PREPARED STATEMENT OF DR. JAMES J. FEFFER, VICE PRESIDENT OF MEDICAL AFFAIRS, GEORGE WASHINGTON UNIVERSITY

Mr. Chairman and members of the committee, I am Doctor James J. Feffer, Vice President for Medical Affairs of The George Washington University.

Our School of Medicine and Health Sciences serves as an abundant source of well-qualified medical practitioners for the District of Columbia and its environs. George Washington University medical graduates practice in all the 50 states (Exhibit A) with the greatest concentration being in the Metropolitan Washington area: 434 in the District of Columbia; 374 in Maryland, and 204 in Virginia. Reference has been made to the essential health services our faculty and students provide to the people of Washington. Core programs of care and education are conducted by George Washington University's staff members and students in a number of hospitals-Children's, Columbia, D.C. General, George Washington University, Fairfax, Holy Cross, Naval, St. Elizabeth's, Veterans Administration and the Washington Hospital Center. Elective educational programs are offered at Walter Reed Army Hospital, National Institutes of Health, Armed Forces Institute of Pathology and the Malcolm Grow Air Force Base. Our resident physicians in the University Hospital and its affiliated post-graduate programs number 320 doctors who render specialized medical care to the community. Our training program for Physicians' Assistants numbers 60.

At a time when every effort is being made to increase our output of physicians and allied health personnel, we face the persistent threat of inadequate funds to support our programs. Unfortunately, we cannot continue our present academic role without the resources of this proposed legislation.

The fiscal plight of our School of Medicine is one on continuous operational losses (Exhibit B) that come as a result of conditions beyond our control. Despite efforts to reduce expenses, to effect economies, and to increase income from various sources, our deficit remains about $5,000 per medical student per school year. Our annual tuition has risen to $3,000, making it one of the highest in the country. In the absence of a guaranteed loan program, we have reached the limit in tuition increases.

Our current 564 medical students come from 42 states and the District of Columbia (Exhibit C). With the trend in medical education toward exposing students to clinical situations early in their careers, the students are an integral part of all our service programs. They learn to become physicians by working with patients in the clinic, the hospital, the emergency room and in their professors' offices. All of our community health programs depend heavily for manpower on students, house officers and faculty.

We are in the second year of operating an academic health maintenance organization, a pre-paid health plan that is of benefit to the residents of the District of Columbia regardless of whether they are publicly or privately insured. While this is essentially a community service, it fulfills an important academic model for future practicing physicians.

Through vigorous effort University officials have raised $10 million to match federal funds for much needed and long awaited facilities for the School of Medicine, which became available to us in May 1973. Although capital funding has been completed, we seek the assistance of this legislation for operational support so young men and women can continue to be educated in these new classrooms and laboratories. Expanded programs for physicians' assistants and nurses, and modern postgraduate educational procedures for practicing physicians are important features of our immediate future.

Since 1825 The George Washington School of Medicine has served with distinction as a local and national source of capable, practicing physicians. We seek support of this legislation in order that our School may continue its vital role in the preparation of future physicians to serve the health needs of our community and our country.

Thank you, gentlemen, for the privilege of appearing before you.

EXHIBIT B

SUMMARY OF ACTUAL AND PROJECTED INCOME AND EXPENSE, FISCAL YEARS 1972-73 THROUGH 1976-77 SCHOOL OF MEDICINE AND HEALTH SCIENCES

Attendance at George Washington University School of Medicine; 1973–1974; Geographical Distribution of Students

Dr. ELLIOTT. Then we can proceed to whatever questions you might have.

First of all, let me say that some of the statements made this morning I think need to be amplified or perhaps even corrected.

UNIVERSITY SERVICES

The statement was made from the Departmental representatives that George Washington has been-and I put it in quotes-"giving some thought to the establishment of a clinical practice plan," which the implication being that if it were done, it would help to alleviate our financial problems.

Let me say George Washington University put into effect a clinical practice plan in 1969 which has been refined somewhat since then, but which we believe to be one of the most sophisticated in the country. And judging from conversations which I have had with university presidents who have medical schools under their administration of which they envy us for the progress that we have made in this very difficult area. And a number of them have confided in me that they still have such ground to cover. And I might say that it is sometimes a painful route to follow.

It disturbed me this morning to hear the representative of the Department suggest that we had not come that route, that we are only giving some thought to it, when this has been known, made known to the Department representatives in each of our annual reports and in supplemental reports since that period.

Mr. MAZZOLI. Doctor, at this point let me maybe suggest this. Do you think they have a different concept of what that practice program is? You might be talking about apples and oranges possibly. Or do you think it was an intentional disregard on his part of the fact that you have been supplying that; and it was his intention to look the other way?

Dr. ELLIOTT. Someone has not been looking at the reports that they have been asking for if they do not know about this plan.

Mr. MAZZOLI. Assuming that they do know about this plan, do you think it does not suit their standards for the kind of program they are looking for?

Dr. ELLIOTT. I would no venture an opinion on that.

Next, let me say, Mr. Chairman and members of the committee, that you have heard in the testimony today a number of commendatory comments regarding our service programs in the greater Washington area the Outreach, the HMO's, and all of those things.

In my prepared statement I have listed a number of these but have not tried in any way to be inclusive.

Let me say in answer to one or two questions that were raised, we are committing more of the university's resources now to health care Outreach programs than we can afford to do. We are stretched beyond

our resources.

Let me add, we do not know yet, in spite of all our experimentation— and we are still doing it-we do not know yet how to deliver health care in a satisfactory fashion to the inner-city poor, nor do we as a nation know how to deliver to rural America.

I think a number of us are experimenting. We are trying; we are working hard at it. But if we give the impression that we are resolving or answering this problem, I think we would be misleading. We do not attempt to do so.

Mr. MAZZOLI. Out of curiosity, is one of the ways that you are studying to deliver health care to the inner city and to the rural areas just letting doctors open up offices as traditionally doctors have opened up offices, or is that so completely traditional as to be a discarded concept?

By that then, part of your responsibility then would be to train doctors to open up offices, hang up a shingle, as doctors have done since Hippocrates, and open up a practice.

GRADUATES

Dr. ELLIOTT. I am sure you are aware that around the country where the States have tried to influence the location of the trained physician after he completes his training, such programs as existed in the Rocky Mountain States, which more or less demanded that the trainee return to his home State, these programs have been general failures; because as was mentioned this morning, the specialization which comes after the M.D. degree has been acquired often leads a practitioner to an entirely new location.

To get back to your question, experience seems to indicate that in the final analysis the individual physician locates because of a whole complexity of factors brought to bear on what his objectives are and where he thinks he may best do whatever it is that he at that point, perhaps at the end of the specialty training, selects to do.

And there is no question that this leads to a concentration in a number of areas.

Mr. MAZZOLI. I agree that they locate because they are near a hospital or they locate where they have friends of another specialty and they can work together; but do you think it is possible for a doctor to make a good living opening up, in the traditional sense of the word, an office downtown somewhere like a neighborhood doctor, or do they have to have some kind of unique delivery approach and some kind of storefront mentality? Or do you think it can be otherwise?

Dr. ELLIOTT. I really do not know. I came to George Washington from the State of Maine. When I left the State of Maine there was something like 115 communities publicly seeking services of a doctor. Mr. MAZZOLI. 115.

Dr. ELLIOTT. They were unable to attract a physician who hopefully would come in and hang out his shingle and develop a practice. Some of them were offering rather substantial financial rewards to do so. Very few were successful.

Putting the inner city in the context that you have mentioned, I think this boils down to the individual physician, man or woman, and what he or she feels is the area of service of his or her own skill, interest, and so on.

Much has been said this morning about the dual purposes to which these two schools serve, the national interest and the local community. I think this is the position that both schools will continue to try to resolve; and I do not believe that either school expects to turn its back on local responsibilities, nor does either school expect to become other than a national resource.