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I think what you have discovered there is of vast importance when we consider that some 47,000 or 48,000 people are killed on the highways each year, and that many times that number are injured. Certainly we need the discovery and research of the Veterans Administration hospitals readily available to the general public. It is far in excess of the losses in the Vietnamese conflict, as grave as those losses have become. Of the over 54 million injured in accidents each year, approximately 22 million, as I recall, are in highway accidents. Some 22 million are in the homes, and less than 10 million on the job. The safety devices are better on the job than either in the home or on the highways, or maybe there are many more people in the homes and on the highway than on the job.

Dr. Wells, how do you see VA fitting in with HEW and the National Institutes of Health in the matter of training manpower and personnel?

Dr. Engle, perhaps you can answer this one, too.

You mentioned this shortage of doctors. We have passed, you know, the Health Professions Act here in Congress in 1963 to build medical schools. We passed an act to set up loan funds to lend money to students to go to medical schools. We have expended that to include schools of dentistry, schools of optometry, schools of podiatry, schools of nursing, and we now have a Nursing Health Act to train nurses to help relieve some of the great nursing shortage.

The administration and many of the research grants made to medical schools in this country are through the National Institutes of Health. I have been advised that the total amount paid for salaries, while under the guise of research, is in excess of 50 percent of the amount of salaries paid to teachers in some medical schools, and conies from the National Institutes of Health. We are pouring vast sums of money, billions of dollars, into medicine in this country through the National Institutes of Health and HEW combined. How will this fit in with what they are doing?

We need a cooperative program here. We do not want any of these three agencies ignoring the efforts of the other one. It is a shocking thing to think what would happen to medicine in this country without this support from the Government, regardless of the violent attack in some quarters, mainly medical quarters, made on the Federal Government's contribution.

Dr. Wells. It is unthinkable what would happen, because it is well known that upward of 60 percent of the entire support in medical schools of this country is coming from the Federal Government through various grant sources. Of course, HEW, through XIH, bas made an enormous contribution, some of this in the form of research, but which later actually has its manifestation in education, so they are very deeply involved in this business.

It is my feeling, and I think many of my colleagues share it, that the Veterans' Administration, as a very large hospital and clinic facility, has really been overlooked as a place to train people. Yet we know that the great bulk of health service manpower training, all the way from the physician down to the nursing aids, actually takes place nowadays in the hospital. There was a time when the bulk of training did take place in classrooms and laboratories of universities and medical schools. Certainly now, the bulk of the training takes place on the job in the clinical setting of a hospital or a clinie.

Now, we have those hospitals and clinics. It would seem to be an extremely logical thing that we make the best possible use of them.

Mr. Chairman, I come from a long line of alert but slightly disgruntled taxpayers, and I feel that we ought to get the most out of an existing resource. Certainly, the Veterans' Administration has an enormously good purpose that has been underwritten by the American people for generations. Here we have had a very fine facility for producing excellent patient care, which we do. As a byproduct of this, we can return to the taxpayer a certain dividend on his veteran dollar, as I see it, in the form of research and education. We can do this at a marginal cost, which is considerably less than one would have to spend if he started from the beginning to create these facilities to produce either research or education.

So it would seem to me that the points taken by your proposed legislation are extremely pertinent. They would allow us to make use of these facilities to enhance and improve the total medical and health service manpower pool in the country.

Senator YARBOROUGH. I have a question of Dr. Engle.

On this composite bill that has been introduced, the last one that we mentioned, the general bill--that is S. 3086—when do you think you might have a statement on that, an opinion on that? How long do you think it might be?

Ďr. ENGLE. I would like to ask Mr. Bronaugh, from the General Counsel's Office.

Mr. BRONAUGH. Mr. Chairman, we received the request for a report at the end of last week. We shall expedite the report to the best of our ability but, of course, any statement of position has to be cleared with the Bureau of the Budget to ascertain executive branch position. But we will certainly try to get it just as soon as we can.

Senator YARBOROUGH. So you have to clear that before it is offered to other agencies after it has gone to the VA.

Mr. BRONAUGH. We will certainly try to get it as quickly as possible.

Senator YARBOROUGH. I would like to have that before we have the executive session consider these bills.

I want to ask a question or two about some suggested changes in the language of the Teague bill, the House bill. I understand this has been worked out by our staff with the Veterans' Administration representative. If it has not, we shall defer the questions until you have had an opportunity to go over them. That is the education bill, H.R. 11631.

It has been suggested that that bill be amended in section (b) at page 1, line 8, after “Administrator”, that these words be added: "shall carry out a program of training and education of health service personnel."

Now, this is a rearrangement coming from the last paragraph, so that the aim of the bill will be stated right in the first section. Is that approved by the Veterans' Administration?

Dr. WELLS. Mr. Chairman, I think that the rearrangement would give proper emphasis to the central purpose of the bill.

Senator YARBOROUGH. And it has been recommended, too, that there be clarifying language, perhaps to broaden the language as to its purpose with reference to the advisory committees. This is on page 2 of the bill, section 2(b), lines 15 and 16. They say, "he shall establish an advisory committee", and so on. This proposed amendment would put in the word "local”, before "advisory committee” at the beginning of line 16, so it would read "local advisory committee." Then, at lines

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17 and 18, it would provide that "such advisory committee shall advise the Veterans' Administration and non-VA principals.”

The purpose of that, as I understand it, is to enhance the cooperation of the VA and the local level committees. If you were working with some hospital or medical school, the local committee would advise the Veterans' Administration of whatever the advisory committee resolved-I understand this committee is advisory only.

Dr. Wells. That is correct, Mr. Chairman. There is just a little bit of confusion

Senator YARBOROUGH. As to what the advisory committee would do and what it was?

Dr. Wells. And "local" would remove the doubt that we were speaking of a legislatively established medical advisory committee that is already in title 38.

Senator YARBOROUGH. Is that approved by the VA?
Mr. BRONAUGH. Neither of these has been submitted to the VA.

Senator YARBOROUGH. Then I ask the VA to study them if they have not. There has been some talk about them, and I thought perhaps you had studied them officially. If you have not, let us bring them up now and I direct the staff to hand copies of these suggested changes to the witnesses.

We have had two or three staff members working on this. In fact, we have had the committee staff members and men from my office staff all working on these bills. We consider this bill of considerable importance in this great shortage of medical personnel in America.

Mr. BRONAUGH. Mr. Chairman, the bill was amended in the House to add this parenthetical phrase, “dean's committee, medical advisory committee or the like". That was recommended by the VA, and, in the report, it was suggested to make it clear that it could be regional committees as well as local committees, which is one reason why I was hesitating.

Senator YARBOROUGH. All right, sir. We would like you to work that out with counsel for the committee. Then we can consider this proposal.

Of course, these will be discussed now and taken up in the executive session of the Veterans' Affairs Subcommittee when we meet after the reports have been completed and the testimony written up to consider these bills in the executive session.

It was also recommended that there be added words at line 25, in the sentence beginning, "Members of each such advisory committee shall be appointed by the Administrator and shall include personnel of the Veterans' Administration and”. It would drop that language no, it would add "appropriate Administrators." In line 25, after the words, "Veterans Administration," add, “and appropriate administrators,” it being thought there that in some cases where deans of medical schools have been dealt with, we have been advised that there has been a little friction with chancellors of universities, because you failed to go through their channels. We just add the words "appropriate administrators.”

I leave that with you. I was under the impression that these had been delivered to the Veterans' Administration and you had had an opportunity to consider them. So I will leave that to you for consideration at the Veterans' Administration.

In line 4 of page 3, after that last sentence, it is suggested that this sentence be added: "The Administrator is charged with responsibility

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of reviewing and approving the steps taken to implement the intent. of the legislation."

Well, I think that that is implicit in the law, anyway, but it has been suggested that it does not seem to assure that the Administrator can step in and straighten out things if something went wrong. Some thought that this additional language should be given to strengthen the hand of the Administrator by putting that responsibility, there to review it if the coordination and cooperation were not pursued properly. You gentlemen can study that and get your letters and reports back, and we shall take it up in executive session if you have not had an opportunity to consider that as of this time.

Mr. BRONAUGH. We shall be happy to review the language.

Senator YARBOROUGH. Doctor, you were telling us that you have cooperative programs now with 87 medical schools, did you say, and 200 other universities?

Dr. Wells. Yes, sir.

Senator YARBOROUGH. Now, approximately how many schools are there in the country training nurses now; do you know?

Dr. WELLS. There are some 500-odd. I cannot give you the exact number.

Senator YARBOROUGH. At any rate, there is a great shortage. None of this Nursing Act legislation has passed out of this Veterans Subcommittee we are a subcommittee here of the Labor and Public Welfare Committee, and we have another subcommittee on education and one on public health. I assume all of them will see this in its whole relationship-VA, public health over here, and education over here. Some of these bills cut across all three subcommittees.

Of course, as you know, we have had some difficulty there in opening up other schools for nursing, and we are trying to expand schools that want to give nursing courses, but there has been a dispute over licensing of them and over the authorization or the authority of the schools to teach and then have their graduates licensed.

Dr. Wells. We have some jurisdictional problems. But our nursing service feels that the figure that they offered in the tabulation is a pretty conservative one, and that they can increase the number of nurses who are trained in VA hospitals. This is a partial training, of course, in the VA hospitals. At the present time, the average duration of nursing training in our hospitals is about 90 days. But there is a tendency to increase this to something of the order of 6 months, with the increasing emphasis on chronic diseases of the type of which we have the clinical materials. They feel that we should increase the numbers and increase the duration of trainees within the VA hospitals, cooperating with existing schools.

Senator YARBOROUGH. Now, what kind of training is this? Is this postgraduate training after a nurse has graduated from nursing school?

Dr. WELLS. No.

Senator YARBOROUGH. You do not turn out a fully trained nurse in 90 days?

Dr. WELLS. Oh, no; this is strictly a fragment of the nurses' total curriculum. There are two large groups-I should say three large groups of nursing occupations that we have reference to here. There are baccalaureate nurses who take a full 4 years of training. They may have 3 to 6 months with us. Then there is the diploma school, the hospital school, which is beginning to drop off but it is still

a very significant factor in the production of nurses in this country. They take a 3-year curriculum, and we get them for some period.

Senator YARBOROUGH. Both the hospital-trained nurse and the baccalaureate nurse are entitled to come under the licensing laws of the country for registered nurses?

Dr. Wells. That is right, they are R.N.'s. Then there is a third category, the so-called associate nurse training, which is the program that really just started about 5 years ago, in which the junior colleges, community colleges, have undertaken to give a 2-vear training course for nurses coordinated with affiliated hospitals. These nurses now are entitled to take the R.N. examinations in all 50 States. So you see. we have three categories, actually, of R.N.'s. Then below that, there are, of course, the other

Senator YARBOROUGH. The practical nurses?

Dr. Wells. We have the practical, the vocational nurse. Five years ago, there were something in the order of 250 vocational nurses in the VA. At the present time, we have something in excess of 2,500

Senator YARBOROUGH. Is this great increase due to the shortage of registered nurses?

Dr. Wells. Well, it is a little bit of both. It is a question of shortage, yes. We are short. On the other hand, it is a question of proper utilization. We hold to the general principle that in the nursing occupations and the others, too, for that matter, a person should not be overtrained for the duty that he is assigned to, because this is excessively expensive. Our nursing service has conducted a perfectly elegant study of utilization of people. They try to put these people into the jobs that they can do best without being either overtrained or inadequate for the position.

Senator YARBOROUGH. What is the difference between a practical nurse and a vocational nurse?

Dr. WELLS. None at all. These are synonymous terms. The vocational term came into use principally because so many of them are public school system-trained nurses through the vocational high schools.

Senator YARBOROUGH. Now, these practical nurses or vocational nurses, is there any kind of licensing required of them, do you know?

Dr. Wells. Oh, yes; there is a separate kind of lower level licensing for the vocational and practical nurses.

Senator YARBOROUGH. Is that in all 50 States?

Dr. WELLS. I believe all 50 States now have a vocational licensing program.

Senator YARBOROUGH. That is all the questions I have at this time.

We have Senator Fannin, of Arizona, with us, a very valued member of this subcommittee, and very much interested in veterans' affairs.

Senator FANNIN. Thank you, Senator. I would like to ask some questions, both on behalf of myself and also on behalf of some of the other minority members.

Dr. Wells, you gave an answer regarding the support of the medical schools and I think you stated that 60 percent of all of the funds that are furnished by the Federal Government-I would ask, Is this capital expenditures and operational expenditures?

Dr. WELLS. If you take the full annual budgets of the medical schools of the country, approximately 60 percent of their annual budgetary outlay is from the Federal Government.

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