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 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' Administration has also been playing an increasingly important role in providing on-the-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 at least 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.

Department of Medicine and Surgery omnibus bill, S. 2666, 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, 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 part-time 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 proceeds 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.

(The material referred to follows:)

ATTACHMENT TO STATEMENT OF DR. H. M. ENGLE, CHIEF MEDICAL DIRECTOR VETERANS' ADMINISTRATION

SUMMARY OF PROVISIONS OF S. 2666, 89TH CONGRESS

This bill would amend a number of sections of chapter 73, title 38, United States Code, relating to the administration of the Department of Medicine and Surgery and the personnel system for physicians, dentists, and nurses. The provisions which involve substantive changes in the law would be designed to eliminate specific problem areas which have developed in the administration of the department. Other proposed changes would have no substantive effect but would merely clarify the statutory language or eliminate obsolete terminology. Specifically

(a) The functional activities of the Department of Medicine and Surgery, stated in section 4101, would be clarified to include a specific reference to "education related to such service" as a part of a "complete medical and hospital service";

(b) The language of section 4102 and section 4105 would be amended to eliminate the use of the obsolete terms "auxiliary service” and “auxiliary” employees;

(c) Section 4103(a) would be amended to provide that personnel for certain positions within the Department of Medicine and Surgery would be appointed by the Administrator "upon the recommendation of the Chief Medical Director." It would also provide for one additional Assistant Chief Medical Director. In addition, a new subsection (b) would be added authorizing the extension, for a period not in excess of 3 years, of appointments or reappointments to a section 4103 position;

(d) The obsolete term "managers" would be deleted from section 4104 and the term "director" would be substituted for the term "manager" in section 4105;

(e) The language in section 4105 would be amended to limit the requirement that all appointees within the Department of Medicine and Surgery must be U.S. citizens so that it would apply only to physicians, dentists, and nurses;

(f) The language in section 4106 would be amended to make it consistent with general personnel terminology (i.e., automatic promotions to advancement). A new subsection (e) would also be added authorizing the administrative adjustment of grade assignments in those circumstances where the grade is dependent upon a combination of qualifications;

(g) Section 4107 would be amended to delete the requirement that a person holding the position of director of an outpatient clinic be placed in the "executive" grade of the pay schedule. In addition, a provision would be added whereby the Classification Act of 1949 would be inapplicable to a nonphysician director of a hospital, domiciliary or center, inasmuch as there is no practical purpose served by continuing to treat the position as if it were classified under such act;

(h) Section 4112 would be amended to delete the requirement for specific monthly meetings of the medical advisory group and provide instead for regular meetings as prescribed by the Administrator;

(i) Section 4113 would be amended to authorize the Administrator to pay the expenses of physicians, dentists and nurses appointed on a temporary full-time or part-time basis in D.M. & S., who are detailed to attend meetings for the promotion of medicine and related sciences;

(j) Section 4114 would be amended to clarify the legal authority to appoint employees within D.M. & S. on a without compensation basis. Such section would also be amended to permit the appointment on a temporary full-time or part-time basis, of a physician who is used on a research project, in an academic position, or where there is no direct responsibility for the care of patients, even though he may not have a U.S. license. This provision would include authority for the appointment of a physician licensed in a foreign country where his actual service is in such country;

(k) Section 5004 would be amended to provide for administrative procedures necessary for the practical establishment and operation of paid parking facilities.

Section 1

DISCUSSION OF PROVISIONS OF S. 2666, 89TH CONGRESS

Section 4101 of title 38, United States Code, would be amended as follows: "There shall be in the Veterans' Administration a Department of Medicine and Surgery under a Chief Medical Director. The functions of the Department of Medicine and Surgery shall be those necessary for a complete medical and hospital service, including medical research and education directly related to such service as prescribed by the Administrator pursuant to this chapter and other statutory authority [for the medical care and treatment of veterans]."

As indicated above, the statement of functions of the department of medicine and surgery would be amended to include a specific statutory reference to "education." This amendment is clarifying only and would make no substantive change in the law, since a complete medical and hospital service has long been considered as including appropriate provisions for educating physicians and other medical and medical support personnel.

H.R. 11631, which passed the House of Representatives on February 7, 1966, would accomplish the same purpose as this section, and, if enacted, would obviate the need for this section.

"The Department of Medicine and Surgery shall include the following: Office of the Chief Medical Director, a Medical Service, a Dental Service, a Nursing Service, [and Auxiliary Service.] and such other professional and auxiliary services as the Administrator may find to be necessary to carry out the functions of the Department."

This amendment eliminates an existing ambiguity in the law. The term "auxiliary service" as now in the law has two possible meanings. In section 4102 it appears to describe an organizational element of the department while as used in section 4105 it only can be interpreted as a broad reference to all employees of the department other than physicians, dentists, and nurses. Since use of the term serves no substantive purpose it would be deleted both from section 4102 and section 4105 solely as a matter of clarification.

Section 3

Section 4103 of title 38, United States Code, would be amended to read as follows:

"(a) The Office of the Chief Medical Director shall consist of the following

"(1) The Chief Medical Director, who shall be the Chief of the Department of Medicine and Surgery and shall be directly responsible to the Adminis trator for the operations of the Department. He shall be a qualified doctor of medicine, appointed by the Administrator.

"(2) The Deputy Chief Medical Director, who shall be the principal assistant to the Chief Medical Director. He shall be a qualified doctor of medicine, appointed by the Administrator.

"(3) Not to exceed [five] six Assistant Chief Medical Directors, who shall be appointed by the Administrator upon the recommendation of the Chief Medical Director. One Assistant Chief Medical Director shall be a qualified doctor of dental surgery or dental medicine who shall be directly responsible to the Chief Medical Director for the operation of the Dental Service.

"(4) Such Medical Directors as may be appointed by the Administrator, upon the recommendation of the Chief Medical Director, to suit the needs of the Department. A Medical Director shall be either a qualified doctor of medicine or a qualified doctor of dental surgery or dental medicine.

"(5) A Director of Nursing Service, who shall be a qualified registered nurse, appointed by the Administrator, and who shall be responsible to the Chief Medical Director for the operation of the Nursing Service.

"(6) A Chief Pharmacist and a Chief Dietitian, appointed by the Ad

ministrator.

"(7) Such other personnel and employees as may be authorized by this chapter.

"(b) Except as provided in subsection (c) of this section

"(1) any appointment under this section shall be for a period of four years, with reappointment permissible for successive like periods, [except that persons]

"(2) any such appointment or reappointment may be extended by the Administrator for a period not in excess of three years, and

“(3) any person so appointed or reappointed shall be subject to removal by the Administrator for cause.

"(c) The Administrator may designate a member of the Chaplain Service of the Veterans' Administration as Director, Chaplain Service, for a period of 2 years, subject to removal by the (Administrator for cause. Redesignation under this subsection may be made for successive like periods. An individual designated as Director, Chaplain Service, shall at the end of his period of service as Director revert to the position, grade, and status which he held immediately prior to being designated Director, Chaplain Service, and all service as Director, Chaplain Service, shall be creditable as service in the former position."

This amendment would increase the number of Assistant Chief Medical Directors, who may be appointed to the Office of the Chief Medical Director, from five to six. Prior to the enactment of the Federal Salary Reform Act of 1962, the law (38 U.S.C. 4103) authorized eight Assistant Chief Medical Directors. Such number was reduced to five upon our recommendations. We now find that this reduction was premature and that one of the authorized positions elimi nated is needed and should be restored. Such restoration is required to reflect a change in the organization of the Department, the expansion of responsibility as a result of new legislation, new programs initiated within existing legislation, and to permit better organizational flexibility.

Paragraph 2 of subsection (b) is new and would authorize the Administrator to extend any appointment or reappointment to a section 4103 position for a period not in excess of 3 years. Currently, the law provides only for appointments or reappointments for a flat 4-year period. Circumstances have arisen and will arise in the future where it will be desirable to extend appointments from 1 to 3 years rather than make a 4-year appointment. An example of this is where an incumbent is near retirement age or where the incumbent is not willing to accept a full 4-year appointment but would be willing to serve for a relatively short period while a qualified successor is being sought.

Section 4

Section 4104 of title 38, United States Code, would be amended to read as follows:

"There shall be appointed by the Administrator additional personnel as he may find necessary for the medical care of veterans, as follows:

"(1) Physicians, dentists, and nurses;

(2) [Managers, pharmacists,] Pharmacists, physical therapists, occupational therapists, dietitians, and other scientific and professional personnel, such as optometrists, [pathologists, bacteriologists, chemists, biostatisticians, and medical and dental technologists."

The purpose of this amendment is to delete the obsolete term "Managers" from paragraph (2) of section 4104, title 38, United States Code. It would also delete the word "pathologists," from the list of nonphysicians contained in subparagraph (2) inasmuch as such individuals are in fact physicians and therefore properly included in subparagraph (1).

Section 5

Section 4105 of title 38, United States Code, would be amended to read as follows:

"(a) Any person to be eligible for appointment to the following positions in the Department of Medicine and Surgery must have the requisite qualifications:

"[(1) be a citizen of the United States, except as provided in section 4114;]

"(2) in the Medical Service-] (1) Physician—

"hold the degree of doctor of medicine or of doctor of osteopathy from a college or university approved by the Administrator, have completed an internship satisfactory to the Administrator, and be licensed to practice medicine, surgery, or osteopathy in a State; "[(3) in the Dental Service-] (2) Dentist

"hold the degree of doctor of dental surgery or dental medicine from a college or university approved by the Administrator, and be licensed to practice dentistry in a State;

"[(4) in the Nursing Service-1 (3) Nurse

"have successfully completed a full course of nursing in a recognized school of nursing, approved by the Administrator, and be registered as a graduate nurse in a State;

"[(5) in the Auxiliary Service-]

"[A] manager] (4) Director of a hospital, [home, or] domiciliary, center or outpatient clinic

"have such business and administrative experience and qualifications as the Administrator shall prescribe;

"[(B)] (5) Optometrist

"be licensed to practice optometry in a State;

"[(C)] (6) Pharmacist

"hold the degree of bachelor of science in pharmacy, or [its] the equivalent, from a school of pharmacy approved by the Administrator, and be registered as a pharmacist in a State;

"[(D)] (7) Physical therapists, occupational therapists, dietitians, and other Lauxiliary] employees shall have such scientific or technical qualifications as the Administrator shall prescribe.

"(b) Except as provided in section 4114 of this title, no person may be appointed in the Department of Medicine and Surgery as a physician, dentist, or nurse unless he is a citizen of the United States."

This section of the bill would amend title 38, United States Code, to limit the requirement that all appointees within the Department of Medicine and Surgery must be U.S. citizens so that it would apply only to physicians, dentists, and nurses. Other employees would be subject to the general Civil Service provisions applicable to other agency employees.

At present, there exists the anomalous situation that a stenographer who is a citizen of a country which is an ally of the United States may be appointed in any of our staff offices, or the Department of Veterans Benefits, but, because she is not a citizen of the United States, she may not be appointed in the Department of Medicine and Surgery even though she would perform essentially the same work wherever she would be appointed. We do not believe that there is any logic in this distinction.

The basic requirement of U.S. citizenship for appointment in the Department of Medicine and Surgery was enacted in 1946 by Public Law 293, 79th Congress,