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Senator CRANSTON. That's an interesting way to answer that question.

You speak also about the fact that “There are only enough intern positions in the State to accommodate one-half of each graduating class," and you refer to the "large number of physicians that are permanently lost to a State community that in 1970 had only 83 physicians per 100,000 population, or approximately one-half of the national average."

This is obviously very important in terms of the crucial issue of the distribution of physicians within the United States.

Dr. DENNis. It really is, sir, and, particularly, for the veteran and his family who do not live in an urban area near the central veterans hospital, this is crucial.

Senator CRANSTON. Do you think we will have trained enough medical students to meet medical needs by, say, 1980, given these approaches by OMB?

Dr. DENNIS. This is an opinion. I think it is dependent upon factors that are not quite clear. I think the kinds of physicians that we produce may

be as important as numbers. We have seen comments in the press recently that indicated we would have a surplus of physicians by 1980. That is a nice problem that I would like to face.

In my experience, at the present time, when we analyze the requests and the complaints and the pressures for more physicians and more health care in our own region, I can't see us having an adequate number within my lifetime. The demands for the utilization of these people is increasing in a geometric fashion. It is how frequently and how well we use them that will also play a part in determining the number needed.

Senator CRANSTON. Can the VA facility in a State like Arkansas help by expanding the training done in affiliation with the medical school?

Dr. DENNIS. Yes, indeed. We feel that by utilizing the VA teaching facility and going out into other VA facilities in the State and developing area health education centers in conjunction with the VA hospital involving interns and residents, we will have an impact because it has been shown that the one thing that does influence where a physician will locate is that point at which he completes his training. That is the place in which he receives his job opportunity, so to speak. It is one way to address the distribution of physicians.

Senator CRANSTON. In summary, do you feel that it is fair to say that the VA seems to you to be a highly viable health resource, not only in the terms of the health care of veterans but the health care of the Nation?

Dr. DENNIS. Senator, it is the only one- health resource-we have that is national in scope. And, the importance of this network, not only in terms of producing physicians, but as a skeletal framework for a system which we all know we don't have, simply is not recognized far bevond your offices, apparently.

Senator Cranston. In regard to maintaining a quality staff to provide appropriate medical care at a VA hospital, are each of the following very important factors in achieving that? First, the university medical school affiliation; second, an active research program; and, third, an active VA-run education and training program.

Dr. DENNIS. Yes, sir. You cannot separate those three things from quality care. I would point out that research is a service deferred.

This year's cure was last year's research. And, General Motors couldn't stay in business without research, and neither can the VA or the medical profession, and I think it is foolish to hear some of the considerations we are hearing today in respect to the retraction of support for research. Of course, there has to be balance, and, certainly, we have to be concerned appropriately with the human needs.

Senator CRANSTON. Dr. Dennis, thank you very much for traveling all that way to be with us today, and for your great help, and I thank the university for making your presence possible.

Dr. DENNIS. It's a great privilege, sir.

Senator CRANSTON. Our next witness is Dr. Hamilton Robinson, dean, University of Missouri, Kansas City School of Dentistry, Kansas City, Missouri. Dr. Robinson, we appreciate your presence. STATEMENT OF DR. HAMILTON B. G. ROBINSON, DEAN, UNIVER


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Dr. ROBINSON. I appear before you as a private citizen. My name is Hamilton B. G. Robinson, and I am dean of the School of Dentistry of the University of Missouri at Kansas City. I have served as president of the American Association of Dental Schools, and as president of the International Association for Dental Research. I am also chairman of the Council on Dental Education of the American Dental Association.

I recently served on the Advisory Council on Dentistry of the Veterans' Administration's Department of Medicine and Surgery, which developed and published the report entitled, “Helping To Meet the Dental Health Care Needs of the Nation: The Potential Role of the Dental Service of the Veterans Administration's Health Care System,”—“The Journal of the American Dental Association," March 1973.

Senator, I would suggest that you get reprints for the members of your committee. I think they are very valuable.

The practice of dental medicine in the VA health care system has demonstrated that oral health and disease is inseparable from general systematic health and disease. It has also shown that the treatment of oral and facial injuries and dental anomalies, and the prevention of oral diseases are now recognized as no less important or critical to the health care of eligible veterans than diseases and conditions of other parts or systems of their bodies. Those of us in the dental profession, in general, and dental education and research, in particular, are grateful to the Congress for its recognition of these facts, expressed through its willingness to enact and fund legislation that supports dental activities as part of total health care for veterans.

Evidence suggests that service-connected deformities or diseases of the orofacial complex are some of the most prevalent and, in many instances, the most debilitating of the ills of many veterans. Proper treatment is critical to not only the well-being and comfort of such veterans, but to the establishment of their self-confidence, and subsequent success in living, working and functioning as members of society. As a result, oral health has become recognized as an essential to total physiologic and psychological health of patients served by the VA health care system, and its effective practice has helped establish dentists as coequal partners with their physician colleagues in that system. With authorization and funding supplied by the Congress, the

, Dental Service of the Veterans Administration's Department of Medicine and Surgery now operates the largest single oral health care system in the United States. To serve the needs of eligible veterans, each of the 168 VA hospitals operates its own dental service with a full-time staff of dentists and auxiliary personnel. In addition to the hospital-based dental services, there are dental clinics in a number of separate outpatient facilities.

In fiscal year 1972, with a dental budget of some $88.5 millionabout 4 percent of the total budget for medical care allocated to the VA health care system that year-more than 396,000 veterans received a full range of dental treatment. Of this number, 231,000 were provided that care within the VA facilities themselves, and the other 165,000 were treated on a fee-for-service basis by some 45,000 private dental practitioners.

In its ability to operate these extensive facilities and provide this enormous amount of care at a level of quality comparable to, or better than, that received by most Americans, a number of important-if not indispensable—attributes of the VA dental service both as part of its own system and as it relates to the total health care system of this country are demonstrated. I should like to point up some of these activities, and make some related observations for the consideration of this committee.

When viewed in its entirety, the VA dental health care system is, in fact, a national resource. It has a great potential to not only deliver dental health care to eligible veterans, but to help the country meet the total dental health care needs of all of its citizens in two ways. First, the VA dental service operates an important and critical manpower training and development resource; and, second, through its dental research programs, contributions are made to new knowledge and techniques in the sciences of dental medicine and dental practice.

The Veterans' Administration today occupies a leadership role in the practice of hospital dentistry. This concept is in contrast to the traditional solo office practice carried on by many dentists in the private sector.

The special environment of the hospital and the resource it provides permit a unique approach to the diagnosis, treatment, and care of oral health conditions for the veteran population. Under this concept, complete oral examinations have been established as an essential part of a complete physical examination. As a result, oral conditions requiring treatment are identified so that both the patient and physician are alerted to the problems and needs. It is an unfortunate reality, however, that these needs cannot always be met, and that an estimated one-half of all patients are being treated for acute conditions by prehospital or posthospital care, or are being discharged from the hospitals still in need of further dental care.

It is for these reasons that I am not only in favor of the outpatient provisions included in Senate bill 59, but would urge that those provisions specifically include dental examinations, care, and treatment and authorize sufficient funds to support such an effort. To illustrate the benefits of this concept, I would point out that through the oral examination of veteran patients during the past 10 years, some 5,000 oral malignancies have been detected in their early stages, thereby enhancing the opportunity for cure in a large number of instances.

To meet the dental needs of its current patients, VA hospitals now employ about 800 full-time dentists, 700 dental assistants, 70 dental hygienists, and 400 dental laboratory technicians. The number of dentists and auxiliary staff varies in each facility according to the size of the hospital and the number of patients it serves.

The ratio of supporting personnel, however, is not always adequate. Despite the growth of team dentistry, only about one-third of VA hospital dental services have hygienists, and there is an average of less than one dental assistant per dentist. As a result, the full potential productivity of VA dentistry is often limited, and the most effective cost-benefit ratio per patient is not realized.

As I have indicated, the hospital dental service was initially developed to provide oral health care as an integral part of medical care for hospitalized patients. However, the recognition of the benefits of ambulatory care for patients not needing hospitalization, the demand for dental care by Vietnam veterans, as provided by a recent law, and the potential of Senate bill 59 can be expected to create even greater demands on the hospital dental programs. As a result, there will be a greater need for dental manpower. This need can only be realized by authority to hire such people or contract for their services, and funds to cover those costs--and I would urge your support for such authorization and funds.

Recruitment of dentists and allied dental health personnel in the VA system has a built-in factor stemming from its extensive education and training programs. At the present time, most VA hospitals are affiliated with 57 of the Nation's 58 schools of dentistry. These affiliations have been progressively strengthened and become increasingly interdependent over the years. They now include a full range of educational activities in the training of not only dentists, but dental specialists, hygienists, assistants, and laboratory technicians. Some 52 other universities and community colleges utilize the unique capability of VA hospitals to provide practical experience for their students engaged in the auxiliary career disciplines of dentistry, and have entered into training agreements with those VA hospitals. A number of other educational institutions have also expressed a desire to develop similar affiliations, and plans for extending these activities are now underway.

Concurrent with the expanded role that the VA dental services have played in the educational efforts of afiliated educational institutions, there has been a steady improvement in the quality of the dental professional staffing of VA clinics. One of the best evidences of this improvement in quality of staff has been the success of VA's career development and specialty training programs in dentistry. In 1955, there were approximately 20 certified dental specialists in the entire VA system. Currently, there are 72 such board-certified spe


cialists, plus an additional 77 who have completed advanced specialty training, and 96 who have received postdoctoral training in general practice as career interns.

The recent special recruiting efforts of the dental service have begun to attract young, highly qualified general dentists, as well as board certified specialists to careers in the VA dental service. This is evidenced by the fact that the average age of all dentists in the Veterans' Administration in 1972 was 45.9 years. This is a reduction of nearly 3 years from the average in 1969, and compares favorably with the median age of 46 for all practicing dentists in the United States. Since 1970, the VA has been able to recruit 198 staff dentists, whose average age is under 33. Obviously, these accomplishments have a direct bearing on providing better quality of patient care to the Nation's veterans. Salaries of VA dentists are on a parity with those of physicians in the system, and have a direct bearing on the successful recruiting efforts I have reported.

Although the quality and magnitude of these accomplishments are significant, it is recognized that these educational activities have a potential for considerable expansion. In this way, the increased needs of the VA can not only be met, but so can the critical needs that have been identified for dental health manpower in the country's total health care system.

Only if sufficient funding is provided for VA educational resources, can all of these potentials be realized. It should also be clearly noted in this regard that such funds can not only be considered as important in producing dental health manpower, but by being invested in an ongoing educational system, will provide the most effective cost-benefit ratio.

It is unfortunate that Public Law 92–541 did not provide funds for dental schools, as such. However, my colleagues and I are interpreting the term “medical schools” to be a generic one and meant to include schools of dental medicine. It is conceivable that if funds are appropriated for the implementation of that law-and I would ask that this committee encourage such action-dental schools and those involved with allied dental health personnel can become involved under both subchapters II and III-and I would hope they would.

Since education and research are inextricably tied together, the Veterans' Administration encourages research in oral diseases, and supports such efforts in its hospitals. Annually, during the past 5 years, Veterans Administration dentists and other scientists engaged in research projects have presented and published an ever-increasing number of scientific papers. For example, at the recent International Association for Dental Research meeting, completed here last week, 33 such papers generated within the dental service were read, as compared with only two at the meeting of the same association in 1955.

The VA Dental Service is continuing its efforts to attract and develop research-oriented personnel. However, success in this effort is severely limited by the availability of funds. The fact is that support for research in oral diseases currently amounts to less than 2 percent of the Agency's total research budget. I would suggest that the budget be increased.

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