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I might add further identification by pointing out that prior to assuming this position, I was dean of the School of Medicine and the Dean's Committee Affiliate Hospital and the director of the University of Oklahoma School of Medicine and Medical Center. I am immediate past president of the Association of Academic Health Centers, and currently on its board of directors.

As a veteran, I am very much interested in the challenges that are before us but my presentation today will be primarily from the evaluation of medical education and its impact upon that veteran.

It has been my privilege, Senator, to have experienced my professional career during the period of time that has seen medicine emerge from an empirical art to a skillful, scientifically based discipline.

During the same period, the Veterans' Administration hospitals, through the dean's committee medical school affiliations have emerged from a status of third-rate institutions to rank among the very best in the country. This partnership has provided the opportunity to develop a critical mass of excellence that could not otherwise have been possible for either the medical school or the VA teaching hospitals.

Only those who have lived with it can appreciate the significant contributions the Veterans' Administration hospitals have made to the production of health manpower in this Nation. At our institution, our medical students devote as much as 40 percent of the time spent in their clinical education and training at the VA hospital. Currently, 80 percent of the Nation's medical school graduates have received some of their education or training in an affiliate VA hospital. Twentyfive percent of this Nation's housestaff, intern or resident physicians, in training today are in our Veterans' Administration teaching hospitals. In these VÅ institutions are 2,200 health professionals who have faculty appointments in an affiliated university medical school. Too few people are aware of the gradual emergence of the VA hospital system as by far the largest single resource for the production of the Nation's health manpower needs. The enlightened congressional support that has made possible this notable VA contribution to health education and health manpower must be enhanced, not retracted. I ask you to consider the following:

One, health care services are in short supply and for many people even unavailable.

Two, health care services are skilled people at work—they can only be produced by a process of education and training, which depends on the availability of appropriately staffed teaching hospitals and clinics.

Three, the only nationwide network of teaching hospitals in existence in this Nation is that provided by the Veterans Administration hospitals.

Four, no longer available to medical schools are Federal HEW moneys that have provided funding for the expansion or construction of medical schools for the purpose of producing more physicians and other health manpower. Since the vast gap between the availability of health care and the demands for health care remains, the essential role of the VA hospital system, in terms of manpower production, requires your most conscientious considerations and unequivocal support.

Five, in this Nation today the greatest undeveloped potential for sustaining an increased level in the production of all of the various kinds of health manpower that are in short supply resides in the medical school Veterans’ Administration teaching partnership models. Paradoxically, the growing pressures to produce more and serve more, at less cost, have peaked at a time the demands and costs are going up and appropriations are leveling off, or are going down.

On the basis of information provided to us, our VA-Dean's Committee Hospital can, with the projected budget for fiscal year 1974, July 1973-June 1974, expect to be fortunate to maintain operations at the 1973 level, yet the service demands are increasing and will be greater.

They can employ no more than the current number of housestaff, residents and interns, at a time the medical school enrollments are increasing and the need for an additional 10 resident positions are essential. Other deficiencies in the fiscal year 1974 budget include:

(1) inability to obtain additional staffing that would permit employment ratios of staff to patients equivalent to that of the average private hospital;

(2) inability to recruit additional professional and allied health personnel required to serve ever increasing demands, particularly in the outpatient areas;

(3) inability to fund the new school of health related professions in order to provide for the students, programs and facilities that would permit even a fraction of the tremendous growth potential in this short supply field of health manpower, and

(4) indefinitely delayed are plans, meticulously generated over a period of several years, to activate an innovative, critically needed program for high-quality geriatric medical care and a unique program of geriatric home care. These latter programs were designed to provide the basis for a new medical school department for research and teaching in the field of aging. Neither institution can do this alone. The importance of the intolerable neglect of research, teaching and care for the aged required no amplification. This is just one aspect.

I think at the other end of the spectrum, Chairman Cranston, are our immediate concerns for our Indochina veterans and their acute needs. I happen to be a World War II veteran, and we are getting older, and we are going to have a very large, aged population of veterans, which has not yet hit us. We are not prepared for this, and if we are going to be, we have to plan and develop now.

Another area in which Veterans Administration budgeting has been unrealistic is in the pay rates for its top professional staff. I am presenting this from the viewpoint of the person who has to deal with keeping superbly-qualified men on the job who want to stay there, but they see their colleagues in practice or even in the medical school with a differential in pay. VA service chiefs with medical school appointments at the rank of full professor are paid $30,000 to $36,000 per annum. Medical school professors, chiefs of service, receive salaries that are from $5,000 to $15,000 per year above the equivalent VA position.

The immediate impact of the “status quo” annual appropriation has been readily identified ; less visible is the long-range impact which is éven more significant. New teaching and training programs always require several years of planning, organization and recruitment prior to implementation.

For example, in response to public demand and need, our medical school, like many others, has recently increased the size of its first year class—with plans for an even larger increase in the near future. Both decisions were predicated on the availability of the resources of the Veterans Administration hospital facility and staff necessary to accommodate an increased number of students at the time they reach their clinical years. This requires interns, residents and other staff. They, in turn, provide services to veterans. What do we tell our legislators? They authorized the student expansion on the premise of available facility resources at the VA. Even more significant to our State is the VA budget limitation that, in effect, puts a "freeze” on intern and resident positions. There are only enough intern positions in our State to accommodate one-half of each graduating class; hence, a large number of physicians are permanently lost to a State community that in 1970 had only 83 physicians per 100,000 population, approximately one-half of the national average. These illustrations may appear to present a parochial flavor, but they do illustrate the domino effect of Washington-made decisions and the devastating impact on public needs that extend far beyond the VA hospital.

All of the foregoing comments underline the paradox of diminished support at a time of increasing need for health care, compounded by a shortage of appropriate facilities and trained people.

In conclusion, I would make a plea that the honorable and distinguished Members of the Congress look at the Veterans Administration hospital operational and capital construction requests with a compassionate concern not only for the health of our deserving veterans and their dependents, but an equal concern for the health of the people of an entire Nation who could benefit directly and indirectly from the health professionals that could be generated by actions that would finance and permit the VA's hospital education and training capacity to expand through the remodeling and renovation of existing facilities and, where appropriate, the construction of new facilities in conjunction with existing medical schools; or, in a limited

a number of select areas to support the development of new medical schools in relation to existing or new VA affiliating hospitals.

I am convinced that a cost-effectiveness study would reveal the economy of the utilization of the potentials of the VA hospital system as a primary national resource for the education and training of the vast pool of all kinds of the health professionals that are going to be required if we are to respond to the health manpower and health care needs of our people in general and our veterans in particular.

Senator CRANSTON. Thank you very much for your very fine and very helpful testimony.

On your last point, how cost-effective generally, without having a precise analysis available, but how cost-effective generally do you feel VA care is compared to community hospitals?

Dr. DENNIS. My impression of VÀ care, if you did a cost-accounting, where you evaluated just the cost of that care, would compare very favorably with the community hospitals. Again, it gets down to a matter of weighing cost-effectiveness and quality of care.

In some communities, Senator, where the community hospital has no teaching program, the VA teaching hospital might have higher costs, and they will have greater patient days. These are matters that

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have to be evaluated, because the teaching hospital has become a tertiary care, referral hospital where more critical illnesses occur. Even though the patient may have the same diagnostic label, it does take more intensity of care, more skill and more equipment in the referral-teaching hospital than you would see in the average community hospital.

Senator CRANSTON. Do you have the average daily care costs, or could you supply them for the record, of the VA hospital with which you are affiliated and the local community hospital? Dr. DENNIS. I can supply them to you. Our affiliated VA hospital

diem cost of $47 which is about one-half that of the national community hospital costs.

Senator CRANSTON. What would it be for the university hospitals?

Dr. DENNIS. In our university hospital, we are more expensive than the VA. Our daily cost is $89 a day.

Senator CRANSTON. Can you give us some comparable figures on staffing between the university hospital and the VA hospital, particularly in relation to the nurses? You may provide them for the record, if you don't have them.

Dr. Dennis. The staffing in a VA hospital of care personnel runs a little under two persons per patient; whereas, in the community hospitals in our area it runs 2 to 3 hospital personnel per patient. I would remind you that it takes three 8-hour shifts each 24 hours. In our VA

system, we have about one-third fewer people to take care of the sick people, as compared with the community hospitals.

Senator CRANSTON. In regard to your prepared statement you state, “Other deficiencies in the fiscal year 1974 budget include, one, inability to obtain additional staffing that would permit employment ratios of staff to patients equivalent to that of the average private or community hospital.”

Can you expand at all on the extent of that disparity and what you see happening under the administration's budget proposal for the VA!

Dr. DENNIS. Yes, sir. While we have a 2 to 1 versus a 3 to 1 situation now, I think we are going to see this go toward a one-staff personnel

to one-patient-per day under the present budget.

Senator CRANSTON. One to one? Dr. DENNIS. I would be afraid of this, Senator. The salaries of nurses in the community hospitals in our area have already gone up and they are going up again, and you are not going to be able, and we are not going to be able to compete on the market for these essential

Senator CRANSTON. How many community hospitals in the country have a ratio like that? Very few?

Dr. Dennis. I would say, at least in our urban centers, our better community hospitals would run 3 to 4 staff personnel per patient per day.

Senator CRANSTON. What kind of a ratio?
Dr. DENNIS. Four to one.

Senator CRANSTON. How many have 1 to 1, as you say the VA may be threatened with?

Dr. DENNIS. I don't think many of them would be permitted to operate at 1 to 1.

Senator CRANSTON. Why not?

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Dr. DENNIS. The quality of care would be unacceptable and is dangerous to patients. I would not want to go to such a hospital.

Senator CRANSTON. How can it possibly be tolerated that VA should have care that is unacceptable and dangerous to patients ?

Dr. DENNIS. Senator, in my opinion, it cannot be tolerated. It is not acceptable.

Senator CRANSTON. We will do our best to be intolerant.
Dr. DENNIS. I will do my best to help you, sir.

Senator CRANSTON. In your statement, you also mention, that the budget would produce an "inability to fund the new school of health related professions in order to provide for the students, programs and facilities that would permit even a fraction of the tremendous growth potential in this short supply field of health manpower.”

Do you feel that the VA can play a particularly important role here, especially with regard to the training and employment of former military medical corpsmen?

Dr. DENNIS. Yes, sir; I do, indeed. This is a particularly significant area, in my experience, for the VA. If I might digress for a moment to address your point and amplify it. Within the university, programs in the allied professional areas-health-related professions—are in a school which must have courses and curricula and training program approved by the university medical center, the board of trustees and the board of higher education within the State.

We found that we could not, within the regulations of the university, and within the university hospital, develop many of the programs in which our veterans are interested and for which our veterans' hospital saw a need and we saw a need.

But, by combining the school for health related professions into a joint program between the Veterans’ Administration hospital and the university, we can provide the certification and accreditation of the university for courses approved. They—the VA-provide the staff, who are on our faculty, and they provide the facilities and the environment in which these people can emerge as trained, skilled health workers, an essential development which simply is not going to happen without a continuation of this partnership. Even if we had the money, we could not do the things the Veterans Administration hospital could do, and we don't have the money.

Senator CRANSTON. I am very interested in your remarks on future VA problems and potential needs in geriatric care. It seems to me, the VA should be a leader in this field.

Dr. DENNIS. Indeed, it should; and nobody has led in this. It is a totally virgin forest, as knowledge goes.

Senator CRANSTON. Also in your statement, you refer to the fact that your medical school, "like many others, has increased the size of its first-year class, with plans for an even larger increase in the near future. Both decisions were predicated on the availability of the resources of the Veterans’ Administration hospital facility.”

What is going to happen in regard to that expansion under the proposed 1974 budget?

Dr. DENNIS. Well, we are going to have so many students around every patient's bed that it will interfere both with good teaching and with good patient care if we permit it to happen. I don't think we can tolerate this either, sir.

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