I, for one, am not certain as to exactly what is meant in the bill. One group says this means one thing. Another group interprets it differently. For that reason, I think it ought to be very clearly spelled out as to exactly what you do mean.

If this is going to affect us, as some of us think it will, we certainly want to know about it, we ought to know about it, we are entitled to know about it, because we are the purveyors of medical care to our people.

We have the right to know all about it in advance, so that we can debate it, kick it around, and determine what merit is in this bill-and I am sure there must be some somewhere in it, but thus far I have not found it to the extent that it has been talked about during this week. Certainly I do not think there is any excuse for pushing this bill through in a hurry. There is every reason for taking lots of time to talk about the many aspects, the many interpretations that have been talked about during this past week, so that continued debate is extremely desirable.

I do think that this gap which has been talked about all week between the researcher and the practicing physician is a myth. I don't believe it. I think that any doctor in this country who has a mind to do it, can keep abreast of the latest advances that we ought to be using.

There are a great many so-called advances that come about that receive a great deal of publicity when they are first announced, and these are some of the advances that we read about, perhaps in the Reader's Digest or some of the other good magazines of the country. Incidentally, like the others, I get a great deal of my postgraduate education from Reader's Digest, McCall's, and others. But some of these have to be given a great deal of consideration and time, and a great deal of testing in many areas, many places, before we ought to be applying them in our own practices.

Some of this research information we should not be applying as soon as it is known. Some of it should be tested only in medical centers where they can control them properly, where there is available to the researcher the facilities for caring for these patients under clinical conditions which we cannot duplicate out in the country.

Some of this research testing I know they have done, because they have done it in my own State university. They have tested and retested some of these things, and after a while they have discarded them. Other things have been tested and retested, and found to be good to

use.

But new discoveries take time to test so that we know what to do about them. Of this I am sure. But we also are cautioned not to accept them prematurely. Sometimes we can't, because they are not available to us. Sometimes we can, and we have to use them very, very cautiously, and sometimes we should not use them at all.

As far as that gap in the knowledge between what might be available to us and what we ought to be using, I don't think there really exists as much of a gap as has been talked about.

In fact, so far as I am concerned, there is no appreciable gap. I don't think my experience is unusual. I think most of the doctors in this country want to know, want to keep up with medical advances.

I am very glad to have been a member of the American Academy of General Practitioners since its inception in 1949. I do not find it difficult in any way to fill this gap, in fact I average about a month a year away from my practice, doing nothing but trying to keep up with the latest advances that I can make use of in my own practice for the betterment of my patients.

I do want to say that something that sounds good to begin with may no turn out to be something of benefit in the long run.

If I am able to answer any questions, I will be happy to do so. I really appreciate the privilege of being here.

The CHAIRMAN. Doctor, I cannot help but feel that there is a sort of blackout in the minds of a lot of people as to what is intended. and the purpose of this bill. I feel that in the minds of a lot of other people, they have gotten the idea that there is a glorified proposal that is buried somewhere deep beneath the surface. They have some idea that the bill is going to interfere with the profession.

I cannot believe that the practitioners of this country in the field of medical science can become completely satisfied that they know all there is to know, and are in a position to apply it to all of their patients.

When we arrive at that point, then I think in my judgment we are admitting that here is nothing else to be learned, and we are astisfied with putting up with what we know and what we are doing.

I have heard so many of you who express great fear of something existing which to me does not actually exist. It is not included in the proposal.

Now, I have not analyzed every word, every page, every paragraph in these voluminous reports, and I don't think I am going to. I think it is too much to expect of me. But I do know what has been explained and proposed.

I introduced this bill in January. This is not something that was brought here the day before yesterday, or last week. That has been proposed since January 19, in the form of a bill.

We are holding these hearings here for the purpose of developing all the facts and information that we can, to clarify if we can, to let anybody pick it to pieces. That is what we are doing. That is the reason we are glad to have your testimony from your own experience. But as I said to the doctor from my own home district this morning, I don't think that those of you who are concerned have really read the bill, and have analyzed the bill as to what it actually proposed, and how it proposes to do it.

I have the feeling that what ought to be done, if we can't do any thing else with these hearings, is stimulate this kind of thinking and encourage more clear thinking on the subject, instead of people being fearful as to what might have been done in connection with the medicare bill, which has nothing to do with this at all.

We will have accomplished that much during the course of these hearings, whatever length of time they may be. I am going to stay here until we hear everybody out, not only today but next week, because we want to develop a thorough record on this bill.

I myself feel that there has been a lot of clarification. I just do not. believe that we ought to take the position that because something is proposed to meet an admitted problem in the field of cancer, stroke, and heart disease, we ought to do what we can to restrain the people who can do it.

You can meet the problem of heart disease, stroke, and cancer better and with more success than any other group of people on the face of the earth.

Dr. SHEPPARD. May I say, Mr. Harris, that it is my conviction that the American physician is doing this as much as he can today, to the degree that his patients will allow him to do it. There are a great many patients who will not come into the office to take advantage of the knowledge we have today.

I wish to reiterate that this patient education has to be a tremendous part of this whole effort.

You picked out the top three sources of death in this country. This sounds to me as a bill against death. People are going to have to die of something, and ultimately they are going to. You cannot prolong life indefinitely. The good Lord did not intend that we should.

I think for a long time these are going to be the top three causes of death. We do need more work, there is no question about it, to make lives longer, and be more meaningful.

The CHAIRMAN. I would regret our taking a hard line that people are going to die, and they might as well die from cancer as anything else.

Dr. SHEPPARD. I do not agree with that. That is not what I said. But they are going to have to die, period. This is inevitable. The changes which have occurred have been fascinating over the period of years. They have gone from infectious diseases to things that we see today.

The CHAIRMAN. Did you read the statement sent in to us the other day, how many thousands of people who die from cancer were under age 60 or 65?

Dr. SHEPPARD. Yes, sir.

The CHAIRMAN. The number of thousands of people under 60 or 65, whatever the age was, from stroke and heart disease?

Dr. SHEPPARD. But there is a trenmedous lot of effort going into finding the cause and helps for these things today.

The CHAIRMAN. That is a wonderful thing, and I highly commend it, but to me, as I said this morning, I don't like to see only those people who happen to be in an area where these things are, get the benefit of it.

I come from a rural area, and I know we just don't have the facilities that they have in this great Children's Cancer Clinic in Boston, or the great clinic of Dr. DeBakey, or others in Houston or the Barnes Hospital in St. Louis. We don't have them. We are just not able or capable of doing it.

If these areas and these complexes can do it, and if we have the organization within the framework of your medical institutions and professional societies, united and working together, I do not see why that is not good.

Dr. SHEPPARD. We are trying to do it within the framework that we have today.

The patients that I have I am able to send in to the centers that I consider to be great centers, Minneapolis-St. Paul and Rochester. I think my patients can get about as good care for anything that we are talking about as they can anywhere else in the country.

If the doctors in those areas do not think they can give them the kind of care they ought to give them, they can send them some place else. We don't try to remain colloquial about where we send our patients. They might go to Houston, Tex., for example, which I would have no objection to whatsoever. They can go to Boston.

If we have a problem we can't solve at home, we will send them anywhere they wish to go, that will attempt to cure the patient.

The CHAIRMAN. But if we had the great facilities such as we have in Rochester and the Mayo Clinic and Houston, Tex., and Boston, more people can be accommodated.

Dr. SHEPPARD. As far as I know, they are turning nobody away today.

The CHAIRMAN. Not everybody can go to Boston or the clinic in New Orleans.

Dr. SHEPPARD. This is true, but the people in my area can go to Rochester and Minneapolis.

The CHAIRMAN. You are very fortunate. We have a number of our people who go to Rochester, and they are happy to do it, but there are very few who are able to do it.

Mr. NELSEN. I want to thank Dr. "Charlie" for appearing today, and I am sure that Dr. "Charlie" does not assume that the medical profession has all the answers, and that research is an unnecessary item, but I think he, as I, is concerned about whether or not this new facility is going to be an improvement over what we already have.

I have been a little bit perplexed about some of the testimony that we have heard. I might also suggest that even the language of the bill which has been here since January, today I think we admit there could be some improvement in it.

I think the discussions we have had here with those who have some reservations, I am sure the chairman will agree, will be productive in getting better language in the bill to make it do what we think it ought to do.

I want to thank my family physician for taking the time to come down here to add his bit, and his reservations, which can be helpful, I know the chairman will agree.

Thank you very much.

The CHAIRMAN. Indeed. I personally am pleased to have your comments out of your experience.

Are there any further questions?

Doctor, thank you so much.

Dr. SHEPPARD. Thank you very much, sir.

The CHAIRMAN. Dr. Alfred M. Popma, chairman of the Advisory Council on Medical Education, St. Luke's Hospital, Boise, Idaho.

Mr. WILLIAMSON. He had to leave, Mr. Chairman. He would like

to have the privilege of putting his statement in the record.

The CHAIRMAN. I regret we were unable to get to Dr. Popma before he had to leave. His statement will be included in the record. (Statement to be furnished follows:)

TESTIMONY BY ALFRED M. POPMA, M.D., CHAIRMAN OF THE ADVISORY COUNCIL ON MEDICAL EDUCATION OF THE WESTERN INTERSTATE COMMISSION FOR HIGHER EDUCATION

I am Dr. Alfred M. Popma, a practicing physician, and former president of the American Cancer Society, from Boise, Idaho. I am a member of the Western Interstate Commission for Higher Education, having been appointed to that position by my Governor. I am also chairman of an advisory council on medical education established by the Western Interstate Commission for Higher Education. This council has three representatives, a physician, a legislator, and an educator from each of the six States in the West, which do not now have medical schools. These are the States of Idaho, Montana, Wyoming, and Nevada, and the new States of Alaska and Hawaii. These six States are characterized by small, widely dispersed rural and small city populations, a lack of internship and residency programs, and limited economic resources.

The advisory council on medical education is concerned with the plight of States such as these, which do not have medical schools, and where there are no opportunities at the present time for qualified students to obtain a medical education within these States. The council is greatly concerned with the fact that the opportunities for obtaining a medical education by the residents of these States elsewhere, is rapidly diminishing.

During the past 2 years, the Western Interstate Commission for Higher Education has sponsored a study of the medical education needs of the four States of Montana, Nevada, Wyoming, and Idaho. This study was carried out by James M. Faulkner, M.D., a distinguished physician, and former dean of the Boston University Medical School. The report of this study has been published under the title, "Opportunity for Medical Education in Idaho, Montana, Nevada, and Wyoming." The study touched on such topics as the geographic characteristics and economic resources of the four States as related to medical education, health resources, including human resources and facilities in the States, the central problem of opportunity for students to obtain medical education, and the question of whether new medical schools should be established in these States.

I believe that this report supports the contentions of this witness, that the quality of the medical practice in these States is good, but that there are serious difficulties related to maldistribution of medical practitioners in the wide and thinly distributed population of these States, and that a concerted effort is necessary to provide a broad spectrum of medical education in these Western States.

This study was conducted at a cost of 2 years in time, and $160,000. I believe that much of the data contained in this study, and in related reports not published as a part of the study, can serve as a basis for planning for the development of resources within these States. Consequently, our advisory council is deeply interested in that portion of this legislation which would provide planning money to develop statewide and regional plans for the development of programs which would assist in the establishment of medical schools within these States.

In representing the opinion and thinking of the advisory council on medical education, it would be our feeling that certain provisions under this proposed legislation would provide an avenue through which might come the additionally needed services for the operation of a medical school.

We further feel that within this proposed legislation, there is an opportunity for careful study and evaluation of the needs of these Western States is regard to the programs covered by the legislation.

The Advisory Council on Medical Education views with great interest that portion of this proposed legislation which provides for planning grants. It feels that if such planning grants would be made available, a purposeful study could be made in each of the Western States of Idaho, Montana, Nevada, and Wyoming, Hawaii, and Alaska, utilizing the full resources of the practicing physicians and medical societies, as well as the related hospitals, educational institutions, and interested and involved nonmedical organizations and individuals, in order to determine the specific needs required within these States in regard to the programs proposed by this legislation. The planning and study would encompass and include the ways and means to incorporate the bringing of medical education facilities to these areas of great need. Such planning and study could be completed within an 18- to 24-month period of time, and at its completion, the entire plan and proposal could be submitted to the Congress for approval, and with a request for funds for implementation.