Dr. Donald King, who is chairman of the University of Colorado Department of Pathology, wrote on October 8, 1863:

I apologize for troubling you with a long-standing problem for which you bear no past responsibility—

this is to the head of the Department of Medicine here in Washing

ton

and perhaps can find no easy solution. The opportunity for a truly integrated university veterans service with mutual benefits to all did exist. Unfortunately at this time the lack of reasonable space, staff and budget to adequately perform the service responsibilities*** make this relationship completely onesided.

MEMORANDUM AND DUTIES IN MEDICAL CARE

This is fairly strong, but this is brought out in the testimony of a number of these and I wonder, Mr. Chairman, if I might not include for the record this memorandum on the whole medical care situation with some of these letters from the deans. If I could turn this over to your distinguished professional clerk, Earl Cooper.

Senator ALLOTT. Do you want that in the record itself?
Mr. GORMAN. I think it is in the public domain, Senator.
Senator ALLOTT. Then it will be included.

(The memorandum referred to follows:)

PRESENT STATUS OF THE VETERANS' ADMINISTRATION-MEDICAL SCHOOL

RELATIONSHIP

At the end of World War II, the Veterans' Administration faced the problem of serving the medical needs of a tremendously expanded veteran population. The agency was not prepared to discharge this objective. In order to do so, and, at the same time, to provide to the deserving veteran the highest quality of medical care and hospital service, the Veterans' Administration undertook, and accomplished, a close working relationship with the majority of the medical schools of the Nation. This partnership was based upon the concept that quality medical service was possible only if the Veterans' Administration could recruit and retain the type of professional personnel capable of delivering such service. The logical place to find the personnel was the medical schools; the logical way to retain the personnel was to create, as far as possible, the environment and opportunities of the best medical teaching centers in the country. The partnership also served the interests and needs of the medical schools for it provided them with the additional facilities to meet the almost overwhelming demands for additional training by physicians whose postgraduate education had been interrupted by their military service.

In its 17 years of operation, the affiliation between the Veterans' Administration and the medical schools has been remarkably successful. American veterans have received, and, in general, are receiving, the highest quality of medical care. Also, as the partnership has developed, the medical service of the Veterans' Administration has emerged as an almost limitless resource for medical research and education. Thus, its impact upon medical knowledge and practice and its benefit to the Nation and to mankind have far exceeded the original objectives. Of this, Dr. Owen Wangensteen, of the University of Minnesota, stated in his address upon receipt of the Passano Award for 1961,1 “During my day three influences have come to have a telling effect upon the medical schools: (1) the Flexner Report of 1911 which damned medical schools for their low standards and for the total lack of a strong educational plan; (2) formation of dean's committees for the operation of veterans' hospitals in connection with medical school activities; and (3) entry of the Public Health Service into the field of support of medical research." In the same vein, Dr. Wesley Spink,

1 Wangensteen, O. H., JAMA, vol. 177, No. 8, Aug. 26, 1961, pp. 558-563, "Credo of a Surgeon Following the Academic Line" (Passano Award lecture).

president of the American College of Physicians, recently spoke (Mar. 13, 1963).' "Looking back over 25 years. I believe that the two most significant developments in medical education in the United States have been the establishment of a working relationship between the Nation's Veterans' Administration hospitals and its medical schools, and the emergence of the tremendous support of medical research by the National Institutes of Health."

The partnership between the Veterans' Administration and the medical schools has become as important to medical science as it is to veterans' medicine. The question is no longer whether there are mutual benefits to be found in working together, but rather how the relationship can be strengthened in order to preserve and increase the benefits for each group. George Packer Berry, M.D., dean, Harvard Medical School, wrote on November 15, 1963, "We must continue to pursue the need to think of VA hospitals in their relation to medical schools as partners in the maintenance of an indivisible triad of teaching, research, and patient care. Only when the triad is indivisible in fact, as well as in theory, is medical care the best possible." The objectives and accomplishments of this long-established partnership between Government and the medical schools support to a remarkable extent the principles expressed by President Lyndon B. Johnson in his "Health of the Nation" message to the Congress of the United States on February 10, 1964, "There is no need and no room for second-class health services. There is no need and no room for denying to any of our people the wonders of modern medicine. *** Medical science has grown vastly more complex in recent years-and its potential for human good has grown accordingly. But to convert its potential into actual good requires an ever-growing supply of ever better trained medical manpower." Recognition of the importance and value of the affiliated program by the medical schools, the contributions they have made to it, and their expressed desire to strengthen and improve it are indeed gratifying and attest to the feasibility of partnerships between Government agencies and the universities. During the past 10 years, however, a series of problems of increasing number and magnitude have developed which now have come to threaten the effectiveness and stability of the partnership. As emphasized by President Johnson, the progress in medical science and medical care since World War II has been tremendous. Rapid expansion of medical school resources and hospital facilities has occurred. The Veterans' Administration has not kept pace. In 1960, the National Academy of Sciences-National Research Council Committee on the Survey of Medical Research in the Veterans' Administration summarized the situation in its report," "The medical care program of the Veterans' Administration faces a challenge today in no way less than that which was successfully met in the years immediately after World War II. This new challenge is in some ways more difficult to meet because the issue is not as clear. The task in 1946 was to cast out an old, inferior pattern of medical care and to develop a new and better one. The present goal is to defend and improve a well-respected medical care system which is besieged by constantly rising costs of medical care, increasing competition for professional personnel, progressive deterioration in the relative strength of its salary scales, and the general complacency characteristically associated with success.'

In March 1961, G. H. Aagaard, M.D., dean, University of Washington School of Medicine, and an active participant in the affiliated program since its inception, wrote, "The Dean's Committee for the Seattle Veterans' Administration Hospital has, for a long time, considered problems related to the present need for facilities at the Seattle Veterans' Administration Hospital and long-range planning for services to veterans in Washington." His increased concern was indicated 3

2 Wesley W. Spink, the Bulletin of the American College of Physicians, vol. 4, No. 6, November-December 1963, "After 25 Years."

3 Letter, Nov. 15. 1963, to M. J. Musser, M.D.. Assistant Chief Medical Director for Research and Education in Medicine, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from George Packer Berry, M.D., dean, Harvard Medical School. Boston. Mass.

4 Doc. No. 224, 88th Cong.. 2d sess., House of Representatives, "Health of the Nation," message from the President of the United States, Feb. 10, 1964.

National Academy of Sciences and National Research Council Committee on the Survey of Medical Research in the Veterans' Administration, final report, June 30, 1960.

Letter. Mar. 8, 1961. to William S. Middleton. M.D., Chief, Medical Director. Department of Medicine and Surgery, Veterans' Administration. Washington. D.C., from G. N. Aagaard. M.D., chairman dean's committee, and dean, University of Washington School of Medicine, Seattle, Wash.

years later (February 1964)' when he stated, "I am sure that we all agree that our veterans should receive the best quality of medical care that scientific medicine can provide. Certainly, this is the only kind of medical care which we wish to use as we teach, by example, residents involved in our university training programs. The program at the Seattle Veterans' Administration Hospital has not been able to keep pace with the demands and the possibilities of good scientific medical care and we earnestly hope that steps can be taken in the immediate future to correct these deficiencies."

In September 1963, Eugene A. Stead, Jr. M.D., chairman, Department of Medicine, Duke University Medical Center, added additional insight when he wrote.' "The VA hospital facilities and staffing compared favorably with its sister university hospital 15 years ago. They no longer do so in many instances, and they cannot remain equal partners in university-sponsored training programs unless radical adjustments are made. Funds for staffing anesthesiology, pathology. chemistry, and radiology departments in depth are needed acutely. Unless these services are able to perform their duties quickly and efficiently, medical and surgical staffs have little incentive to practice efficient medicine."

Richard V. Ebert, M.D., chairman, Department of Medicine, University of Arkansas School of Medicine, expressed his opinion in April 1963," "The present problems within the Veterans' Administration hospitals are also directly related to the budgetary problems which faced these hospitals. In spite of the increases in salary and the expanding needs for the maintenance of a high standard of medical care, the budgets of these hospitals have tended to remain static. This has created several problems. *** Budgetary limitations have also prevented the development of modern laboratory facilities and X-ray facilities."

Experience gained from the operations of 89 VA hospitals affiliated with 78 of the Nation's medical schools has clearly indicated that reasonable comparability in professional staffs and hospital facilities is essential. Because of its inability to keep pace with the growth and development in medical school and university hospital facilites, the Veterans' Administration has been unable to maintain an effective degree of comparability. The most serious disparities are in staffing and equipment. These cannot exist without adverse effects upon the quality of diagnostic and treatment services provided in VA hospitals. An increasing number of medical schools have expressed their concern over the problem as it grows in magnitude and broadens in scope. The following expressions are typical:

Barnes Woodhall, M.D., dean, Duke University Medical Center, January 23. 1963,10 "You will recall that at one of our special medical advisory group meetings I mentioned to our group a rather rough communication that I received from 10 deans on the west coast. We have the same problem here and have been fighting it for some time. *** With my deep interest in veterans medicine, I must say to you that a nationwide skirmish on this issue at the present time would be very unpalatable both from the point of view of the Veterans' Administration and from the point of view of American medicine.”

Stanley Olson, M.D., dean, Baylor University College of Medicine," "What must now be done is to examine the scope and magnitude of these changes and determine what can be accomplished within the framework of administrative policy of the Veterans' Administration in order to counteract recent unfavorable developments and to implement new policies which will enable the Veterans' Administration to regain once more the favorable position it previously enjoyed. "Failure to adopt policies which will reverse the current trends may well result in further weakening of the Veterans' Administration programs of teaching

7Letter, Feb. 20, 1964, to J. H. McNinch. M.D.. Chief Medical Director, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from G. N. Aagaard, M.D., dean, University of Washington School of Medicine, Seattle, Wash.

8 Letter, September 1963. to M. J. Musser, M.D.. Assistant Chief Medical Director for Research and Education in Medicine, Department of Medicine and Surgery. Veterans' Administration, Washington, D.C., from Eugene A. Stead, Jr., M.D., chairman, Department of Medicine, Duke University Medical Center, Durham, N.C.

Richard V. Ebert, M.D., chairman, Department of Medicine. University of Arkansas School of Medicine. Little Rock, paper presented to chiefs, VA Medical Services, Atlantic City. N.J., April 1963.

10 Letter, Jan. 23, 1963, to A. J. Klippen, M.D., Director of Hospitals, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from Barnes Woodhall, M.D., dean, Duke University Medical Center, Durham, N.C.

11 Statement with letter to M. J. Musser, M.D., Assistant Chief Medical Director for Research and Education in Medicine, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from Stanley W. Olson, M.D., dean, Baylor University College of Medicine, Houston, Tex.

and research and ultimately to the abandonment of some existing medical school relationships or to the maintenance of relationships which benefit neither party." While inadequate salary levels have adversely influenced recruitment and retention of professional staff in VA hospitals, the inability of the agency to provide budget support for appropriate expansion of hospital services has become a much more serious problem. Since 1950, as a result of expansion of diagnostic and therapeutic facilities, university hospitals have increased their employee-topatient ratios from 1.5 to levels generally above 2.5. The Veterans' Administration, 5 years ago, developed a plan for staffing ratios of 2 in its affiliated hospitals and 1.5 in its nonaffiliated hospitals. In fiscal year 1963, however, it was able to accomplish no more than an average staffing ratio of 1.4 in its affiliated and 1.2 in its nonaffiliated hospitals. The disparity of these ratios makes it impossible to maintain comparable standards of patient care. The quality of educational programs equally suffers and the exploitation of research resources is seriously curtailed. It has become progressively difficult, if not impossible, to provide "medical care in VA hospitals equal to that available in the community." Resultingly, an increasing number of medical schools have expressed serious concern over the present status of the affiliated program and some reluctance to continue their participation unless existing deficiencies are corrected. The following statements illustrate the attitude of the medical schools:

The dean's committee of the Duke University Medical Center has reported." "But unless a solution is found to continue high quality care and high quality teaching at the Durham-Duke VA Hospital, your dean's committee does not believe the Duke University Medical Center should long continue service responsibilities at the Durham VA Hospital."

John J. Conger, Ph. D., vice president for medical affairs and dean, School of Medicine, University of Colorado, on October 21, 1963,13 wrote, "In short it appears to me that present staffing patterns in all of these areas are minimal and that further reductions are not feasible without threatening the training programs, and, I should think, raising real problems for continued patient care. *** However, if a way out of the problem of these potential staff reductions cannot be found, we will be faced with a serious question of our ability to continue one or more joint programs."

William A. Knight, Jr., M.D., area consultant in internal medicine, reporting a survey of VA hospital, St. Louis, Mo., December 11, 1962," "In conclusion, it must be stated that there are numerous deficiencies existent in personnel, equipment, and space. *** It would seem that the basis for all of these present problems is a lack of adequate funds. * It is also recommended that immediate steps be taken for the correction of existent problems in order to prevent deterioration."

*

Lowell A. Rantz, M.D., associate dean, Stanford University School of Medicine, September 19, 1963,15 "I informed them that there had been a continuous deterioration in Palo Alto with annual decrements in numbers of personnel and services available. ** * I presented each of these as examples of situations in which it appeared that insufficient funds were interfering not only with the programs of the medical school but with adequate patient care."

In a complimentary vein, the dean's committee, VA hospital, Brooklyn, N.Y., concluded in the minutes of its December 5, 1963, meeting,16 "It is apparent to the dean's committee that the members of the professional and administrative staffs have done an outstanding job in patient care and morale for the past year and a half during the shortage of professional staff."

12 Dean's committee statement of Jan. 21, 1963, Duke University Medical Center, Durham, N.C.

13 Letter, Oct. 21, 1963, to J. H. McNinch, M.D., Chief Medical Director, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from John J. Conger, Ph. D., vice president for medical affairs and dean, University of Colorado School of Medicine, Denver, Colo.

14 Report of survey of VA hospital, St. Louis, Mo., to Area Medical Director, Veterans' Administration, St. Louis, Mo., Dec. 11, 1962, from William A. Knight, Jr., M.D., area consultant in internal medicine.

15 Memorandum of Sept. 19, 1963, to members of the dean's committee, Palo Alto Veterans' Hospital, from Lowell A. Rantz, M.D., associate dean, Stanford University School of Medicine, Palo Alto, Calif.

16 Minutes of dean's committee meeting of Dec. 5, 1963, Veterans' Administration hospital, Brooklyn, N.Y.

John I. Nurnberger, M.D., chairman, Department of Psychiatry, Indiana University School of Medicine, expressed himself on June 24, 1963, “I have been tremendously concerned with the problems of competently staffing the neuropsychiatry service at the 10th Street VA Hospital (Indianapolis) ever since I took over this job in 1956."

From the University of Alabama Medical Center, Dean S. Richardson Hill. Jr., wrote on November 3, 1962,18 "We have, however, received no indication that our desperate needs for an increase in the operational budget, especially as it relates to staffing, have as yet been solved. * * * These deficiencies are continuing and, indeed, are becoming more acute each day."

From J. P. Tollman, M.D., dean, the University of Nebraska College of Medicine, the following was received on December 2, 1963.19 "The staff available at the Veterans' Administration hospital has been relatively small to carry out the intensive care programs emphasized by the medical school faculty mem bers."

In the areas of laboratory and X-ray facilities, the following comments quite adequately describe existing circumstances:

On December 26, 1962, J. R. Carter, M.D., chairman, Department of Pathology and Oncology, University of Kansas Medical Center, wrote.20 "About a year ago when several critical situations arose at the VA hospital (Kansas City) a decision was made by our dean that the dean's committee as such should probably not interfere too forcefully at that time, but rather call the difficulties and problems to the attention of the management at the VA and urge them to correct the various deficiencies. These, of course, have not been corrected and it is highly unlikely that they will be were they left to their own devices."

21

Lamar Soutter, M.D., Consultant in Surgery to the VA Area Medical Director. Boston, Mass., advised on August 28, 1963, "Unfortunately the Veterans' Administration has not kept up with other hospitals and is now way behind in X-ray work, both diagnostic and therapeutic. The needs of each institution should be filled as quickly as possible if we are going to provide 1963 care to our patients instead of 1948 care."

Eugene F. Van Epps, M.D., chairman, Department of Radiology, University Hospital, State University of Iowa, on October 26, 1962, wrote of the radiology service in VA hospital, Iowa City," "The X-ray facilities in terms of space and equipment are inadequate and obsolete."

Charles H. Lupton, Jr., M.D., chairman, Department of Pathology, University of Alabama Medical Center, wrote on October 31, 1963, of the laboratory service at the VA hospital, Birmingham." "As a result, the clinical laboratory at the VA compares unfavorably, at least in terms of staffing and equipment."

24

From the Department of Pathology, University of Colorado Medical School, Donald W. King, M.D., chairman, wrote on October 8, 1963, "I apologize for troubling you with a longstanding problem for which you bear no past responsibility and perhaps can find no easy solution. The opportunity for a truly integrated university veterans service with mutual benefits to all did exist.

17 Letter, June 24, 1963, to H. Martin Engle, M.D., Deputy Chief Medical Director, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from John I. Nurnberger, M.D., professor and chairman, Department of Psychiatry, Indiana University Medical Center, Indianapolis, Ind.

18 Letter, Nov. 3, 1962, to William S. Middleton, M.D., Chief Medical Director, Department and Surgery, Veterans' Administration, Washington, D.C., from S. Richardson Hill, Jr., M.D., dean, University of Alabama Medical Center, Birmingham, Ala.

10 Letter, Dec. 2, 1963, to K. W. Brown, M.D., Director, Veterans' Administration hospital, Omaha, Nebr., from J. P. Tollman, M.D., dean, University of Nebraska College of Medicine, Omaha, Nebr.

20 Letter, Dec. 26, 1963, to Theodore S. Beecher, M.D., Director, Pathology and Allied Sciences Service, Department of Medicine and Surgery, Veterans' Administration, Washington, D.C.. from J. R. Carter, M.D., professor and chairman, Department of Pathology and Oncology. University of Kansas School of Medicine, Kansas City, Kans.

Letter, Aug. 28, 1963, to Area Medical Director (Boston), Department of Medicine and Surgery, Veterans' Administration, Washington, D.C., from Lamar Soutter, M.D., Area Consultant in Surgery, Area Medical Office, Veterans' Administration, Boston, Mass. Subject Surgical visit to Brooklyn VA hospital.

22 Letter, Oct. 26, 1962, to Donald McCarthy, M.D., Area Director, Professional Services, Veterans' Administration, St. Paul, Minn., from consultant. E. F. Van Epps, M.D., professor and head, Department of Radiology, University Hospital, State University of Iowa, Iowa City, Iowa.

23 Recommendations for clinical laboratory service, VA hospital, Birmingham, Ala.. from Charles H. Lupton, Jr., M.D., professor and chairman, Department of Pathology, University of Alabama Medical Center. Birmingham, Ala.

24 Letter. Oct. 8, 1963, to J. H. McNinch. Chief Medical Director. Veterans' Administration, Washington, D.C., from Donald W. King, M.D., professor and chairman, Department of Pathology, University of Colorado Medical School, Denver, Col.