Senator YARBOROUGH. Any other witnesses who desire to be heard on this legislation, come around, please.

Mayor Wallace, would you state your name for the record, please, and that of your associate?

STATEMENT OF HON. F. V. WALLACE, MAYOR, AMARILLO, TEX.; ACCOMPANIED BY STAFFORD L. WARREN, M.D.

Mr. WALLACE. My name is F. V. Wallace. I am mayor of Amarillo, Tex., among other things, probably better known in my community as chairman of the Hospital Committee of the Amarillo Area Foundation, which covers a lot of activities.

Senator YARBOROUGH. It is an important committee.

Mr. WALLACE. I would like to advise the subcommittee that we are interested in all of these bills, of course; primarily, and to a greater degree in H.R. 11631, with our interest being that of a demonstration medical school or the cooperation of whatever medical school we may establish with our VA hospital and other facilities.

I would like to acquaint the subcommittee with what we have briefly and that will be the substance of my testimony.

First, we have two general civilian medical hospitals and a third one under construction beginning last Monday, a 241-bed hospital to be built by a local foundation with contributed funds and operated by the High Plains Baptist Hospital, Inc., associated with the Baptist General Convention of Texas. We have one community psychiatric treatment facility. It is the only community facility in the Southwest. It is a 100-bed facility and construction is about 25 percent complete. We have a children's psychiatric treatment facility to be built with private funds and to be constructed starting May of this year. We have a Texas mental health and mental retardation demonstration unit, the construction of which is to start before August 1. All these facilities are located, with one exception, on a 400-acre medical center site and, in addition to that, we have the VA hospital on the same site.

We have 135 members of the Potter-Randall Medical Society who are conditioned and ready and willing to have a medical school in our community.

We serve, medicalwise and hospitalwise and specialized treatment, in an area halfway to Oklahoma City, Denver, Albuquerque, the Dallas-Fort Worth area, Wichita, and El Paso.

It was mentioned here that nursing schools are part of education. We have one established baccalaureate degree nursing school at Canyon, West Texas State University, starting this year, and we have two diploma schools in our existing hospitals. We have a school of laboratory technology and one of X-ray technology. Our Amarillo College is starting a vocational school for the medical sciences, the LVN nurses, which they already have in existence, nursing aids, et cetera.

I would submit myself to questions, Mr. Chairman.

Senator YARBOROUGH. Mayor Wallace, the children's psychiatric hospital is rather unusual, is it not?

This

Mr. WALLACE. That is very unusual. We have in our community one of the three accredited children's psychiatrists in Texas. facility will have 25 in-patients, that is, take care of 25 children on an inpatient basis and an unlimited number on an outpatient basis.

Senator YARBOROUGH. Are there any other children's psychiatric hospitals in Texas?

Mr. WALLACE. To my knowledge, there are no community-built ones. I could be in error, but I do not have any knowledge in existence of more than one. This facility already exists on an out-patient treatment basis.

Senator YARBOROUGH. Do you know, Doctor, of any other children's psychiatric hospitals?

Dr. WARREN. I do not recall any.

Senator YARBOROUGH. Amarillo has a very advanced type of medical installation there.

You expressed an opinion only on H.R. 11631. That is the education bill. Of course, as the statement said, that would involve the expenditure of no more money. They would do what they are doing now in the Veterans' Administration hospital, but it is mainly to recognize the fact that medical education is being carried on there. You have with you, I believe, Dr. Stafford Warren. identify him for the record?

Will you

Mr. WALLACE. I do not know, Mr. Chairman, whether Dr. Stafford Warren is with me or I am with him. I believe I am with him, because he is more experienced than I am.

Senator YARBOROUGH. Are you located in Amarillo now, Dr. Warren?

Dr. WARREN. I have been a consultant, yes, sir. If I may have the privilege, I would like to speak as an individual.

Senator YARBOROUGH. All right, please, we would like to hear you. I believe you were adviser to President Kennedy in the mental retardation problem, were you not, leading up to the passage of that act in 1963?

Dr. WARREN. Yes, sir, I was special assistant to President Kennedy and then later to President Johnson, until last July, when I finished my job and resigned.

Mr. WALLACE. Mr. Chairman, may I be excused? I unfortunately have an appointment with the Federal Aviation Agency with respect to one airport.

Senator YARBOROUGH. Yes, and we will hear the rest of Dr. Warren's testimony while he is here.

Dr. WARREN. Thank you very much, Senator. I appreciate this opportunity and I will take a very brief time so as not to impose upon

you.

I have had the experience since 1947 of being a dean of a new school, starting from scratch, at the University of California at Los Angeles. I became emeritus in 1963 as chancellor of the health sciences. So I can speak with considerable experience about the difficulties in putting together a large conventional medical center, which took all of this time and in fact, is still being constructed and will probably not be completely constructed for another 3 or 4 years.

Now, it is based on a large campus of the University of California at Los Angeles, with 25,000 students in the campus plan, which will be reached in about 4 years. The medical center will house and train some 2,500 health sciences personnel of all categories, except the lower level attendants and those that are not subject to collegiate disciplines. I point to the fact that in the President's program of last year, in the health message, he envisaged 15 to 16 more of these large medical

schools and centers. You cannot get around the fact that these take 10 to 15 years to build and cost something in the neighborhood of $75 to $105 million before you are through with the physical plant.

Senator YARBOROUGH. Each one, you mean, will cost that?

Dr. WARREN. Yes, sir, each center; that involves the schools of medicine, dentistry, public health, and then the curriculums for nursing, social welfare, clinical psychologists, and all the rest that have been mentioned here.

I can speak with great feeling and appreciation of the participation and cooperation of the Veterans' Administration in this venture. It could not have been launched nor continued without the participation of the Veterans' Administration hospitals. I have been on the deans committees that you have heard of since 1947, when General Hawley and Dr. Magnuson first organized this relationship with medical schools.

The veteran care improved tremendously as was indicated in the hospital stay. It could be demonstrated in the early days of our association that the introduction of the educational and training programs, even though they were only authorized by a letter of intent and not by legislation, reduced the hospital stay and shortened the turnover almost 100 percent that is, from something like 3 weeks average stay for the relatively acute cases, this was reduced to almost a week, with great savings in every direction, including better medical

treatment.

Now, you have heard the testimony about the improved care, the amount of research that is going on. I would like to make a plea for an additional venture. While I was special assistant to the President, we were quite aware of the fact that there was a shortage of specialists in the fields of neurology, pediatrics, obstetrics, and all over. prospect of these new medical schools coming in before 1970 to appreciably improve the situation is very poor because of the long lag, difficult financing, and so on.

The

Now, great efforts have been made to increase the number of students trained by new legislation, but this has a peculiar effect that was not expected. It overtaxes the already overcommitted institutions. I think it is fair to say that no dean of a medical school or a health sciences program will agree that he has enough space, enough operating budget, or enough staff to carry the student commitments that he has under his aegis. That is true of our own institution.

In looking around, it seemed to me that there are a great many places in the country where advantage could be taken of the local situation in cities with a population of 100,000. A combination of three existing resources could be organized to support a small medical school program: (1) A Veterans' Administration hospital which has a built-in staff which could be capable of undertaking a part of the educational program as well as research; (2) a community hospital with a population of beds somewhere in the neighborhood of 400. That is only four beds per thousand. A good many cities have this; (3) a local college which could, through its graduate councils or divisions, be responsible for the quality of the education and the research, and incidentally, the quality of the care aspects of this relationship. It ought to be possible with these resources and the

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support of the community-and perhaps with some private funds, to build a small medical school.

Now, most medical schools in the country did just as we did. They started in temporary buildings with a class of around 32 medical students, graduating 32 M.D.'s a year. We did this for a complete cycle, 5 years. This is a time of excellent pedagogy. You have close relationship between a faculty and the student, a thing that is complained about as disappearing now in our medical education because the plant is so big, there are so many students and literally not enough faculty, so the distance between the student and the faculty increases. Senator YARBOROUGH. Would you say, then, Doctor, that in the beginning years of a new medical school, with the more limited physical plant, the close association between faculty and student is a factor that would make that medical education not inferior to that received by a student in a big plant, where he was more distantly removed from the teaching staff?

Dr. WARREN. You are quite correct. This is one of my main points. This is the best education we ever gave to any of our students and I can point to the two schools in Texas where they started out in temporary buildings and I think they will agree that they did the best teaching in these early days when they had a small student body and a relatively large faculty.

You

Now, you cannot get below a certain minimum of faculty. have to have about 15 departments of 2 men each. Then you take advantage of the practitioners in the community who are board certified, and usually there are quite a number. În Amarillo, there are more than sufficient. In Boise, Idaho, which is another place that I have examined rather carefully, you have the same situation. You have in the Veterans' Administration in those communities usually a pathologist and a radiologist. You have heard these mentioned as short in supply. These are potential teachers. I am asking that the Veterans' Administration, under this new legislation and by agreement with the National Institutes of Health, undertake two or three or four pilot programs in suitable places like these two cities, where the community is behind it, but limited to the size of an institution that the community and the resources can support. Though it is going to cost some more money, per student per year I think it will cost less in physical plant and total operating budget. You can build one-story, 30-year-life buildings of concrete block and slab for reasonable prices. To my surprise, I found in these two cities that the cost of such construction, built on veterans' land against the veterans' hospital, would probably be in the neighborhood of $11 to $12 a square foot gross. That is $22 to $24 net useful square feet-it is about 50 percent of the cost for the usual large, skyscraper type of permanent buildings that the State institutions are required to build. This is the taxpayer's money; they have to put a durable plant up and it has to be of the best. Not that these small units are not of the best. This is the building quality that a lot of the junior colleges use now.

Now, if the community grows in the next 20 years, your investment of maybe a million and a quarter dollars in physical plant is a relatively small item to either revamp, modify, throw away and destroy-you have not lost much. But you now have had experience in the com

munity as to what can be supported, what are the needs, how do you go about meeting them.

In studies in Boise, by the Wiche organization, it was quite obvious Boise could not support a conventional medical school, 64 students per class, 72 or 100, which is what they started out to discuss. But I think it is quite clear they can support one with the veterans help at this lower level of 32 M.D.'s graduated per year.

So I would like to submit, with your permission, a small study which I did of this, a summary, for the record. The title is "The Small Medical School as a Quick Source of Medical Manpower."

Senator YARBOROUGH. You may file that. I would like to print it in full in this record as a means of getting it before this committee and the full committee.

(The article referred to follows:)

THE SMALL MEDICAL SCHOOL AS A QUICK SOURCE OF MEDICAL MANPOWER

(By Stafford L. Warren, M.D.1)

Many recent studies have indicated considerable alarm about existing and projected shortages of manpower in the medical and health-related fields. The administration has responded with new legislation which provides funds for matching construction costs, research and training grants, student scholarships and loans and by other methods to stimulate the expansion of existing schools and the organization of new ones for medicine, public health, dentistry, nursing and related professional personnel.

Most of the studies upon which this new legislation has been based were done prior to the recent passage of other legislation which will increase greatly the demands for the medical and health-related personnel required to mount new programs in mental retardation, mental health, the heart, cancer and stroke fields and medicare, to mention only some major ones. These new programs will compound the shortage and for some time the effect will be one of "musical chairs" through parasitism of personnel from one program to serve another.

This problem will arise because of the long leadtime inherent in the conventional development of large new institutions and their facilities. President Johnson's 1965 health message refers to the construction of 16 of the customary large schools and complexes or centers costing in the neighborhood of $25 to $100 million each with large annual operating costs. Few, except the largest and strongest educational institutions, are capable of undertaking such a program.

While it is likely that 16 or more institutions will proceed to do this in due time, the long leadtime required to authorize, fund, organize, build, equip, and staff these institutions, plus the educational cycles required for the training of the professionals, will consume nearly a decade before much output can be expected. Many institutions are encouraged to increase their student bodies. The increase in size of the already overcommitted, underbudgeted, existing medical educational institutions will be slow also. Since it is likely that there will still be a shortage in spite of these actions when they are completed, an additional concept and approach is needed now.

Up to the present time, little or no consideration has been given to the development of many small medical schools developed away from the big metropolitan centers utilizing and building upon existing medical and health facilities and local resources in outlying metropolitan centers of 100,000 or more population.

The more limited scope of the smaller complex is more apt to be within the resources of many more educational institutions and their communities. Such schools, like many small colleges of high repute, can still be complete and of high quality if they are kept realistically within the reach of their local resources. Being small, it is submitted that they can be built and produce graduates of high quality in a relatively short leadtime. The following discussion is directed toward the requirements for organizing a medical complex focused around a medical school graduating 32 medical doctors per year, and others in the healthrelated professions, as representing the smallest practical unit around which to build a balanced medical complex.

1 Vice chancellor of the health sciences, emeritus, University of California, Los Angeles, Calif.