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This statement by the President is a logical extension of the V.A. policy memorandum #2 of January 3, 1916, which encouraged the development of a partnership between Veterans Administration Hospitals and the nation's medical schools. Since 1946, this partnership has improved the quality of health for the ve eran and helped to achieve educational goals in medicine for the country as a whole. By accomplishing both objectives, the nation's health has been strengthened and improved. The veteran not only has obtained the highest possible quality of medical care, but the Veterans Administration has participated in the development of new knowledge applicable not only to veterans but to sick people everywhere.

At the present time the nation has 95 V.A. Hospitals affiliated with 81 medical schools. Almost 12.000 medical students train in these hospitals, and on any given day about 4,500 residents, under the supervision of full-time V.A. staff physicians and consultants from the affiliated medical schools, render patient care to veterans.

II. THE HOUSTON VETERANS ADMINISTRATION HOSPITAL

The mutual respect and confidence that has grown out of this partnership, which was bolstered by the President's statement led Baylor College of Medicine and its Dean's Committee, in cooperation with the staff of the V.A. Hospital in Houston, to develop a five-year plan to improve patient care; a copy of this proposal is enclosed.

The Houston V.A. Hospital ranks among the three most active and productive institutions in the V.A. System. A review of fiscal year 1972 workload data shows that the patient turnover rate and the hospital occupancy rate in the Houston V.A. Hospital are the highest in the country for the volume of patients treated. Last year in this Hospital 14,722 patients out of 33,471 applicants were admitted, and 103,000 outpatient visits were made.

The Houston V.A. Hospital has for a number of years, served as a major referral center for specialized medical problems, and this function has increased when the V.A. regionalization policy was adopted and implemented. Among the various specialized medical programs in the Hospital are those shown in Table 1:

TABLE 1

Alcohol Treatment Unit
Cardiac Catherization Laboratory
Clinical Radioisotope Unit
Day Hospital
Dav Treatment Center
Drug Abuse Unit
Hemodialysis Unit
Home Dialysis
Intensive Care Unit/

Coronary Care Unit
Mental Hygiene Clinic

Muscle Disease Program
Open Heart Surgery Center
Prosthetic Treatment Center
Pulmonary Emphysema Unit
Pulmonary Function Laboratory
Speech Pathology Unit
Spinal Cord Injury Center
Hospital Based Home Care Program
Renal Transplant Program
Cancer Chemotherapy
Cardiac Rehabilitation Program

The 1972 per diem in Houston was $57.50, whereas the national average for comparable general hospitals was $63.73. Thus, despite our many specialized services, highest percent occupancy, and highest turnover of patients, similar V.A. hospitals elsewhere are costing the taxpayer 10.83% more.

Ten to fifteen percent of the veterans currently requiring hospitalization have recently returned from the Vietnam War. These young men are hospitalized for diseases and injuries that were peculiar to this war, such as:

1. Spinal Cord Injury.—The Houston V.A. Hospital is one of eight in the United States to have a specialized center for this severe disability. At present, 40 veterans with either quadreplegia or paraplegia secondary to spinal cord injury are in this Center. To serve the veteran population of Houston, we need a 100% increase in number of beds allocated for this severe disability, and with it, an increase in the number of M.D.'s and the necessary allied health manpower required for optimal management of these patients. Furthermore, this national health problem is sufficiently important to warrant the establishment of a training program for physicians and supporting personnel. After learning the optimal management of these veterans in this specialized Center, these health professionals could go out to other areas of the country and provide these services closer to the home of the disabled veteran, for indeed, here is a classical example of a situation in which an ounce of prevention is worth a pound of cure. Bedsores, bladder infections, for example, are the plague of these patients; they can be acquired in a very few days, they take weeks to cure.

2. Mental Health and Drug Abuse.One of the benefits of the V.A. Research Program has been that a great number of patients with emotional problems can be safely maintained outside the hospital through Mental Hygiene Clinics and Day Hospitals, such as the ones operated by the V.A. Hospital in Houston. Whenever a patient has to be hospitalized when he could be maintained as a day or outpatient, the costs to the taxpayers as well as to the man and his family rise.

We should look carefully at the impact on society of any thing less than adequate care to the sick veteran. These men have given up a good part of their lives in the national interest; we do not want our promises to them to fall short of good medical care. Of 1,200 beds in this Hospital, 400 are devoted to psychiatry, of which 70 are concerned exclusively with drug abuse. In addition, 307 outpatients are enrolled in a V.A.-supported drug-dependence program. Most of these veterans are dependent on heroin, and two-thirds are on treatment with methadone. With our current staffing ratio in psychiatry, we have 17.1 doctors caring for 431 patients, or an average 25 beds per doctor. More doctors will be needed for our drug-dependence program and our mental health hygiene clinics, or the costs to society will increase in many ways. Some of these veterans will have recourse to the crime scene in which case economists estimate that the ultimate cost to the taxpayer will be tenfold that required to maintain good health care as a preventative measure. Houston has a number of excellent psychiatrists that we would like to add to our staff, but because of inadequate funds, we are not able to do so.

3. Multiple Amputees.-For the five years since the height of the Vietnamese War, the Houston V.A. Hospital has had an average of 37 service-connected amputees in the hospital on any given day. A rehabilitation service was established to bring the latest in biomedical engineering research, including the development of new prostheses, to rehabilitate these men. I have had a personal interest in the development of bioengineering as a profession. The National Institutes of Health, the National Science Foundation, and the National Academy of Engineering have recognized and supported collaborative programs between engineering and medicine. At the present time, we need additional personnel to provide a total rehabilitation program. The creation of multidisciplinary centers is sufficiently important to be designated as being in the national interest. These centers would not only rehabilitate these Vietnam amputees to the extent possible, but they would also establish a follow-up program in the veteran's home town to ensure them an opportunity to lead a productive life.

In addition to this special workload that resulted from the Vietnam War, we have had to continue to maintain the best patient care to eligible veterans who have the usual illnesses for their age groups. The present staffing of the Hospital should be increased to give the new veterans the type of care to which we aspire. Similarly, supporting services, such as radiology and laboratories should be increased to continue to give medical care that is competitive with our best private hospitals to the enlarged veteran population.

Moreover, because of the effectiveness of the partnership between the nation's medical schools and the Veterans Administration Hospitals, many educational opportunities have been developed in undergraduate and postgraduate medical education and in allied health training. Indeed, the Houston V.A. Hospital was the first such hospital in the nation to develop a Physician's Assistants Program. There are now about 18 VA Hospitals with such academic programs. At Houston, Baylor has established a joint program with the College of Business at the University of Houston for management development in the health care industry. The administrators of the V.A. Hospital and its professional staff are participating in this program at no cost to the Veterans Administration. This important recent development will help insure top level management officials for the V.A. in the future.

III. WHY DOES THE HOUSTON V.A. HOSPITAL URGENTLY REQUIRE FURTHER SUPPORT?

In section II, I have stated that the Houston V.A. Hospital ranks among the three most active and productive institutions in the V.A. system. Without arguing about exact numbers, my twenty-five years of intimate association with this hospital and countless others throughout the V.A. system, in private and public medicine in this country, and indeed throughout the world, has made it amply clear that the American veteran receives care of the very highest quality at the Houston V.A. Hospital. While we at Baylor College of Medicine are proud of our contributions to the governance of this great hospital, the major credit is due to the two remarkable directors of the Hospital during the past twenty-five years, Dr. Lee Cady and Dr. John Claiborne, the stable and farsighted administration their long regimes and support from the central administration has made possible, and the remarkable and dedicated total team of physicians, nurses, technicians and all the supporting staff they have been able to weld into a unit working for the best interests of the patients under their care.

Why then should I feel that redoubled effort along all lines should now be made to ensure that in the future the American Veteran will continue to receive the very best in medical care; a kind of care that can continue to be measured (1) in its human values, for no care is of value that dehumanizes the patient, (2) in its quality as measured in objective terms of reduced hospital stay, more stable and enduring cures, fewer complications, etc. and (3) in cost, not only per day, but per illness, to the American taxpayer? These can briefly be summarized in 10 essential points.

1. An absolute increase in the number of veterans. There are now some 29 million veterans, an increase of some 6 million in the past 10 years.

2. Increase in the number of Veterans in Texas.—The migration of veterans to Texas is part of the general migration to this state. There is no doubt that an added factor in the migration of veterans to Texas, and to the Houston area is the recognized quality of the Houston Veterans Administration Hospital.

Whatever the reason may be, there is clearly documented evidence that the calls upon the Houston Veterans Administration Hospital have doubled in the past 10 years.

3. The World War II veteran population is aging, and entering the period when heart disease, stroke, and cancer are looming ever larger. These are illnesses that require more time, more effort, more expensive care, and more study than the illnesses of the younger population.

4. The newer techniques and practices in military medicine has preserved the life of veterans with more serious handicaps than have ever survived battle and war services, and the viscissitudes of life than ever before. A classical example is the remarkable spinal cord service at the Houston V.A. Hospital. In the past, few of these patients would have survived. Now almost miraculous rehabilitation of these patients, not only physically, but mentally, is more and more being accomplished. National television at the time of Peace in Vietnam carried interviews with some of these patients which attests to these accomplishments. One of the small, yet very large, factors in the survival of these patients is the use of the newest of antibiotics in the control of the bladder infections to which they are so prone if not carried on a most carefully planned regime. The cost of these life saving and life preserving antibiotics for these patients runs literally into thousands upon thousands of dollars.

5. As every effort is made to reduce the patient's stay in hospital, the costs of laboratory studies, of vital body chemistry, of x-rays, of all the studies that determine and guide treatment, increase in proportion, for as many studies if not more must be made of the short-stay patient than of the same patient if a more leisurely pace were set for his treatment. Thus if, as has happened in the Houston V.A. Hospital, the hospital stay for a given illness can be shortened by 30%, and more patients thereby accommodated, the overall laboratory costs will inevitably rise 30%.

6. With the growth of regionalization, the Houston V.A. Hospital is becoming, more and more, a referral center for difficult cases from other hospitals. Inevitably these patients require more study, more complicated treatment, and more all-over effort; dietitians must plan and cooks must prepare more specialized diets, more laboratory work must be performed, more nursing care is needed, more costly drugs must be administered. The total effort of the hospital, from administrator, admitting officer, transport officer, through staff physicians, residents, and in fact the whole hospital team, is increased.

The very success of the hospital in meeting the medical challenges of today, brings ever new and increasing challenge for the future.

7. The medicine of today in the best circumstances is a coordinated work of a dedicated team; in the future this will prove to be even more important. Doctors, staff and residents, psychologists, physicians assistants, technicians, therapists, ward clerks, orderlies, cleaners, the entire roster of the V.A. staff, in fact, must more and more come to work as a team. Few have been taught how this is to be done, and there are fewer who know how to teach this greatest of all arts. Baylor College of Medicine, in cooperation with the University of Houston, is taking positive steps to ensure that this aspect of professional education will not be neglected in the future. Therefore, to the continual upgrading of the special professional capacity of each member of the medical team, the new parameter of mutual cooperation must and will be taught.

In-house education therefore, must and will demand much greater attention, more professional study, and development of new cadres of personnel to join the old and new professional groups.

Of these latter, it must be mentioned that under the impetus and leadership of Dr. Henry McIntosh of the Department of Medicine at Baylor College of Medicine, the daily supervision and concern of Dr. R. Luchi, Chief of the Medical Service at the Houston V.A. Hospital, and the support of the V.A. system, a training program for Physician's Assistants will graduate its first class in June. By relieving the physician of certain routine duties, and permitting him to work a greater proportion of his time at his highest professional level, this program promises to have a significant and direct influence on the cost of medical care, not only in the V.A. system, but in the entire community.

8. Research.-In 1965, Dr. H.E. Hoff, then Chairman of the Research Committee of the V.A. Hospital (he is now my deputy as Chairman of the Dean's Committee of the Hospital when it is impossible for me to attend) wrote as follows regarding the importance of research in the Houston V.A. Hospital :

“It is clear that if the Veteran's Administration Hospital is to continue to play its part in the development of medicine in Houston, and indeed in the nation, even larger sums must be devoted to research, and that the place of research in the hospital must be made clear to those who allocate funds for the hospital, and to the general public, which makes the funds available in the first instance.

"Why then does a hospital dedicated to the best possible medical care for the veteran population find itself heavily committed to research?

“The definition of what constitutes the best possible medical care is by no means established; it requires precise and detailed statement, not only in its broad categories, but virtually for each patient as an individual. This means the careful study of each patient in terms of his own age, physiological and psychological status, sociological background, and medical history, against the experience in this and other hospitals with similar people in similar circumstances. In many cases this study is not completed during the patient's lifetime, and long-range follow-up studies are an essential part of what may have been a single hospital admission.

“Nor is the definition of the best medical care at all static; it is in a constant state of flux. As new knowledge is gained, treatment necessarily changes, but more importantly, as medicine progresses, patients change, and the hospital population changes. Thus as the infectious diseases are brought under control, the chronic diseases assert themselves; as the diseases of the younger age groups are more adequately treated, the diseases of the older ages accumulate. Once asepsis permitted the surgeon to operate within the body cavities, the abdomen, the brain, and the thorax were in sequence made accessible to therapy. The automobile provides a new kind of trauma; smoking a new distribution of disease. Many unknown genetic, dietary and other environmental factors are no doubt active in producing disease today in totally unsuspected ways.

“This means of course that the physician in the hospital is one of the first, if not the very first to become aware of the changing face of the medical problem, and to react to the demands of these new problems. He must react by devising new means of studying his patients, he must broaden the scope of his studies, and must search for finer details. More than at any other time in medical history he must turn to the chemist, physicist, mathematician, engineer, and to the psychologist and sociologist for help in these studies.

"Research trains the physician and his faculties. Research is an exercise in problem solving. First the problem must be identified and isolated, and given some sort of clear-cut presentation in terms of alternative solutions that can be solved experimentally. These alternatives being disposed of, the selected solution is tested and confirmed by further experimentation. The solution is then incorporated into existing theory and used in the approach to new problems. This differs in no essential from the approach to an individual patient, who, though he might fall within the framework of a specific disease entity has specific problems of his own, and cannot be treated, entirely, as a category.

Research and practice are here mutually supportive. Research can its very nature be more precise, more quantitative, and more rigorously controlled, and medicine has always profited from these qualities in its practitioners; the demands of instrumental accuracy have trained the physician's acumen ever since Galileo began to count the pulse. On the other hand the physician is often forced to think in terms of multiple variables; he cannot neglect psychological and sociological factors for the chemical and physical, he must often make decisions based on clinical judgements that cannot be given a completely objective statement. Research is not hurt but is helped by such qualities, and it is a characteristic of the superior scientist to be able to trace the often tenuous links from one phenomenon to another, and to detect the cause and effect relationships between them.

“This points up the important consideration that the hospital that attempts to provide the best in medical care, and succeeds in doing so a good part of the time, is perhaps the only place where some kinds of research can possibly be carried out successfully. Only in such surroundings can adequate criteria be established, and only here can proper controls be made available, and in particular, only here is there assembled a staff capable of this kind of activity and the facilities for carrying it out.

“We have seen in recent years the immense value of the relatively few clinical research units set up throughout this country under the auspices of the National Institutes of Health. In general they have been quite small units of six to twenty beds. In a real sense every single bed in a Veterans Administration hospital can be thought of as the equivalent of a bed in a clinical research unit, around which it would be possible to gather the kind of staff, services, and facilities to make it of comparable productivity in better care and new knowledge.

“The research and teaching program in a hospital plays an important part in the recruitment of staff. There is a growing number of young physicians, who wish to devote their major energies to patient care, but who wish also to live in an active medical environment, with the time and facilities to carry out this patient care and study against a background of active search for new knowledge through research. To these, research is part and parcel of good medical care just as the opportunity to apply the results of research to improved medical care is part and parcel of research. This kind of physician is interested in teaching, and is interested in associations with scientists and other academic people outside the strictly medical fields. The hospital that is oriented toward the best in medical care, with all that this involves in practice, research, and teaching, and in general with the academic affiliation that almost always naturally develops in such a hospital, will naturally attract and retain this kind of a physician. This insures the continuity of philosophy and productivity and changes the hospital from a user into a producer of ideas, knowledge, and more fundamentally, of adequately trained people.

“In summary, research is an essential part of the activity of a hospital devoted to the best in medical care: it helps to define what such care involves, and it does its part in supplying the new knowledge that is required as the nature of medical care changes, for with each advance in medicine, new and often more difficult problems arise. It serves in the education of the staff, and above all it is a necessary part of the life of the physician who wishes to devote himself to the care of his patients in a hospital and academic environment. It is to be hoped that in the years to come these goals will come to be more and more fully realized.”

Since that time, the truth of these statements has become more and more manifest. The change in the nature of the hospital population toward the more serious and less well understood medical problems, the need for recruitment of research-minded professionals, the new problems in medicine, medical sociology, and medical economics that lay ahead make it imperative (1) that continued increase of funds for research is needed, (2) that professional staff be large enough so that everyone who deals with patients will have time for some

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