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 by 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

research as problems arise from the patients they supervise, and (3) that a cadre of medical investigators be created to give leadership (which should however center mainly on service chiefs) but special knowledge and continuity to the research efforts of the Hospital.

10. Space. The main portion of the structure of the V.A. Hospital is now 27 years old; its newest buildings are 10 years old. Designed and operated as a war-time naval hospital, for the illnesses of young and generally healthy naval enlisted men and officers, it was never provided with the laboratory and other facilities of a modern hospital that must meet the needs of today's medicine, for a different population with more difficult problems, and for a pace of activity undreamed of in 1945.

Size is not the sole or even the most important criterion, but modernization to provide a balanced medical plant to meet the needs of the future, becomes more and more essential.

11. New Program.-In Section II, I spoke of the significant list of new programs instituted at the Houston V.A. Hospital within recent years. They have strained administration, staff of every description, and budget, to achieve. They have demonstrated that better care is not in the long run more expensive care. But to continue to do more along this line will in the long run demand more staff and all that goes with it; if we continue the record of the past, this improved service to more verterans will not increase the daily cost of hospitalization, but rather decrease it, and in the long run reduce the cost for each veteran who is treated at the Houston V.A. Hospital.

All the factors mentioned from 1-9 will foster the development of new programs: new challenges, a dedicated administration and staff, research mindedness-which in reality means the willingness to accept problems and work out practical solutions, and space personnel, and expendibles to do so.

To this I must add that the Hospital is not the only place where good care is given, or needs to be given. Out-patient facilities, day hospital facilities, half-way facilities, and straightforward domicilary care form a satellite-and only a partial one-of the facilities that should surround a great central hospital such as the Houston V.A. Hospital.

Above all, these facilities must be coordinated; they must be part of a total spectrum of medical care, from outpatient screening clinic through all stages to domiciliary care. This is parenthetically, of the greatest impact in the last category; veterans in domiciliary care should not simply be filed away as beyond the help of medicine but be actively studied within a vigorous medical framework. Medical advances should never be permitted to pass them by.

IV. PLANS AND IMPERATIVES FOR THE FUTURE

On page 185 of the document known as the Teague report, and appropriately so for the Honorable Olin Teague, then Chairman of the Committee on Veterans Affairs, issued as House Committee Print No. 9 of the 1st Session of the 93d Congress, and printed at the U.S. Government Printing Office in 1973, the Administration of the Houston V.A. Hospital, asked to "name and describe briefly what the three most pressing needs of your station are today, replied with admirable but comprehensive brevity"

1. Complete modernization to improve existing facilities and provide additional space for such things as more single and double rooms, increased ambulatory care, research and expanded SCI Service.

2. Increased funding and ceiling to support additional personnel in both the inpatient and ambulatory programs.

3. Increased funding for both additional and replacement equipment to reduce significant replacement backlogs and to take advantage of newer equipment presently available.

Later in the year, at the instance of the Dean's Committee, a more comprehensive statement was made in a brochure on a "Five year plan to improve patient care". This has been entered in the record of this testimony and represents a conservative and reasonable projection of the needs of the future as they can be assessed in light of the factors I have listed in section III.

Let me, however, speak personally from twenty-five years of intimate association and deep concern for the Houston V.A. Hospital. I can say with some pride that I played a part in its conversion from a naval Hospital to a Veterans Hospital, I can also acknowledge with deep gratitude that some of my fundamental studies on prosthetic arterial grafts were carried out in the surgi

cal research laboratories of that hospital. Its importance to Baylor College of Medicine of which I am President cannot be overstated, and I believe that the association of the two institutions has been of inestimable value for both.

What do I believe are at once the pressing problems and the great opportunities for the future of the Houston V.A. Hospital and its association with Baylor College of Medicine?

Manpower

Two great administrators, a series of extraordinary Chiefs of Services, two Chiefs of Staffs, Marc Musser and John Chase who need no praises from me that they have not already gained from the circle of their peers, and younger physicians without count, some who have gone on to more senior posts, and some who have remained to rise in the ranks of the hospital, have by their devotion to medicine, and to their hospital, made it the superlative institution it now is.

They have been ably seconded, supported and encouraged by an able and interested group of consultants from Baylor College of Medicine and other Institutions, who in their associations with the hospital, placed the Houston V.A. Hospital in the position of primary priority. I believe we can truthfully say that we have all worked together to make this a great V.A. Hospital and not a Baylor Deans' Committee Hospital.

Around a medical staff of some 90 physicians, 90 Residents, and 225 consultants, has been gathered a total team of some 2100 supporting personnel of all kinds.

These are the people who have made the Houston V.A. what it is today. They and their successors will make its future.

The maintenance, the constant education and upgrading, the renewal, and the growth of this vital organism is to my mind the central core and our greatest challenge for the future.

It is no great mystery how such people are recruited and retained. They must be adequately paid, they must be given time and support to create the medicine of the future in addition to practice the best medicine of today. They must advance professionally and in their understanding and practice of the team approach. This all means:

1. A staff size to permit time from the demands of immediate practice for study and solution of pressing problems.

2. Research funds, partly available to administration as "fluid research funds" to start off promising programs and partly available in competition for programs of demonstrable merit. Salary funds for senior research advisors as well as for beginners in research are essential.

3. Educational programs aimed at upgrading of all personnel, to form genuine career ladders, to mature and indoctrinate the young, to revitalize and remotivate the older. Programs to teach by precept and example the techniques and unique productiveness of the team approach, involving all personnel. Put in older terminology, this is the concept of the "Task Force". In the newer language this is "goal oriented motivation".

I am particularly interested, and indeed concerned, that the highest priority in professional staff be given to an increased number of residents and career investigators. This is not simply because we have been behindhand in increasing these necessary ingredients to good hospital practice, but because the resident is the key to the future of American Medicine. He makes the most direct contact with the patient, he should become the pattern for the students, physicians assistants, nurses, and all the allied health personnel he teaches, leads, and forms the day by day example, but has become the practitioner of the future. The quality of the resident, and the quality of the experience he has in the hospital need our constant concern, and our very best efforts to make his experience at the V.A. of the first quality. It is not too much to say that if we could fulfill this goal all the other matters would be taken care of incidentally.

V. SUMMARY

So it has been in the past twenty-five years. The cooperation with Baylor College of Medicine and the V.A. Hospital has been challenging, it has been productive, it has been personally satisfying. Two administrations and a host of professionals and staff members have learned to work together to make the care of the American Veteran at the Houston Veterans Hospital a human and a medical landmark. New problems come to us daily; in no small part the