiana University School of Medicine, Indianapolis. Maryland: Good Samaritan Hospital and Johns Hopkins University, Baltimore. Massachusetts: Boston University, School of Medi- cine, Massachusetts. University of Massachusetts, Worcester. Michigan: University of Michigan, Medical School, Ann Arbor. Wayne State University School of Medicine, Detroit, Mick New York: New York University. New York Completion of shell space for psychology research laboratories Roosevelt Hospital, New York Research space in a new medical research building for the department of medicine. Albany Medical College of Union Research facilities in a new medical education ~ University, Albany. North Carolina: North Carolina State University, Raleigh. Duke University, School of Medi- cine, Durham. Oregon: Medical Research Foundation of Oregon, Beaverton. Pennsylvania: Temple University School of Medicine, Philadelphia. Rhode Island: Miriam Hospital, Provi- dence. $1, 955, 000 1,076,000 554, 000 1, 369, 000 441, 000 2,387,000 861, 500 225,000 892,000 1,352,000 74,000 2, 150,000 128, 000 137, 300 1,245,500 100, 000 1,028,000 917, 000 1,800,000 330, 000 3,400,000 685,000 259,000 4,930,000 120, 000 255, 000 287,000 1,430,000 767, 000 232, 000 593, 000 1, 115, 000 833, 000 363, 000 Completion of shell space for research, in animal medicine and humane care of experimental animals. A new addition and some remodeling to the Harper-Webber Hospital complex for medical research. PAGENO="0092" 84 HEALTH RESEARCH FACILITIES APPR OVED APPLICATIONS--NOT FUNDED (AS OF JUNE 21, 1968) Institution Description Council recommen- dation Texas: University of Texas, Austin A new facility for health related space for the environmental $579, 000 health engineering division and atmospheric science. Southwestern Foundation for Re- Facilities for research animals 156,000 search and Education, San An- tonio. Vermont: University of Vermont, Bur- Remodeling of space for the department of psychology 408, 000 Iington. Total, 73 projects 72,859, 372 Mr. ROGERS. Are these medical schools? Dr. KENNEDY. About VS percent of our expenditures go to the medical schools and the associated hospitals that are involved in the teaching process. Mr. ROGERS. How do you distinguish between construction for health and research facilities and. construction for the medical school itself? Isn't that quite an overlap? Couldn't either probably qualify? Dr. KENNEDY. We have asked the applicant institutions to dis- tinguish this, and- Mr. ROGERS. What is your guideline that you have to distinguish it in your decisionmaking? Do you have any? Dr. LEE. You mean as to whether it is used for research or teaching? Mr. ROGERS. Yes. It seems to me an institution could come in and say: "Give us a construction grant for our medical school," and "Give us a construction grant for research facilities." Dr. KENNEDY. Right. The application is reviewed in detail. A site visit team goes out to look. We get full submission of drawings, plans, and this sort of thing, and it is on this basis that the decision is made. The schools are under obligation to maintain these for a specified period of time-lO years-for research. And we have a certification procedure under which periodically the institution attests to the fact that these are still in use for research purposes. Mr. ROGERS. Do you teach in research facilities at all? Dr. KENNEDY. I think the distinction becomes difficult at the graduate level. Mr. ROGERS. I would think so. Dr. LEE. But they do not, Mr. Rogers, use these facilities, and this is one of the purposes of getting a more flexible construction authority. Now they have to submit separate applications and reviews for educational facilities-those primarily for education, those primarily for research, and those for the library. Obviously, a researcher is doing teaching along with his research. But in the laboratory this is not used as a multipurpose teaching la4boratory. The teaching of some of the basic sciences is done in specially constructed multipurpose teaching laboratories rather than in the investigator's own research laboratory for which they were given a construction grant for a research facility. Mr. ROGERS. Is the manpower of HEW being handled in NIH? PAGENO="0093" 85 Dr. LEE. The Bureau of Health Manpower and the Library of Medicine are now in NIH. Those are under the direction of NIH, and one of the purposes of this was to achieve a better coordination between these efforts. Mr. ROGERS. Somebody in the Public Health Service on manpower, do they go to the Bureau of Manpower? Dr. LEE. The Bureau of Health Manpower, if they have an appli- cation? Mr. ROGERS. If they need to get manpower for the health service it- self? Do they work for the Bureau to say: "Let's have us provide for the manpower here?" Dr. LEE. If we are recruiting, for example, in Indian health pro- gram? Mr. ROGERS. I am thinking of planning ahead for manpower in the Public Health Service. Is this planned through the Bureau of Man- power? Dr. LEE. No, the programs estimate their own manpower needs. This estimate is then coordinated through the administrator of the health services and mental health administration, through the Director of NIH, and through our Office of Personnel. That office is being moved to the Secretary's office in the reorganization process. And eventually the Surgeon General and I will review those requirements, and they are reviewed in the Secretary's office. And then, of course, they are presented to the Congress. Mr. ROGERS. Why doesn't the Bureau of Manpower handle all of your manpower problems? Dr. LEE. I think they are separable problems, and their primary task is, of course, to administer these programs, to provide us with projects of national needs. It is difficult, I think for them to make the kind of detailed assessment of the number of physicians, for ex- ample, required in the Division of Indian Health, or in other programs. Mr. ROGERS. That is why I thought your Manpower Bureau ought to be interested in that. Dr. LEE. We will have a manpower staff in our office, Mr. Rogers. There will be a staff to provide the overall policy direction and coor- dination of all our manpower efforts. Mr. ROGERS. Thank you very much. May I say, Mr. Chairman, that I have great confidence in Dr. Lee? I think he is doing a good job. There is much we need to do. Thank you very much. Mr. NELSEN. Mr. Chairman, I had one point I wanted to make. This, perhaps, does not deal directly with this program. But for years I have been working on a project, a day-care center for the mentally retarded, and I finally scored after about 5 years of plodding. It was my contention that many of our vacated country schools could be picked up for $1 and would become day-care centers for the mentally retarded. I cited one as an example. Finally a demonstration project was approved, and now we learn after it has been in operation for about 2 years, the funds have been frozen. Funded by the poverty program, we had a day-care center at Swan Lake in Cottonwood County-a very meritorious project. This funding was canceled and instead a center to take care of the alcoholics was started. PAGENO="0094" 86 The day-care center that I first mentioned-where a project had been approved and funds were frozen-not many dollars were involv~d. Yet, in my judgment, in the area of the mentaaly r~tarded, anything we can do is a worthwhile project. I am a complete liberal as far as that is concerned. I wish you would check into that for me. I have been in contact with Dr. Oavanaugh, who has been very cooperative, but now the funds have been frozen. I think this is a tragic situation,. Dr. LEE. We will check on that specific project today and give you a report this afternoon and let you know what the status is. Mr. NELSEN. Thank you very much. I hope that it will be rehabili- tated. Thank you. Mr. JARMAN. Dr. Lee, and gentlemen, we think a good start has been made in the hearings in your presentation of these programs, which are of such great importance and scope. A number of questions have been raised and information requested, and we will appreciate having that. Then, after witnesses have been heard on various aspects of the bill, it may be that we will ask you to come back for additional clarification and discussion. Thank you very much. Dr. L~. Thank you very much, Mr. Chairman. Mr. JARMAN. We have as our next witness our colleague from New York, Congressman Rosenthal. STATEMENT OP HON. BENJAMIN S. ROSENTHAL, A REPRESENTA- TIVE IN CONGRESS PROM THE STATE OP NEW YORK Mr. ROSENTHAL. Thank you very much, Mr. Chairman. I want to thank you for the opportunity to appear. I know the hour is late, and I shall be reasonably brief. I have been concerned for some time with the need for increased attention to the quality of our Nation's medical care system. As a member of the Government Operations Committee, and its Sub- committee on Intergovernmental Relations, I have followed with great attention the operations of the Public Health Service and the National Institutes of Health and their responsibilities for improving medical care services. The passage of Public Law 89-151, the Allied Health Professions Personnel Act of 1966, offered an excellent opportunity for the Public Health Service both to respond to the considerable innovation evident within American medicine on health manpower and to stimulate addi- tional innovation. A careful study of the operation of this legislation during its first 18 months indicates to me that there has been little response and even less stimulation in these fields by the Public Health Service. I was pleased, therefore, that the President's health message con- sidered the need to improve Public Law 89-751 by expanding the scope of Section 794: New Methods. I regret that the improvements sug- gested are limited, however, to that section and do not take sufficient account of the need for more responsibility within the Public Health Service for encouraging the innovation so badly needed-and so well recognized elsewhere in the President's health message-in promoting new approaches to medical care. PAGENO="0095" 87 Specifically, I suggest consideration by this subcommittee of these additional amendments to H.R. 15757: (1) That it is the sense of Congress that the Department of Health, Education, and Welfare has the responsibility for stimulation of new approaches in health manpower. This responsibility should be dis- charged, initially, by reporting in 1 year: (a) On the extent to which the medical profession is already involved in developing new health professions, and, specifically, in developing training programs for physicians' assistants who can assume some of the important, but routine, burdens of medi- cal care, under the supervision of doctors, so that our limited pro- fessional resources can be more fully and efficiently used; (b) The steps which the Department of Health, Education, and Welfare has taken to encourage and assist there develop- ments; and (c) The further steps by which HEW can assist and stimulate the medical profession in developing curriculums, training insti- tutions, and approaches to accreditation and licensing necessary to achieve the fullest possible use of such new health personnel. Mr. Chairman, I have spoken many times in the past few months before doctors and medical educators on the state of our medical care and the need for increasing the efficiency with which we use our health manpower. I have found, as I anticipated, considerable reluc- tance by many doctors both to accept the basic criticism that our pres- ent medical care system is inefficient, discriminatory, and unfair, and the need for broadening and improving the use of paramedical per- sonnel. But I have been amazed and pleased to find many doctors who agree with these criticisms and who favor more help for the new pioneers in medical care research who are already at work today in America. Today's doctors are aware of the kind of work being done by Dr. Eugene Stead at Duke TJniversity in training a whole new class of physicians' assistants and by Dr. John Niebauer's orthopedic team at the Presbyterian Medical Center in San Francisco which is training former army medical corpsmen to take over some of the routine and even menial duties performed traditionally by orthopedists. Doctors are becoming aware, in short, that there might be better ways to prac- tice medicine than those they know today. One of the bars to further development of these ideas is the re- sistance to change not only within the medical profession, and specifi- cally within the American Medical Association but within the Federal Government which finances so many important medical research programs. It is this unspoken but influential alliance between traditional medi- cine and some program administrators in the Public Health Service and the National Institutes of Health which is the real obstacle to more and better clinical medical research. This amendment will encourage those leaders both in HEW and in medical education who want to improve our medical care system by updating clinical medical research. It will provide Congress with the information we need t.o judge the adequacy and extent of our sup- port for promoting better medical care. And it will demonstrate to both PAGENO="0096" 88 the medical profession and to the public our determination in Con- gress to start a critical evaluation of Federal medical research pro- grams. In `addition to this amendment, I would like to urge this committee to support completely the President's request for the extension and expansion of programs to aid our medical schools. Unless the "have- not" medical schools, and particularly the poorer dozen schools in this country, get vital financial aid in the very near future, we face the possibility of medical schools closing precisely when we most need their production of doctors. When it costs $40 to $50 million to start a new medical school-and we will have to pay these sums for a substantial number of new schools if we want to raise our medical standards-it would be inexcusable to allow 10 or 12 schools to close down for lack of operating sub- sidies. The Federal Government's medical research programs are, I believe, `argely responsible for the financial problems of some of these "have not" schools. We have led them to the brink of financial disaster. We must support them now if they are to support our efforts in the coming years to improve medical care by supplying more and better trained doctors and allied health personnel. Mr. JARMAN. Thank you very much. Mr. NELSEN. No question, but thank you for the very fine statement. Mr. ROSENTHAL. Thank you. Mr. JARMAN. We have listed as a final witness for today's session Dr. Doris Ross, of the American Society of Medical Technologists. Dr. Ross, the House has gone into session. We would appreciate it if you would submit your statement for the record and then give us ex- temporaneously some of the highlights of what you recommend to the committee. STATEMENT `OP DR. DORIS LAUI~E ROSS, AMERIOAN SOOIETY OP MEDIcAL TECHNOLOGISTS Dr. Ross. I will be glad to give the statement. I will be brief. We support this `bill. We don't think it is the answer to our problems, all of them, but we do support it. We would like to mention some things we hope will be considered when this act is reviewed. We hope when it is reviewed that considera- tion will be given to undergraduate loans with cancellation clauses, which has already been discussed, more scholarship funds for under- graduate students, and more money for graduate students to help en- courage medical technologists to take part in this education. We would hope we could fund programs for teachers in medical technology to train the people we need in this field. `Thank you again for allowing me this opportunity, and if there is any information you need from me later, I will be glad to give it to you. (`Dr. Ross" prepared statement follows:) PAGENO="0097" 89 PAGENO="0098" 90 for only one more year, and 1~opefully will be making major adjustments next year. Of the changes recommended, however, I would like to comment on the ones concerning "Development of New Methods" as they relate to medical tech- nology. We strongly urge that the public and nonprofit private agencies, orga- nizations and institutions that are to receive grants to develop, demonstrate, or evaluate curriculums and methods for medical technology be those in which medical technologists themselves are active, and be those which have shown by their activities in the past and their interest at present to be concerned with this area of improvement of medical technology education. The clause on funds for evaluation purposes indicates that the government may be evaluating curriculums. We suggest that the role of evaluator is better and more properly fulfilled by educational accrediting agencies outside the gov- ernment. I have indicated that while the Allied Health Professions Act is very much the right step in the direction of solving the shortages of manpower in the medi- cal laboratory, the present law for all its good intentions cannot in its present form and under its present appropriations move noticeably toward solving all the basic problems. In order to make a thoroughly rounded attack, we feel that other provisions need to be ihcluded in the Allied Health portion of the Act. These are provi- sions that would aid all the allied health professions ~concerned and not just medical technology. (1) Undergraduate loans with cancellation clauses are needed in a manner comparable to those provided for nursing, physical education, social work, medi- cine, dentistry and others. While medical technology students may avail them- selves of National Defense Education Loans, the fact is that a medical technol- ogist averages about $G,000 during her first years of employment, a very in- adequate salary for bearing the burden of a large loan. Furthermore, this puts us at a distinct disadvantage in recruitment especially since we must compete with other professions with accessability to such loans. (2) No scholarship funds are available for undergraduate students in medical technology, as there are for nursing, medicine, dentistry, veterinary medicine and others. Again, this puts us at a disadvantage in recruiting. (3) Although graduate traineeship money is available for graduate study, there is no provision In the present law for the development of graduate curriculum into which these graduate trainees could enroll. There are only five universities in the United States today which offer graduate education ip medical technology. These few graduate programs are chiefly devoted to masters programs in the technology education are sorely needed. Over 780 schools of medical technology and laboratory assistants ill hospitals as well as the academic programs on campus are crying out for more teachers and instructors. It becomes obvious that if we are to produce more medical technologists; we must, at the same time, produce more teachers to keep up with the enrollments. (4) Support of part-time study for graduate education through which current faculty and superviors could upgrade their knowledge and skills could go a long way in improving the educational process. Hopefully, tltese suggestions will be incorporated into law to give it additional strength in developing educational programs, opportunities for students, teaching facilities and expansion of educational facilities. Again, I thank you for the opportunity to bring you the views of the American Society of Medical Technologists and their support of HR. 15757. Mr. NELSEN. No questions, but thank you for cooperating with the committee so well. Mr. JARMAN. We appreciate your being with us, and we certainly will give careful consIderation to your statement and your comments today. Dr. Ross. Thank you very much. Mr. JARMAN. The subcommittee will stand adjourned until the same time tomorrow morning, at 10 o'clock. (Whereupon. at 12:15 p.m. the subcommittee adjourned, to recon- vene at 10 a.m., Wednesday, June 12, 1968.) PAGENO="0099" IIEALTII MANPOWER ACT OF 1968 WEDNESDAY, JUNE 12, 1968 HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washi'ngton, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. John Jarman (chairman of the subcommittee) presiding. Mr. JARMAN. The subcommittee will please be in order. We continue today the hearings on H.R. 15757, to amend the Public Health Service Act to extend and improve the programs relating to the training of nursing and other health professions and allied health professions personnel, the programs relating to student aid for such personnel, and the program relating to health research facilities and for other purposes. Our first witness this morning is our colleague from New York, the Honorable Thaddeus Dulski. You may proceed as you wish Mr. Duiski. STATEMENT OP HON. THADDEUS J. DULSKI, A REPRESENTATIVE IN CONGRESS PROM THE STATE OP NEW YORK Mr. DULSKI. Mr. Chairman, I commend you for arranging these hearings on ways to deal with the increasing sh9rtage of health manpower. President Johnson spelled out the problem very clearly in his health message to Congress last March 4. I have been particularly concerned with the urgent necessity for more nurses. The nursing shortage is a severe national problem and: one that we must face if we are to meet our responsibility to society. Last November 28, I introduced legislation calling for establish- ment of a temporary 5-year program of Federal assistance. My pro- posal would help not only the nursing schools to reestablish their financial footing, but also would give limited tuition help to student nurses. I believe very strongly that these steps are in order. Congress sought to deal with the shortage of nurses in 1964 with the Nurse Training Act which I supported. We had high hopes for that program, but it developed that so many schools already were in such financial plight that they could not qualify for assistaiace. It is not only the nursing schools that are having their financial difficulties, but also the would-be students. In their effort to meet (01) PAGENO="0100" 92 operating costs, schools have had to raise tuition rates to a point which is now beyond what many students can afford. In your deliberations, Mr. Chairman, I am sure that you will receive considerable expert testimony and many suggestions for deal- ing with the health personnel shortage. I have no pride in authorship of a solution. I do have intense interest in practical and prompt action toward alleviating the shortage. Mr. Chairman, be assured of my full and continuing cooperation and thank you for hearing my observations. Mr. JARMAN. Thank you for your brief statement Mr. I)ulski. Your views will most assuredly be given every consideration by the committee. Our next witness is also a colleague. We are pleased to have the Honorable Frances Bolton with us this morning. Please proceed as you wish Mrs. Bolton. STATEMENT OP EON. PRANCES P. BOLTON, A REPRESEI'ITATIVE IN CONGRESS PROM THE STATE OP OHIO Mrs. BOLTON. Mr. Chairman, thank you for giving me an oppor- tunity to submit a statement in connection with the hearings on H.R. 15757, the Health Manpower Act of 1968. For many years my col- ]eagues in the House have known of my deep concern with the needs of the American people for adequate health care in general and for nurs- ing services in particular. Last fall I introduced H.IR. 13937, to provide assistance to hospital diploma schools of nursing, as follows: (1) annual grants ranging from $12,000 to $24,000 per school, depending upon enrollment; (2) up to $6,000 per school on a 50-50 matching basis to improve library resources; (3) $400 per pupil grants to each school; (4) annual grants based on 75-25 percent Federal-State matching for establishment of and operation of a State comprehensive planning committee for nursing education. If we are to meet the nursing needs of the Nation the essential role of the hospital diploma schools must be recognized. These schools now supply about 75 percent of new nurses, but in spite of their importance more and more of them are going out existence. The high costs of hospital service join with the rising costs of education to make these programs prohibitively expensive to the average individual. Hospitals attempt to defray tuition and training costs, but they cannot do so much longer. The fact that the diploma schools have not had access to the public funds available for the other types of nursing schools- collegiate and associate degree-has been a serious handicap, and unless we recognize the special needs of the hospital schools more of them will be discontinuing operation. I need not tell you that the shortage of nurses is acute. Tjnfortun- ately, only too often this problem is disregarded except by people who are sick and in dire need. The recently published review of the nursing situation by the Department of Health, Education, and Wel- fare indicated that by 1975 we will have need for 1 million nurses. Presently, there are approximately 640,000 registered nurses in prac- tice; the current need is estimated to be for 775,000 registered nurses. PAGENO="0101" 93 This indicates that we will have to increase the supply to approxi- mately 60,000 nurse graduates a year. The critical nature of the situa- tion facing the Nation will be seen when it is realized that during the period 1964-65 there were 34,686 nurse graduates and during the period 1965-66 there were 35,125-or an increase of less than 500 grad- uates in nursing. Thus, even with the Nurse Training Act of 1964 in effect, we have continued to fall very substantially short of meeting the need. Just what does this shortage mean? The needs of the military have grown with the Vietnam war and these needs require continued and active recruitment of nurses who can come only from the civilian pooi. The 1967 published figures indicate that the Federal Government em- ployed 32,793 nurses. The medicare and medicaid programs will con- tinue to increase substantially the health care being provided, and various studies reveal that the nursing requirements of aged patients are much greater than those for younger patients. The Government has assured the 19 million senior citizens of the country the right to access to care not only in hospitals, but in extended-care facilities and home health services. A great many hospitals report serious shortages affecting their ability to provide care. In some instances, whole sections or floors of hospitals are closed because they cannot be staffed. Some institutions are being forced out of the medicare program because they cannot provide the required nursing supervision. The Federal Government is investing large sums of money in medical research which, when translated into patient care, inevitably means additional essential nursing care. I am including herewith for the record a page of newspaper accounts illustrating the effects of the shortage of nurses on various hospitals throughout the country: THE NURSE SHORTAGE: ExAMPLES OF EFFECTS ON AVAILABILITY OF PATIENT CARE Los Angeles, Calif ornia.-"Cedars-Sinai Hospital reports closing of ten percent of its bed capacity due to a shortage of nurses." (Los Angeles Citizen- News, 8/3/66.) Boston, Massachusetts.-"Some 25 badly needed beds stand empty in the Pratt and Farnsworth Buildings of the New England Medical Oenter Hospital in Boston because there are no nurses to care for the patients they would hold." (Washington Post, 9/18/66.) Louisville, Kentueky.-"The opening of one unit of a two-unit, 22 room addi- tion to the Floyd County Memorial Hospital may be delayed because of a nursing shortage, hospital administrator William I. Fender said today." (Louisville Times, 10/24/67.) Atlanta, Georgia.-"Governor Lester Maddox transferred $50,000 from his emergency fund to finance a `blueprint for action' to meet Georgia's nursing needs by 1975." [The Governor said] "I sure do know about the shortege of nurses. I had to take the third shift at the hospital when my wife was sick." (Atlanta Constitution, 19/28/67.) Providence, Rhode Island.-"Lloyd II. Hughes, executive director of the Rhode Island Hospital, said, `We are unable to completely staff the hospital. As a result, 76 beds representin~ all of the beds on our ninth floor and eight beds in the emergency room are not available to take patients' . . . The situation is part of a national dilemma in which 79,000 registered nurses are needed immediately." (Providence B ulletin, 9/15/67.) Washington, D.C.-"Despite a shortage of nursing home beds in the Wash- ington area, the District's own facility-D.C. Village-has never opened a new 50-bed cottage because of a shortage of nurses . . . [it] needs 16 more registered nurses." (Washington Post, 9/23/67.) . . . "A shortage of nurses has forced PAGENO="0102" 94 D.C. General Hospital to close one of its three children's wards." (Washiagton Post, 5/29/67.) Baltimore, Marylaad.-"Montebello State Hospital is so short of registered nurses and licensed practical nurses that it was forced to close a men's ward.. The hospital has space for 392 patients but, because of lack of staff, was treating only 278 patients as of yesterday." (Baltimore S'un~ 9/28/67.) Mrs. BOLTON. White I am very much in favor of continuing and in- creasing all forms of nurse education-collegiate, associate degree, and diploma-I hope very much that the provisions of my bill, FI.1~. 13937, will be included in the legislation which is fina~ly reported by the com- mittee. It makes very little sense to see hOspital schools close where they have faculty, buildings, and equipment available to produce the needed nurses. Each of the three types of nursing education has a role in meeting the needs. The 1964 Nurse Training Act gave special recognition to hospital schools of nursing, but I am told that many schools have been dis- couraged fr9m participating because of the complex language of that act and administrative regulations; also, the subsidy was related partially to increased enrollment, and many of the schools had already reached their physical capacity. I hope that these objections will be met in the new legislation. Mr. JARMAN. Thank you for your views, Mrs. Bolton. They certainly will be given every consideration. At this time we will hear from another colleague, Congressman Berry, of South Dakota. I understand you have a short statement, Mr. Berry, so if you will proceed. STATLMELNT OP HON. E. Y. BERRY, A REPRESENTATIVE IN CONGRESS PROM THE STATE OP SOUTH DAKOTA Mr. BERRY. Mr. Chairman, I am most happy to endorse H.R. 15757 which provides for increased assistance to hospital diploma schools of nursing. By 1970 we will need at least 210,000 more nurses than we have now to provide adequate care for our growing population, and this legis- lation will help in alleviating the shortage of nurses by stimulating development of comprehensive plans for nursing education, including development of facilities and recruitment of students in each State. The measure also bolsters training resources and staff through annual grants ranging from $12,000 to $24,000 per school, based on enrollment; improves library resources through matching fund grants not exceeding $6,000 per year; will ease the problem by helping to reduce training deficits and control rising tuition costs through $400 per pupil grants to diploma schools, and authorize the Surgeon Gen- eral to participate in determining eligibility of diploma schools for assistance. Virtually every school of nursing in the country is confronted with serious financial problems in the struggle to keep its doors open, and this legislation would do much to assure the continuance of the high standards of the nursing profession we have come to expect. I urge that IJ.R. 15757 be given early and favorable consideration. Mr. JARMAN. Thank you for your concise statement Mr. Berry PAGENO="0103" 95 Our next witness this morning is Dr. William A. Sodeman, a mem- ber of the executive committee on medical education for the American Medical Association. STATEMPLNT OP DR, WILLIAM A. SODEMAN, MEMBER OP THE EX- ECUTIVE COMMXTTEE ON MEDICAL EDUCATION, AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY DR. C. H. WILLIAM RUHE, DIRECTOR, DIVISION OP MEDICAL EDUCATION; AND HARRY N. PETERSON, ATTORNEY, LEGISLATIVE DEPARTMENT, AMA Mr. JARMAN. Dr. Sodeman. Doctor, if you would introduce your associates this morning. Dr. SODEMAN. Thank you, Mr. Jarman. Mr. Chairman, members of the subcommittee, I am William Sodeman, a physician and formerly dean of the Jefferson Medical College in Philadelphia, Pa. I am scientific director of the Life Insurance Medical Research Fund, Rosemont, Pa. I also serve as a member of the AMA Council on Medical Education. Seated with me to provide additional information as may be requested are Dr. C. H. William Ruhe, on my left, director of the division of medical education, and Mr. Harry N. Peterson, an attorney of the AMA's legislative department on my right. We are pleased to have this opportunity of presenting the American Medical Association's comments on H.R. 15757, the Health Manpower Act of 1968. In August, 1963, the American Medical Association, in testimony presented on legislation before the Congress, urged priority for the increase and improvement in the physical facilities available for medi- cal education. We then expressed the belief that there was need for assistance in the construction of new medical schools and for expansion and replacement of the facilities of existing medical schools. As a result of that legislation and the ongoing efforts of the American Medical Association and the American Medical Colleges to encourage the development of new schools and the expansion of existing schools, 17 new medical schools are now officially classed by the liaison com- mittee of the two associations as "in development". Further, the number of first-year students in all American medical schools has increased from 8,298 in 1960 to 8,964 in 1966 and is expected to in- crease to 10,200 by 1970. As encouraging as these results may be, the urgent need for more physicians still exists. Recently, in a March 5, 1968, joint statement on health manpower, the American Medical Association and the Association of American Medical Colleges said, "to meet national expectations for health services, the enrollment of our Nation's medical schools must be substantially increased," Both associations have endorsed the policy that all medical schools should now accept as a goal the expansion of their collective enrollments to a level that will permit all qualified applicants to be admitted. To achieve ex- panded enrollment, it will be necessary to have increased financial support from both Government and private sources for the construc- tion of additional facilities at existing schools and to create new schools. Equally important is increased support for the operational PAGENO="0104" 96 costs of medical schools and for educational improvement and in- novation which could shorten the time required for medical education. The bill before the subcommittee provides a means of furnishing the Federal component of the necessary financial resources. Mr. Chairman, we would now like to comment specifically on the provisions of IELR. 15757 relating to the training of health personnel. HEALTH PROFESSIONS TRAINING Construction grants H.R. 15757 extends for 4 yeais the program of grants for construc- tion of teaching facilities for medical personnel and authorizes "such sums as may be necessary" for appropriation in each year. As was pointed out in the joint AMA-AAMC statement on health man- power, "initiative for development of new schools and expansion of * the established institutions should be locnJly determined." It is dif- ficult to predict exactly how many new schools will be initiated and how many existing schools will choose to expand in any given year, but it is important that Federal matching funds for construction be available as the plans of individual schools are developed and the local matching funds are obtained, Delays in Federal funding not only complicate local planning but may greatly increase total costs because of rising costs of construction and general inflation. There- fore, Mr. Chairman, we would urge in this legislation, and in provid- ing appropriations, that necessary Federal funds be made available when needed so that the orderly development and expansion of medical schools will continue without unnecessary delay. Another provision of the proposed legislation permits a school to make one application to the health professions educational assistance program rather than separate applications to different agencies for teaching, research and library facilities. Since these are integral portions of any medical school it is reasonable to incorporate them in a single application which can be considered as a whole. This desirable provision should simplify and facilitate the process of obtaining Federal matching funds for construction. The bill would also permit space for graduate and continuing medi- c:al education and other advanced trainingto be included in the con- struction project. This is a significant improvement, since graduate and continuing education should be treated as a part of the continuum of medical education in the modern medical center. Inst ~tuConal and special project grants The American Medical Association has long favored "diverse sources of support for medical schools under circumstances that prevent any extramural source from exercising controlling influence." Recently, the American Medical Association's Commission on Research recom- mended that there should be increased funds from both public and private sources for the support of educational programs in medical schools, to correct the imbalance between biomedical research and cdii- cation caused by the "heavy, but desirable, Federal support of re- search." The recommendation further stated that there should be a greatly increased allotment of Federal funds for the operational ex- penses of medical schools, to be matched by those schools through pri- PAGENO="0105" 97 vate or local governmental sources, "with every effort-made to keep the Federal contribution on a supplemental basis." H~R. 15757 provides general institutional grants on a formula basis and special projects grants, which together could pro~ ide the neces sary level of operational support for medic'il schools The proposed formula for the institutional grants appears reasonable and contains the desirable provision that no school could ieceive more in any year than it expended for teaching purposes from non Federal sources during the previous year This ~ ould insure the important local match ing and would "keep the Federal contribution on a supplemental basis." The bill `dso requires expansion of enrollment as a condition for receiving an institutional grant and the proposed formula pros ides further incentives for expansion While this is generally desirable in view of the urgent need for more physicians, the American Medical Association feels some concern on conditioning operational support to expansion. There are currently some medical schools in rather severe financial straits. These schools need increased operational support to maintain their present activities and a requirement that they must increase the student load in order to qualify for such support may serve to defeat the purpose of the program. Accordingly, we stress the im- portance of retaining the provision which authorizes the Secretary to waive the requirement for expansion if he determines that the increase in enrollment would lower the quality of the training provided. The enumeration and clarification of the purposes of the special project grants should prove helpful. In addition, we believe that the assigned priorities for project applications will encourage the develop- ment of curricular innovations and changes in the educational pro- gram to the end that enrollments will be increased and the time re- quired for medical education shortened, if possible. These are two important objectives cited by the recent AMA-AAMC joint statement on health manpower. Before closing on the subject of health professions training, I would like to call your attention to a special situation. I have previously referred to provisions which limit the Federal contribution in any year to the amount of non-Federal funds expended during the previous year. As you are well aware, Howard University College of Medicine, located here in the District of Columbia, receives a substantial amount of its operating funds through appropriations from the Congress Thit medical school should receive adequate financial assistance to permit its improvement aDd development to the fullest extent Accordingly, ~e urge that no application of the Health Professions Educational As- sistance Act in providing various grant assistance be imposed which will operate to the detriment of Howard University College of Medi cine's eligibility for participation in benefits under this act. ALLIED HEALTH PROFESSIONS AND PUBLIC HEALTH TRAINING H R 15757 extends for 1 year the Allied Health Professions Person nel Training Act The American Medical Association recognizes the importance of developing adequate numbers of allied health profes sions personnel, and accordingly, we support a 1 year continnation of the construction and improvement grants provided for in that act. The bill extends for 4 years the program of grants to schools of public health and other public and non profit private institutions to provide PAGENO="0106" 98 graduate or specialized training in public health. It also extends for 4 years the program of grants to cover the costs of traineeships in gradu- ate or specialized training in public health for physicians, engineers, nurses, or other professional health personnel. Mr. Chairman, the American Medical Association supports these provisions extending the programs assisting public health training. HEALTH RESEARCH FACILITIES H.R. 15757 extends for 4 years the program of grants for construc- tion of health research facilities. The association appeared before this committee in 1965 and, at that time, supported an extension of this act. We believe that the continuation of this program is still warranted and we recommend adoption of provisions in IE[.R. 15757 extending the pro- gram of grants for construction of health research facilities. Mr. Chairman, the association is presently reviewing the provisions of the bill relating to an extension of the Nurse Training Act. For that reason, our statement `does not include any comments on that portion of the legislation before you. Mr. Chairman, once again let me express my appreciation and that of the American Medical Association for the opportunity of presenting medicine's views on the important subject of health manpower. Today, in every medium of communication, health care is a principal topic for discussion. We believe that the extenson and improvement of the pro- grams di'scus~ed above will serve the interests of our country by en- couraging a greater production of health manpower. We will be pleased to attempt to answer any questions that the subcommittee may have. Thank you, sir. Mr. JARMAN. Doctor, yesterday a strong point was made in the hearing with reference to the tremendou's increase in Federal funds made available with the objective of more doctors, more dentists, more manpower in the medical field in the country. Concern has been expressed over the fact that there has not been the kind of increase that many of us have expected. In the first stage of your statement you refer to the num'ber of first year students in all medical schools in America, increasing about 675 from 1960 to 1966. Would you care to comment with reference to that point that was made in the hearings yesterday, the very `slow increase in number of doctors that are coming out of the overall program? Dr. SODEMAN. Mr. Chairman, I was not `here for the hearings yester- day, but we are concerned, of course, with the lack of speed with which the increase is taking place. The construction of new medical schools and the evolution of new medical schools i's time-consuming and t'akes 5 or 6 years to get one of those shows on the road, so to speak. For that reason there are difficulties in the evolution of these new schools `in a short period of time. Of the 17 schools in development, I believe five new ones `took stu- de'nts this year~ is that correct, Dr. Rube? Dr. RUHE. Yes. Dr. SODEMAN. And, I think the same thiiig will `be true next year. When. local matching grants, `matching `moneys are necessary, and these must `be correlated with Federal moneys to make an effective PAGENO="0107" 99 program. When it is necessary to bring a faculty together in an area in which ~manpower is short, as far as teaching is concerned, there is difficulty in this kind of evolution. The medical schools that are in action at the present time are con- cerned about increases in the numbers of students and again this is a difficult matter for some of the very same reasons. The self-determination of what schools should do, of course, is one of the factors of importauce in this respect and the incentives to increase are important. The American Medical Association has been greatly concerned about this matter and has advocated, anct does advocate, as many new schools and expansion in as many of our existing schools as can possibly take place. But this is a slow process, Mr. Chairman, and we are as concerned about this as you are. Mr. JARMAN. Mr. Rogers raised this particular point in yesterday's hearings and may have some additional questions along that line. Let me ask you this: Is the AMA position, in general, that there is some imbalance between Federal funds for research and funds for educational purposes at medical schools? Dr. SODEMAN. This is true. This is the AMA position, but the position rests in the fact that we feel that there are not enough moneys for the educational component. We do not feel that a reduction in the research component is in order, but we feel that a balance by developing the educational component is in order to effect a balance which would be suitable. Mr. JARMAN. Mr. Rogers? Mr. ROGERS. Thank you very much. Doctor, I think your statement was very helpful to the committee. i am concerned and would like to get some of your thinking, though, about increasing manpower, which this is trying to do. I notice from the fact sheet on physician population and medical education in the TTrnted States, which is an AMA publication, some facts that are quite disturbing to me, and a lack of results, I think, comparable with the amount of money invested. What would you say the shortage of doctors is in our Nation today? Dr. SODEMAN. The actual number? This would have to be an edit- cated guess, Mr. Rogers. Mr. ROGERS. I understand. Dr. SODEMAN. But the figure commonly given is around 50,000. Mr. ROGERS. 1 see. And, have you projected that figure, say, for the next 5 years? Could you give us your estimate for the record? I real ize you may not have this with you. Dr. SODEMAN. We can give you this estimate, of course, and we would be happy to do so if you wish. Perhaps Dr. Ruhe would be in a position to answer some of these questions now. Mr. ROGERS. Fine. Dr. SODEMAN. The document you have before you is one of his documents. Mr. ROGERS. Good. Dr. RUHE. I am not sure that I understand the question about the projection. Do you mean- Mr. ROGERS. In other words, do you project that this present short- age will increase? Will it decrease in the next 5 years, or next 10 years, or with the increase in population that we have in this country, will it remain constant, or what? PAGENO="0108" 100 Dr. RTJHE. It is a very difficult question to answer- Mr. ROGERS. Yes; I realize it is speculation. Dr. RUHE (continuing). Because the question of need is what de- termines the definition of "shortage" and it is awfully difficult to anticipate what public expectation or demand will be. I think it has grown far out of proportion to what we had anticipated in past years. Mr. ROGERS. The demand has. Dr. RunE. That is right. Mr. RoGERs. Yes. Dr. RUnE. And, the estimate of 50,000 physicians short today is really not our estimate; it is a commonly used figure. One of the things which disturbs us is that it has been very difficult to identify an exact goal, in terms of numbers of physicians, that we are seeking. It is a fact that the proportion of physicians to population has actually been improving. It has been getting better and, if our projections are ac- curate, it will continue to increase. We currently have a ratio of total physicians to population of somewhere around 152 to 100,000, and if our estimates on this are accurate, we will be up to somewhere be- tween 160 and 165 per 100,000 by the year 1975. But whether this will meet the demands for physicians' services is something quite different. All that we can say, really, is that we are adding to the numbers of physicians, but all the people who study this field and attempt to pre- dict what the population will want estimate that, in spite of the rising ratio of physicians to population, we will not meet the demand. So there seems to be a general agreement-and we would concur in this- that in spite of all our efforts to produce more physicians, we are not likely to meet the full demand for physicians' services in the immedi- ately foreseeable future. Mr. ROGERS. Well, now, I wonder if the AMA in its study has a solution proposed to meet the demand. Have you suggestions of how the demand can be met now or what action should be taken ~ Dr. SODEMAN. Mr. Rogers, we are concerned about this. To supple- ment some of what Dr. Ruhe has said, the President's Manpower Com- mission report points out that during the period from 1955 to 1965 the population increased about 17 percent, the number of physicians in- creased about 22 percent, but the services of physicians increased 18 percent. If this relationship continues, it means that the demands on physicians are going to be greater despite the fact that our physician population is going up. For this reason, the utilization of physicians and the utilization of physicians' time are important and how the arm of physicians can be extended in their use and how the services can be rendered is an important part of this total problem. The American Medical Association, as well as everybody else, is greatly concerned about the methods whereby this can be accomplished efficiently, effec- tively, and for the benefit of the public. Mr. ROGERS. Yes. I understand. What I was thinking about, have you suggested that so many new medical schools be `built to be able to turn out so many physicians or have you adopted such a program as that, a specific program to meet the actual shortage? I wondered if you had done that. Dr. SODEMAN. If you mean have the universities been solicited to establish medical schools- Mr. ROGERS. No. That is not what I mean. PAGENO="0109" 101 IDr. SODEMAN. No. Mr. ROGERS. What I mean is, I wonder if what the AMA. has set forth here is the shortage. It will take so many new medical schools or an increase of students in the existing schools. It will require so much money to do this. So much should be Government, so much pri- vate or whatever it may be. I just wondered if you had projected such a program as this. Dr. SODEMAN. Projections of a program of this sort I do not know. Dr. Ruhe, do you know? Mr. ROGERS. I just wondered. Dr. RUnE. No. The answer is we have no formal specific goal for either number of schools or number of graduates. We have estimates of what this is likely to he but again, as I said earlier, because it has been difficult to estimate exactly what the demand for services will be, we have not an exact goal for numbers of graduates. Mr. ROGERS. Well, if you could give us some information as to your projection for the record, based on present ratios, not even projected into what the increased services might be called upon, we hope the services maybe can be decreased if we get the allied health program going where we can use the physician services in a more effective manner. Dr. SODEMAN. We do know, Mr. Rogers, that we are so far behind we need all the new medical schools we can get and all the expansion we can get, but this is not quantitative and you would take quantification. Mr. ROGERS. And, this is what I think would be helpful to the com- mittee so we can project concretely what this Nation must do to close this gap, you see. Now, let me ask you this. What about dentists or did you make any study? Do you want the dentists to tell us? Dr. SODEMAN. I think we would defer to the Dental Association. Mr. ROGERS. What about nurses, the shortage? Dr. SODEMAN. We recognize the critical nature of this shortage. We recognize the problems in the Nurses Training Act and the needs. We are currently deep in discussions on this. We would rather transmit to you in written form at a later time opinions about this than give them during the middle of our discussions. Mr ROGERS Fine Now, I notice from your chart, from 1~58 to 1966 we had a per- centage increase of medical school graduates of 10.4 percent. We had an increase in medical schools in this same period of time of 8 6 per cent, 81 to 88, full time faculty increased 65 7 percent, and total ex- penditures increased 176 5 percent Now, I notice that just in the last number of years from 1961 until 1967, full-time faculty in medical schools increased from a little over 11,000 to 19,000, but graduates did not increase even 1,000 according to figures here because your medical school graduates from 1957, which is even before 1961, you had 6,796 and in 1967 you had 7,743 So, you have an increase in the full-time faculty of some 8,000 persons and yet we only produced 1,000 more graduates. Does not this seem strange to you? Dr. SODEMAN. No; it does not ,sir. Mr. ROGERS. It does not? Tell me why not. PAGENO="0110" 102 Dr. SODEMAN. There are many reasons for this that are not patent, I `think. In the first plaee~'our schools tI~aditionally in the past have had very large numbers of part-time teachers. Mr. ROGERS. No. These are full-time. Dr. SODEMAN. Yes, but we have had many part-time teachers in the past and full-time teachers are replacing them, Mr. Rogers. Mr. ROGERS. Well, I assume-these figures I have given you are full-time faculty members, not part time. Dr. SODEMAN. Right, sir; but they are replacing part-time faculty that do not appear in the figures. Mr. ROGERS. I do not care who they replace. The numbers increased from 11,000 to 19,000 and they are full time. Dr. SODEMAN. During that period of time part-time teachers have dropped off rather remarkably as full-time teachers increased. Then, too, one cannot teach medical students in a vacuum. Medical schools are not medical schools with a hospital attached any more. They are major medical centers with many components in teaching. The graduate programs are important. The research programs are important. Allied health is important. The dispensing of service that is satisfactory is important. We are extending activities into the com- munity and teaching in community services, and so on, outside of the medical center. Mr. ROGERS. Well, has not this basically been true since the early 1960's? Dr. SODEMAN. Not to the- Mr. ROGERS. Has it changed that much in the last seven years? Dr. SODEMAN. It has changed remarkably, sir. And, all of these things, when they add up, make a rather remarkable difference in these figures. People do not teach all of the time. They do research part of the time. They give service part of the `time. And- Mr. ROGERS. Well, this is what I am wondering now. Are we prop- erly using the personnel to instruct to get the doctors out to teach `the present knowledge and to heal people on present knowledge? Dr. SODEMAN. I believe that it is necessary to do this in this way because you must teach medical students in the total setting and pat~ tern of medical care if they are to grasp the whole spectrum of medical care. Mr. ROGERS. Let me ask you `this. Why would it `be that out of 85 schools, 85 `medical schools in 1957, 32 `of those `schools graduated fewer or the same number of physicians in 1967 as they did 10 years earlier in 1957, and yet we h'ave had an increase in faculty, `we `have 176 percent increase in fun'ds. I cannot reconcile these figures. Dr. SODEMAN. One must consid'er that our faculties-our medical school status at `the time where the point of reference takes place, were not in optimal condition and optimal state at that time. Mr. ROGERS. But, this has decreased since the time when it was not even optimal. Dr. SODEMAN. But, quality is increasing at the same time. Mr. ROGERS. Well, how do we know this? Dr. SODEMAN. We can tell this by the w'ay in which students react to the qualifying examinations and by other techniques. PAGENO="0111" 103 Mr. Roai~s. Well, we might get into a big argument on this but I will not go into that now. I would hope this is true in every school. I am not sure that it is true. Dr. SODEMAN. I think it is, sir. I think it is `true. Mr. ROGERS. In every school? Dr. SODEMAN. I cannot vouch for every school. Mr. RoGEns. No, I would think not. Dr. SODEMAN. And then, too, one must realize that medical educa- tion is not a 4-year proposition. Students go to medical school 4 years and get an M.D. degree. They take varying amounts of training after that, some of them spending a total of 7 to 8 years, whether they are going into family practice or a specialized practice of some sort. This means that the educational components are twice as long as the area we are talking about support for. Some of `the individuals are con- cerned in the teaching process in that whole spectrum of those 8 years rather than the simple 4 years of the medical school. Mr. ROGERS. Yes. Dr. SODEMAN. You cannot take those 4 years out of context with the total pattern. Mr. ROGERS. I was just using the figures you gave for comparison, in your paper, which I presumed was a correct comparison. Dr. SODEMAN. Yes. The tables need some explanation, sir. I think that is true. Mr. ROGERS. Well, maybe we need more figures. Perhaps you could furnish `the committee the proper figures you think should he compared. Would you do that for the committee? Dr. SODEMAN. We will be happy to. (The information requested appears on p. 303.) Mr. ROGERS. Because I am very concerned about this, and then par- ticularly with your statement `that you do not think we ought to require as a precedent for Federal funds to be invested in medical schools any increase in student body. Now, if we do not require some increase in production here in effect, with more funds invested, are we not really not meeting the problem? Are we not just saying, well, you do not have to? Here are 35 schools so we just give you and you drop in graduates rather than increase? This does not meet the problem. What we are faced with is a very prac- tical problem. We want quality education, everybody is agreed on this, but still we must set some goals to see some results `begin to happen. We cannot keep voting funds, millions and millions of dollars of tax funds, and not see any results in the number of physicians or nurses or whatever it may be. Now, I would hope you could consider this in your recommendations to us and perhaps give us your thinking on what would be a realistic figure. We have had under the present law a 21/~ Vercent increase of student body or five people, which is nothing. I realize in some medical schools it is something. But for the most part this is not meeting the problem. So, what we have got to do is say what is it necessary to do to bring this school up, to bring it where it is going to produce some more doctors? And, unless we meet this problem, we are going to have chaos in this country `because they are now going into all this medicare business where people are expecting care and if we do not start turning out physicians and the manpower to handle this, I think we are going to be in dire straits, and I am sure you share this feeling, PAGENO="0112" 104 and I know from your testimony this is so. But, I think we must have some concrete guidelines. If we are going to put Federal funds, we are going to have to be assured that there are at least more people turned out and I would hope you could give us some figures in looking over-because you do have expert knowledge in this area-of what you think it would not be unreasonable for us to ask for medical schools. Maybe we could do it on a school by school basis and I do not see why we could not, if necessary, because there will be some schools that can take 20 or 30 or 50 more with a little increase. So, maybe only five. But, we ought to know how many new schools we must really gear for because I think we have not handled the situation well. I am very dis- couraged by the figures that I see before me in your information here where we have had such an increase of faculty but no doctors basically. A thousand. And yet, 7,000 new instructors. Now, it may be true, maybe this is a part-time thing and I would like to get those figures as you say. Dr. SonEiviAN. There are some equivalents in here. Mr. ROGERS. I understand that, but still these are shocking figures. And, it may be that the whole medical education setup in this country needs to be looked at to see how they are using these instructors. I do not know that we are really using them effectively. Maybe the man is spending too much time in research when he ought to be teaching ten more people to really solve the most pressing need we have. So, I hope this committee is going to do a study on manpower use and I would hope your organization would help us in this and support it. Dr. SODEMAN. Dr. Ruhe would like to say something, Mr. Rogers. Dr. IRUHE. May I comment on this, Mr. Rogers? I certainly agree with virtually everything you have said. I believe that the figures are a little bit misleading in the way they are put here. They were put for a particular purpose and sometimes that purpose needs to be explained somewhat. Mr. ROGERS. I understand this and any figures you want to submit on this will be satisfactory. Dr. RtTHE. I think the problem in looking strictly at the growth of full-time faculty and in comparing this with the growth of graduates is that it does not account for the multitude of other activities which are carried on by these full-time faculty. Mr. ROGERS. Well, arc we doing too much, then? Should we confine faculty members more to teaching? Should this be done or- Dr. RUBE. Well, I think one has to make a judgment based on what the current needs and the current demands are. I think emphasis over the past 10 or 15 years has been more in increasing the research activity of our medical centers than it has been in increasing numbers of physicians, and this has been in response to the public interest and, of course, the funds that have been provided for such. In addition- Mr. ROGERS. I would agree with you. I think the Congress has emphasized research so much with the billions we have put in it that it appears now that we are reaping this by lack of physicians where we should have put perhaps greater emphasis on instruction, and so forth, in the medical schools to produce the physicians that can mm- ister present knowledge to people because a lot of people are not going to even get ministered with present knowledge, and this is what causes concern, I think. PAGENO="0113" 105 Dr. RUHE. Yes. I do not mean to minimize the importance of re- search in any way. Mr. RoGERs. I would agree. I do not, either. Dr. RUHE. We believe what has been done in the medical centers has been tremendous in the way of increasing the research potential and what has been developed. There has also been the development of graduate medical education, of nursing education, of the education in the allied health professions and services. All of these things have been coming along at the same time, and Dr. Sodeman mentioned the involvement of the medical man in the community. The regional medi- cal programs are in demand in the communities, and other programs of this nature and all of these things are important and it is difficult sometimes to say which is the most important at any given time. One of the problems, I think, is that there is usually a time lag between recognition of the need for a particular service and the time you can get geared up to supply that service. I think this is particularly true in medical education where there is a time required from the beginning of the pipeline to the end of the pipeline before the people begin turning out. Now, we do have these 17 medical schools currently in development of which seven now have medical students in them and five will next year, and the others will within a couple of years from now, so the pipeline will begin to deliver more people. But we do feel there has been an overemphasis perhaps on some of these other things rather than the producion of physicians over the past few years. I think the joint statement of the AMA and AAMC now emphasizes that and we have been urging all the medical schools now to make their No. 1 priority the production of more physicians. Mr. ROGERS. Good. Dr. RUnE. Now, one word about the question of what the individual school can and should do and whether it should be required to increase. I think we have always supported the concept that in this country the individual university developed on its own initiative and with its own goals and with its own concept of how it should reach those goals provides the strongest education. We still support this. We believe that the individual institution should be permitted to determine what its objective should be and whether it should greatly increase its num- bers or try to maintain a position doing other things without increas- ing numbers. However, as I said before, our two associations have now taken jointly the position of urging all the schools to consider if they cannot increase their numbers. We would prefer as an association not to have every institution required to do this but to provide all an encouragement and incentives to persuade them, those which s this as part of their mission and part of their goal in line with j toT or gear Mr. think develop its own goals, -- our vh 95-540-68--S PAGENO="0114" 106 now, ready to vote millions of dollars. Do you not think it is realistic to say they ought to have some increase before we put Federal funds in? Dr. RIJUE. I think it is in most instances. Mr. Rooi~iis. We haste ~ot to do something like that. Dr. RUEE. In most instances. I think there are some schools in severe financial straits so the provision for an exception in the legis- lation, we think, is a very good one. Mr. ROGERS. Well, perhaps. Dr. SODEMAN. Mr. Rogers, in our statement there is not the implica- tion that money should be given without an incentive to increase. As Dr. Ruhe has just indicated- Mr. ROGERS. I am glad that is clear. Dr. SODEMAN (continuing). We do have schools where the quality of education is such that they need support now to maintain an in- creased quality with the number of students they have and there should be some individualization on this and- Mr. ROGERS. We may have to do it. Dr. SODEMAN (continuing). And the secretary having the right to give waivers. Mr. ROGERS. I do not like too many waivers to the Secretary. You get everything waived. Let me ask you this now. You say you approve the special prójert grants. The proposed legislation, as I understand it, says that this money that is allocated either for institutional project grants can be interswitched. They would hope to use it 40 percent institutional grants, 60 percent project grants. No limitation on project grants. Now, there is a limitation of $400,000. Do you not think there ought to be some limitation on a project grant? Dr. SODEMAN. I think there should be justification for use of any funds up to any amount. Mr. ROGERS. I assume this is so of all of them. Dr. SODEMAN. Yes. Mr. ROGERS. But, otherwise it seems to me, they could use the 60 percent or actually they could use 100 percent in project grants, give it to five universities. I do not think they would do this but we never know. Now, we hare got to write the law where we are going to get some results here. I wish you would give that some thought and let us know ,what you think would be a realistic ceiling on project grants. It has been $400,000. I would not mind raising that limitation some as far as I am personally concerned, but I think just unlimited, I would not support. Dr. SODEMAN. We will give you a considered opinon on this, Mr. Rogers. (The information requested appears on p. 303.) Mr. ROGERs. That would be helpful, and then if you let us know the number of medical schols we should build to meet the actual shortage and then if you would let us know what reasonable increases might be on these medical schools for new students. (The information requested appears on p. 303.) Mr. ROGERS Thank you. It has been most helpful. Mr. JARMAN. Mr. Nelsen? Mr. NELSEN. Thank you, Mr. Chairman. PAGENO="0115" 107 With the reference to the table of instructors, as I understand it, previously part-time instructors did the work in many of the colleges, medical schools. Is that true? Dr. SODEMAN. That is true and it is still true in some degree, Mr. Nelsen. Mr. NELSEN. Now, if the part-time instructors were tabulated, would the comparison be so completely out of line as it is now? Dr. SODEMAN. This is an estimated guess of mine, but the answer is it would not be so far out of line. Still, we have increases in the number of full-time people doing research, and carrying out other functions that were not carried out by part-time instructors before. Full-time people teaching paramedical personnel, nurses, carrying on continuing educ~ation and doing other matters, that there would be some discrep- ancy in these figures certainly, but they would be clarified and justified by the activities of these people in the total spectrum of education. Today continuing education of a physician is extremely important because of the rapid increase in knowledge, as you know very well. Mr. NELSEN. Now, in the dollar comparison, of course, in fairness one must take into account the inflationary trend which has driven all costs up. Isn't it true that there has been quite a change? Dr. SODEMAN. And, it is more remarkable in the health field because the shortage of personnel and because of the the need to go into the marketplace and bid for personnel means that the costs have gone up more remarkably than the average increase for personnel generally across the country. Mr. NELSEN. With reference to the States determining whether they should increase their enrollments, I think there is an attitude develop- ing in the Congress that if Federal money is to be involved the medical schools should expand their enrollment and thus expand their produc- tion. I think this wish should be respected because this is the prime reason why we are trying to help with the total btirden.' Dr. SODEMAN. Mr. Nelsen, we believe that the mOst rapid way to get more physicians is to expand existing schools where it is possible to do so. `The process is a shorter process than in developing new schools. Mr. NELSEN. Getting into the area of research, I have noticed'that there seems to exist a' nationwide competition as to who can make the best heart transplant. Has there been too much emphasis in these areas and a lack of emphasis on the production `of doctors that the country so badly needs? Dr. SODEMAN. I do not think, sir, this is `either/or. I think these things can go along in a parallel way and that the emphasis that has taken place in that kind of process that you are talking about has not been detrimental to the process of trying to develop more physicians. Mr. NELSEN. Yesterday in the hearing I asked whether there should be a greater emphasis on the practical nurse approach in view of the very obvious shortage of nurses. Many competent young ladies that might have a great aptitude in psychology and concern for a patient, might become a practical nurse of great value in a hospital, even though they could not aff oDd to go on to become an RN I was informed that there were certain obstacles in the program that might actually deter the hospital schools from proceeding with ~ more broadly accel erated program Do you have any comment on that ~ PAGENO="0116" 108 Dr. SODEMAN. We are deeply concerned about the problem of short- age of nurses in all categories of nursing. As I indicated earlier, we are discussing this and doing some analyses of this at the present time. We would prefer, if you would permit us, to supplement this with a written statement later on. Mr. NELSEN. Please do so. Dr. SODEMAN. We would be happy to do so. (The information requested had not been supplied at time of printing.) Mr. NELSEN. I am not sure if I understood Dr. Lee accurately, but it is my understanding from what he said, that Federal money would be directed to the school only in connection with those who qualify for a student loan. I am not sure if I understood him correctly, but if there is any aspect of the program that needs to be changed to accel- erate the training of bedside nurses I would like to know about it. This is one area where a minimum of dollars would result in a maxi- mum of production and I hope that this could be given more consideration. Dr. SODEMAN. We hope that our statement will cover the whole spectrum, Mr. Nelsen. Mr. NELSEN. Thank you. No more questions. Mr. JARMAN. Mr. Skubitz? Mr. SKUBITZ. Doctor, if I understood you correctly, you said the ratio of doctors to population, was approximately 152 doctors to 100,000 people. Dr. SODEMAN. That is right. That is what Dr. Ruhe said. Mr. SKTJBITZ. That is one doctor for 666 people. Is this unreasonable? Dr. SODEMAN. I do not think- Mr. SKUBJTZ. Would that overwork the doctor? Dr. SODEMAN. Beg pardon? Mr. SluxmTz. Would that overwork the doctor? Dr. SODEMAN. It does overwork them; yes, sir. Mr. SKTJBITZ. 666? Do you think you would get a young graduate to go to a community that just had 666 people in it? Dr. SODEMAN. There are matters of distribution. Mr. SKUBITZ. I think now you are putting your finger on th~ point-distribution of doctors. I think this is one of our big problems. The second point is the field of research. I think we have enough doctors but they are not distributed properly. Dr. SODEMAN. The physicians doing research and the percentage component of the physicians in this activity is relatively low for the total number of physicians. It is important that this component be maintained because this is the way in which you improve health in the future. Take the Salk vaccine, for example. If these people were not pro- ducing this vaccine, we would have physicians taking care of patients with poliomyelitis which they do not have to take care of now, so in the long run the components of the physicians in research is extremely important and I do not think this percentage is getting out of hand in terms of the past percentages and trends. Mr. SKuluTz. Do you have to run the whole gamut of the medical profession in order to be a research man? Dr. SODEMAN. No, sir. PAGENO="0117" 109 Mr. SKUBITZ, Maybe too many doctors are going just into the field of research and not enough into the practice of medicine. Maybe we should make some changes in this field. What do you think? Dr. SODEMAN. Personally, I do not think so, sir. I think that we need those that we have in research at the present time and we are not increasing this component out of reason. Mr. SKUBITz. Well, Doctor, in 1967 there were 7,743 graduates. I low many of them would you say went into the field of practicing medi- cine, how many into the field of research, how many into teaching, and how many employed by government and industry? Dr. SODEMAN. Perhaps Dr. Ruhe has some figures. I can give an educated guess, if he does not have the figures. Dr. RUHE. We do not have those figures because as you may be aware, it is some years after the man graduates from medical school before what he finally does is determined. He has of course, 2 years of compulsory military service. He has several years generally of graduate education at the internship and residency level. Mr. SRTJBITZ. Can you take any one year, I do not care what year you take, 1961, 1962, 1967, and give us a breakdown of just how many doctors actually go out into the field and practice medicine and how many go into the field of research and how many stay in teaching, and so forth? You know, I have a feeling, Doctor, that a lot of grad- uates are like Congressmen and Government employees. They get accustomed to a paycheck. When they get out of college, they get into the research field until they can earn a little money but they stay in this field. They never want to get out and practice medicine. Mr. NELsEN. Off the record. (Discussion off the record.) Dr. RUHE. Actually, the percentage that go into research as a major activity is still quite small. Based on informal estimates, it is running somewhere between 5 and 8 percent of our graduating classes. In terms of our numbers of total physicians, the active physicians as they identify their activities, the number really is quite small that identify themselves as being with research as their major activity. As of December 31, 1967, out of 294,000 active physicians in this country, only 4,600 classified themselves- Mr. SKUEITZ. I am interested in classes. How many of our graduates immediately start practicing medicine or into research or teaching or become salaried doctors in industry? Would you provide this in- formation? Dr. RUFIE. Yes; we certainly can supply that information. (The information requested appears on p. 303.) Mr. SKUBITZ. That is all, Mr. Chairman. Mr JARMAN Are there further questions9 Gentlemen, we very much appreciate your taking the time to be with us and to add to the record of the hearing on this important bill Dr. SODEMAN~ Mr. Chairman, may I express the thanks of all three of us for your kindnesses to us Mr JARMAN Our next witness is our colleague, the honorable William T Cahill, of New Jersey, who will make a per ~on'il presentatrnn PAGENO="0118" 110 STATEMENT OF HON. WILLIAM T. CAHILL, A REPRESENTATIVE IN CONGRESS PROM THE STATE OP NEW J~EIlSEY; ACCOMPANIED BY NICHOLAS D. HElL, LEGISLATIVE ASSISTANT Mr. CAHILL. Thank you very much, Mr. Chairman, and members of the committee. May I say before starting my statement that I think Mr. Rogers has pretty well anticipated what my views, as expressed in this statement, will be, and I will say to Mr. Skubitz that I think I can supply him specifically with the figures that he wants because we have made a survey of the 88 medical schools in `the United States for the purpose of determining the very question that he has asked. I should also like to say to Mr. Nelson, sharing as I do his views on the practical nurses, and knowing the chairman's intense interest in this entire program, that I hope that my testimony will point out the scope of the problem and perhaps make several suggestions that might, hopefully, contribute to its solution. I think that all of us know that during the past several years hospital officials, medical educators, the press, representative's of organized medicine, and the public representatives in Government, have spoken of an "impending" crisis in our Nation's system of health care. However, it has become evident that far from threatening in the remote future, crisis conditions presently exist. As reported by the President's National Advisory Commission on Health Manpower several months ago, and I quote: The indicators of such a crisis are evident to us as Commission members and private citizens; long delays to see a physician for routine care; lengthy periods spent in the well-named "waiting room," and then hurried and sometimes impersonal attention in a limited `appointment time; difficulty in obtaining care on nights and weekends except through hospital emergency rooms; unavail- aibility of beds in one hospital while some beds are empty in another; reduction of hospital services because of a lack of nurses; needless duplication of certain sophisticated services in the same community; uneven distribution of care as indicated by the health statistics of rural poor, urban ghetto dwellers, migrant Workers, and other minority groups which occasionally resemble the health statistic's of a developing country; obsolete hospitals in our major cities; costs rising sharply from levels that already prohibit care for some and create major financial burdens for many more. Now, gentlemen, however, despite knowledgeable estimates that our Nation is presently short 50,000 doctors, and that by 1970 we will be short 250,000 nurses, the Advisory Commission fails to conclude that these conditions of crisis are primarily the result of a national shortage of health manpower. Rather, it places major emphasis on integrating and coordinating America's medical care delivery system. The major portion of the Commission's report is devoted to demon- strating the need for reorganizing this delivery system with its present "duplication, high cost, wasted, efforts and overlapping aspects." In my opinion, the Commission has misjudged the nature and causes of what is wrong with the American health care system. While I recognize that this crisis is not simply one of numbers, I am convinced that it will be impossible to improve our medical care system without a massive national effort to provide large increases in available physi- cians, nurses, and allied health personnel. In my judgment, without sufficient health manpower there can be no integrated system of health care in the United States. I would thus commend the major thrust of H.R. 15757 which has been called the Health Manpower Act of 1968. PAGENO="0119" 111 This legislation, in my opinion, represents a major departure from the thrust of previous legislation directed to training doctors, nurses, and allied health personnel. Largely, the Federal Government's role has been to provide massive grants for research activities. In 1967, for example, the Federal Government expended over $1.5 billion for medical research and development. Largely, this amount was for research efforts conducted by private or State medical schools pursuant to NIH or other Federal Government agency grants. The effect of this massive research support by Government has been to detract from the number of health manpower graduates each year. In short, our national medical education system has not produced treating physicians for 90 percent of the public's illnesses, but rather a professional corps of researchers and specialists. There is complete agreement, even by representatives of the medical schools and by organized medicine, that research has diverted physi- cians away from the patient and hospital and into laboratories. Medi- cal schools have found it necessary to support education and teaching programs through grants intended for research. Moreover, other results have been serious questions of accountability for funds, waste- ful duplication of research projects and equipment, and an academic grantmanship that has often provided poor research projects and results. In short, even a special study group of the AMA has concluded, and Iquote: The adverse effects of Federal research grants on medical schools arise from many sources. Primarily they arise from the imbalance caused by burgeoning financial support for research in~ the midst of a relative scarcity of funds for educational programs. Now, however, the Health Manpower Act of 1968 seeks to provide a balance between the functions of education and research by providing an improved and more intensive program of Federal financial assist- ance to medical and professional health care education. Under the act Federal grants for teaching facilities, grants for demonstrating the need for reducing the number of years needed to train health per- sonnel and institutional grants which provide broad support to the educational functions of medical schools are expanded. It is especially encouraging to note that the institutional grants will be allocated to medical schools on the basis of a formula which provides incentive to expanding student enrollments. However, in my judgment, the Health Manpower Act contains many. features which tend to perpetuate inadequacies in the existing system of medical and health education. Primarily, this legislation continues to place undue emphasison research and specialization. In my judgment, this legislation should be carefully analyzed by the appropriate congressional committees to determine whether it will produce the intended results of providing widespread health care or whether it will merely institutionalize the existing tendencies of medical and health professional graduates to enter into specialties or research and academic oriented careers. I am convinced that these are the directions that most of the nation's medical school graduates will take unless something is done. Now, Mr. Skubitz, to ascertain the seriousness of this, Mr. Heil, who is from my staff, under my direction forwarded a letter to the deaits of our Nation's 88 medical schools. And we said: PAGENO="0120" 112 Dc~a r I )ean. imr~uaiit to my ontinnmg hiterest. iii biometheal edueatioit and li(lU~ll, I lUll ile5(~1lt1Y atte.iiiptiiig to (oiil1fll(~ d~iti~ whiCh ~vi1l iil(hiCiite the hron(l J1(~15 of 1ll(diC~i1 eduealion ilist.itUtioilS. W'liik~ niuch SC(lflldliFy niforina- tioii exists preliminary investigation indicates that medical 5(110015 have often l)een l)yl)llsse(l in determining these needs. I WOUld thUs greatly aI)I)recmmlte all in(li(lltiOit froiii you of the I}lOfes$iOIllhl treiids th~it recent graduates of your medical school have taken or may be expected to take. While your own con- veiueiit amid available iiitorniatioii may permit a more comprehensive analysis, I would request au estimat~on of the following for your g'rll(IUatmg classes of th;7 aid ~ (1), tue total number of medical graduates, (~) tile percentage that will serve in the Armed Forces, (3) the percentage that will serve with the Armed Forces on a career basis, (4) the percentage who will specialize in one particular area of patient service-oriented medicine, (5) the percentage who will enter an ada(lenlic or research career, (6) the percentage who will pursue graduate stll(hies to achieve a specialty or an academic or research career, (7) the per- cerita.ge who may be expected to enter general practice, (8) the percentage of graduates who will enter miscellaneous careers not mentioned above. Now, we had a response from approximately 60 percent of the schools. We are continuing our evaluation of those schools and if the chairman or any members of the committee would like to see the information, it will be supplied at your request. Our entire file is at your disposal. Mr. ROGERs (presiding). We would like to have that very much. Mr. CAHILL. We would be happy to supply it. Our breakdown is shocking. First, primarily research or academic-oriented careers, 11 percent. Second, general practice, 15 percent. Third, career military service or administrative medicine, 4.5 per- cent. And here, I think, is the clincher. Specialists, 69.5 percent. Now, may I say parenthetically, I cannot blame these young men. When you consider the tremendous work involved in general practice and the literally minimal return financially for that work, and the moderated and regulars hours that come with the specialty and the pro- portionate increase in income, and you relate that to the tremendous number of years that these men really put in to get their medical de- grees, many of them sacrificing a great deal, many of whom we all know whose wives worked to help them through, they really do under our present system, undergo a tremendous personal sacrifice and ex- pense to become a doctor, you really cannot blame them. Mr. ROGERS. What was that figure? - Mr. CAHILL. 69.5 percent are going into specialties. * Mr. SKTJBITZ. Will the gentlemen yield? I do not blame a young fellow for going into specialties. Mr. CAHILL. Nor do I. Mr. SXUBITZ. But as a taxpayer and as a person interested in get- ting doctors into a community, if we are going to put up money to educate these people, provide the facilities, then this is what we should demand. Mr. CAHILL. Yes, but Mr. Skubitz, respectfully I may say that under our present system we are not going to get them. Mr. SKTJBITZ. This is right. Mr. CAHILL. So, we have got to change the system. Mr. SKIJBITZ. This is right. Mr. CAHILL. You cannot expect a young man today under our present system to get into general practice. PAGENO="0121" 113 Now, I have some interesting things here. Mr. ROGERS. Just on that, of course, these who are specialists are also treating the public. Mr. CAHILL. Oh, yes. Mr. ROGERS. So, it is not a case of their being taken out of the treat- ment pattern but the point you are making is that they are just not in general practice. Mr. CAHILL. That is right, although I would say-I think Mr. lieu can confirm this-that many of the specialists are also in the the field of research. In other words, they are specializing in some area of patient oriented medicine while teaching or working on research. Now moreover, if further evidence of the flight from family medi- cine is required, the dramatic statistics indicating ratios of family doctors to population should be considered. While family doctors are in short supply especially in rural areas, the need for doctors is even greater in hospitals. Twenty percent of the internships and 15 percent of residencies remained unfilled in 1966, even after, and this is a shocker to Mr. Cahill, even after nearly 10,000 foreign trained medical gradu- ates were hired to fill these position. Moreover, the 51,800 positions available in hospitals in 1965 represented an increase of 1,400 over the previous year. So, it is fair to assume they are even greater today than they were based upon the statisics that I have. In view of present career directions away from the patient's bed- side, away from the hospital, and away from where physicians are most acutely needed, I would urge that we must undertake a national plan to produce general practitioners in a far shorter time of training than that which is required by the present system of medical education. In my judgment this can be accomplished within the resources and funds available at a Federal level, first, by a deemphasis in the amounts that are spent on medical research. Second, by an increase in Federal assistance to the construction and expansion of existing and new medi- cal teaching facilities and programs. And third, by an immediate effort to improve and ahhreviate medical school curriculum so that general practitioners can be graduated and undertake the treatment of myriad illnesses that can be healed without specialization within a 4-year period. Judged by these standards, the present Health Manpower Act is an important advance in meeting our Nation's health needs. Yet, I believe it will fall far short of attaining this purpose. I am concerned, for example, t'hat title IV provides "Such sums as may be necessary," through fiscal 1973 and an increase from 50 percent Federal assistance to 662/s percent assistance for health research facility construction. In the absence of a formula which would provide any incentive for appli- cants to increase annual enrollment foi' he number of' grauua tes, this piovi Si() 11 (an only fu ~tl icr the pieseiit flight. fron i gel ieral l"~~~- two and l)atie.ilt treatment. I would sinigest that the mentione(l ad- (litional Federal assistance above ~() Peic('llt should only be availai)lo to applications by medical schools where it is demoiistra ted that. th' ))l anned research facility would sign licantly increa~e medical school teaching and enrollment capacity. I would commend the. formula (Olitaliled iii part B of title I which provides that "institutional giants for meeting e.(lueat ional eXl)CllSeS will be allocated in a manner that. will encourage higher enrollment. PAGENO="0122" 114 Under this formula each school will receive a basic grant of 25,000 with the remainder of appropriations distributing according to rela- tive enrollment and relative increases in enrollment. However, in my judgment, these incentives to increase enrollment will have a major national effect on the output of medical graduates only if there are massive appropriations. Most medical schools will continue to find that research is the easiest and the most lucrative way of obtaining funds. What I believe should be undertaken is an effort to tie NIH and other research grants to medical schools to a formula which will re- quire increased enrollments as a condition precedent to receiving Fed- eral research assistance. I would thus advocate that amendment to the proposed Health Manpower Act be considered which would reduce the number of categorical project research grants administered by NIH, substituting therefor expanded "institutional research grants." These institutional research grants should be granted to medical schools rather than to principal chief investigators as is the current practice, and should be allocated on the basis of a formula which would give a weighted priority to those schools undertaking enrollment expansion. May I say parenthetically, it has been brought to my attention and it is presently under investigation, that some of the medical schools in this country are attracting and inviting men to join their staffs and to have high positions on their staffs based in some measure at least on the amount of their Federal grants which they bring with them and which is shared by the institution, and secondly, it has been represented to me, and I am not prepared to present it factually at the moment, although this is also under investigation, that this is having a very marked effect upon the teaching in those institutions because these men, rather than being clinical professors, are really research pro- fessors. These practices are seeping down into the students and in- stead of having the professors available in the classroom, we find they are in the laboratories and some assistant is in the classroom. The whole system, in my judgment, Mr. Chairman and members of this committee, needs a real good examination by this committee and I am delighted to see such interested and knowledgeable men on this com- mittee who are going to do just that. Let me close by saying that while I recognize that this general position is opposed by the AMA and the AAMC, independent prelimi- nary investigation convinces me that such an allocation of research funds is necessary. The AAMC is quick to urge that research is neces- sary to "maintain a balance in the multiversity concept of research, education, and community service." Let us examine this proposition. According to information provided me by the Department of Health, Education and Welfare and the American Medical Association library, the following is the effect on the number of medical graduates at the 10 medical schools in our ~ a- tion receiving the most research money. No. 1, Yeshiva University, the Albert Einstein College of Medicine, received grants of $10 million-I will just give you the millions without the thousands-$10 million. They graduated in 1965, 89 stu- dents as compared to 87 in 1966. That is a decrease. In 1965, 89, in 1966, 87. That is a decrease of two. Columbia University, $10 million~ Graduated in 1965, 114; 1966, 109. That is a reduction of five, PAGENO="0123" 115 Harvard Medical School, $10 million. 133 in 1965; 141 in 1966. Plus eight. University of California, $10 million. 71 in 1965; 70 in 1966. That is a decrease of one. University of Caifornia School of Medicine, San Francisco-the first being Los Angeles-$9,500,000. 100 in 1965; 99 in 1966. Decrease of one. IJniversity of Washington, nine million, 65 in 1965; 81 in 1966. An increase of 16. Washington University, $8 million. 83 in 1965; 85. in 1966. Plus two. University of Chicago, $8 million. 67 in 1965; 59 in 1966. Minus eight. University of Pennsylvania, $8 million. 124 in 1965, 132 in 1966. Plus eight. Johns Hopkins, 82 in 1965, 84 in 1966. Plus two. So, out of a total Federal grant expenditure of $94 million, we graduated from these 10 schools in 1965, 928 students, in 1966, 947, for a net gain of 19, with almost $100 million. Certainly I would agree that medical research has brought about dramatic improvements in medical technology and education, and I certainly concede what the eminent doctor who preceded me said about the Salk vaccine. The thing that does disturb me, however, is that with the elimination of all of the patients that ordinarily would be treated by reason of the discovery of Salk vaccine, why do we not have enough doctors at the present time to take care of the other ail- ments, diseases and injuries, and why have not medical costs in most areas of treatment been reduced. However, I am convinced that there is a major gap between the presently available advanced technology and the manpower now avail- able to apply that technology. This brings us to the argument of quantity versus quality. The con- tentions that any reduction in Federal research funds or abbreviation of medical school curriculum will result in diminished quality of the physicians is in my judgment, nonsense. It is the same contention that the National League of Nurses has employed to rethjn its power of accreditation over nursing schools. Acceptance of that contention by the Congress and by the Department of Health, Education and Welfare, has had disastrous effects on nursing education, particularly on diploma training schools which do not fit in the NLN's plans to make nursing a 4-year college degree program. I thus view the title I, special project grants, section with hope, yet with some degree of apprehension. This section will provide Federal assistance to projects designed to "improve medical school curriculum with a view to helping increase the supply", and here is the key word, "increase the supply of adequately trained personnel in health pro- fessions." Now, while I am talking about quality, as a member of the Sub- committee of the Judiciary Committee on Immigration and National- ity, I have been terribly disturbed by the number of foreign doctors who are coming into the United States and I know the gentleman from Florida realizes the work we have done in that committee in providing the State of Florida with needed help. But the figures as I have them, indicate that in the United States in 1966, we had 2,795 PAGENO="0124" 116 interns, we had 9,483 residents, and we had 34,000 practitioners who were educated outside of the United States who are foreign trained doctors. Now, I am not able to judge the competency or the quality of all of the medical schools in the world, but I think it would be fair to say that many of them do not meet the high standards established in this country, and yet I have seen myself on the night shift at a good many of the hospitals in my state, men who find it difficult to speak the English language who are there as interns, but who are there taking care of the desperately ill during the night hours. Priority is to be accorded those projects which will result in in- creased enrollments with "no reduction in quality of training." I would hope that the qualifying words "adequately" trained personnel and "no reduction in quality" will not be used to prevent truly innovative and effective plans to abbreviate med school curriculum. Now, I do not object to this. I merely say that when we talk about quality, let us be rational and let us be realistic, and let us, if we can, Mr. Chairman, get a statement from the AMA ~nd from the AAMC of what is quality education, because if we have that, we then can objec- tively judge the foreign students and the foreign interns and the foreign graduates, and if all that is necessary is to pass a test along the same lines that a foreign doctor must pass in order to be admitted to practice in this country, then why cannot we train our boys in this country who can have this same amount of education that will permit them to pass a similar test. Why cannot they then practice the same way as the foreign doctor? In my judgment, we as legislators cannot completely defer to organized medicine in determining what is "quality." Now, I am a lawyer and I know many of you are. I cannot practice certain fields of law. Why? Because I am not qualified. I am a general practitioner. What happens if a client comes to my office *and wants my assistance? If it is in the field that is over my head, I refer them to a specialist, and it seems to me that a good practitioner, a good general practitioner, need only know the limits of his own com- petency and his ability to take care of his clients within the limits of his own ability, and if he is a good one, his client is going to benefit, not be harmed, so it seems to me it would be with a medical doctor, The young general practitioner who is not as learned, who does not have the years of training, would recognize immediately that an orthopedic problem required the services of an orthopedic surgeon. He would not attempt to set the broken leg but he would recognize it was a broken leg, but if it were something else, cold, fever, something that would upset a mother in the midde of the night or a father, who was deeply concerned about some growth, he might be able to allay those fears, give the people something that would hold them over until they could get to the specialist, and it seems to me this is what we need in this country. Mr. SKUBITZ. Would my colleague yield? Is it nof a fact, Congress- man Cahill, that your general practitioner in the field usually refers problem cases? Mr. CAHILL. Then, Mr. Skubitz, my point is why, then, insist upon training all of these men in research methodology and in highly spe- cialized fields that they will never use? Mr. SIcumTz. You do not have to convince me. I have raised this very question time and again, Mr. Cahill, with some of my doctor friends. PAGENO="0125" 117 Mr. CAHILL. All right. Well, I have already taken much more time than I intended to take but let me just say this. I would certainly urge this committee to draft amendments to this legislation that would assure the establishment under the special projects section of a demon- stration project designed to prove the feasibility of a 4-year medical school curriculum. When a boy graduates from high school, why cannot he go to a medical school? Why can he not go for 4 years? Why can he not be trained in the general elementary, rudimentary, primary facets of medical education? Why can he not then like the lawyer, serve an externship with the family general practitioner? Why can he not work in the hospital? And, why at the end of the 5-year period can he not be given a limited medical license so that the farm areas and the ghettoes of this country and the families that need a doctor at night and on weekends, can at least have somebody who can distinguish between what is serious and what is not serious. And, it seems to me, if we have that, we would have more specialists willing to get up in the middle of the night. One of the great cries and justifiable complaints of a specialist is that he is disturbed in the middle of the night and he finds that there is nothing really wrong. It is an apprehension that just anybody who had a little bit of rationale, a little bit of knowledge, could allay and say: "You do not have to worry about it until tomorrow morning. The doctor will be in the hospital tomorrow morning. We can take care of it then." But, they get specialists up at 2, 3, 4 o'clock in the morning, call him in, and it is not an emergency at all. So, it seems to me, this whole concept should be tried. This was brought to my attention by the article that was written by Dr. J. Gershon Cohen, who incidentally, had intended to be here today to testify, who called from Philadelphia that because of a plane can- cellation, could not make it. lie is preparing and sending to the committee a statement. But, he is the one who brought this concept to mind. He suggests, and I am not going to testify for the doctor, but he suggests that some of the large medical centers in the United States could be very easily converted into such a teaching school, that all we would really need would be the dormitories and classrooms. They have the facilities. Many of them are 1,000 bed hospitals. They have the doctors, many of whom would be delighted, be honored really, to be able to teach, who cannot get on the staff of an accredited medical school. And, every man in this Congress can testify to literally hun- dreds of boys in his district who are qualified, who are A and B stu- dents, who are financially able to pay their way and who cannot get into medical school. And the reason for it is that there is a limited number of seats and only the very best can get in. And, I often think that a boy today has much more difficulty becoming a doctor than he has anything else in this country, and, gentlemen, I think the time has come when the American people are not going to wait any longer, and if your area of the country is like my area of the country, the Congress of the United States better do something about it because we cannot go on this way much longer. Gentlemen, I am very grateful for the time you have given me. I am sorry I have taken so much of your time, but as you must observe, it is a matter that I have had a very personal interest in for some time. PAGENO="0126" 118 I have a very intens~ conviction that we must produce more doctors and we must produce more nurses if we are to take care of the needs of the American people in the foreseeable future. Mr. ROGERS. Thank you very much, Mr. Cahill, for a very excellent statement and for some of the thoughts you have developed. And this committee will certainly consider them. I know in line with your thinking about a 4-year college education a great deal is being done in this area which this committee has encouraged because we feel that this is a possible approach, and I think you have stated it very well. We are very grateful to you. We would like to have the figures that you have gotten, too, from the various colleges. Mr. CAHILL. I will be happy to do so. Mr. ROGERS. Mr. Nelsen? Mr. NELSEN. Thank you, Mr. Ohairman. Mr. Cahill, I remember the statements made on the floor by you and Mrs. Bolton about the lack of bedside nurses, and the fact) that so many young ladies would find it impossible to become a registered nurse because of the financial obstacles involved. I have made reference to this in the hearings several times. I think the point is well taken because there are so many things that can be done by such a nurse who is not necessarily an RN. I want to thank you for that observation. I wish to say, to)o, that while you have stated that you are a general practitioner and not a specialist in the field of law, I would like to have you plead my case any time, judging from the presentation you have made here tO)day. I think it has been very good and I think it will have a great impact on the action of this committee. I can assure you we are going to study your statement in the record which I know will be helpful. Mr. CAHILL. Thank you, Mr. Nelsen. May I just sa)y for the mo- ment that the thing that troubles me about the nurses, and I, inci- dentally, have a daughter who is a nurse, the thing that troubles me, is a lot of these kids do not want to go to college. They want to) be nurses. They want to take care of the poor. It seems to me that we are just crazy in this country. We have so many kids that want to do so much and we will not let them. We will not let them. We will not give them the opportunity to go into a hospital to learn patient care. We will let them go in and serve candy, let them do all these things, but we will not let them take care of patients~ gain experi- ence through doing, and let them become nurses. This is crazy! We have got literally hundreds of thousands of good kids and we just will not let them do it because they do not have a college educa- tion. it does not make sense to) me. So, I hope you will pursue that, Mr. Nelsen. Mr. NELSEN. Another point I would like to call attention to is that Art Younger, a former member of this committee, tried to provide incentives and provisions in our training of doctors to encourage them to go to a rural area as a general practitioner. It has not seemed to work but we do encourage it, but it has not worked. Maybe we need to closely examine the whole process. Mr. CAHILL. Mr. Nelsen, the profit motive has to work with medi- cine as it does with law and everything else and if we do not make it financially feasible for these young men, reasonably; we cannot ex- pect them to do it. PAGENO="0127" 119 Mr. NELSEN. No more questions. Mr. ROGERS. Mr. Skubitz? Mr. SlcuinTz. I want to commend you on your statement, Mr. Cahill. I think it was excellent and I, for one, want to express my apprecia- tion for you appearing here today. I have always felt that our colleges today are competing for grants- research grants. The net, result is they are taking bright boys and putting them on a research project rather than teaching them to be doctors. Mr. CAHILL. You are~ right. Mr. SKUBITZ. This is why we are not getting trained people in the field. We are getting researchers. Mr. CAHILL. It would be very interesting to me~-I am sure I will not get the information, but I think the committee could-it would be very interesting to me tO see what the deans and the leading pro- fessors of the leading medical schools of this country have by way of personal grants. It would be very, very educational. Mr. SKUBITZ. Mr. Cahi1l~ you mentioned students going to college. A lot of them do not want to go to college because they are taking 4 years of things that they do not think are going to do them ofle whit of good. They cannot get into the field, the field of their choice without taking a lot of courses which seem unimportant and unrelated to them. Mr. CAHILL. Exactly. Mr. SKUBITZ. I have a nephew. He quit college after 2 years and went into the service. When he received his discharge, I asked him what he planned to. do? "I just do not know Uncle Joe," he replied. Then he went on to say that be couldn't see where the courses he had taken in college prior to his Army service would do him one bit of good in earning a living. I sent him to art school. Today he is an artist in the Government service. He had flunked college because he could not see any relationship between the courses in history, et cetera, to the kind of work he wanted to do. Mr. OAHILL. I~ight.' You cafi hdve the kids today that are going into all sorts of fields to help their fellowman. I think medicine and nursing really is a great attraction to all of them. I have taken too much time. Thank you very much. Mr. ROGERS. Thank you very much. (Dr. Gershon-Cohen's statement follows:) STATEMRNT OF DR. J. GERSHON-COHEN, MI),, D. Sc. (MEDICINE), DIRECTOR EMERITUS, DIVISION OF RADIOLOGY, ALBERT EINSTEIN MEDICAL CENTER; PRO- FESSOR OF RESEARCH RADIOLOGY, TEMPLE UNIVERSITY SCHOOL OF MEDICINE The physician shortage is dec~1ed on all sides. In the medica~, scientific, and lay press, on television and on radio, the subject is discussed and documented. Even the Americnn Medical Association, which for 25 years denied that a short- age was in the making, now admits its exists. When the Flexner Report was published in 1911, the substandard practices of many of the 150 medical ~choo1s then in existence were exposed. Sweeping reforms closed about 50 percent of them. Today we have 89 medical schools in operation. We now turn out no more physicians per year than we did in 1911, although the quality of their education has been upgraded until it is among the highest in the world. However, in the intervening 57 years our `population has almost tripled. The supply of physicians which was adequate to meet demands for service in the PAGENO="0128" 120 early 1900s is hopelessly inadequate to meet those of the late 19$Os. In other words, there is a serious imbalance in the law of supply and demand, and when this law is flouted or ignored, trouble invariably follows. This law has been by-passed particularly in the area of general practitioners, the physicians the public needs most. But our current medical educational system consistently produces almost exclusively specialists. By its very length and content, the system makes specialization almost inevitable. The medical student views it as the only way in which he can recoup the inordinate amount of time, money, and energy he has been obliged to invest,. While his high school class- mates have graduated from college and are making respectable livelihoods with their degrees in engineering or metallurgy in their early 20s, he is still a medical student until he is almost 30, a virtual stranger to his growing family, and piling up indebtedness. The courageous few graduates (about 15 percent) who undertake to be primary physicians find themselves too overworked and spread too thin to be the unhurried, compassionate doctor with the listening ear that once prevailed. The public, knowing only that it can no longer find a doctor when it needs one but not und~rstanding why, becomes increasingly irate, No longer is there a balanced competition among the members of the medical profession to supply the service the public expects. A remedy is being demanded-and quickly! A situation of this type is a perfect setting for political intervention. A prescription to remedy this grave state of affairs is offered here. It opposes a new-type medical student trained in a new-type medical school. It could lead to the production, in goodly numbers, of the primary physician, or "general practitioner." A NEW-TYPE PI~EMEDICAL STUDENT Since the length of the physician's education is central to the dilemma, that phase of it deserves first consideration. It is a fact that we lose many bright young physician-prospects to shorter courses in other scientific fields because of the long, expensive haul the medical career entails. I believe we could "reclaim" many of these young people by offering them an abbrevi- ated medical preparation which would permit them to by physicians while they are still in their early 20s, about the same time their classmates were striking out on their own in other fields. The first step in this abbreviation should be elimination of the four pre- medical college years, which could be done by retroplacing the essential basic science courses into the high school years This concept has been discussed with eminent high school teachers, and most of them feel it is practicable. Actually, only five subjects are de rigueur for entrance to our current medical schools: (1) inorganic chemistry; (2) organic chemistry; (~) physics; (4) biology; and (5) calculus. The catalogues of more than 20 universities and colleges were studied thoroughly and, with a rare exception, bear this out. All other courses the premedical student takes in college contribute only to his well-rounded education; they are not specific to medicine per se. The high school students embarking on this career would, of course, be exceptional youngsters. They would be unusually intelligent, emotionally mature, and have a scientific bent. Above all, they would be motivated by a zeal for public service. Good instructors would have to teach these high school courses, and adequate laboratory facilities would have to be available. A suggested roster of study is shown in Table 1. Having mastered these curricula successfully, the high school graduate would matriculate directly into a medical school prepared for him, one that is tailored to educate him specifically for the unique niche in the medical profession that he would occupy. A NEW-TYPE MEDICAL SC~HOOI~ The new-type medical school designed to receive this youngster would Oe unlike any medical school extant. Its purpose would be to educate the student for general practice specifically, from his first year to his last. Our traditional medical schools compel every student to take an incredible spectrum of complicated, esoteric, over-specialized subjects because it has not been decided at the outset by anyone, and least of all by the student himself, what his future role will be. So he is taught endlessly about everything, by the best faculties in the various special fields, so that he may become (if he chooses) a specialist, a teacher, or a research worker in exotic fields. But he is never PAGENO="0129" 121 taught as if he will be a "family doctor." In fact, the subject is rarely mentioned in the medical school curriculum he pursues. And since all his teachers are specialists, he will seldom brush up against a general practitioner who can explain the rewards of this type of practice to him. During years 1. and 2 in the new-type medical school, the student's education would approximate that of the traditional freshman and sophomore (Table 2). But because he has already received a good deal of the necessary basic science instruction during his high school years, less time would be spent on these subjects than would occupy his traditionally-educated counterpart. In year 1, for example, about 30 per cent of his time would already be spent on subjects germane to general practice. In year 2, it would climb to 65 per cent, as nonessential subjects were pared away. In years 3 and 4, all of his time-tOO per cent of it-would be expended on the problems and illnesses encountered in general practice. He will learn of them not from books or classroom instructors, but will see them in ambulatory patients who attend out-patient clinics or when he attends ill patients in their homes to which he has been assigned (Table 2). His teachers will be general practitioners of repute and internists of profes~ soral status. These faculty members know the problems a family doctor must deal with. They also know how to differentiate common ills from those that require the skills of a specialist, and will pass this knowledge on to the student. Specialists, too, will instruct our neophyte, for he must be aware of what specialists and specialties can offer his patients when his own limits have been reached. But the instruction here, too, will be "live" and "by example," nor from didactic lectures and textbooks. The specialists will demonstrate using the very patients the student has been following in clinic Or at home, whose Illness has progressed to a stage that requires hospitalization and greater skills. Allowing the student to collaborate with specialists in the care of hospitalized patients is a form of education that cannot be excelled. While the student watches the specialist at work he not only learns about highly sophisticated medical tech- niques of diagnosis and treatment, and how they can help his patients, but from casual small talk he becomes familiar with many intangible aspects of medical practice. In the fifth, or mandatory "intern year" (Table 2), the student physician Is working pretty much on his own. He is now precepted to a traditionally-educated physician (M.D.) practicing alone, or to a group. Thus, the emphasis of the student's training never wavers in the five years; it is family practice-oriented from high School onward. This single-purpose educational system will engender a very important attitude in our young physician-that of being responsible for the comprehensive care of his patients. He learns to be responsible for the decisions that affect their wel- fare whether they are very young or very old, in good health or bad. The only time he surrenders bi~ province to the specialist is when a problem arises that be has been trained to recognize as lying beyond his capabilities. The tacit agree- ment between his specialist instructors and him is: "You teach me (the primary physician) how to differentiate the various special problems from the ordinary, and when they arise I will turn `them over to you (the specialists) for treatment. But I will remain, as I have been, the patient's personal doctor." For the return of such an arrangement the public would be immensely grateful, for the disap- pearance of a "doctor of one's own" is one of its chief complaints. HOW DO ~E CREATE, STAFF, AND FUND SUCH xrw-TYPE MED~OAL SCHOOLS? Medical schools geared to training primary physicians exclusively could be cre- ated quickly and at very little cost if we use ~a'isting medica' centers as their Buclei. Many of the faculty that now staff these centers could teach the new-mold medical students. Expanded classroom and office space is all that is required. Every medical center already has the most necessary component to any physi- clan's medical training-an established hospital and its busy cluster of out- patient clinics. ALBERT EINSTEIN MEDICAL CENTER-AN EXCELLENT PROTOTYPE In Philadelphia, for example, the Albert Einstein Medical Center is eminently suited for conversion to such a medical school. In this institution is a broad spectrum of physical facilities and teaching personnel. Most staff members are general practice oriented and would make ideal instructors for the new-type medical student. 05-540-68-9 PAGENO="0130" 122 Also at this center is a flourishing basic research department, with more than 20 Pb. D's of professorial rank, who could teach all the preclinical sciences, including anatomy, physiology, pharmacology, microbiology, genetics, pathology, higher mathematics, cybernetics, biophysics, biochemistry, and bio-engineerlng. In the geographic area of this superb center are two exceptional high schools- The Central High School for Boys and The Girls High School o~ Philadelphia. Because of the superiority of their faculties and the challenge of their curricula, these schools attract the brightest minds of the entire city. Their student bodies probably represent the top 10 per cent of the higb-I.Q., highly-motivated young people of the metropolis. To pupils such as these, during their first high school year, we would offer the new-type medical career. We would present its assets and liabilities honestly at the outset, so the students could consider them objec- tively and make a considered choice of this career as their life's work. Can young people this age decide the'ir futures? There are those who contend they cannot; or that, if they decide at 14 to become a doctor of this type, at 18 they may very well decide against it. It is the nature of young people to be inde- cisive. We expect avid enthusiasm one minute and indifference the next in many other things, such as mode of dres'~, choice of friends, and recording stars. We would anticipate many to drop out despite initial expressions of interest, even dedication. But if only a fraction of those who began the courses completed them, we would still `have more than enough students to accomplish what we have in mind. And, with the background in the sciences achieved by the drop-outs, they could easily turn their attention to other fields of their choice. The first matriculates to this new~type medical school could quickly be mus- tered from those excess applicants who are currently `denied entrance to existing schools. We have a yearly application rate of some 18,000 for the 8,900 berths available! Our physician-to-be entering from high school would be about 22 years of age when he graduates from medk~al school. People this age are more mature than we give them credit for being. They marry, raise families, command other men in military service, and are the very age of the physicians-in-training sick people now turn to in hospital emergency rooms and clinics because they cannot find G.P.'s. This primary physician would be young enough to bring vitality and eagerness to his job. He would not be jaded by years of specialized education in subjects he would never use in family practice. He would not yet be encumbered with a growing family or a heavily indebtedness from prolonged schooling. He would be trained expertly and specifically to be `an excellent family doctor, a gener~il practitioner who knows his own skills in relationship to those of specialists-and where to draw the line. He could handle 90 percent of the public's common ill- nesses, for only 10 percent of sick people need the services of a specialist. A NEW DEGREE EOR A NEW STATUS Having field-tested the feasibility of the new-type education in the high schools mentioned and in the special medical school converted from centers like the Albert Einstein Medical Center, the next step would be to field-test the new physician among the medical profession and the public. What degree could we give him to indicate his special niche in our society? When we consider his degree, we should think of it as a truly undergraduate degree, in contradistinction to the current M.D., which is actually a graduate degree comparable to a Ph. P. in other fields, for the possessor usually already holds a baccalaureate degree from his premedical college. Of at least a dozen possibilities, for the purposes of this discourse let us call him a D.CM., for "Doctor of Comprehensive Medicine," which is precisely what he would be. He would not treat an ear, an eye, a heart, or a vascular system, hut the "whole man," the comprehensive patient. The D.C.M. could take a good history (an art in itself) ; make a thorough physical examination; prescribe for and otherwise supervise the majority of ills; maintain rapport with patients by telephone; make house calls; refer to specialists those patients whose ills he feels unqualified to handle himself; and take care of his own patients in the hospital, should hospitailsation be indicated. For this last step, we must restore `an old tradition: We must open the hospital doors to the general practitioner. This move `would benefit the D.C.M., the public, and the profession at large. PAGENO="0131" 123 OPEN HOSPITAL DOORS TO FAMILY DOCTORS If we are going to produce a good family doctor who will remain content to be a family doctor, we cannot make him endure the ignominy of following a patient's case meticulously up to the point of requiring hospital care, then shut the hos- pital doors in his face. We must give him hospital privileges so that he can have parity of status with his peers and be back in the mainstream of medicine, rather than inferior to it or on the periphery. One of the seldom-admitted reasons medical graduates today do not enter general practice is that hospital privileges are denied them and that their status, overall, is considered "second-rate." The D.C.M. would not teach in the hospital. He would not engage in research. He would, instead, investigate his patient's problems in the broader hospital setting with its expanded resources. He would understand that his work would always be under the review of the hospital-based consultant specialist in charge of the department, But It would not be difficult for the D.O.M. to accept these concessions for the privilege of caring for his own patients in the hospital setting, knowing the handsome dividends it would pay: (1) his patients would remain, basically, his patients, even though specialists would temporarily super- vise their regimen; (2) he, himself, would constantly be receiving graduate edu- cation as he watched how specialists handle patients whose needs exceed the skills the D.C.M. can provide; (3) he would keep abreast of the giant steps medicine takes every day by being in the hospital atmosphere where they occur, and the absorption of this knowledge would be a vital backdrop to his major function of being an aware, broadly-informed family doctor. THE PRESCRIPTION CONTAINS "5AFEGTJARD5" We have prepared our new-type primary physician superbly in high school and later in the new-type medical school. Chronologically, he is ready to begin serving the public at 22 years of age. But, some may ask, is he ready to practice at that age? Has he learned enough to blithely hang out his shingle and supervise all the help from social agencies, as well as to handle the ill patients who would soon find their way to his door? Wouldn't we all be uneasy about the qualifications of so young a physician-unless he had passed some decisive examinations? For these reasons, certain safeguards are built into the prescription. The young man would not be permitted to practice by himself as soon as he graduates. He would be required to practice at least a year under the watchful aegis of superiors-a group of G.P.s would be ideal. In this setting he would build his confidence, add to his maturity, sharpen his judgment, and steadily increase his knowledge. As a final test of readiness to practice alone, his competence would have to be certified by the same state and aational boards of medical eaaminers that accredit traditionallY-tro/ifled M.D.s. If he failed to pass at first try, he would be required to extend his preceptorship as long as was necessary. But at no time would he practice alone without, certification. With such safeguards, neithet the medical profession nor the public need to have any qualms about the com- petence of the D.C.M., despite his obvious youth. ONCE A D.C.M., ALWAYS A D.C.M.? Not necessarily. It is possible that the person who decided to be a primary phy- sician in his youth and enjoyed its pursuit for most of his life may wish to alter his status in later years. His family has grown and assumed its own responsi- bilities. He himself is older and less elastic. The demands of a general practice can begin to be wearing when one has passed the zenith of youth. We all know dedicated general practitioners who enter specialties in their later years. The D.C.M. status need not be considered permanent. a trap without au exit. At any time this doctor decides to pursue some special facet of medicine that has intrigued him the sturdy basic education he has received makes specializatiotu possible He need only take the courses necessary to qualify him for the field of his choice He may well appreciate the shorter hours and circumscription of prob- lems afforded by a specialty when his steps begin to flag. Even though he then becomes a specialist, however, for many years he has served the public as a "personal physiciafl"-the capacity it so badly needs. AFTER LOCAL FIELD-TESTING-WHAT After the plan has been field-tested locally and its merits proven, it could then be implemented lfl the more than 50 centers like the Albert Einstein Medical PAGENO="0132" 124 Center across the country. If each one produced but 100 D.C.M.'s a year, it would mean a pool of 5,000 family doctors on which the public could draw for care and advice in ills that now distress them. (Russia at present turns out some 27,000 doctors a year in contrast to our 8,900!) Specialists would be reserved for the problems they are trained to handle best, as well as for teaching and for en- gaging in research activities. The prescription represents a logical, step-wise plan to rebalance the law of supply and demand throughout the profession. The major gain, perhaps, is that a bountiful supply of physicians would again engender competition, something that has long been lacking but which is an integral part of any free enterprise system such as ours. Competition tends to upgrade the quality of services and weed out the indifferent, the improperly motivated, and the inefficient. The patient who receives short shrift at the hands of one D.C.M. will not be in a bind because he has nowhere to turn; he can select another from a good supply, one who will meet his physical, financial, ~nd emotional needs. Competition is a powerful force for innovation and improved technology. It helps to improve the quantity and the quality of all products- including medical care for the public. SUMMARY The Problem Unmistakable symptoms indicate that American medicine is suffering the illness of an acute physician shortage. This is particularly evident in the area of general practitioners or primary physicians. The chief cause for the situation is our failure to meet the dictates of the law of supply and demand, a natural law that cannot be flouted without incurring grave consequences. The Prescription We must produce, quickly, a large number of primary physicians to fill this important void and rebalance supply and demand~ These men would be trained from high school through medical school to be superb general practitioners. They would not be second-rate physicians, supernurses, or physicians' assistants. They would be doctors, with their status certified by the same state and national boards of examiners that qualify current M.D.'s. They would differ from traditional physicians only in attaining their premedical education in high school and in continuing their medical training in schools whose curricula eliminate esoteric subjects G.P.'s never use. The education of this primary physician would be logical and progressive. (1) lIe would start his training in high schools which offer special medically-oriented basic science courses; (2) He would matriculate upon graduation into a new- mold medical school specially structured to receive him, by-passing the four-year premedical college course; (3) He would be taught in these special schools by faculty knowledgable in the needs and problems of general practice and general practitioners; (4) He would concentrate on those subjects essential to his prac- tice, learning only sufficiently about those not germane to his training; (5) He would be apprenticed at graduation for at least one year to a conventionally- trained M.D. or a group of G.P.'s in order to gain practical experience and maturity; (6) He would be assigned a special degree, possibly a D.O.M., to indi- cate to the public and his peers the special training he has received for service to the community; (7) He would be certified as ready for solo practice only after passing rigid examinations as current M.D.'s need to do; (8) He would be per- mitted to care for his patients in the hospital, ensuring for the patient continuity of care and for the D.C.M. continuation education while he watches specialists at work; (9) He would be prepared to enter public service while he is young, vital, relatively unencumbered by debts or a growing family; (10) He would be able, should he so desire later, to enter the ranks of specialists. The Anticipated Results The ingredients of the prescription would `satisfy the dictates of the implacable law of supply and demand. In a very `short time after it had been made universal, the G.P.-to-SpecialiSt ratio would `become more realistic. Healthy competition, long absent, would again prevail, leading to upgraded services and bette'r all- around medical care. The public would be far happier kno'wing it bad numbers of interested family doct'ors in its midst. The `medical profession as a whole would be less likely to come under the mandates of government in `order to `resolve the current physician crisis. Medicare and i'ts offshoots are portents of things to come. PAGENO="0133" 125 Let us exert our initiative while there is still time. Let us act with speed and specificity. Let us act Now! TABLE 1.-~uggestecl curriculum for premedical high school students Periods Freshman year: per week Biology, with laboratory (major) 8 A1ge~bra (major) 5 English (major) 5 World history (major) 5 Latin and/or Greek (mandatory), (major) ` 5 Elements of chemistry (minor) 2 Total periods per week 30 Sophomore year: Chemistry, with laboratory (major) 10 Algebra, with geometry (major) 5 English (major) 5 World history (major) 5 Latin and/or Greek (mandatory), (major) 5 Total periods per week 30 Junior year: Organic chemistry, with laboratory (major) 8 Analytic geometry, trigonometry, algebra (major) 5 English (major) 5 World history (major) 5 Biology, human anatomy (minor) 3 Physics (minor) 2 Physiology (minor) 2 Total periods per week 30 Senior year: Physics, with laboratory (major) 8 Calculus (major) 5 English (major) 5 Introduction to social sciences (ardhropology, psychology, sociology) (major) 5 Microbiology, biochemistry (major) 5 Topics in biological and physical chemistry of biological interest (minor) 2 Total periods per week 30 1 A second language, such as French or German, would be retroplaced into the junior high school curriculum. PAGENO="0134" 126 TABLE 2.-Suggested "core curriculum!' for new-mold medical school Periods per week, rough Freshman year: estimate Anatomy - 3 Neurology (1 each of neurobiology, neuroanatomy, and neuro- surgery) 3 Radiology 3 Physiology 3 Pharmacology 6 Pathology 6 Epidemiology and medical sociology 2 Medicine 5 Physical diagnosis 3 Psychiatry 3 Medical outpatient clinics 4 Total 41 Sophomore year: Pathology 5 Microbiology 5 Physiology 2 Pharmacology 2 Medicine 14 Clinical neurology 2 Pediatrics 2 Psychiatry 2 Epidemiology and medical sociology 2 Elementary physical diagnosis 3 Total 39 `Junior and Senior Years All of the student's time in the junior year would be spent in learning practical family medicine. There would be short, explicit courses in family,, community, social, political, economic, and historical aspects of medical service. Hospital integration would be minor, consisting merely of brief periods which would serve to acquaint the student with the acute, chronic, emergency, and rehabilitative ph'ases of medicine. In the senior year, during the first 6 `months the student should `be assigned as an iiatern in the hospital, getting `experience in minor surgery and obstetrics. In the last 6 `months of this year, he should be placed as a preceptee to a qualified teacher of general practice or to a group of physicians practicing together. In. both the jwnior and senior years, he would be `spending a major portion of his time in out-patient work, learning to integrate all the `clinical `aspects of medicine with his practical and texlbook knowledge. The "Fifth Year" (Mandatory) The traditional internship would be dispensed with. Instead, the young physi- cian, now appropriately titled, would continue to practice `as a preceptee to a solo physician or to a group. During thi's year of experience, he would continue to enla'rge his knowledge and `skills, and would learn first-hand about such things as medical economics and his own unique role in the complex community `set-up for providing medical services `to tb~ public. During this period, his reading mate- rial `should consist of `medical `history an'd two or three scientific journals slanted specifically to the problems of general practice. He would attend hi's patient in the hospital, in collaboration' with specialists. This arrangement would afford him a working knowledge of bow his handling of patients comes under the specialists' surveillance. In turn, it will be the responsi- bility of the specialists to continue to educate the general practitioner. Mr. RoGERs. Our next witness is Dr. Samuel P. Martin, who is pro- vost of the Medical Center at the University of Florida. It is my per- sonal pleasure to greet Dr. Martin. I have known him and know of the very excellent work he does and I think he can probably help us and PAGENO="0135" 127 guide us here because he can give us some answers to some of these questions we have been asking. And, I know of no one who is better qualified to help the committee in this area. It is a pleasure to have you. STATEMENT OP DR. SAMUEL P. MARTIN, PROVOST OP T~tE UNI- VERSITY OP PLORIDA; ACCOMPANIED BY DR. ROBERT C. BERSON, EXECUTIVE DIRECTOR, ASSOCIATION oP AMERICAN MEDICAL COLLEGES Dr. MARTIN. Thank you, Mr. Rogers. You have given me more than an adequate introduction. I am a physician, provost at the University of Florida. I would first like to introduce Dr. Robert Il3erson, who is the executive director of the Association of American Medical Colleges, who is with me here today. Mr. ROGERS. We are delighted to have you here, too, Doctor. Dr. MARTIN. I am appearing on behalf of the Association of Ameri- can Medical Colleges which represents all of the schools of medicine in the United States and 340 of the maj or teaching hospitals. We appreciate very much your courtesy in providing time for us to testify in favor of a bill which, if enacted, will be a great forward step in the history of the health professions in this country. Mr. Chairman, our association has presented a statement to the other body which explains the role of the medical schools in the health manpower picture and sets forth in detail our reasons for supporting each of those portions of the bill which will be directly affecting our institutions. I would like to offer that statement for your considera- tio~i and for inclusion in the record of this hearing. Mr. ROGERS. That statement and your prepared statement will fol- low your oral presentation. You remember the comments on the growth of medical school bud- gets and faculty and the limited increase in students. I think these are very excellent questions and they are very important questions in rela- tion to our problem. I placed before you three tables and I would like to comment a bit on those three tables. Table 1 shows a breakdown of the expenditures. It is obvious that the expenditure of medical colleges rose from $319 million to $882 million over the period of time that Congressman Rogers and Chair- man Jarman noted. Sponsored research, however, in that time rose from $144 million to $514 million, an increase of 256 percent. (Table 1 referred to follows:) TABLE 1.-MEDICAL SCHOOLS-RELATION OF TOTAL EXPENDITURES TO EXPENDITURES FOR SPONSORED PROGRAMS,t 1958-59 AND 1965-66 1958-59 1965-66 Percent increase Total expenditures $319,028,651 $882,184,162 176 Sponsored programs Regular operating programs 144,237,916 174, 790, 735 514,206,314 367, 977, 548 256 111 I Sponsored programs are those undertaken by medical schools at the behest of the Federal Government or private agencies to achieve particular results which are not directly related to the teaching of medical students. Note: Prepared by the Association of American Medical Colleges. PAGENO="0136" 128 Dr. MARTIN. The regular operating budget rose from $174 million to $367 million, a rise of 111 percent, and as one remembers the com- ment made by Mr. Nelsen during that time the dollar changed from its buying index of 1 to 1.24, so that part of that is involved as an inflationary figure. And another part of it, that is a significant part that is there because of our past legislation, is the requirement for cost sharing because as a grant comes in, one has to produce out of one's institutional support things to cost share with the Government on its granting, so that a part of that rise from $174 million to $367 million is cost sharing by the Government. Now, what have the schools done during this period of time? If you look at table 2 you can see something of the productivity. I do not have the same years that you have on the fact sheet hut you will see that the rise in medical-school enrollment was 14 percent. Now, during this period of time, however, if you look at the next figures, you begin to see that the character of the academic medical center is changing. We not only produce physicians but we must produce a number of other people and that is shown very clearly below. (Table 2 referred to follows:) TABLE 2.-MEDICAL SCHOOL PRODUCTIVITY, 1950-66 1950-51 1955-56 1960-61 1965-66 Medical student enrollment MS. or Ph. D. candidates Postdoctoral students or fellows Interns Residents Other full-time equivalents Ph. D. degrees awarded M.D. degrees awarded US. population in thousands M.D. graduates per 100,000 population Full-timefaculty 26, 186 4,281 1, 238 1,786 4, 259 3, 000 225 6, 135 151, 683 4. 04 3,933 28, 748 2,387 2, 000 2,094 6, 192 5, 000 282 6, 845 165, 0S9 4. 15 6,719 30, 093 3,304 4, 317 3,727 13, 273 8, 743 339 6, 994 179, 992 3. 89 11,111 32, 835 7,056 5, 014 3,963 15, 9~7 11,315 606 7, 574 194, 572 3. 89 17,149 Note: Prepared by the Association of American Medical Colleges. Dr. MAItTIN. The M.S. and Ph. D. candidates have increased from, in 1955, 2,300 to 7,000, We had a 190 percent increase. These people are not only researchers hut these people are teachers. Twenty-five to 30 percent of the faculties of medical schools come from this particular group, the M.S., Ph. D. men. From 2,000 to 5,000 in our post doctoral students and fellows, an increase of 150 percent. Our increase for in- terns was from 2,000 to 3,963. An intern requires a great deal of time on the part of faculty for instruction so that again, faculty members are involved in interns. The residents increased from 6,000 to 15,000, in increase of 158 per- cent, and other full-time equivalents increased from 5,000 to 11,000, or about 126 percent. You can see here that our load of teaching is far more than just medical students. Now, as regards other full-time equivalent students, we have the time that `the medical school faculty spends in teaching the nonmedical graduate, but other health professions. Now, if you look down below on the Ph. D.'s awarded, you see that it went from 282 to 606 and the M.D.'s, the rise is there. And then you see the full-time faculty that Congressman Rogers commented on. PAGENO="0137" 129 Now, in addition to the productivity of scholars, we are perforce, and we are glad to this, involved in productivity of service to people. Table 3 is to give you some index of the changing nature of the service to people. This service to people is a very vital part of our education because you cannot educate a physician in a classroom, he has to get his feet wet. He has to get his feet wet under close supervision of another physician in a 1 to 1 ratio, so that it is very time con- sliming. To illustrate our productivity in service, I picked here a series of hospitals for you so that you could see that the number of patients seen in medical center hospitals have increased from the num- bers outlined here, from as much as 10 percent to a high of 87 percent increase in the number of patients that we have seen. (Table 3 referred to follows:) TABLE 3.-MED1CAL SCHOOL PRODUCTiVITY OF SERVICE, 1955-67 Admissions 1955 1967 Grace New Haven Hospital (Yale Medical School) 19, 162 25, 139 University of Michigan 18, 766 20, 070 Barnes Hospital (Washington University School of Medicine) 23, 948 30, 741 New York Hospital (Cornell Medical School) 24, 464 29, 931 Duke University 10, 124 19,309 Vanderbilt University 11, 051 16,603 University of California at San Francisco 8,913 16, 730 Note: Prepared by the Association of American Medical Colleges. Dr. MARTIN. Now for the productivity in research, this has been commented on by a number of people and I am sure that you recognize this, and it has, I think, saved the lives of many people. One of the problems about research, however, that I think there may be some misunderstanding about, is that generally, research does not make life easier. It generally makes life harder for the physician because whereas, before, a little bit of opium might be all that we had to administer, now you have to be pretty wise and you have to know a lot more about drugs than we ever knew before because our goal in therapy is more than relief of pain. Our goal is the elimination of disease and keeping people going. A number of people have commented on this. I felt very much here like I did as a young man once when I got up in an elocution contest. The fellow before me got up and gave the message to Garcia. The message to Garcia happened to be my message, too, and I felt very whacked. I think a great many people here have delivered parts of my message, so I will just go through two or three things that I think are important in this legislation and allow the testimony that is written out here to stand. In section 101 on page 2 of the bill, it provides a single authorization for construction funds to go to all of the schools. We believe it obvious that the cost of the facilities essential for the training of physicians and dentists involve a range of capital expenditures that is different than that involved with the other professions, and we believe that when the appropriations are written, these categories should be separated out rather than use just one single formula for all of them. Our second suggestion involves the same concept in the institutional grants provided in section 707 on page 6 of the bill. Here again, we PAGENO="0138" 130 propose a simple amendment septirating into two items for purposes of authorization and appropriation the two groupings of the health professional sghools whitth are characterized by their markedly dif- ferent costs. We have appended to our statement two suggested a mend- ments which would deal with these. (The documents referred to follow:) AMENDMENTS TO H.R. 157~7 PROPOSED BY TUE ASSOCIATION OF AMERICAN MEDICAL CoLLi~GES DI~AFT AMENDMENT NUMBER ONE On page 2, strike lines 7 through 10 and insert, in lieu thereof the following new sentences: "For grants to assist in the construction of new teaching facilities or to assist in the replacement or rehabilitation of existing teaching facilities for the training of physicians or dentists there are also authorized to be appropriated such sums as may be necessary `for the fiscal year ending June 30, 170, and each of the next three fiscal years. For grants to assist in the construction of new teaching facilities or to assist in `the replacement or rehabilitation of existing teac'hing facilities for the training o'f optometrists, pharmacists, podiatrists, veterinarians, or professional public health personnel there ~we also authorized to be appro- priated such sums as may be necessary for the fiscal ye'ar ending June 30, 1970, and each of the next three fiscal years." DRAFT AMENDMENT NUMBER ~wo On page 6, line 10, after the word "grants" insert the following: "to be made to schools of medicine, dentistry, and osteopathy" and, on page 6, line 11, after the period, insert the sentence: "There are also authorized to be appropriated for the fiscal year ending June 30, 1970, and each of the next three fiscal years such sums as may be necessary for institutional grants to he `made to schools providing training in optometry or podiatry under section 771 and special project grants under section 772." Dr. MARTIN. Our third suggested amendment deals with the `appli- cation for construction. Part A, sections 103, 104, and 105 of the bill, which appear on pages 3,4, and 5. It is, I think, a great step forward to allow the institution to prepare one application rather than many and not have to worry about dividing a room do'wn the center with only certain student's on each side of the room. We feel this is so obviously worthwhile that we urge the committee to make this part immediately effective rather than waiting until after the fiscal year 1969. Our fourth suggestion deals with matching funds. Many medical schools, and generally it is the one that nee'ds the help the most, are not ideally suited or are unable to provide matching funds, yet they are capable of meeting a very great national need. It would be our feeling that rather than 662/3, in the case of grea't need, the Secretary might be able to use regional and national interests to provide 100 per- cent grants to institutions in that category. Our fifth concern deals with section 706 on page 16 of the bill, which authorizes `the transfer of not more than 20 percent of the loan funds to scholarships. We thoroughly approve of this provision. However, we feel some indication should be made in the bill that the money trans- ferred from loans to scholarships `does not have to be made up by the school. These conclude our suggestions for amendments and clarification of the `bill. We have one final point to make and we consider this one a very important one. It is the one that `we urgently request you to give PAGENO="0139" 131 full consideration to. It involves the questions of authorizations set forth in the act. The bill before you provides for such sums as may be necessary. We sincerely hope that this committee will see fit to retain this language. We know the situation with respect to medical man- power. We know the need to expand this. We also know that this will require funding at a far higher level than we could have hoped to achieve in this fiscal year or perhaps even in the year 1970, although we hope that that might change. Neither the committee nor we in the American Association of Medi- cal Colleges know the amount of matching funds that will be avail- able. We know that there are many grants that are approved but not funded. So that it is our belief that this should be left open so as we go into the next 2 or 3 years, the wisdom of this committee together with that of the Appropriations Committee, can respond as the financial pressures are alleviated to some degree. In reference to one part of my presentation, too, I would like to say that it has been the policy of the American Association of Medical Colleges and is their continuing policy that all qualified students should be given an opportunity for a medical education. I put `that in as an aside because I left that out but you will find that in my testimony. We would then suggest, Mr. Chairman, that if your committee believes it must write a fiscal ceiling into this `bill, th'at it request of the admin- istration that it provide you with figures which relate to `the quantity of students that could be produced by those figures and t'hen you make your judgment on the quantity you want rather than on some figure that might be pulled out of the air. I think this is all I have to say at this time, Mr. Jarman. Dr. Berson and I would be very glad to answer any questions that you might ask us. Thank you. (The prepared statements referred to earlier follow:) STATEMENT or THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES. BY Dn. SAMUEL P. MARTIN, PROVOST OF THE UNIVERSITY OF FLORIDA Mr. Chairman, members of the committie~: I am Dr. Samuel P. Martin, Provost of the University of Florida. I am here on behalf of the Ass~c4ation of American Medical Colleges which represents all of the schools' of medicine in the United States and 340 of our major teaching hospitals. We appreciate your courtesy in providing time for us to testify in favor of a bill which, if enacted, will be a great forward step in the hi'sto'ry o'f the health professions in this country. Mr. Chairman, our Association i~a's presented a statement to `the other bo'dy which explains the role of the medical schools in the health manpower picture and sets fo'rth in detail our reasons for supporting each of those portion's of the bill which would directly affect our institutions. In order to conserve the Com- mittee's time, I would like to offer that statement fov your consideration and for inclusion in the record of this hearing. I shall `not burden you with the `statistic's concerning the grave shortages of health personnel in our country. The fac't is self-evide'nt and figures have been presented `by Administration witn~sses. I would iike to make just three brief observations on concomitants of the physician shortage which may not be obvious but which `should be of importance to the Congress. Then I will comment on specific points in the bill which we believe call for amendment or clarification. The first aspect of the physician shortage I would comment on is its relation- ship to the soaring costs of medical ca're. Our system of medical care is and must be a closed system. We will not submit ourselves, our families, or our people to the ministrations of physicians or `surgeons who have not been properly `trained. The number of practitioners is and will be limited by the number of our srbools and the `size of their faculties'. While the number of physicians is `thus PAGENO="0140" 132 limited, the effective dem~ind f~r their services is open-ende~d. T~hat demand has skyrocketed in recent years a~ad, as aiwaysin circumstances where the supply is limited and the demand increasing, the result is higher prices. Thus liar, this is probably not a major factor in the rising costs of medical care but it is' certainly one factor which may become more important and it is one that can only be taken odt of the equation by the passage and full funding of legislation such as you are now considering. The second aspect of our grave physician shortage which I would call to your attention IS the fact that it is real even though hundred's of young Americans who would like to become doctors and who are well qualified to become doctors do not become doctors simply because we-our society-has not given them the opportunity to do so. I would like to impress on this Comm'ittee the fact that in the United States, it is only in medicine and denitistry, so far as we know, that a qualified man or woman cannot find academic opportunity. In every other field, from astronomy, astronautics, and biology through mathematics and physics to zoology, if a young man or woman has what it takes he can find an approved school to admit him. This is not `so in medicine and dentistry. Yet our Association of American Medi- cal Colleges is firmly on the record as believing that every qualified young Amer- ican who wants to be a doctor should have that opportunity. Our colleague's in dentistry agree. We simply do not have enough schools or big enou,gh schools or enough faculty manpowe'r to do the job. If the Congress will give us `the tools by passing and fully funding this legislation, we will do the job. We so pledge. Now, Mr. Chairman, my third point on the doctor shortage: the opposite side of the coin I have just shown you. Inasmuch as we have been unable to train enough of our own people in medicine, we have become woefully and alarmingly dependent on the importation of non-American foreign trained doctors badly needed in their own countries and some of whom are not as competent to treat our people as would be those we could train ourselves. Some 40,000 graduates of foreign medical schools now practice in the United States. Twenty-five percent of the interns and 33 percent of the residents in your hospitals (80% of the staff in some hospitals) are foreign trained. Without them scores of hospitals might have to close their doors, Foreign trained physicians arrive here at the rate of some 8,000 a year and some 2,000 obtain licenses to prac'tice here permanently. We would be delighted to have them do so if it were to secure that sort of ad- vanced training prior to returning to serve their own people that our own doctors at the turn of the century sought when they went abroad to study in Edinburgh, London, Vienna or Germany. But that is not the case. They come, for the most part, and they stay because we have become dependent on the importation of these 2,000 a year while, at the same time, the nation refuses some 2,000 qualified young Americans a chance to study medicine. This, too, is in the power of the Congress to correct. Now, Mr. Chairman, I would like to offer for consideration of the Committee, some specific suggestions regarding amendments to or clarification of the bill. We would have it understood that we think it an excellent bill and we strongly support its passage. The five suggestions we make are intended merely to rein- force what we believe to be its intent on points which might later be miscon- strued or lead to administration problems. Our suggestions follow. One: Section 101 on page two of the bill provides a single authorization for construction funds to go to schools of medicine, dentistry, osteopathy, profes- sional public health personnel, veterinarians, optometrists, pharmacists, and podiatrists. We believe it obvious that the costs of facilities essential to the training of physicians and dentists involves a range of capital expenditures, operating expenses and program complexity of a different order of magnitude than that characterizing the facilities essential to the training of other categories of equally essential health personnel. To avoid the possibility of an interpretation of the Act leading to the belief that a simple formula distribution of the total funds appropriated for construction should be made among all those schools of the health professions involved, we believe the Committee may find it desirable to provide for two authorizations, thus assuring separate consideration of the amounts to be appropriated for facilities used in the training of doctors of medi- cine, dentistry, and osteopathy on the one hand and those for the training of the other categories of health personnel on the other. Such an amendment would not, of course, call for any additional expenditures. We have attached to this statement the draft of such an amendment in the hope that it might prove helpful to your legislative draftsmen should the Committee favor our proposal. * * * * * * * PAGENO="0141" 133 Our second suggestion invo'ves exactly the same concept and would make it applicable to the institutional grants provided for in Section 770(a) on page six of the bill. Here, again, we would propose a simple amendment separating into two items, for purposes of authorizations and appropriations, the two groupings of health professional schools which are characterized by markedly different cost factors. This amendment, too, would cost no additional funds. We have appended to our statement a draft, "Amendmellt Number Two",~ which perhaps might accomplish this. * * * * * * * Our third suggested amendment has to do with the provisions of Part A, Sections 103, 104, and 105 of the bill which appear on pages 3, 4, and 5. These are eminently worthwhile and can provide considerable savings of money, time, and effort to both the government and to our institutions by making it possible to combine into a single application requesta for funds for a multi-purpose build- ing which might combine such things from differing financial resources as educational, laboratory and library facilities. This is so obviously worthwhile a proposal that we urge the Committee to make it immediately effective rather than for "fiscal years ending after June 30, 1969" (Page 5, line 3). * * * * * * * Lines 11 to 16 on page 39 of the bill permit federal grants up to 66% percentum of costs in the case of projects which "The Secretary determines have such special national or regional significance as to warrant a larger grant than is permitted under paragraph (1)" (i.e., 50 percentum). We submit that many medical schools which might be ideally suited and will- ing to undertake special projects of great national or regional significance do not have the matching funds for such undertakings. Moreover, they cannot justify to their local constituents the raising of funds to be used for purposes of no special relevancy to the people of that locality no matter how beneficial the project might be to the nation as a whole or to a particular broad region. We would also point out that the sheer impossibility of raising matching funds in some areas makes impossible the optimum geographic distribution of federal funds which members of this Committee and the Congress in general have long urged upon the Administration. We would urge, therefore, as our fourth suggestion, that this Committee strike "66%" from line 11 of page 39 of the bill and substitute "100%" therefor. Since the funds for any such grant would have to come from the total appropriated for the overall purpose, this would not result in additonal expenditures. Since the Secretary would have to determine the existence of an overriding regional or national interest before making any such 100% grant-and we can assure you that any such would be matters of keen interest to other applicants-we have no fear that such an authorization would be used without serious consideration and full justification. * * * * * * * Our last two suggestions have to do with matter sof clarification of intent which might, perhaps, be as well expressed in the Committee's report as amend- ments to the bill. We believe their objectives are within the intent of the bill but hope that such intent will be made crystal clear. * * * * * * * Our fifth concern is with Section 746 on page 16 of the bill which authorizes the transfer of not more than 20% of loan funds to scholarships. We thoroughly approve the provision. It can be most helpful in allowing schools to cope with such changes in circumstances as may occur between the time funds are applied for and individual student needs become realities. However, we are not sure that the bill makes it clear that an institution trnas- ferring loan funds to scholarships in accordance with that provision will auto- matically be relieved of any responsibility it may have incurred for the return of those loan funds. We hope that this, too, will be spelled out in the bill or in the Committee's report. * * * * * * * That, Mr. Chairman, concludes our suggestions for amendment or clarification of the bill. We have but one final point to make. It is one we consider all important. It is one to which we urgently request you give full consideration. It involves the question of authorizations to be set forth in the Act. PAGENO="0142" 134 The bill before you provides for "such sums as may be necessary"- for au open-ended authorization. We sincerely hope that this Committee and the Congress will see fit to retain that language. We know and we believe that this Committee knows how very great an increase in medical manpower this nation needs. We know and you know that to meet that need will require funding at a far higher level than we can hope to achieve for fiscal 1969 and, perhaps, for fiscal 1970 as well-though we hope not. Neither we nor the Committee knows what amouts of matching funds states, local, communities, foundations, or individual philanthropists may be willing to contribute to start new schools of medicine or to expand existing schools over the next several years. But the Congress will know what the nation can afford and we will know what matching funds might be raised in each of those years. This bill provides the mechanism through whicb we can begin a process that will lead to the solution of our critical health manpower problem. The "Health Manpower Act of 1968" can become an historical document with which each of us can be proud to have been associated. But the promise which this bill holds out can be negated if funding limits are imposed which have no relation to the realities confronting us. The promise can become a mockery. We can well understand the insistence on the part of many member~s of the Congress that most such bills as this contain reasoned figures as to probable costs. We hope they will not insist on applying that principle to this measure. Our real concern, however, is not with the principle or its possible applicability to this bill but rather with the estimates of costs that might be imposed upon it. We have seen the figures given Senator Hill's commiitee by the Administration. We can only say that if any such figures are adopted by the Congress and written into this legislation, we will have been served notice that for the life of this measure we cannot even hope to begin to meet your needs for a meaningful in- crease in medical manpower. We assume that those figures must have been based not on any estimate as to what it will cost to produce the number of doctors the nation will need and our schools might produce but rather on what the Bureau of the Budget thought it could approve in the light of this year's budgetary crisis. We would suggest, Mr. Chairman, that, if your Committee believes it must write fiscal ceilings into this bill, it request the Administration to provide figures which relate the quantity of the various types of health manpower needed to the prob- able costs of producing that manpower. Those are the only sort of figures which should appear in this legislation: figures based on costs of production to output desired. The decision as to what extent the possibility thus created can be realized in a particular year will then quite properly be a function of the Congress acting through the appropriations process in that particular year. We ask only that this measure, when it is enacted, present our people with a balanced picture of both the means and the cost of meeting A~merica's demand for the health man- power it so badly needs. STATEMENT OF WILLIAM N. HUBBARD, JR., ON BEHALF OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES, BEFORE THE SENATE COMMITTEE ON LABOR AND PUBLIC WELFARE, MARCH 20, 1968 INTRODUCTION 5. 3095 is a bill that will find a place with other historic legislation that has carried us so far toward our goal of health for the people of the United States. The American people are deeply concerned about health. ResŘonding to this concern from 1946 to 1963 the Federal Government, largely through the Depart- ment of Health, Education and Welfare, joined state and local governments, health and educational institutions, voluntary health agencies, private philan- thropy and industry in meeting two especially-critical needs hi the attack on disease: the construction of hospital and other facilities for the care of patients (Hill-Burton program), and the support of medical research (National Institutes of Health). Continuing expenditures by the Government in support of these two programs still represent investments in the health of the nation which pay rich dividends, PAGENO="0143" 135 as has been amply documented. It is imperative that these programs be con- tinued and devoloped further. Health service facilities and medical research have made p0551 We dra matic progress in the prevention and treatment of disease, By 1961, a block to the ef- fective use of new knowledge and to the pursuit of further knowledge was the increasing sbortgae of personnel in the health professions, particularly doctors. This block can be removed only by the improvement and expansion of the na- tion's system of medical and other health professional education. The Health Professions Educational Assistance Act of 1963, the Nurses Train- ing Act of 1964, the Allied Heatlh Professions Personnel Training Act of 1~66, as well as the Health Research Facilities Act and the acts supporting public Health professional education have made important contributions toward re- moving that block. The concept of an omnibus bill as S. 3095 is most suitable in dealing with these multiple acts because each of the separate titles supports interdependent efforts that have a common purpose--the achievement of health for the people. This interdependency and common purpose will require ever closer cooperation in planning education and in practice by the many branches of the health professions and allied health personnel. Epitomizing this cooperation and interdependence is the modern medical center. In considering needs of medical and other health professional education, it is important to understand the variety, complexity and interrelationships of acti- vities involved in the training of such personnel. This is especially true in rela- tion to the three components of medical education: teaching, research and service. The inseparable nature of these three functions has led to the "medical center" concept as a more realistic characterization of medial education than the too frequently held concept of the medical school, the teaching hospital, the research program, and community health services as activities independent of each other. However, two separate federal support programs-for medical facilities and for medical research-while understandably directed toward sepcific restricted ob- jectives have complicated the conduct of medical education by failing to recognize that research and service are integral functions with teaching. Thus, the need for service facilities and the need for research facilities in a medical education environment have been considered independently by the government, and provi- sion has also been separate for teaching facilities, although teaching is basic to both service and research. The first hard fact to be faced is that there is not enough health manpower to meet the needs of the American people. There are not enough doctors and not enough supporting people. The shortage of physicians is beyond a question the most critical single element in manpower for health service. Although medical schools have increased their capacity to educate physicians and new schools have been created, the increase in the supply is not keeping up with the need. In light of the growing demands for physicians' services despite the hopeful offsetting factors of increasing his productivity by training as yet undefined categories of assistants, it is clear that more physicians of high quality must be trained as quickly as possible and that the resulting increase in number of physicians will be healthy not only for the nation but for the profession itself. Between now and the middle seventies, we will have approxi- inately 100 medical schools in the United States which can produce the physicians we need. The adequate support of the faculties that are responsible for this medical education is a prime need for the future health of the nation. These 100 instItutions must not have their potential limited by an artificial shortage of funds. Artificial because the investment necessary for them to optimise their output is miniscule In comparison to our country's wealth and in comparison to the enormous benefit such an expenditure would bring to the health of people. In order to enable the nation's medical schools both to meet today's crisis and to attain the longer-range goal of unrestricted educational opportunity, those responsible for allocation of resources must recognize the magnitude of these tasks. There are both immediate and long-range steps which should be taken. The immediate steps are: 1. To increase the enrollment of existing medical schools. Considering the time required to create new schools and to provide a student with a medical educa- tion, there is no alternative to this step in meeting our present emergency. 2. To foster curricular innovations and other changes in the educational programs which could shorten the time required for a complete medical educa- PAGENO="0144" 136 tion. śrhe prOcess of ediic~iting a physician embraces the entire educational experience from high school through residency training. In view of the increas- ing quality of pre-professional education, the growing competence of entering medical students, and the increasing amount of clinical experience provided medical students, the duration of internship and residency training should be reassessed. It shotild be possible to reduce the total length of medical education without sacrificing quality. 3. To meet the r~eéd for ititiovation In educational programs and to encourage diversity in the character and objectives of medical schools. The development of schools of quality Where a primary mission is the preparation of able physicians for clinical practice as economically and rapidly as possible is to be encouraged. Such schools may have less emphasis upon fundamental biologic research than is appropriate for a number of other schools. A longer-range approach to tbe need for physicians is the development of new medical schools. This approach will not solve our immediate, urgent need for more physicians but it is essential for meeting the national needs of 1980 and beyond. The contribution of such schools to the total capacity of the medical education system is important. The advantages of the organization of as many such centers of medical education asid ~1evelopment through the country as consistent with strong programs should be kept in mind. To implement the measures enumerated above will reqriire adequate financial support from governmental and various private sources for: 1. Construction of facilities to expand enrollment of existing schools and to create new schools. 2. Support of the operational costs of medical schools. 3. Stimulation arid incentive for educational innovation and improvement. The university is today the typical institutional setting of the interdependent programs of professional education, patient service, and research that form an Academic Medical Center, recognizing that an analogous setting independent of a parent university exists as well. The core of the Academic Medical Center is the faculty and facilities necessary for the education of the M.D. candidate. But other essential roles are simul- taneously served. Basic medical scientists are responsible also for the graduate degree programs and the research training which are the source of tomorrow's teachers and investigators in these basic health sciences. The research efforts of the basic science faculty create the scholarly environment needed for the kind of education that prepares the student to understand and utilize the scientific advances that will occur during his professional lifetime. These same research efforts produce the knowledge necessary to improved definition and solution of problems vital to human health. The clinical faculty in medicine adds the responsibility for patient care to its obligations for teaching and research. Both the medical school and the hospital phases of the physician's education are shared by the clinical faculty, while they are increasingly sought after for the postgraduate education of the practicing physician. Research and research training programs, both basic and applied, are necessary for these "teacher-physician-scientists" to translate laboratory findings into improved patient care and more effective teaching. Commonly, this same medical faculty shares responsibility for teaching students of dentistry, nursing and pharmacy and allied health workers. The Academic Medical Centers vary widely in their organization for patient service, but all have the obligation to provide exemplary patient care under faculty responsibility. This high level of patient service is necessary to medical education and medical researth, but is also an important community resource. Every Academic Medical Center in the United States is in trouble financially and some are in desperate straits. Improved support is needed to sustain the quality of their existing programs, to permit them to enlarge their output of esseutial medical manpower, and to provide for new programs to enhance the delivery of health services. Basic Institutional t~1upport Grants for Academic Medical Centers As federal health programs have evolved over the past 20 years, they have dealt separately with education, research and medical care. The institutional integrity of the Academic Medical Center is essential to the attainment of the separate and collective missions of these programs and so it is necessary that these missions preserve the inseparable interdependence of teaching, research, and patient care within the Academic Medical Center. 1. Basic institutional support grants should be increased and extended to support the full range of educational programs of the Academic Medical Center. PAGENO="0145" 137 2. Project grants for education or research should allow for overlapping use of these resources within the Academic Medical Center, to the extent that the fulfiUment of the primary purpose allows. 3. Academic Medical Center construction grants should not be restricted to the exclusive use of only one part of the triad of training, research, and service. Common use of an area is inevitable if research and service are part of the teaching environment. 4. A system of accountability which accepts the full range of health-related efforts in the Academic Medical Center should be developed. An accounting concept which requires complete separation of teaching, research and clinical service is not in the best national interest because it decreases the advantages of interaction among these interdependent activities. The medical schools of the Unietd States and their associated Academic Medical Centers require improved support from the Federal Government in order to meet their obligations to the health of the people. The expectations of the people will only be fulfilled through increased output of physicians along with other professional and supporting health workers, through continued support of both basic and applied research, and through enhanced delivery of health care in the community. In each of these functions the medical schools and their associated Academic Medical Centers are an essential national resource. SUMMARY We are told that, after agriculture and manufacturing, health is the largest industry in the nation. The quality of this great system of health care can be no better than the knowledge and skill that serves it. A physician remains at the apex of the team of professional and allied health workers who translate this knowledge and skill into service. It is from the medical schools of the United States and their reltaed Academic Medical Center programs that the knowledge, skill and physician manpower essential to this health-care team will come. By providing these 100 Academic Medical Centers with the resources they need to meet their obligations, the quality and effectiveness of the entire system of health care will be enhanced. Although the total number of dollars involved appears large when isolated, it is very small indeed in comparson with the magnitude of the expenditures for health throughout the nation. It is from a very deep and urgent sense of obligation to meet the health-manpower needs and the needs for improved knowledge and skill that we appear before the Committee to describe the resources that are necessary to meet these public purposes. The real need of hte Academic Medical Centers of the United States actually far exceeds the recommendation in the Administration~s health budget. Every university medical center in the United States, both state and private, is in trouble financially and some are in desperate straits. In order to meet their expanded obligations, all must have the space and the stable program support that is essential for their contributions in education, research, and patient service. The Academic Medical Centers of the United Ctates are a vital resource for the health care of the people of the nation and are an important part of the total assets of the nation. State and private agencies do not provide the funds required by all of the programs of the Academic Medical Centers since they have national as well as local purposes. Unless adequate funds from federal sources continue, we cannot fulfill the obligations to the health care of the people that they have evrey right to expect from us. We therefore urge the committee most strongly that every effort be made to assure that the funds appropriated to health-related educaion, research and service are adequate to meet the needs and expectations of our people. Comments on 2. 3095 The Association of American Medical Colleges strongly supports the Health Manpower Act of 1968 (5. 3095). It will extend and significantly improve the Health Professions Educational Assistance Act of 1963, as amended, the Nurses Training Act of 1964, as amended, the Allied Health Professions Personnel Train- ing Act of 1966, project grants for graduate training in public health (Sec. 309 of the Public Health Service Act) and traineeships for professional public health personnel (Sec. 306 of the Public Health Service Act). Each of these have proven to be sound programs. Much has been accomplished toward the production of additional trained health manpower and the provision of additional educa- tional opportunities in the health fields. But the demands and expectations of society continue to increase, much more needs to be done, and this omnibus blil 95-540-68-1O PAGENO="0146" 138 contains significant improvements and establishes a pattern which we believe to be sound. When these programs can be supported by adequate appropriations, we can make rapid progress toward the provision of educational opportunities for all qualified young Americans in the health fields and an adequttte supply of well-trained medical manpower. Health services are delivered to individuals and society by a vast array of trained people and we would emphasize the desirability of supporting all the schools of the health professions. In `this broader context, an adequate number of properly qualified physicians is of central importance and we should not lose sight of the level of responsibility each of the types of schools carry for the public welfare. We think it is very wise to authorize "such sums as may be necessary" for each title of the Act and for Congress each year to decide how `much of the available federal resources to allocate to these purposes. We recognize the fact that other national needs restrain the amount than can be invested in these programs at the present time. The Congress and the public undoubtedly realize that the Academic Medical Centers can increase their output of physicians, trained specialists, trained investigators, allied health professionals trained in medical centers, research and service to patients and communities only to the extent they are provided financial support. Construction Grants We think it is wise to extend the programs for four years because of the length of time it takes for institutions to develop optimal plans for these complex facilities and to arrange for local matching funds. The provision authorizin.g a school to make all app~llcations to the Health Professions Education Act construction program for the construction of facilities which are to a substantial extent for teaching purposes but are also for health research purposes or medical library purposes is, in our opinion, sound, Indeed almost necessary. Health professional schools typically design and use facilities for these interrelated purposes and, from time to time, reassign rooms or whole sections of buildings among these purposes. We assume that it is intended that clinical facilities justified as essential to the eligible educational programs will continue to be eligible as they have been in the Health Professions Educational Act and consider this very important. We also think it highly desirable that, as provided in this legislation, the facilities be available for graduate, continuation, and other advanced training activities as well as that attributable specifically to the training of persons in the first professional degree programs. The restrictions which have excluded these necessary functions have constituted undesirable and artificial barriers. We hope Congress will make these amendments effective beginning in Fiscal Year 1969, because they will make it possible to use the funds to be appropriated more effectively. Institutional Grants (Formula) We believe the formula proposed in the legislation is an appropriate one. It gives credit for all full-time students with twice as much credit for each student in the increase in enrollment as for other full-time students and includes a factor for the number of graduates. These represent desirable improvements, but it seems important to emphasize that even with an approved formula, what can be accomplished will be limited by the amount of funds actually made available. Unfortunately, the funds appropriate for the present legislation have not been sufficient to pay the full amount authorized by the present legislation. The medical schools of this country have responded to the existing legislation and have ex- panded their enrollments of entering students and have been severely dis- appointed that the Congress did not appropriate as much as its own legislation authorized. The Association of American Medical Colleges has somewhat mixed feelings about the expansion of enrollment as a condition for receiving a formula grant. On the one hand, expansion of enrollment is so clearly desirable that steps in that direction are in the public interest. Relating expansion to the average first-year enrollment for a five-year period is more desirable than relating it to the highest enrollment in a five-year period, as the present legislation requires. We consider it desirable that the Secretary, after consultation with the Advisory Council, have the authority to grant a waiver for this requirement, if that waiver is in the public interest and consistent with the purposes of this part of the legislation. PAGENO="0147" 139 On the other hand, the ability of medical schools and other schools in the health professions to respond to the clear intent of Congress and the needs of society by expanding enrollment has been severely restricted by the limitation on funds for this purpose. This legislation authorizes the appropriation of "such sums as may be necessary". For our joint efforts to meet the needs of the public to be successful, we are convinced that these institutional grants must come to cover a reasonable portion of the educational costs of the Institutions. The basic im- provement grants of the present legislation would cover approximately 10-per- cent of the educational cost of medical schools if they had been fully funded. Medical schools do not have the resources with which to meet a large percent of the costs of much larger enrollments. Special Project Grants We believe the proposals in this section of the legislation are entirely sound in concept. The authority to support planning special projects tQ accomplish the important purposes of this section is especially important. The eligible schools will be far better able to meet the future needs of society if they can develop competence for orderly and continuing analysis and planning of programs. They will need special funds to initiate and probably to continue this activity. The sound way to achieve expansion of enrollment without sacrifice of quality is for institutions to develop plans, receive support that is tailored to their own needs and have the time to carry out those plans. We also hope Congress will make this section effective in Fiscal Year 1969, because it will make possible more effective use of the funds available. Health Professions Student Loans We believe it is desirable to postpone the mandatory repayment of these loans for up to three years service of VISTA volunteers and up to five years for advanced professional training including residencies, and we think that the authority for the institution to transfer to its scholarship fund up to 20-percent of the total funds paid to it for its loan fund is highly, desirable. We believe the need for scholarships is relatively greater than that for loan funds, partly because many medical students are already in debt for their college education by the time they enter medical schools and too large a debt burden limits the opportunity a young physician has to enter public srevice or to serve economically disadvantaged members of society. Health Professions Student Scholarships We believe the added flexibility of authorizing the school to transfer up to 20-percent of the amount paid to it for scholarships to its student loan fund is desirable, although we do not believe this authority will be extensively used because in most institutions the need for scholarships far exceeds the supply. We consider the clarifying amendments as quite helpful. We strongly support the purposes of Title Il-Nurse Training and Title III-. Allied Health Professions and Public Health Training-and would emphasize the very great importance of an adequate supply of w~1l-trained people in these fields and stable and productive educational programs to that end. Colleagues in those professions are more competent to speak to the details of these Titles. Title IV-Health Research Facilities We believe it is desirable to extend this program for four years because of the length of time it takes an institution to plan these facilities and obtain local matching funds. We think it is in the public interest to authorize a federal share of up to 66%-percent of the projects falling within the class or classes determined by the Secretary to have special national or regional significance, but we also approve of the safeguard of providing that no more than 25-percent of the funds appropriated for a fiscal year for this program be available for those projects. In conclusion, the Association of American Medical Colleges fully supports the Health Manpower Act of 1968 (S. 3095) as providing a sound pattern f or the support of an expanded educational capacity which can, eventually, provide an educational opportunity for all qualified young Americans in the health fields and an adequate supply of trained health manpower to meet the health needs of society. We urge Congress to act favorably on this legislation and to make the provisions for construction, special project grants, student scholarships and loans of Title I and all of Title IV-Health Research Faeilities-cffective beginning in Fiscal Year 1969. PAGENO="0148" 140 Mr. JARMAN. Thank you very much, Dr. Martin. We will r&td your full statement with real interest, and we appreciate the advice and counsel you have given the committee on this important bill. Mr. Rogers? Mr. ROGERS. Thank you. I appreciate your statement and the testi- mony, Dr. Martin. Do you use any consultants in the university hospitals or any consul- tants in teaching or part-time instructors? Dr. MARTIN. We use a limited number. This varies from location to location. We are, as you know, in a small area in contrast to a metropolitan area, so we use a rather small number. We do use physi- cians in town; yes, sir. Mr. ROGERS. What about, say, a large city medical college? Would they use a good number of part-time instructors? Would they use a good number of local physicians in the university hospital or what? Dr. MARTIN. This varies from institution to institution. It varies on the availability of physicians. It varies on the time. There is a trend in medical education toward the use of the full-time instructor. This is because of this complicated one-to-one relationship. It is com- plicated material that we present, and the need is for a person to give his full time, his full mental effort to the process of education. Mr. ROGERS. In other words, when you have a student with you in the hospital, the one doctor that goes through treating patients cannot take more than one man with him? He does not- Dr. MARTIN. He rarely takes- Mr. ROGERS. Does not take three or four? Dr. MARTIN. He rarely takes more than three or four and he has to deal with one at a time. This is the real problem with medical education. Mr. ROGERS. There is no way to let, say, even five or six observe him as he treats a patient? Dr. MARTIN. You know, there is no way of learning like having responsibility, and one cannot give responsibility when human life is involved without adequate supervision. And this has us over the barrel in a method of teaching, and I know of no shorter method. I know ways of altering the curriculum and your provisions here, I think, are going to have a very profound influence on making us look at curriculum, look at ways of approaching, ways of doing things better, but still there is going to be that period of one-to-one relation- ship. Mr. ROGERS. Now, when does this come in? Does it come in at the internship? Dr. MARTIN. Sir, this starts at the first time he sees a patient and the first time he interacts with the patient, which is very- Mr. RoGEns. When is this? Dr. MARTIN. That is in the first year of medical school in many schools. It is in the second year of medical schools at practically all of the schools. Mr. ROGERS. So, second year medical. This is after he has had his undergraduate, he is now in medical school and the first year-how much time is devoted to the individual in medical school in actually doing the patient work? Dr. MARTIN. The individual student? PAGENO="0149" 141 Mr.ROGERS. Yes. Dr. MARTIN. This increases each year from part time in the first year dealing with patients, more in the second. Mr. ROGERS. How much time would you think? Dr. MARTIN. Probably no more than 10 percent of the first year and then it will run 25 percent of the second year and the third and fourth year it is a 100 percent. They are dealing with patients most of the time. Mr. ROGERS. And then, they are closely supervised- Dr. MARTIN. They are closely supervised. Mr. ROGERS. In this area? Dr. MARTIN. Now, the intern then takes one step to being unsuper- vised for periods and his supervision is periodic. As a resident, his supervision is less periodic until finally then he is on his own. Mr. ROGERS. Do you see any possibility of working out a 4-year course, say, where you could qualify them to treat in basic diseases and ability to recognize major problems? Dr. MARTIN. I think that to change the character is a dangerous phenomenon because when you as a patient come to see the physician, he does not know whether that cold is a cold or the beginning of some rapidly fatal and fulminating disease. So at that initial contact is when we need our most competent man because- Mr. ROGERS. But, he does not go to the specialist necessarily, does he? Dr. MARTIN. No. He does not, but I say we need at that initial contact of his, our most competent man. Now, I think one of the things that is misleading in many of the things that are presented, when one says 69 percent are specialists, a significant number of those spe- cialists are going to be pediatricians and internists and pediatricians and internists really are a new kind of general practitioner. They limit their practice to an age group but an internist will generally see prac- tically any part of medicine when he sees you the first time. Now, if it is a heart condition, he may also refer you on. I think that in addi- tion to worrying about this whole area, I think that you people should look seriously also at the system of medical care because I thought, as some conversation went on before, if we were building automobiles by the use of a village blacksmith or a cottage industry, we would have serious prc~blems in giving everybody that wants a car a car. Therefore, I think we have to look in addition to the kind of people, to ways of organizing the system. There are all kinds of data on how much we could use ancillary or auxiliary or medical health-related personnel, and .1 think that is going to be a fruitful area. Mr. ROGERS. Let me ask you this. Some of the foreign schools, are they not just 4-year schools? Dr. MARTIN. Some of the foreign schools are 4-year schools; yes, sir. Mr. ROGERS. And yet, they come and practice in this country with- out, I understand, supposedly not without supervision. Dr. MARTIN. I think one has to look at the foreign system of edu- cation, too, because many of the men finishing a foreign high school are further along toward their basic training in biology than they are in our high school before they transfer. Mr. ROGERS. Would this be true in Latin America? PAGENO="0150" 142 Dr. MARTIN. No. I think this is an area that you are going to have to suffer with seriously and I think that the answer is not to train a less well trained physician, but train more helping hands for that physician so he can be more effective. Mr. ROGERS. How many new colleges does he need; does your associ- ation project to fill the gap? Dr. MARTIN. Dr. Berson? Dr. BER50N. Mr. Rogers, we do not have a formal projection on that because cer~ain1y it is a much larger number than we see an early possibility for getting. Beginning with 10 or 12 years ago, my predecessor in this position, Dr. Ward Darley, and Dr. Wiggins from the AMA called on the presidents of a number of leading universities in this country that did not have medical schools to try to encourage their interest in developing them. I am sorry to say that very few of those particular institutions have done so. We feel that, I might add also, that at about the same time Dr. Vernon Lippard, who was then president of this organization, was interviewed by one of the national magazines and stated his opinion that we needed 25 more new medical schools at that time which was 12 or 13 years ago. Mr. ROGERS. Would you let us have some projections of this? Dr. BEnSON. Yes, but it cannot be that quantitive because in my own opinion, it is of the order of a dozen and a half or 2 dozen even as quickly as we can get them and I am not at all sure where we can find suitable educational bases and the kind of local responsibility and interest that has led to the development of medical schools so far. But, we will be glad to provide you with some views on that point. (The following information was subsequently siThmitted:) AssOCIATIoN OF AMEEICAN MEDICAL COLLEGES, Washington, D.C., June 24, 1968. HON. JOHN JARMAN, Chairman, subcommittee on Public Health and Welfare, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR Mn. JARMAN: At the hearings before your subcommittee on the Health Manpower Act of 1968, one of the members of the committee asked me to sub- mit for the record some views about the number of new medical schools that will be needed in the United States. I hope we made it clear to the committee that, while we are happy to share such knowledge and opinions as we have, the Association of American Medical Colleges is not prepared at this time to be entirely quantitative about the number of new medical schools in the United States that should or will be developed within the next decade and a half. It is my personal opinion that it will be in the public initerest if 20 to 25 new medical schools are developed between now and 1980, but I do not think those numbers should be considered as anything more than an educated guess. It is the view of this Association that the development of new medical schools is highly desirable, provided such new institutions can be strong enough to offer their students educational opportunities in medicine of acceptable quality. We believe that new medical schools can be seen as an answer to 1980's needs fo~ increased educational opportunities for young Americans and for increased numbers of physicians educated in U.S. schools. However, expansion of enroll- ment in established medical schools offers the only reasonable way to meet the need for more educational opportunity and for more physicians in the fairly early future. As you know, a small number of medical schools are in such des- perate financial straits that their very survival is threatened. Providing the financial support those schools need to survive is of great importance and will prevent the loss of educational capacity. All the other medical schools have financial problems and face many demands, but they do have strengths and the potential ability to expand enrollments if they can obtain the additional facilities and financial support they need to do so. PAGENO="0151" 143 It is our opinion that the Institutional and Special Project Grants provided in the Health Manpower Act of 1968 provide excellent mechanisms for providing the funds the schools will need if the Act is passed and adequate appropriations are made. The experience of the past decade and a half has demonstrated that after a firm commitment is made by a responsible institution that it will develop a new medical school, a number of years pass before the first student is admitted. This is so because of the time it takes to recruit appropriate leadership, acquire a site, develop plans for facilities, obtain funds from non-federal and federal sources for the construc1~ion of the facilities and for the process of construction itself. It usually takes a student four years to earn an M.D. degree. All young physicians are obligated for two-years of military service and all young physi- clans now spend two to five years as interns or residents in hospitals. For these reasons the development of new medical schools should be seen as a means of providing increased educational opportunities for students now in high school or grade school but not as contributing to the supply of young, fully-trained physi- cians in the next decade. Another general factor of very great importance in the development of new medical schools is that of local initiative. The ability or willingness of educa- tional institutions to grow and provide the academic support that a modern medi- cal school needs is extremely important. The ability and willingness of local groups, communities, and states to provide the financial support a modern medical school requires are vital. And both of these factors are extremely difficult to predict in advance and from a distance. For example, how could anyone have predicted that the Hershey Foundation would have provided the financial support for the development of a medical school in that small com- munity; that the State of Ohio would have reached a decision to develop a medical school in Toledo, `or that Mount Sinai Hospital in New York would have undertaken the development of a medical school and formed an affiliation with the City University of New York for that purpose? We greatly appreciated the opportunity to present our views to your committee. Sincerely yours, ROBERT C. BEnsoN, M.D., J3Jvecutive Director. Mr. ROGERS. I think it would be helpful. You know, project grants, no telling what could be done with those the way it is proposed under the `bill. Dr. BERSON. We think that the project grants could be tremen- dously helpful because medical schools that have faced the question of how can we expand enrollment by 25 percent or 50 percent, have come up with descriptions of what the institutions would need to do it. It almost always involves some facilities and it always involves some other things which can only be described for that institution. They need two men in this department; they need nobody in this depart- ment; they need a particular mosaic of resources, both physical and operational. Now, we think that institutions could come forward with proposals for project grants that would accomplish a great deal for the amount of money invested. To get on a continuing basis, they would have to look forward to the institutional grants and their own resources. Mr. ROGERS. What about requiring them to have more. students, produce more students? Do you not think that is a good idea? Dr. BERSON. I think the incentive is more likely to be effective than the requirement. One thing that bothers me about the requirement in the present legislation is that it was arbitrary and small. Most of the medical schools that have seriously looked at this need and have, felt strong enough `to plan to meet it, do not want to plan to expand by five students or some such-and that was the requirement, but by a considerably larger increment. PAGENO="0152" 144 Mr. ROGERS. This was a minimum. Five was the minimum. Dr. BERSON. Yes, that was the minimum. Mr. RoGERs. You wanted more but I think- Dr. BERSON. I think the incentive is more likely to he helpful. If I may add two things, Mr. Chairman. Mr. JARMAN. May I suggest this? The House is in session and we are in the midst of a quorum call in the House. We have asked permis- sion-we are asking permission to sit this afternoon during the session of the House, and so our objective will be to recess at this time and continue the hearings at 2 o'clock. This committee will now stand in recess. (Whereupon, at 12:15 p.m., the hearing was recessed, to reconvene at 2 p.m. the same day.) AFTER RECESS (The committee reconvened at 2:25 p.m., Hon. Paul G. Rogers presiding.) Mr. ROGERS. The committee will come to order. We will proceed with the questioning of Dr. Martin. STATEMENT OP BR. SAMUEL P. MARTIN, ACCOMPANIED BY DR. ROBERT C. BERSON-~Resumed Mr. ROGERS. It is my understanding that Dr. Blasingame, whom you may know, made a statement some weeks or months ago saying that it might be possible to double the number of graduates if, for instance, we changed procedure on the use of equipment, using lab- oratories twice a day or maybe three times a day, rather than maybe just once. What would be your reaction to this? Dr. MARTIN. Chairman Rogers, this is one of the interesting prob- lems. I know that the capital expenditure looks terrible to you, but capital expenditure, while it is absolutely necessary, is not the biggest cost of running an institution. Say a medical institution, a medical school, would cost $25 million. You generally find that it costs $12.5 million a year to operate a $25 million facility. So, one-half of the capital expenditure is involved in a year's operation. And all through education we are stuck on the capital expenditure. The first thing you would find, I suspect, although this has never been investigated, is that, yes, you could buy a 24-hour-a-day opera- tion, but the first thing you would find is that it wouldn't be $12.5 million, it would be $25 million a year to operate, and I think we have to look at the most effective use of the facility, not the absolute capital expenditure. Yes, I think this is true. I think that in many areas by enlarging the basic science facility alone one could make progress in increasing the class, because the clini- cal-the bottleneck in education is the basic science facility. This is the greatest bottleneck. Mr. ROGERS. Is this where the greatest difficulty is? Dr. MARTIN. Yes. This is the bottleneck. Mr. ROGERS. This comes in the early years? PAGENO="0153" 145 Dr. MARTIN. This is in `the early years. There is one place in the lab- oratory for a student and when that student occupies that place, it is really pretty much a full-time occupancy because he comes back at night. You would be surprised at the amount of hours a medical stu- dent in the basic science part of his training spends in that facility. We find they are open really 24 hours a day now. He has to go back for special work. And this is the bottleneck far more than is the clinical operation. Mr. ROGERS. Well, I think this would be helpful to us in knowing where to put some emphasis `because I think what the committee is going to be interested in trying to do in fashioning this law is to try to point up those areas where we can get some results, and if you could give us some ideas, or your organization could project for us some areas that you think it would he well to try to project use of funds in these areas where there is a clogging, to try to unclog it, in order to speed up some graduates and results here to try to get people out, I think this would be helpful to us. Dr. MARTIN. As you know, in Florida we are planning to increase our class and as you look at the expenditure, most of the expenditure to increase the class will go into basic science facilities because we can operate within our clinical facility fairly well. Mr. ROGERS. Yes, because it may be that we will want to~-we may have to do something along this line if it would work and put some direction in the language of the bill so that some of these moneys would be used, and then, too, perhaps lay a foundation after we try it and see so that additional funds can be directed to help in this area. Dr. MARTIN. I think the greatest help would be additional funds built on the expansion of the class and if you adequately finance this, you will get results. Mr. ROGERS. If you could let us- Dr. MARTIN. I was just getting ready to say before when we were talking that I have a sense that there is a misunderstanding basically between research and education. Money spent for research does very little to educate a medical student. Now, in most industries, like General Motors, the research is done within the plant in Ge~ieral Motors. Where is health research done? There is only one place. Outside of one or two institutes, the health research is done in the medical-academic center, and you have asked us for research. I think we have produced a fabulous amount of this. I think that probably one-third of this room here would be dead today if we had not produced that. So I think we have done that. Now, I think all you have to do is ask for students and support it as you have research and you will get students. You will get physicians. Mr. ROGERS. Yes. Well, this is what I think we need to point up, and bring about, because obviously the need is to do something on physicians, nurses, manpower. Dr. MARTIN. Across the board. Mr. ROGERS. That is right. And where so much money has gone to research, perhaps that can be moderated some. Dr. MARTIN. Well, I hope we wouldn't diminish it because I think the forward progress, the things that we face in heart disease, cancer, and stroke are so terrifying. When you look at the fact that in this room PAGENO="0154" 146 here there is probably at least one, and maybe two, chronic diseases per person. We have got to do something about that and your prc~blem is that somebody has to see them to detect these diseases to do some- thing. But many of those diseases we still don't have the answer to. Mr. ROGERS. No. I am sure of that. But, too, I have gone through NIH pretty carefully. We did a study of about a year and a half on it and many projects are good basic science and good basic research, but I am not sure that they are directed to the goal of the result to cure hearts, cancer, stroke, for instance. Dr. MARTIN. Let me tell you a story that I can't resist telling you though you know it from Florida. You know the screw-worm was one of our worst enemies. The screw-worm was eliminated in Florida be- cause a man found that this fly mated once. Now, he didn't care about screw-worm at all. He found that that fly mated once, but that infor- mation was sufficient in the hands of the applied scientists to eliminate it. When Dr. Fleming saw penicillin on a plate, his actually looking at it, and Selma Waksman on Soil Actinomyces, none of these things had a feedback but they were a body of knowledge of which we applied scientists could say, ah, and then it opened a great vista. Mr. ROGERS. I am not deprecating basic research. Really it is es- sential. But what I am saying is we could be giving more guidance- Dr. MARTIN. You put your money where you want an answer, that is right. Mr. ROGERS. And which we don't do. Dr. MARTIN. That is right. Dr. ROGERS. And we could reduce some funds in that area, still do the basic research in the areas where we need it, and perhaps do something to produce manpower. Mr. Skubitz? Mr. SK1JBITZ. Thank you, Mr. Chairman. I am daydreaming over some of the statistics in your statement, Doctor. I notice on page 3 of your statement you state that 40,000 for- eign doctors in this country are practicing medicine today. Dr. MARTIN. That is right. Mr. SKUBITZ. And aj~e they graduates of the better schools in Europe or not? Dr. BERSON. No, sir. May I respond to this? We have not included here or brought with us the detailed breakdown that a very small per- cent of the foreign medical graduates coming to this country in each of the last several years have come from Western Europe at all. The big percent have come from the Philippines, from India, Pakistan, Greece. Latin America. Mr. Sicuui~z. What are the requirements of a doctor in those coun- tries? How many years of training and how many years of internship? Dr. BERSON. They vary a little bit but typically there is no level of education comparable to college in our country. Typically, they think, they like to think that their high schools take the individual a little longer, a little farther along than our high schools, then they enter the university where the program is from 5 to 7 years in duration, but it is mostly lectures and memory work. Mr. SKUBTTZ. You heard Congressman Cahill's suggestion this morning. PAGENO="0155" 147 Dr. BEnSON. Yes. Mr. SKUBITZ. 308,000 doctors in this country today and 13 percent of them from foreign countries. Dr. BEnSON. That is correct. Mr. SKUEITz. We have about `8,000 students enrolling in the first year of medical schools yet we are admitting 8,000 doctors a year from Europe, which indicates that about half of our doctors today that are treating the public are coming from schools that are inferior to our own. Dr. BERSON. That is correct. Now, this takes a little modification. Typically this figure of 8,000 is from a very recent year. It has been rising each year. Typically those individuals do not stay here very long. They come on an exchange, student visa or some other arrangement which commits them to return home after a period of time which is 3 or 5 years. Now, some of them come on permanent visas and plan to stay and a few others change their status and do stay and become citizens. Mr. SKTJBITZ. I've got news for you, Doctor. Those who come on permanent status stay and the rest of them write their Congressmen and ask the Congressman to help to get a bill through for them. That is all, Mr. Chairman. Dr. BinsoN. Mr. Chairman, some of the questions that have gone on in the last 2 days remind me that maybe it would be useful to re- peat the chronology of some of these developments. As I view the situation, there was very broad agreement reached in this country many decades ago that it was good to have a number of physicians highly trained in certain fields, and some internships and residencies were developed and have now grown to a very active endeavor. There was also pretty broad agreement about the end of World War II that the support of medical research was a rational way to find the answers to problems of diseases that were determined to be of national importance and that the Federal Government should develop mechanisms and put funds into supporting this, and this was done with very excellent results. There was not agreement, not broad agreement, until very recently that we really had a shortage of doctors and nurses, and so on. Now, some people thought we did, as I mentioned earlier, and many medical schools thought so, but not everybody. A lot of people didn't agree, and I recall testimony that was presented to the committees of Congress for many years urging action but not enough people agreed for Con- gress to take action. It was in 1963 that the construction program was authorized and it was funded in 1964 and that is not very long ago. It was in 1965 that the present legislation calling for `basic and special improvement grants was enacted; but it is only this year that the appropriations permit payment of the full amount of the basic improvement grants. So we have a national problem that now a great many people agree is very real and very important, but it is not surprising that we haven't yet gotten many results in its solution. I think we will. I think this bill and its full implementation with funds will be tremendously helpful but I don't think that we should be surprised that a building toward which a constru~tion grant became available 4 years ago hasn't yet produced any physicians because the chances are that they have PAGENO="0156" 148 just admitted expanded classes into the first of those buildings rather than already having turned people out of the long pipeline. Mr. ROGERS. Yes. I was not so much concerned on the construction as I was with the facts that showed from 1957 to 1967 in effect an increase in permaneut teaching staff of some 7,000, 8,000 or 9,000, and yet only an increase of about a thousand in medical graduates. This is what made me wonder if we need to look at our whole proc- ess of education in the medical field, how we are utilizing the talents that we have, whether we are adequately utilizing `them now, because, of course, you brought out that there are Ph. D.'s, and so forth, but still the mass-the problem exists in the first 2 years, 2 to 4 years. So this still is a concern to me on that. Now, let me ask you this, Dr. Martin. What would it take you at your school to increase-how many are we graduating from Florida? Dr. MARTIN. We are graduating 64 and we are asking to go to 100. Mr. ROGERS. Wonderful. Now, suppose we were to-what would it take you to get that up to 200 and how long would it take you, do you think, assuming you have all the money you need? Mr. MARTIN. Let me say this. I would probably, if I had my "druth- ers" and somebody asked me that question, I would say let's build an- other medical school in the State of Florida and we now in Florida have three medical schools, two in operation and one in the mill, and my feeling is, and my public statements are, that Florida should be planning another medical school right now- Mr. ROGERS. Yes. Dr. MARTIN (continuing). That in Florida we rank 37th in the Na- tion in the number of entering students per 100,000 population, which is a very bad position to be in, and when next year, or in 1971, as soon as we can get it, if we had 300 entering students per year in Florida, we would still be behind. And so we will have to build another medical school. And if you asked me, I would say don't put 200 students in Gainesville. Build another medical school. Mr. ROGERS. This is what I am wondering. Is it easier to expand on present facilities- Dr. MARTIN. It is easier tO expand within limits but there probably is an optimum- Mr. ROGERS. What would you think- Mr. MARTIN (continuing). Optimum top figure, and I don't know what that is. I think it depends a lot-we have many good reports on new ways of doing this. There was the report in Indiana that said maybe the best thing to do is build one collosal medical center with three medical schools and then use the specialty hospitals to increase their efficiency. If we could do that in Florida and have two on the campus in Gainesville, fine. I think the point made here when you look over the statistics, is that 100 is not too many, and it is far easier to get up to 100. Mr. ROGERS. Any other questions? Mr. SKUBITZ. Only one thing. Suppose you increase the student body to 200. If we take Mr. Cahill's figure this morning, we are only gcing to get 15 general practitioners out of the group. We are not solving our problem at all. It is like our police force here in Washing- PAGENO="0157" 149 ton. We get 1,000 additional policemen but that only puts 200 on the beat. We want them out on the street. Mr. MARTIN. I think the point I brought up earlier, and it may have been in your absence, is that we ieally are going to have to look at the system of care because I disagree that even money will get many men in the area that you and I want men in. We have to provide some kind of an organized system We `~s physicians have to org ~nize this so everybody gets coverage. I think that, for example, there is good evidence, and this is not a problem before your committee, but it is a problem that you face, the studies doiie on the practice of pediatrics show that 85 percent of the work that a pediatrician does in a day could be done by a well-trained assistant. Now, if we had four assistants who could immediately then take care of that one pediatrician-that one pediatrician could take care of five times as many people. We have seen this with dental assistants. Yet the one thing that I think you want when your family is ill, is to have the bright, alert, perceptive man who knows when to smell trouble and point the patient in the right way, supervising this group. And I think that anything we do to put out inadequately trained independent operators is a sad mistake because you may fall into the hands of that inadequately trained, independent operator. Once the initial decision is made, then I don't care. Yes, nurses, orderlies, many people can give me the care that I want, but when I fall into that chute, I want to be sure I am going down the right chute and the initial switch was the right switch, and I think this is where it is not as simple as in many other things. You want the best brain to make the initial decision and then the future care can go in many directions, and I think that the suggestion that many people have made of a second-rate or lower trained physi- cian at the interface was the decision that Russia made. Russia went that way. They are doing away with it and they are pulling the feld- shers back and they are saying, we want adequately trained people at the front line so that we will have to prepare this whole corps of people and then we have got to devise a system to see that in the wilds of Idaho, if you get sick, that either wheels or something gets you to that adequately trained man because whether you live or die very frequently is determined in the first 5 minutes, 10 minutes, that you come into the system. Now, anybody can give you the tender, loving care and the admin- istration that goes along with that, but that initial contact is im- portant, and I want the very best to see me for the first minute. Mr. SKIJBITZ. Would you agree, Doctor, that 90 percent of the peo- pie get well if they didn't see a doctor ~ Dr. MARTIN. That is right. Mr SKURITZ We are only talking about 10 percent, then Dr MARTIN That is like statistics If you are in that 5 percent, it is mighty fatal, and I don't want to be in that 5 percent Mr SKUBITZ If you are in an area where you had the choice of no doctor or maybe a second rate doctor, which would you prefer then ~ Dr MARTIN I am not sure but what I wouldn't take no doctor and kind loving care because I have seen the second-rate doctors send many people who were not quite ill down a path that made them much more ill. PAGENO="0158" 150 Mr. NELSEN. Get a good veterinarian. Dr. MARTIN. That is right. [Laughter.] No, I think we have got to spend more effort on the system and shore up the doctor, because I am sure that the history in dentistry shows that very clearly. If you have the experts follow us, it would show you the role of the well-trained person as an assistant to the physician. In pediatrics we are already accumulating all over the country good evidence~ This is also being accumulated in obstetrics, good evidence that if the person is working under the brains, that keeps them out of trouble. Then they can do fine but when they start operating independently, I don't want that kind of care. Mr. SKIJBITZ. You may get it under any condition. Mr. NELSEN. Is there any possibility that too much Federal money is going into research and not enough into the general parctitioner approach? Is it possible that in view of the financial needs of many of the students in the medical schools that there should be more aid funneled into the program in which there is the greatest lack of personnel? It is apparent the greatest lack is general practitioners. Should we do more in that area and less in some other area? Dr. MARTIN. One of the interesting things, although people point to us in medicine and say we follow the dollar in our practice, is that this is not true. The most popular specialties in medicine are not the specialties that pay the largest amount of money. Doctors follow the intellectual challenge. Internal medicine and general practice are the intellectual challenges I think in medicine. At least these are still the very popular fields-particularly internal medicine. While radi- ology is not a popular field, yet there is more money in radiology than there is in internal medicine. So I don't think you can get it by hanging a dollar in front of them necessarily. I think you have to again deal with the system. I think that your committee could do medical care a fabulous amount of good by being willing to spend some money on care, experiments in the system of care, spend money to find out how can we get some- body a system of care that will take care of the person in the hills of Tennessee, or in Idaho, or in the swamps of Florida, and spend money in that kind of research. That is the kind of research that would pay off. It is the kind of research that paid off in industry and we are an industry any way you slice it. We are a cottage industry at the moment. I think we will be another kind of industry sooner or later that is a far more organized industry. Mr. NELSEN. No more questions. Mr. ROGERS. Actually, of course, we did write in the provisions, I am sure you know, for research in this particularfield- Dr. MARTIN. That is right. Mr. RoGERs. On delivery of new methods. Dr. MARTIN. Right. Mr. ROGERS. I have had it brought to my attention in the hospitals often, in the emergency rooms, talking about care now, they run a roster of doctors to take their turns, et cetera, and often the very busy doctor pays a doctor who is not quite so busy to take his place. Dr. MARTIN. That is right. Mr. ROGERS. So the kind of person comes in there, as you say, who PAGENO="0159" 151 needs the best care, the most critical time, he often doesn't get it in the community. So we still have this problem, 1 think. Dr. MARTIN. This is an organizational problem and we must, on our side as practicing physicians, meet this, to organize ourselves. Mr. ROGERS. Yes. And I don'~t know anybody who is really doing anything about it. Dr. MARTIN. There is research going on in this. Mr. ROGERS. I don't think we have taken any steps. Dr. MARTIN. I think your action in setting aside money for experi- ments in care have dhanged the face of medical schools. It will get interest in this and get the fellow who is giving good care to go out and begin to try to find out how do we all do this. Mr. ROGERS. Now, in getting back to, let us say, a 4-year doctor, which I think we may want to consider, our other programs should tend to buoy up this man. For instance, the heart, cancer, stroke regional medical center. Wouldn't this tend to make him put the facilities of the experts right at his fingertip in his office? Dr. MARTIN. I think that this would help him but I think that nothing that I know of still will replace at the front echelon the well-trained mind that has the depth of perception that is necessary. Mr. ROGERS. I would agree with you. I think it is, of course, better if we can get a specialist to see you every time for whatever you may have. This would be the best. But where this is not possible for people, then kind of a feldoher system where the man comes in, can take his cardiogram and then this method that we are trying to work out, regional medical programs which they have set up already in some of the areas, they shoot that into the medical center and it is completely diagnosed by the very top experts, and this man doesn't rely on this man nor is he expected to, and it comes back to him with a suggestion, here is this and here is the treatment this man ought to be having. He takes all of the tests, all of the laboratory tests, and they go in and they are analyzed by the experts and they come back, and this isn't the feldoher doctor that is doing this. Dr. MARTIN. You are talking about the multiface screening clinic at Kaiser where you can ~o through the screening process without even having the physician see you until the end, after the data is gathered. But there is never any substitute for that well trained mind sitting down and covering the data. Mr. ROGERS. Well, but what we are thinking of is trying to get medical assistance to people who need it and then getting the experts pulled in. Dr. MARTIN. I am with you 100 percent on the medical assistants, but let's don't. call him a doctor because maybe he doesn't even have to go 4 years. Mr. ROGERS. Well, of course, this could be a decision made. Should he? I would think he prc~bably should have a basis of at least four so that he- Dr. MARTIN. The program at Duke, some of the people, you know, who are being trained as medical assistants at Duke have less than 4 years. Dr. Amos Johnson, if you have heard his story, he has a man who is a high school graduate who is his assistant, gathers this kind of data for him, hut there is no substitute in the end for that well trained brain to drop you down the right dhute in care, and a computer PAGENO="0160" 152 can't do it nor can a 4-year trained brain do it. In fact, it is hard at times even for the 12-year trained brain to pick the right chute as you suggested. Mr. SK1JBITZ. Doctor, perhaps the 4-year student could take care of the 90 percent I am talking about. If he gets puzzled, he can call for the `brain. I)r. MARTIN. The big problem is you may `be dead or down the wrong chute before that is called on and I still feel very strongly that you must see that talented person first, and I think if we relieve the physician of all of the nonmedical things he does, as I pointed out in pediatrics, he can increase his output five times. The dentists have shown us this very clearly, that a dentist can increase his output three times by putting in his office three well trained assistants, and he increases his productivity, and this is where we should be spending our effort and money, in addition to turning out physicians, i's to turn out these people that will `be sure that the physician then h'as his time to make that crucial decision, are you in the five, are you in the 95? Now, once that decision is made, the process is much simpler because if you are in the 95, a ho't `water bottle `and an aspirin and tender loving care is what you need because you will get well anyway. But if yo'u are- Mr. SKTJBITZ. You should have been an insurance salesman. Dr. MARTIN. If you are in that five, what happens to you in the next 2 minutes afte'r you walk in may `mean whether you survive or not. Mr. ROGERS. Of course, what we are looking at now is what is our present system of delivery. When you go into the hospital, in an emergency room, and y'ou don't `have the best often, where there are communities where they don't have any. Dr. MARTIN. Yes. Mr. ROGERS. Then what is the solution `here? Dr. MARTIN. Well, I think- Mr. ROGERS. Thi's is `what we are trying to get at. Dr. MARTIN. I think the solution is let's don't go backward. Let's go forward and let's- Mr. ROGERS. What is this going to take? This is what we are trying to get at. Is it going to take building 12 new medical schools? Will it mean expanding by 50 percent present medical schools? This is what I wonder. Dr. MARTIN. Let's don't talk `only on medical schools. This i's going to mean that you are going to have to `support medical schools, yes, but you are going to have to support health profession education even in technical high schools. Mr. ROGERS. I think we are doing those, aren't we? Dr. MARTIN. In junior colleges. You have this already, that is right. Mr. Roor.ns. The allied health program `was put in for this. Dr. MARTIN. Junior colleges, technical high schools. Mr. ROGERS. This is just beginning to start. Dr. MARTIN. This is ri'ght, and you are going to have to support, then, the baccalaureate and masters programs and it i's going to have to be across the board. In the excellent publication on manpower recently it had the health pyramid and if you draw this-I don't have a chart. Mr. ROGERS. We can see. PAGENO="0161" 153 Dr. MARTIN. I will draw this, but the health pattern here is-let me draw this 8-year trained person. The total block is that large, 8- to 12-year trained people, and then you go down and under that the 7 years and 6 years and 5 years, and then we come to the 4 year, 3 year, and then-these 8-year trained people are resting on a spindle. Now, if you look at how industry does this, industry takes their 8-year people that they support but they support them with an ever- increasing base of less well-trained people, and we haven't done this in health. So that I would agree very thoroughly with what the Con- gressman said, that we need people right out of technical high school trained to do things in the health manpower field. Mr. ROGERS. Well, is this where we should put the extra emphasis, then, in building-filling out the supporting personnel? I)r. MARTIN. It isn't either/or. You have got to work at both ends of the spectrum because you have got a fantastic-we have a fantastic problem coming towards us, an anticipated 24 percent increase in demand for services, and the services now that people need are `not the old services as I pointed out before, they don't need a drop of opium. They need a heart-lung machine and they need all of these new things in addition to kind, tender, loving care, and what you have to do is to look at the whole manpower spectrum. Yes, I think we should expand the physician, we should expand him, markedly, but if you expand the physician without giving him any undergirding, 5 to 10 years from now we are going to be sitting here crying the same song. Mr. ROGERS. Now, what are we doing, and you should know this picture from the medical standpoint, what are we really doing produc- ing allied health professional people and are they really being used by the doctors? Dr. MARTIN. Yes. We are doing everything we can to expand it with- Mr. ROGERS. To what extent? Could you give us some figures on this and how they are being used? I know the dental assistants have come into their own very well but what about a physician? Who does he really use in the system as an assistant? Dr. MARTIN. He now is using a large number of these people but not nearly to the degree that we would like to see this done. Mr. ROGERS. Could we get some examples of where they ought to be using them? T)r. MARTIN. Yes. Mr. ROGERS. If you could furnish us that, it would be helpful. Dr. MARTIN. I will be glad to write you a picture of how I think they ought to be used. (The information requested was not available at time of printing.) Mr. ROGERS. The committee would like to have this so we can start putting some emphasis on it. Dr. BERSON. I might add that all of these personnel who are being trained are being used. They are in great demand, and academic- Mr. ROGERS. To the extent to which they are trained or for lesser- Dr. BERSON. Efforts are being made to make this optimal and a good bit of progress has been made, I think a good bit more needs to be made, and virtually every academic-medical center as well as many 95-540-68--il PAGENO="0162" 154 other institutions is making great efforts to expand and to improve its training of these many categories of workers in the health field. A lot more needs to be done in this whole area and a great many people in the universities, colleges, junior colleges, high schools, are concerned about it and are working on it. * Mr. ROGERS. And I think the junior colleges are trying to work on it. We tried to encourage the junior colleges as well to move into this area. Dr. MARTIN. Yes. Mr. ROGERS. Are there any other questions? Your testimony has been most helpful. We are very grateful for you being here and if you could let us have some of this information, it would be well received. Thank you very much. Dr. MARTIN. Thank you. Mr. ROGERS. There is a quorum call, so, Dr. Ostrander, if you will bear with us, we ~will answer the quorum call and will be back. The committee will stand in recess. (Short recess.) Mr. ROGERS. The committee will be in order, please. We will proceed. Our next witness will be Dr. F. Dan Ostrander, the president of the American Dental Association, and Mr. Reginald Sullens, the as- dstant secretary on educational affairs. Doctor, it is a pleasure to have you before the committee, and Mr. Suliens, we are pleased to have you accompany him. STATEIVIENT OF DR. P. DARL OSTRANDER, PRESIDENT, AMERICAN DLENTAL ASSOCIATION; ACCOMPANIED BY REGINALD SULLENS, ASSISTANT SECRETARY FOR EDUCATIONAL AFFAIRS Dr. OSTRANDER. Thank you, Mr. Chairman, and members of the committee. I am Dr. F. Dan Ostrarider of Ann Arbor, Mich. In addition to being a professor of dentistry at the University of Michigan, I have the privilege of serving this year as president of the American Dental Association. With me is Mr. Reginald H. Sullens, assistant secretary of the American Dental Association for educational matters. We are appearing on behalf of both the American Dental Association and the American Association of Dental Schools. We are pleased to have this opportunity to testify in support of H.R. 15'T5~T, the Health Manpower Act of 1968. The dental profession has been deeply concerned for many years about the problem of providing a supply of well-trained professional and auxiliary dental personnel that w9uld be adequate to the needs of our people. The organized dental profession was one of the earliest supporters of the Health Professions Educational Assistance Act of 1963. We have supported, as well, the additional programs that are now brought together in the four titles of H.R. 15'157. There is no question in our mind that each of these programs was necessary at the time of its passage and remains necessary today. We are convinced that they are central to our national effort to extend and improve the health care available to our fellow citizens. We believe PAGENO="0163" 155 that the support furnished by these measures will continue to be re- quired for some years ahead, especially in view of the considerable number of laws passed by Congress in recent years est~ibiishing new and widely broadened health care benefits to various groups of people such as the elderly, the categorically needy, the medically indigent and young children from impoverished families. Our paramount purpose, then, in appearing before you today is to make clear our support for }II.R 15757 and to urge favorable consid- ~ration of it by this committee. In this brief oral statement, we would like to outline the progress that has been made in recent years, the continuing need for this legislation and, finally, our view of some of the changes the measures you are considering would make in the existing programs. Construction Since the inception of the Health Professions Educational Assist- ance Act of 19(33, a total of 33 applications involving construction, renovation, or rehabilitation have been received from 29 dental schools. These applications include plans for new dental schools as well as additions to or replacement of existing facilities. As a result of only those construction grants that have been funded, it is our understanding that places for 718 additional first-year stu- dents will be created. An additional 195 places will come into being as a result of applications that have been approved but are not yet funded. There are four applications awaiting approval which, if approved and funded, will add 91 more places. And finally, 12 schools have given notice of intention to apply for grants by submitting plans that, in total, would provide 42'r new first-year places. If all goes well, we can project a 1973 freshman enrollment of some 5,455 as compared with the current figures, 4,198. It is important to note that these accomplishments and projections are being carried out on the basis of a genuine partnership with the Federal Government. The 33 applications that have been received involve a total estimated cost of $216 million, of which some $98 mil- lion would come from non-Federal sources. In order to fulfill these projections fully, however, H.R. 15757 must be approved. The sums authorized under the existing law are not sufficient. As of February 21, 1968, appro~dmately $77 million had been distributed by the Federal Government for dental-school con- struction. Applications that are approved but unfunded, deferred or pending will require an additional $50 million, and anticipated appli~ cations will call for $83 million more. As of June 10, only some $1 million was available but not obligated. Considering solely those applications that are approved but unfunded, this constitutes a deficit of nearly $28 million. If all applications now pending or anticipated are approved, the deficit would be at least $133 million. Extension of the law is, then, mandatory in our opinion. Extrapolation of figures submitted by the administration indicates that it contemplates allocating about $170 million to dental-school constniction over the 4-year life of the bill. Measured against need, we consider this to be a conservative figure. Title I of H.R. 15757, which relates to construction, would not only extend existing law but would also amend some aspects of it. The bill would, for example, eliminate the provision that prevents the use PAGENO="0164" 156 of Federal fu:nds for construction of teaching facilities for continuing or advanced education. Of even greater importance is the provision that would permit a single application for construction of facilities that, though sub- stantially for teaching purposes, also would include research and ii- library facilities. Certainly, this would eliminate a great deal of administrative confusion and red tape. Indeed, these changes, and perhaps some others in the bill, are of such manifest value that we are sorry to see they will not take effect until the end of fiscal 1969. The committee might wish to consider moving the effective date forward one year. A substantive improvement also would be made by the provision that will permit up to 66% percent Federal support for renovation or rehabilitation if, in the Secretary's judgment, unusual circumstances exist. In previous years, when testifying on these matters before this committee, we have voiced concern over the possibility that some dental schools might find it necessary to close their doors unless substantial assistance could be obtained. This concern, we are sorry to say, has now become a reality in the case of St. Louis University that has felt compelled, solely for financial reasons, to discontinue its dental school. Had broader financial support been available, the university might have felt able to continue. We are presently aware of four to six addi- tional existing schools that are actively `considering the termination of their dental educational programs. One has requested the American Dental Association to form a task force to study the feasibility of con- tinuance. It is self-evident that the retention of an existing school, its faculty and structure and student body, is at least as important to the future as is the funding of a completely new school that will require 8 or 10 years before graduating its first practitioner. The closing of any existing school would be a crippling blow to our hopes for progress. Institutional graQits Viewed as incentive programs for the improvement of dental edu- cation, the basic and special improvement grants of the past 2 years have been remarkably successful. In 1964-65, the operating dental schools spent approximately $51 million on their teaching programs. In 1967-68, that total had mounted to $77 million, demonstrating clearly that non-Federal expenditures have risen at a rate considerably higher than the amounts distributed by the Federal Government. In fact, current non-Federal expenditures are some $14 million more than they were in 1964-65, `while Federal funds have been increased some $12 million. With the funds available as institutional grants, combined with the non-Federal effort, 45 dental schools have added new courses to the undergraduate curriculum in 28 subject areas, pertinent courses that will significantly improve the services the new dentist can offer his patients. Additionally, 28 schools have reported expenditures of sig- nificant amounts for such purposes as new educational equipment and new clinical teaching aids. With the funds available from the improvement grants, the Nation's dental schools have been able to recrait 173 full-time equivalent faculty personnel, thus enabling them to meet the needs of a student enroll- meat that has increased 10 percent since 1961. PAGENO="0165" 157 These are only beginnings, however, and mli4th more must be done. Statistics relative to teaching personnel strikingly document this fact. In the previous academic year, there were 148 full-time positions vacant. Within the next 5 years, new construction and expansion will create 280 new full-time positions, Within this same 5-year period, some 175 full-time teachers will retire. We are thus facing today, a deficit, in terms of full-time faculty, of more than 600 teachers. The need for extension and expansion of the institutional grant mechanism, then, lies at the heart of any plan for expanding man- power in dentistry and We support its continued existence. The associations believe that the new formula for allocating the grants is, in general, well-conceived. Because special circumstances in a few institutions, we regard the waiver provision respecting in- creased enrollment as essential. Special project grants Much of the preceding comment regarding institutional grants applies with equal force to the special project grants authorized in the bill. The particular value of the special project grants in regard to dental education is that they can be used to meet exceptional prob- lems. We have in mind their use as "rescue grants" to save established institutions. We are pleased, accordingly, that there is explicit author- ity to assist schools that are in "serious financial straits," a description that currently fits several dental schools. Again, we would call to the attention of the committee the fact that the continuation of an existing dental school is as important to public welfare as is the construction of a new school. Scholarship and loan funds We have always shared with this committee the conviction that the opportunity for professionaJ health education should be available to any young man or woman with the talent to pursue it. A lack of per- sonal financial resources should not be a determiniiig factor. The loan and scholarship funds available in the past few years have moved us closer to realization of this goal. The need for these provisions is, if anything, greater than it has been. The cost of dental education to the student has increased as a result of higher tuition fees and living costs. The average tuition cost per year for private schools, in 1963, for exam- ple, was $1,100 and today it is $1,476. The average total expense for the 4-year dental education program, exclusive of living costs, was $7,000 in 1963 and is $9,300 today. In individual instances, this total can be as high as $15,000. The schools have had no difficulty in identifying students needing the scholarship and loan support being offered. In 1967 Annual Survey of Dental Education Institutions shows that 94 percent of the loan and scholarship funds available, both Federal and non-Federal, were awarded. The small amount not awarded was due, almost entirely, to the existence of a few private scholarships or loans that have highly restrictive eligibility requirements. The provision in H.R. 15757 that would permit schools to transfer up to 20 percent of either the loan or scholarship fund from one to the other is, in our view, desirable. The flexibility will permit the individ- ual school to be that much more responsive to the particular needs of its student body. PAGENO="0166" 158 Allied health pro fes.s~ion.s Both associations fully supported passage of the Allied Health Pro- fessions Personnel Training Act of 1966. The program it authorized is barely underway, the value of it and the need for it are abundantly clear and we strongly favor continuation along the lines contemplated by H.R. 15757. Health research facilities The activities authorized under the Health Research Facilities Act are directly and essentially related to the continued expansion of our supply of health practitioners and continued improvement in the education of health students. The final goal, in all instances, is to make the finest possible care readily available to our fellow citizens. If prop- erly funded, the health research facilities law will make an essential contribution and we urge its continuance. In conclusion, we believe that the degree to which dental schools are a matter of national concern can hardly be overstressed. There are, at present, 50 dental schools located in 27 States, the District of Colum- bia, and Puerto Rico. This means that 23 States have no dental school and must depend wholly upon outside resources for the education of practitioners. The 23 States that have no dental school have a cumulative total population (1965 estimate) of nearly 31 million people. There are approximately 14,750 practitioners presently serving that population. As those practitioners retire from practice, their places must be taken by new men supplied from outside their States. And of course, if we are going to improve the dentist-patient ratioS, the new supply must exceed the rate of retirement from practice. At the present time, these 23 States have some 2,168 of their young citizens enrolled in dental schools throughout the Nation. Since State- supported schools must, understandably and of necessity, give priority to their own residents, students from States not having a dental school are accommodated, in 53 percent of the cases, by private schools. And it is these privately supported schools that seem to be suffering most heavily in the current financial crisis. As pressure increases, moreover, it is likely that States will limit further the acceptance of out-of-State students. At present, dental schools that have no State affiliation enroll nearly 50 percent of the some 14,950 students currently studying for dental degrees. Appended to our statement is a detailed recounting of the situation with regard to those States that have no dental school. (The material referred to follows:) PAGENO="0167" 159 STATES WITHOUT A DENTAL SCHOOL State Dentists Population (thousands) Students Private Public Alaska 70 274 5 4 31 Arizona 664 1.611 100 66 64 Arkansas 632 1. 833 87 19 58 Colorado Connecticut Delaware 1,157 1, 895 212 1.985 2. 785 501 149 190 38 97 129 17 64 21 201 Florida Hawaii 2, 899 469 5. 872 731 437 62 233 40 24 32 Idaho 341 691 69 38 141 Kansas Maine 1,039 453 2.269 993 171 35 24 28 7 47 Mississippi Montana Nevada 643 378 185 2.211 718 400 62 51 47 13 26 35 29 15 2 New Hampshire New Mexico 309 322 637 1.037 27 81 22 48 35 13 North Dakota 285 640 30 15 115 Oklahoma Rhode Island South Dakota 994 500 300 2. 411 905 707 206 39 35 95 27 18 1 12 11 Utah - 625 998 203 128 75 Vermont 194 396 11 6 5 Wyoming Total Percent 154 351 33 22 11 14, 740 30.962 2, 168 1, 150 - 53 1,018 47 Dr. OSTRANDER. This concludes our testimony, Mr. Chairman. We are grateful for this opportunity to appear in support of H.R. 15757. We would be glad now to try and answer any questions. Mr. ROGERS. Thank you very much, Dr. Ostrander, for your state- ment. It will be most helpful to the committee. What is the estimated shortage of dentists in this Nation? Dr. OSTRANDER. It is a very difficult thing to arrive at because of a number of imponderables: For example, the degree to which preventive measures that are now known or now being developed will be applied, and I am thinking of fluoridation of public water supplies and other measures that are under research at the present time that give us quite considerable promise for better control of dental caries and periodontal disease. Our present ratio in the population is approxi- mately one to 2,100 people. Mr. ROGERS. One to- Dr. OSTRANDER. One dentist to 2,100 people. I am not sure that we have, like the others who testified today, come to a numerical figure that would actually represent the ideal number of dentists. We are quite sure that there is no likelihood of reaching the level that we would consider ideal in the foreseeable future. Do you have anything to add to that, Mr. Sullens? Mr. SULLENS. We could supply for the record, Mr. Chairman, figures on what it would require to maintain the current ratio and I think this is roughly the best estimate that we could have at the present time. If I recall correctly, I think the estimates that we have made suggest that we will need something in the neighborhood of 5,400 first-year students by 1975 in order to maintain this ratio. We can supply this information for the record if you would like to have it. (Information requested follows:) PAGENO="0168" 160 AMERICAN DENTAL ASSOCIATIoN STATEMENT ON NUMBER OF DENTISTS NEEDED THROUGH 1975 In order to maintain the present dentist-to-population ratio through 1975, we will need to have in that year some 111,000 professionally active dentists. Mr. ROGERS. That would be helpful if you would. Did you say about 15,000 practicing dentists now, or are these students? How many practicing- Dr. OSTRANDER. Students. Enrolled in the dental schools. Mr. ROGERS. How many practicing dentists are there? Dr. OSThANDER. Roughly 90,000. Mr. SULLENS. There are about 97,500 professionally active dentists. Of these, about 7,000 are in Federal Government service, about 1,000 are engaged full time in teaching, and about 500 are employed in state and local public health programs. Mr. RoGERs. What about `the building of new dental schools? What is your feeling on the need there? Dr. OSTRANDER. Well, I am sure that we feel that the-the associa- tion feels strongly, denistry feels strongly, that we do need more schools. I don't think there is any question about that. We have a number of them that are about to begin operation, a number of them that are on the drawing board, so to speak. And we certainly think we need them all. Mr. ROGERS. Do you think there should be some limit on the project grants? The present limit is $400,000. Dr. OSTRANDER. We would hate to see an arbitrary limit, I think, because of the difference in situations in different schools. Some of the schools, of course, are in dire straits, as we have already stated, and I think there should be considerable leeway in the amount of money that can be made available to them under those conditions. Mr. ROGERS. As I understand it, you feel it is a good idea to inter- change these funds in institutional grants, in the projects? Dr. OSTRANDER. Yes. Mr. ROGERS. Do you think it is a proper ratio? I understand they plan to devote about 40 percent of those funds to institutional grants and about 60 percent of whatever funds the Congress may authorize to project grants. Would this be reasonable to you or not? Dr. OSTRANDER. In my opinion it is a reasonable approach. Would you agree, Mr. Sullens? Mr. SULLENS. I think it would be difficult to determine that without a little further study. Certainly some reasonable allocation of the special project grants and institutional grants will have to be made by Congress when the appropriations are made. To get back to your earlier question, Mr. Chairman, on the maximum authorization under special project grants we would prefer not to see such a restriction for the reasons Dr. Ostrander indicated. Applications will be con- sidered by the advisory committee which will make decisions on the amounts of the grants in accordance with the regulations, under the law. I can understand the concern about this but there are some very special problems such as the dental schools we mentioned which are on the brink of discontinuing. These schools might well be saved by the absence of hard and fast restrictions. If there could be some excep- PAGENO="0169" 161 tions made in these c'~ses, I think it would certainly benefit dental education and dental' schools. Mr. ROGERS. Why is it the schools are going under ~ Do you think- aren't there enough students to- Dr. OSTRANDER. It is not a question of students. There are plenty of students available but, of course, dental education is a very expensive form of education and the Universities have to subsidize the dental schools, By no means does the student fee pay the cost of dental education and, of course, these are private universities, privately funded universities which do not have access to State funds. And they are finding it increasingly difficult to support the dental schools. Mr. ROGERS. I notice you think that rehabilitation and renovation' is a proper area for expenditure. Dr. OSTRANDER. Well, we feel, of course, if a school is already in existence and has faculty and a student body and the facilities, even though they may not be ideal facilities, that `it is too bad to disband that school and then expend a considerably greater sum to establish a new school. Mr. ROGERS. Yes. Now, I am not sure that I understand your figures on page 4. It says if all applications now pending or anticipated or approved, the deficit would be at least $183 million. Then you sa~ that it indicates, the figures submitted by the administration, that it contemplates allocating about $170 million to dental school construction over the 4-year life of the bill. You say measured against need we consider this to be a conserva- tive figure. I am not sure I understand that. It seems that $133 million is some- what less than $170 million. Maybe Dr. OSTEANDER. I think Mr. Sullens has those figures. Mr. SULLENS. I will attempt to clarify this. The $133 million figure is based upon applications which are on file with the Public Health Service or indications of intent to file applications. We have every reason to believe that there will be additional applications from insti- tutions both for rehabilitation and for the construction of new institutions that will go far beyond this. In addition, under the provisions of the bill which you are consider- ing, there will be additional construction elements involved, such as the construction of continuing education facilities, libraries, and things of this kind which will increase even the current application backlog or intended backlog of $133 million well beyond, in my judgment at least, well beyond the $170 million figure. Actually the extrapolations that we have made suggest that we are talking about something in the neighborhood of $190 million. And this figure refers to additional applications which we anticipate from universities which have indicated an interest in dental schools but which have not yet been counted. Mr. ROGERS. I thought the $133 million included `that. It said if all applications now pending or anticipated are approved. Mr. SULLENS. I think the anticipated-~-- Mr. ROGERS. The deficit would be $133 million. Mr. SULLENS. I think the anticipated here refers to formal letters of intent, either formal applications or written formal letters of intent. The anticipated schools that I am talking about are places such PAGENO="0170" 162 as Oklahoma, for example, which is seriously considering the estab- hshment of a dental school but has not yet filed either a letter of intent or an application for construction assistance. Mr. ROGERS. But even still that would be some almost $40 million over your anticipated, the $170 million. Mr. SULLENS. Over the period of 4 years; yes, sir. It could well be beyond that in my opinion. Mr. ROGERS. It just seems to me that is a rather generous figure according to what was anticipated. Now, on page 6 you say current non-Federal expenditures are some $14 million more than they were in 1964, while Federal funds have increased some $12 million. So there is a deficit there of $2 million. Is that what you are telling us? Page 6. Dr. OSTRANDER. Essentially what we are saying is that there is good non-Federal support of dental education as indicated by the fact that there is $2 million more in this category than in the Federal funds of $12 million. Mr. SULLENS. According to the surveys we have made, Mr. Chair- man, the increase in operating support of the dental schools from 1964 to 1967 was roughly $26 million, of which $14 million came from iion- Federal sources and $12 million from Federal sources. I think this is the intent of that, to indicate that there is better than 50 percent of the increase that has come from non-Federal sources. Mr. ROGERS. Now, you have had a student enrollment increase of about 10 percent since 1961 ~ Dr. Osm~DER. Right. Mr. ROGERS. Are all of these who are graduating now-could you break down for us, perhaps furnish for the record-I realize you may not have it with you-a breakdown of what happens to the graduates? In other words, how many go into actual-the practice of den- tistry and how many into research, and so forth, specialties. Dr. OSTRANDER. I am sure that we have that data but I don't know that we have it with us. Mr. ROGERS. I understand. Dr. OSTRANDER. We can provide it, I am sure. Mr. SULLENS. Roughly 10 percent of the graduates go into specialty practice, 10 or 11 percent, about 4 or 5 percent into teaching and re- search, but we can provide the precise figures. (The information requested is as follows:) AMERICAN DENTAL ASSOCIATION STATEMENT ON CAREER PLANS OF SENIOR DENTAL STUDENTS Following are the resnits of a 1963 snrvey of the career plans of senior dental students: [Inpercent~ AU Career plans: seniors General practice 75.2 Specialty practice 15.5 Administration .2 Teaching 1.9 Research 1.2 State or local health department .4 Army, Navy, Air Force 4.8 Public Health Service or other Federal agency .8 Total 100 PAGENO="0171" 163 Mr. ROGERS. So the vast majority actually go into active practice. Mr. SULLENS. Yes; after military service. Mr. ROGERS. And I would like to know if you could project for us- you may have these figures-that you could supply this for the record, what you think we need to do to keep up with the demand and to supply dental service for the American people, how many new schools, how many graduates we should be turning out, and your projection of how much could be absorbed into the existing schools and what might have to be done in building new schols, if you could let us have something like that for the record. (The information requested follows:) AMEInCAN DENTAL ASSOCIATION STATE1~EENT ON PROJECTED NEEDS FOR NEw DENTAL SCHOOLS In order to maintain the present dentisit-to-population ratio through 1975, we will need to have in that year some 111,000 ~ofessionally active dentists. The expanded rate of dental school production projected from applications in four categories (funded, approved but not funded, awaiting approval and to be submitted) will enable us to reach an approximate total of 104,000. We will thus fall short of the projected need by some 7,000. Given an average graduating class of 100, considerably larger than is presently typical, ten additional new schools would need to open their doors immediately in order for us to redress that projected shortage of 7,000. Mr. ROGERS. Now, I notice you say you don't think there should be a requirement for a specific number of new graduates or new students over and above what they have been doing. Dr. OSTRANDER. I think we were thinking in terms of those schools tha.t are in borderline status financially at the present time when we are speaking of that, and, some o'f them very badly need help just to keep going, and therefore, I would hate to see it arbitrarily tied to an increase in enrollwent without some opportunity for the Secretary to' use his good judgment on that. Mr. ROGERS. Well, I would presume that if they have a going in-, stitution and they could take additional students, he could still find what is necessary `to keep it going and increas&- Dr. OSTRANJYER. Well, of course- Mr. ROGERS. You see, he has project grants as well as his institu- tionai. grants I would think for this purpose. Mr. SULLENS. Mr. Chairman- Mr. ROGERS. Do you see any objection to putting it on? Mr. SULLENS. I think the point we were trying to make here is es- sentially the same one that the medical representatives made earlier, that we would like to see the bill continue to include the provision for the waiver of this enrollment increase in circumstances which justify such a waiver. I think both the American Dental Association and the American Association of Dental Schools have always sup- ported the desirability of an enrollment increase and in the case of dental schools as well as medical schools, as you heard earlier, this has been far above the minimum requirement. In most instances I think it has run in the neighborhood of 20 to 25 rather than the mini- mum of five. But we would like to see this provision included where there are circumstances that justify a waiver of this particular re- quirement, both in terms of eo'nstrudtion and in terms of institutional grants. PAGENO="0172" 164 Mr. ROGERS. Well, how do you tell? How does the Secretary tell? Most of the schools, you say, aren't making money. Mr. StrLLENS. Well, I think in the case, for example, of a private institution where there is a current matching requirement of 1 to 1, and it could be 2 to 1 under the provisions of the new bill, that it might not in some instances be possible for that institution, partic- ularly in the case of the private institution, to be able to raise the matching funds, and if this were the case, it is a question, then, as has happened in the case of one institution, St. Louis University as we mentioned, and as might well happen in the case of two or three others, of losing a dental school, which means we then face the neces- sity of building a new one at a cost of $10 to $15 million. Mr. ROGERS. Is there any other school attached to-where is it, St. Louis? Mr. SULLENS. St. Louis University is the dental school. Mr. RoGERs. I presume they have other medical-do you have a medical school? Mr. SULLENS. Yes. Medicine and pharmacy. Mr. ROGERS. I wonder if their medical school is in the same financial situation. Do you happen to know? Mr. SULLENS. I don't happen to know, sir. I know the university, as in the case of many private universities, has some severe financial problems, but I don't know the situation of the medical school. Mr. ROGERS. So it is a question where they want to put the priority, I presume. Mr. SULLENS. It is certainly a part of it. Mr. ROGERS. Thank you very much for your testimony. It has been most helpful and if you could submit for the record those items that we have `asked for, the ccxrnmittee~-wou1d appreciate it. Dr. OSTRANDER. Thank you very much, Mr. Chairman. We appre- ciate very much the opportunity of testifying, and I am sure that the data that you wish will be submitted. Mr. ROCERS. Thank you, Dr. Ostrander and Mr. Suliens. The committee will stand adjourned until 10 o'clock tomorrow morning. (Whereupon, at 4 p.m., the committee was adjourned, to reconvene at 10 a.m., Thursday, June 13,1968.) PAGENO="0173" HEALTH MANPOWER ACT OF 1968 THURSDAY, J~UNE 13, 1968 HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON PUBLIC HEALTH AND WELFARE, COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE, Washington, D.C. The subcommittee met at 10 a.m., pursuant to notice, in room 2322, Rayburn House Office Building, Hon. John Jarman (chairman of the subcommittee) presiding. Mr. JARMAN. The subcommittee will be in order as we continue the public hearings on H.R. 15757, introduced by Chairman Staggers, to amend the Public Health Service Act to extend and improve the pro- grams relating to the training of nursing and other health professions and allied health professions personnel, the programs relating to stu- dent aid for such personnel, and the program relating to health re- search facilities, and for other purposes. Our first witness this morning is Dr. Evelyn Cohelan, professor of psychiatric nursing and head of the Department of Psychiatric Nurs- ing at the University of Maryland, who is appearing for the Ameri- can Nurses Association. Mr. ROGERS. Mr. Chairman, may I say and join with the chairman in welcoming the ladies here and we are delighted to see Dr. Cohelan, the wife of our very distinguished colleague from California. We know very much of your fine work and interest. Of course, Miss Thompson, too, has done such an outstanding job. Mr. JARMAN. The committee has worked and we individually have worked closely with your distinguished husband on many legislative matters and we are very pleased to have you and your associates here with us this morning. Will you proceed? STATEIVEENT OP DR. EVELYN COHELAN, CHAIRMAN, COMMITTEE ON LEGISLATION, AMERICAN NURSES ASSOCIATION; ACCOM- PANIED BY JULIA THOMPSON, DIRECTOR, WASHING~TON OPPICE; AND HELEN CONNORS, NEW YORK Dr. COHELAN. Thank you. I have Miss Julia Thompson of the Washington office of the ANA with me and Helen Connors from the New York office of the ANA. I am also third vice president and chairman of the Committee on Legislation of the American Nurses Association, which is the pro- fessional organization of over 900,000 registered nurses in 55 constit- uent associations, the District of Columbia, Puerto Rico, the Virgin Islands, and the Canal Zone. We admitted Guam at the last ANA convention in Dallas just last month. (165) PAGENO="0174" 166 The association's ultimate purpose is to secure for the people of this country the best possible nursing care. One commitment is to elevate the standards of nursing education to insure nursing practice of high quality. I welcome this opportunity to appear here today on behalf of the American Nurses Association to present its views on H.R. 15757, the Health Manpower Act of 1968. We support assistance to the various schools preparing health personnel in the bill. However, our special concern is with title II, nurse training, which would extend for 4 more years the Nurse Training Act of 1964. CONSTEtOTION GRANTS We urge the continuation of the construction grant program for 4 more years. Since the program began in fiscal year 1966, 80 schools have received grants. Much of the construction is in the beginning stage but close to 2,700 new first-year places will result. Many of the grants were awarded for replacement of obsolete facilities and for minor expansion. These have permitted the maintenance of 12,000 student places that otherwise might have been lost. We are very concerned that although the Congress authorized $25 million for construction of facilities in fiscal year 1969, the adminis- tration request is for only $8 million. The Program Review Committee on the Nurse Training Act noted that many programs are still located in makeshift quarters such as barracks, dormitories, and basement areas that are unsafe and poorly ventilated. For example, one nearby university nursing program has 11 offices available for a faculty of something over 70, and I speak with real feeling about this. This is the University of Maryland, the school from which I come, and we have, counting all of the students in the school, something like 1,100 students. We had the plans and the money for the new school building and then it was caught in this last freeze. We are hoping that it wilibe unfrozen and we will then have enough offices for everybody. In the meantime, faculty are using the trunks of their cars to carry teaching materials. Until such facilities are replaced, schools cannot expand enroll- ments. Students are inclined to select attractive schools and faculty choose schools with modern equipment that permits more effective teaching. It gives us a bit of a start to hire a new faculty member and when she says, "Where is my office," you say, "There is not any." We support the inclusion in the constructhm project of space for ad riced training activities, such as continuing education, that are not degree oriented. Continuing education is a great imperative in this time of rapid change in medical and nursing practice. There is a heavy burden on the individual practitioner to keep current and on the employers of nurses to develop the most economical and effec- tive means of bringing and keeping nursing service personnel up to date. Improved utilization of scarce health manpower cannot be ac- complished without changes in traditional functions and organiza- tional patterns and change will only occur through new learning. This is where we need continuing ~education. Research and innovation in the delivery of nursing servIces, must be supported and implemented through comprehensive programs of job orientation and inservice education. In addition to increasing the future supply of nurse man- PAGENO="0175" 167 power, equal attention has to be given to improving the knowledge, skills, and abilities of our present nurse manpower pooi. SPECIAL PROJECT GRANTS We support the continuation of the special project grants to assist schools to strengthen, improve, and expand nursing education. One hundred and sixteeen grants have been awared to 95 schools with an additional 143 programs sharing in the projects with benefits reaching over 33,000 students. H.R. 15757 would expand the present program to permit any public or nonprofit private agency, organization, or institution to apply for a grant that would contribute to the strengthening and improvement of nursing education. We urge this committee to approve this expan- sion of the project grant program. INSTITUTIONAL GRANTS The American Nurses Association endorses the principle of basic support grants to schools of nursing. lEt is increasingly difficult for institutions to meet the costs of education since tuition in many institu~ tions provides only a quarter of the cost of the education. We wish to point out that the baccalaureate programs have the higher average enrollment since four or five classes of students are using the facilities simultaneously compared to two and three classes in the associate and diploma programs, respectively. We believe, there- fore, that additional support should be given to the baccalaureate programs because of the strain put on the faculty and other institu- tional resources to support these large enrollments. We recommend an institutional grant of $25,000 for these baccalaureate programs. A major priority relates to program support for graduate education. There is great need for persons perpared at the graduate level in order to teach, to administer nursing care of patients, ~nd to give leader- ship generally within the field. Graduate education is more expensive than is undergraduate education and certainly far more expensive than diploma and associate degree nursing education. We hope that the Federal legislation will give cognizance to the burdens placed upon institutions of higher learning which are being asked to prepare more and more leadership personnel for the field of nursing. They must have program support if they bear this great responsibility. H.R. 15757 proposes school support in the amount of $15,000. Grants to graduate programs should be markedly improved over that figure. Since there are fewer than 50 schools conducting graduate programs we suggest that each graduate program should have a minimum of $50,000 annually for program support. Again, I can speak with some feeling about the need for additional funds in graduate programs. I am chairman of the graduate program at the University of Maryland and we have approximately 80 full-time graduate students each year in nursing, and then we also cooperate with the Southern lRe~ional Education Board. The need is so acute in the southern region to prepare faculty for junior colleges as well as the other programs, but the junior colleges seem to feel the pinch more than the others because they are expanding so rapidly. We have modified our curriculum and this summer we are offering courses for faculty who are teaching in PAGENO="0176" 168 junior colleges and the second priority is given to those teaching in baccalaureate programs. The modified curriculum is on a trial basis and we hoped that we might get e.ight students who would come during the summer. We have 11 now-4he course does not open until the 8th of July-~and we have many requests from other parts of the country. The University of Florida has been involved in trying to offer summer courses at the graduate level so that faculty who cannot be released for full-time study during the rest of the year can come during the summer and eventually earn a masters degree. So I feel very stro~giy that until we place graduate education at the top of the list, we are not going to be able to supply the needed faculty f~r the other schools. TRAINEESHIPS FOR ADVANCED TRAINING OF PROFESSIONAL NURSES The professional nurse traineeship program was first established under the Health Amendments Act of 1956 and provided financial assistance to nurses preparing for positions in teaching, supervision, and administration. It was extended in 1959 and again in 1964. During the years 1957-66, 16,162 nurses were awarded traineeships. Although this program has increased the number of nurses with graduate degrees, the need is still great. But there really is no substitute for being able to offer a traineeship because the nurse is much more likely then to come back to school. The responsibilities of those who serve in positions in teaching, supervision, and administration in nursing and as clinical nursing specialists are such as to require advanced preparation at least at the master's level. Sound programs of nursing education cannot be de- veloped without qualified teachers. Quality nursing service cannot be provided for the people of this country unless we have sufficient numbers of well prepared supervisors and administrators. In all nursing education programs, as in all programs of higher education, the faculty should hold graduate degrees. Therefore, it is startling to consider the preparation of those presently teaching in all types of schools of nursing. Only 42.8 percent of current full-time faculty members in senior and junior colleges, and in hospital schools have graduate degress. Eighty-six percent of the people teaching in 4-year collegiate schools have graduate degrees, 69 percent of them teaching in junior colleges have graduate degress, 18 percent in hos- pital schools have gradnath degrees, and 11 percent in the practical nursing schools. There are some additional figures that have been supplied for the record in the accompanying table. I will not take the time to read all of them. (The table referred to follows:) Graduate Baccalaureate No degree ~gree Percent Percent Percent Collegiate scbools - Junior colleges - Hospital schools Practical nursing schools 86. 8 69.7 18. 8 11. 1 12. 9 28.4 55. 6 44. 3 0. 3 1.9 25. 6 44. 6 PAGENO="0177" 169 Dr. COHILAN. Obviously it is impossible for schools to prepare nurses to give the quality of nursing care society needs and expects today when so many who mold future practitioners have only basic nursing preparation. In addition to our concerns about the quality of faculty in schools of nursing, we face the acute problem of shortage of personnel to fill these positions. There are 1,744 vacancies in full-time budgeted faculty positions in all schools preparing nurse practitioners. We urge the extension of the traineeship program so that preparation of nurse teachers can continue without.interruption. The quality of nursing practice is improved or deterred by the organizational framework in which the nurse practitioner functions. Effective nursing service administration and supervision fosters a safe, efficient, and therapeutic level of nursing care. Such administration and supervision is dependent upon familiarity with a body of knowl- edge based on sound principles that can be applied in nursing service situations. To be expert requires the thorough study that is possible only at the graduate level. Basic programs prepare practitioners for beginning positions in nursing and not for administration. At this time, the educational attainment of persons holding positions as super- visors and administrators in nursing services has by no means reached the level the profession deems desirable as will be seen from the fol- lowing data collected for all hospitals and related institutions. There are only 11.9 percent of the directors and assistant directors who hold graduate degrees and f2.6 percent of the supervisors who hold gradu- ate degrees. (The table referred to follows:) Graduate Baccalaureate degree No degree Directorsandassistantdirectors Percent 11.9 Percent 30.4 Percent 57.7 Supervisors 2. 6 18. 7 78. 7 Dr. COIrELAN. If we are to raise the level of education of nurses functioning in the critical areas of supervision and administration and fill the vacancies which still persist, it is imperatve that the Congress continue the professional nurse traineeship program it ini- tiated in 1956. As far as the problem of having adequately prepared nurses in nursing service situations, not only is it a problem for the patient if these people are not adequately prepared, but it creates a real problem as we are trying to educate the practitioner, because we would hope that she would see the best kind of nursing care; and when there is not a role model available to the person learning to be a nurse, it present a real problem. A number of faculties across the country are concerned with how we can more effectively work with people in nursing service to improve the quality of care. In 1964, when the traineesbip program was extended, it provided for expansion to include financial grants for assistance to nurses seeking preparation as clinical specialists. The nurse clinician is a master practitioner. She may, for example, be a nurse midwife, a psychiatric nurse, the expert in cardiopulmonary nursing, or in the care of the chronically ill. To become such a practitioner in so broad a field as 95-540-68-12 PAGENO="0178" 170 nursing requires concentrated study at the graduate level in the selected area. Once prepared, this nurse uses her specialist's competence in providing direct care to patients needing expert nursing. She collaborates with the physician in planning and providing patient care, and works with, and teaches, other nursing personnel during the provision of nursing care and treatment. She may teach in schools of nursing and in programs of continuous education. She conducts and participates in clinical research. Highly qualified expert nurses to practice in specialized areas of nursing are essential to improvement in the quality of care. To pursue a doctoral program in nursing requires a large expendi- ture of money for tuition, books, and supplies, and maintenance over at least a 3-year period. Nurses engaged in doctoral work have been previously employed, hence have loss of income during the 3 years of study. As a typical example: Tuition for 2 academic years is likely to be $3,800; books and supplies for 3 years, $600; living expenses for 3 years-2 academic years and 1 year of work on dissertation-$9,000; total, $13,400. Loss income for 3 years when the nurse is not gainfully employed, is likely to be $26,000, so it is really is a high-cost operation. We support the recommendation of the Program Review Committee of the Nurse Training Act that administrative policy regarding dura- tion of support under the traineeship program be changed to permit completion of program requirements. We would also like to call your attention to the fact that over 8,000 registered nurses, graduates of associate degree and diploma programs, are studying for a baccalaureate degree. In 1966, 4,009 were enrolled on a part-time basis. Part-time study is uneconomical in terms of time, money, and effort but this practice persists because on their salaries, nurses cannot save enough to undertake full-time study and there is very little financial assistance available to them. Before they earn their baccalaureate degree, many will have spent 6 or 7 years in part- time study. The American Nurses Association agrees with the recom- mendation of the Program Review Committee that traineeships for graduates of diploma and associate degree programs be provided for up to 2 years of full-time study toward a baccalaureate degree. This would help registered nurses secure more rapidly the level of education their positions call for today and enhance the quality of patient care. I cannot cite figures across the country, but again, in our own graduate program roughly half of the fulktime students have come from diploma and associate degree programs, and the other half have come from baccalaureate programs. This means, then, that for those who have come from diploma and junior college programs, they have had for the most part, to spend several years earning a baccalaureate degree. The primary problem is that they have had to go to school part time, and this is long, slow way of doing it and we would get them through the master's program much faster if we could speed them in. STUD]~NTS LOANS We support the extension of the student loan program. H.R. 15757 would increase the maximum amount a student may borrow to $1,500 in any academic gear. Because the cost of nursing education in senior colleges and universities is, for the most part, higher than in junior PAGENO="0179" 171 colleges and hospital schools, we recommend that students who are candidates for baccalaureate or higher degrees be permitted to borrow up to $2,500 in any academic year. H.R. 15757 continues the foregjveness provision in the present Nurse Training Act and adds a total forgiveness provision at the rate of 15 percent per year for the nurse who is employed in a public hospital in an area with substantial population and a substantial shortage of nurses in such hospitals. Public hospitals in large municipalities have experienced great difficulty in filling budgeted positions. This forgive- ness provision is one means to assist them in recruitment and rentention of staff. SCHOLARSHIP GRANT TO SCHOOLS OF NURSING We urge approval of the provision which would authorize a new 4-year program of scholarship aid to students of nursing. Members of this committee approved, in 1966, an amendment to the Nurse Train- ing Act to provide the nursing educational opportunity grants and for this we have been most appreciative. As you know, very little public or private financial assistance has been available to nursing students iii basic programs. We believe a special effort is required to attract talented high school graduates into baccalaureate programs in nursing. Advances in medicine and in technology, the explosion of knowledge in related fields, dictates that nurses master an increasing body of knowledge and also develop the intellectual ability to make the necessary application in nursing care. Families are often unable to meet the full cost of collegiate nursing education. Repeatedly we hear from deans of collegiate schools and from nursing students of the need for scholarship assistance. From a school located in one of the largest of our cities we have this 5-year example of the need its students have had for financial assistance in order to complete their education. In the 1963 class, eight students out of 24 worked full time; 1964, 11 out of 45; 1965, 11 of 29; 1966, 15 of 28; 1967, 16 of 32. A nursing program is difficult. Add to this full-time work and you must be impressed with the commitment of these students to a career in nursing. DEFINITION OF ACCREDITATION Section 231 of H.R. 15757 proposes a change in the definition of accreditation. The authority of the Commissioner of Education to directly accredit programs of nursing education is deleted, which we approve. However, a State agency would be specifically named as a body of the Commissioner could approve for purposes of acerediting nursing programs. We have grave concern about this proposal. We ask these questions: What State agency? Will a State agency accept federally established criteria? The American Nurses Association believes tlç~at certain safeguards are essential to insure the best use of the ~`edera1 lfirnds that H.R. 15757 would make available. It is most import~uat that only nursing programs accredited by-or having reasonable accurance of accredi- tation by recognized national acerediting body be eligible to apply for funds under the act. PAGENO="0180" 172 All schools of nursing must have State approval. In the vast majority of States, it is the State board of nursing which is charged with this legal responsibility. These boards of nursing have supported the development of a strong national voluntary accrediting program berause attainment of such accreditation indicates a program has achieved more than the minimum standards established by State law. Potential students and faculty are attracted to schools which achieve national accreditation because they believe higher standards will produce more competent practitioners to serve the people of this country. As of October 1967, 75 percent of students were enrolled in nation- ally accredited programs. These then are the programs in the best position to ease the shortage of registered nurses. Of the 25 percent of students in nonaccredited programs, many are in the associate degree programs conducted in junior or community colleges. These have not sought national accreditation to the same extent as the other nursing programs. However, 42 are now fully accredited as compared with six in 1965. Of the remaining 239 pro- grams, 94 are eligible to apply for Federal funds, having achieved reasonable assurance of acreditation or its equivalent. We are confident that directors, faculty, and students in several associate degree programs look forward to full accreditation. One community college program could not apply for accreditation because of an administrative edict, that was based on philosophical opposition to specialized accreditation and to its cost. The students in this program prepared a brief and appeared before the board of edu- cation to argue for accreditation. In addition, they raised the money to pay for accreditation. Their activities convinced the board of educa- tion and accreditation of this program is now underway. Had nurses been satisfied that legal standards were sufficient to insure not only a safe practitioner but a highly competent one, there would have been no movement toward national voluntary accredita- tion. But the need for standards above and beyond those required by law was recognized by the profession itself. The ANA urges, therefore, that you not add the clause "or by a State agency" to the language of the act. I thank the committee for this opportunity to appear and present the views of the American Nurses Association. Mr. JARMAN. Dr. Cohelan, we appreciate receiving this comprehen- sive statement and commentary on various provisions of that part of this bill. What is the shortage of nurses at the present time? Can you estimate? Dr. CollEIA~. When you start playing the numbers game, it gets to be a little difficult. I think maybe Miss Thompson has some figures. Miss THOMPSON. The estimated number of nurses according to the formula that is used at the present time, 300 nurses per 100,000 popula- tion, would indicate that by 1970 we should have 850,000 nurses in actual practice. We have at the present time approximately 613,000 employed actively. About a fourth of these are in part-time work. PAGENO="0181" 173 We have approximately 910,000 registered nurses who hold current licenses, who are eligible to practice, and many of these come in and out of the work force-I mean participate in active work. We have had almost 7,000 nurses return to work under the coopera- tive program we have had with the manpower development and train- ing program and the Bureau of Health manpower, DREW through the refresher courses conducted within the last 2 years. Mr. JARMAN. Is there anything additional to the formal testimony this morning that you can suggest as to how we can meet that shortage in the country? Dr. COJIELAN. Well, I was going to add that the way I measure the shortage in nursing is by the number of requests we get for graduates of our masters program and I have an enormous bulletin board out- side my office in the hall and we post all of these heartrending pleas for nurses with a master's degree. There must be at least 25 or 30 requests for every student that we graduate. So that we are painfully aware of a terrific shortage at that level. And when it comes to short- ages at the bedside, we all know wings of hospitals that are prepared and then not opened because of the shortage. Mr. JARMAN. Thank you. Mr. Rogers? Mr. ROGERS. Thank you. Mrs. Cohelan, your statement I thought was excellent and gave us some very helpful information. In carrying out a medicare program and taking care of senior citizens-where we are going to have to move very heavily, I think, in the nursing homes-is it necessary, do you feel, to have baccalaureate degree nurses there, staffed throughout, or what? Dr. COHELAN. The baccalaureate prepared nurse should be in a position to make judgments about- Mr. ROGERS Supervising. Dr. COHELAN. Who can best care for the patients in those areas and I do not think that we have to have every bedside nurse prepared at the baccalaureate level. Mr. ROGERS. That is what I meant. Dr. COHELAN. But my concern is that there be enough people ade- quately prepared to make decisions about who can best provide the care for these people. Mr. ROGERS. Yes. I would share that feeling, too. I think what we have got to do is try to see what can be done to close this gap as quickly as possible because I think we are going to find the gap is going to increase. Dr. COHELAN. Yes. Mr. ROGERS. Rather than decrease. Now, what happens to your graduates or the graduates throughout the schools of nursing? Do we know-do most of them practice? Do some of them-how many teach? What percentage? Has any study been done on this? Dr. COHErJAN. Yes. As far as our own institution is concerned, I do not have those figures. A few of them, being women, will drop out for pregnancy and family responsibilities; but most of them who are pre- pared either at-well, primarily at the master's level, are likely to return. Many of the people coming into our masters program come in with three or four children. I got all of my advanced preparation when PAGENO="0182" 174 the four children were small. I had the benefit of Federal funds for this preparation. But there were no Federal funds available for doctoral study; so that when I was studying for the doctorate, I was on private funds made available through the National League for Nursing. These funds account for some of the pioneers in the field, but this is just a drop in the bucket, and it is obvious that private funds cannot do all that is needed, So that we do need Federal funds so that there will be many more people studying at the doctoral level. As a matter of fact, at this moment and for the past year we have been looking for some- body to take half of my assignment. I will give up either one of them, head of the department or chairman of the graduate program-but we have looked high and low and there are not people with this kind of preparation; so that I am carrying on with both of these assignments. So, I have a very personal vested interest in seeing that more money is `made available so that more people are prepared at this level. Mr. RoGEns. Now, what percentage actually practice, would you say? Have any studies been made? Perhaps Miss Thompson may have a figure. Miss THOMPSON. I have some figures here that would indicate the variable employment practices o'f nurses because the median age of em- ployed nurses is 39.6. Many of the young women leave and have t'heir families and then return to nursing. In a study that was done several years ago in 13 States, it was shown that the persons with the highest amount or the greatest amount of education have the greatest com- mitment and were more apt to return to active practice than those who had lesser preparation. Mr. ROGERS. Now, should we require each of the schools of nursing to produce more students, accept more students if they receive Federal funds? What would be your fee] ing on that? Dr. COHEIIAN. Well, if we are going to prepare more nurses, it seems to me we need to do two things. We need to encourage the develop- ment `of new schools, if they can get the faculty and will be a strong school; and then `we also need to increase the enrollment in the existing schools. Mr. ROGERS. So, you would favor some provision that would en- courage or perhaps require an increase, if they receive Federal sup- porting funds? Dr. OOHELAN. I would think so; yes. Mr. ROGERS. I would agree with that. Now, could you let us know, perhaps the organization could let us know, some figure that you think would `be reasonable to require s~hools to increase their student bodies by; and also if you could let us have your thinking on how many new schools of nursing we really need to help close this gap. And, if it can be done, `how many in the associate degree, the diploma, as well as the baccalaureate. (The information requested follows:) AMERICAN NURSES' ASSOCIATION, INC., New York, N.Y., June 19, 1968. Representative JOHN JARMAN, Chairman, E~ubconimittee on Public Health and Welfare, Interstate and Foreign Commerce Committee, Raybvrn House Office Building, Washington, D.C. DEAR MR. JARMAN: On June 13, during the hearings on HR. 15757, Repre- sentative Paul Rogers requested that the American Nurses' Association submit PAGENO="0183" 175 for the record projections for 1~75 for the number of nurses needed and the num- ber and kinds of programs needed to prepare the estimated number of nurses. The data on projections of need for nurses are: Master's degree or higher Baccalaureate degree Diploma and associate degree Total 1967 supply 1970 need 1975 need 16, 000 100, 000 120,000 67,600 200,000 280,000 556,400 550, 000 600,000 640, 000 850,000 1,000,000 Note: These estimates are based on an average figure of 300 nurses pe r 100,000 population. Because of varying class sizes and the length of time it takes to complete the different programs which prepare students to be registered nurses, it Is diffi- cult to translate needs for additional nurse manpower into needs for additional nursing education programs. It has been estimated, however, that approximately 49,000 new places for first-year students will be needed to meet the goal of 81,000 graduates in 1974. Increases in first-year places can be accomplished, at least partly, through en- larging existing schools. This course would appear to take best advantage of the employed faculty, library and health care services, for example, which al- ready exist in those institutions. The above data was obtained from the Nurse Training Act of 1964, Program Review Report, PHS Publication #1740, December 1967, pp. 13, 14, 33. Should you wish any further information we will be pleased to secure it for you. Sincerely yours, JULIA C. THOMPSON, Director, Washington Office. Miss TnoMPsoN. I would like to add here that within the last year we have increased the number of schools by 72; 70 of these are asso- ciate degree programs which, I think, is a remarkable number for this short period of time. Mr. ROGERS. In Florida I know they have done very well. They have done well on their exams. They rate very well. Miss THoMPsoN. May I also add that about 38 of the State nurses associations, through some cooperative effort, are conducting resource studies and plans for meeting the nursing education needs of the State, to produce the nurses needed in their State. They have decided how many nurses they need in their area, what kind of educational facili- ties they need to prepare the kinds of nurses that they need and how many with certain levels of skills. Some of these States are much farther ahead than others in their plans. Mr. ROGERS. Yes. Have diploma schools been decreasing or increasing? Miss THOMPSON. They have been decreasing, but they have been phasing into other programs, generally. Mr. ROGERS. Working into associate degree programs? Miss THOMPSON. Or baccalaureate degree programs. Mr. ROGERS. Or a comibination. What about in the armed services? Do you know if there is a short- age in the armed services of nurses or do they draft them so that-is there any call on your organization to supply nurses? Miss THOMPSON. There is no selection service for female nurses but men nurses are subject to the draft under the Selective Service System for the Medical Service Corps. The American Nurses Association has gone on record since the convention in Dallas saying that they would PAGENO="0184" 176 be interested in studying laws for selective service for nurses if such an occasion should arise. At the present time, there is a shortage but we have in our active nurse supply only about 26 percent who are single and the armed services generally require mobile single people, so it does limit the number from whom they can recruit. Mr. ROGERS. Now, as I understand it, too, they do not commission in anything except the baccalaureate nurse group, do they? Miss THOMPSON. At the present time, they are still commissioning persons from the diploma program which have the same number of years as a 4-year baccalaureate. I mean, they equate calendar year with academic year in order to secure a sufficient number of nurses. Mr. ROGERS. In other words, they would have to have a 3-year basic curriculum? Miss THOMPSON. Yes. Mr. ROGERS. Or 4-year baccalaureate. Miss THOMPSON. Yes. Mr. ROGERS. Should this policy be reviewed, do you think, now that we are beginning to have the associate degree nurses come out? Is there any reason why they connot perform services? Miss THOMPSON. This has been considered by the armed services. At one time the Army Nurse Corps did admit the 2-year graduate as a warrant officer. This did not prove to be very popular and there were very few applicants for the warrant officer status. Mr. ROGERS. Yes, but I was thinking of the commission status as such. Miss THOMPSON. The laws which provide for commissions in the services requires that a person have a baccalaureate degree and this is one of the reasons why the 2-year graduate cannot be considered for a commission. Mr. ROGERS. On the 3-year curriculum I think they do that, do they not? Miss THOMPSON. Yes. One of the reasons why it precludes the 2- year graduate. The Veterans' Administration does use the 2-year graduate. Mr. ROGERS. I would hope the armed services would review their situation. We may need to have them come in and talk about this because I think they are not being practical. I am sure they could use them in many places, I would think, and they are closing the door on this. I have a case of a young lady that wanted to get in. She cannot. She is qualified, she has passed State boards and everything. Dr. COHELAN. There is a special program that the Army has put together and the University of Maryland cooperates with them, and we just had commencement and graduated, in effect, an extra 100 nurses who are now going to be commissioned in the Army and the last 2 years they have been taught by faculty under our faculty super- vision, but they have had all of their clinical experience at Walter Reed. And it was the feeeling of those in the Army that they needed an increment of at least 100 baccalaureate prepared nurses and their assignments, I am sure, will reflect this kind of preparation. I would think there might be many other ways that nurses could be used. Mr. ROGERS. Let me ask on your summer courses now, which I think is excellent, where you bring the nurse in to give her increased knowledge. How many summers would it take now, say, to obtain a masters degree? PAGENO="0185" 177 Di COHELAN %iTell, this is just, you know, a trial balloon and the only thing I really have control over is psychiatric nursing and there is a terrific shortage there, so we have limited it to psychiatric nursing. We will teach the two clinical con i~ses the first summer, two more clini- cal courses, working with patients, and so on, the following summer, and then as it stands now, the student would come for two other semesters during the year whenever she can arrange it. If the demand is as great as it appears to be, we may have to modify further and offer the other courses so that all of the work can be comph~ted in the summer. Mr. ROGERS. Well, I would think this perhaps would be a good ap- proach and maybe we should try to encourage this throughout the nation. Dr. COIJELAN. The University of Florida was very forward looking but one of their problems was that they required the graduate record examination which may in my opinion, test a different kind of ability than a nurse coming into a masters program brings. At Maryland and at many other institutions, we do not have that, so that this may account for some of the problems. You know, it depends on the university graduate school requirements. But they were the first ones who thought of it and I have heard from them recently how many they are getting but we have all been hoping and praying that this, too, would catch on, and if it does, these both will be demonstra- tion projects and I would hope that across the Nation the other 50 graduate programs would do a similar thing. I hope we can expand it into other clinical areas, not just in psychiatry. Mr. ROGERS. Is there any reason why your association could not advise State agencies on accrediting ~ In other words~ have some repre- sentative work out some arrangement were a representative confers with a State agency? Dr. COHELAN. I would rather not speak to that myself. The Na- tional League for Nursing is the acerediting body and they are going to give testimony. Is there anything you want to say, Miss Thompson? Miss THoMPsoN. No. Mr. ROGERS, Thank you. Mr. JARMAN. Thank you very much for being with us and helping us make the record. Dr. COHELAN. Thank you. It has been a real pleasure. Mr. JARMAN. Our next witness is Mr. Lewis Blair, St. Luke's Methodist Hospital, Cedar Rapids, Iowa, appearing for the American Hospital Association. STATEMENT OP LEWIS BLAIR, REPRESENTING THE AMERICAN HOSPITAL ASSOCIATION; ACCOMPANIED BY KENNETH WILLIAM- SON, ASSOCIATE DIRECTOR Mr. BLAIR. Mr. Chairman, I am Lewis B. Blair, superintendent of St. Luke's Methodist Hospital, Cedar Rapids, Iowa. I appear in behalf of the American Hospital Association. Accompanying we is Kenneth Williamson, associate director of the association and Director of its Washington Service Bureau. PAGENO="0186" 178 Mr. ROGERS. Mr: Chairman, may I join with you in saying we are delighted to see you gentlemen here. Certainly, your representative here in Washington does a very excellent job, as I am sure you are aware, for the association in keeping your views before the Congress very effectively. Mr. WILLIAMSON. Thank you, Mr. Rogers. Mr. BLAIR. 1J.R. 15757 is a bill to amend the Public Health Service Act to extend and improve the programs relating to the training of nursing and other health professions and allied health professions personnel, the program relating to health research facilities, and for other purposes. We strongly support the purposes of this legislation and highly commend the Congress for its recognition of the essentiality of the Federal Government participating substantially in programs to allevi- ate the severe shortage of health manpower. As the committee is well aware, the Federal Government is sponsoring a number of programs~ which guarantee health services to various groups of the population. The result is an ever-increasing demand for health trained personnel. The continued advances in medical care and improved procedures within hospitals depend upon increased numbers of highly skilled per- sonnel for their application to the public. We are particularly pleased that H.R. 15757 proposes bringing to- gether several existing programs. These are programs affecting medi- cal schools, dental schools and others; programs involving schools in training of nurses together with various forms of assistance provided students in all of these schools as well as the assistance provided the various allied health professions. This should result in greater coordi- nation and improved administration overall of the programs. We cannot stress too strongly the magnitude of the need for greater numbers of highly skilled health personnel and the critical nature of the demand in terms of the overall health of the Nation. We believe the sum~s proposed for carrying out the programs are modest in relation to the needs and we hope the Congress will recognize this great need and authorize such sums as are found to be necessary to fully fund the programs. TITLE I-HEALTH PROFESSIONS TRAINING This section proposes to continue the program providing for the construction of needed teaching facilities and provides various forms of assistance to students in several of the health professions. The bill proposes certain changes which should improve the administration of the program and enhance its potential contribution toward meeting the very pressing need for greatly increased numbers of physicians, dentists and others. We fully support this section of the bill and believe it to be a vitally needed program. TITLE Il-NURSE TRAINING As the members of the committee are undoubtedly aware, the American Hospital Association and the hospitals of the Nation, have voiced strong support for H.R. 13096, introduced by Congressman Rooney. Fifty-nine additional members either cosponsored Congress- man Rooney's bill or introduced similar bills. Many of these Congress- PAGENO="0187" 179 men are members of this committee. We believe these bills go far in recognizing the essential role of the diploma schools of nursing and the fact that the nursing needs of the Nation will not be met except by the continued operation of these hospital diploma schools of nursing. They further recognize the serious economic situation confronting these schools. The fact that the diploma schools do not have access to the public funds available for both the collegiate and the junior college schools has been a serious handicap and unless the Congress recognizes the special needs of the diploma schools large numbers of them are likely to discontinue operation. We believe that H.R. 15757 goes far toward accomplishing certain of these objectives. However, the bill does not, we feel, provide adequate assurances of financial assistance to hospital schools. We cannot stress too strongly the significance of this section of H.R. 15757 in relationship to meeting the health needs of the country. The shortage of nurses is acute and will only be met through a very substan- tial Federal program of assistance. The recently published review of the nursing situation by the Department of Health, Education, and Welfare indicated that by 1975 we will have need for 1 million nurses. This indicates that we will have to increase the supply by approxi- mately 60,000 nurse graduates a year. The criticalness of the situation facing the Nation will be seen when it is realized that during the period 1964-65 there were 34,686 nurse graduates and during the period of 1965-66 there were 35,125 or an increase of less than 500 graduates in nursing. Thus, even with the Nurse Training Act of 1964 in effect we have continued to fall very substantially short of meeting the need. Just what does this shortage mean ~ The needs of the military have grown and these needs can only be met from the existing pool of civilian nurses. These needs of the military as well as the needs of the Vet- erans' Administration will be met in large part by graduates from hospital schools of nursing. An example of the kind of solicitation of nurses may be seen in the attached recruitment material directed to the homes of registered nurses. (The document referred to follows:) DEPARTMENT OF TilE ARMY, U.~1. Army 1~eoruiting Main station, Montgomery, Ala. DEAR REGISTERED NURSE: Did you know that the Army Nurse Corps is no longer what it used to be? Pay increases have recently been received and promo- tion requirements have been revised. It now takes only twelve months to be promoted to First Lieutenant and only twenty-four months of active duty in the Army Nurse Corps qualifies you for the rank of Captain. Registered nurses who are interested in joining may receive a guaranteed assignment to the geographical area of her choice and if qualified may choose to attend one of the advanced nursing courses. Whatever your nursing specialty or interests, the Arms Nurse Corps has it for you. Chances are you chose a nursing career because you wanted a rewarding and challenging job; you wanted to feel useful, appreciated and needed. All this is offered you as a member of the Army Medical Team. The Army wants nurses who like to do real nursing. If you would like more information or a personal interview, please indicate this on the enclosed card. I will be looking forward to your reply. Sincerely, LINDA E. Mooo~, Captain, Army Nurse Counselor. PAGENO="0188" 180 A COMPARATIVE ANALYSIS As civilian nurse Army Nurse Corps Vacation 2 weeks a year 30 days a year. Medical care Possible professional discount.. Furnished. Sick leave Limited Unlimited. Dental care At own expense Furnished. Vacation travel do Free on space available basis Social life do Officers clubs, swimming pools, golf courses, bowling, etc., at greatly reduced rates. Large number of people of similar age and educational background as associates. Education do Worldwide campus: AFIT, USAFI, Bootstrap, ECI. Some programs free others 75 percent tuition paid. Retirement Social security age 62 20-year retirement (50 percent of base pay) plus social security at age 65. Advancement As determined by civilian insti- 1st lieutenant in 12 months, captain in 24 months of date tution. of enlistment. Automatic longevity raises every 2 years, regular promotions. Shopping Civilian stores Base exchange, commissary prices, profit limited by regulation. Travel allowance Normally at own expense $16 daily plus travel expenses. CAN You ANSWER Yus To THESE QUESTIONS? 1. Does your employer guarantee a periodic pay raise? 2. Does `he give you tax free allowances for quarters? 3. Does he furnish you three meals a day, or give you tax free allowance for food? 4. Does he give you clothes that you can wear while on and off duty, or money to buy them? 5. Does he give you eight white hospital uniforms and furnish you laundry service as long as you work for him? 6. Does he give you a 30-day paid vacation each year? 7. Does he furnish full health and accident insurance, regardless of the length of time you have been able to work, and regardless of the length of illness? Does his insurance provide for annual physical examinations and other measures to prevent illness? Does his company plan a pension for life in case you are disabled? 8. Does the job offer opportunity for world travel? 9. Does he furnish free passage (in most instances) during off-duty travel? 10. When you change jobs, does he pay your travel pay, and move your b~eIorvgings? 11. Does he have a company grocery store, drug store, or department store where you can buy merchandise at cut rates? 12. Can you retire at `half your pay at the end of 20 years and 75% pay at end of 30 years without contributing to any kind of retirement fund? 13. Does your employer go out Of his way to furnish you low-cost entertainment, like movies at 35 cents, bowling at 35 cents, `tennis, golf, swimming free, and low-cost membership in a club for people of your own income group and interests? - 14. Does your employer give you $300.00 initial Clothing Allowance? An Army nurse can answer yes to each of these questions. (How many nurses do you know who- Make $8,084.16 (Plus) a year with three years experience ($1,715.16 of this being tax free)? (CPT with three years servIce.) Are working In hospitals which have the latest equipment and supplies that money can buy? Have as many helpers as they need to get the job done? I know a lot of them-they are all in the Army Nnrse Corps. PAGENO="0189" 181 PAY FOR ARMY NURSES 2d lieutenant 1st lieutenant Captain 2 years or less of service: Base pay $321. 00 $373. 50 $466. 20 Quarters allowance 85. 00 95. 00 105. 00 Subsistence 47.88 47.88 47.88 Total 453. 88 516. 38 619.08 Annual taxable pay 3,852,00 4,482.00 5,594.40 Total annual pay 5,446. 56 6, 196. 56 7~428.96 Over 2 years of service: Base pay 443.70 520. 80 Quarters allowance 95.00 105. 00 Subsistence 47.88 47.88 Total 586. 58 673.68 Annual taxable pay 5,324.40 6,249.60 Total annual pay 7,038.96 8,084.16 Over 4 years of service: Base pay 615.90 Quarters allowance 105. 00 Subsistence 47.88 Total 768.78 Annual taxable pay 7,389.80 Total annual pay 9,225.36 NEW PROMOTION REVISIONS (1) Only 12 months of active duty qualifies you to be promoted to the rank of first lieutenant. (2) Only 24 months of active duty and you can be promoted to captain. Mr. BLAIR. The 1967 published figures indicate that the Federal Government employed 32,793 nurses. The medicare and medicaid pro- grams will increase substantially the health care being provided and various studies reveal that the nursing requirements of aged patients are very much greater than those for younger patients. The Govern- ment has assured the 19 million aged of the country the right of access to care not only in hospitals, but in extended-care facilities and home health services. We are far from meeting the needs for these services and they cannot possibly be provided without key staffing by regis- tered nurses. The Government is commendably raising the quality of care to be provided in nursing homes throughout the Nation and stipulating the basic need for registered nurses in order to qualify these institutions to provide care under the medicaid program. A great many hospitals report serious shortages affecting their ability to provide care. In some instances, whole sections of floors of hospitals are closed because they cannot be staffed. Some institutions are being forced out of the medicare program because they cannot provide the required nursing supervision. The Federal Government is investing large sums of money in medical research which, when translated into the care of patients, inevitably means additional essential nursing care. Though the Congress is to be commended for passing the Nurse Training Act of 1964, it is obvious that the very critical nature of the nurse deficit has not yet been fully appreciated. Notwithstanding the benefits of the act, we are not moving forward in any near relationship to the need. The Nurse Training Act and the administration of that act has lent encouragement primarily to baccalaureate and associate degree programs. TJnfortunutely, there is no possibility `whatever of these schools meeting the national shortage of nurses in the fore- seeable future. This was recognized by the Surgeon General's consul- PAGENO="0190" 182 tant group on nursing as long as 5 years ago. In their report of February 1963, that group projected the 1970 needs of professional nurses and foresaw the fulfillment of those needs primarily from hospital schools of nursing. They found the following: (The data referred to follows:) 1961 1970 Total gro4s&ates goals increase Baccalaureate 4,039 8, 000 3,961 A~soelate degree 917 5,000 4.083 Diploma 25, &11 40,000 14, 689 Mr. BLAIR. The increase in the diploma programs amounted to twice that of the other two combined. While the situation continues to become more critical hospital schools which are the major producer of the nurses needed by the Nation (78 percent of the total last year), are closing. There has been an average of 10 schools closing each year for the past 5 years and at the present time 74 hospital schools are making plans to cease opera- tions. Hospitals operating schools of nursing cannot continue to pass on to their patients the ever-increasing financial deficits incurred from the operation of these schools. The criticism of rising hospital co~ts is such that the boards of trustees of greater and greater numbers of hospitals operating schools of nursing feel compelled to close their schools. It makes very little sense to us to see hospital schools close where they have faculty, buildings and equipment available to produce the needed nurses; and at the same time to see new campus facilities being constructed with an enormous economic waste. Certainly, im- mediate action on this section of the bill and making it effective July 1, 1968, instead of July 1, 1969, as proposed, might go far toward fore- stalling the closing of many of the schools. Though title IT provides the vehicle for the much-needed assistance to diploma schools of nursing as well as to the collegiate and junior college programs, we believe the funds provided for in the bill are in- adequate to meet the need. Following are comments on specific sections of title II. Part A-Construction grants Section 201 amends the present act and gives equal recognition to all schools of nursing. This association strongly endorses each of the three types of schools of nursing a rid recognizes fully their respective roles. We approve, therefore, the construction assistance which would be provided to all three types of schools. Section 205 makes collegiate schools eligible for construction grants for advanced training facilities. Inasmuch as advanced training is in no wise limited to collegiate schools, we recommend this amendment provide for facility construction assistance to all schools participating in advanced training. This could be accomplished by a similar amendment to section 483(d) and (e). TJnder the bill the benefits of this section will not become effective until after June 30, 1969. Although we realize there are serious budget- aly problems, we recommend that if at all possible because of the seriousness of the situation, the effective date be June 30, 1968. Part B-Special projects and institutional grants to schools of nursing Section 211 amends section 805 of the act. We believe this is an im- portant section of the bill. The provisions have been broadened so as PAGENO="0191" 183 to authorize grants for a wide variety of programs and to include grants to any public and nonprofit private agency which can contribute toward improvements in nursing programs and which can encourage the coordination of efforts between programs. Section 806 would also be amended to provide direct assistance to all schools of nursing. Each school would receive a lump sum annual pay- ment of $15,000 and in addition would receive an annual payment based on the relative enrollment of students and graduates. This as- sistance, however, is uncertain as to amount and related to unspecified amounts to be appropriated. We believe that particularly in respect to the diploma sChools of nursing it is most essential that they be assured `~ minimum amount per student. Such a need was recognized in Con- gi1~sman Rooney's bill, H.R. 13096. As previously pointed out the col- ]egia)ke and associate degree programs are in the main tied to the public educat~onal system and, therefore, have financial assurances which are not ava~lable to the diploma schools. Without such specific assurances we great'y fear we will continue to see a closing of these diploma schools. Theref ore, ~ve would urge that this section of the bill be amended so that in additioi~ to the $15,000 lump sum payment to all schools, a per student annual P~ayment of a minimum of $500 be specified for diploma schools of nursin~, Part U-Stude'nt ~id Section 823(b) (3~ would increase the rate of forgiveness from 10 percent to 15 percent a year where a nurse following graduation works in prescribed circum~ances. However, we believe the language of the bill inadvertently lbtiits the eligible services to a "public" hospital, whereas the basic pro~vision includes public and privately owned non- rofit hospitals. We recommend that~ the language of the bill be amended to include ~ivate nonprofit as weJl as public hospitals. ~This section of the bii1~ should serve as a strong incentive to students; relationship to tl~e likely income to be paid a student following ation, we believe tl~e forgiveness is fully justified. *on 222(e) of th~ bill would amend section 825 of the Public Service Act to 1~rovide for the allocation of appropriations the schools rathe~' than among the States. Further, it provides allocations shallbe on the basis of the full-time enrollment in ol of nursing rasher than on the basis of the number of high graduates. The t~mendment provides a much more realistic od for the allocation~of funds. 222(h) of th~ bill would add a new section 829 to the bill I permit the tifansfer of up to 20 percent of funds from the program to the sc~holarship programs. A later provision of the also provides for alsimilar transfer of funds from the scholarship to the loan P'kgram. We believe these provsions will permit flexibility in ~he program. P--Scholars hip ~rants to schools of nursing ~ction 293(a) amq~nds part D of the Public Health Service Act to provide for scholarsh~ip grants to schools of nursing. We note that the provisions have been 2~amended so as to pattern the program after the scholarship provis~i~Js of the health professions section of the bill. The PAGENO="0192" 184 scholarship program is essential in making possible the enrollment of students who are confronted with exceptional financial problems and should prove to offer needed encouragement for such students to enter the nursing profession. We wholeheartedly endorse this section of the bill. We believe the bill provides substantial improvements over the authorization for scholarships in the original act. Section 231 pertains to the definition of accreditation. We believe the language of the bill is ambiguous and we are uncertain as to how the language would apply to each of the three types of schools of nursing. We strongly recommend that the language of this ~ection provide that the Commissioner of Education shall be required to recognize ap~ proval by the appropriate State authority as meeting the requiremev~X5 of accreditation under the act or accreditation by regional author~tY or by national aecrediting bodies. TITLE Ill-ALLIED HEALTH PROFESSIONS AND PUBLIC HEALTH ~i7I~AINING This part of the bill pertains to a variety of parariiedical groups which are highly essential to providing high quality h~alth care in the most effective and efficient manner. The provision i~ncludes areas of training pertaining to skills which represent the great advances in hos- pitaE care. We believe this is a very important part, of the bill and we fully endorse this title. Section 301 (a) (4) amends section 794 of the J/ublic Health Service Act to eliminate the phrase "training centers fçir allied health profes- sions" and substitutes in lieu thereof the wordy, "agencies, institutions and organizations." We believe that this is a cor~siderable improvement over the original act and, further, that this langiaage will permit teach- ing hospitals to participate directly in the progr~im. However, this amendment only pertains to titie development of ne methods. Section 795 of the Public Health 5,ervice Act continues t define training centers as a junior college, college, or universi In order that teaching hospitals, which are ejhgaged in the educ of large numbers of paramedical health persc~nnel, may be assist d to the extent that they provide training in the ~rograms covered u der this title, we recommended that the defin~ition in section 79 ~ be amended, so as to read, "in a teaching hospitftl, junior college, col 1ege or university." This amendment is urged forithe reason that the eecLs' of the Nation are so great it is incumbent u~ofl us to utilize full all available qualified educational programs. Ii~ terms of the critica ~fless of the need it makes very little sense to p~pvide assistance on y to certain of these education programs as the act~does at present. Section 302 extends the program of trair~eships for graduat ~ of specialized training in public health. Graduate degree-ma ers degree-programs in a number of universitie~ prepare profesion trained hospital and medical care adminis~trators. The Cong ~ss recently amended the medicare law to requiire licensing of admjin istrators of nursing homes which gives recog~iition to the need f~or professionally qualifying administrators of su~h instittitions. At the present time it is clear that this assis~ance may be granted to students in courses preparing them for admini~tratj~n of health care institutions if the trainee is enrolled in a sch~oo1/of public health. PAGENO="0193" 185 However, it is far from clear that students taking the same curricujum but who are enrolled in other schodis of the university Sucha~ business administration, are entitled to such assistance. At the present time, ther are 16 accredited programs in schools of hospital administration in universities in the united States. Seven of these are in schools of public health. The ether nine a~ in other schools. We strongly~ recom- m~nd that this section be revised to amend section 306 (a) of the Public Health Service Act to provide for assistance~ to eligible students enrolled in all university programs for the preparation of hospital and health facility administrators. This section also includes project grants for graduate training in public health. As the hospital has developed as the recognized center of community health affairs the administrator of such institutions requires specialized graduate training in community health affairs. Such advanced training is made available through the 16 university graduate degree programs~ All of these programs should be fully eligible to receive project grants; Their eligibility should not be dependent upon whether the program happens to be within a sëhool of public health~ We understand at the present time the grants program is being so administered that certain of these university programs are denied assistance. We recommend, therefore, that section 302 of this bill be revised to amend section 309(a) of the Public Health Service Act to include institutions providing graduate or specialized training in programs of "hospital and health facility administration." TITLE IV-HEALTH RESEARCH FACILITIES This title of the bill extends the construction authority for health research facilities. We recommend approval of this part and urge the committee to authorize adequate funds for carrying out its important purposes. The bill before the committee does not specify the funds which wQuld be authorized to carry out the purposes of the legislation. However, we are aware of the amounts which the administration has submitted to the Senate on S. 3095, the companion bill. We assume that similar amounts have been or will be recommended to this committee. So far as title III of the bill is concerned, dealing with nurse training, the funds proposed are totally inadequate in the light of the acute shortage which we have discussed with you. In 1966 there were 1,241 schools of nursing in operation. To provide $15,000 for each of these schools as the bill proposes, would require some $18 million. Added to this would be the amounts authorized to be paid to each school on a per student basis. The total number of students in all schools for 1966 was 139,070. To authorize funds for this number of students at $500 per student would require an addi- tional $69 million, for a total authorization requirement of approx- imately $87 million annually. This is in sharp contrast with the $30 million proposed by the administration for the fiscal year 1970 and with the amounts for future years. Mr. Chairman, we greatly appreciate the opportunity of appearing before the committee and presenting to you the views of the hospitals of the country on these matters which are of critical importance to the operation of hospitals and all health care institutions, thus, to the 95-540--68----13 PAGENO="0194" 186 provision of health services. In closing, may I reiterate our great con- cern over the shortage of health care personnel. While we recognize the serious fiscal problems facing the country and this Congress, nevertheless, we feel required to urge the committee to authorize sufficient funds to provide the needed health personnel. Mr. JARMAN. Thank you, Mr. Blair. I think it is a very effective statement. Let me ask you with respect to your own St. Luke's Methodist Hospital in Cedar Rapids, how many students do you have in your school? Mr. BLAIR. About 200. Mr. JARMAN. What did it cost you to operate your school in the 1966-67 period? Mr. BLAIR. Our fiscal year for the school ends on September 30th and for the fiscal year then which ended September 30, 1967, the total costs were $569,910. Mr. JARMAN. And how was that financed? Mr. BLAIR. $181,000-well, $168,041 were paid by tuition. There were gifts of some $13,454, so there were total cash receipts of $181,495. This offset that portiox~ and left the remainder of $388,415. In our conduct of the school, we put emphasis not only on the aca- demic content, the didactic content, but also on the clinical education and in the process of the students learning how to care for patients, they obviously provide care for patients. In the process of these students providing this care, we make careful estimates as to what we feel it would cost if this same amount of care were provided by other paid personnel. On the basis of these calcula- tions, which I think may be a little on the generous side, but during the same fiscal year the value of these services was estimated to amount to $332,833. Applying this also, then, as a credit against the cost, this still left a deficit operation of $56,782. Mr. JARMAN. What has been the experience of your students in pass- ing the State board examination for nurses? Mr. BLAIR. We are very happy that our program has seemed to be effective. Iowa, which has the lowest illiteracy rate in the United States, we feel that at the other end it has a very high educational level, has also demonstrated a level among the. 50 jurisdictions. It normally ranks in the top 10 or 15 of the 50 jurisdictions in State board results. The school sponsored by the hospital with which I am associat- ed, has characteristically been in the top group of our Iowa schools, of which there are 22. This also places the school at a high level nationally as well. This last year our graduates placed our school first among these 22 schools, including the university schools. We had no failures at all. Ours was one of the three of the 22 schools which had no State board failures at all. Mr. JARMAN. Mr. Rogers? Mr. ROGERS. Thank you, Mr. Chairman. Mr. Blair, I thought your statement was excellent. I think many of the suggestions you have made have a great deal of merit and I am sure this committee will consider them very seriously. Mr. BLAIR. Thank you. Mr. RoGERs. Is it necessary, do you feel, to give money to every diploma school? PAGENO="0195" 187 Mr. BLAIR. I feel so. The record shows that our schools are closing. I made reference to the recommendation, the evaluation of the Sur- geon General's committee back several years ago and they ar.e depend- ing, they are looking forward to the diploma programs providing some 15,000 of the approximately 25,000 increase that was recommended. We simply cannot afford to pass up the opportunity that these schools provide. Mr. ROGERS (presiding). I would agree with you. I think it is very essential to do something for the diploma schools. I was just wonder- ing, for instance, in all of the various programs, if it is necessary to give money to every school. There may be some that are adequately funded. In other words, should there be a showing of need, some cri- teria set forth, before qualifying for Federal aid? Mr.Br4~&IR. I think that the only criteria should be that of accredi- tation by the State agency, and alternately, the other accrediting agen- cies that may apply to the associate degree programs of baccalaureate programs where they are approved by the regional association. Mr. ROGERS. Well, now, suppose you have a school that is not pres- ently accredited and the reasoh is it has not got enough funds to do what it necessary to become accredited. Does not that school need the money more to bring it up than the one that is already accredited? Mr. BLAIR. That certainly may be one of the factors. Now, of course, all of the schools are accredited by the State agency and all of the graduates of these schools that take State board examinations take one examination, the one and only examination, and this is an examination as developed under the auspices of the American Nurses Association and it is taken by the graduates of associate degree programs, diploma programs, whether they are 2-year, 3-year programs, or by the bacca- laureate programs. The financial need of the school is eloquently evident as one considers the effects of the accreditation programs, their efforts to increase. The natural effect of this has been to create a gap at one time, and now and then we hear tired references to exploitation of students. This certainly is long gone. There is no student that I am aware of that is exploited. They are substantially flnan~ced. Unfortunately, it is by the financially pressured patient who is underwriting this cost in our hospital schools. Mr. ROGERS. Now, you, I believe, furnished figures saying in 1961 the diploma schools graduated a little over 25,000. Will you reach the 1970 goal, do you think, of 40,000? Mr. BLAIR. No. We are having a miserable time with this and there has been very little increase over that which the Surgeon General's consultant group measured back then. rfhe problem in part is that be- cause of a variety of problems, many schools have just thrown in the towel and have closed. Mr. ROGERS. Now, could you letus have, and I know you have given us some background, but specifics as to the number of students, in- creased number of students, that could, be taken in and individually graduated from the diploma schools or hospital schools? What would have to be done? How many would we have to be sure we reached goals that have beeen set and what financial support would be anticipated? I realize you may not have this, now. Mr. BLAIR. Well, in. rpund flgi~res- Mr. ROGERS. You could submit it for the record. PAGENO="0196" 188 Mr. BLAIR. We are graduating from the hospital diploma programs about 25,000 graduates per year. The Surgeon General's recommenda- tion was that this be increased to 40,000. The only estimate I have heard other than this, is to increase it fui'ther. One estimate referred to was 60,000 graduates per year. In our school-now, of course, there may be some institutions that have closed that might be encouraged to reopen, assuming their build- ings and facilities were still available. Mr. ROGERS. We had one that closed in my area, for instance, just recently. Mr. BLAIR. But against this, I think this might give us some per- spective. In my particular school, the educational plant costs value, divided by the 200 students, indicates a plan,t cost of about $40,000 per graduate. Now, if we want 15,000 more graduates per year, ignore some unused facilities, 15,000 graduates times $40,000 comes up to about $800 million. Now, assuming that the sponsors can put up some of this money, say 50 percent of it, here is. $400 million, of additipnal facilities that conceivably might be federally financed~ No one has any illusion that this can be done instantly but if, for example, we were to undertake a 5-year program, this would mean $80 million a year just for con- struction of facilities for diploma programs aside. from those. thwt are needed by the collegiate or associate degree programs. Mr. RoGERS. Well, now, I wonder if a number of hospitals, if they got support, would not have the physical facilities pretty much. You might have to. build some but not to the extent that you have just projected. For instance, in my area they conducted a school. They are no longer~ doing it. There is no reason why they could not open that up again with proper support, without going into large con- struction programs. I think a survey would have to be done and per- haps your association could be helpful in this in getting your hospitals to let us know, your each State association, which would be very help- ful if we could have this information, to know how many could go in, what they do think would be required, and trying to stress that they should keep construction down, I know there would be a tend- ency for everybody to put on some new buildings. This is always so, understandably so, but honestly to try to meet the problem without incurring any more than a minimum amount of construction cost, and getting to a real training program and putting our money into the training where we will be turning people out rather than doing a large building program if possible. Mr. BLAIR. I think your suggestion is excellent. I am confident that our association has an intense interest, a tremendous sense of responsi- bility, and would be glad, out of data perhaps already assembled and perhaps augmented by other information that we would be able to get, to present some information on this. I am in complete agreement that we ought to start where we are, that we ought to build on existing resources. I do not think it would take a simple mathematic projection of these facilities that I just mentioned in order to reach the goals. We are mindful that all stu- dents do not have to litre in dormitories. We are mindful that other arrangements can be made so as to maximize our educational facilities. Mr. ROGERS. Well, I would be very interested in pursuing that be- PAGENO="0197" 189 cause I think it is essential for us to dO something to train more nurses. Otherwise, we are going to be in a very serious condition, even more so than now, and particularly as you brought out in the increased demand for medical services in this country, which is continuing to grow and will with the medicare program. Mr. WILLIAMSON. We have heard, Mr. Rogers, from a number of hospitals operating schools that are watching this legislation and if they can get some real help from it, their boards of trustees are in- clined to remain in business. If they do not, they are going out of busi- ness. So, I think the figure we have given of schools that now plan to close is going to be markedly increased. Mr. ROGERS. I think that was 74, you said. Mr. WILLIAMSON. Seventy-four, yes, but lacking some real support there will be a good many more that may likely decide to throw in the sponge. The extent of public criticism over growing hospital costs, you are well aware of. Mr. ROGERS. I share it. Mr. WILLIAMSON. You share it. I would just as soon not get into that. Mr. ROGERS. We will do a separate study on that later. Mr. WILLIAMSON. Yes; I understand. We will have some good in- formation for you at that time. Mr. ROGERS. I know. It would be helpful. You always are. Thank you. Mr. WILLIAMSON. There are a number of hospitals that have never been in the nursing school business, but with financial assurances might well get into the business, too. Mr. ROGERS. Yes. This is what I think we need to encourage and if your organization would undertake for us to make some contact here and let us have some specifics ~s soon as possible, I think this could be helpful in drafting this legislation and let us start doing something immediately, because I would agree with you, postponing this another year is simply going to compound the problems. If we could use existing facilities, and like you say, these hospitals have in effect, teaching staffs with their doctors there who could be encour- aged, and then we have so many junior col]eges, perhaps they can work in conjunction with the junior colleges in setting up programs, too, some that have not gotten into this at all, so I think the possibility of outlining a program that could begin to solve this shortage problem is very real if we will proceed. So, if you could give us some of this information, I think it would be helpful. Mr. BLAIR. We will certainly get that information to you and to the committee. (The information follows:) PAGENO="0198" 190 Rc,ponse to American Hospital Association questionnaire ~Schools open, June 2~, 1968 Mailed 694 Replies (approximately 66 percent) 457 Schools reported closing 19 Not included in other questionnaire. No indIcation on any form that additional funds would change future plans to close. Not completed 3 Usable 435 Total 457 Question NO. 1. Would you accept a Federal subsidy? Yes 428 No 7 Total 435 Quention No. 2. Would you increase size of classes? Yes 356 No - 6 Not usable 6 Total 428 how many per class would you increase? Less than- 5 3 5 to 9 51 10 to 14 104 15 to 19 51 20 to 24 43 25 to 29 22 30 to 34 14 35 to 39 4 40 to 44 9 45 to 49 3 50 to 54 7 55 to 59 5 Over 60 1 7 No response or not usable 33 1 2 schools each said they would increase by 70, 80, and 125 students. 1 school said 66. Mr. ROGERS. Now, let me just ask this, In the institutional grant, under the legislation, they provide for institutional grants and project grants interchangeably, so that it is left up to the administrators in the department to decide what they will do. Should we set a division there or not? In other words, ~hou1d we require 40 percent of it to be spent in institutional grants or 60 percent in project grants or vice versa or what, or should we leave it completely to the discretion of the administrator? Mr. BLAIR. My inclination is that there shbuld be a measure of flexi- bility. My major concern on these two points is that we do need some construction. I think the most urgent need is the grant to the institu- tion for this to meet the ongoing costs of education. Mr. ROGERS. The institutional grant? Mr. BLAIR. Yes. The $15,000 and the $500 per student that I refer to specifically. I think that if this effective date can be moved up, I am confident it would not only deter, it would reverse many institutions that are now planning on closing. PAGENO="0199" 191 Mr. Roo~Rs. Also in the bill, on the medical education part, it pro- vides for project grants. We now have a limit on project grants of $400,000. The legislation does not-would remove that. Should we put a limitation somewhere on project gi ants ~ Mr. WILLIAMsoN. I think that the legislation proposing to remove it is very desirable, Mr. Rogers, because I think the administrators then are free to discuss with the applicants where they can best spend the money and feel free to best spend the money to accomplish the most in the quickest time. Mr. ROGERS. Well, except for the fact that you have 50 States and all sorts of organizations in there, and suppose they decide to put all this money in about three or four institutions or 10 or 20 institutions. Is this better to build those 10 or 20 or 30 rather than to help 60 or 80 or more? Mr. WILLIAMSON. `Well, our experience with the administrators is that they have tried to even up the money and avoid-in other words, they have always recognized this problem, in our experience, and they have tried to not give an undue share to any one institution. We have had the reverse experience, Mr. Rogers, where they have not done this and then we have ended up with money at the end of `the year that we lost. So that I think that the `administrators, if they sense the way the program is moving, if in a given year there are not the number of applications which t'hey can judge t'imewise, then to use the money that they have with such applications that they do ha~re accomplishes the most good. Mr. ROGERS. You think the committee ought to try and see h~w t'hey administer it. Mr. WILLIAMSON. I do. With real flexibility and see how it works. Mr. ROGERS. How many students are generally in your diploma schools? Would it run from what number, what range?. I ju~t wondered offhand if you can supply a figure for that. Mr. WILLIAMSON. There are 139,000 students in all schools and 78 percent of those are in hospital schools. Mr. ROGERS. No. What I mean, like in a hospital school, how many students? Mr. WILLIAMSON. The average students per school? Mr. ROGERS. That is right. Mr. WILLIAMSON. Gee, I do not know. Do you? Mr. BLAIR. I think- Mr. WILLIAMSON. There are figures available. Mr. BLAIR. I think we have some data that we can ,come up with something pretty fast. Mr. RoGERS. Would you say it is around 100? Would it average this? Mr. BLAIR. It would come close to that. The total number of diploma programs are 767 and the total number of enrollments are 84,000. So, there would be a little over 100 per school. I would estimttte around 110, 115, something like that. Mr. ROGERS. This would generally prove out. You have 200, I believe, in your school. Mr. BLAIR. Yes. The tendency has been `for there to `be fewer schools and larger schools, and I think there is a good rationale for this. PAGENO="0200" 192 Mr. RoGERs. Let me ask you this. Do you use the doctors in the hos- pital as instructors? Mr. BLAIR. I would say only to a minimum extent. Formerly, the doctor was a very prominent part of the faculty, but over the last 15 years this role has been just about reversed. He provides, normally, lectures on very specific points, but the lectures are overwhelmingly provided by the faculty of the school of nursing or by the faculty members of the college with which the school may have an association for basic science and general education. Mr. ROGERS. Well, then, your instructors, there, for instance, you have your nurse instructors- Mr. BLAIR. Yes. Mr. ROGERS. Would they also do hospital work or would they devote their time exclusively to- Mr. BLAIR. No. They are fulitime. Mr. ROGERS. I see. All right. Any questions? Mr. SKTJBITZ. Mr. Blair, insofar as nursing schools are concerned, my education has been sadly neglected. I would like to ask you a few questions about them. Mr. BLAIR. Please do. Mr. SKUBIPZ. How many years does a student attend nursing school before she can graduate? Mr. BLAIR. Well, this depends upon the school. At present there are nursing education programs and associate degree programs which in- volve residence requirement of about 21 months, two academic years and the intervening summer. There are some two-calendar year pro- grams, there are some of these sponsored by hospitals. Hospitals also sponsor-have curricula involving three academic years with the sum- mers `off. There are some that have two calendar years and then the third year being an academic year. There are those that have three calendar year programs. Mr. SI~T5BrrZ. What are the requirements to be a registered nurse? Mr. BLAIR. The requirement is simply to pass this one `State board examination which is the same examination given in all ~f the `50 jurisdictions. Mr. SKUBITZ. Does the student usually have to attend school 2 or 3 years in order to- Mr. BLAIR. This is governed by State law. Formerly, there was a pattern requiring 3-year residence. Now, I think all have probably reduced this to 2 years or graduate from an approved program. Mr. SKulBIrrz. How many `hours does a student go into a classroom for instruction each day? Mr. BLAIR. This will vary quite widely, I believe, also' among the schools. Mr. SIctTBITZ. Well, is it a half a day or do they attend classes all day long? Mr. BLAIR. Some days, yes. In our `particular program, I think our faculty `has in recent years developed what they call class days and ~s I understand it, I think all of their classes in a particular specialty, for example, may be given on 1 day and then their supervised clinical experience will occur on certain other days. I think there is a heavy emphasis on the `didactic work during the first year, first portion, what- ever it may be, and then a-something of a shift to emphasis on th~ PAGENO="0201" 193 clinical work in the laboratory, so te speal~, in the latter part of the program, I would suspect that in the typical hospital sch'opl that the work in classroom would probably amount to about a third to a half of the time. This is a shotgun guess. Mr. SKUBITZ. Is that in the classroom? Mr. BLAIR. Yes, sir. The class involves, of course, in our instance full- time registration in the college with which we are associated during the freshman, year. During the second year there is a heavy emphasis of didactic work on the nursing subjects, specifically. And, even during the clinical periods there are so-called ward classrooms which are very small, seminars. Mr. SKUBITZ. What I am getting at is this: Nurses spend a part of their time, about a third of their time in the classroom and the other two-thirds of the time working in the hospital. Is this correct? Mr. BLAIR, Yes. Under the supervision of the clinical instructor, who is a full-time member of the nursing school faculty. Mr. SKtTBITZ. All right. Now-does the student pay tuition? Mr. BLAIR. A student pays tuition, yes. In our instance the tuition amounts to a total of about $2,700, I think, $2,700 or $2,800. This is- Mr. SKIJBIPz. A year? Mr. BLAIR. This is a total `of all fees for 3 years. This includes tui- tion, fees, `books, and uniforms. Mr. SK1JJIITz. Does it include dormitory facilities? Mr. BLAIR. Yes. This is the total cash payment made by the student? Mr. SKUBITZ. It runs about $900 a year, then, correct? Mr. BLAIR. This would be the average, yes. Mr. SKUBITz. Now, when they are workng on the floor, do they draw any salary for d'oin~ this sort o'f thing? Mr. BLAIR. No, sir. This is a part of the program `and this is viewed as a part of their educational experience because we recognize that as the student is giving this care under the supervision `of the clinical instructor, nevertheless, it does have value and we credit this to the budget of the school of nursing. Mr. SKUBITZ. And the `students that work on the floor un4er super- vision, they relieve the head nurse of a lot `of her duties, is this not correct? Mr. BLAIR. I would not say they relieve the head nurses, n'o. They do care for patients under the supervision of the clinical instructor and to the extent that this service is rendered, it reduces- Mr. SKTJBITZ. If you did not have student nurses you would have to hire registered nurses to do the same job. Is this correct? Mr. BLAIR. Yes, sir; this i~ true, and this is why we have made a- we have included this in the arithmetic in our reports on the sdhool. Now, the National League in its accreditation program, frowns on this. So, as of no'w, the reports going to the school do not include this, but they take a rather dubious view `of this kind o'f arithmetic. They seem to think that thi's means that we are exploiting the students, I guess, or that we are using her for nursing service rather than for nursing education. We feel in. this i~elatio'nship the nursing service that is provided is sort of an accidental consequence of `her learning and we do not want to ignore `this in the eç~onomics of the school operation. PAGENO="0202" 194 Mr. SKtTEITZ. When I was in the hospital, about the oniy person I saw were the student aides. I seldom saw the head nurse. Mr. BLAIR. I was saying the value which they were rendering as they `were `being supervised `by the clinical instructor is a byproduct, I should say. Mr. SKUBITZ. Our chairman asked about t'he instructors. Don't the doctors act as instructors? Mr. BLAIR. I suspect that this will vary from school to school. In our school, and I think in many, in relative terms- Mr. SIUYBITZ. Your school is an exception to the rule, is this not correct? Mr. BLAIR. Naturally, I d~ not want to `be so immodest as to- Mr. SKLJEITZ. In the average nursing school, who does the instructing? Mr. BLAIR. I think the fact is, sir, that `the overwhelming amount of instruction is `by the nurse `faculty. I think that the physicians will give instruction on specific disease entities, perhaps will talk about the treatment and perhaps certain medical procedures, but overwhelm- ingly, the instruction is by the nurse faculty. Mr. SIcTJBITz. The nurse faculty, as our chairman brought out, not only teadhes but also `serves in the hospital, is this correct? Mr. BLAIR. Well, now, these may be two different kinds of faculty, but as they serve in the hospital and clinical instructors, they are in a teaching role. They are not rendering service themselves. While the student, as she renders service, as she learns in the process of caring for a patient, and as a byproduct of this, provides patient care. This is not the case with the clinical instructor. T'he clinical instructor does not care for the patient but is instructing and supervising the student as she does, may do so. Mr. SKIJBITZ. How many instructors do you have in your school? Mr. BLAIR. Well, the total faculty would approximate- Mr. STrrJBIPZ. I am talking about your regular faculty. Mr. BLAIR. We would `have close to 30 nurses on our faculty. Of these there is, of course, the director, a couple of assistant directors, then there are the ones who head up the fou'r major area's of medicine- surgery, obstetrics, pediatrics, and psychiatry-and then, there are those that are assistants and/or clinical instructors. I think that would `be it. Mr. SRITJBITZ. Do they draw additional pay for acting as instructors in the school? Mr. BLAIR. No. This is what they are employed as and what they are paid for. Our school of nursing, in our charter o'f organization, might look like a department of the hospital, but actually, it is con- ducted as a separate, what our nurse friends like to call as a single- purpose agency, and its function is to provide nursing education to these student nurses. Mr. SIUTBITZ. Is your school separate from the hospital, a se'parate building? Mr. BLAIR. Yes, sir. It is connected by a tunnel for the students' convenience but it is a separate building. Mr. SKTJBITZ. Do you have patients in this area? Mr. BLAIR. No, sir. PAGENO="0203" 195 Mr. SKIJBITZ. You said it costs about $40,000 to educate a student; is tthat correct? Mr. BLAIR.' No. I may have created a misimpression. I said the nursing education plan, the facilities, the building, the equipment, the total value of this divided by our number of graduates would mean that the facilities would amount to about $40,000 per graduate. Mr. SKTJBITZ. The cost of construction equipment, faculty- everything? Mr. Br~IR. Yes. Mr. SKUBITZ. How many years are you taking to depreciate this building? Mr. BLAIR. Fifty. Mr. SKIJBITZ. I think that is all at this moment, Mr. Chairman. Mr. BLAIR. I would like just to offer one final comment. I sense from previous witness that our testimony has largely complemented each other. I thought as I listened to it there was an emphasis on preparation of educators and administrators and certainly this is important. The testimony that I have attempted to present has put its emphasis on the preparation of nurses to care for patients. I think that as we have attempted to say, this is an immediately urgent thing. The urgency we have attempted to empha~ize by indicating a desir- ability of an earlier effective date and the employment of all of our facilities, and the one major point of difference in the testimony of the two witnesses has been on this matter of standards for accredita- tion, and it is our feeling that it is imperative that if this job is going to be done at all, we have got to use all of these facilities, and since the graduates take the same examination, the public is well protected against any incompetence in this way, we would urge this part of our recommendation especially. Mr. ROGERS. Thank you very much. I noted your difference in testimony on the accrediting and I might say I have had some interest in this problem and plan to continue it because I think it is very im- portant, proper accreditation. Also I am pleased to note the presence of Mr. Lacey Sharp, the very capable colleague of Mr. Williamson, who has been helpful to this committee in getting information over the years. Thank you very much. Mr. SKUBITZ. One question. Are some of these schools closing be- cause you cannot get students enrolled in the schools? Are you having any trouble getting students? Mr. BLAIR. I think that the reasons why schools close certainly in- clude this to some extent. The fact is that there have been a variety of problems that face the sponsor of a hospital school of nursing. One, as has been implied by both mine and the preceding witness' testimony, is the difficulty of acquiring faculty. Mr. SKUBITZ. Mr. Blair, let's get away from your school. Let us talk about the average. How many of the 74 hospitals may be closing be- cause girls are not enrolling in the courses? Mr. BLAIR. I do not believe that this is a major factor, sir. I think the major reasons are problems of recruitment of faculty, problems of finance, problems of frustration, I think, in connection with some of the requirements for accreditation. PAGENO="0204" 196 `Mr. SKUBITZ. My only thought is that you charge $900 a year tui- tion. A girl goes to classes a third of the day, carry bed pans, fix beds and take guff from patiehąs the rest of the day-maybe this would dis- courage a lot of girls from becoming nurses. Mr. BLAIR. The nature of the curriculum, both didactic and clinical, has changed much over the years. I think that now and then we see references to an activity program of students that actually harks back to the early part of this century, and I believe that this is not charac- teristic of the average program as you are trying to depict it. Mr. S~KUBITZ. Thank you. Mr. ROGERS. Thank you very much. We appreciate your coming. Mr. BLAIR. Thank you. Mr. ROGERS. Our next witness is Miss L. Ann Conley, who is presi- dent of the National League for Nursing. The House is in session, but the committee will try to continue until the bells ring. So, we are de- lighted to have you here and the committee would be pleased to receive yoUr testimony. STATEMENT OP L. ANN CO'NLEY, PRESIDENT, NATIONAL LEAGUE POR NURSING; ACCOMPANIED BY DR. MARGARET HARTY, DIREC- POR OP NURSING EDUCATION Miss CONL1~Y. Thank you very much. We will try to be as brief and as efficient as we possibly can. I am also professor at Wayne State University, College of Nursing, in Detroit. I am pleased to testify today for H.R. 15757, the Health Manpower Act of 1968, on behalf of the National League for Nursing. I have with me Dr. Margaret Harty, who is an NLN staff member. She is director of Nursing Education for the NLN. Mr. ROGERS. We are delighted to have you, too, Dr. Harty. Miss CONLEY. Our organization favors the bill. The National League for Nursing is a nonprofit voluntary organization founded in 1952 to foster the development and improvement Of nursing education and nursing service. Its varied menthership-nurses, allied health workers, private citizens, health agencies, and the schools of nursing them- selves-works together to promote quality patient care. A fuller de- scription of NLN is appended to this statement for the record (exhibit I). We are directly concerned with the goals set forth in the 1968 act and heartily endorse the intent to guarantee health, safety, and good medical care to all Americans. We suppolt, in particular, title II of the act, nurse training. We point specifically to several provisions not included in the Nurse Train- ing Act of 1964. We favor, `first, the extension of grants to institutions or agencies to help plan or develop nursing education programs (sec. 211). *We favor, second, the inclusion of all three types of nursing school's (associate degree and baccalaureate in addition to diploma) under the institutional grants (sec. 211). Our only concern here is that the n&cv grant formula not penalize those diploma schools, of nursing in which enrollments are decreasing. This is happening in some 3-year schools as well a's in those which are shortening their programs and thus have fewer students to count. During the last academic year, however-as PAGENO="0205" 197 Mr. Blair has so well put before you already-72 percent of the gradu- ating nurses were from diploma schools. We have these figures in our exhibit II. Despite decreasing enrollments, accredited diploma schools will need continuing assistance for some time to come to make their needed contribution to the nurse supply. We favor, third, the removal of the statutory ceiling on formula grants, special project improvement grants (sec. 211), and nurse teacher traineeships (sec. 221), and the increase in maximum annual loans to students, together with the more liberal provisions for the can- cellation of those loans (sec. 222). If there should be need to limit funds appropriated for loans in this year of tightening budgets, we urge that priority be given to graduate students in order to insure the leadership essential for the best education and utilization of the current and future nurse supply. My organization must, however, respectfully object to the insertion of the phrase "or by a State agency," in Part D: "Definition of Accredi- tation," section 231. We raise our objection for two reasons: First, the specific meaning of "State agency" is unclear and could conceivably refer either to a State board of education, State board of nursing, or some other State agency. Second, standards set by such State agencies as boards of nursing vary widely from State to State; these standards are, in any case, aimed at minimum acceptable achievement rather than at excellence in educa- tional preparation. In raising this objection, Mr. Chairman, I am speaking particuhtrly for the 1,043 schools of nursing included in the membership of the National League for Nursing. 1 am also endorsing the testimony of the American Nurses Association in its support of national accredita- tion as the basis on which a nursing education program should be declared eligible to receive Federal funds under the I{ealth Manpower Actof 1968. These 1,043 schools representing every constituency in the United States have joined together voluntat~ily through the mechanism of the National League for Nursing to improve nursing education so that patient care services will reflect the best that nursing can provide. In So doing, they conduct a continuing program to improve nursing educa- tion across the country-to help schools of nursing meet and maintain high standards. The nursing school members of our organization `participate in voluntary accreditation through the league as one means of improving their own education programs `and, at the same time, stimulating all schools to similar self-improvement efforts. Their belief in accreditation is not lim~ited to nursing education. They are applying what the former execntn~e director of the National Commission on Aecrediting, W,ilham K. `Selden, ha's described as society's call "for imagination and enlightened initMtive in the estab- lishment and enforcement of academic stand~irds . . ." ~ In doing so, nursing schools assuthe responsibility for'~lf -evaluation and voluntarily submit themselves to judgn~ient by their peers. Stand- ards of educational excellence are developed and maintained in this 1 Selden, William K., "Accreditation-The Struggle O~rer Standards in Higher Education." New York: Harper & flow 1960, p. 92. PAGENO="0206" 198 way by most professions which deal with human life and welf are- ni~dic~ine, dentistry, for example, as well as nursing. Voluntary national accreditation, then, Mr. Chairman, is nursing education's response to its own challenge-to provide the best possible nursing education in this country, aiming ultimately only at high quality in patient care. We feel certain that the intent behind the present bill is the same. We believe that the purposes of the proposed legislation can best be accomplished by making Federal funds avail- able to those schools which are already meeting, or show promise of meeting, standards of excellence they, themselves, have determined to be reasonable and universally attainable. These are the schools which qualify for full accreditation or for reasonable assurance of accreditation within the framework of the National League for Nursing. These are the schools which have the greatest potential to expand their enrollment and reduce attrition rates. These are the schools which can prepare the types of nurses you would want to care for your families and yourselves. The National League for Nursing is recognized officially as the national accrediting agency for nursing education `by the National Commission on Accrediting for bachelors and masters degree pro- grams in nursing and as an auxiliary accrediting association at the associate degree level. The Office of Education and the American Nurses Association, the professional organization of registered nurses, officially recognize the National League for Nursing as the national accrediting agency for all nursing education programs. This recog- nition comes to the league as the administrator and coordinator of nursing education accreditation on behalf of all schools of nursing. Nursing schools-both members and nonmembers of NLN-have rallied to this voluntary system of accreditation. Approximately 61 percent of the 1,269 programs preparing registered nurses now have national accreditation. The figures are included in exhibits II and. III. Another 12 percent have reasonable assurance of accreditation, assuring their eligibility for Federal funds, and indicating that their standards are such that they will soon be ready to seek full accredita- tion (exhibit No. IV). Further evidence of nursing education's respect for peer evaluation is that the majority of masters degree programs in nursing make grad- uation from an NLN-accredited baccalaureate program a prerequisite for acceptance of students. At the last counts of the 265 nurse faculty with doctoral degrees employed by colleges and universities, 221 were in accredited programs (exhibit No. V). In hospital-based diploma schools, 1,539 of the 1,753 faculty with masters degrees were in accredited programs (exhibit No. V). This is because the best qualified faculty ususally seek positions in schools whose academic standards and whose student bodies will make the best use of their knowledge and abilities as teachers. In these days of rapid growth in higher education, students are aware that they should seek the best possible education for whatever field they choose. They know that accreditation means high standards. For this reason, accredited programs in nursing find it easier to attract qualified students who will reap the most benefits from their education, as already stated by Dr. Cohelan. Right now, NLN accredited pro- PAGENO="0207" 199 grams enroll 75 percent of all the students in schools preparing reg- istered nurses (exhibit No. II). Graduates of nationally accredited nursing programs show better results on their State licensure examinations than those from non- accredited programs. During the past 5 years, the proportion of fail- ures for graduates of nonaccredi'ted programs was approximately twice that for graduates of accredited programs (exhibit No. VI). The State licensure examination, which is the same across the coun- try, must be passed before a nursing graduate has the legal right to practice as a registered nurse. Nursing schools were quick to respond to the challenge of the Nurse Training Act of 1964, with its provisions that Federal funds should be made available to nationally accredited schools or to schools with reasonable assurance of meeting the criteria for national accreditation. Reasonable assurance is the method by which schools with the po- tential for developing quality nursing programs can become eligible for funds to help them attain the high standards required for full accreditation. Through NLN, schools set in motion new procedures for granting reasonable assurance of accreditation to programs which had not yet sought national accreditation. From the incepiton of the Nurse Training Act to January 1, 1968, 253 programs out of the 314 which applied, were granted reasonable assurance by NLN. Of these 253, 104 are now fully accredited by the NLN, and a further 41 li~ve applied for national accreditation (exhibit No. IV). If I may make an aside, I think the time involved in this makes this achievement phenomenal. This same flexibility guides the league in its reactions to the many factors affecting both edncation and nursing today. Under a recent arrangement, the National Commission on Accrediting recognized the league "to engage in agreed to eligibility determination procedures for Federal funding (of associate degree programs) in cooperation with the regional accrediting associations" as' well as to grant formal program accreditation to associate-degree programs seeking specialized accreditation from NLN. To date, the six programs which have ap- plied have been declared eligible for Federal funds under alternate procedures worked out with the regional accrediting associations.', The testimony which I have given here today, Mr. Chairman, is aimed at supporting the belief that through channeling Federal funds to schools meeting the criteria for national accreditation, as set by their peer group, or to schools manifesting reasonable assurance o~f achiev- ing such standards, the basic aim of strengthening nursing edncation and increasing the numbers of qualified graduates can best be met. This will mean added protection for patients, since they will benefit from higher standards of nursing care. I have been speaking not only as president of the' National League for Nursing, but as an American citizen-a member of the vast general public in whose hands, ultimately, rests the responsibility for patient care in this geat Nation. On behalf of all your constituents, including each individual and agency member of the National League for Nuis- ing, I call upon the Congress to see that funds requested under this Health Manpower Act are expended in a way that will guarantee qual- ity patient care. This can be achieved best by making national aecredi- PAGENO="0208" 200 tation, or reasonable assurance thereof~ the requisite for nursing school eligibility for Federal funds under title II, section 231, of H.R. 15757. Full data and other exhibits substantiating or enlarging upon points I have made are appended to this report. I respectfully request that they appear in the record. Also attached is a folder entitled "Nursing Education Accreditation-A Service of the National League for Nurs- ing." I request that this be printed in the record, too. (Exhibits and booklet referred to follow:) EXHIBIT I ROLE AND FtJNCTI0N5 OF THE NATIONAL LEAOUE FOR NURsING The National League for Nursing is a membership organization, formed in 1952, to improve nursing service and nursing education through cooperative ac- tion by nurses, allied professional persons, other citizens, nursing service agen- cies, and schools of nursing. It fosters community planning for nursing, the de- velopment of nursing manpower, and high standards of nursing education and nursing servlce~ The League has 23,000 Individual members and 1,800 agency membera Its in- dividual members are professional and practical nurses, nursing aides, doctors, hospital administrators, educators, social workers, therapists, and interested citi- zens. Its agency members are nursing schools and nursing service agencies. C~iistituent leagues for nursing are organized in most states and localities. NLN activities are governed by an elected board of directors representing var- ious facets of nursing service and education, consumers of nursing services, and constituent leagues f or nursing. NLN's annual budget of some $3 million comes from membership dues, fees for services and publications, and grants. N~1RSING PROGL~M NLN works to improve organized nursing services In hospitals, public health agencies, nursing homes, and other community, agencies. It encourages coordina- tion of public and voluntary community health services and continuing nursing care of patients from hospital to home. It offers consultation, conferences, sur- veys and studies, and issues publications and reports on a varlčt~ of nursing service subjects. NLN nationally aceredits community public health nursing services and develops criteria and other tools for hospitals, nursing homes, and other institutions to use in self evaluation. NLN works to improve nursing education programs in universities and colleges which lead to bachelors, masters, and doctoral degrees; hospital diploma pro- grams, junior college associate degree programs, and practical nursing programs. It provides consultation, information, and publications; conducts conferences for the improvement of curriculums, faculty preparation, student instruction, and evaluation. Through the League nursing sChools. develop criteria for self evalua- tion and national recognition. The League is the national accrediting agency for all types of nursing education programs. TESPING SERVICES NLN conducts national testing services for nursing. It constructs and processes professional and practical nurse licensing examinations, administers NLN pre- administration tests for nursing school candidates, and provides achievement and qualifying tests for nursing students, practicing nurses, and aides. RESEARCH NLN annually gathers and publishes statistics on nursing sebool admissions, enrollments, and graduations; makes studies of costs, salaries, policies, and practices in public health nursing agencies. It undertakes special Studies and demonstration projects to yield data on such matters as the career patterns of nurses, administrative practices in nursing, community planning for health serv- ices, and teaching content and methods. PAGENO="0209" 201 TNFOnMArIöN NLN is a clearing house for information about trends in nursing, personnel needs, community nursing services, and schools of nursing. It publishes a wide variety of materiale about community planning for nursing, nursing education opportunities for young people, management and teaching, and evaluation of nursing services and nursing education programs. COOPEI~ATIVE ACTIVITIES NLN maintains active liaison with some 00 other national organizations. With the American Nurses' Association, it cosponsors a national nurse recruitment program, a film service, and the National Student Nurses' Association. EXHIBIT No. Il-A ADMISSIONS AND GRADUATiONS FOR BACCALAUREATE PROGRAMS IN NURS1NG, SEPT. 1 THROUGH AUGUST 31, 1962-63 THROUGH 1966-67, BY ACCREDITATION STATUS Academic year Accredited --________________________________ - Not accredited Number of programs Admissions Graduations Number of programs Admissions Graduations 1962-63 1963-64 1964-65 1965-66 1966-67 129 134 141 147 151 8,192 8,828 10,511 11,701 11,937 3,878 4,466 4,910 5,050 5,613 54 54 57 63 170 1,405 1,442 1 324 1,458 2,133 603 593 471 448 518 ENROLLMENTS FOR BACCALAUREATE PROGRAMS IN NURSING ON OCT. 15, 1963-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year . Number of Enrollments Number of Enrollments programs programs 1963 1964 1965 1966 1967 129 134 141 147 151 21,179 24,104 26,670 28,858 31,256 54 54 57 63 170 3,938 3,563 3,708 4,223 5,343 1 Includes 31 programs with Teasonable assurance. Source: National League for Nursing Research and Development. EXHIBIT NO. Il-B ADMISSIONS AND GRADUATIONS FOR DIPLOMA PROGRAMS IN NURSING, SEPT. 1 THROUGH AUG. 31, 1962-63 THROUGH 1966-67, BY ACCREDITATION STATUS Academic year - Accredited -~ Number of programs Not accredited Number of programs Admissions Graduations Admissions , Graduations 1962-63 1963-64 1964-65 1~65-66 1966-67 - 573 569 574 577 577 27,834 29,929 31,067 31,625 27,345 2Q,399 22,309 21. 470 21,514 23,059 287 271 247 1220 190 8,600 8,007 8,542 7,279 5,938 6,039 5,929 5,325 4,764 4,393 95-~54O-6S-----14 PAGENO="0210" 202 ENROLLMENTS FOR DIPLOMA PROGRAMS IN NURSING ON OCT 15 1963-67 BY ACCREDITATION STATUS Accredited Academic year - - Number of Enrollments Not accredited Number of Enrollments programs programs 1963 1964 1965 1966 1967 573 569 574 577 577 71,880 72,970 74,825 73,858 70,299 287 271 247 1220 190 21,391 20,119 18,935 16,793 14,114 lIncludes 22 programs with reasonable assurance, Source: National League for Nursing Research and Development. EXHIBIT NO. Il-C ADMISSIONS AND GRADUATIONS FOR ASSOCIATE DEGREE PROGRAMS IN NURSING SEPT. 1 THROUGH AUG. 31 1962-63 THROUGH 1966-67, BY ACCRED1TATION STATUS Accredited Not accredited Academic ----- - -- year Number of Admissions Graduations Number of Adnlissions Graduations programs programs 1962 to 63 5 320 154 100 3,170 1,325 1963 to 64 5 247 154 125 4,214 1,808 1964 to 65 6 337 225 168 5,823 2,285 1965 to 66 19 1,258 667 199 7,380 2,682 1966 to ~ 42 2,731 1,378 `239 8,616 3,276 ENROLLMENTS FOR ASSOCIATE DEGREE PROGRAMS IN NURSING ON OCT. 15, 1963-67, BY ACCREDITATION STATUS Accredited Not accredited Academic year -_________________________ Number of Enrollments Number of Enrollments programs programs 1963 5 528 100 5,828 1964 5 365 125 8,148 1965 6 595 168 10,969 1966 19 2,082 199 13,256 1967 42 4,445 `239 16,491 I Includes 91 programs with reasonable assurance and 3 programs considered equivalent under the special procedure for eligibility for Federal funds. Source: National League for Nursing Research and Development. EXHIBIT NO. Il-D ADMISSIONS, GRADUATIONS, AND ENROLLMENTS IN BACCALAUREATE PROGRAMS IN NURSING (RN.), BY TYPE OF PROGRAM AND ACCRED1TATION STATuS AS OF JANUARY 1968 Accreditation status Number of programs Oct 15, 1967 Enrollments Oct 15, 1967 Admissions Sept 1 1966- Aug. 31, 1967 Graduations Sept. 1 1966- Aug. 31, 1967 Accredited 151 Reasonable assurance 31 Not accredited 39 Total 221 31,256 2,664 - 2,679 11,937 937 - 1,196 5,613 242 276 36,599 14,070 6,131 ADMISSIONS, GRADUATIONS, AND ENROLLMENTS IN ASSOCIATE DEGREE PROGRAMS IN NURStNG (R.N.), BY TYPE OF PROGRAM AND ACCREDITATION STATUS AS OF JANUARY 1968 Accredited Reasonable assurance ` Not accredited Total 42 94 145 281 4, 445 7, 439 9,052 20,936 2, 731 3, 814 4 802 11,347 1 378 1' 172 2 104 4:654 PAGENO="0211" Total 767 84,413 33.283 27,452 1 Includes 3 programs considered equivalent under the special procedure for eligibility for Federal funds. Source: National League for Nursing Research and Development. EXHIBIT III EDUCATIONAL PROGRAMS IN NURSING, 1967-ASSOCIATE DEGREE, BACCALAUREATE, DIPLOMA, MASTERS DEGREE, BY STATES AND ACCREDITATION STATUS Associate degree Baccalaureate Diploma Masters degree Total Number Total Number Total Number Total Number programs accred- programs accred- programs accred- programs accred- ited ited ted ited Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming Total 2 2 12 11 0 0 0 0 2 2 2 2 2 1 4 4 16 15 16 14 3 3 6 6 3 2 16 15 1 1 4 1 3 2 3 3 5 3 4 4 3 2 14 9 O 0 0 0 1 1 1 1 1 1 1 1 9 5 55 41 6 4 12 12 2 1 13 17 2 2 16 14 4 3 10 8 7 5 7 6 1 0 5 4 I 3 3 17 14 6 4 45 38 7 4 20 16 8 6 16 15 I 2 1 5 2 7 5 18. 14 1 1 1 4 4 1 3 3 11 10 1 1 0 0 1 2 1 8 3 5 2 33 28 I 1 1 1 1 I 24 15 83 50 8 3 22 6 1 3 1 6 5 1 7 6 50 42 1 2 2 8 4 1 2 2 3 3 11 6 95 71 2 1 8 2 I 2 2 5 5 I 2 1 5 1 3 1 6 5 4 3 12 11 7 6 22 13 2 2 3 3 1 1 2 2 5 3 22 10 I 0 0 0 0 5 4 7 6 3 1 8 4 8 3 16 16 1 1 0 0 221 151 767 577 I 203 ADMISSIONS, GRADUATIONS, AND ENROLLMENTS 1N DIPLOMA PROGRAMS IN NURSING (RN.), BY TYPE OF PROGRAM AND ACCREDITATION STATUS AS OF JANUARY 1968 Accredited Reasonable assurance Notaccredited 577 70,299 27,345 23,059 22 1,447 560 487 168 12,667 5,378 3,906 State 2 0 4 0 41 3 0 16 6 3 11 11 Ii 0 3 3 2 0 3 0 0 0 11 3 0 3 0 0 0 0 0 0 0 0 0 2 0 61 0 0 0 0 2 0 46 0 0 42 281 Total program figures as of Oct. 15, 1967, 1, 269; Number of accredited schools as of Jan. 1968, 770. Source: National League for Nursing Research and Development. PAGENO="0212" 204 EXHIBIT IV DATA ON NLN REASONABLE ASSURANCE OF ACCREDITATION UNDER NURSE TRAINING ACT OF 1964 JFrom the beginning of the Nurse Training Act(Public Law 88-581) to Jan. 1,1968,314 nursing education programs sought reasonable assurance of accredtation from the National League for Nursing;256 (82 percent) of these received reason~ able assurnucej Total Baccalaureate Associate Diplo~ia and master's degree Number of programs whici applied for reasonable assurance 314 63 146 105 Number of programs granted reasonable assurance Number of programs denied reasonable assurance Number of programs granted full accredtation following initial receipt of reasonable assurance Number of programs for reasonable assurance scheduled for accreditation visits in 1968 1 256 58 104 41 46 17 17 9 1132 14 36 25 78 21 51 7 Number of programs denied accreditation after receipt of reasonable assurance 13 1 1 11 1 Includes 3 associate degree programs considered equivalent under special procedures for determining eligibility for Federal funds. Source: National League for Nursing Departments of Associate Degree Programs, Baccalaureate and Higher Degree Programs, and Diploma Programs. PAGENO="0213" EXHIBIT V FULL-TIME FACULTY TEACH1NG IN NURSING DEPARTMENTS, SCHOOLS, OR PROGRAMS AS OF JANUARY 1968 BY TYPE OF PROGRAM AND HIGHEST EARNED CREDENTIAL Type of program by accreditation Doctorate Highest earn ed credential Masters Baccalaureate Associate degree Diploma Total Number Percent Number Percent Number Percent Number Percent Number Percent Number Percent Baccalaureate and higher degree: Accredited 203 84.6 2,934 85.4 491 80.9 0 0.0 4 80.0 3,632 84.7 Not accredited-RAI 9 3.8 221 6.4 41 6.8 0 0.0 0 0. 0 271 6.3 Not accredited 28 11.6 280 8.2 75 12. 3 2 100. 0 1 20. 0 386 9. 0 Total 240 100. 0 3,435 100. 0 - 607 100.0 2 100. 0 5 100. 0 4,289 100 0 Associate degree: Accredited 5 45.5 271 2&5 91 15.9 1 16.7 2 5. 9 370 22. 5 t~ Not accredited-RA 1 2 18. 2 347 34. 0 177 30. 8 1 16. 7 5 14. 7 532 32. 3 ~ Not accredited 4 36.3 403 39. 5 306 53.3 4 66.6 27 79.4 744 45.2 ~ Total 11 100.0 1,021 100.0 574 100.0 - 6 100.0 34 100.0 1,646 100.0 Diploma: Accredited 13 92.9 1,539 87. 8 4, 111 84. 1 31 57.4 1,785 76.7 7,479 82. 7 Net aceredited-RA 0 0.0 16 0.9 78 1.6 3 5.6 62 2.7 159 1. 8 Not accredited 1 7.1 198 11.3 701 14.3 20 27.0 481 20.6 1,401 15.5 Total 14 100.0 1,753 100.0 4,890 100.0 54 100.0 2,328 100.0 9,039 100.0 Total: Accredited 221 83.4 4,744 76. 4 4,693 77. 3 32 51.6 1,791 75.7 11,481 76.7 Not accredited-RA I 11 4. 2 584 9.4 296 4.9 4 6. 5 67 2. 8 ~62 6.4 Not accredited 33 12.4 881 14.2 1,082 17.8 26 41.9 509 21. 5 2,531 16. 9 Grand total 265 100. 0 6, 209 100. 0 6,071 100. 0 62 100.0 2,367 100. 0 14,974 100. 0 1 Reasonable assurance. Source: National League for Nursing Research and Development. PAGENO="0214" * 206 EXHIBIT VI NUMBER OF CANDIDATES AND PERCENT FAILING STATE BOARD TEST POOL EXAMINATIONS FOR LICENSURE OF REG1STERED NURSES Accredited Non-accredited Type of program - ________________ Numberof Percent Numberof Percent candidates failures candidates failures 1961-62: Baccalaureate 3, 127 4 664 Associate degree 121 6 772 Diploma 17,875 12 5,313 Total 21,123 11 6,749 1962-63 Baccalaureate 3,325 3 612 Associate degree 193 4 1, 534 Diploma 20,411 8 6,504 Total 23,929 7 8,650 1963-64: Baccalaureate 3,696 6 744 19 Associate degree 144 10 1, 133 25 Diploma 20, 118 13 5,950 24 Total 23,958 12 7,827 24 1964-65: Baccalaureate 4,948 6 587 19 Associate degree 219 15 2, 807 21 Diploma 23,901 11 6, 051 21 Total 29 068 10 9,445 21 1965-66: Baccalaureate 4, 791 7 521 24 Associate degree 197 21 3, 003 24 Diploma 20,268 13 4,242 21 Total 25,256 12 7,766 22 Source: National League for Nursing Evaluation Service. EXHIBIT VII NLN ACCREDITING PRACTICES AND CHARGES FOR ASSOCIATE DEGREE, BACCALAUREATE, AND MASTERS, AND DIPLOMA NURSING PROGRAMS For reasonable assur Characteristics - NLN agency members ance of accreditation For full accreditation - ---------------- -- NLN agency members Nonmember agencies Nonmember agencies Length of visit 1 day 1 day 3 days 1 3 days.1 Numberofvisitors2 2 2 2. Schedule of visits - - 1 visit I visit Every 8 years for associate Every 8 years for associate degree, baccalaureate degree, baccalaureate and masters programs and masters programs, every 6 years for every 6 years for diploma, diploma. Accreditation $100 plus travel $100 plus travel $50 per day per visitor for $1,500 fee. charges. and per diem and per diem travel and daily ex- expense of expense of penses. This is a pro- visitors, visitors, rated charge to equalize charges for all geo- graphic locations.2 I May be 2 days for associate degree programs. 2 Annual membership dues (associate degree, $235~ baccalaureate and masters, and diploma, $575) support xli NLNJ services, including accreditation. Source: National League for Nursing. EXHIBIT VIII-A NATIONAL LEAGUE FOR NURSING PROCEDURES-REASONABLE ASSURANCE OF ACCREDITATION UNDER IHE NURSE TRAINING ACT OF 19434 NEW NURSING PROGIIAMS A visit is planned upon receipt of the following material: 1. (a) 4. statement indicating approval of the educational institution by the appropriate regional accrediting association or evidence that the institution is a candidate for regional accreditation; or (b) A statement indicating that the 21 23 21 11 15 18 17 PAGENO="0215" 207 hospital controlling a diploma program is accredited by the Joint Commission on Accreditation of Hospitals. 2. A statement indicating approval of the establishment of the new program in nursing by the State Board of Nursing. 3. Acceptance by the institution of current criteria used by the National League for Nursing for accreditation purposes and statements of intention to continue work toward meeting the criteria and seeking accreditation following graduation of the first class. 4. The philosophy and purpose of the nursing program. 5. The commitment of the controlling institution to support a nursing program ~peeifying the extent of committed financial support by the controlling institution. 6. The names and qualifications of the chairman or director and of the faculty already employed. 7. The plan for recruitment and selection of faculty. 8. The length of program and the credential that will he conferred upon successful completion of the program. 9. The methods to be used in selection and admission of students. 10. The plan of the proposed curriculum. 11. The criteria used in the selection of agencies for clinical experiences for students. 12. The physical facilities (classroom, administrative, housing, if any) cur- reiftly available and to be provided for the nursing unit by the college. 13. College or school catalog. EXHIBIT VIII-B NATIONAL LEAGUE von NURSING PROCEDURES-REASONABLE ASSURANCE OF ACCREDITATION UNDER THE NURSE TRAINING ACT OF 19434 ESTABLISHED NURSING PROGRAMS A visit is planned upon receipt of the following material: 1. A statement from the administrative officer of the institution indicating acceptance of current criteria used by the National League for Nursing for acerediting purposes. 2. A statement from the State Board of Nursing evaluating the nursing program. 3. (a) A statement indicating that the collegiate institution offering the program is accredited by or is a candidate for accreditation by the appropriate regional aecrediting agency; or (b) A statement indicating that the hospital controlling a diploma program is accredited by the Joint Commission on Accredi- tation of Hospitals. 4. A statement of intent to continue to work toward meeting the criteria and seeking NLN accreditation within three years or at the termination of a Teaching Improvement Grant. 5. A statement of the philosophy and purpose of the institution and of the nursing program. 6. Evidence of the commitment of the institution to support a nursing program that specifies the extent of committed financial support by the university, college, or hospital. 7. Information regarding the quallficatioims and major responsibilities of the dean or director and of each faculty member. 8. The plan for selection, upgrading, promotion, and tenure of faculty. 9. Policies used for selection, admission, promotion, and graduation of stu- dents. 10. Current enrollment by class. 11. Number of admissions to program per year for past five years. 12. Number of graduations from program per year for past five years. 13. Curriculum plan. 14. Brief course descriptions, 15. Description of resources and facilities. 16. Methods used to evaluate the program. PAGENO="0216" 208 (Booklet text follows:) Nunsixu EDUCATION ACcRniiITA'rIo~, A SERVICE OF THE NAL~ONAL LEAGUE FOR NuRsING~ Accreditation has been called a way, of ljfe in American education. So, too, it is in nursing education-accreditation, by the National League for Nursing. NLN aecredits programs of study in nursing offered by senior colleges and uni- versities, junior and community colleges, hospitals and in'dOpen~ent schools, and vocational and other secondary schools. NLN's accreditation services are designed to stimulate schools to improve their nursing programs and to provide a mark of recognition for those Which meet certainqualitative criteria. ACCREDITATION AS A PUBLIC SERVICE Accreditation is a public service as well as a service to educational institutions offering programs iu nursing. One of its purposes is to provide the public with well prepared nurses. It serves as an aid, too, to students, parents, and counselors in evalunating schools and in selecting nursing education programs, It provides a yardstick by which both tax funds and voluntary contributions can be channeled into high quality education. It assures the community that a school has a competent faculty and administration, that its curriculum meets the standards nursing school faculty themselves know are good atid attainable, and that the educational experience will be a profitable one for the student. Community groups of many kinds are concerned about nursing education and involved in developing new educational resources for nursing. National accredi- tation makes guidlines to quality in nursing education available to ~ommunity planning groups. ACCREDITATION AS A SERViCE TO NURSING SCHOOLS Nursing schools have rallied to national accreditation since the inception, of the program in 1948 2* The significance of this support is heightened `by the fact that national accreditation is voluntary-a school seeks NLN accreditation of its program of study because of the values accreditation holds for the school. National recognition is one of these. Another is the opportunity a nursing school faculty, going through the accreditation proceSs, has to participate in its own evaluation of the school and to plan and execute changes that will improve the program. As a rule, accredited programs in nursing find it easier to attract quali- fied faculty and students than do nonaccredited programs. Their graduates cus- tomarily score higher on state board examinations to become licensed to practice as nurses than do the graduates of non-accredited programs. Having national standards to meet often helps a school withstand local pressures to initiate or continue questionable educational practices. Acceptance of accreditation as an instrument for improvement stems' from the American tradition to excel, to exceed the minimum expected. State boards of nursing approve schools of nursing for the preparation of students' qualified to take the state licensing examination to practice as nurses. The criteria that must `be met for national accreditation are over and above the requirements for legal recognition within a state, and they are established by the schools them- selves. Accreditation in nursing education also is geared to the nationwide pro- grams of accrediting in higher education as appropriate. It is speclali~ed ac- creditation, condncted by nurse educators to evaluate programs of study for the purpose of maintaining educational standards in nursing. Thus accreditation benefits to a school are benefits also to the profession in improving the practice of its members. 1 The National League for Nursing Is recognized as the national accrediting agency for nursing education by: the National Commission on Accredlting-for baChelors and masters degree programs in nursing; the United States Commissioner of Education-for all nursing education programs; the American Nurses' AssociatIon-~--for all nursing education pro- grams; and the National Federation of Licensed Practical Nurses-for practical nursing programs. 2 National Nursing Accredlting Service was established in 1948 to unify the separate accreditin'g activities of several national organizations concerned with accreditation in nursing. When the National League for Nursing was formed In 1952, the National Nursing Accreditlng `Service became one of the seven national services, committees, and organizations which merged to form the new organization. Nursing accredlting activities were then' cen- tered in NLN. PAGENO="0217" 209 THE NLN ACCREDITIN~ PROGL&M NLN accredits all types of nursing education programs-graduate programs for professional nurses at the masters degree level, bachelors and associate ds~gree nursing programs in universjties, senior, junior and community colleges, diploma programs offered by hospital and independent schools, and practical nursing pro- ~rams. For each, accreditation is hased on the principle of evaluation by a peer group. The myriad activities involved in evaluation are undertaken by the seg- ment of the NLN membership and staff active and experienced in the type of pro- gram under review. Masters and bachelors degree programs are evaluated by faculty in ~mbers of accredited programs in senior colleges and universities. Faculty members from these programs develop and review the NLN criteria used in evaluation, make accreditation visits to the colleges and universities, and compose the board of review which makes the decision on a school's accreditation. Whenever possible, NLN visits a college or university for nursing accreditation concurrently with representatives of the regional accrediting associations in higher education who evaluate the institution as a whole. Seventy~one per cent of the baccalaureate programs hold NLN accreditation. Diplomatic programs are evaluated by faculty members of accredited pro- grams in hospitals and independent schools of nursing. Faculty members of ac- credited diploma programs develop evaluation criteria, visit schools, and com- pose the board of review. Sixty-nine per cent of the diploma programs through- out the country are nationally accredited. Associate degree programs in junior and community colleges, as the newest facet of nursing education, are one of the most recent groups to utilize NLN accreditation services. Associate degree programs are growing rapidly ttbrough- out the country to meet community needs, and many are yet too new to seek national accreditation. Thus, NLN accreditation of these programs is not yet as well established as for other types of nursing education. The NLN evaluation criteria, however, provide guidelines to quality education in nursing that en- able junior and community colleges to establish sound nursing programs. More and more are joining the ranks ~f accredited programs. As with baccalaureate programs, school visits for NLN accreditation are scheduled when possible, with visits of representatives of regional accrediting associations evaluating the college as a whole. Practical nursiag accreditation was initiated by NLN in 1966 and for the majority of these schools, too, NLN accreditation is a new and largely future goal. Criteria and evaluation procedures have been established, and the first programs approved, In offering national accreditation to practical nursing, NLN recognizes these programs as an integral part of nursing education. ACCREDITATION IN ACTION The experiences of a typical nursing school illustrate NLN accreditation methods and the attention to detail, the communications "musts," and the judg- mental faculties exercised throughout the evaluation of a school and its nursing program. First a school applies for accreditation. After doing so it submits a written self-evaluation report substantiating the ways in which it meets the criteria which have been established by and for the type of program it offers. The criteria are published by NLN ai~d are available to all schools. In addition to being a guide for the preparation of the self-evaluation report, they serve as a yard- stick by which a school may pace its own improvement efforts and determine its readiness far accreditation. * The self study through which a school faculty goes in order to prepare its report often Is considered one of the most valuable aspects of accreditation. Teachers and administrators must look searchingly into the philosophy and pur- poses of the program and the ways in which the program is meeting the nursing needs of the community. They must analyEe and report on the organization and * administration of the school, the qualifications of faculty, the curriculum offerings, policies in effect for students in nursing, the resourCes and facilities used by the school to educate its students, and the methods by which the school periodically evaluates itself. * * An accreditation visit then is scheduled at the convenience of the school. At least two persons always visit a school to ensure balanced~ judgment. Visits may be made by faculty members of the type of program under review, by an PAGENO="0218" 210 NLN staff member, or both. A college or university may also request a visit from a generalist from a regional accrediting association when a joint visit with this group is not possible. The purpose of the accrediting visit is to clarify the material in the self- evaluation report, to elicit additional information that may be needed, and to serve as a communications bridge between the school and the board of review which will evaluate its program. At the conclusion of the visit, usually two to three days, the visitors' report is read to the faculty and administration of the school so that they may be aware in advance of all data to be reviewed by the board. One further step is taken to assure this. Following the visit, a copy of the visitors' report is sent to the administrative head of the school and to the dean or director of the nursing program for comments and acceptance before presentation to the board of review. The board of review which makes the evaluation is composed of nurse edu- cators from accredited programs of the type under review, selected to represent various types of program control and sections of the country. The board ap- proves a program for NLN accreditation for a specified number of years, and those which are accredited and those which are not are sent a written com- munication outlining the program's strengths and weaknesses. An accredited school may be asked to submit a subsequent report outlining the progress it has made in meeting recommendations of the board. A school may return for evaluation at any meeting of the board of review or appeal a decision of the board. These procedures, and others in the accred- iting process, are designed to assure the school's personnel that every effort is made to judge its program fairly and on the basis of concrete evidence of the way in which it meets the criteria. NLN annually publishes ]ists of nationally accredited programs in nursing These appear also in Nursing Outlook, the League's official magazine, and many schools tell their communities, through their newspapers and other media, when they have obtained accreditation. ACCREDITATION COSTS The cost of League accreditation services is borne partially by the League and partially by the schools. Methods of payment vary with type of program. For instance, senior colleges, universities, and hospital and independent schools are entitled to receive accreditation services, along with other NLN services, for the annual dues they pay for membership. Junior and community colleges and practical nursing programs enjoy subsidized membership dues, and pay a per diem fee for travel and expenses of accreditation visitors. Non-member schools pay an over-all fee for accreditation services. NLN's Board of Directors establishes membership dues and accreditation fees and has voted to move toward uniformity in these for all types of programs. Specific information about accreditation fees and membership dues should be obtained directly from NLN. NLN S~5ITOOL IMPROVEMENT PROGRAM Accreditation is only one phase of a broad program conducted by NLN to help schools of nursing meet and maintain high standards. As a membership organization to which both schools of nursing belong as member agencies and nursing school faculty belong as individual members, NLN engages in many school improvement activities. It offers consultation to schools of nursing to help them with pressing problems. Revision of the curriculum may be one of these. Helping a new school of nursing get underway, assisting in coordination of the facilities of several schools for educating all nursing students in a community, or the use of television in teach- ing may be others. Educational developments are as legion in nursing these clays as they are in other fields. Any nursing school, accredited or not, may call on NLN for consultation, advice, and counsel. Through conferences, meetings, and workshops, through studies of educational practices and the publication of research findings and other information materials, nursing schools participate in the NLN school improvement program and are aided by it. NLN provides evaluation services for testing applicants to schools of nursing and for use in determining the achievement of students during their school program. League information provides guidance to prospective students. PAGENO="0219" 211 As accreditation is one facet of the NLN school improvement activities, SO school improvement is one facet of the total League program. NLN works also to improve nursing services. ON THE RECORD Although NLN accreditation has widespread acceptance as an instrument of Improvement in nursing education, NLN seeks constantly to substantiate the effect of its accreditation efforts, for data such as- NLN accredited programs enroll 75% of all the students in schools preparing registered nurses. NLN accredited programs comprise 60% of all the nursing schools in the country. NLN accredited programs attract the best qualified faculty. For instance, of the 254 nurse educators with doctoral degrees employed by colleges and universities, 222 are teaching in accredited programs. In diploma programs 1,331 of the 1,571 faculty wIth masters degrees are in accredited programs. ACCREDITATION AND THE FUTURE `Revolutionary" often is used to describe what is going on in nursing educa- tion. Whether the changes taking place and being projected are revolutionary or evolutionary, they are taking place-changes in the systems of control of nursing education, in the assumption of community responsibility for education for a professional field, in the movement of nursing education into the general pattern of education in the country. Accreditation, as a method of evaluating the par- ticulars of present day nursing school practices, will change as nursing education -changes. The essential ingredient of accreditation-decision by a knowledgeable body of peers-and the purpose of accreditation-raising and maintaining high standards in nursing education-however are unchanging and unchangeable. Miss CONLEY. I thank you, Mr. Chairman, and members of the subcommittee, for this opportunity to appear before you. If I can answer any questions, or supply additional information, I shall be happy to do so. Mr. ROGERS. Thank you very much, Miss Conley, for a very excellent statement setting forth the position of the National League for Nursing. What has concerned me is whether it is proper policy for the Congress to delegate to a private agency the determination of whei~e Federal tax dollars shall go, and I am not sure on this. If a school is accredited, we all want high standards-if the school is accredited they have reached these standards or acceptable standards. Why should they be the one that continue to get the money? Why should not we give it to those who are not accredited to really help bring them up and increase the quality of education where it is really needed? We do not need to increase it where you have got accredited schools because the quality is there, and yet this-do you see what I mean'? This denies funds to the very institutions that need it. Miss CONLEY. Sir, if just funds would do it I might agree with you. Mr. ROGERS. Well, this is all we have to go on, you see. Miss CONLEY. Yes. There is the reasonable assurance step here. If you were to look at the criteria on which i~easonabie assurance is based (and this is available to you), you would see that these are mimmal standards necessary to educate people to give care to the patients in this country. Reasonable assurance includes really the basic things which a school must have in order to move toward accreditation. You have to have certain basic things or you do not have a school. PAGENO="0220" 212 Mr. ROGERS. Yes, I understand that, but I would think an institu- tutional accreditation might suffice to qualify for Federal aid to improve specific programs. This is what I am concerned about; and, to allow a private agency in effect, is turning over the legislative authority to say tax dollars will go here or there. Miss CONLEY. it believe that schools are really acerediting each other; in other words this is peer evaluation. NLN happens to be the organi- zation in which the schools themselves hold membership. Peer evalua- tion is a very old custom in this Nation. Accreditation has never been an official agency function, approval for licensure State by State has. Mr. ROGERS. On an institutional basis, regional. Miss CONLEY. Yes. now frequently. Mr. ROGERS. Not necessarily a program by program in every instance. Miss CONLEY. Frequently, Mr. Chairman, a program in nursing education is not accredited because the institution as a whole does not hold regional accreditation. We only accredit programs in accredited institutions. Mr. ROGERS. But the point I am making is, as long as it is approved by, say, a State agency or a regional agency should it then be denied funds to try to bring it up to standards? And would it be better once it has basic approval as an institution to then allow Federal funds to at least go in there? They can work for accreditation because every institution, I would think, would want to be accredited. In other words, what I am trying to say, should we not really try to help these schools that are not accredited, and then we are in effect, denying them that help by saying you cannot get it until you are accredited, or you have given us every assurance. Well, they cannot give you that assurance until they get some money. They cannot get money, because we will not do it. So, we get caught on the horns of a dilemma in some of these institutions, I think. Miss CONLEY. May I tell you the two criteria for eligibility for reasonable assurance, sir? I quote: The college shall have appropriate regional accreditation or have evidence that the institution is seeking accreditation. The nursing' program shall be approved by the state board of nursing. Mr. `ROGERS. Well, then, a State agency could do this. There would be no reason why they could not-this is not a very high requirement. I would think a State agency could in effect~ bring this about and allow funds to go in there. Miss CONLEY. May I ask Dr. Harty to comment on this, please? Mr. ROGERS. Yes, certainly. Dr. HARTY. Sir, I think it would be ideal if every nursing school in the United States were given a large `bloc of money if the intent were that, on a philOsophical base, money in and of itself will result in excellence or will put one on the road toward excellence. The realities are that there are not enough moneys to do this, and, therefore, the element of priorities immediately enters in. In making priorities in the field of nursing, and recognizing that the purpose for these moneys is to insure that there will be a quantity type of quality, but also a. quality type of quantity, it also becomes essential to make, choices. When one delegates this task to the National League for Nursing, one is literally saying to the experts in the field ~f nursing education, give us your counsel regarding where this money would be most effective PAGENO="0221" 213 and where the citizens of the Unit~d States would be likely to get the greatest benefits. Mr. Roo~ns. I understand the philosophy behind it and I wOuld hope every school can be accredited, I approve of quality education wherever we can get it. The only thing I am saying is that once a school gets the accreditation, the standards are pretty well set; there. So, we ought to then be looking at what we can do to bring up the standards of these schools that do not have it in order to begin to get some quality and quantity which we must have in this Nation. And, if we encourage these schools by giving support to reach standards, I think this is fine. But, in effect we are denyingthis right now. You say you have got to reach that basically first. Dr. HARTY. Then, one looks at the point of reasonable as~nrance again. This was the mechanism established so there would be no bar- riers, so that it would be a simple process for a school immediately to begin to work toward the concept of excellence and to find means of doing so. When one speaks of regional accreditation for the institution, the National Commission on Accrediting speóifically states that, in awarding accreditation to an institution, it does not make special decisions or determinations regarding specialized programs. There- fore, regional institutional accreditation does not, in and of itself, accredit or make a specific point of citing the excellence or the quality of a particular program. When one considers State approval, one needs to remember that the State-for the protection of it~ citizenry-says only that a school must have the~minihial bas~ to start. The peer gioup itself is identified in all fields a~ coniposed of persons who are most expert in this area. It seems logical to make it less difficult for the group to turn to its own peers for assistance. This would be again, as you so rightly put it, a philosophic base. When we look at number of nonaceredited schools, we are speaking of a very small number, since the majority of schools of nursing have moved to reasonable assurance or full accreditation. Mr. ROGERS. Mr. Skubitz? Mr. SKUBITZ. I have one or two questions. To become accredited, would your association determine such things as the training and the number of teachers on the faculty? Whether a high school diploma is to be required for admittance, or 2 years of college; whether we should have a 2-year course, 3-year course or 4-year course? Are these the things that you would deter- mine before you recommend a school? Miss CONLEY. The organization has an established accreditation procedure. This is why, sir, we appended a little pamphlet to our testimony and asked that it be put in the record. I think, as a citizen you would be interested in that, sir, even if you were not a Congress- man. There is a little blue pamphlet ("Nursing Education Accredita- tion," see p. 208) that you have three that gives a grat deal of infor- mation Let me just say, however, that criteria for the evaluation of educational programs in nursing of any kind are developed by the schools themselves. I happen to have here the "Criteria for the Evalua- tion of Educational Programs in Nursing Leading to a Diploma." In this case the council in our organization representing the diploma schools in this country themselves developed the criteria by which they are measured. Each of these agency members, each hospital school PAGENO="0222" 214 of nursing which belongs to NLN, has two official representatives on that council. This might be the director of the hospital and. a nurse faculty member. it might be two nurse faculty members. It .might be a board of trustees member and a nurse faculty member. I would hope they would always have one of the nurses on the faculty as one of their representatives. Mr. RoGERs. Excuse me. May I interrupt just a minute? We have a call. That is the second bell. Could we-I think we had better take a recess, and if we can get permission, we will sit again at 2 o'clock, if you could join us at 2. Miss CONLEY. I would be pleased to, sir. Thank you very much. Mr. ROGERS. Thank you. The committee will stand in recess until 2 o?clock. (Whereupon, at 12:35 p.m., the hearing was recessed, to reconvene at 2 p.m., the s~~me day.) AFfER RECESS (The subcommittee reconvened at 2:40 p.m., Hon. Paul 0. Rogers presiding.) Mr. RoGEIrS. The committee will come to order, please. We apologize. Just about the time we were ready to start, they had anGther vote, so we hope we will have time now to finish. Mr. Skubitz~ I think you were questioning. STATEMENT OF L.. ANN CONLEY, ACCOMPANIED BY DR. MAROARE1~ H.ARTY-~Resumed Mr. SJ[UBITZ. I have no more questions. Mr. ROGERS. It is my understanding that the National Commission on Accrecliting pi~efers an institutional accrediting position rather than a program. Is that basically true? You would not know their position? Dr. HARTY. They do accredit institutions, sir, yes. They do not accredit programs. Mr. ROGERS. I believe that-is there anything you might want to add? I think you were explaining to Mr. Skubitz but you have given him the answer. Miss CoNLI~Y. You asked me a question. I did not have an adequate answer for it. I was glad to have a little time to think. I went back into history a little bit in my thinking. At one time I took, as many people have, a course in the history of higher education in this country. I do not remember the exact date, but I think it was during the early 1800's when we did not have in this country the development of graduate programs. At that time, if you remember, graduates of medicine used to go to Germany for postgraduate educa- tion in medicine before we had anything here in graduate education. The same was true for engineering arid other professions, particularly in the science field. At that time medical schools were in a chaotic state, and universi~ ties, particularly in Germany, were asking the U.S. Govern- ment to say whether a graduate of this medical school should be admitted because we had many very, very poor medical schools. At that time the Federal Government made the decision that it could PAGENO="0223" 215 not go into the. business of deciding quality of education, and it turned to the schools of medicine and other schools to set standards by peer groups. This was the beginning of the listing by the Federal GOvern- ment of colleges and universities. That list still comes out annually. So, if we are looking for a prece- dent foi the Federal Government turning to professional groups that ask their peers to set standards, we can go way back to the early 1800's. Mr. ROGERS. I was not so much concerned with precedents. I realize there is ample precedent. What I was suggesting is whether this should be reviewed, not that you would not still allow a group to set standards and try to improve your standards. Miss CONLEY. Yes. Mr. RoqERs. But simply not allow that group the determination as to whether Federal funds would or would not go to an institution. In other words, maybe we ought to give, as I was just saying, support money to those who have not met certain standards to bring them up to standards. This is the point I was making. I realize there are precedents. Miss CONLEY. May I refer, however, to section 805, under the Proj- ect Grants section? There is provision there for projects to get schools of nursing ready to apply for accreditation and provide the moneys required. Project proposals could go in there for that purpose. Mr. ROGERS. Yes. Well- and if this is so, I do not know that there is any reason why we should not give them money as long as we know they are going to do well. This is the point. And then you should not have it on a basis of some nongovernmental group deciding where the tax funds go. This is a review I want to make of the problem. Miss CONLEY. In the Project Grants section, moneys would assist schools to get ready for accreditation, which was your concern, I believe section .805 takes care of this. Mr. ROGERS. It perhaps could do that. Mr. SKUBITZ. I would like to ask one question. Who accredits medical schools? Miss CONLEY. The interesting thing, sir, is this, that no medical school or dental school could exist unless it was accredited. This has been developmental in these two older areas of professional education in this country. If a new dental or new medical school is to start, the first thing that the institution does is to turn to the profes- sional peer group for approval to start, rather than go first to the licensing boards in the State, as a new nursing school does. Mr. SKUBITZ. Who accredits the medical school in Kansas or Missouri? What national organization sets up the standards? Miss CONLEY. The American Association of Medical Colleges, sir. Mr. SKUBITZ. Is that right? Miss CONLEY. Yes. So you see, nursing is unique, and I propose to you that what the nurse does for and with and to the patient is as critical as what dentists or physicians do. We are a vital group for the patient and, sir, I do not have to convince you of that. You told us all about that in your own case. Mr. ROGERS. Thank you very much. Your testimony has been most helpful. Miss CONLEY. Thank you very much, sir. Mr. ROGERS. Our next witness is Mr. Charles W. Bliven, executive PAGENO="0224" 216 secretary of the American Association of Colleges of Pharmacy, and he will be accompanied by Dr. Warren E. Weaver, the president of the association. STATEMENTS OP CHARLES W. BLIVEN, EXECUTIVE SECRETARY, AMERICAN ASSOCIATION OP COLLEGES OP PEARMACY; AND DR. WARREN E. WEAVER, PRESIDENT Mr. Roe~s. Welcome to the committee, gentlemen. We are pleased to have you, and we apologize for keeping you waiting so long this afternoon. Mr. BLIVEN. We appreciate the opportunity to appear before you this afternoqn, Mr. Chairman. My name is CharlesW. Bliven, and, as you hai~e indicated, with me is Dr. Warren E. Weaver, dean of the School of Pharmacy at the Medical College of Virginia, and president of onr association. I am executive secretary of the American Association of Colleges of Pharmacy, and I present the statement in this capacity. Before as- suming this office more than 6 years ago, I served for 14 years as dean of a school of pharmacy, I appear before you in behalf of the membership of the American Association of Colleges of Pharmacy, which consists of 74 schools and colleges of pharmacy, and we have approximately 1,460 teachers engaged in instruction and some 14,100 undergraduate and 2,000 graduate students enrolled in our schools. And I might add that all of our 74 schools, members of our association, are accredited. The curriculum leading to the undergraduate professional degree has required a minimum of 5 years since September 1960. Two of our member schools offer a required 6-year curriculum, and at least two others offer this longer program on an optional basis in addition to the minimum program. In `the 5-year program at least 3 years of work in the professional subjects are required in addition to a 2-year basic science program. In the 6-year curriculum at least 4 years are mandatory beyond the 2 years of science. The objective of the American Association of Colleges of Pharmacy is the promotion of education and research within the member in~titutions. I appear before you in support of titles I and IV of H.R. 15757, the "Health Manpower Act of 1968." Title I would extend and broaden the program for the construction of teaching facilities for students in schools of pharmacy and in other health professions. It would extend the student loan and scholarship provisions to give financial aid to needy students in these professions, and authorize special project grants to all schools of the health professions. In ad- dition it would provide institutional grants to all such schools except the schools of pharmacy and of veterinary medicine. Title IV, as you know, would extend the health research facilities program. Public Law 88-129, the Health Professions Education Assistance Act of 1963, included schools of pharmacy in the construction program and Public Law 89-290, which amended and extended this legisla- tion, provided scholarships and loans for students of pharmacy. How- ever, our schools were not included (in fact we did not ask to be included at that time) in part E of the law which provides basic PAGENO="0225" 217 improvement grants and special improve~nent grants for schools of medicine, dentistry, osteopathy, optometry, and podiatry. But we do wish to express our gratitude for construction funds and for financial assistance to our students made possible under these acts. }T.R. 15757 would, make sohools of pharmacy eligible to apply for special project grants (sec. 772) but would exclude them from receiv- ing institutional grants (sec. 771). We ask, Mr. Chairman, that }LR. 15757 be so amended as to imike schools of pharmacy eligible for institutional grants. 111'n power Approximately 90 percent of our professional PerS01~flel are pi~- ticing in the community pharmacies throughout the country. The remaining 10 percent are engaged in the many other areas of the Profession: in the. pharmacies of our hospitals; in the control, research, or product development laboratories of the manufacturing plants; as medical service representatives to the physicians; in our educational programs; in Government; and in the Armed Forces. The schools of pharmacy are making every effort to respond to the demands 1~or personnel from all of these public health areas. The educational pro- gram in pharmacy provides our graduates with an excellent back- ground in the basic sciences as well as in the professional courses. For this reason allied health fields are utilizing an increasing number of our graduates. To provide an adequate number of pharmacists for the profession and the allied health fields, our schools and colleges of pharmacy will continue to need financial assistance through the proiri- sions of this legislation. In the important area of hospital pharmacy where about 10,000 pharmacists are employed, the demand is greater than the supply. Of the 7,000 hospitals only 2,339, less than one-half, have the services of a full-time pharmacist and only 2,644 (38 percent) have the services of a pharmacist on either a full-time or part-time basis. The annual replacement factor for full-time hospital pharmacists is estimated to be 12.8 percent or 621-about 17 percent of the 1967 graduating class. The continually greater demand for pharmaceutical services by our increasing population necessitates an increased output of pharmacists. The annual increase in the number of prescriptions filled in the com- munity and the hospital pharmacies is one factor in this increasing demand for the professional services of pharmacists. In 1967 nearly 1.1 billion prescriptions were filled-about 70 million more than in 1966. I might mention that the increase in the number of prescriptions filled in 1967 represents a 205-percent increase over the number filled in 1947. Also in 1967 the average community pharmacy filled 21,000 prescriptions as compared to 7,000 in 1947, an increase also of 200 percent. This increased number of prescriptions alone-that is, the 70 mil- lion-on the average requires the yearly services of about the entire graduating class of 1967. Thus, the annual increase in the number of prescriptions and the failure to graduate a sufficient number of pharmacists to meet our annual manpower replacement needs clearly indicate that all pharmacists-in otir hospitals and in our community pharmacies-are having greater and greater demands made of them for professional services. 95-540-68---15 PAGENO="0226" 218 With respect to the need for pharmacists, I might add that our schools of pharmacy together with our associations are, through short courses, training community pharmacists to serve as consultants in nursing homes and small hospitals. This is a project which we have undertaken through the guidance of' the Public Health Service. Still another factor to which the attention of all of us should be directed is the increased manpower demands for pharmacists which will result from health legislation such as medicare and medicaid. I refer not only to pharmaceutical services as we currently think of them but also the other areas of health service where our graduates can and will be expected to serve. Our member colleges have the responsibility of graduating an adequate number of pharmacists at both the undergraduate and graduate levels to meet not only the replacement needs of the profes- sion (currently 4,300 undergraduates annually on a replacement r~ate of 3.5 percent per year) but also the demands of our rapidly expanding area of the health sciences. A rather constant pharmacist-to-popula- tion ratio of 67/100,000 existed from at least 1920 until about 1960; this included all licensed pharmacists not merely those in practice. Information compiled by the iTS. Public Health Service shows that as of 1962 there were 123,057 licensed pharmacists, excluding Puerto Rico, residing in the State of registry. But this number in- cluded retired pharmacists, those who may have been seeking positions, and those who were employed outside of the profession. In relation to population there were 66.2 licensed pharmacists per iOO,000 popula- tion. However, the number of licensed pharmacists in practice in the United~ States as of January 1, 1962, according to the same report numbered 117,377 which on the basis of a population of 188 million provided a pharmacist to population ratio of 62.4 per 100,000. As of January 1, 1965, the number of resident pharmacists in practice was 118,284 or 61.2 per 100,000, and I mention this because a table `to which I am now~ going to refer is compiled on that basis. Mr. ROGERs. Did you say 118,000'? Mr. BLIVEN. Yes, sir. Mr. ROGERS. Thank you. `Mr. BLIVEN. Table C, which is part of this report, gii~es information on the average annual number of pharmacists and requirements for replacements, new entran'ts, and the total need for pharmacists in practice in the United States for 5~year periods during 1965-80 in order to maintain the 1965 ratio of 61.2: 100,000 population. For the period 1965-70, an average of 5,900 replacements and new entrants will be needed. This number is 57.6 percent greater than the 3,744 graduates in 1967. To further emphasize our manpower problem, on `the basis of the estimated number of graduates in the years ahead, this output of 5,900 may not be reached until 1976 (see table D) at which time our average annual need for graduates will be about 7,400 to maintain' the 1965 ratio, of practicing pharmacists to population of 61.2 per 100,000. Thus, on this basis the pharmacist to population ratio will continue to show a gradual decrease. Faoilitze$ ` This emphasizes the need for continued expansion of e~is~ing schools and the possible need for new schools. In earlier statements before this PAGENO="0227" 219 committee it was stated: "~ * * the needs of schools of pharmacy appear to be the replacement or rehabilitation of existing structures and the expansion of some to meet area needs. There does not appear to be a need for the establishment of new schools." Now that we have data on the 5-year program, which was initiated itt 1960 and produced the first graduates in 1965, the need for some new schOols or at least `a more rapid expansion than at present of existing schools appears es- sential if the pharmacist to population ratio is to be maintained at the 1965 level. It should be mentioned that the Fordham University College of Pharmacy, a private institution, will cease to take students into the professional program after 1969. In a survey conducted in December 1967, 12 schools of pharmacy reported projects approved and funded during fiscal year 1963-67 with the Federal share amounting to $9.1 million (total cost of $26.9 million). Two projects were renovations, the remaining 10 schools reported an increase of 367 first-year places. Six additional schools indicated construction is planned during fiscal year 1968 and 1969 with five schools reporting the total Federal share at $5.1 million (total cost at $8.8 million). The increase in first-year places is esti- mated to be 116. During the 3-year period fiscal year 1970-72, 21 schools indicated they plan construction projects. The total estimated Federal share- 14 schools-is $18.2 million and the estimated total cost of construc- tion-18 schools-is $40.2 million. The estimated number of new places is 454. Fifteen schools stated they plan construction beyond June 30, 1972. The provision of H.R. 15757 which would permit schools to submit one application for multipurpose facilities is a most desirable change. With the necessary increase in attention being devoted to continuing education, and to graduate training, the inclusion of facilities for such purposes in the construction program would permit a greater coordination in planning and the development of a more complete and interdigitated program. Student aid As stated previously, we did not seek in 1965 inclusion in the basic improvement grants and the special improvement grants provisions of the legislation. Instead we sought, and Congress did include, stu- dents of pharmacy in the loan and scholarship portions of the bill. For this we are grateful, and we believe that it is an important factor in our increasing enrollments in entering classes; i.e., the third year of the 5-year program. In 1966 about 13 percent more students en- rolled than in 1965, and last year the increase was almost 6 percent over that for 1966, According to information provided by the Bureau of Health Man- power, scholarship funds in the amount of $1,003,200 were allocated to schools of pharmacy in fiscal year 1967. Of the eligible class of 5,134 students, 1,051-20.5 percent-of our students received grants. `The average grant was for $648 and 67.9 percent çf the funds allocated were used. In addition to these F.ederalschola~ship `funds, our schools used almost 100 percent of the scholarship funds available to them from other sources. A survey condńcted in January 1968, by the American Association of PAGENO="0228" 220 Colleges of Pharmacy on the use of scholarship funds allooated for fiscal year 1968, showed the following: (1) Of the 73 schools receiving funds, 69 reported allocations total- ing $1,812,103; (2) Grants totaling $1,322,309 were made to 2,104 students for an average loan of $628; (3) About 74 percent of the allocated funds were used as of December 1968. With respect to loa~i funds, the Bureau of Health Manpower re- ported that of 73 eligible schools in fiscal year 1967,45 received fu~ads-'- a majority of the remaining schools continued to use NDEA funds- totaling $1,638,887 and that loans averaging $700 were niade to 1,584 students. Thus 67.7 percent of the funds were used. Again, a survey conducted in January 1968 by the American As- sociation of Colleges of Pharmacy revealed that 48 schools received loan funds for fiscal year 1968 totaling $1,887,740; loans totaling $1,416,271 were made to 1,935 students for an average loan of $732; and that 75 percent of the funds had been used as of December 1967. These figures, 1 believe, indicate the need for student financial assistance in schools of pharmacy. The estimated need for loan funds for fiscal year 1969 through 1972 was ascertained and, for the 45 schools reporting, the need is as follows: 1969 $2,242,270 1970 2,489,395 1971 2, 720, 500 1972 2, 952,460 Total 10,404, 625 rrhe provisions of 11.R. 15757 which permit, with the permission of the Secretary, the transfer of up to 20 percent of the money from the scholarship fund to the loan fund and vice versa is a very desir- able feature. Too, the change in the definition of those eligible for scholarships is most helpful. While in a survey conducted in January 1968, only about 10 percent of the deans of pharmacy indicated some change in the basic law was considered desirable, the most frequent comment was in regard to the limitation placed on the use of the funds because of the current wording; in fact, two schools failed to make any scholarship grants because of the university's interpretation of ~* * * students of low-income families who without such assistance would be unable to pursue the course of study * * I~titutional grants and specia7 project grants As noted earlier in this statement, the American Association of Colleges of Pharmacy requests that schools of pharmacy be included among the health schools eligible for institutional grants. At the pres- ent time our schools have no broad Federal financial assistance pro- gram available. Our schools are eligible for support through the general research support program administered by the National In- stitutes of Health; but the fact is that, while schools of medicine and dentistry automatically receive the basic grant of $25,000 annually plus additional funds calculated on rese'arch expenditures, schools of pharmacy are required to have grants totaling $100,000 during 1 year from the Public Health Service in order to be eligible for the PAGENO="0229" 221 basic grant of $25,000. About seven of our 74 schools have qualified for the general research support grants at one time or another, but only four or five have qualified in any one year. One of our needs now is for grants which can be used by the schools to strengthen their total programs, the undergraduate as well as the advanced programs. As in other health profession schools, a graduate pro~raAm in the pharmaceutical sciences is essential in obtaining and retaining staff, in strengthening the undergraduate program, and in contributing new knowledge in our special area of the health sciences. In a report made in January 1968, the American Council on Phar- inaceutical Education, the aecrediting body for schools of pharmacy, made the following statement: While the Council is under . . . rather diffuse pressures shared by others in the accrediting field, it is also under the more immediate pressures of the crisis in higher education as it affects pharmaceutical education. No one can read the newspapers today without being aware of the serioUsness of this crisis which is largely a money crisis caused by inadequate funding on the one band and infla- tionary pressures on the other. These are difficult problems to understand in pharmaceutical education for there are surface manifestations that all is well. Direct pharmacy budgets are up some 16 percent this year-this refers to the year 1967-68-for example, new buildings for pharmacy were erected during the year and others are under construction (since World War II, 27 new free-standing buildings and 20 shared buildings have been erected for pharmacy), the size of the full-time faculty has inched up to a new record number, the faculty published several hundred re- search papers and books and were granted 16 U.S. patents during the past academic year. But underneath this rosy facade, there are several evidences of problems growing more acute. Private institutions have raised tuition nearly to the limit of the market- place and several have had to be taken over by the State. State legislatures are hard pressed for sources of support almost universally and some States are extremely malnourished. While the past 2-year percentage gain in legislative support for higher education in the Nation is 44 percent, one State with a college of pharmacy showed only a 6.5-percent gain and another only 12 percent. While the national 8-year gain in legislative support for 1968 over 1960 was 214 percent, one State gained only 73.5 percent. The recent direct pharmacy college budget increases have gone almost entirely into salaries. This means that some faculties do not have ade- quate supplies, equipment, libraries, and travel funds with which to work effectively. While industrial support for research appears to have increased last year, Federal support for research was diminished by nearly $1 million. The American Association of Colleges of Phar- macy most recent survey shows that the number of unfilled faculty positions in pharmacy has increased since 1963 from 81 to 124. Seven colleges of pharmacy are looking for new deans currently, and there will be other additional retirements next year without doubt. The revolution in the health professions precipitated by medicare calls for a fresh approach to curriculum planning that has now begun, but still has a long way to travel. In addition, I wish to note that only recently-January 1968- the American Association of State Colleges and Universities and the National Association of State Universities and Land-Grant Colleges in a joint statement commented on education in health related fields stating in part We urge corrective legislation to end this discrimination to major health. related fields especially as concerns basic and special improvement grants for PAGENO="0230" 222 support of the instruetiopal function at ~choois of pharmacy and veterinary science. The American Association of Colleges of Pharmacy is in the process of studying program costs in schools of pharmacy. This is one part of a project designed to further delineate the needs of our schools, and is considered as an essential first step in strengthening our pro- grams in pharmacy. To' dat~, figures from 29 schools are* available, 24 State schools and five non-State schools. The study covers the academic year 1965-66. The average total expenditure for all schools was $443,733, and the range was from $124,963 to $1,554~390. Net cost-or gain-mfor- mation is available on 27 of the 29 schools. Twenty-four of the 27 schools showed deficits; the average deficit was $327,705, with a range of $63,178 to $1,192,211, and a median of $281,544. The average cost of the undergraduate program per undergradu- ate student for all schools was $1,300 with a range of $631 to $2,294, and a median of $1,516. The average cost per graduate student-20 colleges reporting-was $2,272, with a range from $1,158 to $14,883, and a median of $2,799. Lastly, the cost per undergraduate student on the basis of total expenditures of the 29 schools was $1,988. On the basis of the formula given in H.R. 15757, it is not possible to determine the institutional grant funds needs for schools of phar- macy. However, using the formula for the current basic improvement grants provision and the estimated enrollments given in table D, the need would be $9.9 million in fiscal year 1970. Based on the average estimated enrollment for fiscal year 1970-73, the need would be about $10.7 million per year for the 4-year period, or about $146,000 per school per year. As you are well aware, under H.R. 15757, schools of pharmacy would not be eligible for participation until fiscal year 1970. Thus, our request for inclusion in the institutional grant provision may be viewed as a request for "legislation for the future;" it would not affect the 1969 budget. We ask your serious consideration of our needs. But please be assured that we in pharmacy are mindful of the many demands of the current period and that priorities must be given consideration. How- ever, we are hopeful that the urgencies now with us will have lessened by fiscal year 1970. Certainly, we would be remiss if we failed to acknowledge with ap- preciation the inclusion of our schools in the special project grants provisions of the bill. These will be helpful, In view of the several purposes for which they can be used but, as stated earlier, our schools have no source of broad Federal financial assistance such as the in- stitutional grants with which to meet the exigencies which arise and which could not be met immediately by a project grant. Research ~facWties Title TV would extend the research facilities construction program for 4 years through fiscal 1973, authorizing "such sums as may be necessary." The AACP supports this extension and hopes that the funds available in the years ahead for this essential program will more nearly meet the demands than do funds currently available and those expected during 1969. PAGENO="0231" 223 Summary In summary, the American Association of Colleges of Pharmacy supports titles I and IV of the Health Manpower Act of 1968, but a sks that title I be amended to include schools of pharmacy~ in the in- stitutional grants program section 771. This broad source of support, as well as the funds available through the other provisions of titles I and IV, are essential to the continued development of the total programs of our schools to the end that adequate pharmacy manpower may be available to meet the needs of the public. (The tables referred to above follow:) TABLE A-UNDERGRADUATE ENROLLMENT IN CONTINENTAL US. SCHOOLS OF PHARMACY, 1964-67 Year Last year 2d from lastyear 3d from lastyear Total 1964-65 1965 66 1966-67 1967-68 3,557 3,770 3,871 4,085 3,977 3,990 4,024 4,476 4,427 4,583 5,173 5,561 11961 12,343 13,068 14,122 TARLE B-Graduates from undergrctdvcite curriculums of conttaen~tal UJ~L schools of pharmacy, 1958-67 Year: Graduates 1958 3, 683 1959 3, 686 1960 3, 497 1961 - 3, 438 1962 3, 699 1963 4, 163 1964 12, 195 1965 3,360 1966 .~ 3, 659 1967 3, 744 The small number of graduates in 1964 was the result of the transition from the 4- to the 5-year program in 1960 by those schools not already on the longer 9rogram. TABLE C-AVERAGE ANNUAL NUMBER OF PHARMACISTS, AND REQUIREMENTS FOR REPLACEMENTS, NEW ENTRANTS, AND TOTAL NEED FOR PHARMACISTS IN THE UNITED STATES FOR 5-YEAR PERIODS, 1965-80' Period Average annual number of Requirements * Replace- New ments a entrants Total pharmacists 2 1965-70 1970-75 1975-80 - 120,000 128,700 138,700 4,200 4,500 4,800 1,700 1,800 2,600 5,900 6,300 7,400 ~Puerto Rico is not included. 2 Based on Bureau of Census population projection of February 1967, series B, on the population increase as being linear, and on 1965 pharmacist-to-population ratio of 61.2:100,000. 2 Calculated at 3.5 percent of number of pharmacists. PAGENO="0232" 224 TABLE D.-ENROLLMENT BY CLASSES IN SCHOOLS OF PHARMACY FOR 1967-68 AND ESTIMATED ENROLLMENTS AND NUMBER OF GRADUATES FOR YEARS 1968-69 TO 1975-76 Year 3d last year1 2d last year2 Last year 8 e Estimated total nrollment4 Estimated number of graduates 1967-68~ 1968-69 1969-70 1970-71 1971-72 1972-73° 1973-74 1974-75 1975-76 5, 561 5,900 6,260 6,642 7,000 7,080 7,160 7,240 7,320 4, 476 4,960 5,263 5,584 5,925 6,244 6,315 6,387 6,458 4, 085 4,337 4,806 5,100 5,411 5,741 6,050 6,119 6,189 14, 122 15,191 16,329 17,326 18,336 19, 065 19,525 19,746 19,967 3, 936 4168 4,619 4,901 5,200 5, 517 5,814 5,880 5,984 I Enrollment increase based on 6.1 percent, the average increase for years 1963-67. 2 Enrollment decrease from preceding class based on 10.8 percent, the average decrease for years 1962-66. Enrollment decrease from preceding class based on 3.1 percent, the average decrease for years 1962-65. Attritmn rate from last year based on 3.9 percent, the average rate for years 1962-64. 5 Actual enrollment. o Assumes construction will continue beyond fiscal year 1972 at same average rate and new places will be available at same average rate per year as for the period fiscal year 1964-69 (483 places divided by 6 years equals 80 places per year). Mr. BLIvEN. Mr. Chairman, I think President Weaver has a very brief statement, and after that we shall be happy to attempt to answer any questions you may have. Mr. ROGERS. Fine. We will be glad to hear you, Dr. Weaver. Mr. WEAVER. Thank you, Mr. Chairman~ My name is Warren Weaver, and I an-i dean of the school of phar- n-lacy at the Medical College of Virginia in Richmond, Va., from the third district represented by Mr. David Satterfield. I appear on behalf of the membership of the association and my colleagues in pharmaceutical education. We, in pharmacy education are, of course, most interested in titles I and IV of H.R. 15757. We are most grateful for the support provided pharmaceutical education in the past and as proposed in this legislation. Our greatest concern is that schools of pharmacy are not included in section 771 and we request amendment so that schools of pharmacy are eligible for institutional grants. Dr. Bliven, in his statement, has given you a great deal of detailed information about pharmacy and the schools of pharmacy in this country. .1 would wish to emphasize that we in pharmacy education are directing great effort toward change in our curriculum and modifica- tion of our offerings so that the graduate in pharmacy can take an even more meaningful role in the health care team. All of us are interested in the highest quality of health care that can be delivered to the citizens whom we serve. Pharmacy has assumed a significant role in this respect to the past and wishes to keep abreast of the other health professions in the future. We in pharmacy are firmly committed to a program of patient oriented education. Our ability to carry forth this commitment is directly related to our ability to obtain additional support. As we see it, all elements of the health care team. must move forward together if the goal of high quality medical care for all citizens is to be realized. It is not my purpose to belabor you with the details of pharmaceutical PAGENO="0233" PAGENO="0234" 226 produce the number of graduates needed to maintain the 1965 pharmacist to population ratio of 61.2 per 100,000. The table given below projects the capacity, the enrollment, and the number of additional students which can be accommodated as of September, 1970. It will be noted that the first-year enrollment will be at least equal to the expected capacity, but smaller entering classes in previous years and attrition will cause the second-year and third-year classes to be slightly under capacity-a condition which will occur for only a short time after 1970. A study is currently underway to update the capacity figures and the projected enrollment figures to our schools. This Information Is not expected to be avail- able until the middle of 1969, however. CAPACITY, ENROLLMENTS AND ADDiTIONAL STUDENTS WHICH CAN BE ACCOMMODATED BY SCHOOLS OF PHARMACY, SEPTEMBER 1970 Capacity Enrollment Additional students lstyear' 2dyear 3d year 6,550 5,840 5, 660 26,550 5,584 5, 100 0 256 560 Total 18,050 17,234 816 1 The 1st year refQrs to the 3d year of the 5-year program. The number of places available to this class and attrition determines the number of students in the remaining classes, although the number of places actually available maybe somewhat greater. 2 Based on the average annual increase for the years 1963-67 (6.1 percent) the number of students may exceed this figure by 92 students. (See table D of prepared statement.) 2. Give the committee a projection of your needs. Do we need additional schools of pharmacy? The table given below depicts the projected needs of séhools of pharmacy to provide the number of graduates necessary to maintain the pharmacist to popu- lation ratio at the 11X15 level of 61.2 per 100,000. Thus, as of September 1970, 7,398 first-year places will be needed, 848 more than the 6,550 expected to be available. By September 1973, there will be a need for 1,136 new first-year places beyond the 6,550 such places available in September 1970. But the net increase in the number of new places between 1971 and 1973 is expected to be only 290, leaving a deficit of 846 places. Another 96 new places will be needed by September 1974, but construction plans for the period 1973-1974 are unknown. Since schools of pharmacy became eligible for construction funds in 1963, new spaces have been added at the rate of about 80 per year, a rate too low to catch up with the manpower deficit and to meet the annual needs. As mentioned In my prepared statement: "-the need for some new schools or at least a more rapid expansion than at present of existing schools appears essential if the pharmacist to population ratio is to be maintained at the 1965 level." In view of the deficit of new places (848 by 1970) and the need for about 100 new places annually, it would appear to be unwise to expect the expansion of existing schools to meet the total need therefore, some new schools of phar- macy are deemed essential. PROJECTION OF 1ST-YEAR UNDERGRADUATE STUDENT PLACIS REQUIRED BY SCHOOLS OF PHARMACY ANNUALLY FOR THE PER1OD 1970-75, AND THE NUMBER OF NEW PLACES REQU1RED, BASED ON SEPTEMBER 1970 CAPACITY, TO PRODUCE THE NUMBER OF GRADUATES NEEDED FOR THE 5-YEAR PER1OD Year ~ 1st-year places New places' ~ Graduates2 1970-71 1971-72 1972-73 1973-74 1974-75 Total 7,398 ~ 7,590 7,686 848 944 1,040 1,136 1,232 6,140 6,220 6,100 6380 6,460 37,950 31,500 I New places required above the September 1970 capacity of 6,550 places. sThe graduates needed is based on a linear projection of data given in table C of the prepared statement. PAGENO="0235" 227 3. Would it be desirable and feasible to require schools of pharmacy to take an additional 10 percent of the student body, if they get funds from the Federal govermnent? Those schools receiving fUnds for construction under existing legislation must, in the case of minimum expansion, increase the first-year enrollment by a 5 per- cent or 5 students, whichever is greater. In the case of major ex~an~sion, the first-year enrollment must be increased by 20 percent or 20 students, whichever is greater. To obtain the basic improvement grants under existing legislation or in the case of the institutional grants program of H.R. 15Th7, first-year enrollment must be increased by at least 2% percent or by five students, whichever is greater. The enrollment increases required in the construction program seems entirely appropriate since increased capacity can be incorporated in the construction plans. The incentive to increase enrollments as provided in the institutional grants program (Section `771 (a) (1) (A) (ii)) should prove helpful in increasing the output of health personnel. The requirement of an increase of 2% percent or five students (Section 771 (b) (1)) is reasonable for most of our schools. But this requirement annually may prove unWise in some schools where capacity enrollments exist or where the quality of the educational program would be weakened. However, iii such cases this requirement can be waived by the Secretary. In September, 1967, about one-half of our schools had an increase in first-year students of 5 percent or more over the previous year. In some instances it is likely that there was a lack of qualified applicants to increase' the number of first-year enrollees, and in other instances, the class may have been at capacity. Since the availability of institutional grant funds would enable schools to seek additional qualified students, it would seem imprudent to withhold grant funds solely on the basis of the inability of a school to meet the increased enrollment criterion. As stated above, the incentive provision contained in Section 771 (a) (1) (A) (ii) should serve as a stimulus to increase student enrollment and could possibly preclude the need for the requirement for increasing the first-year enrollment as contained in Section 772 (b) (1). Mr. ROGERS. Mr. Skubitz? Mr. SK1JBITZ. Mr. Bliven, are you a pharmacist? Mr. BLIvEN. Yes, sir. Mr. `SKTJBITZ. When did you graduate? Mr. BLIVEN. Oh, I wish you had not mentioned that. Iii the State of Nebraska, in 1934. Mr. SKUBITZ. How many years did you attend college? Mr. BLIVEN. I went `to school 4 years. Mr. SKUBITZ. Now 6 years are required; is that correct? Mr. ELIvEN. 5 years is mandatory. Two schools in California require 6 years. Mr. SKUEITZ. Why is it necessary to go 6 years to become a pharma- cist? Mr. BLIVEN. Some of our 6-year programs-~--and ~this is true, I think, for the programs that are adding 1 year to the 5-year program- is for purposes of specialization in such areas as hospital pharmacy, medical, service representatives, and perhaps Dean Weaver- Mr. SKiJBITZ. Specialization. Mr. BLIVEN, Yes. Specialization. Now, this is not necessarily true of the two California schools. They have increased considerably the amount of basic biological sciences, for example, in their curriculum, and I would add that some of- Mr. SKUBITZ. Is that necessary? Mr. BLIVEN. Yes, I `think it is. Mr. SKTJBITZ. I am fearful that no matter how much money we give, the result would be raised standards and less pharmacists. PAGENO="0236" 228 Mr. Rooi~ns. If they are going to fill those prescriptions right. Mr. WEAVER. I would say it is not a question of raising standards but a question of sophistication of delivery of health aid today. Mr. Roai~~its. All the new drugs, etcetera. Mr. SKUBITZ. We have two pharmacists in our family and three doctors, so I have talked to them quite `often about it. Mr. WEAVER. One of our big problems is to give continuing educa- tion for fellows like myself who graduated back 80 years ago and need to be kept abreast of current developments. Mr. SKTTBITZ. That is all, Mr. Chairman. Mr. RoGERs. Thank you very much. Your testimony is most helpful. `Our next witness-I believe we have three from the American Vet- erinary Medical Association. Dr. W. R. Pritchard, who is dean of the School of Veterinary Medicine, University of California. Dr. Pritchard, pleased to have you. Dr. W. T. S. Thorp, dean of the College of Veterinary Medicine, University of Minnesota. And Dr. Erskine V. Morse, dean, School of Veterinary Science and Medicine, Purdue. It is a pleasure `to have you gentlemen with us, and we appreciate your coming and being patient with the committee. If you would like to file statements for the record, they will be received and printed in full, and if you will just give us copies, I think we can get to the points quicker. STATEMENT OP DR. W. T. S. THORP, CHAIRMAN, JOINT COMMITTEE ON EDUCATION, AMERICAN VETERINARY MEDICAL ASSOCIA- TION Dr. THORP. I have a statement, and I have submitted it. I am Dr. W. T. S. Thorp. I am representing the American Vet- erinary Medical Association as chairman of their joint committee on education. As you said, I am also dean of the college, University of Minnesota. The American Veterinary Medical Association strongly supports the passage of H.R. 15757 as introduced by Congressman Staggers and entitled "The Health Manpower Act of 1968." In supporting this act, though, we urge the committee to amend the bill to include vet- erinary medical colleges under the provisions authorizing institutional grants. It is my understanding that this morning the Senate Commit- tee on Health and Welfare reported out S. 3095 and did include veterinary medicine in the institutional grants. Mr. ROGERS. Did you appear before the Senate committee? Dr. TEEORP. Yes, I did. Mr. ROGERS. You must have been persuasive. Dr. TITORP. Mr. Chairman, at this point I would like to submit for inclusion in the record of these hearings a prepared statement of the American Veterinary Medical Association and the statements of Dr. Price, the dean at Texas, Dr. M. R. Clarkson, Dr. John McKibben's discussion of veterinary education, Dr. Booth, the dean at Colorado, Dr. Armistead's statement, the dean of Michigan State. Dr. Mark Al- lam, the dean at the University of Pennsylvania, Dr. T. S. Williams, dean at Tuskegee, and Dr. James A. Greene, dean at Auburn, and Dr. Kingrey, the dean of Missouri. PAGENO="0237" 229 Mr ROGERS Do you have any statements Dr `1 IIORP Yes, they have been submitted to the staff Mr ROGERS How large are they ~ Your official statements- Dr TIITORP The official statement is here in detail Mr ROGERS We will put that in the record Di FH0RP It was our hope to put the others in the record Mr RoGErs We will either put them in the record or keep them for our official files Dr. THORP. They are short statements. Some of them are essentially like a two-page letter. Mr. ROGERS. That will be fine, then. Without objection it will be so ordered. (Dr. Thorp's prepared statement and additional statements re- ferred to, follow:) STATEMENT OF W. T. S. THORP, D.V.M., ChAIRMAN, JOINT COMMITTEE ON EDUCATION, AMERICAN VETERINARY MEDICAL AsSocIATIoN I. FUTURE REQUIREMENTS FOR VETERINARIANS rphe American Veterinary Medical Association estimates that there are today approximately 26,000 veterinarians in the United States. This represents a ratio of 13 veterinarians per 100,000 population. However, in 1961 the Senate Com- mittee on Government Operations estimated that to adequately serve the health needs of the United States, a minimum of 17.5 veterinarians per 100,000 popula- tion would be needed by 1980.* This would mean 44,100 veterinarians for a population estimated by the U.S. Bureau of the Census to reach 252 million by 1980. Although American colleges of veterinary medicine at present are graduating approximately 1,000 veterinarians per year, in the next 12 years approximately 600 veterinarians per year will be lost to the profession due to death or re- tirement. Consequently unless student enrollment in veterinary colleges in- creases substantially, only about 31,000 veterinarians will be available in the United States in 1980-more than 13,000 short of the estimated need. In order to implement th.e total needed expansion of veterinary education, additional colleges must be established, existing colleges remodeled and ex- panded, the training of veterinary teachers must be accelerated, new teaching staff must be added and instructional and research programs adequately funded, and additional loan funds and scholarships made available to academically quali- fied students from lower income families. To earn his Doctor of Veterinary Medicine degree, a student must complete a minimum of 2 years of pre-veterinary college training in a college of veterinary medicine. The average graduate veterinarian, however, has studied more than 7 years to earn his D.V.M. degree. In the public interest, passage of the Medical Manpower Act of 1008 is urgently needed. Its enactment would enable the veterinary professioli to provide: A. NECESSARY BUILDING TO INCREASE ENROLLMENT IN EXISTING VETERINARY MEDICAL COLLEGES In 1967 at least 3 qualified ap licants were turned away for each cepted in ~ I rv ~ ir vet I, PAGENO="0238" 230 B. STABLE, LONG-RANGE FUNDING FOil RESEARCH, INSTRUCTIONAL PROGRAMS, AND EFFICIENT ADMINiSTRATION The heavy emphasis in our society on research and public health exerts a substantial influence on veterinary medical education. It requires additional faculty competent to teach highly specialized subjects; the acquisition and operation of modern sophisticated teaching aids; the development and long- i~ange ftnding of research-oriented imstrhc'tionŕl prograros; the establishment of multiple-service laboratories; multiplication of seminars and self-learning courses of all kinds, and the expansion of personnel to coordinate and administer these programs. C. ESTABLISHMENT OF NEW VETERINARY COLLEGES There are 18 colleges of veterinary medicine in the United States. Even with expansion, these colleges will be unable to supply all the veterinarians needed in the years ahead. Moreover, many qualified students from the 33 states lacking a veterinary college find it impossible to obtain a veterinary education. In recent years, several states have considered establishing new veterinary colleges but have postponed action because of the high cost of cQnstruction, maintenance, staffing and operating a college of veterinary medicine. P. LOANS AND SCHOLARSHIPS TO VETERINARY MEDICAL STUDENUS TO FINANCE THEIR EDUOATION ~ survey of deans of. American veterinary colleges reveals that (1) many, students are unable to achieve and acceptable level of scholastic performance in their professional studies because of the necessity to work excessively long hours at part-time jobs to support themselves, (2) many students who would prefer to be veterinarians elect other degree programs because of their inability to finance 6 or more years of veterinary education. II. JUSTIFICATION FOR FEDEIiAL SUPPORT Veterinarians for the 50 United States are supplied by 18 veterinary colleges in 17 states. Consequently, they are national resources in the fullest sense. It is eminently logical, therefore, that federal support be extended to these colleges. Because of the high cost, it is unlikely that each slate can support a college of veterinary medicine on its own. Therefore, each veterinary school will con- tinue to enroll students from states having no veterinary college. For the foreseeable future, existing colleges probably could supply the needs of their own 17 states with, state funds, But it is unreasonable to expect these states to finance the total expansion of veterinary, medical educational facilities that is required nationally to meet the growing need for veterinarians. In some parts of the United States, those states without veterinary medical colleges have entered into agreements with schools in nearby states. However, even where a contract exists,. the pe~~entage of applicants admitted from con- tract states is much smaller than that from the state in which the school is located. Obviously, equal educational opportunity does not exist for aspiring veterinary medical students throughout the United States. Passage of the Medical Manpower Act of 1968 would do much toward providing equal educational op- portunity for all students who wish to study veterinary medicine. Modern veterinary medicine has achieved, a high level of scientific sophistica- tion and performance. Its contributiops to human health and welfare establish veterinary education as a precious national resource which must be supported and promoted in the national interest. III. THE SERVICES OF VETERINARY MEDICINE TO SOCIETY 1. ANIMAL HEALTH PROTECTION Farm Awimals Approximately 10,000 veterinarians care for the nation's farm animals. These practicing veterinarians protect the health of farm animals supplying protein food vital to healthy, bitman nutrition.. The demand for protein food is increas- ing and will continue to increase in order to meet the needs of a rapidly in- creasing population. The veterinary practitioner also cooperates with state and federal veterinarians in the eradication or control of major livestock diseases many of which, such as PAGENO="0239" 231 tuberculosis and brucellosis, are communicable to man. Veterinary service and counsel on animal health problems is supplied mainly by the farm animal practitioner. Veterinarians are currently responsible for the health of 108.5 million cattle, 51 million bogs, 24 million sheep, 435 million poultry, and 31 million horses. The combined inventory and production value of the Nation's livestock was 41 billion dollars as of January 1, 1967 (U.S.D~A. estimate). Pets and Recreational Animals The veterinarian who concerns himself with the diseaseS of pets and pleasure animals enhances the emotional we1l-being of their owners. Moreover, he pro~ tects man against diseases transmissible from pet a~i~als, such as rabies, leptospirosis, bacterial diarrhea, ringworm, staphylococcosis, and psittacosis. The steadily increasing number of pet animals attests to their popularity and to the pleasure they provide. The maintenance of their health is a vital part of the profession's contribution to society. 2. GOVERNMENT SERVICE l1J.~. Department of Agriculture Veterinarians are necessary to carry out many functions of state and federal government agencies in the United States. Veterinarians have been engaged in the eradication of livestock diseases including those communicable to mati, since 1884 when the Bureau of Animal Industry became a part of the United States Department of Agriculture. Two diseases of particular public health significance, both of which are targets of a joint eradication effort by U.S.D.A. and the individual states, are tuber- culosis and brucelloSis in cattle. Bruceflosis in swine is another eradication tar- get, because it is a major source of human bructillosis. Successful elimination of brucellosis in cattle and swine wi'l not only largely remove the major sources of human illne~s, hut will also reduce losses of animals through abortions caused by the disease. Veterinarians working either as members of federal and state government agencies, or as private practitioners, have been responsible for reducing losses to farmers from brucellosis from $90 million in 1947 to $12.5 million in 1967. As a result, reported cases of human brucellosis have dropped by 94 percent sin~e 1947. In 1917, tubercolsis affected 1 out of 20 cattle; the disease affected only 1 in 8,000 in 1967. The death rate for tuberculosis in man in 1917 was 125 per 100,000. In 1965, it was 4.1 per 100,000. Although the reduction of tuberculosis in cattle is not solely responsible for the decline of the disease in man~ it has played a major role. The joint efforts of government veterinarians and veterinary practitioners have been responsible for the near elimination of human extrápulthonary and pulmonary tuberculosis of bovine origin from most of North America. The goal is to eradicate these two diseases completel3r hi animals because until this is accomplished, people will continue to be victims of these diseases throttgh contact with infected animals. Food Hygiene Veterinarians direct meat and poultry inspection programs for federal, state and local governments. This country enjoys the highest pe~ ~apita consumption of meat and poultry in the world; approximately 200 pounds of meat are con- sumed by the average person each year. In response to the nationwide demand for consumer protection, Congress passed the Wholesome Meat Act in 1967 (Publte Law 90-201) and Congress is now considering bills pertaining to inspection of pob1tr~ and poultry meat pro- ducts. The above legislation requires hundreds of veterinarians to implement the new program. Veterinarians participate in food hygiene research and advise an~1 assist in the development and maintenance of recommended ordinances regarding milk sani- tation, poultry inSpection, and sanitation of food service establishments. Animal diseases are of public health significance because sense are tr~nsmissible~ to man through milk, meat, poultry and other animal fOod ~tOdnets. Food pi~oduct~ may also serve as vehicles of human infections, namel~, typhoid fe1f~r, diphtheria, scarlet fever, and streptococcal infeëtioris. PAGENO="0240" 232 In fiscal year 1966, 104,988,350 animals werO slaughtere~ under Federal Meat Inspection. Veterinarians direct all slaughtering and administer the over-all meal inspection program, as well as the humane slaughter law, which requires that animals be rendered insensible before slaughter begins. During 1966, over 264,902 animals at slaughter were condemned by veterinarians as unfit for human con- sumption. In addition, over 9,765,514 animal carcasses were temporarily re- tained until diseased or affected portions were removed. (Federal Meat Inspec- tion. A Statistical Summary for 1966. United States Department of Agriculture, Consumer and Marketing Service, February 1967, pages 2~-12.) Department of Health, Education, and Welfare-U.$. Public Health $ervioe In 1913 the U.S. Public Health Service organized a veterinary medical program and in 1947 established the veterinary officers' corps. Members presently occupy key positions in a variety of programs throughout the Service. Veterinarians are today employed by the Service in the fields of milk and food sanitation, labora- tory animal medicine, comparative pathology and physiology, industrial health, epidemiology, infectious diseases, air pollution, radiological health, cancer and cardiovascular and kidney disease research. Food and Drug Administration Veterinarians in the Bureau of Veterinary Medicine of the Food and Drug Administration are concerned with the protection of human health. They develop scientific methods for detecting worthless or harmful drugs and assure that foods, drugs, and cosmetics are wholesome, safe to use, made under sanitary conditions, and truthfully labeled. They determine the safety or danger of addi- tives (such as antibiotIcs and other growth stimulating drugs) in feed consumed by food-producing animals to insure that meat, milk, or eggs are safe for human consumption. During 1967, the Bureau reviewed 1,200 new drug applications. The Bureau also processed 7,700 applications for the use of new drugs in the manu- facture of medicated feeds. Department of Defense Veterinary officers in the Armed Forces work closely with the Medical Corps and other health services wherever prevention of diseases and the promotion of the well being and efficiency of the soldier, sailor and airman is at stake. In addition to food inspection, veterinary officers help in maintaining surveillance over post or base sanitation, and are called upon to assist in controlling epidemic disease outbreaks where knowledge of the cause, source, prevention, and pro- cedu:res for disease eradication is essential. The military veterinarian is also an important member of the epidemiological team. Military veterinarians assigned to the Walter Reed Institute of Research and the Armed Forces Institute of Pathology are directly concerned With the identification, control and eradication of the major animal diseases transmissible to man. In support of these basic objectives, veterinarians are currently engaged in areas such as pathologic examinations, research in nutritional diseases, basic studies in immunopathoiogy, development of new vaccines and improvement of existing ones, studies in the pathogenesis of "standard" and "new" diseases of laboratory animals, and development of better biological systems for viral isola- tion studies. Aero-space and bio-astronautics research programs using experimental animals are conducted by Air Force biomedical teams. These studies on animals encom- pass hyperventilation, anoxia, overpressures, radiation, deceleration, accelera- tion, and related hazards, and stresses of space travel. Data derived f rem these studies are interpreted with a view to man. Some 60 AIr Force veterinary officers with post-doctoral training in medical-scientific disciplines such as pathology, laboratory animal medicine, food technology, raidobiology, physiology and toxicology, serve as essential members of the biomedical research teams. These highly trained veterinary officers provide the Air Force Medical Services with a research capability and a reservoir of knowledge and skills in widely diversified areas. Military veterinarians have made many contributions to the health and comfort of civilians. Perhaps the broadest service of the military veterinarian to the health of the public was the establishment and maintenance of minimum standards of sanitation in many thousands of food producing and processing establishments through4mt the country. Such establishments had to comply with military standards of sanitation in order to qualify for government con- PAGENO="0241" 233 tracts. As a result, quality control and improved sanitary metbo~s were taught to a large segment of the America n food imlustry. There were approximately 2,200 veterinarians in the military service during World War II. 3. 1NSTITT~TIONAL WOEK Teaching Of the 18 colleges of veterinary medicine in the United States 17 are state institutions relying on state funds as their primary source of financial support. The 18 veterinary colleges employ approximately 1,400 veterinarians on their faculties, and in 1967-68 enrolled 4,623 students. Veterinarians are also employed by universities which do not have veterinary colleges, to teach ~tudemts enrolled in agricultural and biological science programs, to conduct health-related re- search involving animals, and to care for university~owned animals. Veterinarians also are being employed in increasing numbers by medical schools in the areas of comparative medicine, pathology, epidemiology, and as laboratory animal specialists. Research In the United States, the total annual losses of livestock and poultry and their products through disease, parasites and insect pests amount to about 2.7 billion dollars (Losses in Agriculture. Agriculture Handbook No. 291, Agricul- tural Research Service, U.S.D.A., August 165). The need to increase the effectiveness of animal disease control is urgent not only because animal diseases are economically wasteful, but also because many of these diseases are transmissible to man. In 1965, it was estimated that veterinarians in the animal health industry (pharmaceutical and biological) alone controlled a segment of industry valued at $600 million annually. Veterinarians bold positions of leadership in approxi- mately 310 different companies operating in the chemical and pharmaceutical industries of the United States. Although many veterinarians engaged in research serve the areas of animal health, veterinarians play a vital role in industrial research and development of drugs and other chemicals consumed by man. The greatest recruiting fervor is in the field of toxicology. Veterinary toxicologists are primarily concernd with developing knowledge of the toxic potential of chemical substances, and their fate in the environment, in order to prevent poisoning. Veterinarians serve as directors of toxicology research for many of the major pharmaceutical companies developing drugs for human use. Veterinarians have pioneered in toxicologic research concerning space; en- vironmental hazards; pesticides; toxicants in food, air, and water pollution; and chemical warfare agents. Veterinarians' activities include research in the discovery and development of drugs and other chemicals to be used as food additives in the treatment of human and animal diseases. After a new cehmical is syntbeized, the veterinar- ian is responsible for determining the potential value of the chemical in treatment of disease. Before the chemical can be released for human trial, he must determine, through a long series of testing in many species of animals whether or not the chemical is toxic. Veterinarians in the biologics industry are engaged in discovery and develop- ment of new vaccines, serums, and other biological products of animal origins. Veterinarians have the responsibUity not only for determining the value of potential products, but also for assuring both the safety and potency of the products. Federal veterinarians supervise activities in 58 companies licensed to produce biologics for disease prevention and as treatment. 4. COMPAEATIVE MEDICINE Since the time of Pasteur, veterinary medical scientists have made significant contributions to medical science. Smith and Kilbourne's recognition that an artbropod could serve as a vector of an infectious disease, Texas fever, was a highly important medical discovery. Jenner's use of cowpox virus to immunize against smallpox, and Ramon's success in producing an effective iiiununizing agent against tetanus in horses were medical milestones. Dr. Karl F. Meyer~s work on botulism was hailed by ilWdUifle and the ctuining industry a~ a major accomplishment against this highly fatal food-bormie disease. Commonly used fracture splints (Stader) amid hip prostheses ( Gorman), as well as spinal an- 9i~-540-6S-----16 PAGENO="0242" 234 esthesia were first clinically (Benesch) developed by veterinarians in the treat- ment of animals. Today's widespread use of oral polio vaccines follows a 15 year period during which oral polio vaccine proved effective in animals. Hundreds of similar examples of the contributions of veterinary medicine to medical science could be listed. Current studies in comparative cardiology, cancer, connec- tive tissue diseases, metabolism, hematology, muscle disorders and infectious diseases undoubtedly will yield similar results. Veterinary medicine occupies a particularly advantageous position among the sciences in its opportunity to make contributions to medical science. Nearly every member of the veterinary medical profession, whether he is engaged in private practice, regulatory veterinary medicine, or in research, constantly en- counters disease conditions in animals an understanding of which may contribute to medical science and the welfare of mankind. The profession has an obligation to exploit opportunities to study animal diseases to the extent of its resources. Many of the most prevalent and serious human diseases have counterparts in animals. Vital experimental procedures which rule out the use of man may be undertaken jointly by physicians and veterinarians on animals serving as ex- perimental models. In this context, several animal diseases are receiving increased attention. Leukemias and Hodgkins type tumors occur frequently iii domestic animals; they are similar in most respects to their human counterparts. Other forms of cancer common in animals, particularly dogs, provide excellent opportunities for investigating these diseases with a view on man. There are respiratory diseases in animals which at present are largely un- explored, and which present distinct similarities to several important human diseases. Pulmonary emphysema of horses and cattle, and certain viral pneumonias of cattle, sheep, and dogs may be cited as examples. Degenerative nervous disorders similar to multiple sclerosis in man are repre- sented in several animal species. There are several collagen or immunogenic diseases, particularly in dogs, horses, mink and mice, which provide counterparts to such human ailments as rheumatoid arthritis, collegen associated kidney disease, lupus, and certain forms of anemia. Some of the animal diseases known to be caused by viruses may provide answers to certain human problems. Cardiovascular diseases, par- ticularly of older dogs, are common examples of other experimental models. 1\f any more examples may be cited.: The broad training offered in veterinary medicine, encompassing several animal species, provides an ideal background for the pursuit of such studies. Full utilization of the unique capabilities of veterinarians may well shorten the search for answers to many enigmatic hu- man diseases. Many medical schools and hospitals engage veterinarians as full time faculty members in teaching and research. This permits emphasis on comparative studies to medical students and researchers and promotes collaborative efforts. A pro- gram of this nature is under way at the Johns Hopkins School of Medicine. Five veterinarians on the medical faculty are actively engaged in collaborative re- search in comparative medicine. More positions are open in other institutions but cannot be filled because of the dearth of trained veterinarians. 5. LABORATORY ANXMAL MISDJOINE The expanding establishment of laboratory animal colonies in medical and dental schools, large hospitals, drug companies, feed manufacturing firms and other institutions has created an urgent need for veterinarians trained in labora- tory animal medicine, which is closely allied to comparative medicine. Healthy, genetically defined laboratory animals are essential to medical research. What was generally acceptable 20 years ago as a laboratory mouse or rat would have little value today. As research becomes more sophisticated the demand for pedi- greed rodents, either with known microbial flora or completely germ free, is rising. Laboratory animals are now used extensively in medical research. Studies on these animals have led to improvements in the health of both human beings and animals. An understanding of naturally occurrin.g ~iseas'es of laboratory animals is necessar~T for the interpretation of resuits of experimentation. The National Institutes of Health now have a section whose veterinarians śIevote their efforts to the study of such diseases. There has been a co~finuing im- provement of the, health care and huiuane staaclards for the use of experimental animals. PAGENO="0243" 235 Veterinarians are ideally qualified to select or control the reproduction of healthy animals for medical research, to insure their well being and humane treatment during the holding period prior to copd.ucting experiments, and to provide proper post-experimental care. As a result of the passage in 1966 of the Laboratory Animal Welfare Act- which specified "adequate veterinary care" in the faculties covered by the bill- new and heavy demands are being placed on veterinary medicine to fill positions for laboratory animal specialists. 6. ZOONOSES Zoonoses are infectious diseases of animals which are transmissible to man. There are over 100 known diseases, according to the World Health Organization, which people can acquire from animals. In the field of zoonoses the veterinarian plays a key role on the epidemiologic team. Rabies, associated with the bites of rabies ipfected animals, has been known and feared since antiquity. Veterinayi~ns haye played a ma~or role ,ir~ re- ducing the incidence of rabies in domestic animals, with corresponding re- duction in human rabies. Ip fact, 1907 marks the first year in our history with no recorded deaths from rabies. However, an ominous development in recent years has been the increasing recognition of rabies in wild animals, notably in bats. More than 30,000 persons each year are bitten by suspected rabid animals and are required to take treatment. It will; take a concerted effort to insure public protection against this new threat. Horses and man fall common victims to viral sleeping sickness (encephalomye- litis). This mosquito-transmitted infection is carried by apparently healthy wild animals and birds, and therefore is ~Iifficult to eradicate. Man. and horses ac- quire the disease as a result of being bitten by infected mosquitos, but do not spread the disease themselves. A veterinarian, Dr. Karl F. Meyer, of the Uni- versity of California, was the first to recognize virus encephalitis in American horses (1930), and the first to warn of the danger of this disease to man. A veterinarian, Brigadier General Raymond A. icelser, of the U.S. Army Veteri- nary Corps, was the first to show that encephalitis virus is transmitted by mos- quito bites (1933). Salmonellosis, influenza, infectious hepatitis, staphylococcal infections, and internal parasitisms caused by the tapeworms of cattle and swine, are some of the diseases also capable of being transmitted by or from animals to man. Basic to the most effective progress toward suppressing the zoonoses are efforts such as those mounted in 1960 with the establishment of the Illinois Cen- ter for Zoonose Research, a component of the University's College of Veterinary Medicine. Unique is the multidisciplinary team approach of the Center toward ascertaining the factors that bear on emergency and. rece~slon of, zoonotic di- seases. The recognition that no one profession or scientific discipline, medical or other, has the total competence to solve complex problems of even a few zoonoses, a staff composed of veterinarians, pby~icians, anthropologists, ecologists, cli- matologists, demographers, microbiologists, zoologists and other scientists has initiated already fruitful and promising programs. The World Health. Organization's Advisory Committee has pointed Out that one should not overlook the dynamic and changing pattern of microorganisms, heir adaptation to the new animal hosts, and their potential and actual transfer to human beings as pathogenic organisms. The COmmittee stated, "The emer- gence of new zoonoses or the uncovering of unsuspected human-animal relation- ships in communicable diseases are therefore to be expected." Recent emphasis ha~ been placed on the transmission of disease from manY to animal. In the pa~t it was. considered logical to assume that the animal could act as a reservoir of human disease. The reverse possibi1it~, while equally logical, had only recently been given any serious thought. Since it is n~w rare for man to acquire tuber~ulçsis from cattle, regulatory officials are becoming more aci~tely aware Of the p~oblehi of cattle~ contracting the disease from man. The problem. is not only reported in the tjniteci States, but also in other countries, inciuding the N'etherlan~s, Great~ Britain and Israel. 7, PIlE ~ORE1~N DISEASE THREAT , The concept of. ~`preventi~n" has enabled. veterinarians to protect this country from the importation of diseases that could adversely a1'f~et our food supply, economy and health. PAGENO="0244" 236 Over the past few years many animal diseases and parasites, once relatively confined to small areas, have penetrated the local defensive barriers of other countries. South African types of foot and mouth disease virus (SAT-FMD), African horse sickness and African swine fevel have spread from endemic areas with disastrous results among the domestic animal populations. SAT-FMD was first reported outside of Africa in 1962-spreading to the Middle and Near East and subsequently into Iraq, Israel, Jordan and Syria, Turkey and Iran. Asian Type I FMD was reported in Israel and West Pakistan in 1964. It has since been reported in Russia with serious loss of livestock and now threatens the farm animals of Eastern Europe. The seriousness of this outbreak is emphasized by the lack of an effective protective vaccine for control purposes. African horse sickness spread to the Near and Middle East, subsequently to India, with the result that there has been a devastating reduction in animal transport and power in those countries depending solely on the equine species for such services. African swine fever spread into Portugal, Spain, and France, killing millions of swine. All of these could be brought to the United States to challenge all of our defenses against Importation of disease. Lumpy skin disease of cattle, Rift Valley fever (an important viral disease of sheep, cattle and man) and East Coast fever (a highly fatal protozoan disease of cattle) are being reported in areas far beyond those of their origin. Great Britain has just experienced the most severe outbreak of foot-and-mouth disease in its history. According to the Animal Health Division of U.S.D.A., over 2,300 herds (415,800 animals) died or were slaughtered from the beginning of the outbreak to February 1968 in a campaign to eradicate this devastating diseane. Diseases and pests continue to travel With man. animals and plants. In our modern world, international commerce in livestock and food products is ever increasing, providing many new opportunities for rapid spread of disease. Inter- national trade and travel continue to increase b~tween areas that were formerly remote and not readily accessible. Man can and does, innocently or Illicitly, carry with him items of food and plants that are hosts to disease organisms. There has been a steady and rapid increase of this kind of traffic to the United States. Through inspection of imported animals, poultry, and all aminal by-products, veterinarians prevent entry of foreign diseases into the United States. Of the 981,000 animals and 2,950,829 birds presented for import during 19q7, 43,961 animals and 9,365 birds were refused entry because they were carrying diseases contagious to man and animals. During the same fiscal year, veterinarians in- spected and certified over 69.000 animals for export to foreign countries. Addi- tionally, more than 15.6 million pounds of meat and meat food products from foreign countries were condemned or refused entry in 1967 (figures supplied by U.S.D.A., Animal Health Division). 8. RADIOLOGICAL HEALTH Nuclear energy and its byproducts affect the biosphere in such a manner that their study necessitates a multidisciplinary approach. Because environmental medicine is the major theme of veterinary education, and because the impact of the environment is studied for many species of mammals and birds, veterinary medicine is an important discipline in radiological health. The Public Health Service has recognized the important contributions vet- erinary medicine can make to its various program activities, particularly in the area of biomedical research. The Service's Division of Radiological Health eiuployes fourteen veterinarians. In most instances, these veterinarians have had specialized post-graduate training in radiobiology, radiological health, or associ- ated specialties such as biophysics, radiation pathology, biochemistry, and similar fields Further recognition of the importance of veterinary medicine is reflected in the radiological health training grant program sponsored by the Radiological Health Division; one of the most successful of these programs has been conducteff since 1961 by the graduate school of the Veterinary Medical College of Colorado State University. The research projects include studies of the developmental and aging effects of radiation exposure on large colonies of animals. The Atomic Energy Commission also utilizes veterinarians in planning and conducting research. Objects of their studies include the effects of radioactive PAGENO="0245" 237 isotopes on the biological systems of animals, and the movement of radioactive materials in food. Veterinarians on the staff of the U.S. Department of Agriculture conduct similar studies dealing, for example, with the effects of radioactive fallout on agricultural production. These studies include the development of remedial meas- ures that can alter the movements of radloisotopes in the food chain, including food animals, and reduce or eliminate the consumer's intake of radioactive materials. 9. PROTECTION OF ENVIRONMENT One of the major concerns of health authorities today is the progressive con- tamination of our environment. Air and water pollution and food contamination concern the health community as never before. Veterinarians are aware of the responsibility they have in assuring the safe use of pesticides and food additives. The veterinary profession has contributed to research undertaken to study the movement of environmental contaminants through the food chain to man. More- over, veterinarians are in a position to influence the safe use of animal feed addi- tives and pesticides by their clients and others. By example, in their daily contacts with the owners of animals, and through their employment in govern- mental and regulatory agencies, veterinarians are in the forefront of the battle against environmental contamination. STATEMENT OF ALVIN A. PRICE, D.V.M., DEAN, COLLEGE OF VETERINARY MEDICINE, TEXAS A. & M. UNIVERSITY An important and significant part of the broad area of public health is the environment in which man lives, works, and plays. It is a scientific truth that health and disease are related to the conditions of the habitat in which a living individual resides. When the environment is polluted, contaminated, or otherwise not compatible with the physiological well being of the creatures living within it, the health of Its living inhabitants will deteriorate. Therefore, public health is more than medicine. Public health depends upon the continuing surveillance and active programs of many disciplines, one of which is veterinary medicine. The contributions of veterinary medicine to public health have been docu- mented. The eighteen colleges of veterinary medicine in the United States are a national resource in that by far the majority of the veterinarians of the United States who are actively engaged in the practice of the profession were educated in those eighteen colleges of veterinary medicine. Through i0~5, the currently existing colleges of veterinary medicine had graduated over 25,000 veterinarians, more than the total number engaged in the profession in the same year. Iii addition to the educating of veterinarians, colleges of veterinary medicine are central to research in the area of animal health and disease. Human health, from the consumption of animal product foods to pets in the family household to the condition of wildlife in areas of recreation, is related to animal health. Biomedical research, in its broad application, is dependent upon the use of animals. Without veterinary medical care and study, these animals would not be the effective laboratory tools they are today and medical progress would be severely curtailed. Colleges of veterinary medicine supply the trained manpower to maintain protein food producing animals in a high stato of health and efficiency for the producer and consumer. America is the safest place in the world to invest in and rear livestock because it has a resource of trained v mci I cal manpower. Only 10 nations of the world have agricultural surpluses and ~ decreasing. Those 10 nations contain oni~ 15~4- of the world population. By the l~)S~Ws. those `~1FJ)1uses may not lie ava'laI)le to help feed the other ~5% (ii thC warP! population. .\lcait 40% of the w ovid's livestock is in the davelopccl countries and these conui tries provide S0~ of the world's a'Htnai protein footis. If productivity in tio Ha derdcveio~ (ed count ries Whi(li have (W)'~ Of thP WOrl(I'S I iV&StO(k could iC 1 iought to the efficwney attained 1 Tu the (level oped countries, there would lie a(ie(lnate protei U foods for sill. In the underdeveloped countries, 60% of the people suffer from malnutrition. Three million children die each year from causes related to or aggravated by PAGENO="0246" 238 malnutrition. Adequate animal protein foods are desperately needed to reduce the tide of starvation. Improved animal health can go a long way toward achieving such a goal. Colleges of veterinary medicine throughout the United States lack the necessary facilities and operation capital with which to train the number of veterinarians needed in this country. Salary scales for faculty and staff are less than those required to attract and maintain the personnel with the qualifica- tions essential to the teaching and research programs. Especially critical in some of the colleges is the inability to employ and retain qualified subprofessional personnel. The 18 colleges of veterinary medicine are mostly state supported and the 17 states in which colleges are located cannot carry the full load for the entire nation. More states should build and finance colleges of veterinary medicine. This is not likely to happen without Federal assistance. Basic improvement grants to currently existing colleges of veterinary medicine are sorely needed to make improvethents in weaker areas of the total college programs. Strong areas can achieve support more easily than weaker ones. Consequently, the strong grow stronger and the weak grow weaker. This does not achieve the total goal of efficiency and effectiveness toward which all colleges wish to move. Two relatively new programs have become the obligations of colleges of veterinary medicine and for which the colleges are not equipped, staffed, and adequately supported. These programs are: (1) the training of auxiliary per- sonnel, and (2) continuing education. Both of these programs are extremely important in the total veterinary medical manpower pooi and in the updating of former graduates. Because these programs are not adequately supported and because the colleges cannot default in these great needs, these programs are eroding the already inadequate resources of every veterinary medical college in *the country. Formula based and continuipg Federal assistance to all colleges of veterinary medicine is desperately needed for achieving the laudable goals of these two programs. Congress is urged to lend a sympathetic ear ~nd a helping hand in the crisis which is upon the veterinary medical colleges of this groat nation. By so doing, veterinary medicine can continue to play the vastly important role in helping to make America stronger and the people of the world a better fed and healthier population that some day the people of all nat~ioiis may live more comfortably in a more tranquil environrqent and in peace one with the other. STATEMENT OF Pu. M. R. CLARKSON, EXECUTIVE SECRETARY, AMERICAN VETERINARY MEDICAL ASSOCIATION To talk about the future of veterinary medical education means, of course, to talk about the future of veterinary medicine. Learned discussions about curriculum, teaching aids, student selection, and faculty assignment are always fascinating, but they will remain *largbly irrelevant unless their usefulness is constantly measured against the question: How will tomorrow's veterinarian fit into tomorrow's society? That society is in the making today, and the changes we witness are nothing but the first manifestations of the new socio-economic environment for which we will have to train our students. Veterinary medical practice has already been profoundly affected by these changes; veterinary medical education, on the other hand, is just beginning to reorient itself structurally and functionally to the incipient realities of the 21st century. The principal changes which, in my opinion, will most significantly Influence veterinary medical education are now occurring in the fields of agricultural economics, in housing and urban development, and in biomedical research. As far as agriculture is concerned, the two most important developments to affect veterinfiry medicine's role in this complex and vital sector of our economy are these: First, a marked trend toward huge livestOck units managed with all the efficiency and ramifications of the most modern, diversified business enterprise. Second, the urgent task to provide foods of animal origin for a shairply rising population at home, and to satisfy, whether by direct assistance programs or through the export `of knowledge, and protein hunger of the rapidly expanding populations of large underdeveloped areas of the world. The increasing density of herds, coupled with advanced technology in live- stock production and management, has already led to marked changes in the PAGENO="0247" 239 nature of large animal practice. If my interpretation of `these changes is correct, a thorough grounding in the principles of epidemiology, refined diagnostic skills, a keen understanding of the art of working with others in a mti1ti~specialty group practice, and a sure footing in agricultural economics have become indispensable tools in training today's veterinary student to meet tomorrow's agricultural world. As `an illustration, `the current foot-and~mouth disease epizootic in England may impress us `today as an isolated, though tragic occurrence. In the years ahead, epizootics of many dangerous animal diseases could be ever- present threats unless the veterinary medical profession is fully prepared to meet them through both long-range programs of prevention, and immediate control measures. The need to feed our own growing populace and to help feed others will make unprecedented demands on veterinary medicine in terms of manpower, training, and skills. In an article appearing in a recent issue of the Journal of the Ameri- can Veterinary Medical Association, Dr. J. C. Thompson, Jr., of `the Department of Physical Biology at cornell University, reported that "as the world attempts to solve its food problems, the need for veterinarians will increase tremendously. Without control of diseases and improved survivability thete will be little im- provement in food productivity from animals." To train veterinarians in sufficient numbers to meet world-wide demands for their services is, of course, essential. But something else seems to me sig- nificant. The world food situation, growing more serious each year, undoubtedly will give rise within the profession to the need for global exchanges of knowl- edge, skills, and programs of education, and thereby add to the profession a `new World-wide dimension. Its impact on veterinary medicine, already acutely felt by medicine, dentistry, and other health professions, could be considerable. In turning now to urbanization as the second ~leld of consequence to veterin- ary medical education, I am addressing myself chiefly, although by no means exclusively, to the small animal practitioner. Here, again, we come across the words "density" and "exchange of ideas" as key words ~characterizing the changes which importantly influence both practice and education. Density, because population growth, crowded living conditions in our cities, and the increasing popularity of companion animals all combine to emphasize the inter- dependence of animal health and human health. One inm~ediate effect of these factors will be that they will bring into sharp focus the public health respon- sibilities of the small animal practitioner, an aspect of small animal medicine which has not found in the veterinary medical curriculum the consideration it requires. Exchange of ideas, because a sophisticated, prosperous, mundane, and acutely health conséiohs pet owner will expect for his animal the same kind of superior medical service he takes for granted when it comes to his own health require- ments. Moreover, as the ownership of a pet becomes for many a source of emotional stability in a society in which the individual is submerged, we must increasingly turn our attention to the fears and anxieties of the pet owner as well as to the maladies and afflictions of the pet. All of these `trends combine `to create new points of contact and reference between small animal medicine and other professional disciplines, and contain obvious implications for veter- inary medical education. The persistent urging by many of our best educators for a surer footing of the veterinary student in the liberal arts and humanities will be vindicated in the clinics of tomorrow. With these remarks I am already touching on yet another development whose impact on veterinary medicine has been, and will continue to be, enormous: specialization. Unquestionably a boon to the profession, it also causes many of the headaches that plague veterinary medical administrators and educators alike: How can we preserve unity of organization while encouraging diversity of scientific interest and competence? How can we bring the new research find- ings-doubling, as some say, every five to ten years-to those who, although often still young in years, have become professionally obsolete? How should we design the pre-veterinary curriculum, the professional courseS, and post-graduate train- ing to achieve, without becoming superficial, a maximum exposure of our students to the scene of contemporary biology and medicine? Top advances in the life sciences are the feat of Dr. Arthur Kornberg of stanford University and Dr. Mehrad Gouliam of the University of Chicago in synthesizing a virus-like substance and thereby creating a primitive form of life; and the human~to-human heart transplants carried out in Cape Town, South Africa, and in California. I am mentioning these two events because they PAGENO="0248" 240 illustrate the breathtaking pace at which we are movipg in the domain of bio- medicine. Surely, achievements such as these are of intense interest to veter- inarians and, therefore, should be in the back of our minds when we talk about the development of tomorrow's veterinarian. You might say, "But we still have parasites in pets, and scours in calves." We do, and we probably will for a long time to come. However, it is against this background of an age literally reaching for the stars that we must measure our plans and efforts in veterinary medical education. In the light of the changes briefly summarized it seems, for example, that the requirements for pre-veter- mary education should be questioned. The current 2-year pre-professional edu- cation may no longer be adequate to give the student an understanding of society, to teach him to think, and to offer him those courses which are prerequisite to his professional courses. Should we, then, restrict the selection of veterinary students to graduates of baccalaureate programs of various kinds? Since veter- inary students today frequently have 4 years of pro-veterinary training, this step, which finds approval among many educators, should not be difficult to accomplish. The purpose of the professional curriculum is to provide the foundation upon which graduates develop the many competencies necessary for the profession to fulfill its role of service to society. The student should be taught the principles of biology and medicine, and acquire at least a basic understanding of the art and science of clinical veterinary medicine. But, the professional course of studies, no matter how sophisticated or diversified, today points beyond itself to a lifetime of learning. Postdoctoral education, graduate education in the basic sciences, internships and preceptor- ships and, perhaps most important of all, programs that bring the latest findings of research and experience to the practitioners, are indispensable parts of the total programming of veterinary medical education. These thoughts about the future of veterinary medical education may not be uppermost on your minds as you are about to begin construction of a new college of veterinary medicine on this campus. You might have found it more helpful-and probably more entertaining-had I titled my talk "Seven Mistakes Most Commonly Made By Planners and Builders of Colleges of Veterinary Medi- cine" or, "How I Built A 15 Million Dollar College With Only 19 Million Dollars." For a while I indeed intended to address my remarks to the practical issues and problems you are facing in building your school. I could have talked, for example, about the wisdom of allocating sufficient construction funds; the need to recruit an adequate number of qualified faculty members; and about such technical and mechanical things as an audio-visual center; an adequate library; service laboratories; integrated study courses; closed-circuit television; the vital need for adequate clinical materials, and even the need to plan for expansion before you have laid the cornerstone to your first building. Yet I felt, for one thing, that there are people available to you who, because of their experience and training, are much more qualified than I to speak to you about these things. Moreover, I was certain that there were very few things, if any, you hadn't already thoroughly explored at this stage of your development program. Lastly, I didn't wish to usurp the responsibilities of the AVMA's Council on Education which, in its "Essentials of An Acceptable Veterinary Medical School," explicitly states that it will assist schools to meet the require- ments for accreditation, and that it will consider evaluation of a newly estab- lished school at any stage of its development. There could be no more propitious time for building a new college of veterinary medicine. The urgency of such an undertaking is amply illustrated by three recent legislative measures. The Veterinary Medical Education Act of 1966 marks the first significant national attempt to balance the supply of veterinarians against the nation's steeply rising demands for their services. It has created a favorable climate for your goals and will provide some of the means essential for their accomplishment. Following on the heels of this piece of legislation, the Laboratory Animal Welfare Act and the Wholeosme Meat Act of 1967 have focused national attention on two vital areas, medical research and consumer health protection, in which success or failure depends crucially on the availability of well-trained veterinary medical personnel. Yet for my part, I feel that the grand design, the vision, if you will, of this profession at the age in which it operates will ultimately determine the success or failure of your new college in graduating the type of veterinarian we need and want. More than 200 years have passed since Claude Bourgelat, the French PAGENO="0249" 241 lawyer and riding master, founded the world's first school specializing in veteri- nary science. The buildings of the small Ecole veterinaire at Lyons may have been, according to our modern standards, primitive, and the textbooks he wrote for his students, and which they had to learn by heart, may be as obsolete today as the methods Of diagnosis and treatment he practiced. Yet his under- standing of the importance of scientific research, which finally triumphed over the deeply entrenched empirical and often superstitious procedures of the past, and his intuitive grasp of the moral nature of our profession are of timeless validity. There is hi the code of ethics he wrote for his students a passage which expresses well what I believe must be the final justification of efforts in train~ ing a new generation of veterinarians. "Ever imbued with the principles of honor imparted to them," he wrote, "the students will never depart from them. They will distinguish between the poor and the rich. They will never set too high a price on the talents which they owe only to the benevolence and the generosity of their country. Finally, they will prove by their conduct that they are all equally convinced that wealth exists less in what one possesses than in the good one can do with it." Thank you. STATEMENT OF DR. JOHN S. MCKIEEEN, PRoFEssoR, DEPARTMENT OF ANATOMY, COLLEGE OF VETERINARY MEDICINE, IOWA STATE UNIVERSITY, AMES, IOWA VETERINARY EDUCATION Veterinary educators are faced with the critical decision of when and how we should teach the increasing amount of pertinent knowledge demanded by our profession. Expansion In clinical areas has condensed the time devoted in the basic areas. Can we relieve some pressures on the professional curriculum through the preveterinary, graduate, or post-graduate programs? Is our objec- tive to graduate better qualified veterinarians in all areas or should we special- ize? Are we still stereotyped by the past? Historical trends in our profession have influenced some of our present answers to these questions. The first veterinary school established in Lyons, France, in 1761, emphasized one animal, the horse, and particularly its anatomy. Similar emphasis was noted at the first state supported College of Veterinary Medicine in the United States established in 1879, at the institution now designated Iowa State University. Between 1852 and 1948, some thirty-four, mostly private veteri- nary schools were initiated and closed in the United States and Canada. Many occupied livery stables where the emphasis was on learning by doing. Matricula- tion requirements usually included an elementary or grade school diploma. The course typically consisted of two sessions of four months each. The evolving curriettlurn In the first quarter of the twentieth century, three-year programs were gen- erally required in college veterinary curricula. Dc-emphasis of the horse and cooperation in more complex studies of all domestic animals and factors related to disease commenced. The public image of the veterinarian as a horse doctor persisted resulting in the lack of financial appropriations for the dying profession. Progress was stymied in all areas of veterinary education. It was emphasized that research and education must be depended upon to keep the veterinary profession from lagging behind its sister profession. I~nowledge had increased faster than it was possible to change curricula to meet the newer needs of graduates. During the 1930's, few students could afford college. ~` ~s, great strides were u ~`~`-~ )V~ ~-~" a to~~~" fi~ uden~ vet V ~cor PAGENO="0250" 242 apparently is occurring naturally because of the increasing competition for ad- mission into a relatively static profession numerically. Since 1949, all veterinary schools in the United States have required two years of pre-veterinary training. In 1965, 860 of 1,388 first-year veterinary students in the United States had completed more than the required two years of pre-veterinary training. This period has been generally regarded as a time when students broaden their educa- tion. It has become, however, a period with little flexibility, with elective courses quite limited. Required courses in mathematics, chemistry, physics, and English need to be, but are in all too few Instances, adequately covered in high school. This allows more time for more broadening electives in the pre-veterinary curriculum. Block of time are continually shifting within the framework of the four-year irofessional curriculum. The efficiency of the traditional four-year curriculum has been challenged. The trimeSter program now in effect since 1963 at the Texas A & M College of Veterinary Medicine provides additional student contact hours and reduces the total investment by students in time and money. Students gradu- ate after nile continuous terms or three years under this system. The Michigan State program includes eleven quarters of eleven weeks each. A three-year pro- gram designed for the Iowa State Veterinary College has not yet been instituted. Various methods have been employed to ensure adequate coverage of basic material and still allow clinical experience before graduation. None has been successful in producing veterinarians proficient in all phases of veterinary medi- cine upon graduation. Instead, hopefully, we have provided each student with basic information upon which he can build his proficiency by further study and experience. As our profession matures, the now heterogeneously emphasized facets of the curricula characterizing each veterinary school should mold in:to a more homogenous whole. Perhaps then we can eliminate national and state board examinations. The present author agrees with Armistead and Glarkson that specialization in veterinary practice is not only inevitable, but is desirable and is a symptom of growth. Programs designed for further experience and specializastion in human medh~ine are in existence in veterinary medicine. These include preceptorships, post-graduate training, and graduate education. Preceptorships or precepteeships Involve undergraduate third and fourth year veterinary students who are sent singly or in pairs for variable periods of time with a practicing veterinarian. The last preceptorship program in the dental profession will be dropped this year and only 20 of th~ 86 medical schools had pteceptorships in 1962. Some feel that this program at the Auburn School of Veterinary Medicine is very beneficial. Three months of the senior ~rear is spent with selected practi- tioners under this program. The present author finds conflict between the need for more time to present material and the premature entrance into practice. Postgraduate training by symposiums, seminars, workshops, and short courses offered by universities, clinics, and veterinary organizations offers an excellent though limited means of reaching practitioners. It serves primarily as a re- fresher program or as a means for informing practitioners of new developments or techniques. Not enough practitioners participate unfortunately. Graduate programs include interniships, residencies, and degree programs. Internships immediately follow graduation from veterinary school and consist of one or two years of supervised practice in medicine with continued instruction in the science and art of medicine. The intern learns by doing and by association with experienced clinicians. Residencies include education and training following the internship which provides preparation for the practice of a specialty. Three or more years are generally served. Graduate programs leading to the degrees Master of Science or Doctor of Philosophy are generally preserved for academic or industrial futures rather than to improve ones practice skills and knowledge. The present author agrees with Pritchard that graduate programs are the weakest link in the chain of veterinary medical education today. Compulsory graduate programs are in existence in many foreign countries including India, Germany, Holland, and Scotland. Some indicate that internships should be the resl)onsibility of the licensing authorities in the state where the applicant seeks to practice. Graduate programs at universities generally have the advantage of a better staff and facilities; however, instituting internships at universities on a large scale would require the allocation of further funds which probably would not gain priority in the legislatures. Presently, Societies for the Prevention of Cruelty to animals, several veterinary schools, and scattered group practices PAGENO="0251" 243 provide a limited number of internships in small animal medicine. Far more applicants are turned away than acce~ted, however. This author would encourage an expansion of the former and latter programs to better meet the demands in this area. Far fewer interusbips are offered in large animal medicine. This author believes this will change within the next ten years, as the advantages of group practices are more fully appreciated. Specialization within these clinics will ensue and further demands will be made on universities for residency programs. Pres- ently some universities and S.P.C.A. organizations employ residency programs. SUMMARY The veterinary curriculum bias changed over the past century in the United States. Eras which concentrated on the health of one animal or group of animals have been expanded to include not only the health of all our domestic animal's, but emphasis on public health, laboratory animals, and various research projects. rfbe problems of public image and lack o'f financial support are still not entirely solved. We have evolved from the status of technician to more deductive and inductive veterinarians. To continbe our self improvement specialization seems inevitable. This cannot replace the basic core of material obtained in the profes- sional curriculum, but must be built upon this framework. Greater responsibilities must also be assumed by the high schools, thins ullo'wing better utilization of the prime time in `the p'r'e-veteninary curriculum. We are still site'r'eoty,ped after the past, but with innovation and insight we can convert the influences of the past into assets in the fuiture. STATEMENT OF NIcHoLAs H. BOOTH, DEaN, COLLEGE OF VETERINARY MRDICINE AND BIoMEDICAL SCIENCES, COLORADO STATE UNIvERsITY, FORT CoLLINs, CoLO Veterinary medicine is now contributing significantly to the total biomedical effort of the nation in many health disciplines, including public health. Un- equivocally, the prevention and `control of animal diseases are not only im- portant from a public health standpoint but are necessary, if the animal protein and nutritional needs of an expanding human populations are met. Accordingly to Dr. M. R. Clarkson, Executive Secretary of the American Vet- erinary Medical Association, "The greatest single obstacle to meeting the world's requirements for food products of animal origin is the crippling and unnecessary drain incessantly inflicted upon the world's fo'od resources by major infection's and parasitic livestock diseases". In biomedical research, veterinary medicine is serving importantly in ad- vancing knowledge which is basic to the understanding of animal and human disease processes. The importance of using animal models in studying genetic, metabolic and pathologic conditions similar to those seen in man is an excellent et~ample of veterinary medicine's contribution to public health. Presently, col- leges of veterinary medicine in the United States provide intensive instruction in several courses relating to public health. For example, courses on dairy and meat products inspection, epizootiology, and zoonoses are offered to veterinary medical students. Consequently, the veterinarian is trained to serve side by side with other members of the health professions within the public health diciplines. Colleges of veterinary medicine `are important `national resources which de- serve considerable financial support from state, federal, `and private sources. If superior talent is attracted into veterinary public health, fellowship and assistantship support is critically needed at the postgraduate level concomitant with improved support at the undergraduate level. Furthermore, sufficient financial resources are needed in the recruitment of topnotch biomedical in- structors and scientists. Although financial support renovation and construction of facilities has been difficult to procure for college's of veterinary m'edicine, passage of PL 89-709 by Congress in 1966 is expected to assist immeasurably in replacing obsolescent equipment and facilities' as well as to `assist in `the ox- pansion `of present facilities in many of the veterinary medical colleges. Un- questionably, p'ast and current financial support of colleges of veterinary medicine from state and federal sources has been considerably below `the level that is necessary to maintain high caliber instructional and research program's. Although the Colorado State Legislature has been sympathetic to the annual financial reques'ts of the College of Veterinary Medicine and Biomedical Sciences PAGENO="0252" 244 at Colorado State University, only a small fraction of the requests were granted because public funds were inadequate. The annual loss of food-producing animals from infectious and parasitic diseases in the United States is approximately three billion dollars. Pbis figure exceeded all the money appropriated, i.e., 2,618.1 million ~lollars, for the U.S. Public Health Service and also exceeded the 1,123.2 million dollars appropri- ated to the National Institutes of Health in fiscal year 1067. The total budgets spent on veterinary medical education and research in 19G7 are estimated at less than 30 million dollars for the 18 veterinary medical colleges and repre- sent less than one percent of the annual sum of money lost from animal diseases. It is indeed unfortunate that such a small amount of money is being invested for veterinary medical education and research in the United States. Improve- ment in human health resulting from control of animal diseases will more than justify all public expenditures for veterinary medical education, research, and all animal disease control programs ever conducted in. the United States. Since it is estimated that twice the number of veterinarians over the present number, i.e., 26,000 is needed by 1980 in North America, greater financial sup- port will be required to overcome the severe manpower shortage. Expansion of present facilities and the development of new colleges of veterinary medicine cannot possibly occur rapidly enough by this time to double the number of veterinarians. Despite this, every effort must be made at the state and federal levels to increase the output of well trained and competent veterinarians to meet the public health and animal health needs of the nation. In moving toward this objective, a realistic balance between education and research must be at- tempted. Veterinary medical education in our colleges could be greatly improved under a policy that provides comparable support for all its functions, whether It be teaching or research. Present policies have made the support of the veterinary medical faculty almost entirely dependent upon publication production and research accomplishments. The unilateral support of one func- tion over the other develops a lopsided and uncompromising situation in our teaching and research programs. Since it is necessary to be practical and pragmatic in achieving a so-called academic balance of functions, it is urged that support be granted which does not distinguish between the instructional and research activities of veterinary medical colleges. STATEMENT or W. W. ARMI5TEAD, DEAN, CoI~LEGE or VETErINARY MEDICINE, MICHIGAN STATE UNIVERSITY It is sadly paradoxical that the prospects for adequate future support of veterinary education from state sources should dim at the very time when veterinary medicine's contributions to human health and welfare are expanding at an unprecedented rate. Since World War II, the veterinary colleges have prospered In an environ- ment of mushrooming university growth. State legislatures, which habitually appropriate funds on an enrollment basis, have supported the universities well during this period of postwar expansion. In turn, veterinary colleges have been well treated by their parent universities, even though veterinary enrollments have grown much more slowly than has enrollment of universities at large. Nearly all American veterinary colleges are located at large public universities where most of the college enrollment growth has been absorbed. The growing tendency of these universities to limit enrollment, plus the proliferation of two- year colleges, now are producing a leveling-off of enrollments on most of the campuses where veterinary colleges are situated. Consequently, there will be less new money available to the universities and to the veterinary college than they have become accustomed to during the past 20 years. The veterinary colleges therefore must turn to sources other than the state legislatures for financial support to improve their educational and research programs and facilities. Improvement must include several features: 1. Curriculum revision to modernize the education of veterinarians for many kinds of activities unthought of when present curriculums were designed. 2. Increased and improved reserach, including more basic research for the bene- fit of both animals and man. PAGENO="0253" 245 3. More comprehensive post-DVM education (something leghilatures are reluctant to support), to include: a. Formal graduate degree programs b. 1~esidency and specialty training programs (no sources of support exist for these at present) c. Broader, more relevant continuing education programs 4. Expansion and modernization of facilities to accommodate further increases in enrollment and to permit the development of new areas of veterinary interest such as: a. Laboratory animal medicine b. Comparative animal disease research. c. Clinical specialty training d. Program~e~, independent learning Jaboratories e. Genetic and nutritional disease research f. Moderp toxicology It is imperative that veterinary education receive increasing financial support during the next two decades because of the great and growing importance of veterinary medicine to human health and welfare. Because they must serve the 50 United States, the 18 U.S. veterinar~r colleges are a national resource in the truest sense. Moreover, because of America's position of political power, wealth, and food productivity, American veterinary colleges also are a powerful asset to a world growing rapidly more crowded and more hungry. STATEMENT OF DR. MARK W. ALLAM, DEAN, ScHooL OF VETERINARY MEDICINE, UNIVERSITY OF PENNSYLVANIA Veterinary medicine has assumed a role of ever increasing importance in the protection of man's health by being active on several fronts. The well being of the world population depends on the availability of adequate and wholesome food supplies. Constant surveillance of the health of food producing animals and strict supervision of food products processing is a necessity. The veterinary medical profession must continue its practice of preventive medicine and epidemiological studies in the interests of controlling disease, particularly if the disease is transmissible from animal to man. Community health today depends on cooperative action of all disciplines in the health sciences. Added financial support of our undergraduate and graduate educational programs must become avaialble if we are to continue meeting even our minimum obligations. All of us recognize that increasing obligations of any profession go hand in hand with a rising cost in meeting these obligations. It is no longer possible to provide professional medical education at the existing level of support. The spiralling costs of administering a curriculum today will, without question, result in an annual increase of $2,000 per student at least. The faculty of the University of Pennsylvania School of Veterinary Medicine has developed a new and imaginative curriculum which would provide the student with the opportunities for self-learning and independent development. As might be expected, the improved curriculum will call for more faculty and an increase in laboratory space. However, the value of the teaching program would be so great to prompt one to say that funds must become available in support of it. We do not have the required financial support at the moment, and a realistic appraisal of the situation also leads us to ask where the funds are coming from. In order to fulfill past, present, and particularly future obligations, veterinary medicine must move ahead, and basic improvement grants constitute one answer to the problem. STATEMENT OF T. S. WILLIAMS, DEAN, SCHOOL OF VETERINARY MEDICINE, TUSKEGEE INSTITUTE I am pleased to have this opportunity to make this statement before your committee on the Public Health Mministration Bill in support of the inclusion of Improvement Grants for Veterinary Medicine. I know that you have long recognized the great urgency for additional support for veterinary medicine. The present critical shortage of veterinary medical man- PAGENO="0254" 246 power and concomitantly the dire need for adequate resources to overcome this shortage are matters of serious concern to the profession and our nation. This urgency is of critcal concern to those of us so closely associated with the educa- tion of veterinarians who will be intimately associated with our nation's total health and welfare. I know, too, that you are fully aware that, like our companion field of human medicine, there is no shortage of qualified applicants for the spaces available in our several schools of veterinary medicine in this country. It is not likely that the inadequate resources now available for the existing enrollments can be expanded to permit the increase in enrollments needed in the next decade to meet the demands for veterinary services. More alarming is the fact that the present shortage of qualified teachers for our veterinary medical programs would be even more critical in any attempt to expand rapidly to meet the need for sharply increased enroUments. It is unfortunate, in our opinion, that so few of our citizens fully appreciate or recognize the contributions of the veterinary profession to public health. Veterinary medicine as one of the "healing arts" shares eqtially with others of the medical professions the responsiblity for safeguarding the health of the nation's public. Our first line responsibility is that of safegwirding the health of the nation's animal population. Apart from this primary function, the present concept of the veterinary profession places the health of every living being fully within the scope of the broad range of our several professional activities. The full economic significance of the contributions of the veterinary pro- fession to our nation's public health cannot be minimized. The veterinary practitioners are our first line of defense against diseases of our vital and ever expanding livestock industry. You know full well the benefits which have accrued as a result of the cooperative efforts of veterinarians in both Federal and State Governmental service in the control of livestock diseases which are constant threats, not only to our livestock industry, but to the public health as well. Veterinary medical research singly or, as is often the case, in concert with allied medical scientists has been, and continues to be a significant part of research in problems of human health. In our own research laboratories here at Tuskegee Institute our research scientists are now working on problems of significant im- portance to human health. The veterinary colleges, since they are the source of veterinarians, are in a most important position to further these contributions to the eventual solutions of disease problems of animals and man. Our full potential is only limited by inadequate resources to do this significant work. All of our veterinary schools are faced with almost insurmountable financial problems as they endeavor to meet the challenges and demands placed on them as sources of the vitally needed veterinary personnel. We are p~trticularly grateful for the assistance provided by Congress in the form of the Health Professions Educational Assistance Act which provides for Veterinary 1~Jducational Facilities Construction and Student Loans, but strong effort is now needed to provide basic operational fund assistance. Our own position, since we are located at a private institution, is stringently acute. We are being hard-pressed to provide justification to our administration for the excessive expenditures required to endeavor to keep abreast at the current level. Plainly stated, unless we can find a new source of financial resources we may not be able to continue as a source for veterinary education. The Basic Improvement Grants not now included for veterinary medicibe would materially assist us in this financial crisis. Veterinary schools, since there are now only 18 in the country, constitute national resources, not local, state or regional, but vital national resources for needed health professional personnel. As such they merit national support; inclusion of the basic ithprovement grant would be a step by this Congress in the direction of assuming its rightful obliga- tion to the veterinary profession. Our own school is now trying to operate at a level that is 50% of the median operating cost for the schools in this country. This is truly an impossible situation. We must have assistance if we are to survive. it is interesting to note that in the last data available on comparative operating costs for colleges of veterinary medicine, at least seven of the 18 schools are operating at a level considerably below what would be considered a median operating level. This, gentlemen, indicates a critical financial picture for these vital educational institutions. It has been said that the "half life" of a veterinary education IS quite short; that so much of what we teach and what students learn is obsolete in a very brief period. This means that we must be ever alert to the changing needs for our PAGENO="0255" 247 curriculum. All of the veterinar~!= schools must then constantly engage in the new curriculum development to endeavor to provide the most effečtive education fcir our students. Equall~t we must make a strong effort to provide continuing edu- cation for those already graduated to compensate for the short "half life" of their education. Simply put, then, our veterinary schools have an almost impossible task ahead in the face of inadequate resources of veterinary medical manpower and funds to do the multiplicity of responsibilities that are ours. We urge your favorable consideration of our request to restore to the pro- posed legislation Basic Improvement Grants for Veterinary Medicine. Tuskegee Institute strongly supports the inclusion and urgently tieeds your assistance. STATEMENT OF JAMES El. GREENE, D.V.M., DEAN, ScHooL OT VETERINARY MEDICINE, AUBURN UNIVERSITY I am Dr. James B. Greene, dean of the school of veterinary medicine at Auburn University, Alabama, and a member of the Executive Board of the American Veterinary Medical Association. It is the wish of the American Veterinary Medical Association to express strong support for the passage of H.R. 15757 introduced by Rep. Staggers, and entitled "Medical Manpower Act of 1968." In expressing our support for the Act, however, we urge the Committee to amend the bill to include veterinary medical colleges under the provision authorizing institutional grants for the operation of health professions schools. Such an amendmentwould assure that the Act will serve to the fullest possible extent the nation's growing needs for health services. The numerous responsibil- ities modern veterinary medicine has assumed In the areas of biomedical research and public health require long-range funding for research, instructional programs, and efficient administration in colleges of veterinary medicine. The colleges of veterinary medicine, in common with the colleges of medicine, dentistry, oste- opathy, optometry, and podiatry, need assistance in the ovOr~all administration of expanding educational programs. Veterinary medicine is a health profession concerned with the health and welfare of animals and man alike. Not only are veterinarians actively engaged in diagnosis, treatment and control of a broad spectrum of diseases among many species of animals, but they are also key members in the nation's medical, public health, research, and military teams. Veterinarians are responsible for protecting a $41 billIon national investment in livestock. They protect the health of the public against sOme 100 diseases transmissible to man from both farm and companion animals, and they safeguard the wholesomeness of meat and meat products, poultry, and milk and milk prod- ucts. At U.S. ports of entry they prevent the introduction of animal diseases from foreign countries and enforce health regulations in inter-state and intrastate traffic in animals and animal products. At numerous research institutions, both governmental and private, veteri- narians contribute to the advances in bio-medical and comparative medical re- search. They are engaged in the care of experimental animals used in medical research and are responsible for the interpretation and application to man of findings obtained from animal research studies. They also participate in the de- velopment and testing of biological products for both animals and man. Veterinarians in the Armed Forces serve as public health officials for troops at home and overseas. They supervise inspection of food prepared and served to troops at home and abroad, and are engaged in research studies of bacterio- logical warfare, effects of excessive radiation and radioactive fallout, effects of space flight on living beings, diet development for' astronauts, and space food packaging. Veterinary medicIne is a decidedly consumer-oriented health profession. In 1966, Congress passed the Laboratory Animal Welfare Act (Public Law 89-544) and in 1967, the Wholesome Meat Act (Publh~ Law 90-201). Now the 90th Congress is considering bills pertaining to the inspection of poultry and poultry meat products. S The implementation of all of these legislative measures, ip their initial stages alone, will require the partlcip~tion of hundreds of Veterinarians, placing addi- tional heavy' demands on veterinary medical ~manpOwer ~lt a time when there exiSts already a critical shOrtage of veterinarians in all fields. In 1961 the Senate Committee on GovernnTient Operations estimated that the nation faces a shortage of 15,000 veterinarians by 1980 when 44,000 veterinari- PAGENO="0256" 248 ans-nearly twice the number of today's veterinarians-will be needed to pro- vide for minimum veterinary manpower needs. In view of mounting population pressures, the increasing need for consumer protection, the accelerated pace of bio-medical research, ancj the spectre of food shortages in our time, this estimate must now be considered extremely conservative. The gigantic task of supplying sufficient numbers of competent veterinarians for the nation's growing health needs is the i~sponsibility of 1l~ colleges of veteri- nary medicine in 17 states. The~e colleges are o1~ten understaffed, many lack modern teach~ug and training aids, mostareovercrowd$, some opcz~ate in nearly obsolete facilit~ies. Eecauso of all of these inadequacies, they now have to turn away from three to four qualified applicants for each freshman student they admit. It has been clearly demonstrated that the states are unable to furnish the col- leges with the support they need. The American. Veterinary. Medical Association therefore urges passage of the Health ManpoWer Act of 19t18, together with an amendment to include colleges of veterinary medicine in the institutional grants provision. STATEMENT (YE `DII. B. W. KINGREY, Thr~'N, ScnooL OF VETERINARY Maoiciwu, Uxivansrrx or Missouni One of the major developments during the past few years has been the unex- pectedly heavy pressures on the veterinary medical profession to share the re- sponsibilities of public health. This is first apparent on the university campuses where medical school faculty and veterinary medical faculty share the teaching of series of courses concerned with public health. At the University of Missouri there are eight faculty members from the School of Medicine with joint appoint- ment on the veterinary medical faculty. The same number of veterinarians share appointments in the School of Medicine. The arrangement is effective and shares the load with maximum benefit to medical students, veterinary medical students and graduate students. One of the major factors in the current advance of human health students dur- ing recent years has been the utilization of the living larger animals as models for the human in research. The pig alone has been utilized for the development of a long list of effective treatments. Each of many animal species have certain fea- tures that closely parallel the human. Thus members of the animal kingdom may be selected to form a battery that, in the composite, nearly duplicate the human. In the work utilizing animals to solve human health problems we find the veteri- narian and the physician working in collaboration. This is a most rewarding and logical approach. However, the number of veterinarians required for participa- tion in comparative medical research is depleting veterinary medical manpower in the more traditional areas. The School of Veterinary Medicine at the University of Missouri has as the major and unyielding financial problem the lack of funds for facility construc- tion. In the competition for building dollars the sheer increase in student num- bers causes the construction of additional classrooms to be highest on priority of construction programs. The demand by society for `the annual graduation of more veterinarians is well documented. However, during the past 20 years the nation has responded by creating only `one new college of veterinary medicine. This places great pressure on existing schools to expand their enrollments. Because veteri- nary medical facilities are expensive and because of the truly regional and na- tional nature of the veterinary medical institutions it is a serious problem to find adequate funding for the construction of additional buildings to respond to the needs and demands of the nation. Pressure on existing facilities are also exaggerated by the mounting number of veterinarians seeking graduate training as well as the very real need for ex- pansion of instruction through continuing education. On the University of Mis- souri campus alone the number of doctors of veterinary medicine pursuing ad- vanced degrees increased from four in 19(34 to 59 in 1967. Obviously facility con- struction must appear as an essential response to such responsibilities. At the University of Missouri support through operational funds has been in- creased rapidly. The existing space has been `equipped, staffed and supported to the maximum. Should additional space be made available the major operational needs would be for modern' teaching devices, suitable support for outstanding faculty and for the support of auxiliary staff. PAGENO="0257" 249 Curriculum developments in the schools of veterinary medicine have been slow in their response to a changed environment. There is now a real need for sub- stantial studies of the veterinarians' activity and the identification and charac- terization of trends to enable present curriculums to be wisely remodeled. Mr. RoGERs. What amendments do you recommend now? You said to include the colleges. Dr. Tnour. To include veterinary medicine in the institutional grants. Mr. RoGERs. That is your basic recommendation. Dr. THORP. Yes. I should like to at this time refer to the testimony that Dr. Martin gave yesterday in relation to medicine and dentistry, and I have discussed this with him, relative to the shortage of physi- *cians and dentists. He pointed out in his statement that in the case of medicine and dentistry, this was an area in which there was not an opportunity for students to get in; not the academic opportunity, and so far as they knew, it was not so in other areas. I will just point out that the same thing is true in veterinary medi- cine and I will use Minnesota as an example. We have 215 applicants for a class of 60 in the fall of 1968. Many of these are from Minnesota, many of them are from North and South 1)akota and Wisconsin. I would also like to further point out in relation to the testimony yes- terday that the cost of educating a veterinarian is essentially the same as the cost of educating a physician and in some cases more. Mr. ROGERS. How many years are required? Dr. THORP. Four years beyond the 2 years of preveterinary work. Two years is a minimum. Most of our graduates have about 7 years. I want to say also that there are many areas in veterinary medicine in which the facilities and equipment are the same as the other medi- cal sciences. As shown in the prepared testimony which you will put in the record, the schools and colleges of veterinary medicine are really a national resource since there are only 18 in this country. There are many well-qualified motivated pre-veterinary students who cannot secure entrance and avail themslves of this educational opportunity. In closing my brief summary, we appreciate the assistance which the Congress and the administration have provided for the construction of teaching facilities and student loans, inclusion of scholarship grants, special project grants, in the present legislation. These will be most helpful in assisting the colleges to expand and meet the increasing demands for veterinarians as part of the health manpower team. We do, however, wish to be included in the institutional grant. Thank you very much for letting me appear today. I will be glad to answer some questions after the other gentlemen who are with me-S I would like to call on Dr. Pritchard now. Mr. ROGERS. All right. STATEMENT OP DR. W. R. PRITCHARD, DEAN, SCHOOL OP VETER- INARY IVLEDICINE, UNIVERSITY OP CALIFORNIA, DAVIS, CALIF Dr. PRITcHARD. Mr. Chairman, Congressman Skubitz, I would like to make only two points and will be very brief. I have a prepared state- ment that I would like to have introduced in the record. Mr. ROGERS. Without objection, it will be made part of the record following your oral presentation. 95-540-68-17 PAGENO="0258" 250 Dr. PRITCHARD. The veterinarian is the member of the health team that deals with diseases of all kinds of animals except people, and in this way he makes significant contributions to human health, and I want to point out one quite unique way that this is done. As you know, a great deal of research on human diseases must be done with animals. This is fine and it presents no problems if the dis- ease can be reproduced in animals. However, there are hundreds of diseases, particularly the chronic and debilitating diseases, that cannot be reproduced, so there is no way to do research on causes, mechanisms by which the disease is produced, or prevention unless people are used. It is becoming increasingly clear however that most if not all of these diseases occur naturally in some animal species. Consequently the veterinarian in his daily work, whether it be with livestock, pets, zoo animals, laboratory animals or any other kind of animal, is in a posi- tion to locate for medical science these animal disease models that are so important for medical research. And I emphasize that he does this in his daily activity as a veterinarian. 1 would like to mention very briefly one or two of these models that are being used at our school. The first one is pulmonary emphysema, which is one of the most important diseases of people today. In fact I believe one out of every 14 people on social security disability pay- ments actually have emphysema. Fortunately, this disease also occurs in horses, `and veterinarians working in our school have learned a lot about the mechanisms by which this disease is produced in horses, have been able to reproduce it, and are now using the horse on studies on the cause of emphysema. They actually house groups of horses and also monkeys in large buildings and are studying the effects of air pol- lutants, such as ozone, on lungs and determining how these materials cause emphysema. Another good example is leukemia. Leukemia is a commonly occur- ring and highly fatal disease of people; but fortunately it also occurs in a number of animal species. Just about everything we know about the cause of leukemia has come from studies on mice, cattle, dogs, and cats. Very recently some real progress was made in understanding leukemia `as a result of studies in the cat. The first cat studied was brought to the veterinary medical teadhing hospital by a practicing veterinarian that had recognized that the cat had leukemia. Researchers collected plasma from the cat, spun it at very high speeds; and, lo and~ bdhold, under the electron microscope, there were millions of viral particles. For the first time they were able to concentrate large quanti- ties of leukemia virus and now are making major strides in certain aspects of studies on leukemia. This progress stemmed directly from the efforts of a pet animal practitioner who indirectly was able to make a significant contribution to medical science because he knew how to recognize leukemia and recognized the importance of his patient to send it to the university for further study. Now, there are many, many other similar examples, but it is not really necessary in view of the shortage of time, to go into them. I passed out some pictures. You see Burkitt lymphoma and bovine lymphosarcoma are very similar diseases in man and animals. I also have a picture of some sheep with a genetic defect and a lady that is not ill but who carries the defective gene for this disease. The disease,. Dubin-Johnson syndrome, an important disease of children is identi- PAGENO="0259" 251 cal in sheep and people. Sheep are excellent models in which to study the disease. Some of the finest work in the country is being conducted at School of Veterinary Medicine at Kansas State University on this and similar diseases by Dean C. E. Cornelius and his group. This is a very important problem in babies. Mr. SKUBITZ. I am glad you mentioned that. Mr. Chairman, I would like to ask unanimous consent to insert a statement by Dr. Cornelius into the record. Mr. ROGERS. Without objection, it will be made a part of the record at this point. (The statement referred to follows:) STATEMENT OF DR. C. E. CORNELIUS, DEAN, COLLEGE OF VETERINARY MEDICINE, KANSAS STATE UNIVERSITY The many contributions of veterinary medicine to human health have become nationally acknowledged as classical discoveries important to understanding human disease. The discovery of numerous nutritional deficiency diseases, the development of advanced surgical techniques including organ transplants, the testing of many new drugs beneficial to man, the discovery of animal models in which to study human disease, and the control of over 150 animal diseases transmissible to man, are but a few of the important responsibilities of veterinary medicine. It has been said that the greatest contribution of veterinary medicine in the next decade will be what basic information flows to human medicine concerning the many animal diseases with counterparts in man. We need to discover new animal models for studying cystic fibrosis, the rejection of organ transplants, multiple sclerosis, emphysema in the over populated city, a variety of leukemias, many types of cancer, and coronary heart disease to mention only a few. Through the use of such animal models, key discoveries can be made in colleges of veterinary medicine and in cooperation with leading human medical centers. We must not let this golden opportunity be missed due to insufficient funding of the few colleges of veterinary medicine that exist in the United States today. There is insufficient resources in colleges of veterinary medicine today to stimulate such programs as mentioned above in comparative medicine unless basic improvement grants are made available. This is due to the great expense of medical education and research today. Colleges of veterinary medicine are presently faced with a lack of resources for the training of students In com- parative medicine. The serious deficiency of qualified scientists In this field of comparative medicine is appalling. In addition, poor physical facilities in many veterinary medical colleges limits research programs which are directly related to human health. Basic improvement grants to veterinary medical col- leges along with the support of improved teaching and research facilities is the only answer that will allow for the training of these new medical scientists. They will be unique to all of medicine. Many veterinary medical colleges in certain smaller states receive state support at only 1.5-2 million dollars per year. They will be unable to develop meaningful training and research programs in comparative medicine during the next decade unless institutional grants of $300,000 to $500,000 per year are available from resources outside the state. The injection of many new discoveries on animal diseases from veterinary medicine into human medicine could well be the key to understanding many of our worst crippling diseases in man. I strongly urge that the new programs recently initiated in developing new veterinary medical manpower for the health sciences as well as increased Institutional support be continued; only by such a program can the colleges of veterinary medicine make a substantial contribu- tion to the health of mankind. Dr. PRITCHARD. I would like to make one other point relating to demand for veterinarians. Each year 3,000 to 5,000 letters are written to us by people interested in a veterinary medical education. About 400 to 450 qualified applicants apply for admission to the school each year; we are able to accept only 80. Last year these 80 students PAGENO="0260" 252 averaged 4.2 years of pre-veterinary medicine obtained at some of our Nation's finest colleges and universities with better than B aver- ages. They are indeed an outstanding group of young people desiring to enter the profession of veterinary medicine. Lack of spaces for the 250 to 300 is not really the point I want to make. The important issue is, what happens to some of the other 3,000 i~o 5,000 that do not finally complete their applications for the school? We have looked into this matter, and we find that too man-v do not ~nter veterinary school because they cannot afford the long aiid expen- $ive education required to qualify as a veterinarian. We are getting very few people from the lower income groups because veterinary medical education is expensive and these people just cannot afford it. Consequently, if it were possible for anyone to go to veterinary school regardless of cost, I am sure the number of applications would be greatly increased. Even though five times as many applications as places for students is bad enough, it could be much worse if potential applicants from enough low-income groups were included. Thank you very much. Mr. ROGERS. Thank you very much, Dr. Pritchard; appreciate it. (Dr. Pritchard's prepared statement follows:) STATEMENT OF Pu. W. R. PRITCHARD, D.V.M., DEAN, SCHOOL OF VETERINARY MEDICINE, UNIVERSITY OF CALIFORNIA, DAVIS, CALIF. I am Dr. W. fl. Pritchard, D.V.M., Dean, School of Veterinary Medicine, University of California, Davis. I would like to make a statement about some contributions of veterinary medical science to human health and welfare, and comment on the critical financial problems facing American colleges and schools of veterinary medicine. I am sure that others will comment on many additional ways veterinarians contribute to human health and welfare. Veterinary medicine has evolved as that branch of medical science responsible for the control of diseases of all species of animals except man. The D.V.M. applies the principles of biology and medicine to the alleviation of pain, suffering and ill health in animals serving man. He is responsible, too, for the protection of people from those animal diseases that also affect man Most importantly of all, however, veterinary medicine makes highly significant contributions to the health and welfare of people through research by adding to our knowledge of diseases and disease processes. I shall try to briefly describe some of the unique ways that veterinary medical science contributes to human health. A RICH HISTORY OF RESEARCH ACCOMPLISHMENTS Since the time of Pasteur, veterinary medical scientists have made significant contributions to the body of knowledge that constitutes medical science. I shall cite only a few examples typical of many hundreds made by veterinarians. Smith, KilbOurne and Curtice, seeking means to control Texas fever of cattle, a disease threatening the cattle industry of this nation in the latter 1800's, dis- covered that arthropods, in the case of Texas fever a tick, are capable of spreading disease. This finding has proven to be one of the most important principles of infectious disease control. It has led to successful control of many important arthropod-borne diseases of people such as malaria, yellow fever, sleeping sickness, Chagas' disease, and numerous encephalitides. A French veterinarian, Ramon, working on ways to protect French cavalry horses from lockjaw, developed the first effective immunization agent against a toxin. Successful methods of preventing tetanus, diphtheria and other diseases induced by toxins in people resulted from his work. Karl F. Meyer, D.V.M. of the University of California, devised means to control botulism in canned foods, making the great food canning industry possible at a very critical time in its history. William Feldman, D.V.M., formerly of the Mayo Foundation and now the U.S. Veterans Administration, more than anyone else is responsible for emptying the nation's tuberculosis sanitariums of patients formerly doomed to something PAGENO="0261" 253 akin to life imprisonment. This veterinarian brought to the human medical com~ munity the methods successfully used to control T.B. in cattle and, in addition, led the nation in research which resulted in the successful treatment of this diseaSe. Otto Stader, D.V.M., a practicing veterinarian specializing in pets, developed a revolutionary method of reducing fractures in animals. Many Americans, par- ticularly former World War II servicemen, owe their arms, legs, jaws and other bones to the Stader splint, which in its time was an important contribution to fracture repair. The use of oral polio vaccine was backed by nearly 15 years of experience with the successful use of oral vaccines in animals. These are only a few of hundreds of examples of ways the health and welfare of people have benefited by veterinary research. ANIMAL DISEASE MODELS OF DISEASES OF PEOPLE It is becoming apparent that for nearly every disease of people there is a simi- lar or identical disease in some species of animal. The animal may be a dog, eat, mouse, horse, rabbit, turkey, chicken, sheep, cow, deer, primate or even a fish. Many of these animal disease models are far better suited for studies on the nature of a disease and means to prevent or treat it than are sick people. Hence, research on these diseases contributes directly to the health of people by increasing our understanding of diseases and disease processes in man. Animal disease models of diseases of people are becoming increasingly impor- tant to medical research. Chronic and degenerative diseases such as cancer, stroke, heart disease and emphysema have become the chief killers and disablers of the American people. Unfortunately, there is no adequate way to reproduce many of these diseases in animals for study. On the other hand, many of them occur under natural conditions in lower animals, hence veterinarians have a unique opportunity to provide medical science with models of these diseases for research. A veterinarian's training and experience with the biology and diseases of these animals make him esp&ially qualified to conduct research on the prin- ciples of disease and disease processes with these models. EXAMPLES OF USEFUL ANIMAL DISEASE MODELS FROM TIlE U. C. SOHOOL OF VETERINARY MEDICINE Veterinarians from the Western United States refer livestock, zoo, wild and fur-hearing animals, laboratory animals and pets with unusual diseases to our School's Veterinary Medical Teaching Hospital for intensive study. Many of these diseases are models of diseases of people, with valuable research poten- tial. Hence, a veterinary school serves as an effective screening mechanism to discover and characterize models of disease in all kinds of animals that might be valuable research tools. Members of the faculty of our School have discovered or made significant con- tributions to the understanding of over 40 animal disease models of important diseases of people. I would like to briefly describe three of them. Emphyserna.-Em.physema is a severe, progressively disabling disease of people. The prevalence rate is high in the United State's and is increaSing rapidly. In a recent year one of every 14 citizens receiving total disability payments from social security bad emphysema. A similar disease also occurs in horses. A team of researchers composed of D.V.M's, M.D.'s and other health scientists initiated studies on emphysema in the horse in our School 6 years ago. This team has succeeded in reproducing emphysema in the horse; thus, for the first time, medical science has `been provided with an experimental system in which to study cause, prevention and treatment of emphysema. The group, beaded by Dr. Walter Tyler of the School of Veterinary Medicine, now is determining the role of air pollu- tants and other agents as possible causative factors of emphysema. Their results will be more important to human than to animal health. This important progress was made possible only because a veterinary and human medical research team together attacked an important human health problem. Leakemia.-Leukemia is one of man's most feared diseases. How would any of us react to the knowledge that one of our loved ones had this highly fatal disease? How many people know that nearly everything known about the cause, spread and possible means of prevention of leukemia has been learned from studies on leukemia in animals. The most promising research on leukemia in the world PAGENO="0262" 254 today is being conducted on naturally occurring disease in mice, cattle, cats and dogs. We know that leukemia in the mouse is caused by a virus and have obtained excellent leads on how it is spread in cattle. Where would we be in leukemia research today but for these animal disease models? We probably would not have the foggiest notion of the nature of the disease and, indeed, might not have much of an idea about how to find out. If leukemia is ever brought under control, and we are confident that it will be, much will be owed to the animal disease researchers who discovered the models and have condtteted research on them. Liver Disease in Man and Bheep.-Exciting progress is being made in under- standing perplexing liver diseases of people as a result of the discovery by veterinarians in sheep of two diseases caused by liver function defects. One of these liver diseases in sheep is identical to Dubin-Johnson syndrome in man. Together they have provided medical science with its best "models" for under- standing liver function in health and disease. Both veterinary and human medi- cal researchers are using these sheep for important research on liver disease in people. FINANCIAL 0R1515 IN VEPERINARY EDUcATIoN America's schools and colleges of veterinary medicine face their most serious financial crisis in the long history of veterinary medical education. Because vet- erinary medical education must be offered at the graduate level and requires in- tensive instruction in the basic clinical and medical sciences, as well as a great deal of contact with animals, the cost is very high. Data obtained from the Uni- versity of California indicate that the cost of veterinary medical education ex- ceeds that of most medical schools. The reasons are clear. Instruction in veteri- nary medicine is at the same high academic plane as it is in human medicine. The students have completed at least in our School, over 4 years of preveterinary medicine in strong schools and colleges. They enter our veterinary medical school with an average of more than a "B" obtained in some of the nation's top colleges and universities. The course of study is very similar to that in a human medical school, except that all aspects of the program emphasize, in their labora- tory and clinical portions, more contact with animals because the animal- not man-will be the patient of the veterinarian. Consequently, more time must be devoted to animal aspects of laboratory exercises in anatomy, physiology, surgery, obstetrics and similar courses, than in human medical schools. This increases edu- cational costs fantastically because animals used in veterinary medical pro- grams, including those in anatomy, must be purchased and are not donated to veterinary schools as they are to most human medical schools. Adequate clinical instruction requires an abundance of animal patients for study. Unlike human hospitals, many of these patients must be admitted and eared for at a cost less than the real cost of the services rendered to the patient. This is true because the fee that cart be charged is limited by economic factors and no medical insurance exists for animals. The cost of care is far greater than In private animal hospitals because they are used for teaching. Conse- quently, clinical education, by and large, costs a great deal and the activities of the veterinary clinician do not result in earning money for the veterinary medical program, as is the case in many human medical schools. The cost of operating a veterinary medical school amounts to approximately $7500 per professional student per year. The cost of educating an undergraduate student is far less than this. Consequently, legislators and university adminis- trators are sometImes unable to allocate sufficient funds to veterinary medical programs when the demand for educating large numbers of students cannot be adequately met. The problem is accentuated by the fact that since there are only 18 veterinary medical schools In the country, a significant number of students in all schools of veterinary medicine come from out of the state that supports a veterinary medical school. Consequently, legislators are reluctant to spend the required funds to adequately support a veterinary medical program. They reason that because a few states must educate all of the veterinarians for the entire United States, federal funds should be made available to assist in sup- porting veterinary medical educational programs. Their reasoning is hard to refute. In my opinion, if veterinary medical schools are to meet their commitment to supply badly needed veterinarians for all types of service to society, at least 50 percent of the total costs of veterinary medical education must come from other than state sources. 13'or our School this would amount to approximately $3,750 per student per year. PAGENO="0263" 255 DEVELOPMENTS IN TI~ CURRIO~LUMS OF SCHOOLS OF VETERINARY MEDICINE Schools of veterinary medicine throughout the nation currently are conducting searching examinations of their teaching programs. Teaching and learning in these schools is being scrutinized in greater detail than at any other period in the history of veterinary medical education. Good teaching is acquiring new respectability and, in turn, faculty interest in excellence in teaching has in- creased a great deal. New curriculums are being developed by most schools of veterinary medicine throughout the nation. Our School adopted a new curriculum in 1966 designed to better prepare graduates to fulfill the needs of the profession as the medical specialist who deals with diseases in all species of animals. We have con- centrated on providing a fundamental education on tAe biology and disease of all kinds of animals to make it easier for veterinarians to adapt to the constantly changing nature of the profession. It also will better prepare them for the life- long learning that is absolutely essential in order to keep up with developments in the profession. Veterinary medical educational programs already firmly established at the graduate level are providing opportunities for the first time for graduates to concentrate in certain disciplines, and hence acquire greater depth of knowledge in certain aspects of veterinary medical science. More responsibility is being placed upon the student in the learning process. More time is being made avail- able for self-learning activities, such as library study, work in instructional resources centers, more clinical study and more thorough work-up of cases, individual research projects and other similar types of self-study programs. A greater proportion of the class time Is being devoted to discussions, seminars, workshops and problem-solving exercises rather than to lectures on materials that, in many instances, could be better obtained from textbooks, journals and other sources. One of the most important changes in veterinary medical curriculums is the effort to condition the graduate for lifelong learning. The D.V.M. can hope to obtain little more than an understanding of biology and diseases of animals and an introduction to clinical veterinary medical science while in school. The rest he must learn after graduation. Hence, one of the most important aspects of his education should be the attainment of proficiency in the skills of self-learning, the methods of finding answers, the techniques of problem-solving, and the motivation to continue to grow professionally for the remainder of his life. The incorporation of more self-learning techniques in the veterinary medical curric- ulums should assist in developing habits that will lead to successful lifelong learning. It must be remembered that all of these innovations increase the cost of education. IiJaucatio~ica Resources Many veterinary medical schools are beginning to incorporate in their teaching programs more of the important advances that have been made im the science and technology of education during the past few years. Programmed learning, new audio-visual techniques, greater use of models, computer-assisted educational programs and other innovations are being used to an ever increasing extent to improve the efficiency and quality of the veterinary medical educational process. Several schools are planning the development of medical education departments. Some are being developed in cooperation with schools of human medicine. It is the avowed intention of the Association of American Veterinary Medical Colleges and the Council on Education of the American Veterinary Medical Association to constantly improve the educational program of the U.S. Schools of veterinary medicine. Symposia and seminars on veterinary medical education are being held throughout the country in ever increasing numbers. This intense interest in the improvement of veterinary medical education is one of the most refreshing developments in veterinary medical schools that has occurred in the last half century. SUMMARY In summary, veterinary medicine has made and will continue to make im- portant contributions to the advancement of biomedical science. New knowledge about animal biology, diseases and disease processes is being obtained as a result of research being carried out in veterinary medical institutions. Studies on animal diseases that are similar to afflictions of people provide a highly unique PAGENO="0264" 256 mechanism by which important information on the cause, control and treatment of diseases of people can be made. Veterinary medical educational programs are as costly, or more costly, than human medical programs because many more animals are required in the teaching program of veterinary medicine and veterinary medical teaching hospitals do not earn incomes proportionate to human medical hospitals. Schools of veter- inary medicine are experiencing considerable difficulty in obtaining adequate state support because only 18 American veterinary schools serve the needs of the entire nation. Many states resent the expenditure of their own funds for educa- tional programs that benefit other states. Great strides are being made in the improvement of veterinary medical ccitt- cational programs. New approaches to teaching and learning and research on medical education are being developed. The application of the latest advances in educational science is being incorporated into the teaching programs of most veterinary medical schools. Mr. ROGERS. Dr. Morse. SPATEMENT OF DR. ERSKII'IE V. MORSE, D.V.M., DEALN, SCHOOL OP VETERINARY SCIENCE AND MEDICINE, PURDUE UNIVERSITY Dr. MORSE. Mr. Chairman, with your permission I would like to have my statement introduced into the record. Mr. ROGERS. Without objection, it will be made a part of the record following your oral presentation. Dr. MORSE. Mr. Chairman, Congressman Skubitz, I would like to discuss the contributions of veterinary medicine in food production and in consumer protection. Our country has a tremendous obligation as a world leader and is probably the prime producer of animal food products in the world today. Approximately 10,000 die each day and 3 million a year due to starvation. It is quite interesting just to show the great need for animal pro- tein. Cannibalism in the Caribbean was greatly reduced with the importation of Spanish cattle. Only 2 percent of our world, though, is ideally suited for production of crops. This means 64 percent of our land mass is in permanent pasture. It is because of ruminants, i.e., cattle, sheep, and goats that man can live in a great deal of our world. These animals convert unpalatable roughages into highly palat- able meat for human consumption. Eighty percent of the meat and milk and eggs are produced by 40 percent of the world's livestock. It is no accident the United States is a leader in food production and a great deal of this has been brought about by first-rate research in genetics, husbandry, and disease control and prevention. We also have a marvelous system of st~rveillance, keeping disease out. We have all heard about the foot and mouth epidemic in Great Britain in which 415,000 cattle were killed because they were infected or exposed. If this same disease were to infect our cattle, we would lost 25 percent of our totaJ cattle. Another disease, rinderpest or cattle plague, is fortunately not with us. In the 18th century, in Europe alone, 200 million cattle succumbed to rinderpest. In the 20th century through World War II, ocver 2 mil- lion cattle died annually in the Far East before the plague was brought under control by veterinarians. Essentially veterinary medicine and veterinarians are a minority group. There are only 25,000 of us. We do need help to continue these good efforts and to protect our food supply. PAGENO="0265" 257 I would say we will need 15,000 more veterinarians by 1980 to con- tmue the good level of service which we are currently providing. Obviously more research is needed, better diagnostic methods, world.. wide reporting on animal diseases to protect our own animals and, of course, exportation of technical know-how to the developing coun- tries are necessities. Consumer protection-Secretary Philip Lee commented briefly on this yesterday, I am sure. There are 135 diseases of animals directly transmissible to man. There are a number of human infections which are transmitted by contaminated food between human beings. We have the problem of chemical residueis and pesticides in our meat and food products. There is the need for better plant and sanita- tion inspection of food processing establishments. Veterinary protec- tion really starts for the consumer on the farm where the animals are kept healthy. This means wholesome meat, eggs, and milk. Veterinary surveillance continues in transit, prior to slaughter, following slaugh- ter in the processing plant, and through the whole processing and storage operation. We can look with pride to our U.S. Army and U.S. Air Force Vet- erinary Corps officers. Our schools are supplying a large number of these officers every year. Twenty-five percent of our 1968 graduating class at Purdue will be on active duty by September. All the food is inspected by the veterinary corps for all branches of the service. The 18 U.S. veterinary medical colleges graduate the doctors of veterinary medicine (D.V.M.'s) which have enabled our country to produce ample as well as the safest meat, milk, and eggs. This legis- lation will greatly assist these colleges to supply the needed profes- sionals to continue this fine service to producers and consumers alike. It is a pleasure to appear before you, gentlemen. Thank you very much. (Dr. Morse's prepared statement follows:) STATEMENT OF Dn. 1~R$ICINE V. MonsE, D.V.M., DEAN, SCHoOL OF VETERINARY SCIENCE AND MEDICINE, PURDUE UNIVERSITY FOOD PRODUCTION The prospect of peace between nations of the world and the prospect of civil tranquility within our own nation are closely related to a most powerful free. "dom-freedom from hunger for all people. Wars and civil strife may he caused by factors other than hunger, but where there is starvation there can be no peace. During the past five years, the population of Asia is reported to have risen 12% and in Latin America 17%. Food production in these two vast areas has increaSed 10% during the same period. The net result is that per capita food production has fallen 3% in Asia and 7% in Latin America. Two-thirds of the world population lives in food deficit areas, and 60% of these people suffer from malnutrition or diseases aggravated by malnutrition. Only 10 countries of the world have food surpluses and they contain only 15% `of the world population. Hunger claim's 3 million lives each year, and 50% of the population in many developing countries die before the age of 15 years is reached. Plants provide the world with 70% of the available dietar~t protein and 30% comes from animal sources. While both of these sources are important to human nutritional needs, animal products are superior in protein quality and require less bulk consumption per unit of protein intake. The North American's daily diet includes an average of 66 grams of animal protein. In Africa only 11 grams are available and in Asia the figure is 8 grams per day. Why is America so far ahead of many areas of the world in available animal protein foods? The answer must include the investments which America h~s PAGENO="0266" 258 made to create a great reservoir of veterinary medical knowledge and manpower. Dr. M. R. Olarkson, Executive Secretary of the American Veterinary Medical Association, said in a public symposium of the National Research Council of the National Academy of Sciences last June: "On the whole . . . world animal agriculture today presents a vast potential for the production of foods, sufficiently large to satisfy the world's need for animal proteins of high quality. Without in any way underestimating the eco~ nomic, ecologic, and logistic factors adversely affecting the utilization of this potential, particularly in the developing countries, I suggest that the greatest single obstacle to meeting the world's requirements for food products of animal origin is the crippling and unnecessary drain incessantly inflicted upon these resources. by major infectious and parasitic animal diseases. Adequate disease control is the first and fundamental `must' in successful meat, milk, and egg production." A statement by the National Academy of Science last year spoke to the essen- tiality of veterinary medical services when it said: "That animal diseases are economically crippling is clearly evident. That they are unnecessary has been amply illustrated wherever the introduction of veter- inary medical service has led to the control of once rampant animals dis- eases.. .. Faced with the two-pronged task of feeding its own growing popula- tion, and rendering aid to those struggling desperately for the basic necessities of life, the United States can no longer afford any delay in opening up to its fullest a source of food unequalled by any other reservoir of life-sustaining sub- stance.. . . The National Academy of Science calls upon and urgently requests the Federal government and the scientific community in every stratum of its en- deavors to join hands in establishing, developing, and supporting accelerated na- tional and international programs aimed at the control and eradication of animal diseases." Annual savings resulting from the elimination of bovine piroplasmosis (Texas fever), from the United States equal the total cost of its eradication. The control of bovine tuberculosis provides a monetary savings every two years equal to the cost of the control program. Although individually less spectacular, there are a host of more insidious, yet debilitating, animal health and parasite problems which collectively are such costly handicaps to efficient, productive, and profit- able livestock production that the United States can no longer afford to delay their control. The costs of animal diseases vary from 15% of potential animal yield in the developed countries to as high as 50% in some of the developing countries. These great losses have been endured through the ages, but there is now a new and pressing urgency to limit this unnecessary toll. The world has now undergone great and unprecedented changes which require more effective disease control if the livestock industry is to thrive and fulfill its potential in the production of food for man. America is the safest place in the world in which to invest in and produce livestock products. We have a veterinary medical profession in this country which is unexcelled anywhere in all of history. Yet, in the United States alone, we sacri- fice to animal diseases and parasites a staggering 2% billion dollars worth of animal products each year. A United States population of 600 million people is not going to occur overnight some 100 years from now. It will be a progressive increase which has already be- gun. It is not futuristic and we must begin to face it today. The gap between existing food supplies and essential food requirements is changing, and the change is not for a better fed people. We have a crucial challenge before us, one which is made sharp by physical states of desperation. The challenge is to raise the level of animal health and productivity in the United States and throughout the world to meet the essential animal protein food needs of an expanding popula- tion. If the challenge is to be met, if hunger and starvation are to be conquered, then, increased attention must be given to the wastes of our potential food resources. A summary of the President's Science Advisory Committee Report on The World Food Problem, released June 18, 1967, said: "The report warns against the false hope that some `panacea' will appear as an easy answer to worldwide food shortages and decries the publicity accorded to synthesis of food from petroleum, food from algae, and similar processes as rais- ing false hopes and undoubtedly lessening public concern about the seriousness of the food supply in the developing nations . . PAGENO="0267" 259 Five things must be accomplished in meeting the needs for animal health and in reducing the wastes of animal diseases: 1. Research on the diseases of food producing animals must be increased. There is a developing imbalance of research fund support for diseases of animals related to food production as compared to diseases of animals with direct human health implications. The latter merits support and should be continued and increased. However, if the former is not brought alongside, man can become the healthiest starving critter the world has known. 2. Veterinary medical manpower must be increased. At the fastest possible rate which can be accomplished in the most efficient of educational process, the United States will have inadequate veterinary medical manpower in 1980 With prospects of even more acute shortages beyond that point. 3. Veterinary medical diagnositic laboratories and an effective and accurate national disease reporting system must be developed and expanded. From such a network can come the data so essential in animal health management. 4, Regulatory authority must be strongly supported and new laws and regu- lations provided as needed to control and or eradicate existing diseases and to prevent the importance of others from which this country is now free. 5. Greater emphasis, across this nation and in foreign countries, must be ap- plied to the problem of ineffective or negative use of currently available animal health "knowhow." Extending knowledge to the producer and continuing educa- tion for the graduate veterinarian must have high priority in the decade im- mediately ahead. We know how to do more than we do. CONSUMER PROTECTION The meat markets of this country are, for the most part, well stocked with good, wholesome meat of varieties and standards pleasing to the consumer. The cus'- tomer can feel safe in his protection against transmissible diseases through his meat supply. He consumes great amounts of meat, milk, and eggs each year and is confident that his health is protected and he eats with pleasure and freedom from fear. Contrast this with the open. unrefrigerated, fly-infested and rodent- inhabited meat markets of many countries today where there is no effectively regulated meat and animal products inspection system. Consunier protection is an unpopular and argued subject in some quarters. Why should the government protect a citizen who does not want this protection? The answer is clear. The majority of our people seek protection from that over which they have no individual control and look to collective protection through legalized governmental processes. The dissenters derive the benefits afforded the majority, and in this great land of ours, have a right to dissent. However, they do not have the right to deny the majority the collective protection it seeks. Veterinary medicine plays a central role in consumer protection. As relates to safe and wholesome animal food products, this role extends from the healthy herd and flock through the processing plants and market place to the very hands of the consumer. The American housewife can acquire, prepare, and serve to her family a nutritious, safe, palatable, and wholesome meal because there is surveillance by a guardian created in the due process of law. The system is costly, but in terms of consumer protection, it is one of the best and most productive of the investments Americans make. The veterinary services of the U.S. armed forces seeks procurement and de- livery of safe and wholesome food supplies to our fighting men around the world. There is no other current system by which this important job can be accomplished. The Wholesome Meat Act of 1967, and a Poultry Inspection Act are programs aimed to secure good food for American people. They, along with the Laboratory Animal Welfare Act, require additional veterinary medical manpower. REQUEST The Congress is requested urgently to take the steps necessary to support and strengthen a valuable national resource-veterinary medicine in the United States of America. The incthsion of veterinary medicine in all of the provisions of H.R. 15757 including the important institutional grant provision, and the passage of HR. 15757 will give greater strength to veterinary medical education and make possible its meeting the challenge it seeks to deliver for all people. PAGENO="0268" 260 Mr. ROGERS. Thank you, Dr. Morse. Mr. Skubitz? Mr. SKUBITZ. Doctor, did you say there were only 15,000 veteri- narians in the country? Dr. MORSE. There will be 15,000 more needed than we will currently have by 1980 and our current veterinary colleges will be unable to produce them. Mr. SKTJBITZ. Recently we passed the dirty meat bill; today we passed a filthy chicken bill. Are the inspectors required to be graduate veterinarians? Dr. MORSE. There are some lay inspectors, a number. Actually, they are supervised by veterinarians. Mr. SKUBITZ. If we are going to really inspect meat and inspect chickens, shouldn't the inspectors be veterinarians? Dr. MORSE. Ideally, yes. Mr. SKTJBITZ. Otherwise we are passing laws and we are hiring inspectors that are not competent to judge whether or not the meat is contaminated. I think if the Congress, Mr. Chairman, is going to take steps to protect the consumer, we must secure competent inspectors. Mr. ROGERS. Right. Mr. SKUBITZ. That is all. Mr. ROGERS. Would you let us have your estimate from your or- ganization as to how many new schools might be needed or what in- crease can be assumed by present facilities, and should there be a requirement that the schools, if they have Federal grants, take on additional students, at about what level? The law as we put it in some years ago, it is two and a half percent, or five students. I would hope that would be increased. Dr. THORP. There would be no objection to a 5-or 10-percent put-in as a requirement. We see no objection to it. As far as the existing schools and existing facilities, I doubt if there could be too much of an increase without a considerable increase in numbers of faculty and facilities. Facilities are really the bottleneck as well as faculty, and to maintain faculty. Mr. ROGERS. Of course, this bill is to get at that problem. Dr. PHORP. Yes; and in regard to new schools, there is, as you know, a new school probably developing at Gainesville, Fla., one which has been authorized by the State of Louisiana for Louisiana, and a school is being set up in Connecticut at the University of Connecticut. Ten- nessee is considering a school. My estimate would be that in the next 10 years there will probably be five or six new veterinary schools in the country. Mr. ROGERS. Will this meet the demand? Dr. THORP. This will help meet the demand along with an expan- sion of the existing schools. We are at Minnesota-or the faculty is in the process, and have come to the conclusion that we are going to try to double our enrollment in the next 10 years as a gradual buildup. We are taking this into consideration, relevant to facilities that we are going to ask our legislature for, the 1969 legislature. Mr. ROGERS. Good luck. Dr. THORP. So we would go to 120 eventually, but the existing facilities I don't think will help us too much. PAGENO="0269" 261 Mr. SKTIBITZ. Have you had difficulty with your legislature getting money for your school of veterinary? Dr. THORP. Well, it was started in 1947. We have been building at it piecemeal. We have come to kind of a gentlemen's agreement that about every other legislative session-they meet every 2 years in Minnesota-we are able to take a major step in our main teaching facilities. Mr. SKUBITZ. I was shocked to learn that the school in Kansas is on probation. There is something wrong with our State legislature and I intend to find out what is going on in Kansas. We are quite proud of our school at Manhattan for years there, and I don't know what happened but our school has been placed on a probation basis. Dr. THORP. I might point out that Dr. Pritchard is a graduate of Kansas. Mr. SKTIBITZ. Manhattan? Dr. PRITOJIARD. Yes. If I may, I would like to comment on your question. A study was conducted about 3 years ago which indicated that in order to meet the needs for veterinarians until 1980, the enrollment at all of the present schools would have to be doubled and about six new schools created. So that is- Mr. ROGERS. This gives us a general picture. Dr. PRITcHARD (continuing). The scale of need. Mr. ROGERS. I was interested in your comment, too, on the part that veterinary medicine plays in the life of our Nation. I have in- troduced a humane bill for laboratory animals which I hope your organization will get behind. I think it is essential for us to do that because if you have well animals, your research is going to come out better and save millions of dollars there alone. So I would hope that you would look over this legislation perhaps and give us some comments. Dr. Tnom~. I might comment in that connection, the National Acad- emy of Sciences has pointed out there are about 2,000 biomedical research laboratories in the country and we also point out that there are only 106 veterinarians that have been certified in laboratory animal medicine. This is one of the areas where there is an expanding horizon for the need for veterinarians. Mr. ROGERS. Thank you very much. Our last witness today is the president of the Association of Uni- versity Programs in Hospital Administration, John D. Thompson. He is the president of the Department of Epidemiology and Public Health at the School of Medicine, Yale University. STATEMENT' OP JOHN D. THOMPSON, PRESID~ENT, ASSOCIATION OP UNIVERSITY PROGRAMS IN HOSPITAL ADMINISTRATION; AC- COMPANIED BY GARY PILERMAN, EXECUTIVE DIRECTOR Mr. ROGERS. It is a pleasure to have you with the committee today. Mr. THOMPSON. Mr. Chairman, I have a not too lengthy statement, which I will ask to read into the record, I will try to be brief and as concise as possible. Mr. ROGERS. Thank you. This will be helpful. PAGENO="0270" 262 Mr. THoMPsoN. I am John Thompson, director of the graduate program in hospital administration at Yale University. Today I am representing the Association of University Programs in Hospital Administration, which is an organization of graduate faculties work- ing cooperatively to improve the quality, delivery, and effectiveness of health services through programs in administration at the master's degree level. I am accompanied by Gary Filerman, executive director of the association. Mr. ROGERS. Mr. Filerman, it is a pleasure to have you before the committee. Mr. FTLERMAN. Thank you. Mr. THOMPSON. There are 24 graduate programs in hospital and health administration in the United States. The field is a relatively new one, and is experiencing tremendous growth and viability at the present time. Most of the programs are relatively new-lO having been organized just since 1960. There are eight more in various states of being planned and about ~30 other colleges and universities are actively considering launching programs in hospital administration. This is, incidentally, happening throughout the world. Underde- veloped countries, which have more severe health resources problems than we do, hasten to establish hospital administration programs. The growth of the programs reflects wide recognition by the public of the importance of effective, appropriately trained hospital manage- ment. Of the more than 5,000 program graduates, between 3,500 and 4,000 are estimated to be in top-management positions in hospitals and related facilities. An additional 1,000 to 1,500 occupy key positions in State health departments and Hill-Burton agencies in particular, Blue Cross and other prepayment plans, health planning organiza- tions, and voluntary health agencies. Program graduates are serving as assistant deans of medical schools and in medicare, medicaid, the regional medical programs, and in the comprehensive health planning program as executives at all levels. It is fair to say that graduate programs in hospital administration are f he primary source of trained administrative talent for health activities in this country. This is a field which owes its existence to the Rockefeller, Rosen- wald, and W. K. Kellog Foundations. They, and Kellog in particular, have invested large sums in the programs, but they feel that a success- ful demonstration cannot be supported by foundations indefinitely. It is time for society to assume responsibility. The growth I have outlined to you also reflects a high degree of interest on the part of universities in what is clearly a key social re- sponsibility. Hospital administration is an increasingly attractive career choice for bright young people who combine managerial apti- tude with a feeling of social responsibility. Some of the best students on the campus demonstrate an interest in hospital administration. Many of these students, and this is important, are not considering other health careers, but are also considering Government, industry, and other graduate schools. The graduate programs have some unique characteristic which will be of interest to the subcommittee. In the first place, they are located in a variety of departments of colleges within the university. Eight are in schools of public health, seven in graduate schools of business PAGENO="0271" 263 or public administration, five are in general graduate schools, and others are parts of schools of medicine, health-related professions, and health services administration. Two are joint programs of two sep- ~rate colleges. So, the programs do not fall administratively into the familiar niches. What this means is that these interdisciplinary pro- grams are located in departments which have much to contribute to health program management, but with the exception of the eight in public health are outside the framework of most Federal support programs. Even programs in medical schools fail to gain access to necessary support because of the assumption that medical schools train only physicians. It is also important to point out that the programs are very interdisciplinary. Regardless of the setting, most draw management teaching from the management school, medical orientation from ~aoulty physicians, systems development content from engineering, und so forth. They involve teachers from economics, sociology, politi- cal science, and other faculties. The background of the program faculty members reflects this diversity. Hospital administration is proving to be an effective vehicle for mobilizing the full scope of disciplines which we must have working together for improved health services. This has particularly high payoff in the research activities the programs sponsor, which are contributing significantly to im- proved health care. Mr. Chairman, we applaud the significant improvements in health manpower programs which the Health Manpower Act of 1968 em- bodies. Most of the people encouraged and aided by the programs under this act will work in hospitals and related facilities. Many will receive much of their training in hospitals. The Labor Depart- ment reported that, in 1965, there were 2.7 million jobs in the health service industry. About three-fourths-2 million-were in hospitals, and another quarter of a million in nursing homes. Of the predicted ~,350,00O health service industry employees in 1975, 3,375,000 will work in hospitals. It is toward the need for these people `that the 1968 Health Manpower Act is focused. The act stresses, for example, nursing education-about two-thirds of all active professional nurses are employed in hospitals and related facilities-other professions could be mentioned to reinforce the point that the hos~ital is the prime consumer of health manpower. When we speak of optimum utilization of scarce and expensive health personnel, we are really speaking of effective hospital management. The empha- sis in the act, and in other places, on new health technologies, is largely focused on hospital-based technologies. How such technicians are utilized, indeed, if they are utilized, depends in large part on hospital management. While we are considering health manpower here today, it should be recalled that although all health costs are rising very fast, hospital costs are outpacing all others. And 60 to 65 percent of hospital costs are salaries. Critics of health costs call for more effective utilization of personnel to control costs, Critics of quality of medical care call for more personnel with better training, as well as for more effective in- stitutional quality controls. In addition, of course, the public has a vast investment in the bricks and mortar. Through the Hill-Burton program alone, the public has invested billions of dollars in hospitals. PAGENO="0272" 264 The hospital administrator has the primary responsibility for the effective use of the public investment be it in bricks or people. He also has major responsibility for creating the kind of environment in which new methods can be introduced and effective manpower utilization schemes implemented. If there is to be innovation in the allocation of health duties, it will come through the efforts and stimulation of effec- tive management in the hospitals. Hospital administrators have also taken the leadership in extending the role of the hospital to serve more than patients in `bed-so that other needs of the community are served with the highly expensive resources cdncentrated at the hospital. The graduate programs are preparing administrators for these tasks. The fact is, however, that the impact of the graduates has been limited. Less than half of the 7,000 general hospitals in this country' are headed by professionally trained administrators. Very large seg- ments of the Nation's health facilities have almost no trained ad~ ministrators. This is true of mental hospitals-with half of the Na- tion's beds-rural hospitals, and extended care facilities. Within the past few weeks, the 24 programs awarded about 400' master's degrees. It has been estimated that more than twice that number could have been placed. The demand for trained administra- tors far exceeds the supply, but the supply can he enlarged through increased teaching capacity and ability to compete for the really ex- cellent students which this field can attract. The graduate programs are quite small. The 2-year curriculum is intense and demands excellent faculty resources and seminar teach. ing. The number of well-qualified applicants is only slightly below the' number of openings nationally and `the more well-established schools have more applicants than they can no'w take. The Hill-Burton pro- gram recently provided support to our association for a recruiting effort which we are confident will close the gap in a short time and is significant recognition of the importance of the field. We are also encouraging the establishment of new programs and establishing formal accreditation to stimulate educational quality. The pimary barrier to meeting the Nation's needs for more well-trained health' administrators is adequate faculty and the second acute need is student support. Mr. Chairman, we have been working for 12 years for hospital' administration graduate programs to have equal `access to funds made available under sections 306 and 309 of the Public Health Service Act. Perhaps it is a surprise that this is a problem. For a long time the Public Health Service staff held that hospital administrators are not public health workers and the programs therefore ineligible' for assistance. At the same time other divisions of the Public Health Service' worked to promote the hospital as the nucleus of community health programs. More recently, on June 5, to be exact, the University of Chicago, one of our outstanding programs in hospital `administration, was refused support because the review committee "became convinced that the program was basically one in hospital administration," and that priority is given to the development "of curriculums stress~ the community as a base and the interrelationship of the various com- munity organizations related to the coordination of health care sys- tems as opposed to the approach reflected in many `present day' PAGENO="0273" 265 hospital administration curriculums which concentrate primarily on the management and operation of the hospital itself." This statement is typical of the response hospital administration programs have received from the Public Health Service and reflects a total disregard for the role of hospital administration in realizing the objectives of the 1968 Health Manpower Act. It also completely ignores the overwhelming evidence presented at the 1965 White House Conference on Health of the critical role of medical institutions in manpower development and utilization as well as the National Ad- visory Commission on Health Manpower and the Manpower Report of the National Commission on Community Health Services. It ignores former Secretary Gardner's Advisory Committee on Hos- pital Effectiveness which said: The Committee believes that there is no element Of health manpower whose impact on hospital effectiveness is more important than the hospital adminis- trator's. The Committee recognizes the contribution to improvements in hospital administration made by existing university programs and their graduates but the fact that less than half the hospitals in the United States are administered by graduates with specific training for these responsibilities suggests that the educational programs~ need to be expanded. To achieve that purpose, the Committee strongly urges that the education and training of hospital administrators in the principles of effective management should be encouraged and facilitated by fellowships, scholarships and training grants financed by Federal funds. Both the second and third National Conferences on Public Health Training, in 1963 and 1967, convened by the Surgeon General, called attention to the need for assistance to hospital administration pro- grams. Nonetheless, so low a priority has been given as to freeze hospi- tal administration programs out of consideration regardless of the merits of the case. Mr. Chairman, we are not content to ask for clarification in the committee report of the eligibility of hospital administration programs in all university settings for assistance under section 306 and 308 of the Public Health Act, though that indeed would be helpful. We re- quest that section 302 of the Health Manpower Act of 1968 be specifi- cally amended to prorvide for assistance to graduate programs in hospital and health facility administration in all university settings and to students enrolled in such programs. Only by such explicit action can we achieve equal opportunity for this very critical program to obtain necessary assistance and establish a priority for such assistance which is in keeping with this Nation's health manpower needs. And if you will remember, the material presented to you this morn- ing by the American Hospital Association, the last part of their presentation covered somewhat the same points. Mr. ROGERS. Yes. I noticed there has been some agreement there. Did you testify before the Senate committee? Mr. THOMPSON. I did not. Mr. RoGERS. Did anyone for your organization? Mr. THoMPsoN. No', sir. Mr. ROGERS. So this really has not been presented over there at all. Mr. THOMPSON. Right. Mr. ROGERS. Thank you so much for your statement. It will be most helpful and we will consider all of the poir~ts you have raised and the 95-540-68-------18 PAGENO="0274" 266 suggestions for amendment to make sure we do have proper hospital administrators.. Thank you so much. We appreciate it. Mr. THOMPSON. Thank you. Mr. ROGERS. This concludes the hearings on this bill. (The following material was submitted for the record:) UNIvERsITY OF PENNSYLVANIA, Philadelphia, Pa., June 10, 1968. Hon. HARLEY 0. STAGGERS, House Office Building, Washington, D.C. DEAR CONGRESSMAN STAGGERS: My concern over certain provisions of the Health Manpower Act of 1968 prompts me to discuss with you particular aspects of the profession of veterinary medicine and the urgent need for continued and expanded federal support of our nation's schools of veterinary medicine. The professions of human and veterinary medicine have long shared a common heritage. Although the early history of veterinary medicine was closely related to the cure and treatment of domestic animal diseases, this segment of veteri- nary science today is only one aspect included within the broad scope of this health discipline. Increasingly, the science of veterinary medicine is serving as a proving ground for the solution of problems related to the transmission, alle- viation and treatment of human disease. Veterinarians today are providing answers to basic problems in public and environmental health, human nutrition and reproduction, food production and agricultural economics. Increasingly, practitioner-scientists trained in our nation's 18 veterinary schools are taking their places beside others in the health professions to assure our citizens a con- tinuity of comprehensive medical services which result in better health and more freedom from disability and morbidity than would be possible without the contribution of veterinary medicine to the total health cosmos of our nation. Today the concept of "One Medicine" is realistically `supported by a dynamic collaboration as veterinarians, physicians, dentists and scientists in the allied fields of biomedicine work together to achieve maximal well-being for men and a healthier environment conducive to more productive living. Typical of the kinds of programs undertaken by veterinarians whose professional interest is directed toward studying the animal counterparts of human diseases are two major studies currently in progress at the University of Pennsylvania School `of Veterinary Medicine. Dr. David Detweiler is engaged in a study to determine the post-mortem incidence of cardiovascular anomalies in dogs, the clinical evi- dence of heart disease and various parameters of cardiac function in healthy and diseased animals. Such studies have a direct correlation to the various kinds of congenital heart anomalies occurring in man. They also provide valuable information regarding the pathology, physiology and biochemistry of coronary artery disease and inyocardial infarction, leading causes of death among human beings. In another project, a disease almost identical to human leukemia, bovine lymphosarcoma, is being studied by a team of veterinary investigators under the direction of Dr. Robert Marshak Health scientists have always been faced with the enigma that as certain kinds of diseases are eradicated or brought under control, other more complex dis- eases and associated problems rapidly assume the newly vacated position of urgent priority for study and solution. In the field of animal diseases, many conditions peculiar to our highly industrialized and technological society are conducive to the development of special kinds of problems which merit the serious attention of veterinarians. Such problems include the mass production of livestock and poultry, concentration of animals in small geographic areas for feeding and economic management, transportation over long distances for marketing and breeding, and the addition of hormones, chemicals, drugs and antibiotics for increased growth and production. The close proximity of animal pets and animals which participate with man in sporting or relaxation activities multiplies the opportunity for human infection with disease agents harbored by or transmissible from animal to man. For those interested in scientific research, the specialized kinds of experience which constitute the training of a veterinarian make his knowledge and skill of unique value in the design and execution of experimental animal models capable of determining the projected effect on man of an outer space or subterranean PAGENO="0275" 267 environment. Veterinary scientists have been among the innovators of some of the original research programs designed to quantitate the effects of acceleration and deceleration on human and animal metabolism and problems related to acclimatization at atmospheric pressures and composition at variance with those normally encountered by man. Many other opportunities for valuable contributions in the field of scientific research parallel these newer challenges in which many of our nation's vet- erinarians are engaged. The production of vaccines and antitoxins to control the spread of both human and animal diseases has traditionally been a field in which veterinarians have worked together with physicians, immunologists, bio- chemist, pharmacologists and scientists from any other basic and clinical disci- plines. Many advances in human medicine and surgery, including develOping and perfecting open heart surgical techniques, hypothermia, the introduction of im- proved drugs for anesthesia and splinting techniques for broken bones have been pioneered with the aid of veterinarians. Other essential areas of research include the design and management of methods for insect and parasite controL Today about 50% of the nation's veterinarians work with farmers and agri- cultural specialists to produce quality cattle, swine, sheep and poultry for human consumption. It is conservatively estimated that losses to the livestock industry incurred by the morbidity and mortality caused by animal disease and infection amount of 15% of total production annually. A considerable portion of the price the consumer pays for poultry, eggs, milk, meat and other animal prod- ucts reflects losses to the farmer due to death and disease of animals he is unable to market. Estimations of the economic losses due to the six major disease problems among cattle, sheep and swine-mastitis, leptospirosis, bloat, hog chol- era, erysipelas and brucellosis-range from 800 million to 500 million dollars yearly. Allied to the work of veterinarians in the field of disease eradication and control is the valuable assistance many veterinarians have given to our allies and to the lesser developed nations of the world as they have worked to rebuild or strengthen their livestock industries and improve their national economy. Veterinarians are engaged in a wide variety of programs and activities oriented to provide our citizens with more wholesome and economic nutrition. Some of these include improving the quality of meat products, solving problems related to the sanitary preparation, packaging and storage of food products, the effect of drugs, food additives and insecticide residues on food products and monitoring the food industry to insure that legal safeguards regarding product identification, preparation and quality are respected. Of the 100 diseases known to be transmissible from animal to man, about 30 occur with some degree of frequency in the United States of America. The effective cooperation of veterinarians with other public health professionals has been specifically responsible for significant reductions in the incidence of rabies, tuber- culosis, brucellosis, parrot fever and other diseases of man. At various research stations throughout the United States, veterinarians and other public health officials are alert to the identification of animal diseases which are not presently found within continental United States. These activities have prevented the introduction of the dreaded hoof and mouth disease and rinderpest. Continuing research studies in the control and eradication of such diseases are essential because there is constant danger that such diseases may accidentally be intro- duced into our country at any time because of the ease and rapidity with which world-wide transportation functions as a disease vector. In order to insure our nation's supply of manpower to staff these varied and challenging opportunities available today and tomorrow for those whose aptitude, ability and interest lie within the realm of veterinary medicine, our nation's veterinary colleges need continued and expanding federal support. In order to fulfill their commitment to those eager, capable and deserving to pursue the arduous training necessary to qualify as a graduate veterinarian, our nation's veterinary colleges urgently need federal funds to expand their teaching faculties. Currently, three qualified candidates are not admitted for every student that is admitted to veterinary s~bool simply because teaching facilities are not available. Equally needed is financial support to completely equip and expand laboratories and clinical facilities and classrooms and to provide the means for the continuance of valuable fundamental and applied research. Loan and other plans to ease the financial problems associated with prolonged professional schooling must be made available to students in the basic veterinary science cur- riculum and to attract graduate students to the basic and clinical scicuces. Those with graduate training are urgently needed as teachers in the biological and PAGENO="0276" 268 physical sciences and to train others as research workers and as public health officials. Today veterinary medicine is so much a part of the health of man that this profession and its future practitioners should receive the same consideration with respect to federal support as medicine and the other health professions. It is essential that basic improvement grants be continued and extended to our naition's veterinary schools so that they can continue in their expanding contribu- tion to our nation's health. Sincerely, LUTHER L. TERRY, M.D., Vice President for Medical Affairs. THE AMERICAN PUBLIC HEALTH ASSOCIATION, INC., Washington, D.C., June 12, 1968. Hon. JOHN JARMAN. Chairman, ~`1ubcommittee on Public Health and Welfare, Committee on Interstate' and Foreign Commerce, Ilayburn House Office Building, Washington, D.C. DEAR MR. CHAIRMAN: I wish to inform you of the American Public Health Association's views on legislation which your Committee is now considering rela- tive to the continuation of programs intended to assist in the development of health manpower, HR. 15757. The APHA in the past has supported each of the programs contained in this legislative proposal; I would like to comment on them individually and suggest improvements to the basic legislation. The APHA recommends that the authorization for the Health Professions Educational Assistance Act be continued. The impact of initial authorization has yet to be felt because of the time lag necessary to realize originally intended benefits. Considerable time is needed to increase the ranks of physicians, dentists, and other health professionals and this should in no way overshadow the nation's duty to increase their number. Our Association believes that the authority of' this provision should include colleges o'f veterinary medicine as institutiona eligible for basic improvement grants. Contributions of doctors of veterinary medicine to human health are well known; and there is a need to train even more individuals in the field of veterinary medicine. We recommend, therefore, that basic improvement grants be made available to colleges of veterinary medicine. The American Public Health Association also believes there is a justification for continuing the priority for training nurses. The shortage of qualified' nurses is a critical problem not only in the health program.s recently authorized by Congress, but in delivering existent health care needed throughout the country. Consequently, we urge that the authority for nurse training be continued. The third title under this Act relates to the training of allied health profession- als. We urge the continuation of this authority and point out that this program has not had an opportunity to prove its worth. This is due in part, we think, to the inadequate financing appropriated. It is worth noting that until skilled per- sons assume `the responsibility for `the various roles in the medical care spec- trum, the already overworked physicians, dentists and nurses will continually fail to meet the monumental demands for health ea~-e. Therefore, we support the continuation of the authority for `allied health professional training. Most certainly the grant authority proposed by the `bill, H~R. 15757, should be extended for project grants to train personnel in schools of: public health, nursing, engineering, in departments of preventive medicine at medical schools, and in other appropriate areas. We are not familiar with the Administration's views on the amounts of funds needed to implement these programs. There might be some reason for persons to disagree as to what is necessary, but we would urge that these authorizations be at least equal to and preferably exceed au- thorizations contained in the presentAct. We hope `that Congress will act affirmatively on this forthcoming legislation and we hope it will incorporate our suggested changes within this legislation. I would appreciate your makng these recommendations a part of the hearing' records. Sincerely yours, BERWYN F. MATTISON, M.D., Eweentive Director, PAGENO="0277" 269 AMERICAN OSTEOPAThIC ASSOCIATION, Wa~shington, D.C., June 21, 1968. Hon. HARLEY 0. STAGGERS, t~hairinan, Interstate and Foreign Commerce Committee, house of Representative's, Tf7ashington, D.C. DEAn Mu. CHAIRMAN: The American Osteopathic Association is genuinely grateful for the opportunity to present its views on HR. 15757 during its con- sideration by the Committee on Interstate and Foreign Commerce of the House of Represejitatives. The American Osteopathic Association believes that H.R. 15757 provides the impetus for the solution of some of our health problems. We endorse the health recommendations of the President in his message to Congress on March 4, 1968. The proposed Health Manpower Act of 1968 em- bodies his goals ". . . to meet the urgent need for more doctors, nurses, and other health workers" . . . "to deal with the soaring costs of medical care and to assure the most efficient use of our health resources", and "to launch a nation- wide effort to improve `the health of all Americans." The objective of the American Osteopathic Association is to, promote the public health, to encourage scientific research, `and to maintain and improve high. standards of mMical education in osteopathic colleges. The Osteopathic profession is deeply involved In the attack on our nation's health problems in many ways. The need for more physicians is undisputed and the five colleges of osteopathic medicine continue to increase the number and quality of their graduates. The 1968 class of 430 graduate5 was almost 20% larger than that of 1966. Total enrollment in the same period has increased over 8%. However, the rising cost of education, especially in the health pro- fessions is a huge obstacle to the necessary expansion of the educational capacity of our colleges, both qualitatively and quantitativel~. Seldom does a college have th,e capability of expanding its student body, faculty and facilities without outside financial help. Traditionally, the members of the osteopathic profession have contributed a higher percentage of financial support to `their colleges than have the members of the other health professions. Today's costs and needs require additional support such a~ that provided by HR. 15757. The bill under consideration extends and strengthens five laws vital to our health manpower programs. Of most immediate concern to the American Os- teopathic Association and the American Association of Osteopathic Colleges is Title I of HR. 15757 which relates to Health Profession,s Tralining. The construction grants, institutional `and special project grants for training and student aid available under the Health Professions ~lducational Assistance Act of 1963 have played a major role in our ability to graduate a steadily increasing number of better trained osteopathic physicans and surgeons, 63% of whom are general practitioners providing direct health care to the people. This proposal is aimed at simplifying procedures and better coordination of the support of construction so that schools planning to construct facilities to serve a variety of functions will not be forced to deal with several authorities and several different review procedures and priorities. This would mean the elimination of many problems which have hindered the progress of some pro- grams. Flexibility is desperately needed if the `problems of `the individual schools are to be solved and costs kept to a minimum and we welcome the flexibility of planning and operation and the increased support proposed in the grant and student aid programs which Title I provides. Along with this lncrei~sed support comes greater responsibility. The assurance by the Federal Government of fair and proper distribution of funds and the demonstration of efficiency and good faith by the health professions will enhance this ever-growing partnership in Health. One pervading problem faces our expanding educational institutions,: `the ques- tion of quantity versus qu'ality. Such a dichotomy should not exist. What is needed is the fusion of the two and yet in the past an emphasis on quantity has aroused concern over quality. The question often raised is how to get the most out of what you have. Where facilities are limited and the faculty small, it is unrealistic to demand expansion, yet a vicious circle has developed in the health professions. In order to secure Federal support, an institution must in- sure an enrollment increase. This places added pressures and workloads on the administration and faculty and regression, instead of progress may result. Care PAGENO="0278" 270 must be exercised to be sure that quantity is not the major factor in determining the eligibility for financial support or the quality of the end result. We do not want the committee to feel that the American Osteopathic Associa- tion is disinterested in the other titles of H.R. 15757. It most certainly is in- terested, but would prefer to let those in the health profession whe are more knowledgeable, comment on their specific problems. On behalf of the American Osteopathic Association and the American As- sociation of Osteopathic Colleges may I convey their sincere appreciation of the opportunity to present their views to your committee. Sincerely yours, Ro~ J. HARVEY, D.O., Director. PHARMACEUTICAL MANUFACTURERS ASSOCIATION, Washington, D.C., June 18, 1968. Hox. JOHN JARMAN, Chairman, Subcommittee on Public Health and Welfare, Hayburn House Office BuikUng, Washington, D.C. DEAR MR. C~11AIEMAN: This letter is submitted on behalf of the Pharmaceutical Manufacturers Association concerning H.R. 15757, a bill entitled "The Health Manpower Act of 1968." It is a companion measure to S. 3095, a bill similarly entitled, on which hearings were held before the Senate Labor and Public Wel- fare Committee on March 21. This bill, among other things, would extend and improve the existing construction program for teaching facilities for students in the schools of medicine, pharmacy, and other health professions; it would also broaden the student loan and scholarship program to provide financial assist- ance to needy students in these professions. The PMA is a national trade association representing 136 firms which manu- facture approximately 95 percent of the nation's supply of prescription drugs. We respectfully call to the Subcommittee's attention the historical fact that there has been no important development in the field of effective drug therapy for more than a quarter century where members of the PMA have not played a significant role either in the discovery of the therapeutic agent or in defining its utility and making it readily available to the professions of medicine and pharmacy. The PMA is vitally interested in this legislation because of the effect it has on the health of this nation and upon the people who are providing our medi- cal and health services. Graduates of our medical and allied health schools are meeting the demands of Federal and state governments, of the armed serv- ices, of education, of research, of community services, and of industry. The pharmaceutical manufacturing industry employs many physicians, pharmacists, and others and our concern, therefore, is that the nation have an adequate supply of such personnel. The PMA believes that the extension and improvement of the construction program for teaching facilities which was initiated in the 88th Congress by the enactment of the Health Professions Educational Assistance Act is in the best interests of the nation because it makes possible theeducation and training of a greater number of physician and pharmacists. If our country is to be able to meet the demands for services now being made on its health professions, the enrollment in our medical, pharmacy and other health schools must be in- creased. To achieve this expanded enrollment through construction of addi- tional facilities at existing schools, as well as through the creation of new schools, we feel that it is necessary to have increased financial support from both the Government and private sectors. The PMA also approves the provisions of H.R. 15757, which make schools of pharmacy eligible to apply for special project grants; however, the bill excludes them from receiving institutional grants. We believe that H.R. 15757 should be amended to extend eligibility for institutional grants to schools of pharmacy, thus including schools of pharmacy among the other health schools eligible to receive such grants. It would be appreciated if you would make this letter a part of the printed record of your Subcommittee's hearings on H.R. 15757. Respectfully submitted, 0. Josnrrt STETLER, President. PAGENO="0279" 271 Tim NATIONAL ASSOCIATION OF RETAIL DRUGGISTS, Washington, D.C., June 18, 1968. Hon. Jouw JA1IMAN, Chairman, Subcommittee on Public Health and Welfare, House of Representatives, Washington, D.C. DEAR MR. JARMAN: The purpose of this letter for the printed record of H.R. 15757 hearings is to apprise you and other members of the important Public Health and Welfare Subcommittee of the U.S. House of Representatives Com- mittee on Interstate and Foreign Commerce regarding the views of the Na- tional Association of Retail Druggists on H.R. 15757, the "Health Manpower Act of 1968." The National Association of Retail Druggists, with the largest national mem- bership of retail pharmacy owners in the country, has historically been vitally concerned with all aspects of pharmacy education. Our concern is emphasized by the fact that 90 percent of the nation's pharmacists are employed in retail drug stores. N.A.R.D. represents over 40,000 independent retail pharmacies comprising about 90 percent of such stores. More than 75,000 licensed phar- macists are engaged in the practice of pharmacy in our member stores. We support continuation and the proposed extension of the program for the construction of teaching facilities for students in schools of pharmacy. We sup- port extension of the student loan and scholarship provisions for needy phar- macy students and authorization of special grants to pharmacy schools. In 1965 the N.A.R.D. took a similar position which received favorable con- sideration by members of your distinguished committee. We are concerned that H.R. 15757 does not provide institutional grants for pharmacy schools, for we believe that an inclusion of pharmacy schools deserves reconsideration as such inclusion would probably enhance greatly the diversified health care training programs in the college of pharmacy and would materially benefit the public. From our vantage point, the N.A.R.D. believes retail pharmacy is an essential link in the expanding Health and Medical Care programs. The drug distribution system in America through retail pharmacies is superior to all other approaches and is the one In most demand by the public. The retail pharmacy in the com- munities is indispensable and irreplaceable. We are confident that institutional grants for pharmacy schools are necessary to attract and secure appropriate teaching personnel and to pharmacy college services on a basis that is adequate to meet the future managerial and professional challenges of retail pharmacy. It is our recommendation that consideration be given to amending HR. 15757 so that pharmacy schools might be eligible for appropriate institutional grants. In the interest of high caliber pharmacy education for a greater number of pharmacy students to meet the critical shortage of pharmacy manpower, the National Association of Retail Druggists appreciates this opportunity to express its views on H.R. 15757. We recognize H.R. 15757 as health legislation of major interest to the public and to the pharmacy profession we proudly represent. Sincerely yours, WILLAED B. SIMMoNs, Ecoecutive Secretary. AMERICAN AssoCIATIoN or COLLEGES OF P0DIAERIC MimxcxNn, Washington, D.C., June 17, 1968. Hon. HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, U.S. House of Representatives, Washington, D.C. DEAR Mn. STAGGERS: The American Association of Colleges of Podiatric Medi- cine supports H.R. 15757 known as the "Health Manpower Act of 1968." The Association of Colleges is a voluntary, not-for-profit, corporation. The five member colleges of podiatry are accredited by the American Podiatry Associa- tion's Council on Education, the agency recognized for this purpose by the Com- missioner of Education, U.S. Department of Health, Education and Welfare. The colleges are all private, independent, non-profit institutions. The minimal educa- tional program is four years of podiatry college after two years of under- graduate work One third of the podiatry college graduates also complete an addi tional year of internship in various hospitals and colleges of podiatry, and some of them additional residency years, for a total of as much as ten years beyond PAGENO="0280" 272 high school. Podiatrists are licensed by examlnling boards in every state to treat the foot by medical and surgical means. As your Committee will knows, the podiatry profession has been deeply con- cerned for many years about the problem of providing a supply of well educated professionals adequate to meet the health needs of our people. As a direct result of the provisions of the Health Professions Educational Assistance Act the five accredited colleges of podiatry have been able to increase first-year student en- rollment from 167 four years ago to 311 this year, an increase of 86.2 percent during this period. Despite the increaSing number of well qualified graduates the Nation's critical shortage of podiatrists is as yet only being abated very slowly. Podiatric care is becoming more available to larger proportions of our population. The Congress last session included podiatrists' services for Medicare beneficiaries. Also, Title XIX programs in the various states utilize the services of podiatrists, the facili- ties and resources of the colleges of podiatric medicine are cooperating fully with these community health programs. In other areas increasing numbers of podiatrists are being sought for posi- tions on community public health teams, The armed services have doubled the spaces for podiatrists during the past two years and further expansion is pro- jected. Podiatrists are making increasing contributions to the Nation's health manpower resources. The U.S. Department of Labor in Report No. 323, June, 1967, "Health Man- power 1966-75-A Study of Requirements and Supply," pinpoints the need for in- creased numbers of podiatrists. "To meet projected needs, the average annual number of graduates of podiatry colleges must be increased substantially above the current levels between 1966 and 1975. Some increases in facilities are ex- pected as a result of funds provided by the Health Professions Educational Assistance Act of 1.963. However, a great deal of additional action is necessary to increase the capacity of the schools," says the report. Our purpose is to make clear our support of H.R. 15757 and to urge favorable consideration of it by this Committee. In this statement, we would like to outline the progress that has been made in recent years and the need for continuation of this legislation. Construction-All five colleges of podiatric medicine are planning construc- tion of new facilities and major expansion and renovation of existing facilities. One college has received approval for matching construction funds under the l)resent act. Additionally, projects and plans are underway for the opening of one or more new colleges within the next four to six years. Institutional grants.-C~ollective1y, the member institutions of the American Association of Colleges of Podiatric Medicine received $559,850 for Basic Im- provement Grants for FY 1968. These funds were used almost exclusively to em- ploy new faculty, increase faculty salaries, convert part time faculty to full time faculty, and to provide supporting staff for the faculty. As a result of these grants the educational program has been considerably enlarged and much enriched. special project grants.-The Special Project Grant requests for FY 1968 ($1,- 234,817) will be used to augment the faculty programs begun in the basic Im- provement area. The funds will be used to provide additional teaching personnel, additional supporting personnel, additional necessary teaching equipment and supplies in both the basic science and clinical science divisions, as well as for other related faculty improvement projects. S~clsolarship grants.-In FY 1968, 120 podiatry students received $84,389 in scholarship support. The amount of monies requested by the students was ap- proximately double the sum which was finally allocated. Based upon a survey con- ducted by the American Association of Colleges of Podiatric Medicine in .January, 1968, it has been determined that over one-half of the students currently receiving scholarship funds would not have been able to continue in college had they not received these awards. ~tudent loans.-In FY 1968, 3.84 students received $397,879 in loan support. The same situation exists for loans as for scholarship grants. Without these funds fully one-half of the student body would either have been totally unable to con- tinue their podiatric education or would have been forced to seek extramural, less accessible forms of educational financial assistance. It should be noted that the aforementioned figures for scholarships and student loans are equally applicable to both categories. Many podiatry students are deriving assistance from multiple sources. It is the opinion of the American PAGENO="0281" 273 Association of Colleges of Podiatric Medicine that increased financial assistance to the individual students under the direct control of the colleges would ensure more future practitioners and students better qualified to pursue studies in an atmosphere not characterized by omnipresent financial worries, and without limiting matriculants to the upper socio-economic strata. The Amei~ican Association of Colleges of Podiatric Medicine is pleased to take this opportunity to express its strong support for ER. 15757 entitled "Health Manpower Act of 1968." This bill when enacted by the Congress will have a posi- tive and substantial impact upon the future health of the American public by making it possible to increase the number of doctors of podatric medicine (valued members of the health manpower pool) by providing continued assistance for improvements in the teaching programs of podiatry colleges, and by providing loans and scholarships for young scholars who otherwise might not be able to consider a career in podiatry. It is our opinion that H.R. 15757 will provide some of the funds needed to meet critical problems facing the health professions today. On behalf of the American Association of Colleges of Podiatric Medicine it is respectfully requested that this statement on HR. 15757 be considered by your Oommittee and included in the record of these hearings. Respectfully yours, MAX M. POMEXANTZ, M.D., President. THE JoErNs HOPKINS UNIVERSITY, ScHooL OF MEDICINE, DEPARTMENT OF PATHOLOGY, Baltimore, Md., June 10, 1968. Representative HARLEY 0. STAGGERS, Chairman, Committee on Interstate and Foreign Commerce, ilayburn Building, Washington D.C. DEAR Mn. STAGGERS: This is to affirm support of The Health Manpower Act of 1968 and to urge an amendment which would extend institutional support to include veterinary medicine, for the contributions of veterinary medicine to human health in the field of comparative medicine and research are especially vital. It has become apparent that studying the naturally occurring diseases of animals which are counterparts of human disease can make signficant contri- butions to medical knowledge. To mention but a few, studies of the causes and treatment of such human diseases as leukemia, heart disease, and inherited disorders, have good equivalents in animals and are being explored by applied and basic methods which could not be utilized on human patients. Veterinarians, because of their backgrounds in Animal Medicine are best equipped to perform many of the investigations. There are currently 10 veterinarians actively engaged in teaching and re- search in comparative medicine at Johns Hopkins. Five of these persons are in post doctoral training programs which will prepare them for careers in comparative medicine. Several medical schools have formed departments within their faculties to develop similar programs and also to provide the necessary care for experimental animals for this has often been neglected. Medical schoola are actively seeking personnel to staff these departments, but unfortunately the other demands of veterinary medicine continue to require virtually all available graduates. The future of medical research and teaching will depend to a continually greater extent upon comparative medicine and the contributions of veterinarians~ specifically trained in these areas. Veterinary medicine is a very small profession as compared to medicine and to impose limitations on the availability of vet- erinarians for careers in comparative medicine will certainly compound the shortages already present. The needs of future populations, not only in these areas, but even more critically in the care of food producing animals, will cer- tainly be far greater than at present. In consideration of the above points, we strongly urge the inclusion of veterinary medicine for institutional support under The Health Manpower Act,. PAGENO="0282" 274 Certainly the contributions of veterinary medicine to human health, both directly and indirectly, equal or exceed those of the other allied professions which are to receive this support. EDWARD C. MELBY, 1r., D.V.M., Associate Professor and Head, Division of Animal Medicine. ROBERT A. SQUIRE, D.V.M., Ph. P., Assistant Professor of Pathology, Assistant Professor of Animal Medicine, Director, Comparative Pathology. tINEVERSITY OF KANSAS MEDICAL CENTER, Kan8a8 City, April 18, 1968. HON. HARLEY 0. STAGGERS, Chairman, House Interstate and Foreign Commerce Committee, House of Representatives, Washington, DC. DEAR CONGRESSMAN STAGGERS: I am respectfully presenting my views con- cerning the proposed legislation for the support of veterinary medical edu- cation and requesting that consideration be given to including the 18 veterinary schools and colleges in the basic improvement grant program. My experience has been in human medical education but I have visited several of the veterinary medical schools and know well several of their Deans. Furthermore, at the request of the Association of American Medical Colleges, I have led in developing a federation of schools of health professional edu- cational organizations and have purposely involved in this federation the As- sociation of Schools of Veterinary Medicine as well as medical schools, nursing schools, pharmacy schools, and allied health professional schools. This new federation scheduled next to meet on July 10, 1968, also includes representa- tives from the Office of the Secretary of HEW and the Bureau of Health Manpower. Further testimony as to the importance of the veterinary medical schools in the health professional educational team lies in the fact that virtually all medical schools now employ veterinary physicians to care for experimental and teaching animals. Still more important, however, is the fact that more and more human disease analogues have been found in animals thus providing pretotypes for the study of human disease. Animal vectors in the transmission of human disease are still poorly understood. You may question the lack of progress in this regard until recently by point- ing to the fact that all medical schools have used experimental animals for years. This raises a very improtant point in that in the past investigators in medical schools have been attempting to produce human diseases in normal animals for study purposes. The medical school animal laboratories have not focused on naturally occurring analogues of human disease in animals. The latter has been done by veterinary schools which have been poorly supported and overburdened with teaching so that research in veterinary schools has not flourished until recently. Moreover veterinary medicine has been oriented to agricultural activities as evidenced by the fact that many of the veterinary schools are in connection with state agricultural collegs and not state uni- versities, the latter of which harbor the mediCal schools in our state university systems. In Kansas our veterinary school Is 200 miles from the Medical School. The Dean of Kansas State College of Veterinary Medicine and I have been attempt- ing to bring our two staffs together in spite of the distance problems. In short by this letter I am describing veterinary medicine as a progressively more im- portant part of the health team and urge that in federal legislation it be treated as such. Sincerely yours, GEORGE A. WOLF, Jr., M.D. Dean and Provost. PAGENO="0283" 275 Tim PENNSYLVANIA STATE UNIVERSITY, THE MILTON S. hERSHEY MEDICAL CENTER, COLLEGE OF MEDICINE, Hershey, Pa., J~tne 11, 1968. Hon. HARLEY STAGGERS, Chairman, Interstate and 2~'oreign Commerce Committee, House of Representatives, Washington, D.C. DEAR CONGRESSMAN STAGGERS: I regret that it will not be possible for me to attend the hearings on HR 15757 scheduled later this week before your Com- mittee on Interstate and Foreiga Conunerce. I will be out of the country on an assignment for the Association of American Medical Colleges. I am Dean of The Pennsylvania State University College of Medicine which has this year taken its first class of medical students. In the teaching of medical students for the ultimate care of human patients, animals are widely used in laboratory teaching exercises. We have completed this year at Hershey a model facility for the housing of animals for both teach- ing and research. These facilities have been constructed wtih the aid of matching funds provided by the Congress. It would be impossible to do the type of teaching without these facilities. The operation of the facilities and the care of the animals is the responsibility of graduate veterinarians who work full-time for the Medical School, in addition to caring for the animals to see that optimum provision is made for their welfare. The veterinarians study the diseases which appear naturally in animals. Many of these diseases are caused by the same agents which produce human disease of similar character. The lessons learned from study of such disease processes can often be applied more easily and quickly than if the studies were initiated first in the human being. Training of veterinarians to serve in medical schools is initially done in colleges of Veterinary medicine. These institutions need more support, both to train the professional people who may ultimately work in a medical school and to conduct research done primarily on the animals and animal diseases them- selves. The basic information on the causes of many types of chronic illnesses which are becoming increasingly important in human disease processes requires long-term study of animals. Research is also badly needed in the basic biologic aspects of behavior, both of the group and of the individuals. Much behavioral research can be effectively done in animals species and the principles then extrap- olated to the human being. I urge your support of legislation which will improve the facilities needed for the training of veterinarians who will perform studies that ultimately will have an impact on human health. If I can comment in any further way on any of the points in the bill you have under consideration, please command me. Respectfully yours, GEORGE T. HARRIS, M.D., Dean. CASE WESTERN RESERVE UNIVERSITY, FRANCES PAYNE BOLTON SCHOOL OF NURSING, Cleveland, Ohio, April 29, 1968. Hon. HARLEY 0. STAGGERS, Ohairman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR Mn. STAGGERS: I am writing to you with regard to the proposed Health Manpower Act of 1968. I wish to comment particularly about items in Title II of the bill. As it now stands, the bill would require that a State agency would be named as an accrediting authority for schools of nursing eligible to receive Federal funds. I oppose this provision vigorously as a nurse educator and as a citizen interested in wise. use of Federal funds and in support of legislation that will improve the health care of citizens in our country. Voluntary accreditation has been the one force that has remarkably up- graded the quality of nursing education in our country. Currently, seventy-five per cent of all students enrolled in nursing schools are enrolled in schools having such accreditation. Graduation from an accredit~d school almost without ex- ception is a guarantee that a graduate will be able to pass the licensing ex- aminations; in contrast, graduation from a nonaccredited school does not give such assurance. We cannot afford to waste Federal funds in support of educa- tion that is not worthy of accreditation by the national voluntary accreditation PAGENO="0284" 276 ageney. You should know that the largest enrollments are in schools having National League for Nursing accreditation and thus expenditure of Federal funds in those schools would alleviate the current nursing shortage. I am concerned about a second provision of the bill, namely, that of program support for the schools. As proposed, each school, regardless of type, would receive program support in the amount of $15,000. Graduate education is far more expensive than is undergraduate education. Moreover, institutions of higher learning bear the greatest burden in that they must prepare leadership personnel for all schools and all service agencies. May I suggest that the bill be amended with a remarkably increased provision ~or program support for grad- uate schools. An annual support grant in the amount of $50,000 for each would be more appropriate. We appreciate your help and support in regard to this legislation and Will be eager to watch its movement through the legislative chambers. Sincerely yours, ROZELLA lvi. SCHLOTFELDP, Dean. Missouni VETERINARY MEDICAL AssoCIATIoN, Columbia, Mo., April 8, 1968. Hon. ,T0HN JARMAN, Chairman, ~ubcomnrittee on Public Health and Welfare, House of Representatives, Washington, D.C. DEAR REPRESENTATIVE JARMAN: We are writing to you about (Senate Bill S. 3095), or H.R. Bill 15757. We would like to bring to your attention that institu- tional grants for veterinary medicine have been left out of these pieces of legis- lation. We feel that it by all means should be included. According to the Department of Labor Report, published in November 1965 specific attention was given to the great demand and short supply of veteri- narians. This situation had been predicted in 1961 when the American Associa- tion of Land Grant Colleges and State Universities unvisioned a need for 64,440 Veterinarians (now 23,000) by 180. In 1902 the United States Subcommittee on Reorganization and Internal Orga- nization under Chairman Hubert H. Humphrey reported "Estimated number of Veterinarians needed in North America by 1980 is 47,250". Upon the already serious deficit came the passage of the Laboratory Animal Care Bill in 1966, Food and Drug Legislation, the Wholesome Meat Act of 1967 as well as the contemplated Poultry Inspection's Act of 168. Military require- ments, bromidicail research and public health demands far exceed the supply. Veterinarians are also being used to collaborate with, and relieve the shortage of, Physicians. One of the major factors in the current advance of human health standards dur- ing recent years has been the utilization of the living larger animal as models for the human in research. The pig alone has been utilized for the development of a long list of effective treatment. Each of the many animal species have certain features that closely parallel the human. Thus, the members of the animal king- dom may be selected to form, a battery that, in the composite nearly duplicate the human. In the work utilizing animals to solve human health problems we find the Veterinarian and the Physician working in collaboration. This is a most re- warding and logical approach. iJowever, the number of Veterinarians required for participation in comparative medical research is depleting Veterinary Medi- cal manpower in the more traditional areas. The inadequacy of the School at the University of Missouri is Illustrated by the migration of Veterinarians into the State. Of the Veterinarians newly li- censed by the State of Missouri recently only 25% were graduates of the Univer- sity of Missouri, the other 75% migrating here from other Universities. Because there are only eighteen Colleges of Veterinary Medicine located in 17 states the existing schools must provide for the needs of the 33 states not having Schools of Veterinary Medicine. This means that, more than any other major health profession, Veterinary Medical Education is truly of a regional and national nature. Federal support is extremely important. Yours truly, D. R. HANEY, D.V.M., Chairman of the Legislative Committee. PAGENO="0285" 277 Bos~ox Uxivznsrry, ScHooL 01? NURSING, Boston, Mass., February 2, 1968. Hon. Puiiir J. PIIILBIN, House of Representatives, Washington, D.C. Mv DEAR REPRESENTATIVE PHILBIN: I wish to express my opposition to the H.R. 13096, introduced by Represeuitative Fred B. Rooney, and S. 2549, intro- duced by Senator Lister Hill. The purpose of both bills is to prevent attrition and promote development of public and nonprofit private diploma schools of nursing. Experience with similar provisions of the Nurse Training Act of 19~34 demon- strated that payments to diploma schools has not decreased student attrition, nor has it developed these programs. There was a net decline of 24 diploma pro- grams during 1966. However, during the same period, there was an increase of 32 programs in junior community and four-year colleges. Money should be appropriated to assist these two types of programs in expansion. Support should be made to nursing pro- grams in general, with no designation of type of program. You are undoubtedly aware of the recent discussions in the Department of Health, Education, and Welfare about whether the Federal Government should enter the field of ac- creditation of institutions of higher education. The belief was accepted by all concerned that, in a democracy, voluntary nongovernmental type of accreditation was the wisest path to follow. I would also like to make a very strong plea that nurses be included on all committees established by Congress to consider health and welfare. All legisla- tion should be so stated. Nursing is such an essential aspect of all health and welfare programs that it is practically impossible for any group to plan for the best health care for the people without consultation with, and the cooperative thinking of, the nurse. Sincerely yours, ANNE KIBRICK, Ed. D,, Dean. OKLAHOMA BOARD OF NURsE REGISTRATION AND NURSING EDUCATION, Oklahoma City, Okia., June 24, 1968. Hon. HARLEY 0. STAGGERs, Chairman, Committee on Interstate and Foreign Commerce, House of Represenf- atives, Washingtoim, D.C. DEAR Sin: H.R. 15757, the Health Manpower Amendments of 1968 has been considered recently by the Public Health and Welfare Subcommittee of the Com- mittee on Interstate and Foreign Commerce. Title II or this bill would extend the Nurse Training Act of 1964 for four more years. We solicit your support of this bill and believe that the "Program Review Report of the Nurse `Training Act of 1964" (PHS publication No. 1740) will verify the value of this Act, as well as provide guidance for the Congress in this most Important matter. Section 231 of H.R. 15757 proposes a change in the definition of accreditation which is of great concern to us as the state approving agency for schools of nurs- ing in the state of Oklahoma. It is essential that schools of nursing receiving federal funds be accredited by a recognized national acerediting agency if proper use of federal funda is assured. In most states, a state board of nursing has the legal responsibility for ap- proving schools of nursing which meet minimum standards established by the statute and regulations, Accreditation by a recognized national acerediting agency is evidence that the school of nursing meets more than minimum stand- ards. The quality of nursing education is seriously threatened if this clause is not deleted. We request that you also consider the types oą pressure which can be exerted in the various states on an administrative agency and the likelihood that this would result in even lower standards, in some instances. Your interest and support for our concern regarding this legislation are sin- cerely appreciated. (Miss) FRANCES I, WADtLR, R.N., Ecoecutive Director. PAGENO="0286" 278 MIssIssIPPI NuRsEs' AssoCIATION, Jackson, Miss., June 24, .1968. Hon. HARLEY 0. STAGGERs, Chairman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR REPRESENTATIVE STAGGERS: Through recent communications, I have learned that the American Nurses' Association has expressed concern to you aibout the proposed change in the definition of accreditation, Section 231 of HR 15757. On behalf of the memhei~s of the Mississippi Nurses' Association, I want to express our concern and re-affirm the position of the American Nurses' Associa- tion. We vigorously oppose the use of tax funds to nursing programs that have not raised standards for national accreditation or for reasonable assurance of accreditation `by a recognized national accrediting body. Omission of accreditation by a national ~ccrediting agency will lower standards only. Two schools in our state have been accredited by a national agency (Na- tional League for Nursing). We are having a high percentage of failures (51%-1967) on state board exam- inations. The Nurses Board of Examination and Registration feels that if all schools would raise standards above the minimum requirements by a state accrediting agency, there would be less failures. The failure rate is of great con- cern in this state and could be Improved with upgrading standards. Our aim is for quality professional care and any lowering of standards could only result in a down hill trend-quality is certainly more to be desired than quantity no matter how great the shortage. We urge you to support national voluntary accreditation of nursing programs as pre-requisite for eligibility to apply for federal funds and will appreciate your interest and' Influence in removing the clause "or by a state agency" to the language of the Act. Sincerely, Mrs. ONEITA DoNGIzux, Ewecutive Director. MEDICAL SOCIETY OF THE STATE or NEW YoRIc, New York, N.Y., May 31, 1968. Hon. F. J. HORTON, House Office Building, Washington, D.C. DEAR Ma. HORTON: The House of Delegates of this Society adopted the follow- ing resolution, at its annnal meeting in February 1968. Resolved, That this House of Delegates of the Medical Society of the State of New York urge that the appropriate Federal agency study the proportion of grad- uating physicians who enter the field of medical research and the extent to which Federal support encourages duplication of research and diverts needed man- power from medical practice. The Council directed me to transmit this statement to the senators and rep- resentatives from New York State. Sincerely yours, HENRY I. FINEEERG, M.D., lilcoecutive Vice-President. MnaCER UNIVERSITY, Macon, Ga., June 13, 1968. Hon. JOHN JARMAN, Chairman, ~ubcomniittee on Public Health and Welfare, Rayburn House Office Building, Washington, D.C. DEAR CONGRESSMAN JARMAN The bill H.R. 15757, known as the Health Mann- power Act of 1968, tleserves and will receive the support of all educators in medi- cal and medical-related education. I deeply hope that it will be passed. Mercer University owns an.d operates the Southern School of Pharmacy in At- lanta, Georgia, and consequently we are conscious of the critical neredsi of all health educational endeavor, but especially pharmaceutical education. It is for- tunate for us at this time that pharmacy is Included in the Special Projects Grants under Title I, Part B, Section 772 of H.R. 15757. PAGENO="0287" 279 Pharmaceutical editcation, and indeed all medical education, now stands at a very critical juncture, The vast changes taking place in medical practice mean that new directions must be planned and implemented carefully in order that the total public health pregram of this nation may continue to. advance. It is my opinion that the Special Projects Section will contribute materially to this de- velopment in medical education. I note that in previous aid programs pharmacy has not been includud in the Institutional Grants Section and that it is not so included under Title I, Part B, Section 771 of this Bill, In my judgment, phar- macy should be included here because of its role in the total health program of our nation. I am sure you are aware that over the past few years a number of privately operated schools of pharmacy in the United States have been forced to close because of lack of financial support. The number of pharmacy schools in this country has decreased to seventy-four, and with the growing demand for ade- quately trained people in the profession, it seems to me that it would be wise to include pharmacy in the Institutional Grants Section. Doubtless you have thought \~ of this, ~ one who has been connected with medical education for many / ~ I want~ to express my thoughts on the matter. Agá~q~I hop\thi~ Bill will pass and that you and your committee will see fit to add p~mac~to Title I, Part B, Section 771. With thanks, and with good wishes, I an~ ~\ Yours ~ Rurus C. HARRIs, Presfdent. MERcER UNIvERsITY, SOUTHERN ScHooL or PHARMACY, Atlanta, Ga., June 13, 1968. Hon. JOHN Ji~u~ic, Chairman, Eubcominittee, on Public Health and Welfare, Ray burn Ho'u$e Office Building, Washington, D.C. M~ DEAR CONGRESSMAN JARMAN: I have just received information from Dr. Charles W. Bliven of the American Association of Colleges of Pharmacy that hearings on H.R. 15757, the Health Manpower Act of 1968, began Tuesday, June 11. All of un in pharmacy are deeply grateful for the assistance our schools have received and are now receiving under Public Law 89-290. This assistance has been a stimulus to provide schools such as ours the motivation to plan for the future. Our school has been approved for a construction grant and many of our students have received, and now are receiving, ucholarships and loans under this program. For this, we are grateful. Under Title I, Part B of H.R. 15757, I note that pharmacy has been included in the Special Project Grants Section 772. This will be most helpful to all phar- macy schools, but more especially the private schools such as ours who have faced, and are now facing, serious financial straits. It is my understanding that the American Association of Colleges of Pharmacy has requested that pharmacy be included under the Institutional Grant Section 771. I hope your committee will see fit to add pharmacy, as this support would help us tremendously with our enrollment and our efforts to better train pharmacists so that they may take their proper place along with other men~bers of the health team. Although enrollment at our school has increased over the past few years, support from an institutional grant as this would allow us to increase our enrollment more so that we could meet the needs of pharmacy in this section of the country. Again, let me thank you and your colleagues for your support of Health Education in our Nation. Yours sincerely, OLIVER M. LITTLEJOHN, Ph. D., Dean. AUBURN UNIVERSITY, SCHOOL or PHARMACY, Auburn, Ala., June 13, 1968, Hon. JOHN JARMAN, Chairman, subcommittee on Public Health and Welfare, Rayburn House Office Building, Washington, D.C. DEAn REPnuSENTATIv1~ JARMAN: I wish to submit a statement in support of the inclusion of schools of pharmacy in the Institutional Grants Provision of the PAGENO="0288" 280 Health Manpower Act 1968 (H.R. 15757). I feel additional support for pharma- ceutical education is critcial at this time for the following reasons: 1.) With the meager support presently available to schools and colleges of pharmacy, it is becoming impossible to offer competitive salaries in areas such as pharmacology. In this area pharmacy must compete with professional schools receiving insti- tutional grants. This unfair competition in many cases is resulting in an inferior instructional program at a time when great stress in pharmaceutical education is being placed on a sound background in the pharmaceutical and medical sci- ences. 2) As Dr. Goddard has mentioned in recent addresses, the pharmacist should be prepared to serve the patient and the medical practitioner as a con- sultanit on drugs, drug formulations and adverse drug reactions. Schools and colleges of pharmacy are presently revising their entire curricula to prepare graduates for this expanded responsibility. Funds are needed to provide addi- tional staff in clinical pharmacy and clinical pharmacologY. 3.) It Is becoming increasingly difficult to maintain minimal standards necessary for continued accreditation without support beyond that presently available. 4.) Funds are presently not available to support a graduate program in the pharmaceutical sciences. An opportunity for graduate study is essential in order to attract and retain an outstanding faculty. 5.) The pharmacy curriculum is considered "high cost" in comparison to other curricula in the University due to the large number of laboratories in which numerous animals, drugs, chemicals, pharmaceutical adjuvants and supplies are consumed and expensive instrumentation must be supplied. I assure you pharmaceutical education is facing a critical period in which it will be very difficult for it to continue to meet its obligation to the health man- power pool without participation in `the Institutional Grants Provision of the Health Manpower Act of 1968 on some basis. Sincerely, SAMUEL T. CoRa* Ph. 0., Dean. LOUISIANA STATE UNIVERsITY AND AGRIOULTURAL AND MECHANICAL COLLEGE, SCHooL OF VETRRINARY MEDICINE, Baton Rouge, La., June 13, 1968. Representative JOHN JAJIMAN, Chairman, subcommittee on Public Health and Welfare, House Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C. DEAR REPEE5ENVATIVE JARMAN: I have been informed that the Health Man- power Act of 19~38 (HR 15757) will be considered soon by your committee. Having been a resident of Oklahoma for twelve years, I am aware of your interest in the advancement of veterinary medical education. Here at Louisiana State Uni- versity, authorization has been given to the establishment of a School of Veter- inary Medicine. This school, when completed, will be one of the 19 in the United States to supply veterinarians to the State, the Region and the Nation. As you know, Veterinary Medicine is an essential component of health man- power of Louisiana and of the Nation. This branch of medical science is respon- sible for `the control of diseases' of all species of animals except man and has made significant contributions to the fund of knowledge that has advanced the health of the nation. Veterinary Medicine must be considered as a National resource and Veterinary Medical Education should receive the same degree of federal support extended to the other health professions including eligibility as recipients for the institutional grants provision of the Act. We are in agreement with the purposes of this Act and encourage you to give favorable consideration to the contiiTued and expanded federal support for the health and medical sciences. Sincerely, EVERETT P. B~scH, Dean. PAGENO="0289" 281 U~IVEImITy OF ILLINOIS, COLLuGE OF PIIA~MAOY, Chicago, Ill. June 1,, 1968. Hon. JOHN JARMAN, Chairmaa, Swbcom,nvittee on Public IIea~lth and Wclf are, Committee on Interstate and Foreign Commerce, It ay burn Office Building, Washington, ~ DEAn Sin: My name is George L. Webster and I am Dean of the College of Pharmacy of the University of Illinois, Chicago, Illinois, and I am the immedi- ate Past President of the American Association of Colleges of Pharmacy. I present this statement in behalf of my colleagues in pharmaceutical educatiop and for the purpose of furthering the delivery of more and better health care to the public. At the outset, I should like to express our apprecitalon for the Inclusion of colleges of pharmacy in the provisions for Special Projects Grants, Section 772, line 11 of HR 15757. I wish further to describe a concept by which the program of providing more and better health care can be accomplished with the aid of pharmacists and with the financial support which can be made available by including colleges of pharmacy in the proposed Section 771 of HR 15757. Many conferences during the past three years have emphasized the shortage of health care personnel. Physicians, nurses, and dentists have emphasized the need for others to perform some of the necessary tasks which have traditionally been done by them but which can be done by others who are properly trained and motivated. Specifically, there is a need for someone who is capable of counseling physi- cians and dentists regarding the choice of drug and dosage form to accomplish a given therapeutic purpose; a professional with the competence to counsel the public on their choices among drugs and dosage forms which can be purchased without a physician's or dentist's order and which will be compatible with those drugs which may have been prescribed for a primary medical treatment. There is a need for someone qualified to give advice as to the type of medical service needed by an ill person, a directive service which is readily available such as in a neighborhood Pharmacy. There is need for a knowledgeable pro- fessional to be consulted on the principles of providing for uncontaminated air and water, the control of communicable diseases, the services available for the recognition and treatment of degenerative diseases, the principles of emergency aid for household poisonings and the location of poison information centers for major catastrophes. These are a few of the health care tasks which my colleagues and I in phar- maceutical education project for the pharmacist in the near future. We have planned new approaches for the education of students now enrolled in our col- leges and new programs for the renewing of attitudes and information for practicing pharmacists. These new, and we believe, necessary programs are needed now but are beyond our fiscal capabilities because of budgets already committed as far as three years in advance. The financial aid which could become available by being participants in the provisions of Section 771 would allow those colleges of pharmacy which have completed plans to activate them within a short time and stimulate other colleges oct pharmacy to develop along this line. All programs developed to date require that students of pharmacy spend a significant time in a hospital ward under the direct supervision of a clinical instructor, studying the regimen of medication used on bona fide patients, analyzing the results as they are recorded on the charts and as they become apparent from interviews with the patients. To be effective, this interaction needs a background of knowledge about pathol- ogy, abnormal physiology, diagnostic procedures and behavioral sciences. It will require substantial additions to the budgets of our colleges of pharmacy to provide the added faculty to teach these subjects. Since pharmacists in community practice will need similar information in order to enable them to practice as effectively as the newly graduated pharina- cists, our colleges will need funds to supply it to the professional community. Colleges of pharmacy have a further obligation to educate scientists who can staff the industry and the federal ~cientiflc groups with persons who can create new drugs, new dosage forms and evaluate the relative effectiveness of similar dosage forms. 95-540-68--------19 PAGENO="0290" 282 All of the above obligations of our colleges of pharmacy can be greatly en- hanced by being able to participate in the programs sponsored by HR 15757 and, in particular, Section 771. I respectfully a:sk that your committee give your approval to the inclusion of colleges of pharmacy In this Section. GEORGE L. WEBSTER, Dean. [Telegram] Nnw YORK, N.Y., June 18, 1968. Hon. H&iu~y 0. STAGGERS, ChoArman, Committee on Interstate and Foreign Commerce, House of Representatives, Washington, D.C.: The National Student Nurses Association wishes to communicate its support of H.R. 15757 which would extend the Nursing Training Act of 1964 for four years. At our convention last month the representatives of our 60,000-member association of undergraduate students of nursing went on record as believing that it is of paramount importance that nursing schools receiving federal funds be accredited by the National League for Nursing. At the present time 75 percent of nursing students attend NLN-accredited programs. We believe that students of nursing deserve to go to schools which .are nationally accredited and that patients too, deserve this protection. Patient care depends on the quality of education. We urge you to include accreditation of nursing schools by the National League for Nursing as a criterion for receiving federal funds. FRANCES TOMPKINS, Erecutive Director, NationaZ student Nurses Association, Inc. STATEMENT OF THE NATIONAL ASsoCIATIoN or STATE UNIVERSITIES AND LAND- GRANT COLLEGES The National Association of State Universities and Land-Grant Colleges repre- sents 99 major sate universities and land-grant institutions located in all 50 States and Puerto Rico. Its members enroll ilearly 30 percent of all students in the nation. They award 44 percent of all medical and dental degrees in the nation and 50.9 percent of thoSe in other health professions. In addition, they contain all but one of the nation's schools of veterinary science. In the future, these institutions will inevitably produce an even greater share ocf the nation's badly needed health manpower, as much of the expansion of medical education Is taking place in state and land-grant institutionsL At its annual meeting in November 1967, our Association, meeting jointly with the American Association of State Colleges and Universities, commended the 90th Congress "for its recognition of the need for substantial programs of support for education, extension activities, and library servieeI~ in health-related fields through the enactment of the Health Professions Educational Assistance Act, the Regional Medical Programs Act, and significant expansions of existing legislation." We are pleased that the Congress has continued to demonstrate its interest in these fields by its consideration of the Health Manpower Act of 1968. We partic- ularly commend and endorse the provision of this Act which makes direct operational support available to schools of nursing. The needs of the schools of nursing are such that in its 1968 statement of policy positions concerning recom- mendations for national action affecting higher education, the Association urged that this kind of support be extended to these schools. The Association is also pleased to note that ll.R. 15757 contains provisions for extending the eligibility for special improvement grants to schools of phar- macy and veterinary science. This too was a matter of concern at our most recent annual meeting. Our member inStitutions, however, would like to see the committee carry this extension one step further. They are also anxious to see schools of pharmacy and veterinary science eligible for institutional, basic improvement grants. In the words of our 1968 policy statement, "We note with concern that eligibility for assistance for the schools of pharmacy and veterinary science is limited to construction aid. We urge corrective legislation to end this discrimination to major health-related fields, especially as concerns eligibility for basic and special PAGENO="0291" 283 improvement grants for support of the institutional function at schools of pharmacy and veterinary science." In conclusion, we support and commend the general objectives of H.R. 15757 and hope that the modification we are suggesting can be Incorporated into this legislation. STATEMENT OF JESSE P. DERRICK, D.V.M., PRESIDENT, THE GEORGIA VETERINARY MEDICAL ASSOCIATION The Veterinary Profession, while the oldest of the medical professions, is probably the least understood insofar as the importance and contributions to human health and wcifare. Most familiar to the average citizen is the professional care provided for the animal population. The care of animal pets in our society is an essential and much appreciated service, but the major contribution to man's well being has been the high level of professional care provided to the livestock population which serves as a source of food. Within recent years an additional responsibility of the veterinary profession has emerged to the forefront-participation in bio- medical research programs to study and resolve the health problems of man. Within this sphere of professional activity, the Doctor of Veterinary Medicine assumes two major roles. First he functions as an independent scientist studying disease processed in animals and providing basic biological data and knowledge which can be extrapolated to man. Each of us is already benefiting as a result of knowledge gained through the use of animals and the future resolution of major health problems such as cancer, heart diseases, mental health, and popula- tion control will, to a significant degree, depend on the availability of well trained scientists in veterinary medicine. Secondly, the increased use of animals as experimental models for biological research has placed a demand on the veterinary profession which far exceeds the ability of veterinary schools to train adequate members in the facilities presently avaih~ble according to a recent survey of the Institute of Laboratory Animal Resources of the National Academy of Science. There are over 2000 institutions and facilities in the United States whose programs require the use of research animals. All of these need access to veterinary support by veterinarians specifically trained in the specialty of laboratory animal medicine, and, at the present time there are only 106 who have been certified by this Specialty Board. It is probable that the entire output of veterinarians from all the schools in the United States would be required to meet the existing need for veterinarians in laboratory animal medicine, and this is only one of the specialties in biomedical research dependent on the knowledge and special skills of the veterinary scientist. In addition to vastly increased activities of veterinarians In biomedical re- search, the recent passage of meats and poultry inspection regulations to protect the consumer requires increased number of veterinarians. Further requirements are compounded by the increased need for animal protein food stuff in the world calls for more veterinarians to control diseases. The World Food Agricultural Organization estimates that a 50% reduction of losses from animal diseases in the developing countries is a realistic goal and that it would result in 25% increase in animal protein produced. This reduction in animal disease losses can come about only by an increased supply of veterinarians educated to conduct biomedical investigations to solve many of the problems resulting in death of animals and likewise in man where the diseases are trans- missible to man. The present occupations of veterinarians in the USA are as follows: 7 percent in large animal practice, 19 percent in small animal practice, 31 percent in mixed practice for a total of 57 percent of the veterinarians in the USA that are con- ducting practice. The remaining 43 percent are engaged in other activities such as teaching, research, consumer regulatory work for the government and industry. The need for veterinarians considerably exceeds the productive capacity of the present educations system. A long range forecast indicates that 40,000 veteri- narians will be needed by 1980. This figure is 12,000 in excess of what our present veterinary colleges can provide. Obviously the additional 12,000 veterinarians can be educated only by enlarging existing schools and building new schools. There are 18 schools of veterinary medicine for the 50 states of the USA and each serves more than the state in which it is located. The School of Veterinary PAGENO="0292" 284 Medicine, University of Georgia serves a total of five states: Georgia, South Carolina, North Carolina, Virginia and Maillafld. Veterinary schools should be viewed as a national resource instead of a state resource and therefore partly supported by federal dollars in supplement, to the appropriation from the state in which the school is located. The demand for entrance into the professional program of the veterinary schools far exceeds the capacity of the existing schools. For example, the follow- ing numbers of eligible preveterinarY candidates were interviewed for entry into the School of Veterinary Medicine at the University of Georgia: 1967 (1968)' Georgia - South Carolina 10 (14) North Carolina 10 (13) Virginia - 24 (30) Maryland 28 (46) Total 121 (156) -~ 1 Tentative. The figures above in parentheses are approximately for 1968 because inter~ views are now in process and the academic year for determining eligibility is not completed. All of the above candidates have exceeded the average college student grade point and have survived elimination on personal interview ex- aminations conducted within each state. From this total the University of Geor- gia accepted 64 students for the entering class of 1967; not all of these will be graduated because of the normal attrition rate. If federal assistance in the form of an institutional grant were available for improving our present educational plant, and if a constructions grant were avail- able for building an addition to the present schools of veterinary medicine, we would have matching state funds to increase the size of our entering class to a minimum of 85 students for an increase of 33 percent. From the above discussion the critical importance of H.R. 15757 (Health Man- power Act of 1968) in support of veterinary education is obvious for the South- eastern States. This bill would provide vital support for construction grants, stu- dent loans, and scholarship grants in the 18 schools of veterinary medicine in these 50 states. It is unfortunate that veterinary schools have not been declared eligible to receive institutional grants under ll.R. 15757 in view of the direct contribution of veterinarians to biomedical research, public health and consumer protection. The importance of educating veterinarians to protect the health of man is incontra- vertible. We cannot emphasize too strongly the importance of making schools of veterinary medicine eligible for institutional grants under the Bill. STATEMENT OF AREA TEN COMMUNITY COLLEGE, CEDAR RAPIDS, IOWA INTRODUcTION In reference to HR. 15757 (Staggers, W.Va.) which proposes to amend the Public Health Service Act, there are areas of nursing and allied health training which need to be considered especially as they relate to their educational en- vironments. It was indicated in Titles II and III of the proposed legislation that both public and nonprofit private agencies will be eligible for grants, but there is no specific mention of public comprehensive community colleges or area voca- tional-technical colleges. IOWA LEGISLATION With the establishment of sixteen of these area schools in Iowa by the sixty- first General Assembly in 1965, it has become a reality to serve not only needs of ndults in health occupations education but also education and training needs in a variety of occupations. The law, in fact, has been termed a model in its com- PAGENO="0293" 285 prehensive approach toward serving all adults. Specifically, the Iowa law pro- vides for the following: 1. The first two years of college work including pre-professional education. 2. Vocitional and technical education. 3. Programs for in-service training and re-training of workers. 4. Programs for high school completion for students of post-high school age. 5. Programs for selected high school students in vocational-technical education 6. Student personnel services. 7. Commuaity services. 8. Vocational education for persons who have academic, socio-economic or other handicaps. 9. Training, re-training and all necessary preparation for productive employ- ment of all citizens. 10. Vocational and technical education for persons who are not enrolled in a high school and have not completed high school. GROWTH AND DEVELOPMENT or IOWA HEALTH OCCUPATIONS EDUCATION Throughout the nation there continues to be a shortage of qualified workers who can care for the sick in hospitals, nursing homes, clinics, doctors' offices and other health agencies. In recent years a restructuring of traditional health- care patterns has taken place. The greatest single change is the emerging role of health care personnel prepared in vocational-technical programs in which they achieve the necessary knowledge and skills to function as effective mem- bers of the health-care team. To date, 204 health occupations have been identified and new ones are constantly emerging. In 1958 the Division of Vocational Education, Iowa Department of Public Instruction initiated an agreement and contracted with the University of Iowa to provide state consultant services for health occupations education in Iowa. The State consultant staff hold University of Iowa faculty appointments and compose the Program in Health Occupations Education in the University. This program is housed on campus and is promoting and implementing a strong health occupations education state-wide program. The expansion of health occupations education In the many states has been enhanced by partial reimbursement with the George-Barden Act of 1956 and the Vocational Education Act of 1963. In addition, there are states which con- duct some health occupations education programs federally reimbursed only with Manpower Development and Training Act funds. In Iowa, however, ar- rangements have been made with the State Employment Security Ctmmission whereby any person qualifying for Manpower Development and Training Act funds may be admitted to a program funded under the Vocational Education Act provided he also meets the admission requirements of the program. Table I shows program growth in Iowa. The Iowa Division of Vocational Education, like its counterparts in other states, cooperates with public educational institutions throughout the State to provide programs which prepare graduates for employment in various types of health occupations. Presently in Iowa, 910 students are enrolled in 34 such preparatory programs of one and two years in length and 584 students have taken advantage of the supplemental programs. In the 1968-69 school year, several of these programs will increase enrollments and some will admit an additional class at mid-year. Also, during this same year 8 new preparatory programs will be in operation. Multiple 4-week pre-employment programs for nurse aides and orderlies are also offered throughout the State. Health occupations education programs in Iowa are administered by com- munity colleges and area vocational-technical colleges. All programs are ap- proved by the Iowa Board for Vocational Education arid those preparing practical nurses and associate degree nurses are also approved by the Iowa Board of Nursing. While uniform standards~ policies, and procedures are reflected in these pro- grams, they have sufficient flexibility to allow tailoring to each local situation. All facets are controlled by the administering public educational institution. It employs the coordinator and instructors and is responsible for the provisions of adequate resources and facilities. Appropriate clinical facilities are made avail- able through contractual agreements between the administrative agency and hos- pitals and other local health agencies. PAGENO="0294" 286 IOWA DEPARTMBNT OF PUBLIC INSTRUcTION DIVISION OF VOCATIONAL EDUCATION HEALTH OCCUPATIONS EDUCATION SECTION TABLE I TOTAL NUMBER OF PREPARATORY HEALTH OCCUPATIONS EDUCATION PROGRAMS IN IOWA BY YEAR Numh~r = j 39 38 : - -~ -~ - 1~ 1~ -~- -~ I- -~--~ ~D -~- -~ 2~ 2~3 ~ 21 -~- - - - ~ I- 19 1' -~ T7 -Ifl.- 1L~ ~-~- 11 `,- 10 / , t~ 7 D S 3 I ~? 6 I 6 0 4 Year ~:t~ to ~ (r~ (1) 0) H to (C) ~ ~j- (0) (3) H Ř LI) ~ U) 1) 05) H t~- (C) ~ tO 1-C) (3) H cxt Of) ~ 0- U) (3) H C~ U) I CC) 0) (3) H t~ (0 ~ 0) (.1) 0) H H U) ~ C) (0 0)) H (N (0 1 H (C) 0) H 0) C) 1 ~ (0 CD H Z~ (0 1 CO (C) 0) H (0) (CL ~ ~ (0 (5) H (C) 0~ C)) (0 (0 (C) ~ U) (C) 0- (0 (0 U) Ci) 0) 05) H H H PAGENO="0295" IOWA DEFAL1TEWI 01' PUbLIC IN3T~CiCTI0N DIVISION OF VOCATIONAL UCATIOl HEALTh OCCUPATIONS EDUCATION SLUIION `N1J~ER OF PREPARATORY kIEALTtI OCCUPATIONS EDUCATION PROGRASS iN IOWA LD~ TIPS DY YEAR I I practical urce -~ - 1:111:1 = iii_ - T - `~. - ~ractica1 * ~icaInur5T~~ - 3 practical nurse - ` practical nurse ~ ~ ic 1967 - 1968 YEAR NUMBER TYUJC l2;3T~'~679 101112131 181q201 - 1966 - 1967 associate decree nurse - epelitins reosi tecunici 1965 - 1955 dentaL assisi siedical latoretdry mauled assis tent practical nurs rrectical 1cooi atorv 1968 - 1955 964 1962 - 1963 1961 - 1062 1960 - 1961 1959 - 1960 1958 - 1959 1957 - 1958 1956 - 1957 1955 - 1956 1954 - 1955 I 1~53 osthcat assistant practical nurse W~ATcnt lathrat nedical assistant practical nurse osdical assistant practical nurse ~tical nurse PAGENO="0296" 288 State and local advisory committees are used. Their members advise in mat- ters pertaining to the program and serve as liaison between the community and the program. With representation from interested professional, paraprofessional and lay groups in the community, these committees contribute to program de- velopment, implementation and evaluation. Doubtless, the growth of health occupations education programs will continue in the years ahead. In Iowa the health occupations education program moves ahead with multiple activities, interests, and an identifiable degree of success and effectiveness.. There continue to be unmet needs for heatlh workers in our state. While the gap between need and preparation is still great. it has and will be further lessened if we continue to be persistent in improving and expanding quality programs. Of concern the past two years is that the practical nursing programs have had far more qualified applicants than they are able to accept. This trend persists despite efforts to provide adequate counseling and guidance to encourage prepara- tion to the highest level of abilities. By their own choice and with persistence, some select practical nursing who are potentially successful in programs prepar- ing students to become registered nurses. Hopefully with the present and ex- tended development of Associate Degree programs in our State, this situation will improve and larger numbers of nurses can be prepared in both levels of preparation. Dr. William H. Stewart, Surgeon General, U.S. Public Health Service, has esti- mated that to meet the health care needs of our society there must be 10,000 health workers prepared each month for the next ten years. Despite the growth in educational programs in health occupations to date, further expansion seems imperative. Vocational education has a vital role in helping to meet this challenge. Through further expansion of quality health occupations education programs it will con- tinue to meet the objectives of its primary two-fold purpose: (1) to prepare per- sons for gainful employment, (2) to assist in meeting the needs of our society. AREA TEN COMMUNITY COLLEGE: A COMPREHENSIVE APPROACH IN IOWA Area Ten Community College, one of sixteen merged area colleges, comprising seven counties in Eastern Iowa, has developed as a comprehensive multi-purpose institution. Included in its broad spectrum of opportunities are the largest num- ber of Health Occupations Education offerings in the state. In cooperation with the University of Iowa and the Office of the Chief Consultant of Health Occupa- tions Education for the State Department of Public Instruction, Area Ten is building towards a comprehensive Health Occupations Education Center which will initiate and implement regional demonstration programs. as well as serve the continuing needs of adults in the area. Current programs either in operation or beginning this fall at Area Ten, include Environmental Assistant, Dental Laboratory Technician, Orthopedic Assistant, Occupational Therapy Assistant. Practical Nursing, Medical Assistant, Nurse Aide and Dental Assistant. Programs being developed for initiation in a year include Medical Laboratory Assistant, Im- mediate Care Assistant, Associate Degree Nursing (both pre-professional and RN), Nursing Home Administrator and Social Work Assistant. HEALTH OCCUPATIONS CENTER: NEED FOR FUNDS These cluster programs and others yet to be developed form common cores of learning experiences and offer broad occupational opportunities for adults of varying abilities, interests, and aptitudes. This is in keeping with the college's open-door policy which in turn provides developmental alternatives according to individual needs in certificate, diploma, and associate degree programs. Program development costs, as well as instructional and equipment expenses, have been partially reimbursed through the Vocational Education Act of 19t13. These funds, however, do not allow for construction, student loans, scholarships, and so forth, which are proposed for funding in Mr. Stagger's bill. Obviously federal assistance, especially construction grants, is vital to new and developing institutions such as Area Ten Community College, as well as other public community colleges and vocational-technical colleges throughout Iowa and the nation. PAGENO="0297" 289 TRENDS IN HEALTH OCCUPATIONS EDUCATION When looking, simultaneously, at health service needs and human resources to provide health workers, it becomes evident there is potential for, and merit in, a more effective correlation of human resources with employment opportunities. A much better utilization of all levels of human resources can be accomplished through suitable and adequate preparation of health service workers. It is im- perative that this preparation be provided in quality educational programs ad- ministered or supported by an agency firmly committed to the educational role. ~ ~ Economics of Education-Current studiqs have been initiated to com- pare the social, governmental and individual investment in education with the return on this investment to society and the individual. As educational programs at all levels seek a progressively larger share of the available public resources, there are many searching questions pertaining to priorities for which public education funds will be allocated. To date, very few cost analysis studies have been attempted which would identify the most beneficial or economic utilization of public education funds in view of personnel prepared. Based on principles es- tablished in other areas and studies in this field, indications are that a larger, more comprehensive program will prove to be by far the most efficient structure. 2. The Changing Structure and Role of Public Education-There have been dramatic changes in the demands on the public education system in recent years. Society expects this system to provide appropriate educational programs for people of all ages, levels of ability, and interests. A significant shift in organiza- tional structure and a marked expansion in type of educational programs are well underway in an attempt to fulfill this expectation. Public colleges and universities have long provided the occupational prepara- tion for the health professions at the baccalaureate and higher degree levels. A similar obligation, to provide preparation at less than professional level for the great majority of our young people and adults who will not complete a college degree, is being recognized in the emerging role of public education. This emerg- ing role prompted the need for larger population and financial bases to provide an adequate student flow. The result has been a significant organizational change, the establishment of educational programs on an area or regional base. A major role of this comprehensive community college or area vocational-tech- nical college is to provide educational programs which are occupationally oriented. A number of these are preparatory program.s offered parallel to the first year or two of college; others, usually of shorter duration, are for retraining and/or upgrading. 3. The Shift in Orientation for Health Occupations Education-The trend to shift Health Occupations Education programs from service institutions (hospital, clinic, or other health agency) to an area or regional educational institution is compatible with the role of the comprehensive community college or area voca- tional-technical college. Simultaneously, a basic change in philosophy is taking place. This philosophy embraces the principle of charging educational costs to educational institutions supported by the public tax base. Traditionally, programs to prepare health oc- cupations personnel emerged in service institutions with a subordinate role in education. The costs of such programs have necessarily been included as service charges and therefoi~e borne by patients. Many programs operated by service institutions have been discontinued due to financial stress. Also, the mobility of our present work force precludes the retention of those trained in a particular service institution long enough for them to return services commensurate with the investment made. Shifting the cost to a broad educational base seems appro- priate and more compatible with this increased mobility of our labor force. There are additional advantages to support this shift of Health Occupations Education to community colleges or area vocational-technical colleges. Because of the size and numbers of inter-related programs, the proportionate overhead and administrative costs will not only be decreased but they will be borne by education. The potentially larger pool of recruits, with proper guidance, will provide a steady flow of appropriate applicants. The socially accepted objective of "going to college" can be realized and status derived from attending this type of institution, rather than a service-oriented institution, will likely enhance enrollments. PAGENO="0298" 2~O LEGISLATION CONCERNS Our concerns in regard to legislation are several: 1. that the Public Health Service Act not be limited only to associate degree programs in the various nursing and allied health occupations programs, but rather that it allows for Health Occupations Education Centers like the one being developed at Area Ten Community College in which certificate, diploma and associate degree programs form interwoven clusters de~lgned to meet the wide diversity of adult needs. This is not only efficient and economical in terms of Cross utilization of space, equipment, and instructors, but also allows more choices to adults according to their individual interests and abilities. 2. that the public comprehensive community colleges and vocational-technical colleges be recognized as the prime movers in meeting the education and train- ing needs for para-medical and allied health occupations, and that strong pro- visions for them be written into the Public Health Service Act. (a) The trend and impetus has already been established in this direction and is recognized by professionals in Health Occupation as being valid. (b) The policy of private hospital programs of requiring health occupations trainees to. spend extended pediods of time in repetitive so-called clinical training is economical neither to the hospital patient nor to the student, al- though it allows the hospital to hold down employee costs. Instead it is pro- posed *that public educational institutions using a broader tax base can educate more economically in a shorter period of time and yet provide sufficient clinical training by contracting with public and private non- profit hospitals. 3. That the business of education, particularly the education and training of adults at the sub-baccalaureate level who have been largely overlooked by private institutions because of social, economic, or other handicaps belongs in the public community colleges and vocational-technical colleges created and committed to serve these citizens. By the same token, such educational institu- tions would be unjustified in opening in-patient hospital facilities. CONCLUSION In summary, the responsibility for designing and maintaining innovative health occupation.s education programs, in order both to alleviate the shortages in health occupations and, perhaps more importantly, to provide economical education for all people, has already been assumed by public community and vocational- technical colleges, especially those mandated by legislation like thcat of Iowa. Much progress has been made considering limited resources. It would seem to run counter to the spirit and intent of previous legislation not to emphasize the public community colleges and vocational-technical col- leges, both from the standpoint of social concern and economics in the written form of the Public Health Service Act as it finally evolves. Respectfully submitted, ELIZABETH KERR, Director of Health Occupations Education, Division of Medical Services, the University of Iowa, Chief State Consnltant to Health Occupations Education Section, Vocational Education Branch, State Department of Public Instruction. Dr. S. A. BALLANTYNE, Superintendent, Area Ten Community College. STATEMENT or CLARENCE R. COLE D.V.M., PH. D., DEAN, COLLEGE OF VETERINARY MEDICINE, THE OHIO STATE UNIVERSITY, CoLuMBus SUMMARY Veterinary medicine is one of the health professions concerned with the health and well-being of animals and man, the control of diseases transmissible from animals to man, and discovery of new knowledge in comparative medicine. The broadening role of professional activity pertaining to human health, coupled with a rapidly increasing population and the resulting demand for foods of animal origin, is bring to emergency proportions the already critical shortage in the nation's supply of veterinary medical manpower. PAGENO="0299" 291 A large part of veterinarians' professional activity is directed toward pro- tection of the consuming public. One primary responsibility of veterinarians is the prevention of human illness derived from animal sources. In response to the nationwide demand for consumer protection, Congress in 1967 passed the Whole- some Meat Act (Public Law 90-201) and the 90th Congress will consider at least three bills pertaining to inspection of poultry and poultry meat products. The Laboratory Animal Welfare Act of August 24, 1966 (Public Law 89-544) has placed vast responsibilities upon veterinarians to initiate and execute a nation- wide program for laboratory animal welfare. The above new national programs demand hundreds of veterinarians at a time when there is already a critical shortage of veterinary medical manpower. Studies have indicated the need for doubling the number of veterinarians by 1980 and more than tripling the number of veterinarians in several fields of specialization in veterinary medicine by 1975. The gigantic task for increasing the number of veterinarians is currently the responsibility of the eighteen veterinary medical schools and colleges located in seventeen states of our nation. Veterinary medical colleges have been unable to capitalize upon well established new educational techniques because they were denied the educational improvement grants provided to other health professional colleges under Public Lw 00-290. Insufficient funds have handicapped educator's attempts to adopt modern methods of education-such as classroom use of com- puters, closed circuit television, and autodidactic laboratories-to veterinary medical education. Achievement of minimal goals for increased enrollment and maintenance of the quality of professional education requires vast increased financial support. Experience has clearly demonstrated that adequate funds for development and expansion cannot be provided by the seventeen states which are currently attempting to educate veterinary medical personnel for all fifty states. Facilities and operational support are not adequate even for the number of students currently enrolled in the veterinary medical colleges in this country. If enrollment is to be increased, it is imperative that veterinary medical col- leges be included in future legislation relating to the following support of educa- tion in the health professions: educational improvement grants, construction of teaching and research facilities, institutional support for innovations in veterinary education, and student loans and scholarship grants. THE ROLE OF THE VETERINARIAN IN OUR SOCIETY The activities of all veterinarians contribute to public health. Veterinary medi- cine is concerned with the health and well-being of animals and man. It is con- cerned with the control of diseases transmissible from animal to man and with the discovery of new knowledge in comparative medicine. During the past twenty- five years, activity in comparative medicine and the biomedical sciences has itmreased at a spectacular rate and has greatly expanded the role of the veterinary medical profession. Public health responsibilities of the veterinarian, A large proportion of veterinarians' professional activity is directed toward protection of the consuming public. The primary objectives of the veterinarian are to prevent human illness derived from animal sources and to protect the health of animals. Veterinarians carry a large responsibility in the field of public health. Many state and municipal codes require at least one veterinarian on the board of health. According to a 1900 report of the Ohio Department of Health, veteri- narians have the largest representation of any professional group serving on local health boards. Veterinary medicine provides specific benefits to human health in three major ways: (1) Removal of sources of infection to man through eradication or control of those animal diseases transmissible to man, (2) Development of preventives or treatments that can be adapted for use in man, and (3) Develop- ment of food hygiene programs that protect the consumer against food-borne diseases. Removal of sources of infection-More than 100 diseases of animals are transmissible to man. In 1945, 10,000 cases of rabies were reported in animals, and thousands of people in our nation were treated for this deadly dises se. As a result of research and training, the incidence of this disease has dropped more than 50 per cent In the past fifteen years, and 1967 marks the first year PAGENO="0300" 292 in our history with no human deaths from rabies. Veterinarians vaccinate seven million of the nation's fifty million dog and cat population annually. Research is under way `to develop means for elimination of rabies in bats and other wildlife. Many viral diseases of man are transmitted by insects, and the survival of the virus depends upon birds and other animal hosts. Three types of insect- borne virus encephalitis are recognized in the United States. Veterinarians determine that species of animal life that are essential reservoirs of infection and those that form necessary links in the animal-human infection chain. Development of Treatment of Preventives.-V'eterinary medicine, formerly oriented to the study of animal diseases for the benefit of animals thmselves, since 1940 has been oriented to comparative medicine and the biomedical sci- ences. Advances in veterinary medicine contribute materially to human welfare through the protection of man against certain transmissible diseases, the insuring of a stable economy for production of essential food and fiber, and the safeguarding of `the wholesome supply of food products of animal origin. Today, veterinary medicine is faced with the additional challenge of providing adequately trained manpower for research where animals serve as biological models for studies `of diseases that primarily affect man, and whose solution can only indirectly benefit animals. Food Hygiene-In respons'e to the nationwide demand for consumer protec- tion, Congress passed the Wholesome Meat Act in 1967 (Public Law 90-201) and Congress will consider at least three bills pertaining to inspection of poultry and poultry meat products. The above legislation requires hundreds of veter- inarians to implement the new program. Veterinarians participate in food hygiene research and advise and assist in the development and maintenance of recommended, ordinances regarding milk sanitation, poultry inspection, and sanitation of food service establishments. Animal diseases are of public health significance because some are transmissible to man through milk, meat, poultry and other animal food products. Food products may also serve as vehicles of human infections, namely, typhoid fever, diphtheria, scarlet fever and strepito- coccal infectiGns. The American public takes wholesome food supplies for granted and does not realize that often it is only through the activities of veterinarians that foods *of animal origin come from healthy animals and are inspected to insure their safety before reacihng the consumer. In fiscal year 1968, 104,988,350 animals were slaughtered under Federal Meat Inspection. Veterinarians direct all slaughtering and administer the over-all meat inspection program, as well as the humane slaughter law, which requires `that animals be rendered insensible before slaughter begins. During 1966, over 264,992 animals at slaughter were condemned by veterinarians as unfit for human consumption. In addition, over 9,765.514 animal carcasses were temporarily retained until diseased or affected portions were removed. Veterinarians in the Bureau of Veterinary Medicine of the Food and Drug Administration are concerned with the protection of human health They develop scientific methods for detecting worthless or harmful drugs and assure that foods, drugs, and cosmetics are wholesome, safe to use, made under sanitary conditions, and truthfully labeled. They determine the safety or danger of additives (such as antibiotics and other growth stimulating drugs) in feed consumed by food-producing animals to insure that meat, milk, or eggs are safe for human consumption. Unfortunately, the shortage of veterinarians' avalable for food inspection has curtailed the federal, state, and municipal food inspection programs and has sometimes allowed adulterated, unwholesome, mislabeled, and contaminated food `to reach the consumer. A wide variety of chemicals are used to protect animals and crops against insects. Many of these chemicals leave a toxic residue which is cumulatively deposited in the animal. When the residue exceeds acceptable levels of safety, the affected product is disposed of in accordance with good food hygiene principles. Protection Against Importation of Foreign Diseases-The risk of introducing foot-and-mouth disease into the United States grows with increasing travel abroad and the prevalence of the disease throughout much of the world. Great Britain is experiencing the most severe outbreak of foot-and-mouth disease in it~ history. Over 2,300 herds (415,800 animals) died or were slaughtered from the beginning of the outbreak to February 1988 in a campaign to eradicate this devastating disease. PAGENO="0301" 293 Through inspection of imported animals, poultry, and all animal by-products, veterinarians prevent entry of foreign diseases into the United States. Of the 981,860 animals and 2,950,829 birds presented for import during 1967, 43,961 animals and 9,365 birds were refused entry because they were carrying diseases contagious to man and animals. During the same fiscal year, veterinarians inspected and certified over 69,000 animals for export to foreign countries. More than 156 million pounds of meat and meat food products from foreign countries were condemned or refused entry in 1967. Veterinarians in research Three quarters of all veterinary medical prescriptions written today are for drugs that were non-existent twenty-five years ago. Contributions to knowl- edge in comparative medical sciences since World War II are greater than those made in all previous years of history. The activities of veterinarians holding research or service positions in govern- ment and industry are not as well known to the public as those services rendered by the veterinarians engaged in farm practice or operation of small animal hospitals. Yet one-third of the vterinary profession is engaged in the former category of activty. In 1965, it was estimated that veterinarians in the animal health industry (pharmaceutical and biological) alone controlled a segment of industry valued at $600 million annually. Veterinarians hold positions of leadership in approxi- mately 310 different companies operating in the chemical and pharmaceutical industries of the United States. Although many of these individuals serve the areas of animal health, vet- erinarians play a vital role in industrial research and development of drugs and other chemicals consumed by man. The greatest recruiting fervor is in the field of toxicology. Veterinary toxicologists are primarily concerned with develop- ing knowledge of the toxic potential of chemical substances, and their fate in the environment, in order to prevent poisoning. Veterinarians serve as directors of toxicology research for many of the pharmaceutical companies developing drugs for human use. These include companies such as Eli Lilly, Upjohn, Huff- man LaRoche, CIBA, Warren-Teed, Pitman-Moore, Wm. S. Merrell, Sandoz and Syntex. Veterinarians have pioneered in toxicologic research concerning space; en- vironmental hazards; pesticides; toxicants in food, air and water pollution; and chemical warfare agents. Veterinarians' activities include research in the discovery and development of drugs and other chemicals to be used as food additives in the treatment of human and animal diseases. After a new chemical is synthesized, the veterin- arian is responsible for determining the potential value of the chemical in treatment of disease. Before the chemical can be released for human trial, he must determine, through a long series of testing in many species of animals whether or not the chemical is toxic. Veterinarians in the biologics industry are engaged in discovery and develop- ment of new vaccines, serums, and other biological products of animal origins. Veterinarians have the responsibility n~t only for determining the value of potential products, but also for assuring both the safety and potency of the products. Federal veterinarians supervise activities in more than seventy com- panies licensed to produce biologic's for disease prevention and as treatment. Study of spontaneous disorders in lower animals provides information more relevant to human disease than does the study of artifically-produced diseases in laboratory animals. A number of spontaneous models for human diseases have been delineated by veterinarians, viz, systemic l'upus erythematosus in dogs and mice, porphyra, in cows and pigs, atopic diseases in dogs, and balding in primates other than man. Veterinarians are studying animals with naturally occurring diseases (such as diabetes, heart disease, cancer, and blindness) which are identical to their counterparts in man. In December 1966, a faculty group in the College of Veterinary Medicine at the Ohio State University made an important breakthrough in cancer research. They discovered that leukemia is transmitted through the air and that animals inhaling the virus develop leukemia. Veterinarians in the Army and Air Force Veterinary medical officers of the Armed Forces play a major role in pre- ventive medicine and environmental health by protecting the health of service- men stationed throughout the world. The functions of a military veterinarian PAGENO="0302" 294 are similar to those of the veterinarian in civilian life. His training in the medical sciences enables him to participate in preventive medicine and research activities. The military veterinarian has paralleled his physician counterpart in con- tributing to human health and welfare through his responsibility for inspection of all foods of animal origin consumed by the serviceman. The Department of Defense has assigned world-wide food inspection responsibilities to the mili- tary veterinarian. In addition, he has responsibility for disease control through appropriate food handling, inspections of community areas, utilities and waste disposal, and rodent conrtol. Because his training in medical science is parallel to that of the physician, the Doctor of Veterinary Medicine assumes preventive medicine research func- tions in addition to those which are related to foods of animal origins. Large numbers of veterinarians in the military service are engaged in research. For example, research on the solution of high altitude problems by using animals and vehicles projected into space; acceleration anj clecelerations; space flights; and space travel. Through animal experimentation, veterinarians determine the effects of radiation upon animals and, by extrapolation, upon man. Other examples are flight and ground feeding research; preservation of foods by radia- tion; research designed to protect against biological warfare; research on dis- eases transmissible from animals to man; and World-wide laboratory support. Veterinarians in laboratory animal medicine The laboratory animal industry is valued at nearly $500 million. Original research data using animals in space prior to manned flighrs is an example of the veterinarians' participation. New treatments for disease, new vaccines, and new surgical procedures are flr~t developed by veterinarians on animals to demonstrate their value and safety before such drugs or procedures are used for man. Animals used for biomedical research total 37 million annually. Veterinarians are using millions of animals to study cancer-causing and cancer-inhibiting chemicals, to measure the effects of radioactivity, and to study the reactions of living organisms in space. Laboratory animals constitute a vital resource for medical and other biological research. Animals must be painstakingly calibrated and standardized as the most sensitive instrument in many health research projects. Loss of laboratory animals from disease or malnutrition can have an impact far beyond the cost of the animals' replacement. It can meet set- backs in scientific efforts in which millions of dollars are invested. One of the growing phases of veterinary service is to provide healthy, uni- form laboratory animals, for these represent indispensable elements in bio- medical research. Veterinary research is concerned with the diseases common to man and animals, and recognizes the usefulness of animals for experimen- tation in the study of human health problems. Advances In animal health re- search often open doors to the solution of human disease problems. Generally, research in veterinary medicine makes contributions to human health and well- being as well. The magnitude of the role of veterinarians in laboratory animal medicine is illustrated by the budget and staff of Dr. Zinn, Director of Laboratory Ani- mal Resources at the National In~titutes of Health. He has a budget of $3.6 million and a staff of 300 employees. Veterianarians in large animaZ practice Veterinary research, clinical practice, public health, and regulatory activities in the United States have made possible an abundance of safe, wholesome pro- tein foods. The average per capita consumption of food in the United States exceeds 1500 pounds per year. Over 650 pound's per capitn are foods of animal origin. Veterinarians are currently responsible for the health of 108.4 million cattle, 100 million hogs, 30 million sheep, 2.5 million poultry, and 3.1 millIon horses. Estimates of the value of these animals are: cattle, $12 billion; swine, $1.2 billion; sheep, $201 million; and poultry, $480 mullen. Veterinarians in smali animal practice These veterinarians, recognizing the close as~ociatiort between pets and their owners, are constantly striving to eliminate or minimize diseases-such as rabies, psittacosis, and tuberculosis-which might be ti~ansmi1ited to hnman beings. PAGENO="0303" 295 They provide service to 25 million dogs, 20 million cats, and an estimated 20 million caged birds in the United States. TUE INCREASING NEED FOR DOCTORS OF VETERINARY MEDICINE The national demand for veterinarians has increased as the population has in- creased and as the veterinarian's role in our society has broadened. The nation's present total of 24,328 D.V.M.'s cannot fulfill the current responsibilities of the veterinary medical profession. Recent new legislation has placed extensive additional demands upon veter- inarian~. Hundreds of veterinarians will be required to carry out the require- ments of the 1967 Wholesome Meat Act and the 1966 Laboratory Welfare Act. Several hundred more will be required when bills on poultry inspection, cur- rently before Congress are enacted. A.s our population increases and creates a demand for a greater food supply, control of animal disea'ses becomes imperative. Current estimates indicate the need for a 50 per cent national increase in food production by 1975 and a 200 per cent increase by the year 2000. The federal government places a $2.8 billion annual price tax on livestock and poultry losses due to infectious and non-infectious diseases, insects, parasites and nutritional disordars. In addition to this actual loss, more than $245 million was spent in 1959 for pharmaceuticals, biologicals and other treatments for ani- mal use. Industries ultimately affected by loss of livestock through disease include meat packers, tanners and animal fiber producers, The meat packers report an esti- mated $31 million loss due to condemnation of carcasses in 1960. Nationally, disease causes a loss of $6.73 per head on feed lot cattle going to market. In Ohio alone, the animal loss exceeds $3.5 million. An increasing proportion of doctors of veterinary medicine annually enter bio- medical research and service in salaried positions in industry and government. According to a survey conducted by the American Veterinary Medical Associa- tion, 45.4 per cent of all veterinarians who graduated in 1964 entered health ac- tivities other than private practice. (In contrast, only 29 per cent of the 1964 newly graduate physicians entered fields of health activities other than patient care.) Many enter professional health-related activities in areas such as (1) public health; (2) laboratory animal medicine; (3) U.S. Army and Air Force; (4) animal disease control agencies; (5) biomedical research in government, universities, and industrial laboratories; (6) meat inspection service; (7) World Health Organization and Food and Agriculture Organization of the United Nations; and (8) The Pure Food and Drug Administration. The competition for doctors of veterinary medicine is evidenced by the exten- sive advertising of industrial firms and the federal government in &,ience magazine and in the professional veterinary medical journals. A shortage of veterinarians has made it impossible for the pharmaceutical and chemical induis~ tries to employ adequate numhers to conduct research designed to discover, de- velop, and test drugs and chemicals for food and cosmetic additives and for treatment and prevention of disease. In the field of toxicology, this shortage has reached emergency proportions. With over 3,000,000 chemicals known, and new ones being synthesized at the rate of 7,000 a year, far more veterinary toxi- cologists are needed than presently can be trained by the colleges of veterinary medicine. The international tragedy which occurred a few years ago, when many babies were born witho'ut hands or feet because pregnant mothers consumed thalidomide, could have been averted by animal testing of the compound "thalid- omide" prior to human use. The "Community Health Concept" being promoted across the United States further exaggerates the need for veterinarians. The commentary on the urban "rat problem" in a recent issue of Time magazine cited five major diseases ofthis rodent which are readily transmissible to man. Doctors of Veterinary Medicine have made significant discoveries pertaining to each of those five major diseases. Veterinarians are adaptable professionally and scientifically, and will serve well within the framework of the new "Community Health Concept." Dr. W. T. S. Thorp, a member of the Advisory Council of the Bureau of Health Manpower, U.S. Department of Health, Education, and Welfare baa predicted a shortage of 20.000 veterinarians by 1985. He declared that this is occurring at a time when modern medicine in all its categories, including veterinary medi- cine, requires a greater degree of competence and specialization than ever before. PAGENO="0304" 296 THE NEED FOR FEDERAL SUPPORT OF VETERINARY MEDICAL EDUCATION Citizens who are genuinely concerned with our nation's total health and wel- fare, recognizes an emerging national emergency created by the extreme short- age of veterinarians. The obvious answer is to expand the colleges of veterinarp medicine in a manner which will enable them to accommodate the large num- bers of young men and women who apply for admission. Facilities and opera~ tional support are not adequate even for the students currently enrolled in this veterinary medical colleges in this country. At one of the oldest and well-established colleges of veterinary medicine, 50 per cent of the professional students and a large portion of the faculty are lo- cated in temporary space in the university's garage. That college is awaiting funds to become available for construction of teaching and research facilities. Equipment for instruction is either antiquated or so limited as to handicap the lahoratory instruction in many schools. Their factulty and technical personnel are being lost to colleges of medicine, industry and government laboratories in the fierce competition for veterinary medical manpower. Eighteen colleges in seventeen states carry the burden of supplying the na- tion's veterinarians. Each of these colleges is accredited by the Council on Education of the American Veterinary Medical Association, and their graduates are eligible to take state and national board examinations in veterinary medi- cine, dentistry and surgery; but the number of veterinarians graduated each year from all colleges totals only about 1,000. Six to eight years of university education is required for the Doctor of Veteri- nary Medicine degree. The courses required are nearly identical to those required for the degree of Doctor of Medicine, except that all species of animals except man are considered. After two to four years of pre-veterinary medical education in the university, students may apply for admission to the College of Veterinary Medicine where an additional four years of professional education is required before the degree of Doctor of Veterinary Medicine is awarded. During the past sixteen years at The Ohio State University, 66 to 75 percent of the well-qualified applicants for admission to the College of Veterinary Medicine could not be accepted because the college has inadequate facilities and faculty to accommodate more students. For the same reasons, during the past sixteen years, 89 per cent of the Doctors of Veterinary Medicine were refuSed admission to the Ph. D. programs in one of the departments. The deficiencies in veterinary manpower are assuming alarming proportions. The number of professional students in the nation~s colleges of veterinary inedi- clue must be increased by two- to three-fold if a national emergency is to be avoided. The following is a quotation from a report in the 1961 proceedings of the Amer- ican Association of Land Grant Colleges and State Universities: The best estimates based on current needs indicate that the number of veterinarians in the country should be tripled by 1980. . . . in order to ac- complish this . . . the capacity of all the present veterinary colleges must be doubled and at least five new veterinary colleges established immediately. In response to an overwhelming demand for graduates, most veterinary col- leges are now developing means of accommodating more qualified applicants by increasing class size, or moving toward year-round teaching programs. Estimates have also indicated that a 300 per cent increase in the number of vet- erinarians in the many specialties in veterinary medicine will be needed by 1975. Achievement of minimal goals for increased enrollment in the Colleges of Veteri- nary Medicine and maintenance of the quality of professional education requires vastly increased financial support. Experience has clearly demonstrated that adequate funds for development and expansion are not and will not be provided by the states In which the nation's eighteen veterinary medical colleges are lo- cated. Since these colleges must educate veterinarians for the entire nation, fed- eral support of their development and expansion is clearly justified. The efforts of veterinarians to maintain animal health and directly and indirectly to promote human health justify the contention that veterinary education is as deserving of federal support as any other health profession for which provisions have already been made in the Health Professions Educational Assistance Act. Insufficient funds have handicapped educators' attempts to adapt modern principles of edu- cation-such as classroom use of computers, closed circuit television, and auto- didactic or autotutorial laboratories-to veterinary medical education. PAGENO="0305" 297 Veterinary medical colleges have been unable to capitalize upon the well- established new educational techniques because they were denied the educational improvement grants provided to other health professional colleges under Public Law 90-290. Research on veterinary medical education and innovations in cur- riculum have been hampered by the lack of significant financial support. It is imperative that veterinary medical colleges be included in future legislation relating to the support of education in the health professions, including: educa- tional improvement grants, construction of teaching and research facilities and institutional support for innovations in veterinary education and research and student loans and scholarship grants. The undeniable potential of the Veterinary medical component of the health professions can be reached through continued and expanding support by the U.S. Public Health Service. STATEMENT OF DAvID E. DANIEL, DIRECTOR OF COLLEGE RELATIONS, LOUISBIJRG Connnen, LOUISBURG, NC. Mr. Chairman, it is with gratitude for the opportunity extended to me that I render a short written statement which directs attention to the outright and criti- cal need for federal operational funding in nursing education. Particular ref- erence to the associate degree nursing program will be made. The conclusion to be drawn is that H.R. 13096 or H.R. 15758 should carry provision for general operational funding for all programs which produce the registered nurse. In my opening remarks I wish to quote from a recent publication entitled Nursing in the $out/a by Hessel H. Flitter. Permission for use of this material before this committee has been granted by Dr. Winfred H. Godwin, Director of the Southern Regional Education Board, who with the financial help of the Kel- logg Foundation, produced the publication. "In 1957, the National League for Nursing recommended a conservative ratio of 300 nurses per 100,000 population. Six years later, taking the expansion of health facilities and programs and other factors into account, the Surgeon Gen- eral's Consultant Group recommended a minimum goal of 375 nurses per 100,000 population by 1970. More recently, the Division of Nursing of the U.S. Public Health Service reassessed the situation and set a goal for 1975 of 450 RN's per 100,000 population." 1 ". . . registered nurses . . . are prepared for beginning practice through three types of progams: diploma programs administered and supported by hospitals, generally three years in length; associate degree programs administered by junior or community colleges or, less often, by senior colleges or universities, usually two years in length; and bachelor's degree programs administered by senior col- leges or universities, four to five years in length. "Each of these types of program must be approved by the state board of nurs- ing in the state in order for graduates of these programs to be eligible to take the state licensing examination. Upon successful completion of this examination, the nurse is registered iii that state and entitled to be called an `RN.'" 2 "A large amount of the nursing services obtained by citizens in the South is given by practical or vocational nurses. Practical nurses are qualified to give care to the sick in hospitals and nursing homes under the orders of a physician or the supervision of a registered nurse. Practical nurses generally receive their education in one-year programs administered by vocational and technical schools, hospitals, junior colleges, high schools, and independent agencies. Each program is approved by a state agency and only graduates of state-approved programs are eligible to take the state licensing examination. All 50 states have some provisions for licensing practical nurses, and 15 have legislation which requires licensure of all persons employed as practical nurses. "Federal legislation which provided funds for educational programs, such as the Manpower Development and Training Act of 1962 and the Vocational Edu- cation Act of 1963, has influenced the rapid expansion of programs preparing practical nurses." "Of the three types of programs which prepare nurses for licensure as RN's- diploma programs constituted 80 percent of these programs in the nation and 77 I Hessel IT. Flitter, Nursing In the E,~outh (Atlanta: Southern Regional Education Board, January, 1968), p. 1. 2 Ibid.; pp. 7-8. Ibid., pp.. 23-24. 95-540-68-----20 PAGENO="0306" 298 percent in the South in 1960. By 1966, diploma programs had decreased to the point where they represented 65 percent of the programs in the nation and 58 percent of those in the South. "Although the diploma programs are still the most numerous, the most rapid growth in recent years has been in the associate degree programs administered mainly by junior colleges. In 1960, associate degree programs represented six percent of the nursing programs in the South. By 1966, they represented 23 percent of the programs in the South and 32 percent of the 218 associate degree nursing programs in the nation."4 "In the period between 1960 and 1966, the South experienced an overall in- crease of 28 percent in admissions in the three types of programs that prepare nurses for licensure as RN's. When the admissions are examined for each type of program, wide variations can be seen. Bachelor's degree admissions increased by about 85 percent, associate degree admissions increased by 650 percent, and admissions to diploma programs decreased by more than nine percent." ~ "In 1966, the South averaged a ratio of 198 nurses to 100,000 population. National goals for 1975 projected needs for 450 nurses per 100,000 population. At the present rate of production of nurses, and in the face of an expanding population, by 1975, the South's supply of nurses may drop to 185 per 100,000 population. For the region to reach a conservative goal of 300 nurses per 100,000 population would require that graduation from schools of nursing be increased by 1975 to nearly four times the number graduated in 1966." TRENDS IN NURSING EDUCATION "There is a critical shortage of nurses throughout the nation today, but nowhere is the shortage more pronounced than in the South. Not only is the South's present need 1~or more nurses at a critical `stage, but the prospects for the future are even more alarming. Significant trends . . . indicate that the situation in the South will get worse in the years immediately ahead, unless a concentrated effort to increase the nurse supply is launched now."7 The development of the two-year associate degree nursing program is wide- spread across the nation. Over 225 college controlled programs leading to an associate degree in nursing education are in existence in the United States and its territories. Currently North Carolina has eight associate degree programs: six based in state-supported institutions; two based in Baptist junior colleges, at Boiling Springs (Gardner-Webb Junior College) in the West, and Murfrees- boro (Chowan College) in the East. As two-year associate degree programs become the trunk line to the registered nurse labor supply, the baccalaureate four-year nursing degree is becoming the trunk line to the ever increasing com- plexity of Medical nursing supervision and administration. Baccalaureate pro~ grams now exist at nine colleges and universities in North Carolina, and are anticipated in at least two others It is apparent that the patient-care nurse labor force will coninue to be in critically short supply with the expansion of the baccalaureate program. The baccalaureate graduate tends to serve increasingly in administration and supervision, while the associate graduate tends to provide basic patient care. Certainly we need both in North Carolina, and care must be taken to insure and maintain proper balance. "In 1966, an average of 319 nurses were employed per 100,000 population in the states outside the South. In the South, only 198 nurses were employed per 100,000 population."8 Three-year diploma schools for nursing now number twenty-two in North Carolina. These programs are based in public and private hospitals. Many of these diploma schools are of excellent quality. However, authorities in the nursing field agree that operational costs are becoming increas~ng1y prohibitive for many hospitals; that the hospitals face a disadvantage in that they cannot usually provide a college setting; that the search for and maintenance of a com- petent faculty is ffiost burdensome. Further, these authorities agree that re- cruitment is becoming more difficult with each passing year, and more expensive. Therefore, while excellent diploma schools should be encouraged to persevere, and should receive federal operational funding as provided in H.R. 13096, many 4 Ibid., p. 25. 5 ThIS., p. 2S. p. 44. ~ Ibid., p. 1. SJbid., p. 1. PAGENO="0307" 299 feel that the three-year diploma school is out of step in today's concept of nursing education. In Hessel II. Flitter's study it was revealed that during the period October 1965, to October 1966, 1 diploma school was opened and 25 were closed in the United States. In the South, including 15 states, 1 diploma school was opened and 7 closed. During that same year in the United States, 44 associate degree programs opened and none closed. Of that number in the Southern region 17 opened and none closed. Some hospital schools have been quick to get out of the business in order to affiliate with a nearby college. Cleveland Memorial Hospital in Shelby, North Carolina, is a good example. Its diploma school was costing approximately $90,- 000 per year. Now the Cleveland Memorial Hospital i5 supporting the associate degree program at Gardner-Webb Junior College in the sum of $20,000 per year. The hospital in Rutherfordton is supporting that program in a like amount; and, both institutions are serving as cooperating hospitals in the practical area of the Gardner-Webb curriculum. Since 1963 five hospital diploma schools have dissolved in North Carolina. All are now associated with educational institutions as cooperating hospitals to our associate or baccalaureate program. In short, Louisburg College recognizes the critical need for additional nursing personnel in the north-central Piedmont of North Carolina. The institution also recognizes the national trend in nursing education to be the two-year associate degree program which is based at a junior college. We at Louisburg College are also aware that private junior colleges which have exised primarily to serve the liberal arts curriculum must become service oriented to a much greater extent. The two-year program at a junior college meets the educational needs of stu- dents who wish to obtain their nursing education in a relatively short period of time in their own community and in a college setting where they can secure col~ lege-level general education and nursing education. Graduates of this type of progress are eligible to take the State Board Examination for Registration as a nurse. Therefore, Louisburg College proposes the establishment of an associate degree nursing program to begin in the fall of 1969 with an approximate enrollment of from 30 to 40 students. It is estimated that $50,000 per year for the five years 1969-1974 will be needed for operational funding. Therefore, it is imperative that federal operational funding be provided, not only for hospital diploma schools, but also for the associate degree and baccalaureate programs in educational institutions. STATEMENT OF KARL R. REINHARD, D.V.M., PH.D., DEAN, COLLEGE OF VETERINARY MEDICINE, OKLAHOMA STATE UNIVERSITY, STILLwATER, OKLAHOMA Fundamentally, medical science and veterinary medical science are one. The differences between veterinary and human medicine result from the idiosyncrasies of Species with regard to morphology, adaptive physiology, pathoecology and economic and sentimental values of the indiVidual. Realistic appraisal leads to the conclusion that economic considerations account for the disparity between veterinary medical and human medical practice. This separation of the profes- sions on the basis of species srid economic considerations cannot logically be carried over into the sciences undergirding them, for advances in those sciences inevitably lead to progress in both professional fields. To cite a few instances, mechanical pinning of fractures was developed to a great extent In the treatment of traumatic injuries of dogs. The transmission of infectious disease by arthro- pods (Texas fever) was proved in the course of a veterinary disease investigation. Although variolization was the first procedure derived for immunization against viral disease, mass immunization against viral infections by parenteral admini- stration of virus preparations was developed largely in veterinary medicine (hog cholera; canine distemper). The determination of the etiology of Dicounieral (Sweet Clover) poisoning of cattle was an extremely significant veterinary dis- covery which yielded great benefits later in application of the chemical agent in the treatment of human cardiovascular disease. Conversely, many discoveries in human medicine have been applied profitably to the practice of veterinary medi- cine, notably in the treatment of degenerative and chronic diseases of household pets and other animals of sentimental or surpassing economic value. Most of the therapeutic compounds developed in recent years for human medicine have not only been tested in animal models, but have been uSed in veterinary medical practice to its betterment. PAGENO="0308" 300 The value of veterinary medicine in the protection of health and productivity of farm animals has a direct bearing on the well being and excellent state of nutrition of the American people in assuring a large, economical supply of foods of animal origin. This fact, alone, is worth substantial federal support of veteri- nary education and research. The presence of a veterinary profession-in these days of peril of war-affords a large reserve of auxiliary professional competence for medical and surgical treatment and care for the American public, should a national or local disaster occur. It is probably true that present federal plans for civil emergency do not include plans to utilize veterinary physicians and surgeons at their true potential. Present plans call for the uSe of veterinarians to inspect foods of animal origin and similar activities-which could be conducted just as well by trained tech- nicians under emergency situations. However, whether or not present plans are adequate for full utilization, the veterinary profession could provide thousands of skilled surgeons and physicians who could be assimilated by the medical profession for emergency use in regional or national disaster. Scientifically, the veterinary profession can be of inestimable value for the conduct of comparative medical research (interpreting the latter term in its broadest aspect). Wherever animals are involved in experimentation, comparative medical research is in progress. While it would be impossible-and unwar- ranted-to have every animal experiment under veterinary supervision, it is true that animal experimentation has suffered, in general, from the lack of applica- tion of good principles of animal medicine which are known to most veteri- narians. Neirertheless, it is also true that, due In part to inadequacy of numbers of veterinarians available and in part to lack of sufficient specialized orientation, the veterinary profession is pressed to provide full service in this area and must strive to correct the deficiency as early as possible. The veterinary profession, in the academic, governmental and industrial set- ting, has produced an immense amount of information of direct or corollary benefit and applicability to the advancement of human health. This applies not only to the solution of problems of diseases shared by man and animals, but also to discoveries of fundamental veterinary scientific value which bear directly on human medical issues. Since the passing of the horse as the prinicpal means of local transport and, with it, the passing of proprietary veterinary colleges, individual states have borne almost all of the cost of education of the nation's veterinarians-private and federal contributions have been almost negligible until recent times. While state support has been the salvation of veterinary education for a generation or more, some of the difficulties in attainment of a full professional mission are also traceable to state interests. For the most part, veterinary colleges are on agricultural school campuses. While this helps to keep the profession well- oriented toward its large and serious agricultural responsibilities, it has also served to retard the development of small animal medicine and in fuilfillment of many veterinary roles of importance to the nation. Furthemore, state funds are dedicated overwhelmingly to support of teaching programs. The small propor- tion of state funds devoted to veterinary research is often dedicated to issues of limited scientific significance or scope~ Under present circumstances, it is ex- tremely difficult for veterinary colleges to utilize funds for research facility construction because the necessary matching funds are not easily obtained from state and private sources. The size of the professional limits the fulfillment of its traditional role as well as the extent of its participation in medical and public health services and research. Only eighteen schools are established and in operation. These are hardly sufficient to bring the practicing profession to a size commensurate with national needs. There are plans for moderate increase in class size and the establishment of two new schools-but these will not be adequate to bring the size of the profession in line with its role, both actual and potential. Further- more, classes cannot be expanded nor schools established without first obtaining sufficient veterinary academic manpower. With quantity we also need quality- to expand student bodies without commensurate and preliminary expansion of academic staff can only lead to mediocrity of the finished product. The dilemmas of the veterinary profession are matters of vital national concern and worthy of congressional action. Rightful concerns consist of the following: 1. Provision of adequate numbers of veterinarians, appropriately trained, for health practice, particularly in the area of animal-borne disease~ PAGENO="0309" 301 2. Provision of adequate numbers of veterinarians, appropriately trained, for fundamental and applied research in comparative aspects of medical and health sciences. 3. Provision of adequate numbers of veterinarians, appropriately trained, for research and practice in laboratory animal medicine. 4. Provision of special training for veterinarians to augment the medical man- power required for care in event of national or regional disasters. 5. Provisions of more and better-oriented veterinarians to meet the public demand for care of agricultural and pet animals through more efficient and innovative techniques of providing mass animal health care. Note that the concern is not only for more veterinarians-but for veterinarians with advanced or specialized skills. To meet these and corollary needs, I believe it is greatly in the public interest that the federal government should give strong support to: 1. The establishment of new veterinary schools, particularly in environments where they can develop fundamental medical science programs of great merit. 2. The establishment and further development of graduate level training in the basic veterinary medical sciences. 3. The support of veterinary professional studies and the support of veter- inary graduate studies in health and medical sciences by increased loan and scholarship support. 4. The provision of teaching and research facilities in medical sciences, at veterinary colleges, with greatly decreased requirements for matching funds. 5. The development of centers of excellence in important, specialized areas of veterinary medical sciences in veterinary colleges which by virtue of staff development or location have developed unusual potentials. 0. The development of a program for integration of the veterinary medical profession into the emergency medical care activities of the nation in disaster situations. 7. A determined effort for greater incorporation of veterinarians and veterinary scientists in the service and research activities of the federal government wherever the professional talents or special proclivities of veterinarians can be utilized profitably. STATEMENT OF CHRISTINE STEVENS, PRESIDENT, ANIMAL WELFARE INSTITUTE, NEw YoRI~ Specialization in the practice of medicine has obscured the fact that there is but one medicine, whether it be studied in man or in animals, as modern research is generally done, and whether it be practiced on man or on animals. Veterinary medicine obeys the same biological principles, is based on the same scientific studies and takes part in contributions to medicine as a whole. Because of the major role of animal experimentation in modern medicine the veteri- narian's training is of the first importance in soundly based research. To achieve the aims of H.R. 15157 colleges of veterinary medicine shonld be given assistance on the same basis as medical schools. To do otherwise would be to omit what is in many cases the most essential part of health research for the benefit of human beings, a knowledge of animal health and needs of the animals used in the laboratory. Long needed improvements in care and housing of research animals are now being made in scientific institutions throughout the country in compliance with the Laboratory Animal Welfare Act, P.L. 89-544. One of its requirements, that animals receive "adequate veterinary care" means that the demand for men and women trained in veterinary medicine will continue to increase, to the benefit of research results and the animals used in obtaining them. Enforcement of this valuable statute is carried out by the humane veterinarians of the Animal Health Division, Agricultural Research Service, Tnited States Department of Agriculture. The outstanding advances in animal welfare made since they have undertaken the inspection and licensing of animal dealers and the inspection and registration of research facilities is worthy of high praise. It is a tribute to veterinary medicine generally and the devotion and ability of these men in particular that so much should already have been accomplished in a field where stultifying and unproductive controversy had reigned for years till practical scientific and humane principles were put into effect in implementing the new law. PAGENO="0310" 302 For the continued enforcement of the Laboratory Animal Welfare Act, P.L. 89-544, for the continued enforcement of the other important programs of U.S.D.A's Animal Health Division in disease eradication or control, protecting, the health of livestock on which we depend for food and other necessary products, well trained veterinarians are absolutely essential. The nation's veterinary schools need and deserve the support which would be provided if they are in- cluded in the provisions of the Section on Institutional Grants of H.R. 15757. We pride ourselves as a nation on our humane attitudes. We pride ourselves on development of preventives and cures of disease and injury. For the con- tinuing development and the support of these ideals and goals. good men trained in the veterinary medical discipline must graduate in increasing numbers from the eighteen colleges which give the D.V.M. degree. On behalfof the Animal Welfare Institute I respectfully urge the distinguished niembers of this committee to amend H.R. 15757 to include veterinary colleges before recommending its passage by the full House of Representatives. STATEMENT OF FRED C. DAVISON, PRESIDENT, UNIVERSITY OF GEORGIA The Role of Veterinary Education in Agriculture is of traditional and obvious importance because of the necessity of controlling and eliminating diseases of animals producing food for man. However, an increasing and even greater role for veterinary education is training new graduates to function as an indepeclent group of scientists with a vital and legitimate role in biomedical research and public health programs. The research contribution of veterinary scientists to basic health sciences by use of experimental animals is of tremendous benefit in solving problems afflicting and affecting the health of man. The study of com- parative medicine by veterinary biomedical scientists has provided many solu- tions to disease problems in man. All indications point to the increased use of experimental animals for research to solve problenis of aging, cancer, heart dis- ease and other fatal diseases that shorten or dehilitate the life of man. In addition to vastly increased activties of veterinanrians in biomedical re- search the recent passage of regulations for meat and poultry inspection to protect the consumer requires an increase in the number of veterinarians. The increased human need for animal protein food stuff in the world also calls for more veterinarians to control animal diseases. The World Food and Agricul- tural Organization estimates that a 50 percent reduction of losses from animal diseases in the developing countries is a realistic goal and that it would result in a 25 percent increase in animal protein production. This reduction in animal losses would result principally from an increased supply of veterinarians edu- cated to conduct biomedical investigations to control diseases causing deaths in animals and likewise in man when transmissible. Approximately one-half of the veterinarians in the USA are engaged in prac- tice. The majority of the others are engaged in teaching and research or in sup- porting positions such as laboratory animal medicine. The present occupations of veterinarians in the USA are as follows: 7 percent in large animal practice, 19 percent in small animal practice, and 31 percent in mixed practice for a total of 57 percent of the veterinarians in the USA who are conducting practice. The remaining 43 percent are engaged in teaching, research, consumer regulatory work for the government, industry and in specialities such as laboratory animal medicine. The latter category is a prominent example of a new activity for which insufficient veterinarians have been educated. The demand for veteri- narians with special qualifications in laboratory animal medicine to support pro- grams in biomedical research has appeared suddenly and is unfulfilled. A recent survey by the National Academy of Science identified about 2000 biomedical research laboratories in the USA, which housed experimental animals and needed the services of a veterinarian. At present only lOG veterinarians hold board certification from the American College of Laboratory Animal Medicine. The entire output of veterinarians graduated from all the schools in the US this year would not meet the existing need for veterinarians in laboratory animal medicine, which is only one of the many specialties in biomedical research for which veterinarians are in great demand. The need for veterinarians considerably exceeds the productive capacity of the present educational system. A long range forecast indicates that 40,000 veter- inarians will be needed by 1980. This figure is 12,000 in access of what our present veterinary colleges can provide during that period of time. Obviously the acidi- PAGENO="0311" 303 tional 12,000 veterii~arians can be educated only by enlarging existing schools and building new schools. There are 18 schools of veterinary medicine for the 50 states in the USA and each serves more than the state in which it is located. The School of Veterinary Medicine, University of Georgia serves a total of five states: Georgia, South Carolina, North Carolina, Virginia and Maryland. Veterinary school~ should be viewed as a national resource instead of a state resource and therefore partly supported by federal dollars in supplement to the appropriation from the state in which the school is located. The demand for entrance into the professional program of the veterinary schools far exceeds the capacity of the existing schools. For example, the follow- ing numbers of eligible preveterinary candidates were interviewed for entry into the School of Veterinary Medicine at the University of Georgia: 1967 1968 Georgia South Carolina 10 14 North Carolina 10 13 Virginia 24 30 Maryland 28 46 Total 121 156 All of the above candidates have exceeded the average college student grade point and have survived elimination on personal interview examinations con- ducted within each state. From this total the University of Georgia accepted 64 students for the entering class of 1967; not all of these will be graduated be- cause of the normal attrition-rate. If federal assistance in the form of an institutional grant were available for improving our present educational plant, and if a construction grant were avail- able for building an addition to the present School of Veterinary Medicine, we would have matching state funds to increase the size of our entering class to a minimum of 85 students for an increase of 33 percent. From the above discussion the critical importance of fl.R. 15757 (Health Manpower Act of 1968) in support of veterinary education is obvious for the Southeastern states. This bill would provide vital support for construction grants, student loans, and scholarship grants in the 18 schools of veterinary medicine In these 50 states. It is unfortunate that veterinary schools have not been declared eligible to receive institutional grants under HR. 15757 in view of the direct contribution of veterinarians to biomedical research, public health and consumer proteétion. The importance of educating veterinarians to protect the health of man is in- controvertible. We cannot emphasize too strongly the importance of making schools of veterinary medicine eligible for institutional grants under this bill. AMERICAN MEDICAL ASSOCIATION, Chicago, Ill., July, 9, 1968. Hon. JOHN JARMAN, Chairman, subcommittee on Public Health and Welfare, Committee on Interstate and Foreign Commerce, U.$. House of Representatives, Washington, D.C. DEAR CONGRESSMAN JARMAN: On June 12, Dr. William A. Sodeman appeared before the Subcommittee on Public Health and Welfare of the House Committee on Interstate and F~reign Commerce to present testimony on behalf of the American Medical Association regarding H.R. 15757, the Health Manpower Act of 1968. During the discussion which followed it was agreed that certain sup- plementary information would be forwarded at a later date. That information follows: At one point Mr. Rogers asked for estimates of what the shortage of physicians would be in five years. We do not have such an estimate, nor is there agreement as to the extent of the present shortage. It should be realized that in recent years the number of physicians has been increasing faster than has the population and that the shortage is due to an increa:se in demands and not due to a decrease in the ratio of physiciano to population. From 1955 to 1965 the population of this PAGENO="0312" 304 country increased 17% and the number of active physicians in~reased 22%. The recent report of the National Advisory Oommission on Health Manpower pre- dicted that for the decade eiiding in 1975 our population is expected to increase by 13% and the supply of physicians by 17% or 18%. It is calculated that in 1960 there were 149 physicians per 100,000 people in this country. In 1965 the figure had increased to 153 per 100,000 people and it is expected that in 1975 it will be 160. Nevertheless, changes in the way physicians are being used and increasing demands for their services lead us to predict that `in the coming decade the physician shortage will grow. The average physician, for example, Is spending a much greater proportion of his time in administrative duties and there is a growing need for physicians in full-time administi~ative positions occasioned by recently enacted Federal programs. Mr. Rogers called attention to relatively large incr~a'ses in total budgets `and numbers of full-time faculty and much smaller increaSes in numbers of graduates'. 1)r. Sodeman pointed out that the figures do not tell the whole story ~nd agreed to provide further explanation. As Dr. Sodeman pointed out, the figures presented made no reference to the role of partti'me faculties in mediCal schools. Advances in medical science, the growing importance of res'eai~ch, and other factors have compelled the medical schools to depend to a greater extent upon full-time, salaried faculty. While the ntaOber of part-time faculty also has in~creased, the relative role of the full-time compared with the part-time faculty has increased substantially in recent years. Of greater importance is the increased responsibility of the medical schools for research. Between 1958-1959 and 1965-1966 the total expenditures of the Nation's medical schools increased by $563,155,511 as the Fact `Sheet indicates. However, $369,968,598 or 65% of this increase is `accounted for `by funds avail- able for su'pport of sponsored programs, mostly research and research training. While the increased research activity of the medical schools undoubtedly hn- proved the quality of the educational program's of the medical schools, it would not be expected to increase appreciably the number of medical students' the schools were capable of educating. It should be remembered also that medical school faculties carry a large share of the responsibility for the education o'f students other than medical students. In recent years there has been a marked increase in the number of such students. It wa's found, for example, that in 1960-1961 medical ~cbool faculties were re- sponsible for 33,364 students other than undergraduate medical students, cal- culated in terms of full-time equivalent's. This is more than the number of under- graduate medical students at that time, 30,093. In 1965-1966 this number had increased to 43,335, an increase of about 30%. Finally, there was a rather substantial inflation from 1958 to 1966. `Mr. Rogers pointed out that the `bill's requirement of an increase of 21/2% or five students was an insignificant requirement and asked for our recommenda- tion as to a more substantial one. The bill also provides that, in the ease of the institutional grants, a large part is distributed in such a way that a school receives twice as much per additional student as for one previously enrolled. We `believe that, if the appropriation under this bill is sufficiently great, this provision provides enough incentive for the schools to increase `their enrollments. If the appropriation is very small, it would not be effective rqgardless of the requirement. We doubt that it would be wise to require every school to increase its enrollment. Some already are in a very critical financial situation and the enrollment `could not be increased without serious risk of lowering the quality of their educational programs disastrously. Mr. Rogers asked Dr. Sodeman to "let us know what you think would he a realistic ceiling on project grants." It is now $400,000. Mr. `Rogers indicated that he would agree to raising the limit but rot removing it. To a greater or lesser extent a limit ties the bands of the people administering the Act. The size of the appropriation pretty well limits the amount that can be granted `to a given school. According to our information some schools are incurring annual deficits in excess of $1,000,000, a situation that cannot continue. `If the limit in the bill were raised from $400,000 to perhaps $1,000,000, it might be possible to rescue such a school from its critical situation. The amount, if at all, that a given school can or should expand must `be deter- mined by the local situation. `This involves such `matters as the state of the `buildings, available space for expansion, architectural considerations, the avail- ability of local funds for matching purposes for construction, the availability of PAGENO="0313" 305 local operating funds, and so on. The establishment of new schools depends upon the number of universities in the country in a position to establish medical schools and our success in persuading them to do so. There is no present pos- sibility of too many medical schools being established. If many additional univer- sities are persuaded to establish medical schools, it will be because the Congress has made it economically possible for them to do so by providing both construc- tion funds and operating funds under attractive conditions. Mr. Skubitz asked if we would provide information as to what proportions of one graduating class is going into practice, into research, into teaching or indus- try. It should be realized that a number of years elapse after a class graduates before the ultimate destination of its various numbers is known for somewhere between two and six years of graduate training and two years in the armed service follow graduation. Mr. Cahill's questionnaire circulated to the deans showed the present intention of two recent graduating classes as these were known to the deans answering the questionnaire. It was reported to Mr. Cahill by the deans who replied to the questionnaire that of the students graduating in 1957 and 1958, 69.5% expected to specialize, 15% expected to go into general practice, 11% into research or academically oriented careers, and 4~5% into military service or administrative medicine. The latest study showing what students graduating in a given class year actually do a number of years later is one conducted in 1905 and 1966 of the physicians who had graduated in 1955, ten years earlier. It was found that in the class of 1955, 69.9% were in private practice, compared with 77.6% of the class of 1950. 9.5% were in teaching or research compared with 6.3% of the class of 1950. 76.8% of the class of 1955 limited their practice to a specialty and 17.7% were in general practice, com- pared to 681% and 24.6% respectively for the class of 1950. Tue relevance of these figures to the behavior of the class of 1908 is uncertain. I hope that the information provided above clarifies and amplifies adequately that presented in our testimony before the Committee. Let me express on behalf of the American Medical Association appreciation for the opportunity provided our witness to appear before the Subcommittee and present our views on the subject of health manpower. Sincerely, F. J. L. BLASINGAME, M.D. STATEMENT OF HENRY B. PETERS, O.D., ON BEHALF OF THE ASSOCIATION OF SCHOOLS AND COLLEGES OF OPTOMETRY AND THE AMERICAN OPTOMETRIC AssoCIA- TION Mr. Chairman and Members of the Committee, I am Henry B. Peters, 0. D., Assistant Dean, School of Optometry, University of California at Berkeley. This month, I am completing a one-year term as President of the Association of Schools and Colleges of Optometry whose members are the nation's ten optometric teaching facilities. I also serve as a member of the American Optometric Associa- tion's Committee on Public Health and Optometric Care. The Association of Schools and Colleges of Optometry and the American Optometric Association appreciate this opportunity to express support of HR. 15757, the Health Manpower Act of 1968. While there are a few points we feel may warrant further consideration before passage, there is no question about the need for continuing the programs with which the bill deals. Optometric educational institutions have witnessed firsthand some of the re- sults of the Health Professions Educational Assistance Act and subsequent amendments. One of the most recent events pointing up the benefits of the Act was the dedication of a new optometry building at Indiana University in April. The building houses the Division of Optometry and provides additional facilities for graduate school programs in Physiological Qptics. In June last year, the College of Optometry at Pacific University, Forest Grove, Oregon, dedicated its expanded facilities made possible in part by a $300,000 grant under P. L. 88-129. There are other projects in progress, includ- ing facilities at Illinois College of Optometry in Chicago and Southern College of Optometry in Memphis, Tennessee. The remaining six colleges of optometry have also taken steps to improve or expand their facilities or teaching programs. Continuing Federal support is essential to assure the availability of optometry school graduates to provide vision care services to our 200-million citizens. Grants and loans authorized by existing legislation have played a major role in further PAGENO="0314" 306 upgrading the quality of optometric teaching facilities and increasing the number of students the schools are able to train. We do have some reservations about the new formula requiring a 21/2% or five-student increase of first year students as the basis for qualifying for a grant. It is conceivable this requirement for expanded enrollment could lead to even more serious difficulties for optometric teaching institutions already hard-pressed financially. One of our schools, the University of Houston College of Optometry, provides a good example of how this may work. In a letter to the AOA comment- ing on this legislation, the Dean of the school states: "i' * * we are caught be- tween needing to build for programs which we do not have or delaying building until we have developed the programs for which we do not have space." This is a fairly typical situation among most of our schools and colleges. They cannot qualify for federal assistance until they have the additional enrollment, but they cannot physically accommodate the additional enrollment until they have federal financial assistance to provide more space. It is our thought the required increase of optometric manpower might be achieved more efficiently and economically by new or additional schools rather than by arbitrary expansion of our present ten schools. The pending proposal will also expand the scope of existing laws to include other disciplines important to the general health of the public; this is commend- able. We would urge that any funding formula contained in this bill be carefully reviewed to assure that programs initiated under existing law in no way be curtailed. We hope Congress in its wisdom will move promptly to provide funds suffi- cient to accelerate the health care training programs and to assure the necessary increases in funds required to administer such programs. The amendment to Section 723 of the Public Health Act is an important one, as it extends the use of facilities to research, medical or health library purposes, in addition to teaching. Research constitutes an essential adjunct to training of health care practitioners. Adequate library facilities provide reference data to support research activities. Since this portion of the Act applies to professions other than medicine, however, we feel it would be appropriate to amend the lan- guage on page 4, line 19, it read "health professions library" rather than "medical library." Deans of the various optometry schools were solicited for comments on this legislation when it was first introduced as S. 3095 in the Senate, a bill identical to H.R. 15757. Responses from some of the schools are attached to this statement for your information. Statements from other optometry schools may be sub- mitted separately. The Association of Schools and Colleges of Optometry and the American Optometric Association are pleased to have had an opportunity to support this legislation, which will assure that health care professions will be able to further extend the record of achievements made possible by the original legislation being improved upon by HR. 15757. HENRY B. PETERS, MA., O.D., F.A.A.O. Title: Associate Professor of Optometry, Assistant Dean and Director of Clinics, School of Optometry, University of California. Place and Date of Birth: Oakland, California, 1916. Education: A.B., University of California, 1938, Optometry M.A., University of Nebraska, 1939, Educational-Psychology. Professional and/or Business E~eperience: President, Association of Schools and Colleges of Optometry, 1967-68. Vision Consultant, Contra Costa County, California, School Dept. Vision Consultant, Lawrence Radiation Laboratory (AEC), Livermore. Vision Consultant, Kaiser Aluminum and Chemical Company. Research Fellow, American Research Council of Optometry, 1938-39. Lecturer, Los Angeles College of Optometry, 1939-40. Lecturer, Claremont College, Claremont Reading Conference, 1940. Fellow, American Academy of Optometry, and former Chairman of Sec- tion on Public Health and Occupational Optometry. Fellow, Distinguished Service Foundation of Optometry. Fellow, American Association for the Advancement of Science. Member of the Faculty, University of California, School of Optometry, since 1946. PAGENO="0315" 307 Vice-President, Children's Vision Center of East Bay. Member, Committee on Public Health and Optometric Care, American Optometric Association, 1963-64, 1967-68. Educational Director, PHS-AOA Training Seminar on Optometry in Pub- lie Health, February 1967. Special field of interest is vision screening and its application in schools and industry. Author and co-author of many articles on optical problems and vision, vision screening in schools, industry, and transportation. Member, Ad Hoc Program and Review Council, California Medical As- sistance Program. Activities: Member, Sigma Xi and Phi Beta Kappa; "Optometrist of the Year," California, 1959. Personal History: Lt., U.S. Naval Reserve, 1942-46. COMMENTS BY OFFIcIALs OF SCHOOLS AND COLLEGES OF OPTOMETRY REGARDING S. 3095 Illinois College of Optometry (Private), Chicago, Illinois: "Would like to go on record in support of this bill". (Dr. Alfred A. Rosen- bloom, Dean). Indiana University, Division of Optometry (State), Bloomington, Indiana: "While there is built into the bill some provisions to increase enrollments over the present figures, the legislators should consider the possibility of pro- viding for an increase in the number of colleges of optometry rather than merely expanding present facilities." (Dr. Henry W. Hofstetter, Director). Ohio State University, School of Optometry (State), Columbus, Ohio: "We are in favor of the legislation, but do not favor the bonus or double pay- ment for schools which increase their enrollment levels above those of prior years." (Dr. Fred W. Hebbard, Director). Los ANGELES COLLEGE OF OPTOMETRY, Los Angeles, Calif., March 21, 1968. Dr. W. JUDD CHAPMAN, Chairman, Committee on Legislation AOA, Tallahassee, Fla. DEAR DR. CHAPMAN: Thank you for supplying the comments and copy of S. 3095 to this college and our opportunity to comment is appreciated. In reply to your telegram of March 20th, I have wired the Washington Office a summary of our attitude about this proposed legislation as follows: "Opinion of this college S. 3095 represents great improvement over previous requirements of Public Health Service Act, particularly in provisions for Library and Re- search facilities and method of payment of Institutional improvement grants. Favorable action recommended. Letter follows." As all of you must be aware, the availability of Federal Grants for construc- tion, basic and special improvement grants, scholarships to students, loan funds, and the like have represented major improvements to all schools of optometry. The American Optometric Association and its hard-working committees and staff are to be complimented on the work they have done to make all of this possible. In our opinion the new proposed legislation as is outlined in S. 3095, repre- sents another major improvement in the wording of the Public Service Act. As previously stated in our telegram we are particularly pleased with the at- tempt to include research itnd library facilities in the provisions of the act. For most colleges of optometry this can be a very welcome and convenient change for by the very nature of their specialization optometry schools require the im- mediate availability of these facilities within their buildings. Additionally, we are in favor of the proposed change in the method of dis- tribution of funds to the various professions. We believe it is as important to consider the number of graduates as it is to consider the entering class. To the suspicious mind this might appear as an incentive to graduate students who are not as fully qualified as they might be but I believe that era in this profes- PAGENO="0316" 308 sion, as iii the others, has long since passed and each school is concerned with graduating a candidate for the profession with the highest qualifications that it is possible to give him. As is the intent of the bill, this consideration for the number of graduates may very well be the incentive to improve the counselling arid exercise the concern that some young men seem to require. We do have some concern about the requirements for eligibility as it will require `a slight increase in enrollment for the entering class at this college. This is a problem which must be resolved between the Council on Education which establishes the ceilings and the individual colleges or the Association of Schools and Colleges collectively. For most schools this problem will be re- solved when new construction has taken place and expanded facilities are avail- able. In general we believe the proposed changes for the Public Health Service Act are to the advantage of education in the Health Professions and we strongly recommend the hearing committee act favorably towards its passage. Sincerely, CHARLES A. ABEL, O.D., Dean. PENNSYLVANIA COLLEGE OF OPToMETRY, Philadelphia, Pa., March 21, 1968. Dr. W. JUDD CHAPMAN, American Optometric Association, Washington, D.C. DEAR MR. CHAPMAN: S. 3095 is an important hill, but the most important area is the pooi of fund's relative to Basic Improvement and Special Projects Grants (pages 6 and 7). Should this area be so funded that there would be less than $1,500 per student, the bill will be not worthy of its function. This year's operating budget here at P.C.O. breaks down to a cost `of $2,735 per student. Our projections indicate a direct teaching cost of $3,375 within two years. If one realizes that our tuition is $1,200 per annum, you will be painfully aware that a vast chasm exists between cost of education and school income. Tuition has risen to its maximum here in Pennsylvania. Competitive health care professions teaching institutions charge from $400 to $1,200 per annum as tuition. It should, therefore, be obvious that tuition is not the answer to the need for additional funds. We in optometry have not as yet developed our capability for priYate fund raising. This is true of most of the health care professions teaching `institutions. This facet of fund accumulation is too far in the future for effective use. State assistance is still in its early stages. Here in Pennsylvania, it amounts `to approximately 8% of our operating budget. It is, therefore, imperative that the Federal Government become more involved in the funding of all of the `health professions teaching institution's. As the professions become more affluent, it beeom0s more difficult to recruit new teaching personnel and retain old personnel. The rewards of' private practice must be matched by the schools if competent faculty are to `be used in teaching. `The schools cannot do so without massive new funding. There must be a "crash" program for the `training of new teachers. A ten-year program is a must. Graduate optometrist's must be en'ticed into post-graduate studies to prepare themselves for teaching. This will take fellowship's of approxi- mately $7,500-$10,000 per annum each for four-year periods. This to the end of new `M.A.'s and Ph.D.'s beyond the O.D. degree. Senate Bill 5. 3095 is `a most commendable piece of legislation. The keys to its efficacy will be the amount of funding and the complexity of `the regulations set forth by H.E.W. No institution `in the health care field can afford the personnel to spend full time preparing `proposals to H.E.W. The work is overwhelming and if this is required, it will subvert the philosophy of the Congress. Simple regulations and reporting prucedures are `the concomitant of a successful program. Thank you for the opportunity of getting this off my chest. Tf I may be of further assistance, please feel free to avail yourself of my time. Cordially, STANLEY S. WILLING, Ed. D., Dean. PAGENO="0317" 309 THE MASSACHUSETTS COLLEGE OF OPTOMETRY, Boston, Mass~, March 21, 1968. Mr. RICHARD W. AVERILL, Director, American Optometric Association, Washington,, D.C. DEAR Mu. AVERILL: I would like to say that as Dean of The Massachusetts Col- lege of Optometry, I am heartily In favor of supporting the following legislation: Bill No. S3095-~"Health Manpower Act of 1968." Please have this endorsement included in the Appendix. Sincerely, HYMAN R. KAMENS, OP., Dean. UNIVERSITY OF HOUSTON, COLLEGE OF OPTOMETRY, Honston, Tee., March 26, 1968. Mr. H. E. MAULMAN, American Optometric Association, Washington Office, Washington, D.C. DEAR MR. MAHLMAN: This is in answer to the telegram by Dr. Chapman concerning S. 3095. All in all, these appear to be worthwhile amendments to the Public Health Service Act. The section under "Grants for Multipurpose Facilities" page 4, line 13-23, appears to be of great import to us. We have been working for a graduate pro- gram for many years. Our inability to start the program has been due to lack of faculty with the Ph.D. degree. We would also like to institute optometric tech- nology and internship programs as well as a cooperative, optometric technician program. We are somewhat hampered in starting these programs by the limita- tions of our present physical facilities. Consequently, we are caught between needing to build for programs which we do not have or delaying building until we have developed the programs for which we do not have space. This section seems to hold great value iR terms of building facilities for a graduate program to produce instructors and researchers in an area where there is now a great need for manpower. In addition, this section includes library facilities which are most important to us. I ani somewhat concerned, however, by the term 4'medical library" in line 19. It would be far better, from our point of view, if the term "medical" were changed to "health professions." If lines 9~-12 on page 5 mean that the act is encouraging Continuing Education, this would also facilitate our providing updated material for the practitioner. We have had competition this year between our Continuing Education Program and our regular program for classroom, laboratory, and clinical facilities. I find the change in title to "National Advisory Council on Health Professions Education Assistance" pleasing. All in all, the amendments appear to improve the Public Health Service Act and should be supported. Sincerely, CHESTER H. PHEIFFER, Dean. (Whereupon, at 3 :50 p.m., the hearing was concluded.) 0 PAGENO="0318" PAGENO="0319" PAGENO="0320" 3