The passing of this bill will provide one way that medical education can be provided for areas such as our's here in Boise. Further, this bill offers an opportunity for continued education for local physicians of this region.

Again our sincere thanks to you for your vigilant attention and interest in matters which affect our State.

Sincerely,

H. WESTERMAN WHILLOCK,
General Manager, KBOI Radio.

Senator YARBOROUGH. The first witness today is Dr. Martin Engle, the Chief Medical Director of the Veterans' Administration.

It is an honor to have you and your staff, Dr. Engle. Will you introduce all those you brought with you to testify and then proceed with your testimony? I believe you had had an opportunity to study these bills. I assume you will testify on all of them; is that correct? STATEMENT OF DR. H. MARTIN ENGLE, CHIEF MEDICAL DIRECTOR, VETERANS' ADMINISTRATION, ACCOMPANIED BY DR. B. B. WELLS, ASSISTANT CHIEF MEDICAL DIRECTOR FOR RESEARCH AND EDUCATION, AND A. T. BRONAUGH, ASSISTANT GENERAL COUNSEL, VETERANS' ADMINISTRATION

Dr. ENGLE. Yes, Mr. Chairman.

Senator YARBOROUGH. Will you introduce anybody you have with you?

Dr. ENGLE. We have with us today Dr. Wells, sitting on my right, Assistant Chief Medical Director for Research and Education. We also have in attendance Mr. Bronaugh, General Counsel.

We also have Dr. Cain, who is Chief of Research for Psychiatry and Neurology.

Senator YARBOROUGH. Is he going to testify? Is he here for all of the bills?

Dr. ENGLE. No, sir; he may be asked to assist in response to any questions in his area of interest.

Senator YARBOROUGH. As to allocating certain amounts of funds for specific purposes?

Dr. ENGLE. Yes, sir.

Senator YARBOROUGH. All right, then.

Dr. ENGLE. Mr. Chairman, we have a statement that we would request your permission to read.

Senator YARBOROUGH. Fine. Proceed, Dr. Engle, in your own way. Read your statement and elaborate if you see fit. We have some very important bills here, and we want the best information we can get for this subcommittee.

Dr. ENGLE. Mr. Chairman, members of the subcommittee, it is a pleasure to appear here today and present the views of the Veterans' Administration on the legislation before you. It is understood that four bills, and the Veterans' Administration reports that have been submitted thereon, have been made a part of the record.

Senator YARBOROUGH. Doctor, of course, the bills have been made a part of the record, as always. But, of course, that report from the Veterans' Administration has not been made a part of the record. That will be made a part of the record prior to your testimony. (The report referred to follows:)

PREPARED STATEMENT OF DR. H. MARTIN ENGLE, CHIEF MEDICAL DIRECTOR, VETERANS' ADMINISTRATION

Mr. Chairman and members of the subcommittee, it is a pleasure to appear here today and present the views of the Veterans' Administration on the legislation before you. It is understood that four bills, and the Veterans' Administration reports that have been submitted thereon, have been made a part of the record.

With your permission, our statement will cover the purpose and effects of the bills, pertinent legislative history, cost estimates, and a brief résumé of the views of the Veterans' Administration.

H.R. 11631-MEDICAL EDUCATION

A bill to amend title 38 of the United States Code to clarify the responsibility of the Veterans' Administration with respect to the training and education of health service personnel.

H.R. 11631 would amend section 4101 of title 38, United States Code, to provide that in order to more effectively carry out the basic functions of providing a complete medical and hospital service for the care and treatment of veterans, the Department of Medicine and Surgery of the Veterans' Administration, should carry out a program of education and training of health service personnel. Such a program would be carried out in cooperation with schools of medicine, dentistry, osteopathy, and nursing, and such other institutions or organizations which the Administrator deems appropriate.

This mandate for carrying out a program of training and educating health service personnel is accompanied by a related provision whereby various advisory committees or bodies would be established at any school, institution of higher learning, medical center, hospital, or other public or nonprofit agency, institution, or organization where the Administrator has a contract or agreement to train or educate such health service personnel.

The enactment of legislation of this type would not of itself result in any increase in the training activities of our Department of Medicine and Surgery. Insofar as the basic purpose is concerned, this bill is similar to section 1 of S. 2666, 89th Congress, introduced at the request of the Veterans' Administration, in that it would provide specific statutory recognition for the third element (education) of the three elements that are widely recognized as essentially inseparable activities which are necessary for a complete medical and hospital service; namely, patient care, research, and education. We believe that such a specific statutory recognition is highly desirable even though a complete medical and hospital service has long been considered as inherently including provisions for educating the medical personnel employed therein. Nevertheless, education should be afforded the same statutory recognition as is afforded treatment and research, by including a specific reference thereto in the formal statement of the functions of the Department of Medicine and Surgery.

The Department of Medicine and Surgery is, of course, primarily responsible for the medical care and treatment of veterans. However, if we are to continue the high quality medical care we are now providing to eligible veteran patients it is essential that an environment conducive to teaching, learning, and research be maintained in the Veterans' Administration system of affiliated hospitals, and outpatient clinics. The recruitment and retention of competent professional and technical staffs are directly dependent upon the existence and availability of progressive and meaningful programs of continuing education, inservice training, and opportunities for career advancement through learning experience.

Medical education and training is a most important factor in obtaining and retaining the high quality of medical care which is necessary in order to protect the health of the people of this Nation. The Veterans' Administration has made a significant contribution in this area. Currently, 87 Veterans' Administration hospitals are actively affiliated with medical schools, and the Veterans' Administration has become the largest single source of clinical experience in connection with medical and health service education. Veterans' Administration facilities are being used increasingly by medical schools for the teaching of physical diagnosis in the preclinical years, and for clinical clerkships in the last 2 years of medical school. In 1964, 1,872 second-year medical students took their physical diagnosis work in Veterans' Administration hospitals, and 6,908 third- and fourth-year medical students were assigned to Veterans' Administration hospitals for a part of their medical clerkships. At the graduate level, some 3,000 residents hold appointments in Veterans' Administration hospitals. Moreover, the Veterans' Ad

ministration has also been playing an increasingly important role in providing onthe-job training for nursing and allied medical and administrative personnel. Sixty-nine Veterans' Administration hospitals provide basic professional training for 4,270 nursing students, and more than 2,900 other paramedical trainees receive a part of their professional education in the Veterans' Administration system. We hope that this bill will receive early and favorable consideration by the subcommittee.

S. 2666-DEPARTMENT OF MEDICINE AND SURGERY OMNIBUS BILL

A bill to clarify and otherwise improve chapter 73 of title 38, United States Code, relating to the Department of Medicine and Surgery of the Veterans' Administration, and for other purposes.

S. 2666 was introduced by the chairman of this subcommittee. It would accomplish a number of perfecting changes in the law governing the Department of Medicine and Surgery, which, within the Veterans' Administration, administers the hospital and medical care program.

Many of the technical amendments proposed concern improvements in terminology or mere clarifications in language to reflect current conditions or circumstances. Some of the amendments proposed would, however, involve substantive changes in the law which experience has demonstrated to be desirable.

Except for the proposed authority in section 9, to pay the expenses of parttime and temporary full-time physicians, dentists, and nurses while attending professional meetings, there would be no additional expenditure of public funds resulting from the enactment of the proposed legislation. While we cannot give an exact estimate of the cost which would be attributable to section 9, we can state definitely that it would be minimal.

The bill would also amend section 5004 of title 38, to provide express authority for the Veterans' Administration to establish, operate, and maintain parking facilities in conjunction with the hospitals and domiciliaries it operates. Basic authority for the operation of such facilities exists, but in general terms. The proposed amendment would spell out this authority and also specifically authorize the collection of reasonable fees, under certain circumstances, from employees, visitors, and others using the facilities, as well as providing certain operational refinements. The VA has long provided parking lots in conjunction with our hospitals and domiciliaries. The Comptroller General recognized our general authority in this area, just last year, in a decision involving parking facilities at future VA hospitals. He ruled, however, that in view of the language now contained in 38 U.S.C. 5004, with respect to fiscal procedures involving garage rental proceeds, any proceed received from a pay-parking facility must be deposited into the Treasury as miscellaneous receipts.

This bill would authorize fiscal procedures very similar to those now authorized by section 5012(a) of title 38, United States Code, with respect to facilities leased for living quarters, in that proceeds received from the use of these parking facilities from certain classes of individuals, could be used for their operation and maintenance.

A full explanation of each proposed amendment is set forth in this detailed discussion of the bill's provisions, which I now submit for the record. Mr. Chairman, I hope this will receive early and favorable consideration.

S. 2748 MEDICAL SHARING BILL

A bill to assure adequate and complete medical care for veterans by providing for participation by the Veterans' Administration in medical community planning and for the sharing of advanced medical technology and equipment between the Veterans' Administration and other public and private hospitals.

S. 2748, which was also introduced by the chairman, would authorize the Administrator, when he determines it to be in the best interest of the prevailing standards of the Veterans' Administration medical-care program, to enter into agreements providing for the exchange of use (or under certain conditions the mutual use) of specialized medical facilities between Veterans' Administration hospitals, and other public and private hospitals or medical schools in a medical community.

Any such arrangement would include a provision for reciprocal reimbursement based on a charge, unit or otherwise, which covers the full cost of services rendered or supplies used. Any proceeds to the Government resulting from such arrange

ments would be credited to the applicable Veterans' Administration medical appropriation.

In the past decade the dramatic advances in medical science and technology have produced highly specialized and costly staff, procedures, and equipment. Because of the cost of such equipment, and the scarcity of the technical staff required, the availability of such resources is extremely limited. In the everchanging complex of medicine with all its ramifications, the cost of medical care and treatment will continue to climb for all users. This applies to the Veterans' Administration Department of Medicine and Surgery as well as to community medical facilities.

The Veterans' Administration, which operates the largest single system of medical facilities in the world, has within its system a portion of these scarce medical resources in various locations, and has provided considerable leadership in the field of medical research. This leadership, however, has its attending obligations. Today, the health needs of many communities are not being met either because of the complexity of the problems, or the magnitude of the resources required.

While current law permits the use of our facilities by nonveterans in emergencies for humanitarian reasons, we are unable to permit the use of such facilities and equipment, as well as expertise of our staff, for nonemergent situations even if there are no other similar facilities available. This situation exists even though these scarce medical facilities are not always utilized to the maximum and could be available to the community, without detriment to the care and treatment of veteran beneficiaries, during periods when our immediate needs do not require maximum utilization.

Possession of the newer complex medical diagnostic or treatment modalities in the Veterans' Administration and others by affiliated or local hospitals with shared use of each by both groups, would make for more efficient utilization of such diagnostic or treatment modalities at lower unit costs for all. For example, very special facilities, staff, and equipment are necessary for hemodialysis. Sharing some of the costs for such services by mutual use on a time-available basis could have the effect of increasing the Nation's limited supply of scientists and equipment in this field.

Benefits will be gained by both the Veterans' Administration and the entire medical community if we can enter into agreements for the mutual use, or exchange of use, of specialized medical resources. Cooperative use of such equipment should result in a much broader therapeutic armamentarium. In addition, such shared usage of facilities would reduce the need for each hospital to have on its staff highly trained scarce categories of professional personnel. Accordingly, we believe that the proposed agreement will improve our capability to provide complete medical care for veterans.

We do not anticipate that the enactment of the proposed legislation will result in any additional expenditure of public funds. It should, instead, reduce the overall medical costs to the Government for certain of its complex medical-care obligations. As a result, such legislation will, in the long run, undoubtedly result in economic gain to the Government as its full potential is achieved.

Mr. Chairman, we likewise hope that this bill will receive early and favorable consideration by the subcommittee.

H.R. 203

A bill to amend title 38, United States Code, to set aside funds for research into spinal cord injuries and diseases.

The objective of this bill is to require the Administrator to set aside out of appropriated funds at least $100,000 for each of 6 successive fiscal years to be used in conducting research into spinal cord injuries and diseases, and other disabilities that lead to paralysis of the lower extremities.

Mr. Chairman, I would like to point out in the beginning that by its terms and in its context the bill would require the use of funds provided for prosthetics research rather than funds appropriated generally for medical research. The research covered by this bill is not directed to the field of prosthetic and orthopedic appliances and it is our thought that if the bill is favorably considered it should be amended to provide for medical research. We shall be glad to cooperate in drafting an amendment to that end if desired.

We estimate that approximately $200,000 was expended in fiscal year 1965 for research directly related to spinal cord injury and disease. There is every reason to expect that the Veterans' Administration will continue to engage in an ample measure of research in the field to which this bill relates and that this will involve

expenditures exceeding the amount required to be set aside by the bill each year. Unless there is some thought of supplying statutory emphasis in this area, it is difficult to perceive any justification for this legislation. As indicated in the Administrator's report, we think it would set an unwise precedent for earmarking research funds for various neurological disabilities and diseases, of which therë are many.

It is our conviction that for research purposes the nervous system should not be considered in a piecemeal fashion and exclusively in relation to specifie disabilities. As an example, multiple sclerosis affects all parts of the nervous system, even though it is also a disease seriously involving the spinal cord. To pursue our research efforts on a fragmentary basis might impair total research in the field of many disabilities related to paralysis of the lower extremities. For these reasons, it is our view that the research program of the Veterans' Administration would be better served if no limitation of this specific nature were enacted.

Mr. Chairman, that completes my statement. We would be happy to answer any questions the members of the subcommittee might have on these proposals.

Dr. ENGLE. With your permission, our statement will cover the purpose and effects of the bills, pertinent legislative history, cost estimates, and a brief résumé of the views of the Veterans' Administration.

Medical education: H.R. 11631, a bill to amend title 38 of the United States Code to clarify the responsibility of the Veterans' Administration with respect to the training and education of health service personnel.

H.R. 11631 would amend section 4101 of title 38, United States Code, to provide that in order to more effectively carry out the basic functions of providing a complete medical and hospital service for the care and treatment of veterans, the Department of Medicine and Surgery of the Veterans' Administration should carry out a program of education and training of health service personnel. Such a program would be carried out in cooperation with schools of medicine, dentistry, osteopathy, and nursing, and such other institutions or organizations which the Administrator deems appropriate.

This mandate for carrying out a program of training and educating health service personnel is accompanied by a related provision whereby various advisory committees or bodies would be established at any school, institution of higher learning, medical center, hospital, or other public or nonprofit agency, institution, or organization where the Administrator has a contract or agreement to train or educate such health service personnel.

The enactment of legislation of this type would not of itself result in any increase in the training activities of our Department of Medicine and Surgery.

Insofar as the basic purpose is concerned, this bill is similar to section 1 of S. 2666, 89th Congress, in that it would provide specific statutory recognition for the third element-education-of the three elements that are widely recognized as essentially inseparable activities which are necessary for a complete medical and hospital service; namely, patient care, research, and education. We believe that such a specific statutory recognition is highly desirable even though a complete medical and hospital service has long been considered as inherently including provisions for educating the medical personnel employed therein. Nevertheless, education should be afforded the same statutory recognition as is afforded treatment and research, by including a specific reference thereto in the formal statement of the functions of the Department of Medicine and Surgery.