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Senator CRANSTON. Don't you think it was indicated that there is a discussion of an arbitrary ceiling, regardless of what can be done with ambulatory care, regardless of how many people really need inpatient care!

Dr. BERGEN. I think there is, yes.

Senator CRANSTON. I discussed our regional medical educational center provision in the VA health manpower law earlier. I believe that continuing education is terribly important and we should not delay in getting on with implementing that new law. I trust you agree?

Dr. BERGEN. I certainly do, sir. At least from our point of view there has been a great confusion in this area. There has been some indication over the last year or year and a half that the regional medical program would assume this roll. At the same time, there has been some indication that a separate program, health education centers would be developed, and there is also this part of Public Law 92-541 that has not been implemented.

We think the concept is very sound, but we feel it is important for a decision to be made as to which element of Government is going to implement the program. Now, we think the VA system is eminently qualified. What it is already doing with its large number of facilities, its joint programs, and with many educational institutions in addition to medical schools, and dental schools, make it eminently qualified to be a focal point of development of such educational centers.

Senator CRANSTON. Thank you very much. You have been very, very helpful.

Dr. BERGEN. Thank you sir.
[The prepared statement of Dr. Bergen follows:]


MEDICINE AND DENTISTRY OF NEW JERSEY, NEWARK, N.J. It is a privilege and an honor to appear before you today to testify about the College's many joint undertakings with Veterans Administration Hospitals in New Jersey, and to relate to you our hope and intention that the College may have the opportunity to substantially expand these beneficial relationships through the creation of a third medical school in South Jersey in conjunction with the construction of a Veterans Administration Hospital in that part of the State.

The College of Medicine and Dentistry of New Jersey is composed of the New Jersey Medical School located in Newark, the Rutgers Medical School located in Piscataway, and the New Jersey Dental School located in Jersey City. The College is responsible for the operation of several health care facilities including Martland Hospital in Newark, Raritan Valley Hospital in Greenbrook and the Institute of Mental Health Sciences in Piscataway. In addition, the College has numerous state-wide responsibilities including continuing education, strengthening of graduate medical education training programs and the development of models for health care delivery.

The affiliation of the College with the East Orange Veterans Administration Hospital has been extremely beneficial for all concerned. The Veterans Administration Hospital system provides a number of natural advantages for medical education. It provides an important source of patient material for the teaching of medical students. Approximately one-third of the second, third and fourth year classes receive a portion of their training at the East Orange facility. Equally important, the orientation of the Veterans Administration system toward full-time staff appointments and toward delegation of responsibility particularly to house staff has been of great assistance in permitting the East Orange Veterans Administration Hospital to function well in the medical education framework. As a result, the integration of programs between the East Orange facility and the New Jersey Medical School has been more intensive than at other affiliations of the College.

In return, the Veterans Administration Hospital receives numerous advantages as a result of its participation with the medical school. Prior to its affiliation with the College the East Orange Hospital had no intensive care unit, no coronary care unit, no dialysis unit, nor any vascular caterization program. In large part these deficiencies were due to the difficulties experienced by the Hospital in attracting adequately trained staff. Furthermore, the hospital had difficulty attracting sufficient housestaff to meet its needs.

The affiliation with the medical school has substantially altered the picture. The assurance of faculty appointments and the stimulation involved through participation in a teaching environment has greatly enhanced the ability of the Veterans Administration Hospital in East Orange to attract highly qualified and in some cases nationally known individuals to its staff. It has also been of great assistance in attracting housestaff.

These remarks are not intended to imply that no problems exist with our affiliation. Clearly, certain difficulties persist, particularly the fact that the Veterans Administration population continues to be made up almost exclusively of adult males, thus, circumscribing its usefulness as a total teaching environment. Nonetheless, our experience with the Veterans Administration Hospital in East Orange provides convincing evidence of the value of this sort of relationship between a medical school and a hospital in the Veterans Administration system.

It should also be noted that historically the East Orange Hospital played a crucial role in the continued survival of the New Jersey Medical School. In 1966, a time of considerable turmoil in the history of this institution, the school encountered a situation where its core teaching facility was no longer available to train medical students. Had it not been for the willingness of the Veterans Administration Hospital in East Orange to take us in, to provide space for the erection of certain facilities and to act for a period of three years as our primary affiliate, it is indeed possible that the New Jersey Medical School would have ceased to function as a four year medical school. Therefore, not only does the College wish to maintain and strengthen its present relationship with the East Orange Hospital, but it also acknowledges a deep sense of gratitude for the crucial role that that institution played in the survival of the New Jersey Medical School some years ago.

Despite the excellent present relationship with the East Orange Veterans Administration Hospital, I would be remiss if I did not mention some of the more disquieting implications of the fiscal year 1974 budget and other actions taken by the Administration. For example, the 1974 budget contains a mandated reduction to 80,000 in the average daily patient census. We are informed that this is to be made up through more rapid patient turnover. We are fearful, however, that the result will be a reduction in the quality of patient care or a forced reduction in demand for care or perhaps both.

In the research budget as well we notice some reductions from last year's funds. In part this is to be made up through carry-over monies generated through forced savings in this year's research budget. At the present time several research programs of great importance are underway at the East Orange facility, including studies concerning hepatitis, which affects many drug users and individuals who have found it necessary to receive blood transfusions, studies on the affect of smoking on animals, and studies on portal hypertension, the most common cause of death among individuals with liver disease resulting from the abuse of alcohol. We are concerned that not only will present efforts be curtailed, but that future research efforts of importance not only to Veterans Administration but to medical science in general will not be undertaken.

We are concerned about the staffing ratio of 1.59 at the East Orange facility and its affect on patient care. We are concerned that maintaining the same system-wide staffing ceiling into next year while at the same time opening additional facilities will cause further deterioration in an already unsatisfactory level of staffing. Furthermore, the forced reduction in grade among general schedule personnel at the Veterans Administration Hospital may well result in the hiring of less qualified personnel and a reduction in the ability of the East Orange facility to compete with neighboring institutions in the hiring of needed staff.

What concerns us most in this whole matter is the intentions of the Administration for the future. The beneficial and fruitful relationships that have been established between the Veterans Administration Hospital system and medical education cannot survive constant, long term pressure for reductions in budget, decrease in staffing ratio and cuts in the patient census. We would urge that any attempt to follow this course of action be resisted to the fullest extent.

Finally, I would like to take this opportunity to bring to your attention what I believe to be a historic opportunity for the involvement of the Veterans Administration Hospital system in the development of new resources for the training of physician and allied health personnel. Three important factors have combined to create this unique opportunity.

First, in 1972, with the assistance and determined efforts of this Committee, the Congress approved and the President signed Public Law 92–541. This law authorizes monies to be appropriated for the purpose of making grants to assist in the establishment of new state medical schools at colleges or universities that are primarily supported by the states in which they are located if such schools are located in proximity to or operated in conjunction with Veterans Administration Medical facilities. The statute allows these grants to be used for the leasing to the institutions of land, buildings and structures under the jurisdiction of the Veterans Administration, for the alteration and remodeling of such buildings and, on a declining basis over a seven year period, for assistance in the cost of providing faculty salaries. These grants are made with the proviso that the State involved make a commitment to provide the proposed school with adequate financial support and that the school meet adequate professional standards.

The second signficant factor is found in the Appropriations Act for HUD, Space, Science and the Veterans Administration for the fiscal year 1973. In this Appropriations Act there is set aside 3.7 million dollars for planning and site acquisition for a Veterans' Administration hospital in southern New Jersey/ Philadelphia, Pa. metropolitan region.

Third, during the past year, at the request of the Governor, the College of Medicine and Dentistry has been conducting a feasibility study concerning the possibility of the establishment of a third medical school in the southern part of the State. This study has convinced us that there is indeed a strong need to produce additional physicians for the area, to provide more medical education opportunities for the residents of South Jersey and to make available to the entire southern portion of the State the benefits that would result from the establishment of a medical school in South Jersey including continuing education, recruitment and retention of housestaff, recruitment of highly qualified attending physicians and the general improvements in the quality of care that go hand in hand with the creation of a teaching environment.

Unfortunately, however, our feasibility study has created concern as to the ability of existing clinical facilities to provide an adequate clinical base for the establishment of a third medical school in South Jersey. While there are many excellent hospitals providing fine care to the residents of that part of the State, few have made the commitment of medical education in the form of graduate education for interns and residents that would be required to sustain a medical school. Thus, while the interest and the need are apparent, we remain concerned as to the feasibility.

The confluence of these three factors sets the stage for this unique opportunity for the Veterans Administration Hospital system to play a crucial role in the creation of a new medical school. A decision to proceed with the building of a new Veterans Administration Hospital in South Jersey area would substantially alter the long range situation with regard to clinical teaching facilities in that portion of the State and would make it possible for the College of Medicine and Dentistry of New Jersey to proceed with the development of a third medical school. Furthermore, the appropriation of monies under Public Law 92–541 and the assurance of the availability of these monies for the establishment of a South Jersey medical school would, in conjunction with a new Veterans Administration Hospital, assure the financial viability of the new medical school during its formative years and thus guarantee its rapid development as a full medical school.

I strongly urge this committee to support this unique opportunity for the Veterans Administration to make possible the establishment of an entire new medical school and urge you to do everything possible to assure that a Veterans Administration Hospital will be constructed in South Jersey and that sufficient monies will be appropriated under Public Law 92-541 to bring this project to fruition.

Thank you again for the honor that you have accorded me in inviting me to testify here before you today.

Senator CRANSTON. Our next witness is Dr. Richard P. Schmidt, dean of the College of Medicine, vice president for Academic Affairs, State University of New York-Upstate Medical Center, Syr

acuse, N.Y.


Dr. SCHMIDT. Thank you very much, Mr. Chairman.
Senator CRANSTON. Thank you very much for being with us.

Dr. SCHMIDT. I am honored to be with you, and in being asked to come. I have submitted a written statement. With your permission, I would like to summarize some of the points in there.

Senator CRANSTON. That would be most helpful.

Dr. SCHIMIDT. First of all, my own background. I have served both at medical schools and in the Veterans Administration in various capacities. Before I became dean at Syracuse, I served for a little over 2 years as the chief of staff of the Veterans Hospital in Gainesville, Fla.

I am currently, I guess, outside of the VA again, but intimately involved. because across the street we have a Dean's committee VÅ hospital, with which we have an active and effective partnership in the area of medical and allied health education, and also in research.

First of all, I think the system of patient care in the VA is generally good. I think it is one of the most efficient systems that I have ever seen in my life. However, I think it is, at the present time, from my personal observation near the breaking point, whereby efficiency can breakdown with resulting collapse of the quality of

I believe the VA to be underfunded from the standpoint of ratio of staff to the number of patients to maintain the quality of service which our veterans patients deserve and expect.

There has been some rather peculiar and odd things. First of all, I think those who were the architects of the partnership of the Medical Schools at the end of World War II should be commended. They have produced one of the most effective educational, research, and patient-care systems which has ever or will ever exist.

There are several aspects, however, which are perhaps out of touch with the times and for the future. One of these is that the emphasis is on the funding of a hospital care system and not a system of comprehensive care. It is my belief that the veterans medical care system should be that of comprehensive care to the eligible veterans irrespective of the modality of care, irrespective of the need for hospitalization.

I would oppose an arbitrary limit or an arbitrary ceiling being placed upon hospitalization, but I would be equally opposed to saying that the only way a patient can get care is to be eligible and to



need to come into the hospital as a horizontal patient in bed as opposed to a vertical patient receiving ambulatory care.

The improving efficiency of ambulatory care, has an additional side light in that it tends to increase the cost of inpatient care, although perhaps decreasing the number and increasing the efficiency, The patients in the hospital tend to be more acutely ill and demand more services, which causes the cost to rise. Also, new methods and new technology improve patient care but increase costs beyond that which we would expect by inflationary pressures alone.

There are really three missions of a medical school, and three missions of a veterans hospital. The first is patient care. We may see this in somewhat different light from the educational standpoint, but I think that no system, no hospital, no clinic, no university hospital, no veterans hospital can exist in any quality whatsoever unless this comes first, and is of high quality.

This interlocks with the educational function, and I do not believe that quality education could occur in an institution where quality care is not carried out. These are hand-in-hand.

You have had other witnesses today speak of the research. There has been a great deal of rhetoric concerning the rather abrupt drop in research funding, especially that for basic research and for research training. I personally feel that this is exceptionally shortsighted but the rhetoric can be supplied by others.

Dr. DeBakey, earlier this morning, eloquently illustrated the very marked reduction in the amount of research training and, hence, I believe, the benefits to mankind—both in terms of humanity and also in terms of economics.

We can point to some of the major economic savings that have occurred because of biomedical research. You heard some this morning that the VA was very instrumental in establishing the modern treatment of tuberculosis. The cooperative drug studies were done at the veterans hospitals and clinics. New hospitals were built for the patients, for care of patients with tuberculosis no longer had to be used for that purpose. Needless to say, this has been a major breakthrough, both in the treatment of patients from the standpoint of economy and humanity.

This break-through in treatment resulted in savings of millions and millions of dollars that would have been required to keep these patients in hospitals for 6 months, a year, 2 years or 3 years, as was the case when I was a medical student.

I have considerable fear, Mr. Chairman, that the care system in the VA, if it continues to have the constricted funding in the hospitals, if it is not funded as a comprehensive care system, will deteriorate so that it no longer can be used as a fine example for our students.

We already see them somewhat restive by comparing what they can do for their patients in the Veterans hospitals compared to the universities hospitals which are closely affiliated.

On the Syracuse hill where we work, we have hospitals under several different bureaucracies. One, our State university hospital, which is an instrumentality, of course, of the State University of New York.

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