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we could work him up on an ambulatory basis, thereby saving $12 a day for hospital service. The out-patient department fee would certainly be only approximately one-tenth of that amount.

There are many people who do not need hospitalization to be worked up. This patient with high blood pressure still requires a diagnostic work-up to find out exactly the status of his kidneys and the status of his heart even though he feels quite well. You can do such a work-up in a diagnostic clinic, thereby permitting an inexpensive but accurate evaluation of his condition. An ambulatory case need not be admitted to the hospital for this work-up.

With an out-patient department we could begin to teach the indigent people something about their medical condition. Education of the indigent patient is very important. As far as I know, there is no one in this District who is interested in educating the indigent patient.

The indigent diabetic needs just as much education, perhaps more than does a private patient. He must be told something about his disease. He must be instructed if he is a diabetic how to take insulin and how to recognize the symptoms of hypoglycema. If we do not do this, the patients will not cooperate with us and will have exacerbations of their condition much more frequently and, of course, hospital expenses will necessarily mount.

There is no short cut to good medicine. You cannot practice economy uness you practice good medicine. If you do not practice good medicine, you practice false economy, and these patients who are admitted to the hospital will cost a lot more to take care of than it would if we provided them with out-patient care.

TRAINING AVAILABLE IN AN OUT-PATIENT CLINIC

There is one more reason for having an out-patient department. We have on our staff a lot of residents and interns from all over the country who come to us for training. I do not think, and no one else believes, that hospital training by itself is ever adequate for a man who desires to practice medicine. He must have training in an outpatient department. He has to be able to size up a patient and to

ake a diagnosis rapidly. He has to learn to use his brain instead of all the diagnostic procedures that are available to him in the hospital. If he did not, the patient would never be able to pay the expense of his visit.

OPERATION OF THE CLINIC Mr. STOCKMAN. An out-patient clinic about which you are talking is a department in a hospital where the patient comes there; you do not go to his home?

Dr. FAZEKAS. That is right. We have already provided home care at Gallinger Hospital for those patients who cannot come to an out-patient clinic. This is a very important facility which is necessary for a large number of the patients that we care for at Gallinger Hospital.

Mr. STOCKMAN. Your idea is that having them come there and getting a little care might keep them from being hospitalized?

Dr. FAZEKAS. Absolutely.

This is nothing new. Every first rate hospital in the country provides for out-patient care. As Dr. Seckinger indicated, the number

of patients visiting the out-patient service is more than a hundred times that in the hospital.

Mr. STOCKMAN. You would make no calls at the home; they would have to come to you?

Dr. Fazekas. They come to us. That is what is done in an outpatient clinic.

COST OF OUT-PATIENT CLINIC

What could we do to help in this problem of out-patient care if we were provided with an out-patient department at Gallinger Hospital? We have at Gallinger Hospital at least the physical facilities for establishing an out-patient department. The first floor of the isolation building is not being used at the present time. We have no plans for its use in the future. It lends itself admirably to an out-patient service because of its arrangement. With a minimum of construction we can convert this first floor of this isolation building to an outpatient service, separating it into two parts, a surgical division and a medical division. We can take care of the surgical and medical patients who need clinic care. This arrangement would give us facilities to handle from 60,000 to 75,000 clinic visits a year.

We estimate that the cost per clinic visit at our out-patient department would be $1.50 a visit in contrast to the $2 a visit that you people are paying now to the various contract hospitals in the city.

You may ask, how can we do this job much more economically than the other hospitals in the city. The answer is obvious. We have worked up our cases completely in the hospital. We have taken their X-rays, their electrocardiograms, we know their blood chemistry. We do not have to repeat these studies in the outpatient department. The records of our patients will be available to the out-patient department. This will obviate the necessity of repeating all the studies that these others are required to do if they want to work up these cases adequately.

Mr. FURCOLO. Does that figure of $1.50 that you quoted, or whatever it was, include the cost of any medicine or drugs that is is given them?

Dr. FAZEKAS. It includes the cost of medication and everything else.

Mr. FURCOLO. In other words, it includes the service, the injections, or whatever medicine is necessary?

Dr. FAZEKAS. Medication and service.

In the formulation of this out-patient department we have tried to make it as complete as possible. We have X-ray facilities for our surgical patients and fluoroscopy for the medical patients. We have a central laboratory which will be used by the surgical division and medical division. We have a pharmacy that can be used of course by all patients coming into the clinic. In addition, we will have a record room where accurate records will be kept of all patients coming into the out-patient clinic and these records will be integrated with the in-patient records.

In addition to these facilities, we will have social workers who can follow up the case, see what the home situation is, and begin to provide for these patients what I have referred to as total patient care.

PREVENTIVE MEDICINE

The indigent patient comes to the hospital only when he is so sick that he needs hospital care. There is very little preventive medicine practiced in the District of Columbia. If the indigent patient had a facility whereby he could be screened and where his physical condition could be evaluated patients in whom a disease is found could be referred to the out-patient department.

Mr. YATES. Do they practice preventive medicine in public hospitals in other cities?

Dr. FAZEKAS. Yes, sir; they do. In the first place, they have an out-patient department to which a patient can come any time he feels sick and there he is evaluated and then, if he needs hospitalization, he is hospitalized. If he does not need hospitalization, he is sent to the appropriate clinic for care.

Mr. Yates. What is preventive medicine? I thought it was taking care of a person before he becomes sick.

Dr. FAZEKAS. Let us say a patient comes in the hospital with a headache and you find that the patient has high blood pressure. Rather than neglect his high blood pressure and just treat him for a headache, as we do in Gallinger Hospital, one should begin looking after his high blood pressure. In other words, we are interested in all the problems of the patients and not just the symptoms that bring them to the clinic.

PERSONNEL NEEDED

Now with respect to the details, I have listed here the personnel that will be required to run this out-patient clinic. We need a physician who would be in charge of the many clinics associated with an out-patient department—the cardiac clinic, diabetic clinic, neurological clinic, tuberculosis clinic, and so forth.

We will need residents and interns assigned to the clinic. We feel that to handle a load of from 60,000 to 75,000 out-patient visits a year we will require 6 residents and 6 interns. These interns and residents will be assigned full time to the out-patient clinic.

We are going to have a cashier-receptionist in the out-patient department. We feel that many of these patients can pay a little something for the medical attention that they will receive. Even if these patients could pay only for the medication they receive, it would certainly be of considerable help.

Mr. STOCKMAN. Do you have an estimate on what your collection would be?

Dr. FazEKAS. I received some information on that this morning. I was told that from our present out-patient facilities we collected about $8,500 a year so that we certainly ought to take in, if we expand our out-patient visits, more than that amount.

Mr. STOCKMAN. Will not everybody come there, figuring it is free?

Dr. FAZEKAS. No. They are examined by the Permit Bureau, and if they can pay even a little bit, they are required to do so. They are seen by people who determine their eligibility and whether or not they are able to pay. I think if people can pay a little bit, it is good for their morale.

We need a pharmacist who will dispense medicines. We will need two laboratory technicians. All patients who come to the out

patient department must have certain diagnostic studies done. There may be electrocardigraphic studies, BMR's, and blood chemistry. This work will be done by the technicians.

We need a social worker to follow up these cases to see what other help our patients might need other than medical attention.

We need a nurse supervisor and three staff nurses, and, of course, we need attendants to help take care of these patients.

A detailed discussion of these various positions is presented in the written justifications.

Mr. FURCOLO. I suppose it is probably the people in the Permit Bureau who do it, but in addition to all these that you listed here that have to do with the strictly medical end of it, would you not need quite a little additional personnel to determine who was and who was not eligible on the basis of residence?

Dr. FAZEKAS. We certainly would need more workers to determine the eligibility of these patients.

I have a detailed list of the equipment that would be needed to set up this out-patient department.

Mr. FOWLER. What is the cost of the equipment?

Dr. Fazekas. The cost of the equipment, including the building changes, comes to about $15,362.

Mr. FOWLER. What is the cost of the supplies and materials?
Dr. FAZEKAS. Supplies and materials will cost $9,500.

Mr. FOWLER. You have those all listed. We can introduce them in the record, Mr. Chairman. Your total request would amount to what?

Dr. FAZEKAS. It comes to approximately $70,000.

PATIENTS HANDLED

Mr. BATES. How many patients do you handle?

Dr. FAZEKAS. We handle from 60,000 to 75,000 visits per year with this set-up that I have given you here.

Mr. BATES. At what saving?

Dr. FAZEKAS. 60,000 visits at $1.50 a visit comes to $90,000. It would pay for itself and make money the first year.

Mr. FURCOLO. I do not follow you on how you get that saving. Mr. Bates. They are paying private hospitals $2 a visit.

Dr. FAZEKAS. This would permit us to take care of our own patients that we discharge from our hospital and take care of a large number of patients in the community also.

Mr. BATES. And give you a system which is comparable with other cities of this size?

Dr. FAZEKAS. Yes; it would make it a more rounded institution and let us practice care other than just hospital care, which is so important for the patient.

POSITION OF MEDICAL SOCIETY AND HOSPITAL ASSOCIATION

Mr. Bates. Has the District Medical Society taken any position with respect to this proposal of yours?

Dr. FAZEKAS. No, they have not.

Dr. SECKINGER. Mr. Chairman, may I state that the District Medical Society is interested in the over-all picture of the care of

the indigent here in the District of Columbia and in that capacity or in that category I am certain that they recognize the importance of Gallinger Hospital as the largest institution in the District of Columbia. There has been no official action so far as the society is concerned except that they are interested in the over-all picture of more adequate care for indigents.

Mr. BATES. Has the hospital association taken any position?

Dr. STEBBING. They have the feeling that if our clinic is going to be established and theirs cut off entirely, it will be a loss to the city, and in that they are correct. However, many of them would admit that a hospital such as ours should have a clinic, and to give us a clinic would not necessitate cutting off theirs entirely because they make the point that there are people scattered all over the city who require clinic care and they should be able to attend a clinic within a reasonable distance of their home. That is true, but then a great many of them are in the southeast area, a large number are closer to us geographically than they are to any of those other hospitals, and they should come to us for that reason as well as for the fact that those who come to us as in-patients should certainly be followed at our hospital. There is no argument about whether or not a large general hospital should have an out-patient department. It is just a question of how large it should be.

ARRANGEMENT WITH PRIVATE HOSPITALS

Mr. Yates. It is a question of the peculiar arrangement which the District has with the private hospitals. I do not know of any other city that has that arrangement.

Dr. SECKINGER. Other cities may have contractual arrangements as we do, but if they have a large municipal hospital they have a large out-patient service also. It is part of institutional development for good hospital care.

Dr. FAZEKAS. I think what you have to decide is whether you are interested in subsidizing hospitals or providing good medical care.

Dr. STEBBING. The private hospitals did not base their claim on the ground that they needed a subsidy. They based it on the ground that they were treating wards of the District of Columbia and should be paid for same.

Dr. FAZEKAS. It is our job to treat the indigent patients.

Mr. Yates. Last year I asked that question and they said that there had been a failure of community funds for private hospitalization, and in order to help out the hospitals and at the same time provide medical care, a contract was arranged with the private hospitals in the District of Columbia so that in turn they would be able to get some earnings out of the care of patients and thereby stay in existence, their existence having been threatened as a result of failure of funds. At the same time they were able to take care of the needs of the people in the District.

Dr. FAZEKAS. Why was it not recommended years ago?

Dr. STEBBING. They had always taken care of tax eligibles the year before but the Community Chest never made a distinction except a few years ago when their funds became low. Then they drew this line between tax eligibles and indigents. The private hospitals were

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