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well possible that licensure, periodically, may become necessary. This is necessary for continued education for every health professional in every region of this country, it will become mandatory for every institution, and the Veterans' Administration, obviously, will be one of the primary agencies for health care delivery, and would have to take an essential role.

We at Northport are developing with the State University of New York at Stony Brook a new sort of arrangement in which the Northport Hospital becomes 1 of 5 or 6 which are a part of a tightly integrated consortium of institutions with a deployment of different functions for each institution.

The veterans hospital at Northport will have a very significant role in continuing education and I hope, therefore, for this reason that Public Law 92-541, S. 59 will be passed.

Mr. Chairman, forgive me for talking of the extension of services at a time whem OMB is speaking of restrictions, but I addressed myself to those key features which, I think, have not been covered in too much detail by the previous speakers.

Now, I would be delighted to answer any question, explicate or clarify any of my statement.

Senator CRANSTON. I won't forgive you for it, but I thank you for it. Do you feel that there is a particular need for VA to really provide leadership in this continuing education field?

Dr. PELLEGRINO. Yes, sir, I do. The leadership does not lie anywhere at the present time. I think the Veterans' Administration, because of its size, because of the fact that it has a mandate for education should move into this area and can move into this area very well.

Senator CRANSTON. In Public Law 92-541, we have a handy law and a way that we hope will have the VA providing that leadership. We heard this morning from the Veterans' Administration that although research support is being reduced, the reduction will not have an impact on the research that could be achieved in VA hospitals. Are you aware of programs which have been eliminated or reduced as the result of these cuts?

Dr. PELLEGRINO. No; I am not, because at this point we have a new affiliation. One of the problems we suffer from is the reduction of support, is that we will not be able to establish a research program at all. We are starting from ground zero.

Senator CRANSTON. It eliminates one from starting?


Senator CRANSTON. Could you describe the impacts on patient care and hospital morale that the VA's arbitrary grade rollback requirements have mandated since this reduction?

Dr. PELLEGRINO. I think my predecessor, Dr. Clayton Rich handled it very adequately, and I would only be repeating what he has said. The morale affect is very clear.

Senator CRANSTON. Your discussion, and your prepared statement about the expansions of eligibility for certain dependents and of ambulatory care for the nonservice connected included in S. 59 is, I

think, the best and most concise one that I have yet seen. Equally impressive is your very perceptive discussion of the new subchapter III, and the new chapter 82, added by Public Law 92-541.

I plan to send a copy of this statement to Chairman William Jennings Bryan Dorn of the House Veterans Committee for use by that Committee in considering S. 59. I think it will play a very helpful part in the House as well as in the Senate.

Do you have any suggestions as to where we might cut in the VA budget, the same question that I have asked others?

Dr. PELLEGRINO. No, sir, I do not. I think I am in the same position as my predecessors.

Senator CRANSTON. What about in the budget generally?

Dr. PELLEGRINO. I am not so bashful as my predecessors. I am a citizen that supports very strongly the statement that you made this morning on places where the budget could be cut. I sincerely hope that your efforts and those of others, like mind, will be successful. Senator CRANSTON. Thank you very much.

In your prepared statement, you say your support for the specific provisions of S. 59 is based on your conviction that they will improve the care of veterans and especially those veterans in the category for which we have the greatest moral responsibility as a Nation. And you say that surely the veterans should not receive inferior care when a comprehensive pattern is available to the nonveteran in the community.

I want to say that I agree that we must set a high standard, that it is terribly important to keep that thought in the forefront.

You also state in your prepared statement, the veterans hospitals also permit easier and better controlled opportunities for developing newer kinds of health manpower, for better models and patterns of delivery of care, and utilization of personnel.

What about training and employment by the VA of former military medics, is that another place where the VA can perform another great role in breaking ground for the development of careers for these veterans?

Dr. PELLEGRINO. Yes, indeed, I do. As a matter of fact, we and others in the physicians assistants programs are drawing on that reservoir and are using the veterans hospitals for that purpose.

Senator CRANSTON. In the prepared statement, you refer to the return in benefits to patient care and education for the money expended for certain types of education can be higher in a veterans hospital than in comparable institutions under private auspices.

Why? Could you support that in the record?

Dr. PELLEGRINO. I would be glad to attempt to do so. Just give me the bottom line on that. These are the things that I think add up to the fact that the veterans hospitals are primarily patient care oriented institutions and that must be their primary goal.

When you try to do this in educational institutions you are buying a large reservoir of people, but also a lot of other things, which you don't necessarily have to do in a veterans hospital.

Senator CRANSTON. I thank you very much. Let me say that you have been as good as Willie Mays in his prime, as cleanup hitter, so to speak. Thank you.

[The prepared statement of Dr. Pellegrino follows:]



Mr. Chairman and members of the subcommittee: I am Dr. Edmund D. Pellegrino, Vice President for Health Sciences and Director of the Health Sciences Center of the State University of New York at Stony Brook, New York. I appear today as a physician, teacher, and academic health center administrator. I am also representing the Association of Academic Health Centers, of which I am President-elect. The latter is a national organization of the chief executive officers of the multi-school medical and health sciences centers in the United States, comprising some 80 institutions, nearly all of which are associated in patient care and teaching with the Veterans Administration Hospitals and health care system.

I have enjoyed some fifteen years of personal experience working with the Veterans Administration Hospital in Lexington, Kentucky, as Chairman of the Department of Medicine at the University of Kentucky and currently with the Veterans Hospital at Northport, New York. My comments will be based on these experiences with the Veterans Administration Hospitals as significant and indeed, indispensable elements in the production of health manpower for our nation.

I will limit my remarks to a few selected provisions of S 59 which I believe to be important for the improvement of the medical care provided for veterans and which simultaneously enhance the capacity of the veterans teaching hospitals to contribute even more significantly to the production of health manpower. I will refer to PL 92-541 only as it relates to these issues since its enactment and/or funding are so closely related to certain of the provisions of S 59.

Three issues will be addressed-expanding the use of Veterans Hospitals to include the families of certain categories of veterans, extensions of ambulatory and out-patient services to veterans and expansion of educational programs for health related personnel.

I believe also that these important objectives are achievable in a more economical and cost effective manner by optimizing the use of the Veterans Hospitals than by other methods available in the foreseeable future to expand education of health professions. The Veterans Hospitals can, in addition, assume a primary role in bringing a closer congruence between the number and kinds of health personnel we train and the manpower needs of veterans and society as a whole.

May I thank you for the privilege of submitting these remarks for your consideration. I am confident that the members of this sub-committee and the whole Congress will accurately assess the social significance of the provisions of PL 92-541 and S 59 in the light of their importance for the health of this country. All the members of the Association of Academic Health Centers are committed to a further enhancement of their cooperative efforts with the Veterans Administration for the immediate and long-range benefit of the people we serve. We await only the enactment and funding of these two pieces of legislation, to fulfill this obligation even more effectively than in the past.


This provision is essential for the comprehensive care of the totally disabled veteran. We are all increasingly aware that treating a totally disabled person as an isolated unit without accompanying treatment of the members of his household is less than optimal and indeed self-defeating. The emotional and physical illnesses of other members of the family of a totally disabled individual have profound effects on the disabled person.

Only when the care of the total family unit is possible is maximal benefit achievable for the totally disabled veteran. This in turn shortens his hospital

stay, or prevents his readmission in times of physical and emotional crisis. The emotional problems of the totally disabled veterans are often rooted in the emotional and physical state of the members of his family. It can be stated categorically that the emotional problems of a family are so deeply inter-related that piecemeal treatment of one member without simultaneous and coordinated treatment of other members almost assures failure.

The totally disabled veterans or the family of a veteran who died from a service-connected disability have the greatest moral claim on all of us. They should receive optimal care at least equivalent to the best standards of care extant for the non-veteran population. Care of the family as a unit is an aim of the best medical care today and its availability should be assured to those veterans who have made the greatest sacrifices for the welfare of their fellow citizens.

Care of the total family is also important if we examine the mandated educational function of the veterans administration hospitals. These institutions have made, and will in the future, make very significant contributions to the development of health manpower of all kinds. The veterans administration hospitals and the nation are beneficiaries of this effort. The absence of provisions for the care of women and children and of family units has always been a serious deterrent to the optimal use of veteran's facilities for education in the health professions-especially, today in terms of the understanding of the need for comprehensive care. The new provision for the care of the families of certain categories of veterans will materially improve the utility of the veterans hospitals as settings for clinical education in the following ways:

(a) Care of the total family is an important experience for all students of medicine, nursing, allied health, dentistry, and social welfare. The availablity of such experiences at veterans hospitals will make it possible for students to take more -or all of their clinical training in such institutions.

(b) The veterans hospitals are now at a disadvantage in competing for interns and residents because of their inability to provide experiences in the care of women and children. With the new provisions, they will be able to compete more effectively for the best house staff candidates. Providing a more complete experience in all the clinical specialities in turn, enhances the quality of care provided in all departments of the veterans hospitals.

(c) The veterans hospitals will now be able to extend the range of their training to include family practice residencies, physician assistants, and family nurse practitioners and pediatric nurse practitioner programs. These new categories of health workers are needed in veterans hospitals as well as in civilian life. They represent the new reservoir of manpower we must train if we are to provide for the neglected types of care; primary care, long term care and preventive medicine.

(d) In the case of our Health Sciences Center at Stony Brook, there is an additional advantange. We have developed a new mode of affiliation-called the clinical campus. In this arrangement the VA Hospital at Northport functions as an extension of the Stony Brook campus and provides extended clinical experiences for students in the Schools of Medicine, Dentistry, Nursing, Allied Health and Social Welfare. To maintain an equal position with reference to the other clinical campus, in the Stony Brook consortium, the Northport VA Hospital should be able to provide the full spectrum of clinical experiences available at the civilian hospital. Enactment of S 59 with its provisions for care of families will greatly enhance the utility of the Northport Veterans Hospital as a true clinical campus.1

(e) The pattern of clinical campuses being developed at Stony Brook can serve as a pattern for other regions if P.L. 92-541 is funded and veterans hospitals enter even more extensively into the system of medical education. With the retrenchment of other federal funds and the continuing need for health manpower output to serve the needs of the veterans hospital and the nation, the veterans administration hospital system will, in many parts of the country, become the major clinical resource for new and even existing medical schools. This role will be markedly compromised if the care of women and children and of family units is not a part of the spectrum of care offered to veterans in these institutions.

1 E. D. Pellegrino: The Regionalization of Academic Medicine: The Metamorphosis of a Concept, Journal of Medical Education, vol. 48: 119 1973.


This amendment of Title 38 for the first time, permits the provision of outpatient and ambulant services for certain categories of veterans and for the wives and families of veterans who die from service connected disabilities, as well as for the families of veterans totally disabled. This provision would remove another of the major limitations to the optimal care of the veteran treatment. It is also in keeping with the national trend to greater emphasis on ambulatory care. We are all seeking to avoid unnecessary hospitalization wherever possible in the interests of cost reduction. But out-patient care also allows for better treatment of many illnesses where hospitalization can slow down diagnostic evaluation and treatment schedules and impede eventual recovery.

This amendment on ambulatory services is just as important as the foregoing one in enhancing the service and educational validity of the veterans hospitals for the following reasons:

(a) Outpatient and ambulant care is the essential link between any hospital with its community. It serves to interrelate hospital care and home care to the advantage of each. By extending and liberalizing their ambulant services, veterans hospitals will enjoy a closer relationship with the veteran in the community and thereby improve the totality of his care. Truly comprehensive and continuous care cannot be practiced without this articulation between community and home on the one hand and hospital on the other, which the outpatient department serves to link most effectively.

(b) Ambulant care is an essential feature of the education of all health professionals. No institution can be a complete clinical educational instrument today without offering opportunities for experiencing this kind of care.

(c) While important for all the specialties, ambulant and outpatient care is absolutely essential for the preparation of primary care physicians, family care physicians, family nurse practitioners, physician assistants and most of the allied health personnel. Without the opportunity to care for individuals and families as total units on an ambulant basis clinical educational programs will be compromised. Again the veterans hospital will be at a disadvantage in competing for high quality students, house staff and career health professions. (d) If preventive medicine is to be practiced-and this unfortunately is not the case now on any extensive basis-it will be practiced in the ambulant and not the hospital services. The veteran, along with the civilian population of this country are in need of a more coordinated attack on the preventable disorders. Preventive medicine requires careful health counselling, psycho-social behavioral modification and alterations in diet, smoking and exercise patterns. Such measures are impractical unless ambulatory care is permissible. The veterans should enjoy the benefits of preventive medicine for his own welfare. But preventive medicine can also cut, or diminish, the cost of his care by avoiding certain disorders entirely, or at least mitigating their presence. We are not yet applying the knowledge we already possess to prevent or delay costly disability and disease.

The veterans administration hospital system could lead the nation in this respect if it were to provide ambulant service as proposed and tie this in with the education of new health care personnel specifically trained to provide preventive services.


Like the other two provisions I have commented upon, this provision is as important for the improved care of the veterans as it is to help meet future manpower needs of the veterans administration and the nation.

(a) A continuing source and a rational distribution of skilled health manpower must be provided to meet present and future health needs of veterans. In many hospitals there are deficits in numbers and kinds of health manpower; especially in the areas of health related professions trained to provide the newer types of medical care. The training of allied health personnel is essential in civilian and veterans hospitals if comprehensive care is to be provided adequately and its practice extended throughout the country. This is especially true in the neglected types of care; primary health care, family

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