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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 surgical 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.
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 better we do the more is laid upon us. Our cause is as important, perhaps only in a less spectacular way, as the Statesman who once said "give us the tools and we will do the work."
Senator CRANSTON. The testimony of Dr. Fudenberg has indicated great savings in research, and obviously in the long run research can mean savings, can't it?
Dr. DEBAKEY. There is no question about that, I don't think there is any doubt about the effects of research. One can take as a very good illustration the total amount of money that was invested in the research of poliomyelitis compared to the total amount of money that is annually expended on the part of the public and society in general in the care of poliomyelitis patients. With the elimination of poliomyelitis, all that money is obviously saved. That is a very small fraction, the amount of research is a very small fraction of the amount of outlay of moneys for the care of patients of poliomyelitis just in one year alone.
Senator CRANSTON. Last year, Dr. DeBakey, legislation which I authored authorized the designation of VA regional medical education centers to provide continuing education and the opportunity of conducting clinical investigations and demonstrations in VA facilities. I discussed this at the very end of this morning's hearing, while the VA was with us, with Dr. Musser.
The VA hasn't utilized this authority at all. Could I have your comments on the potential benefits to the veteran, and to research in the designation of such centers?
Dr. DEBAKEY. I think there is no question about the potential benefit and value of it. I think it is most unfortunate that they haven't found it possible to proceed to the implementation of that program, but there is no question about its value in terms of its expansion of medical personnel. It is badly needed.
Senator CRANSTON. What do you believe the level of funding for VA research programs should be in fiscal year 1974 ?
Dr. DEBAKEY. I would recommend 5 percent of the total budget.
Senator CRANSTON. I thank you very, very much, and I am glad we had this opportunity to hear your testimony.
We have to leave, that bell means we have to go to the Senate floor in the Capitol to vote.
Thank you very much for your help and for your testimony.
[Whereupon, at 12:15 p.m., the hearing was recessed, to reconvene at 1:30 p.m. this same day.]
[The prepared statement of Dr. DeBakey follows:]
STATEMENT OF MICHAEL E. DEBAKEY, M.D., PRESIDENT OF BAYLOR COLLEGE
Mr. Chairman and Members of the Subcommittee :
I am pleased to have the opportunity to testify before this Committee regarding the importance of medical research in VA Hospitals. I would like to discuss with you the significance of the Veterans Administration's involvement in medical research, its unique qualities which make it best suited to conduct certain types of research, and the desirability of investing funds in research to be performed in this Agency as it relates to the quality of medical care.
Medical research as a part of the Veterans Administration's responsibility began in 1946 and was initiated with the establishment of a Committee on Veterans' Medical Problems in the National Academy of Science, National Research Council, which emanated from a proposal that I had made to the Surgeon General of the Army. This operated through a follow-up agency which is still functioning today as an important resource in answering critical questions concerning what happens to veterans who contract certain diseases or are injured while in the military service.
The intra-mural research program was started in 1955 and since then has been closely associated with patient care programs of its constituent hospitals. In 1960, the National Research Council reviewed this program and stated, “the afiliated 1A hospitals started to attract physicians interested in combining teaching and research with medical practice; many of these doctors entered the employ of the VA only after receiving an assurance of research opportunities."
By 1968, the program had attracted sufficient attention for the National Research Council to make an extensive evaluation of it at the request of the Office of Science and Technology and the President. The first recommendation was “that the Legislative and Executive Branch of the Federal Government explicatively accept the principle that the VA is obliged not only to provide optimum medical care to the veterans, but also, to the extent of its professional and physical resources, to contribute to the advancement of medical knowledge through research and to the dissemination of medical knowledge through education for the benefit of the nation as a whole.”
They also commented, “it is the Advisory Committee's conclusion that the research program compares favorably with other broad national programs of vital medical research.” And finally, they commended the Agency "for relating the program to its primary mission during a period of rapid growth.”
The need for the research budget within the Agency has been examined almost continually since the beginning of its program. In 1960, the Committee of Consultants on Medical Research (of which I was a member) of the Senate Committee of Appropriations stated “other Federal Agencies besides the National Institutes of Health should continue to maintain strong programs in support of medical research. These programs should not only serve the specific health mission of these agencies and make their operations more effective but should also utilize their special opportunities to make contributions of particular value in the total research effort of the country.”
What has the record shown? These may be considered as (1) research which has directly helped the veteran patients, (2) research which has affected the nation's health and which could have been performed only in the VA Hospitals and (3) research which has been done in the VA, where it has received immediate and wide application by virtue of close association between the research laboratory and the broad system of clinical care. In any given year, numerous examples could be given of the first circumstance. Moreover, in the VA's annual report for the past year, studies have been identified with immediate and direct improvement. In the care of liver disease, it has been shown that low levels of the plasma protein, albumin, are not necessarily due to the decreased production of this substance. Also, in patients having alcoholic withdrawal symptoms, chemicals have been identified (Aldehydes) which are associated with the symptoms. New forms of suppression of the immune system have been used which have improved the incidence of success of transplantation of organs. (Nearly one quarter of all renal transplants in the country have been performed at VA Hospitals). Taken individually, it is sometimes difficult to demonstrate clearly a major change in medical practice concerning specific illnesses. There is no question however, that research in the drug therapy of tuberculosis, which began in 1946 and was conducted within the VA hospitals, was associated with almost the elimination of the need for hospitalization of patients for this disease. It has also decreased the need for surgical treatment for tuberculosis from commonplace to negligible.
What sort of research is the VA uniquely capable of performing? Obviously, it is the cooperative studies which have been an increasingly important resource for improvement in the nation's health. VA investigators can rapidly amass significant statistics by drawing on the largest volume of clinical records and patients available to any single agency in the western world. The significance of the availability of such voluminous material for study should not be minimized. It makes it possible to determine wheiher one treatment is better than another in a considerably shorter period of time and more authoritatively than would be possible in a single hospital or group of hospitals, no matter how prestigious. In addition to the successful treatment of inberculosis, I might cite drug therapy for psychiatric illness, which enabled the VA to decrease its cost considerably for new construction of neuro-psychiatric hospitals. Cooperative studies on high blood pressure have been cited by experts of the American Heart Association as “ a milestone of inestimably great importance in the therapy of blood pressure", and the researchers received the Lasker Award for this work. These studies are all designed in search of answers to important therapeutic questions, and delay in answering them can only be detrimental to the health of large numbers of individuals, both veterans and non-veterans. Important current studies include evaluation of the effect of coronary arterial surgery, the health implication of the sickle cell trait, and a number of programs designed to identify the best drugs for the treatment of cancer, particularly those malignant lesions most common in veterans. The Special Action Agency on Drug Abuse Prevention, recognizing the unique ability of VA investigators to perform cooperative studies, has urged the VA to increase its research efforts in this direction.
Should the VA restrict its research to studies that cannot be performed elsewhere? To do so would deny the country a great research resource. The intimate association between the research laboratory and patient care promotes rapid clinical application of basic scientific advances and points up the important medical problems that require solution by basic research. To be sure the University Hospitals serve a similar purpose, but the VA has always emphasized its role of patient care and has attracted the scientist most interested in performing research directed toward the preservation of health.
It is difficult to determine the degree to which research support helps to recruit and retain physicians in the VA system. To get the answer would require the withdrawal of such support-a foolhardy approach, since such an act would result in a loss of the Chiefs of all the major bed services as well as most of the staff physicians presently receiving research support in affiliated hospitals.
What is to be gained by decreasing research funding? Presumedly, it would save money, but the available evidence does not support this contention.
Dr. H. H. Fudenberg has assessed the financial benefit of biomedical research (Journal of Laboratory and Clinical Medicine, Volume 79, March 1972). He estimated, on the basis of standard costs benefit analysis, some of the savings which have resulted from the discoveries in several fields. The list is interesting because VA research has played the major role in bringing into practical application the basic research on tuberculosis and viral hepatitis, and has made major contributions in kidney transplantations. The technique of radioimmunoassy, which can measure extremely small amounts of diverse substances, has been developed almost entirely by VA researchers. Dr. Fudenberg's Cost Analysis of this assay alone indicates that: “Application of the radioimmunoassay technique has resulted in a test that will detect at least 85% of Australia Antigen positive blood and should, when applied on a mass basis cost little more than 35¢ per test. It would mean an end to much of America's expensive and damaging transfusion hepatitis problem and will save $100 million yearly.” He also states: "It is impossible to estimate the potential savings in the immediate future from recent discoveries such as immunologic measurement of blood digoxin levels and reversals of digitalis toxicity (on the order of $600 million a year).”
I have already commented on the major roles played in the treatment of tuberculosis by the VA. From 1954 to 1959, Dr. Fudenberg estimated savings of hospitalization costs for the country, "conservatively at $3.77 billion, and sav. ings due to elimination of decreased productivity at $1.2 billion for a total estimated economic benefit of $5 billion.
What then is an appropriate research budget for an Agency such as the VA? If this is considered as an investment from which we reasonably expect a good yield, the figure could be unspecified. For comparison, however, it might be pointed out that in 1971 the Department of Defense spent 10.8% of its budget on research. Commercial pharmaceutical companies spent 11.4% while the VA was spending one-half of 1% of its total budget and only 3% of the budget for the Department of Medicine and Surgery. Since 1971, this figure has decreased to 2.5%, the lowest in more than a decade.
In conclusion I should like to urge the funding of VA biomedical research because it will not only provide better quality of health care for the veteran as well as the rest of the people in our country but it will also enable the VA to attract and retain the highly qualified professional staff to guarantee quality medical care.