DEPARTMENT Or' THE ARM! Office of The Surgeon General Washington, D, C, MEDCH/SI 13 February 1948 MEMORANDUM FOR Subject; Report of Conference of The Surgeon General with Amy Surgeons and Ccorianders of Named General Hospitals 1, There is transmitted herewith f r your information a copy of the report of trie conference of The Surgeon General with army surgeons and commanders of named general hospitals on 15 - 16 January 194-8, at The Pentagon, Washington, D* C, FOR THE SURGEON GENERAL; II • vj • LOi-A'I Colonel, M. C, Executive Officer CONFERENCE OF THE SURGEON GENERAL vrith ARM! SURGEONS AND COM, ANDERS OF HALED GENEIAL HOSPITALS Washington, D, C. 15 - 16 January 19A8 INDEX Tab Subject Page A Address of We leone 1 B Statement of Conference A ins A C The Civilian Consultant Program , 10 D The Consultant Pr ran, First Amy 19 E The Consultant Program, Letternan General Hospital . • • 31 F Special Problems Np Consultants 5A G Administrative Problems in Consultant Program 56 H Atomic Energy 58 I Physical Medicine. .... 61 J Modernization of Equipment . 66 K Residency Training Program . , 68 L General Discussion of Personnel Situation . • • 8A M Procurement Plan 88 N Dental Personnel Problems 96 0 Nurse Personnel Problems , . 101 P Medical Service Corps Problems 107 Q Womens Medical Specialist Corps 110 R Class 3 Inspection & Veterinary Personnel 113 S Hospital Administration Problems , 127 T Influenza Vaccination, 136 U Clinical Photographic Laboratories 138 V Progress in the Development of Airborne Hospitals, , , , * . • 14-2 Final Discussion, , ,,, 145 CONFERENCE OP' TEE SURGEON GENERAL with ARi.il SURGEONS and CQliiiiNDERS OF iLu.iED GENERAL HOSPITALS ■.lashington, D, C, 15 - 16 January 1918 The Surgeon General*s Conference with Army Surgeons-and Commanders of named general hospitals was convened at 0900 hours, 15 January 194B, Room 2CA41, The Pentagon, Washington, D, C, The following were present: OFFICE oF THE SURGEON GENERAL Major General Raymond M, Bliss, USA The Surgeon General Brigadier General George E. Armstrong, USA Deputy Surgeon General Colonel Earle Standlee- MC Deputy for Plans DEPARTMENT OF Tlin, nIR PORCE Major General Malcolm C, Grow, USA The Air Surgeon ARi Y GROUND FORCioS — i Colonel Frederick A, Blcsse, AC The Ground S‘urgeon ARMY SURGEONS ‘ "T nri 1 r ‘ ' 1 ‘ " 1 r ■■■- * Brigadier General Guy 3. Lenit, USA Surgeon,, First Army Governors Island, N, Y, Colonel George w, Rice, MC Surgeon, Second army Ft. George G. Meade, Md. Colonel Myron P. Rudolph, MC Surgeon, Third Army Ft, McPherson, Ga, .h.Ri IY S UliG-ijO H S CG N T, Colonel Robert P. Lillians, IIC Surgeon, Fourth Ft. San Houston, Tex, Colonel Eugene W, Billick, MC Surgeon, Fifth ijny 20 North Rackor Drive Chicago, 111, Colonel Alvin L, Corby, I.iC Surgeon, Sixth Amy The Presidio of San Francisco, Calif, Colonel Floyd V, Kilgore, MC Surgeon, military District of Washington Washington, D, C, GO: TAMPERS OF NAMED GENERAL HOSPITALS Major General George G, Beach, Jr,, USA Amy Medical Center Washington, D, C, Major General John M, .Mills, USA Brooke ray Medical Center Ft, San Houston, Tex, Colonel Harry .... Clark, MC Murphy General Hospital wait ham, Mass, Colonel Leroy D, Soper, MC Tilton General Hospital Ft. Dix, rl. J, Colonel Land L. Liston, MC Ft, Totten Amy Medical Center Ft. Totten, N, Y, Colonel Cleon J, Gentzkovr, MC Valley Forge General Hospital Phocnixville, Pa. Colonel Grand H, Stanley, MC Oliver General Hospital nugusta, Ga, Colonel Asa A, Lehnan, IIC Amy c: Navy General Hospital Hot Springs, Ark, COilAJ-IDARS 01 dHED GENERd HOSPITALS GOUT, Colonel Paul H, St re it, LIC Brooke General Hospital Ft, Sam Houston, Tex, Colonel George A. Royer, mC Am, Beaumont General Hospital El Paso, Tex, Colonel Robert LI, Hardaway, LIC Percy Jones General Hospital Battle Creek, Rich, Colonel Harry D, Offutt, mC Percy Jones General Hospital Battle Creek, Rich, Colonel Edwin H, Roberts, AC Percy Jones General Hospital Battle Creek, Rich, Brigadier General Omar H, muado, USA Fitzsimcns General Hospital Denver, Colo, Colonel Liaxwell G, Heeler, LIC Hadigan General Hgspital Tacoma, Hash. Colonel Dean F, Winn, AC Lettcrman General Hospital San Lrandsco, Calif, Colonel Johm Li, welch, mC mcCornack General Hospital Pasadena, Calif, Colonel Charles L, Kirkpatrick, AC U, S, Ailitary Academy West Point, N, Y, GUEST CONFEREES Colonel Richard Collins General Staff Corps Colonel Henry L, Thomas, MC Procurement Branch, G-l General Staff Colonel Clifford V, Llorgan, LiC Deputy Post Commander Army Liedical Center i/ashington,D, C, Lt, Colonel Schuessler, DC School of Aviation medicine Randolph dr Force Base, Tex, A. ADDRESS OF FELCOME. . . .Major General Raymond F. Bliss Gentlemen, this is still the first month of the new year so I hope that it is not too late for me to extend to you per- sonally my best wishes for 194-8. f think that 1948 will be a crucial year for the Medical Department of the Army. I hope that it will be a successful year,-. But of this I am certain-— the degree to which we shall solve our problems and the extent of our success will largely depend on our understanding of the difficulties that face us and- our willingness to adopt a con- structive attitude in solving them. Te see each other too infrequently. One price that we pay for faulty communication is the uncertainty many of you must feel when you are asked to accept the results of our planning without really knowing whjr we are doing what we are doing. I want to spend the next few minutes in outlining to you three major revolutions that are currently underway, which., before they have run their course, will have a great bearing on the Medical Department of the Army, These revolutions will change it, but in a way, I hope, that will leave us with a- solid foundation so that we can continue to develop. There is a revolution going on within the Medical Department itself. Many principles and practices that were taken for granted in the years past have been suggested for reappraisal in light of our new situation, . Those which have been unable to stand up to this searching reexamination are being altered. Despite faulty com- munication, I am sure that you are well aware that professional • quality is the keynote of our new orientation*. Tre want our., doctors to grow professionally. 7:e want them to practice medicine in the Army equal to the best in civilian life. There are only two standards in medicine, good and bad. The Army is interested only in good medicine. To that end we are currently engaged in the elaboration of our postgraduate training program to which so many of you have already contributed so much. I cannot forego telling you that Dr, Thomas of Johns Hopkins University, at the end of his recent tour of duty, reported to General Paul that what he saw of this program at Brooke—and he saw it all—was equal to the best with which he was acquainted in civil life,. For a program scarcely more than a year old this was high praise indeed, Fe cannot all become orthopedic surgeons, dermatologists, or cardiologists; but each member of the Medical Corps can and will, grow v/ithin his field of concentration. To this we are now moving from the exploratory to the operating stage in our career- finding program. As far as is humanly possible—and that is quite far—we hope to take all the necessary action that will contribute to a young man's professional development. And this time I use "professional” in the broad sense of the term. It includes the future clinician, administrator, or expert in preventive medicine. 1 Since you represent the administrative leaders of our Corps, I think it might be well for me to stress that in the future we hope to make it possible, for a man’ to go to the very top of the Corps without being forced to shift out of his 'medico-military specialty. Moreover, we plan to devote much greater efforts in training of our medical administrators. One more word on this point, We are about to reappraise the relations-of our hospital commanders to our professional chiefs. The details must still be worked out. Our second revolution bears on the change in relation of the Medical Department to the Army, It is no secret to you that for •many years the operations of the Medical Department have been seriously hampered by the cumbersomeness.of the {military structure within which we operate. All I can tell you is that the present high command is very sympathetic to any and all plans which we shall submit to alter, these old arrangements in order to heighten the efficiency of medical operations. We need to have greater technical control over our medical means, We are-.short of men today. As time goes on, we shall be much shorter. Fe must devise plans to use every doctor to the fullest extent on professional work, and have enough of that to keep him busy. If we- do that, and I'm sure £hat we can, we shall not only reduce our requirements by a substantial amount, but we shall add to the morale of the Corps by providing opportunities for a man to be professionally busy all day. If we do that, we shall also be making a contribution to procurement; for many doctors, the kind we want most, will not come into the Regular Army unless they are sure that they can live a full professional life, I cannot tell you in detail how we plan to accomplish this particular objective of redesigning the pattern of medical care. But I can give you one indication of the lines along which we are thinking. During the war, v.re made one effort at area ..hospitalization, ,i!;e called it the regional hospital plan. But it was a’rather static approach. We simply designated various facilities for various purposes, and instructed the hospitals in the- areas to transfer patients accordingly. Of course,'we reflected differences in missions in our staffing, 'This was the beginning, but T think we can and must do much more., t, I .■believe that every doctor in-the Army must' have a hospital as his base. Tie must belong. If he is assigned to an out- lying dispensary, it does not follow that he must remain there all day. Perhaps, two hours in the morning with a nurse on duty all da.y will be ample. There is no reason why he should not return to his hospital base after his dispensary hours have been completed and work-in the hospital for. the rest of the day. Similarly, if there is a station hospital like Belvoir, some 15 or 20 miles distance irom a general hospital like Walter Reed, there is no reason why the young doctor assisting in ophthalmology who sends his more difficult cases to the general hospital, should not be able to spend two or three half day’s a week on the opthalmological service of the, general hospital, following up his .old patients' and benefiting from the clinical experience which would be his as a 2 member of a service in a general hospital. Of course, such a system will necessitate an area medical officer who will have control over all medical means in the area. The.Navy has just developed an organizational arrangement in which The. Surgeon General has- in-,each'.area a personal representative who, in addition to controlling all medical means on behalf of the Bureau of Medicine and Surgery in Washington, also serves on the local commander’s staff. We in the Army hope to profit from'..this. I may add that, in the deliberations of the Forrestal Committee on Unification, each service is trying to profit by adopting the best that the other service has evolved. That is one sure road to successful coordination. Of course, we are pursuing many others. The.third revolution currently underway relates to the changes which have already come about and those that will still come about betweepsthe Medical Department in the Army and the civil medical profession. The day of isolation is over. We are not self-suffi- cient, we cannot be self-sufficient even if we wanted to be, and we should not want to be self-sufficient. The Army belongs to the people. Army medicine is a branch of American medicine. We have been the fortunate recipients of the most valuable assistance from the, civil medical profession, especially from those leaders who served with us during the last war. It is only necessary to call attention to the Medical Advisory Committee to the Secretary of the Army, the Medical Consultants Society of World War II, and the many individuals who served as consultants to my office and.to your offices; but most important, to the many who are acting as attending physicians at our larger hospitals and who are carrying so large a part of our crucial postgraduate training program. We have every reason to be proud of the Army Medical Department and what it has accomplished in the past and what we all hope it will be able to accomplish in the future. We all have reasons' to be concerned about the continuing welfare of the Medical Department, It is my considered opinion that .by integrating civilians in our work and by the civilians integrating us in their work we can strengthen the Medical Department of the Army and American medicine of which it is a part and together grow stronger and stronger. I may tell you that medical schools have already begun to add some of our men to their faculties. By reforming ourselves, by reforming our relations with the Army, and by reforming our relations "with civil medicine we are laying a solid foundation. No matter‘hov; trying the situations that we shall be forced to face during the coming months, when the impending personnel shortages will be a problem, no matter what our other trials may be, we must not weaken this foundation. For if the base is strong the .structure to be erected on the base will endure. I am sure that everyone of us is committed to making the Medical Department of the Army as strong as possible so that it can continue to serve with distinction. 3 B. STATEMENT OF CONFERENCE AIMS....Brig. General George S. Armstrong Gentlemen, I am very happy to see all of you. I apologize if I more or less stick to a little prepared script this morning, something which I do not ordinarily like to do, but I am doing it primarily because of the time element. The aims of this conference are manifold. The chief aim, of course, is to bring together your thinking and ours in such a way that our approach to the current problems of the Medical Department is more or less standardized. The policies of The Surgeon General and the Medical Department today are at wide' variance with those of a few years ago. I think I am safe in assuming that the bulk of our personnel are familiar with these new policies. Our problem, yours and mine, is to see that those policies are known and carried out by every person in the entire Medical Department. The success of any organization depends not on the formulation of policies at the top, but in their complete and thorough dissemination and then finally their ultimate utilization. Conferences, such as this one, as The Surgeon General has said, should be held more frequently. But frequent conferences are not expedient. Fence, we shall try to compress into two short days the material we should take weeks to discuss, and undoubtedly many important subjects will not even be touched on. Even so, it is expected that the agenda are such that some time will be given wherein you may visit the divisions of the office in connection with those problems that are peculiar to your bailiwick and not of general interest. By the way, our- key people in the office will be here on Saturday morning. As you will note from the agenda, a great deal of emphasis is placed .on what we consider our two most pressing problems; viz, the consultant program and personnel procurement. The former is impor- tant because of the dependence which of necessity—and choice, I might add—-we are placing today on our civilian assistants both for the care and treatment of patients and for our training program. Our consultants must, for many reasons be employed most carefully. In the first place they must be employed economically,•as you will learn later in the' conference; although we have a tremendous sum.of money set aside for the consultant program it is not enough to warrant ill- considered use of the consultant services. Secondly, the importance of the consultant in our teaching program is such tiiat he must be looked on as any other attending staff officer and must be trained to. accept and to fill a veiy personal responsibility for his part in the hospital activities, whether the latter be at a station or gen- eral hospital, I will not take up more time on this subject, as we have several other speakers who will elaborate upon it. The personnel procurement problem is an extremely grave one. If you could know the man-hours that are being put in, attempting to arrive at the solution of this problem in this office, you would be thoroughly amazed; and yet, with all the plans that may be formulated 4 here, the answer to the procurement problem is in your hands. No amount of printed material or press releases or personal letters will draw the personnel that we desire and so vitally need. Person- nel can be obtained only by personal contacts. I am very firmly convinced of that, '.Then an individual, for example a doctor, be he a recent graduate of a medical school or a professor of medicine at Hopkins, like my friend Doctor Thomas back there, comes to The Surgeon General's Office to make inquiries about an Army career, everything stops, and everyone from the most recently hired CAF-2 up to General Bliss gives this.individual his undivided attention. He is person- ally hand-carried from office to office, with pep talks from consult- ants, officers of the procurement Branch of the Personnel Division, and finally The Surgeon General or his Deputy, whichever one happens to be free at the moment. Yet too often this same doctor has been on duty, day after day, week after week, perhaps for months or even for a few years in an Army hospital without any one ever having talked to him about a military career. We hold conferences in this office to which are invited representatives of your installations and organiza- tions. Days are spent discussing procurement problems, directions given for programs and propaganda, and weeks later we find lieutenants in your organization who do not even know that an ASTP with six months' active duty pan make application for the Regular Army. I remember at a conference of general hospital commanders a little more than a year ago, when several of you were here, I was asked to make some impromptu remarks regarding procurement of medical officers. I cited the example wherein the young officer reported to a general hospital and was treated in exactly the same manner that I was treated twenty years ago, an interview with the executive officer, opportunity given to express a preference of the type of service desired for assignment, and the young officer was then promptly informed that he was being assigned to an entirely different type of service, without any expla- nation as to whys and whereforef Gentlemen, this does not procure personnel for the Medical Department today. Every officer, including those in the Medical Department, must be treated as you- and I would like to have been treated twenty years ago. It is a new deal whether we like it or not, and the approach of men like General Willis on ray left is *the only hope by which I think we may ever expect to attain our goal. Every officer, regardless of the corps, and I dare say almost every enlisted man who reports to Brooke Army Medical Center, is very promptly and personally interviewed by the commanding general of that Center. The man or woman is allowed to discuss freely his or her thoughts regarding the military service. Every opportunity is given to express preference and every opportunity is taken by the commanding general to attempt to solve the medical problem,* but that is not all. This same gentleman, and I trust you will pardon this personal reference, does not satisfy himself with the initial personal interview, but from time to time sees these same individuals, espe- cially the younger ones, to discover if they are satisfied with their services and whether or not anything can be done to make their per- sonal or professional life more pleasant and attractive. Gentlemen, 5 this is not a purely Medical Department problem.• It is a part of the changed times, and personnel handling and .personnel procurement must be personalized whether you are dealing with'Medical Department per- sonnel or the'employees of General Motors, Too often wo hear stories, many perhaps unfounded and many unquestionably true, wherein the doors of the commanding officers are closed to all but the key members of the staff. Not long ago a young officer of the Regular Army Medical Corps on duty at one of our general hospitals initiated a letter of resignation. It left the hospital bn its way to the Adjutant General without one single soul calling the officer in and discussing the resignation with the view to discovering and removing, if possible, the cause of his action. This means that the chief of his service was not sufficiently inter- ested, it means that the executive officer was not sufficiently inter- ested, nor adjutant, nor the commanding officer. The papers were for- warded over the signature of a warrant officer who treated the paper as he would a routine requisition for supplies. The holding of the people that we already have in the regular establishment is an even more important part of our procurement program than is the bringing in of completely new and untrained recruits. We have discovered that perhaps our most important and valuable, if not our only important and valuable, instrument by which we may hope to attract young officers, particularly in the professional corps, is our professional training program. Rightly or wrongly, one-sided or not, this is a fact of which we are convinced in this office. This means that all of us must look to our training program not only in our teaching general hospitals, but also in every medical installation which we .operate, A station hospital or dispensary may and should become a'training installation. This means,that the concept and impor- tance of training must permeate down through every small tributary of our entire medical system, A training program not only offers our best procurement induce- ment, but at the same time it stimulates and elevates the standards of medical service throughout the Army. A young major who attempts to use clinical material which he has in a dispensary for teaching pur- poses learns just as much or more than the young lieutenant whom he is endeavoring to teach. While I am on the subject of teaching and elevating the standards of medical service, there is another phase of medicine from which the profession is straying far afield. This is a problem which affects civil as well as military medicine, I am referring to the lack of appreciation by young doctors both in and out of the service of the importance of the art of the practice of medicine. I can remember as a. boy that my grandfather told me that in.his opinion the art of medicine was ninety-five per cent, the science five. With the increase in technical knowledge I am sure that the latter figure no longer obtains. It is far greater but there still should be a tremendous importance placed on the art. This problem lias 6 been discussed With various medical educators, and they agree that the blame should be placed on our medical schools. Be that as it may, we have in the service today several thousand doctors who have not the slightest concept of the proper•doctor-patient relationship. As I go about the country I am constantly encountering examples of the failure of young doctors, and I might add that in some cases the older ones, to treat the patient as an individual and not just as another ’’case,” And that is particularly true with the emphasis being placed on training, I was down at Ft. Monroe the other day and Colonel Blesse had just run into a couple of examples. A young doctor invited a young lady into the pre-natal clinic. He looked at her record and her weight that the nurse had just taken and found that in- stead of losing three pounds that she had been instructed to do the month before she had gained three. He threw the record on the desk and said "get out, you are not following our directions,' we want no part of you." Now George Reyer brought up a case just yesterday, A call from a sergeant* his wife had just had an accident, and she was bleed- ing profusely about the face. It was 4:30 and the young man said "call back at five o’clock, the OD will be on then and he, will come out." Those are examples that you are all encountering every day. It is a problem which is very difficult to correct. The long range correction depends on the examples set by the more mature medical officers. The short range corrective program should include frank,discussion of the matter by commanding officers with their professional staffs. If the commanding officer feels that he has some one more able to discuss it, as, perhaps, the chief of one of his major, services, by all means delegate the job. But some one should, from time to time, take time out to emphasize the importance of the doctor-patient relationship. General Bethea, in a bulletin not long ago, put out a very fine paper on this subject. It was written by Lt. Colonel Bauer, He emphasized the fact that patients should be seen every day by some one. We are not doing that. The chiefs should see them regularly too, as often as he can, perhaps once every four or five days or perhaps once a week. But patients should be seen. If you are not doing anything for the patient, tell the patient why nothing is being done for him. Don’t belittle other installations and other doctors in front of the patient. See that your senior officer doesn’t bawl out, as we say, the' junior officer in front of the patients. The same, by; the way, applies to your staff conferences, as I understand that the..practice obtains irksome places. There are many other phases of this matter. We have tried to think of a way to get it on paper and get it over to you, and decided in favor of bringing it up .today. It is something that we strongly feel you should pass on—I am speaking particularly of .the Army Surgeon—pass on to your post surgeons, and see that sometiling concrete is done about it today, and then see that it is emphasized from time to time-as is necessary. , There are various other ways by which the service can be made more attractive. I have already emphasized the importance of the personal 7 contact, particularly on the part of the commandersj and the importance of its follow-up, Secondly, the staff should be kept informed as to what is going.on not only in its particular installation, but in the Medical Department aS a whole. Now we realize that too often the latter information does not receive sufficient dissemination in this office. This we hope to correct. But when- we get the information to' you gentle- men wo expect that it •will promptly go on down not just within your own office, but; to every individual .assigned to your installation or to any installation within the scope of your responsibility. A constant and a thorough check should be maintained by all opera- tors to assure that no administrative task is being done by profession- al individuals that properly could be done by administrative personnel. Incidentally, the other day we had word, George (Rice), that one of your posts had been cut greatly in its Medical Service -Corps personnel just as they had-plans to take over a lot, of duties which have been done by professional men. We discovered-that the Medical'Service Corps was the only corps in your area on which we were not controlling your allot- ment, from here, so that will not be an excuse in the’future. -Your cut wasnjt sent from here. No blame on anybody, and we'll try to get it rectified for you. Next is the matter of rotating personnel in the performance of mors mundane tasks. We recently had a letter from Bob Hill* He gave the most beautiful picture, and a very drab one, of the personnel procure- ment _ situation at Ft. Banning today. No fault of the Army Surgeon, no fault of Bob Hill's. I won't say where the fault ist Ai any rate, they are insisting that his officers do a lot of duties which to all intents and purposes could be done by well-trained enlisted men. You know, those of you that have served at Benning and the other service schools, they want -doctors out on every little problem, etc. I am-not speaking of the times you send out troops to take part in a tactical exercise.. Now the- approach to that, if you can't sell the commander on the economy of force by sending an enlisted man that's well-trained to do the job,' is to explaizi to your junior officers why it'.s having to be done, and then rotate, the thing and not make the same individual do it day after day, and week aftpr .week. Another thing is the matter of your men in the dispensaries. As-mentioned by General. Bliss a moment ago, we're trying to build up the concept of a medical center at each post, and, if it is possible, to operate your dispensaries by men assigned to the hospital so that it's a part-time job. That's the idea. If you can't then by all means rotate them, I agree with your thinking that a man learns more- medicine in a dispensary than in any other place. It was my experience, and I am sure that it was yours. But that's not the way these lads feel about it today. The dispensary still must be operated. Therefore, we must do it in such a way that will keep these lads- the happiest that we can make them under the situa- tion with which we are now dealing. I rather doubt that we shall have time during this conference for any prolonged discussion of our reserve problems. They are most vital, and should receive the utmost consideration by all of you and by your assistants. The importance of stimulating medical personnel of all categories in our reserve program is one of our biggest challenges today. Various officers in The Surgeon General’s Office have been working for months on concrete plans that may give us something that ■will interest the busy and the worthwhile civilian personnel whom we should like to reach. Your officers are working, too. For the first time, Reserve and National Guard officers are in attendance this week at our course on medical aspects of nuclear energy. This is one of the fields of great interest to civilian doctors particularly—one which we should exploit to the highest degree. Those of us in the office are thoroughly sold on the soundness of our current program. If you are not sold I believe it is because you are not sufficiently familiar with it. That, then, is the chief aim of this conference. To let you know how we are thinking and what we are ■chinking, with the idea that when this is accomplished you will go back imbued with the spirit of passing on to others what we are trying to pass on to you. 9 C. THE CIVILIAN CONSULTANT PROGRAM. Colonel Frank L. Cole- General Bliss and gentlemen of the conference; I have a few things to distribute to you before we start the actual discussion. Here is a list of all consultants that have been appointed in the office. I should like all of you to have it. And these two lists have been com- piled by the Education and Training Division from information which they have obtained from hospitals, on which I will speak a little later in this talk. But I should like these distributed now. The subject which has been assigned to me as you have seen on the agenda is MThe civilian consultant program.” The civilian consultant program, as you may or may not.know, was planned, at least the plans were started, in the latter part of 19-45. In the beginning of 194b, these plans became more concrete, so that we wore at that time beginning to appoint a certain number of civilian consultants* This program was originally instituted because of the success which had followed the use of expert professional consultants during the second World War. As you all know, following the war we lost a groat number, in fact all of our high-powered civilian consultants, I mean of our civilians who were in the Array and were acting as Amy consultants, and as the result of that it was necessary for us to build up a civilian consultant program out of those men who had had service and out of other men who had been recom- mended to us by the Civilian Consultants Society. Following this meager start in 1945 and going on into the early part of lc'46, in Day and June, we began to appoint those consultants. There was considerable confusion, naturally, as to what their duties were and how they would be integrated into our Army hospitals. Also about that tine there was being promul- gated the residency training program. Now this residency training program and the civilian consultant program are two programs that we feel must work hand in hand in order to attract young officers who nay want to make the Army Medical Corps their career. Following this, we began to get a number of applications for appointments as consultants. And this program was gradually built up until the beginning of 1947, when the actual residency training pro- gram went into effect. By that time we had sot up in all our hospitals, all our training hospitals, a good many of our station hospitals, and in all our army areas, a pretty good nucleus of civilian consultants. Mow these consultants are to assist in the treatment and care of patients and will have several functions; one of them of course is to assist in the care and treatment ,f patients. They are the bulwark, so to speak, of our consultant program; so that whenever problems come up with respect to patients we can call in these consultants, or the con- sultants can treat the patients when they arc making their regular rounds through the hospital, so that all our patients should be covered with a very fine lino of expert medical attendance. Mow the next and another important duty of these expert consultants is to assist in the residency training program. As you knew, when the residency training program was set up, it was done with the idea of getting as many men through tfro specialty boards as possible, so that wo could carry on our program under our own power rather than roly too much on our civilian consultants. We have felt all along that this civilian con- sultant program may not hold out too long, because it depends entirely on appropriations from the Congress, However, up ’to the present time, our appropriations have been ample and we are still able to carry out this program, and, as far as we know, we’ll be able to carry it on ±\-r a considerable tine. In the residency training program, our consultants are to act as teachers and adviser operators, if necessary, make ward rounds, teaching rounds, in order to instruct and carry m the program that is outlined for the training of our men in residency and also for the interns and others who may be taking refresher courses. Now the present outline of policy is covered in a general way in Change, 5 of AR 40-10, which cams out 21 October 1947* That's a revamping of the original Section III of WD Circular 101, which came out in 1946. We have consultants set up in every specialty that is peculiar to our hospitals. Wo have surgical, medical, and all the various subspecial- ties throughout the medical set-up in our specialized hospitals. All hospitals do not have all the subspecialties set up, f- r the reason that' they do not specialize or do not have patients in every class which may be represented in those subspecialties in medicine. We have three classes of consultants. Headquarters or SCO consultants are the ones who work in conjunction with the offices here in The Surgeon General's Office. We have army area consultants. They are appointed for the surgeon of the army area and through him are used throughout the area in the station hospitals. In some station hospitals, for instance at Bragg, at Knox, and at Benning (large station hospitals), we have con- sultants who are appointed locally for those particular hospitals. How- ever, these consultants are all appointed to the army surgeon of the particular area, although they may be set aside for particular use of that station hospital near which they reside. However, they are under the direction of orders of the army surgeon and to be used any place in the army area where that army surgeon wishes to send them or the con- sultant 'wishes to go. In some instances we have run into difficulty in the army areas sending, or having moved by the army area surgeon, a consultant from me city to -a distant place because the consultant feels that it's too far away and he can't spare the time. But fortunately those cases have been very much in the minority. Most of these con- sultants have responded most graciously to every call which has been made on them. ■ ' • • Then we have the So-called teaching consultants or consultants assigned to our general hospitals. Originally when the residency train- ing program was set up, as you know, we set it up in practically all of our general hospitals.. After a year, we found this program could not be carried on successfully in all of our hospitals because of local conditions which prevail, ver which we have no control. So, beginning the first of this year, that is the first "of January 1946, this resi- dency program was curtailed to five general hospitals that we- now designate as our teaching hospitals. Now the consultants wno are 11 assigned to those teaching hospitals have multiple,; duties to perform. In the first place, they are the teaching consultants. They are the . ones on whom we are relying to teach and train and guide our residents who are training. They are the ones on whom we are relying to get credit for these men for their board certification. I think most of you realize and know that, before a man is eligible to take the board examination, it is necessary for him to be .trained in a recognized hospital that is accredited by the particular specialty board, bo it is necessary that the hospital be sponsored and have on its staff regularly assigned board members of the particular specialty our man is to be certified in. I am going over this rather hurriedly because our time is somewhat cramped. There has been some confusion as to how these consultants are to be appointed. So I; would like to take just a moment to clear up this point. The consultant is recommended by the army surgeon, if it’s for an array area, writing to this office and stating that he has a gentle- man by the name of John Jones, or whatever it nay be, whom he wishes to have appointed as a consultant to his army area. In this letter, the array, surgeon should give the man's background, his name, address, train- ing, education, and so on, and the particular board in which he is certified. When these names come in here, they are cross-checked, and we try to obtain from our contemporaries on the civilian consultants committee, the committee which is made up of consultants of World War II> an opinion as to this man's ability and what they think of him. Many times this is not entirely, necessary because these men are outstand- ing and do not belong to the organization to which I have referred. However, these names are gone into very carefully, and the backgrounds are carefully checked, and then from .this office an, invitational letter is written to the man, his Form 57 is sent, and he is asked to•fill in that form and return it to this office. And in the letter it is stated that he has been recommended by the army surgeon in a particular area for assignment as, a consultant on his staff. Now the same thing holds true of the general hospitals. These names should be submitted by the commanding officers of general hospitals through this office, giving the background of the individual, and from this office the papers will be sent to the man, and he will be invited to become a consultant. If that is not done, and in some cases it hasn’t been done, the papers have been sent directly from the hospital to the man, and the next thing we knew here came the application with the man’s papers. We may, in checking over our files and checking back with this consultant's society, find out that that man is not particularly the man that should be appointed for that particular position. In other words, he is not recommended as a consultant. Then there is an embarrassing situation, because the man has already been invited to come in; he lias filled out , his papers and sent them in, and we have to v;rite him a letter or write back to the commanding officer and ask him to write a letter and tell the consultant that unfortunately.circumstances do not permit, at this time, of his being appointed a consultant. Not; as to assignment of the consultants: Consultants appointed to army areas are assigned and under the direct use and direct super- vision of the surgeon of that area. He usually uses then as he sees fit, sending then on trips to go around and visit his station hospi- tals, and he nay send then very ■ fton. He nay send then to investigate particular problems; he nay have something happening in.one particular hospital that he wants investigated by an outsider; he has his con- sultant when he can send in there and make a report for him. The consultants assigned to the general hospitals arc assigned by this office, be write a letter, when the nan has been appointed, and say that this nan has tyeen appointed and that he is new ready for use by your hospital or army area. The salary of these consultants as you know is $50.00 per day, plus .six dollars per dion for travel. There has been some question recently on this six'dollars per dien, I think it was brought up by Colonel Gorby yesterday, and we have the answer for you Colonel Gorby, which we will give to you later. Now there are a few deductions that arc made on this $50,00 a day, so that, when a consultant asks you how nuch money he is going to get, you can tell him that ho is going to get $50,00 a day, less certain deductions which are mandatory by law,* These deductions that are mandatory by law are; that a man can only work so many hours a week, and that he can’t work a full seven days a week as most doctors do, taut under Civil Service Regulations ho can only work five days a week. We run into this when we use our overseas consultants. Sc, for the time being, most of these consultants are not used for a length of time longer than five days, unless they are on some special mission <_r some overseas mission or something of that kind. But our consultants in this country who are assigned to the army areas and who are assigned to general hospitals rarely work over five days a week, Now.it has been General’■ Bliss1 recommendation for a long time, and we have tried to! got this into operation and I think in some instances it is in’ operation, for the appointment of one consultant in each major specialty to act as the coordinator for that group, I am sure this can be worked out very satisfactorily in the general hospitals, I think in the general hospitals it will be no trouble at all to have your education committee designate one officer who will act as the coordinator or tho. chief consultant or whatever you want to call him for tho group—for instance, the surgical group or the nouropsychiatric group or the medical group. In army areas this is going to be a little difficult,.especially in areas that are large and areas in which the population is centered in certain centers. For instance, we’ll take the Sixth army Area, and I have talked this over with Colonel Gorby, He has three centers of population; one in the south, one in the bay area, and one in the north, I think it would be impractical for him tfc appoint one man for his whole area who would be the coordinator of consultants for the whole specialty which he represented, I think perhaps he should appoint one in each one of 13 those groups—one of these crons .perhaps, if ho could, but I think it would bo an impractical thing.; for hin to appoint a nan in medicine, say in San Francisco, who would coordinate the nodical activities of tho ones up in Seattle. That nay be true in other amy areas. How- ever, in tho closely knitted amy areas like the First, I think it could be worked out very well sc that one of these'coordinators could be sot up fur each specialist group. If this nan is appointed, and in many instances he already is appointed, and wo are hoping that he will be appointed in all general hospitals upon your return, this should be carefully considered by your education comittoe at each hospital. Let your consultants pick cut the nan, with the advice of the commanding officer, of course. It nay be, and I think it probably would be, an excellent idea to rotate these people and not put one nan in and leave hin there' forever; because we realize, and I an sure you gentlemen knowj that there are petty jealousies among these con- sultants, If the consultant is appointed as the chief consultant or chief coordinator or whatever ycu want to call hin, it nay set up a little friction and little jealousy among the other consultants unless this is done by tho Consultants themselves or unless they are well re- presented on the committee which does have tho final appointment of this nan. If that is done, then I think you will have no trouble, and they will have no reason to flare back at the commanding officer because he picked out a certain nan to act as the coordinator of con- sultants , The question is brought up from tine to tine as to how the money is holding out on these consultants, and I have some charts that have been prepared by Colonel Duke’s division after he obtained a great deal of information from the hospitals. And here is an analysis' of the obligation fur consultants for tho fiscal year 1947, that is, up until the end of last June, As you will notice beginning in January-— that’s when we started this consultants program really with a bang— the amount of money spent went up very fast. These represent tens of thousands of dollars, and finally, when we get it all totaled up, we have spent at the end of the fiscal year $229,345 on the pay and, travel of consultants. New in the general hospitals this represents 478 consultants; the station and regional hospitals, remember, are not re- presented here. The‘Army Medical Center, the army Institute of Path- ology, etc.,, $22,015.20. For department consultants, that means for consultants here in The Surgeon General’s Office and the activities iconnected therewith 343,000 and then on down the line. Notice that the amount spent' for consultants in the fiscal year ending last June 30 was 3424,Bl2, and we had appropriated" $92 4,000, So ycu see we fell far behind spending all the money that was actually appropriated for the number of consultants ..during that year, This year, sc far, we have $9000,000 appropriated, for the use of consultants, and for the first five months of this fiscal year up until the end of November we have spent 3299,000 or approximately one-third of the total amount which has been appropriated for. this fiscal year. In addition to this, however, we are establishing now, beginning this month, overseas con- sultants. We are trying to send, and I an setting up now, these teams to go over, and we expect to send at least throe consultants each month 14 to the European Command and as many as we can get to send to the Pacific, We won't have three each month for the Pacific but we will have three in perhaps alternate months if we can get that number to go, /aid that's going to make a great cut into this amount of money which has been appropriated; but sc far we arc well within our appropriation. If we, in five months, have spent $299,000, practically a third of our money, we are still well within the amount which was appropriated for the whole year. But with this overseas consultants deal which is going on now, it's going to boost up the amount of money spent for consultants many tines over what it is now, 'The time is running out, but there arc two things which I an very eager to present to you, and those are the two sheets that were distributed to you in the beginning of this talk. On one we take the consultant activities for the f.. ur teaching, Amy general hospitals. For four teaching Army general hospitals (it was only from four teach- ing general hospitals that the information necessary to compile this was obtained) this is the breakdown to show' you how these ccnsultants are used and the amount of time and so on that was devoted by each one of these consultant groups to the particular specialty involved. In medicine we have fifty-one consultants, and the number of visits from the first of July, i.e., for the first six months of this fiscal year, were 1,313. I am just going over part of this, but I want to go over that much to familiarize you.with it, and then you can study it at your leisure. In medicine, the average duration was two and a half hours; in surgery, four and a half hours; anesthesia was ten hours; neuropsychiatry, five b urs; radiology, only two hours; and pathology, two hours, -New what wo arc endeav. ring to put over to you gentlemen at this conference, so that you can take it back with you after you have studied this, is the amount of time which your consultants are putting in. You will find that in a large number of instances, your consultants are not putting in enough time in the hospital, Nov; I have gone to hospitals, and I believe that this ispJt peculiar to any' particular hospital, I think it is peculiar to most of cur hospitals. There is a great deal of-time spent by ccnsultants in going over the niceties of the day. Sitting there talking about the party they went to and so on, and then finally they come around and say, "ViTcll, what are we going to see today,1' and the chief of the service or the section says, "V/ell, I have a couple cases up hero .I would like you to soo," So he'goes up and sees those two cases, and that is the end of the visit. Now that is not What wo consider an ideal use of, consultants, Those ccnsultants arc men of high repute in their neighborhood, high repute in their district and cities-,' men who are leaders in medicine, and we want these men to be used for the. prupose for which they were appointed, I feel that in many cases they arc not used to the fullest extent. In this chart you will notice that in many of these instances these men are net used to the. full extent. Then, if you. go into the next column of the general activities of consultants you will find the number of Ward rounds; in medicine, 885; surgery,!,201; anesthesia, 110, Anesthesia I think can bo excused from ward rounds because their work will net be on -wards. Their work will bo in an operating room, '{■ i , . . 15 Neuropsychiatric, 291. Radiology and pathology of course would not require ward rounds. The number of lectures in medicine was 186; the number in surgery, 366, and so on all the way down. Now what ¥fe should like for you to do is make a shift in this from the number of didactic lectures, for instance, except those that are required, to increase the number of teaching ward rounds, T/e feel that most of these men in training get their greatest help and their greatest amount of knowledge fr-n teaching ward rounds. Now werdon't moan by that that all talks and didactic lectures should bo abolished. Far from it. But we do feel that there should be a definite shift from the didactic lecture in favor of the teaching ward rounds. Now as to the'number of conferences—those conferences are very valuable. These conferences can be very !■. rial or they,can be very informal. But I think an infom conference in which the residents and staff are breught together and cases are discussed informally with the c-. nsultants and with the staff is an excellent way of teaching. The number .of operations of course, will be a variable one and will depend on the ability of your chiefs of surgical service, on the ability of the men on his staff and his sections, and .also on the number and type of severe operations and so on v/hich are performed in that particular hospital. So that is a variable and need not be paid much attention. However, there was a question brought up in our questionnaire that was sent out. It asked;’ "Can consultants perfprm operations in hospitals?M Of course they can. Consultants can perform operations in hospitals. That's one of the ways of teaching, and that's one way of treating patients. There shoul be no hesitancy, whenever the chief of the surgical service or any of the sections of surgery is in doubt as to his ability to perform any operation, in calling on the consultant apd asking him for help. Not/ the estimated value of these consultants and so.on in the last column, the one on the right; you see the estimated value is excellent, good, and poor. And you will find them as listed in this column, , On the other sheet, aro consultant activities again. These are the cost of consultant activities, which have been ,figured out by our fiscal division that ma.de a breakdown of this chart. You can see ffpm this exactly what your consultants-are costing you. You can see from this the average duration of the visits, as we had on the other chart, the number of ward rounds, number of lectures, number of con- ferences, number of operations, arid other activities. Then you have ah: estimated value of the consultants over' hero on the next to the right hand column, which is an evaluation that was sent in by you gentlemen from your hospitals. NowLyou.will sec that some of these are marked excellent, some are good, some on whom wo had nq record, and some arc marked poor. As to'those-consultants who aro marked poor and on whom you render a report that they arc poor: when it comos to reappointing those mon next Juno you will all bo sent a letter to recommend consultants whom you Wish to reappoint for the next fiscal year. That’s the time to drop these people. Just drop a letter to this.office and.state that the following mon as consultants arc recom- mended for reappointment and the others arc not recommended, and then we can drop them and not reappoint them. This is a hurried summary of this because;our time is running over-and the discussion will come up on these points later. niSCTTSSJOU lEAEThT PIj.SS; I would like to say something at this point w? th reference to Colonel Cole's discussion. v-e had a bill in the last Congress that would oermit us to enroloy civilian consultants the same way that-the Veterans' Administration does on a full or part time basis, he are going to ask for that legislation again. I think it will solve some of our administrative difficulties if we're able to nut men on salaries rather than on ',.*10.00 a day, and it will Probably be a little cheaper. I think in the main that the consultants that we have are actually an attending staff, I think they should not be considered primarily as con- sultants but rather, particularly in the hospital, as attending surgeons and attending Physicians, houghly sneaking, during the war we had a full time, competent staff in each hospital, without any attending men. Civilian hospitals very generally throughout the country have no full time men except their interns and residents. It 1s somewhere in between that wo must get, so that our men coming to our general hospitals will, in fact, correspond to the attending physicians and attending surgeons as they operate in civil hospitals, I think our consulting service can be exemplified, perhaps in an example, again in obstetrics, that we had in one of our hospitals recently, Tt was an obstetrical service which was rather extensive in numbers of deliveries a month, and that hospital obstetrical service was and is in charge of o man who had had only a rotating internship and who desr'red to do obstetrics. Fe is doing that. lJo has, or had, no particular supervision. TJo is a mood man, there isn't anv Question about that at all, and he is grind good work. However, to Place a young man like that in charge of a fairly largo obstetrical service, or any other kind of service without super- vision, is not good medicine, according to present day standards. Now our conception is that, in instances like that at our hospitals, the service should be in charge of, or supervised by, a competent man, whether it bo one of our men or whether it be a civilian con- sultant. This does not moan by any means that the civilian con- sultant should come every day to the hospital, but he should be so much in charge of that service that he can satisfy himself that the service is being carried on properly, and the staff is performing according to the best standards, and he will be avail able when necessary, too, for any emergency calls. One other program which I wish briefly to discuss is our Plan to send consultants to the overseas theaters. As far as Europe is concerned, we are now planning to send three consultants a month as a team. One of those men, Incidentally, will be either an Army, or a Navy medical officer, qualified—that especially. 17 Those tears will go to about fifteen hospitals in Europe. They will two or three Hays in residence at each hospital and will act in two or throe ways. ' will certainly stimulate the young men who arc "on duty in those hospitals, The young men • will, be expecting them and will have their interesting lined up. In a way they will constantly- be supervised, for they will know that once a month they will bo visited by three leaders in medicine, furthermore, we are arranging, and I think it probably has boon oretty well consummated now, with the various specialty groups and the American Medical Association, that a certain amount of credit mil be given to our young men because of the visits of these consultants. You knoY/, they are all interested in having their work recognized, I just wanted‘to interpose that between.Colonel Cole’s and General Genit’s discussion. I). THE CONSULTANT PROGRAM, : ' • • FIRST ARMY...,, ...Brigadier General Guy B* Denit Our friends in The Surgecn General’s Office have been good enough to say that the civilian consultant program is working exceptionally well in the First Army, Now, if that be true, there must be some reasons for it, and since my predecessor. General Ualson, had initiated this program, I thought it was up to me, before talking to you, to analyze tne reasons and give them to you for what they are worth. Now, somebody has already said, for any program or any cause to be successful, there must be a firm belief by tne leader in that cause as to the rightness and the justice of that cause, and I am a firm believer in this consultant program for many reasons. First, I am -sure that, as General Bliss has said over and over again and all the rest of us have said, we all want the Army medi- cal service to be the best service*in the country; and we certain- ly cannot have this service under present conditions without out- side help, because we do not have sufficient key specialists to meet the requirements, either in number or in quality. Therefore, we do need the help and advice of our friends, our civilian consultants. Since, then, they have been good enough to volunteer for this, we should make every effort to use tnem most effectively and most economically. Now, the consultants for tne First Array Area are obtained in various ways. v/e all know, and General Bliss has referred to it, of the existence of this Consultant Society, This splendid organization has dedicated itself to assisting us in our professional problems. Therefore, I feel that we should use this friendship to the maximum extent possible. Then, before we select anybody or nominate anybody to The Surgeon General for consult mt for the First Army, we are very careful. 'Ye not only make a thoroughgoing semen of their qualifications, but v/e ask the opinion of one or more of the key members of this Consultant Society, 1 am thorou lily convinced that the fraternity of consultants should be a very select one and that tne original members should be extended the courtesy of deciding, upon its new members. 1 know of no better way in which to bring tne whole program into disrepute than to initiate into this fine fraternity mediocre members. •men The Surgeon General writes the letter to the consultant nominated by the First .army to ask him if he will accept appoint- ment, he tells him that the First Army Surgeon will communicate with him concerning his duties. Our letter to the newly appointed consultants is somewaat as follows; "Dear Doctor; I have received a copy of your correspondence with The Surgeon General’s Office and note with interest your questions 19 regarding the different aspects of civilian’consultant's visits. "In your letter dated to Colonel Blitch you asked several questions. I ywant te. assure you that here in the First Army Area tue duties of expert civilian consultants are entirely professional. .It is certainly our intention that you be incon- venienced us. little us possible with .so-cuiled red tape, so that your efforts may be expended s.olely toward the improvement’ of the Army medical service, and not concern you w-ith other medical activities more military in nature. "I am enclosing a copy of a letter dated 9 January 1946, subjects "Visits of Civilian and Military Consultants," in which was briefly outlined some of our views pertaining to visits of civilian c onsultant,s. "The major medic <1 installations under the jurisdiction of this headouarters are us follows: Station Hospital, Fort Jay, Governors Island, II,Y. * Station hospital. Camp Kilmer, N.J. Station Hospital, Fort Monmouth, N.J, Station Hospital, p"ort h; mi It on, Brooklyn, N.Y. Staten Island Area Station Hospital, Staten Island, N.Y. U. S. Army General Dispensary, 39 fhitehall St., N.Y., N.Y. U..S. Army General dispensary, Boston, Mass. "7h.ilo the installations listed below .me under control of The Surgeon General, they sometimes call on this headquarters for services of Army civilian consultants-; Tilton General Hospital, Fort Dix,'N.J. Murphy General Hospital, Maltham. Mass, Fort Totten General hospital, Fort Totten, N.Y. "In reference to your questions regarding the frequency of inspection visits, X wish to inform you that no definite schedule of visits is established. v/hen we. feel that a visit by one of the army consultants to an installation is indicated, we make such request of the consultant. If the date is convenient to him, we arrange the necessary details, such as issuance of orders, arrange- ments for transportation, etc. Our present Array consultants make on the average of about two visits a month. These visits usually require only one day each, but they may, on occasions, require somewhat more time.■ Some of the hospitals close ta or in New York, such as the Station Hospital at Fort un.y. Governors Island, may require a visit of only ono-half day. "I wish to take this opportunity to express to you my appreci- ation of your interest in the civilian consultant program of the 20 Army, and look forward to your serving with us in tho capacity of consultant in . "With kindest personal regards. Sincerely yours,". Our consultants are employed in several './ays. First we have array-wide civilian consultants who, after working out with us a mutually satisfactory schedule, visit our various hospitals. In preparing the schedules we attempt to have an internist, a surgeon, and a neuropsychiatrist consultant visit each hospital in the First army Area it least once a month. The consultants of the various other specialties are called on from time to time to visit the hospitals, but not in such frequency. Our schedules are arranged so that the other specialists visit each hospital from six to eight times a year. All of our consultants are encouraged to render rather full reports of personnel problems, diagnostic pro- cedures, treatment methods, adequacy of equipment, etc. These reports first go to the commanding officer of the installation visited for his remarks, and are then forwarded by him to the army surgeon, he in the surge.on’s office take these reports seriously and make every effort to follow with such means as are availible to us the recommendations contained therein. Tho reports are then for- warded to Tho Surgeon General’s Office, requesting help when such is needed. Next, we have teaching consultants at Fort Jay, consisting of one surgeon, one internist, and one neuropsychistrist. The teaching medical and surgical consultants visit the hospital at least twice a week, but no reports are required, since we wish them to devote all their time to purely professional matters and to instruction. The teaching consultants will on occasion operate or assist in difficult oases. a ’ I The relationship between the commanding officer, the chiefs of services, ward officers, and the consultants has indeed been most cordial. All concerned- welcome the visits of those consultants, and every member of the professional staff is benefited by the Ward rounds and the round-table discussions. 7/e want these teaching con- sultants in all of our station.hospitals, since wo believe this teach- ing program to be extremely valuable; but it has not been put into - effect in other station hospitals because the professional staffs at these have not, in the past, been sufficiently trained to warrant- such a program. '■ .mother method of using the consultants is for "emergency con- sultations '.’1 The following examples illustrate tnis: An IIP in New York City was shot through the head and rushed by civilian authorities to Roosevelt hospital in a dying condition. Ahen we were notified, we at once called Dr. -nawrence Foole, our neurosurgical consultant, and informed him of the situation. He visited the patient at once and 21 advised us 'that he was too ill to be moved, he requested that he perform such operative procedures,in the civilian hospital as might bo necessary. This was done and we are convinced that the life of the soldier was saved by Dr, Poole's quick and expert attention. On another occasion, when Fort Totten General- Hospital was first opened, we had cur pediatric consultant visit the hospital to advise us concerning what was said to be a slight outbreak of infantile diarrhea. Dr. Joyner went to Totten immediately and advised us by ’phono that the'hospital was not t that time sufficiently equipped to care for this outbreak. Upon his advice all babies were transferred to- the Fort Hamilton Hospital where we had in operation a superior pediatric service. The mothers remained at Totten. After consultation with the commanding officer of Fort Totten Medical Center, it was determined that the obstetrical section' of the Fort Totten Hospit il should.be completely revamped, and the obstetrical service there should be closed .for the time being, and all obstetrical cases should be sent to Staten Island area Station Hospital, no called upon Dr. Ralph ;7. Gause, our obstetrical consultant, to assist us with plans for a satisfactory obstetrical service. Thus, these obstetrical and pediatric consultants were employed extensively in drawing up plans and specifi- cations for the modernization of the obstetrical and pediatric sections of the Fort Totten Hospital. These consultants not only gave of their time .and advice to this particular project, but assisted us in the re-establishment of the obstetrical section at Staten Island Area Station Hospital and in ad- vising as to the cure.and treatment of the babies which we removed to Fort Hamilton. Ail the babies responded quickly to expert care. In order to modernize the obstetrical service.at Totten the sum of-&50, 300 was necessary. This money was not immediately available', but, owing to our insistence on the necessity for this work, md with the complete backing of the two consultants, the condition was con- sidered by the First Amy Engineer as of an emergency nature, and the necessary funds were provided, i am told that wnon the project is completed Fort Totten will have a .odel obstetrical set-up. It, was through the effolrts of these same consultants’that the high standards that now obtain at.our embarkation and debarkation hospitals are being maintained, ‘ Another example of the cooperation and use of the consultants was that just recently we asked Dr. G. G. Duncan, one of our internists in Philc.delpl.iia, to investigate' what was believed to be a high incidence of atypical pneumonia' at Fort Monmouth, This contact was made by telephone,and in a few days.a thorough investigation hud been made, and concrete recommendations .were submitted. I would like to point out in this connection that Dr. Duncan found that it was owing to the expert diagnostic procedure being used by the young medical officers of that 22 hospital that these atypical cases of pneumonia were discovered, and that the incidence rate probably was not excessively high, but that all such cases were promptly discovered and reported. We believe that we have in our army areas Regular hr my medical officers of such high calibre that they too are capable of acting as consultants. Therefore, with the approval of the commanding officer of one or two of our station hospitals, we have appointed members of their staffs as consultants to the First Army, These excellent young officers have frequently been sent to our smaller station hospitals not only to act as consultants to officers with less experience, but to perform operative and diagnostic procedures as well. Our commanding officer of the First Army. Laboratory is likewise employed as a laboratory consultant for ill of our Army installations, makes frequent trips. The same can be said for our physiotherapist and dietitian, he also use the best of our mess officers to assist in establishing ideal conditions in other messes. The question has been raised, and i am oi the opinion that it is The Surgeon General's policy, that a chief consultant as coordinator should be appointed in each army area. I believe this policy to be unwise for many reasons. First, most of our consultants do not have the time to .act in a supervisory capacity in addition to their pro- fessional visits to our installations, nor do we. want them to expend their time on this work. Second, it will'take a Solomon to make a choice when so much talent is available. Third, consultants are individualists and want to consult with the chief surgeon rather than with an intermediary. Fourth, we believe that every use should be made of the consultants, and that the program should be run as econom- ically as possible, I believe the army surgeon is-, in' the best posi- tion to make the best use of the talent'made available to him in the most economical manner. I know from personal experience that con- sultants do not like to have a boss other than the chief surgeon. We feel that in this day of modern medicine -we should not rely solely on the viewpoint of one doctor or on the medical opinion of one section of the country. It is a great source of satisfaction to us to know that we not only can have consultants from the New York doctors but also can ca 11 on tnose from Boston concerning the same condition and can thus evaluate better the recommendations made. Tne question has been asked me wnethor or not wo are appointing too many consultants in the First Amy Area. My answer to this question was ”No,tT that in tne First Army we have only one consultant in pediatrics, roentgenology, tnomcic surgery, neurosurgery, and obstetrics and gynecology. There should be several consultants in each one of the specialties, because, by having a larger group available, it is possible for us to secure at least one who my have the time to accomplish a particular visit for us. We also want to get at least one representative for the following specialties; urology, dermatology. 23 otolaryngology, ophthalmology, cardiology, and anesthesiology, i/hi 1 e wo use consultants in these specialties infroquently, their value to the service will be inestimable at such times as we are up against a case needing a high order of professional talent and the patient can- not be moved for one reason or another to a general hospital. I believe that, by having a large group of consultants available, we are promoting good feeling among a larger group of the civil medical profession, which is so essential at this time to the future Medical Department of the array. In summarizing, lot us state that the civilian consultant program is of inestimable value to Army medicine not only from-.the purely professional aspect, but from the morale factor as well. The younger officers look forward with great enthusiasm to the consultants’ visits. I 'believe that the program has been a stimulus to the procurement program of the Army and the close liaison and'cooperation between civil medicine and Army medicine is exceedingly beneficial to all con- cerned. ■ In the near future, as the shortage of Medical Corps officers bocone more and more acute. It is probable that *we shall have to rely more 1 and more on our civilian consultants. Therefore, we are attempt- ing constantly, to expand our program in• the,-First army Are? and are endeavoring to secure at least three competent consultants in every specialty. In this connection wo are attempting to obtain civilian dental consultants highly trained in oral surgery. I should again like to emphasize that one of the best methods of maintaining a cordial relationship With these consultants is through close personal relationship and that the surgeon and ids assistants should exercise every effort to save the consultants from harassing and'Administrative details and drrahge promptly for their transporta- tion, accommodations, and pay. In closing,. I should like to say that our consultants have been splendid in .meeting our requests for visits to our hospitals. Like- wise, we have had the finest cooperation from General Bliss, Colonel Cole, Colonel Blitch, and the entire staff of The Surgeon General’s Office. DISCUSSION COLONEL COLE: 'Noll, I’ve enjoyed very much the remarks which General Denit has made and there are two or three points that the General has brought out which I think should be re-emphasized, One especially is the cordial relationaship and the cordial cooperation which we are trying to fester between the Nodical Corps of theA*rmy and our civilian consultants and civil medicine in general. One -i f the finest ways to do this of course is through our consultants. General Denit fortunately has almost an unlimited number of highly qualified men in practically every specialty on whom he can call, and he has his consultant program set up so that practically every specialty is covered by a very good high-powered consultant. As time goes on we. can visualize that this consultant program may got smaller as we got more men in the Army who arc qualified and who become specialists before the board. But there is one point that I think we should never forget—the fostering of the cordial relationship with civil medicine through our consultant program. I think this is one of the finest means wo have, as General Denit brought out in his talk, to put over to the civilian practitioner and civilian specialists in general just what the problems arc in the Army with which we have to cope new and in the future. During the. war we had a galaxy, one might say, of highly qualified specialists, .fell, wc don’t have that any more, and only through cooperation and work and engendering this feeling of good will with our civilian confrerees and through our consultants can we keep up this good relationship. There is one thing I would like to ask of General Denit and of all surgeons— we would like to have in this office an outline cf the schedule of the teaching program, Ac don’t particularly care about the individual subjects that are carried on in that program, but we should like to have sent in to us once each month an outline- of the schedule, for example, which you conduct at Fort Jay. A'o think it would bo very illuminating, and it may be something from which wo can base future planning for other army areas. I should like to emphasize also the emergency consultation. That point has boon brought up time and time again in our isolated areas, what can they do in case of an emergency consultation? A’cll, if they have these consultants already appointed it is easy to get one of those men to cone out and not-only see the patient once but follow the case up and render assistance over quite a period of'time, I think that is very important. Another question which General Dcnit touched on but did not go into very fully, and which comes up‘from time to time, is the use of- consultants•in treatment of civilian dependents, Now in our training program we have a program sot up for the training of obstetricians and gynecologists. That •.entire program is predicated on care of dependents. Soldiers do not give birth to children, but their dependents do, and for that reason I think Ac have ample ground on which we can back up any call for emer- gency treatment or the use of consultants in handling civilian depend- ents who arc bona fide patients in our Army hospitals, * 'GENERAL BLISS: Open discussion now,• which. I assume will concern con- *'■' ■sultants in the army, areas rather than the consultants that have to do withour general hospitals, I’d like to hear from you. 25 COLONEL WILLIAMS; I have one little bit of discussion and one question to put to the conference. The first is discussion not about civilian consultants but about specializing in the younger medical officers, We built up our medical staffs in our stations and station hospitals as well rounded as we could to cover the various medical specialities, and the bulk of those people are of course ASTP’s, Now they are starting to terminate their service with the Army and month by month we lose them. This immediately throws our staffs out of balance', I have in mind one small statidn hospital which will lose eight out of thirteen medial officers in the nextJfour months. Nothing unusual about that, but when we get through we have nothing in the staffs to cover internal medicine, EENT, and laboratory as very important parts of that hospital. Now my point is that we- are going to take the attitude in our Army that those men of course are not specialists at all. They have had abbreviated internships and many of them rather limited, as, for instance, a man taking a straight surgical internship. We recognize that he is not a specialist in any way at all, but that he is interested in surgery above other branches. But, as we go down in strength and upset the balance of our staffs, we’re going to ask those people to step out beyond their announced interests and be doctors and take care of the patients that we have. The only alternative would be this business of shifting a youngster from Sill to Now Orleans and from New Orleans to Bliss and so forth. They are not specialists .and the shift simply moans that they would continue tu get the service that they desire, but balanced against the loss of time, the money spent, and the diffi- culties they "would have in finding a homo in a new station. We’re not going to do that; we are going to ask them to broaden out beyond announce! interests. The other thing has to do with the annual physical this year, and consultations. The tendency has been very marked in the last few years of bringing in to maximum use the specialists in doing our physical examinations, particularly the annual physical. That’s even more marked in the orders for this year’s physical. Our problem is going to be that, in most, of our stations we’ll have only one or two regular medical officers. Those men arc net specialists. The rest of the medical servic will be young ASTP’s, Now, when we require that any abnormality be sub- mitted for consultation, I’m faced with one of two things; either the consultation is of only moderate value or there is the very strong*possi- bility that there will be a tendency, conscious or unconscious, to mark minor abnormalities as normal in order to avoid the inconvenience of getting that officer examined by a consultant. We do' not have very many consultants in ny area. We have only five, and we can’t ask them to go hundreds of miles and sec a single individual. We are going to have a problem at stations of fifty, sixty, or a hundred officers fur annual physical and a hospital staff net capable of giving the really valuable consultations required by the examination, ’Wo also have the'problem, which I think all army areas have, of the recruiting service. Recruiting has become so important that those men arc absolutely sacred. They can’t 26 be picked-up end moved around, be can't send then within a reasonable time to a general hospital for an examination, Lb cannot send the examiners to them to be able to give them all the consultations they need. That last point is my question, if there is any happy solution I would like to have it, COLONEL RUDOLPH: I have a question to ask. Do you want a monthly report from,the larger station hospitals that are not necessarily indicated as teaching hospitals? . COLONEL COLE: No, we don't require monthly reports from the large station hospitals except this: if you arc carrying out, as General Dcnit .is.at Ft, Jay, a regular teaching program in which the consultants participate and in which you have a regularly scheduled teaching program, then we should like to have the reports come in here, at least a schedule of your teaching program* Does that answer your question Colonel Redclph? COLONEL RUDOLPH: Yes. COLONEL BILLICK: I have cone to, this conference with two desires in mind, one is to have a group ‘of consultants that I classify as teaching consultants in my station hospitals, I also want consultants that I can call in, local consultants, living near Leavenworth, living near Riley, living near Fb. Sheridan and near Carson, that I can call in for emergen- cies, I think we have forgotten one thing about the OB consultants and the consultant for dependents. It is my understanding that government funds do hot exist to call in such consultants, In other words, I can call a consultant any time I care to for a soldier but I cannot call him in for a civilian, I had a very celebrated case just three weeks ago at Fort 'Sheridan, The daughter of a Lieutenant General, the chief of a service in the Department of the Army, Colonel Dowell was absent on leave when she decided to precipitate her emergency, and I didn’t knew that the young lady was in ,-the hospital the next morning or I would have gone over to assist. An AS TP boy took care of her, I have no OB consultants on my list. She got along very nicely. The premature child was put into an incubator and the,last word I hoard when I left Chicago last Saturday was that, he had gained back his birth -weight, I’d very much like to have OB'consultants, dermatologists, and pediatricians. But, frankly, I don’t think we have money to' pay them. If we have, I would like to be enlightened, I was asked to appoint an ophthalmologist, I have one ophthalmologist who is being taken away from me; he is at Fort Leavenworth, I have no other ophthalmologist in the Fifth Army and, frankly, I don’t know what this consultant in ophthalmology would do when ho wont around my station hospitals except to givo mo an adverse report of the ophthalmology service, I would like to hoove an ophthalmclgist located near these station hospitals that I can call in to take care of emergency cases* or to consult. It is my understanding that these ccre- sultants are to‘ tour the hospitals and advise and supervise the service in that ho spital. And I would like the program bo expanded much further than -that. Since Colonel Lillians brought up the recruiting program I should like to speak1of that, too. It’s the plan of the Fifth army to use certain centers within our area for recruiting soldiers., - and, since I don't have, the doctors, we are going to employ civilian doctors. We are going to examine these recruits except for the x-ray of the chest. The . boy will hold his right hand up, be sworn in, become a soldier, and then he will arrive at his training center, and there he //ill receive his x-ray of the chest. And I am fraid some of them are going to turn up with active tuberculosis. As a matter of fact, I have one case already who has done just that. I want the members of the conference to understand that I fully agree with the consultants program, but I don't see how I can employ it within my army area as widespread as it is, and' when my five Army consultants that I now have under my control are any place but in Chicago. I even have one- whose residence I believe is in Cleveland, Ohio, in another army area. And I would like to be able to appoint individuals locally and have them locally around the station hospitals where they can bo employed, GENERAL BLISS: I guess Colonel Cole will be here in a moment, but there is actually no question about the availability of consultants for taking care of any patients who are in the hospital. Is that clear? No ques- tion whatsoever, legally, financially, or otherwise. That's what the •consultants are for? to take care of the patients who are in our hospi- tals. Any patient who is authorized to get into one of our hospitals is authorized to have the best care that can be given or the same care which is given to everyone else. As I said before, ray conception of the con- sultants is that each hospital should be covered by a consultant who does not go there necessarily when he is called in to see some interest- ing patient, but who has the responsibility of telling the surgeon that the service is or is not properly covered at that hospital. He goes to the hospital as often as the surgeon may want him to or as often as they jointly think it is necessary* he does anything or everything which may be done, not just being called in as a consultant. This consultant system is devised and thought out on an entirely different basis than the old conception of calling in the consultant when you needed him to help on an operation or on a specific case. Someone else can answer the question about the consultants for annual physicals and all that. COLONEL COLE; I am sure that General Bliss has answered most of your questions, Colonel Billick. The very fact that we have these patients, that they're entitled to be treated in that hospital, is enough evidence that they can be seen and be taken care of by consultants. Now we can go right back to our teaching hospitals. We have OB and GIN services set up there as I said before. These are all, or at least the majority of them are, and they are taken care of, seen, consulted over, and their treatment as is asked for is directed and taken care of by the consultants. Now as to having all your consultants appointed in Chicago, I think that's fallacious. I think you should appoint your consultants in the areas near the hospital which you wish them to serve. At Fort Sheridan, for instance, you can appoint consultants from those towns near Sheridan, if they are available. I -think Highland Park and some of those other towns up there certainly must have consultants of the caliber which you would desire as consultants. I am sure they are present in Colorado Springs, Now I would like to read from AH 40-10, Change 5, paragraph 4e_, and this is in answer to your question that the con- sultants tour the hospitals and advise the commanding officer of what is going on in his hospital: 11 They may be calld upon by the commanding officer for any professional service or advice or appropriate pro- fessional assistance he may desire of then.11 Assistance can mean operating, or anything else, as we interpret it, I think that there .is no reason why you can’t, under existing regulations, appoint con- sultants for your station hospitals in the areas, provided they are available near the hospital involved, COLONEL RICE; There is one, there arc a number of points that are very important on these selections of Amy consultants; one of them is to attempt to appoint them in areas whore the hospital is located in order that they will be able to make the.trip, most of thenfdo not care to take long trips, because they are busy people in their communities, Therefore, if they can be appointed near those hospitals or in centers whore hospitals arc located, you will got more service out of then than you will if you try to appoint then in one locality and ask thorn to make trips that required three or four days. Another point on the teaching consultants I believe worthy of cement is; when those teaching consultants arrive at the hospital they should come at a certain appointed time so that the chief of service concerned can have the interesting cases ready and the staff there for those cases. Often—times, the consultant reports in the hospital and nothing has been prepared for him as far as the teaching side is concerned. So ho makes ward rounds and doesn’t do veiy much so far as teaching is concerned. Now your chiefs of service should bo responsible to see that these clinics are organized and, when the consultant arrives, that they have not only the patients that they arc going to sgo, but also the staff is available and there at the time so that they can get the most cut of those conferences. I have used con- sultants to see civilian patients, I’d like consultants also to come in and operate on patients, 'Jo have seventeen of them. TTo have also had consultants go frmi Baltimore to outlying stations- to examine psychiatric patients on whom there was a question of disposition, I thought that was the just thing to do. General Dcnit mentioned one point that struck me between the eyes, and that is that the a my surgeon should have a closer relationship, a more friendly relationship between himself and his consultants. Ho .should know them personally. If you don't knew then personally it isn't long until they lose interest; they don’t accept your invitations to visit your hospitals or they find excuses net to go, whereas, if they know you personally I think they will do it more readily than if you don't know thorn, GENERAL DENIT: Jo have written a letter, and I have a mimeographed copy of it here, to each one of our people, I won't go into the preamble but wo state tlat it is desired that the following be adopted as a protocol during the visits of the consultants. Commanding officers concerned to meet the consultant and extend him all possible courtesies and acquaint 29 hiii with the perioral problems confronting the installation. The chief of service concerned,will insure that all patients on his service have been carefully worked up and ready for presentation. As many-members as possible of the particular service nakc ward rounds with consultants, . fork should be kept at a niniiiun during the surgical consultant's visit in order to allow the naxinun number of officers to be present on the ward founds, unless the consultant specifically requests other arrange- ments, On the completion of the ward rounds wo like a general discussion held in which the, consultant may summarize his day's findings, etc, he try call the consultant up on the 'phone and tell him exactly what tire he leaves and exactly what time he is going tc arrive at the hospi- tal, or wo send him a TjX and toll him.. That's the protocol we have, to keep from wasting time. . Now, I don't believe in these one— or two- hour visits for 050,00 a 'day, he. try to arrange it sc that they will leave New York early and get down there in tine to stay practically a whole day. Two hours for 050.00 is a little bit too much for no, and we're not guing to encourage that kind of consultation in the hospi- tals , p. TTR COISUT taut PPf qPAl", 1 he.pm AH GTf.KEFAT Ff S 1 Tt1 Colonel Sean F. T’inn genera!) plmss and Genf1 emen, we1 re a little behind time so J wi 11 rear! some of this rather rapidly ■’ r order to cover the ii el d, ' e mafe mistakes when me began to implement this nro- gram, because in the beginning it was a Question of trial and error, be had no precedents by which we could govern our actions. Although we had circular 87, which covered certain .requirements, it was by no means an answer to all. the problems which arose. It was evi lent from the start that a coordinator on the companding officer's staff would be essential. ■ Although it was considered desirable to orovi.de a fulltime medical officer of senior grade to perform this duty, no officer with the necessary Qualifications was then or has since been available. Tbe iob was therefore given to the executive officer as an additional duty, who, with an administrative officer as an assistant, was in charge of all hospital training activities, Mthough this plan has worked well, it is not entirely satisfactory, because the many and varied responsibilities of an executive officer prohibit his keeping in sufficiently close contact with all the phases of the program. A move to improve this shortcoming has recent] y been adopted. One experienced medical officer from each service las been .selected by each chief of service to assist the coordinating officer, and the chief duties these individuals are to assist in preparing for residents and interns on their respective services, schedules which will permit the over-all schedule to operate without conflict aim1 which wild insure a maximum of time' for residents to use in attention to patients and bedside instruction. These officers also are expected to acquaint themselves with the various oppor- tunities afforded in the 1 ocal medical schools for extra-curricu- 1 ar training and to coordinate the utilization o'p these facilities by residents and interns. They are further expected to maintain close liaison with other services In the hospital so that each chief of service may keen informed of any training activities 'or interesting and instructive cases in the various wards that may be of value to his own trainees. They also are used to organize these conferences so that there is no delay in getting patients to the Place of meeting, see that the interns and residents on the gob have the cases to present, and keen some kind of informal record of attendance of consultants. It is believed that such a system would he useful even if the program coordinator is employed as a fulltime officer. The education committee of course was set- up. in the pre- scribed manner with the chiefs of services, commanding officer, the executive officer, and three civilian consultants as members. The latter arc r)r, Carleton '’athewson, Professor of Surgery, at Stanford; hr, Kerr, Professor of Surgery, California; 31 and T)r, Bowman, Professor of Psychiatry, California, committee early reached the conclusion that the utilization of consultants should be left to the discretion of the chiefs of services rith general supervision by’the committee as to the adequacy of their use. This system has been followed. However, as a matter of hindsight, it is my Personal opinion that the more detailed consideration of the method of utilization of consultants by the education committee would have been advisable and will be instituted. It is desired to stress that the chiefs of services have the real responsibility in sotting up and executing the program. The chief of service must constantly ask himself, and ho must ask his consultant, how ho can improve his particular program. That is done, and it has resulted in drawing out some valuable' suggestions. Another thing that the chief of service must do is' to participate actively in this program himself. VJe require the chiefs of service alwavs to■ get up and talk and ** i to prepare to talk when one of their cases is being brought up. Put I feel that the chiefs of services should not be over- shadowed by any consultant. We realize that they are much more high-powered, but we’vo got 'the obligation to instill respect for the opinion of the chief of service on the part of his iuniors, and we1 ve got to get him accustomed to teaching and standing on his feet and talking. So I think itTs very important. It is the firm opinion of the education committee at Letter- man that implementation of the program, must be decentralized to the training hospitals and should in no way preclude full com- pliance with the indent and spirit of 1'he Surgeon General’s directives. There are many factors involved which support this opinion. Among these .may be Mentioned local physical plant, organizational framework of the hospitals, the type and qualifi- cations of assigned personnel who participate and/or contribute, and the Personalities of the attending staff- and their availability, interest, • and. effectiveness in. teaching. The variations, in the problems inherent to each ’professional service have made for some apparent lack of uniformity in our system of utilization of consultants. . *nd I wild rapidly explain how we use them on the various services. On the- surgical service two general surgeons have been found'sufficient .to conduct ward rounds, clinics, round-table discussions,etc,, and to assist in a teaching capacity during surgical operations, Poth of these men are fulltime professors at their medical school, and thus are experienced and excellent teachers. They have demonstrated a keen interest- in the program and a Positive intention to turn out well-trained surgeons and successful specialty hoard candidates. These consultants are Dr. Carleton Fathowson, Professor of Surgery at Stanford, and his assistant. Dr, Cohn. They have,made it Possible for our residents, 32 interns, and staff to participate in surgical rounds, in a cancer conference, and x-ray conference each 11 ednesday morning at San Francisco County Hospital, activities which these consultants, themselves conduct and which have supplemented immeasurably our own clinic facilities—especially regarding'the acute cases that vc sometimes have a shortage of in the general hospitals. Both of these consultants are unselfish and untiring in their contri- bution to our Program. While they have been from time to time to perform certain serious or unusual surgery, they have ordinarily acted as teaching assistants to the staff officers and the residents. In this capacity they have been outstandingly helpful and have given freely of their time and patience. During the year, Dr. Hathewson has given many nightly lectures on timely subjects and at present is presiding over a weekly quiz course of round-table discussions based on Questions previously used on examinations of candidates for specialty board certification. This has proved of definite value and stimulation to study to residents and staff members alike, now are supplementing this quiz with the demonstration of preserved gross specimens and appropriate slides so that the candidates will become accustomed to seeing specimens preserved in formalin as they see them on the board examinations. We have about fourteen consultant surgeons, in -addition to the two mentioned, who are used for ward rounds, instruction, special teaching clinics, and for assistance in operative surgery in the sub-specialties of neurosurgery, vascular surgery, obstetrics and gynecology, urology, proctology, thoracic surgery, anr1 anesthesiology. These consultants have entered into our program eagerly and with enthusiasm. Those on urology have been particularly helpful in supplementing our clinics with their private cases and in furthering our civilian relationships. The same can be said of the- consultants in obstetrics and the other sub-snecialties. On the orthopedic service we have seven consultants. Two of these ° It ornate weekly in a' two-hour clinic on various orthopedic subjects with presentation of illustrative cases by the residents. Another has teaching rounds one afternoon each week, and occasionally participates in operations. Dr, Sterling Bunnell and his assistant conduct teaching rounds one afternoon each week on hand and plastic cases and participate in operations at times. Two instructors in anatomy from the University of California staff are used one evening weekly to supervise a course in anatomy of the extremities, including cadaver dis- section by residents, A lecture and demonstrati on"1 also is given by these consultants. Saturday from to nine A.r. residents visit the following hospitals in rotation; University of Wli fomiy Children's Hospital, Wranklin 33 Hospital-, Shriner's Hospital, gnn Francisco Hospital, and St. Vary's Hospital. -A' program is presented by the staffs of these hospitals covering various orthopedic Problems with presentation of cases. On the medical service fifteen consultants are utilized. Four of, these make teaching ward rounds on the general medical wards once weekly; one of those also gives a forty-five minute lecture after a five minute case presentation once weekly. Another of this group supplements his ward rounds by lectures on a special subject, such as thyroid disease, from time to tine. Four medical' consultants confine' their teaching to weekly clinics, on gastroenterology and gastrosconic examinations, cardiology, endocrinology, and rheumatology, except that the consultant in rheumatology spends an additional half day weekly in-ward rounds. Dr. Kerr, Professor of bedicine, at the University of California contributes a monthly teaching clinic on special cases. Dr, Kerr takes an active interest in our teaching urogram and has ma.de available to us many of the teaching clinics at the University of California, Ho has been instrumental in our pro- curing three exceptional young officers (AUS) who have been singularly valuable in our resident training. Dr. Kerr’s long experience in medical education rrmkcs him of particular value on our staff. The four consultants in dermatology contribute fifteen hours to-this section—three hours, five days Per week. One Is assigned to teaching ward rounds and the oth r three teach in the wards and outpatient clinics. They are headed up by Dr, Drederic G* Novy, a very fine skin man on whom we depend a good deal for his advice and recommendations. The resident, the only one be have in dermatology spends seven hours weekly at the ’University of California. The laboratory service has two tissue pathologists and one PhD in biochemistry as consultants. The latter has boon used for a series of lectures for training courses in anesthesia and for some fifteen two-hour lectures to the staff and student officers on biochemical processes. One of the two consultants in tissue Pathology is used exclusively for lectures and.demon- strations -on surgical pathology, ' Weekly meetings have been held for approximately four months utilizing the surg:oil study sets ' supplied by' the Army Institute of Pathology, On completion of this survey of general surgical pathology, it is contemplated starting’ a series of weekly lectures lasting approximately four months each in the various specialties such as urological pa- thology, etc. Prior to introducing this training, our staff officers had very limited forma], direction in their efforts to review pathology in preparation of board examinations. The second' consultant in tissue pathology is a very busy man and has found it difficult te give us very much time, it nrajsont he attends one weekly departmental conference in the pathology section in which controversial cases, both autonsy and surgical, are pre- sented for his comments and suggestions. On the neuropsychiatric service, the more or less unofficial di r ctor of the consultant group is "nr. Karl F, Bowman, professor of Psychiatry at California and director of the Langley porter Clinic, There are two additional consultants in psychiatry; one in psychiatry and psychoanalysis; one In neurology and electro- encephalography; and one in neuropathology and neuroanatomy. All of these consultants occupy responsible teaching Positions at either California or Stanford, A total of approximately twenty hours weekly is spent by these consultants in a teaching capacity at the hospital. In addition, the residents attend the Langley Porter Clinic once weekly for a conference of an hour and a half duration, the combined neurological-neurosurgical clinic of one hour1s duration at California, and the Ft, Zion Hospital Clinic, one hour weekly. Plans are under way for the appointment of a consultant to implement teaching of dynamic psychology and psychiatry that is psychoanalytic, and a consultant in clinical psychology. In general, consultants on this service are utilized in both didactic and clinical teaching capacities, i.o., lectures and actual work with patients, in the diagnosis and treatment of difficult unusual cases, as advisors to the chief of service and sections, and for highly technical activities such as interpreta- tion of unusual electroencephalograms. For the most part, their time is devoted to patients presented in clinics—patients chosen for their teaching value in diagnosis and treatment. The psycho- analysts devote part of their time to a general clinic, reserving the last hour of each session for individual work with the one resident. The consultants advise the chief of service an his request ns to the progress of residents in the courses which the individual consultant teaches. In general it may be said that the teaching consultants are an integral part of the service. The cordial Personal relationship which has so far existed between the consultants and chiefs of service has -aided immeasurably in arranging outside clinics and maintaining good relationships with local specialists in general. In the x-ray service two consultants are used. One of these devotes two hours once a week. The other spends about two hours once eve 17/ two weeks. This amount of time has Proved ample in the opinion of the chief of service. One of the principal benefits of the consul t0nt program in the radiological service has been the injection of fresh thoughts into diagnostic and therapy procedures. This is stimulating to the entire staff and has a most salutary effect in keening the staff abreast of current developments in the field. 35 In otolaryngology there aro two consultants. One of these has teaching ward rounds from eight to twelve one- day each week. The other has a clinic, as well as ward rounds, one afternoon each week, ft the end of these periods each consultant gives an informal lecture to the, residents and other interested staff members on subjects chosen by the attending staff and the chief of service and designed for corrorohensive coverage. Each of the consultants has been a participant in difficult surgery when indicated. One- night a week residents have attended 'an-otolaryngology conference at the Uni- versity of California, ■ In onthalmology, four consultants are used. Doctor Frederick Cordes, Professor of Ophthalmology at California gives a clinic once every two weeks at which interesting inpatients and out-, patients are discussed. Two other consultants conduct morning and afternoon weekly clinics, /mother consultant attends the ophthalmology clinic one morning every other week teaching pathology to the residents and other trainees. Each attending surgeon has given one lecture a week covering the most important aspects of ophthalmology. The attending staff on this service rendered helpful advice to the chief of service' in regard to. the procurement of drugs and instruments. They invite the residents and other members of the staff to special meetings at both the local schools and have kept us abreast of current developments at both institutions, They have all shown a great interest in the work going on at 7etterman and have made many helpful suggestions .concerning teaching and the treatment of patients. In physical medicine we have only one'consultant,' who spends about two or,more hours a week depending bn the number of patients to be seen. All the medical officers including the residents of course are invited to attend this conference, but it is not com- pulsory, .The consul tant, Dr, Northway, has arranged to. give a series of. lecture's to the entire staff during the current month. In the dental service sight consultants are used, all of whom are Part or full time Instructors in loc°l schools, Primarily the consultants are employed in presenting the didactic phases, of the teaching program and in the- supervision of the annlicatory work of the interns. Treatment of patients by consultants is ■ limited to the most difficult, and unusual cases which are demon- strated to the inte ms and staff. Dental interns Participate- in the following conferences at the University of California of Dentistry: Four hours every other week in roentgenology? two hours each week in peridontia? two hours•each week in oral pathology. 1 e might say that deans at both of these dental schools are very enthusiastic about this.program and'are render- ing a great deal of support. 36 General Observations—In ores anting our problem to the attending staff the point has been emphasized that our aim is to turn out veil-trained men and to make our training: urogram good enough to attract men to the Army as a career. The educational committee has felt that the clinical material available must be carefully evaluated and dilution of our facilities avoided. It has been the concern of the committee that the tendency to over- load the urogram, by a desire to prepare a large number of officers for specialty hoards or by th recurring assignment of groups of officers for short-time training periods might seriously jeopardize its success. This is especially true as 1 eng as staff officers who are actively preparing for their specialty boards must share in the clinical -facilities. The morale of the attending staff, csnecial ly those members who have developed a keen interest in helping to nut the Program over, could easily be impaired if they ha,re reason to believe that, overloading is serious 13?- interfering with adequate tr°5 ning and its successful, prosecution by a project the nracticability of which may still be a question in their minds. Certainly the residents are not going to be satisfied if clinical material is diluted and inadequate, Now in a personal communication to General Armstrong ho asked me to discuss the following aspects of this program: First the general administration, including appointment and control and coordination of civilian consultants. The general administration of the consultant program has already been touched on. Consultants are required to sign in at headquarters each time they visit the hospital, They are not required to si an out. This would not be desirable or necessary. At the end of each ray period the Adjutant certifies to the civilian payroll officer as to the number of visits each consultant has made. Payroll s are prepared with this certificate as a basis, and checks are mailed to the consultants. No minimum hours of attendance ar required. In this connection, and with reference to the chart that Colonel Cole has distributed, I am very sure that those hours are largely guesswork, because I don't believe wo wire required to keep this information. mhe chief of service concerned now is being required to maintain a record of the type and number of hours of instruction given. This has boon found, to be necessary in order to comnil 1 reports recently instituted by The Surgeon General 's Office, V-3 are greatly indebted to Gr. Trank P. Berry, one of the consultants to The Surgeon Tonoral, for his assistance in the selection of our original attending staff. In' collaboration with Gr, Carleton rathewson, he was instrument0! in providing an exceptionally fine group of teachers. Most recent appointments have been made on the recommendation of the hospital commander 37 after consultation wjth the chi efs of services and the civil;; an members of the education committee. However, there have been some appointments made direct by The Surgeon leneral’s Office, It -s a well-known fact that there arc outstanding men in the modiea] schools who have made recognized contributions to medicine and medical literature but who are not qualified as teachers. Tb- :’r appointments to the attending staff shoul 3 be avoided. It is our opinion that all re commendations for appoint- ment should origihate with the hospital commander. Selections have not been .base.d particularly on how outstanding the physicians or surgeons were,' or hew nationally known thejr wore, but on whether they have proved themselves as teachers in the local universities and how conscientious they would prove to be at teaching their .seec-* a] ties in the Army training program. The policy of appointment of consultants on a yearly basis should be continued, and, further, that appointments be renewed only after the local education committee has passed such renewal. It is further believed that the reactions of the residents to the teaching qualifications of consultants should bear some weight in making any final judgment, The consultant staff should be thor- ough! y aware that they are under constant scrutiny, and that they cannot expect their services to b° continued from year to year unless they put forth tb■•'ir b-°st efforts toward participation in the Program. Ultimate control over consultants should at all times be exercised by the commanding officer through the educa- tion eommittee. The second point he.wanted me to discuss was utilization in general, including their use in th treatment of patients, teaching and consultation, as- profession0! advisors to me, and in evaluation of Professional, personnel. Utilization in general should devolve upon the chiefs of service under the general supervision of the education comrittee. This should include the Privilege of rotating certain consultants on. different sections of the service when deemed advisable. Consultants should understand that the clinical material with which they are dealing must not be used for their own personal gain but should be utilized to the maximum for the teaching of residents and interns just as would an instructor in a medical, school. Surgical consultants should impart th°ir knowledge by acting as assistants in operations rather than as the operators. Their experience and knowledge can best be- taken advantage of if they participate with the staff surgeons and with the residents as the latter become qualified to perform operations. It is recognized of .course that there are some r*ifpicult and unusual operative procedures in which it is desirable to have the consultant actually Perform the operation with the assistance of the hospital staff. Consultants should be used both in teaching ward rounds capacity and for holding teaching clinics. 38 Chiefs of sonricos should be almrt to see that the consultant's time Is hilly utilized throughout the period of ids -,n sit. It is not considered adv-sab?e to have different consultants conduct regular teaching ward rounds on the sane patients. Our experience indicates that teaching clinics that arc frequently held in ward da yr corns and to which n at fonts are carried for presentation by their senior officers have been of cspecial value. It is not believed that the attendance at such clinics should be considered as unwarrantably taking the time of residents and interns from bedside instruction or actual work with patients, %anybody here, I am sure, has made ward rounds with large groups of people and the follow on the periphery doesn't even hear what's said rand he loses interest. And I don1t think that type of teaching is nearly as good as the teaching clinics. If you have only four students, then ward rounds arc all right. They are all right anyway, but there is a better way out. It is rare that a member of the attending staff is used in a purely consultant capacity. How- ever, this is resorted to in the case of certain individuals such as a dean of a medical school, whose intangible value to the program is great, but who has not been able to devote'a regular period of time to the program. ¥e have been very delighted to have persuaded the Doan of Stanford to accent the consultant's position, and I believe next week the Doan of California will also consent, be need those people very badly, 1 think, to influence our students. I think they should know what the pro cram is all about| they should believe in it. 1 believe that nither one of these doans bel eved in it very much until Conoral Arm- strong told them about it3 1 think he convinced those two men, 1 e want somebody in those positions, the deans of medical schools, who will certainly give our stafT thn rn‘gh.t sort of goal e0r our program. The consultants ar~ encouraged to consult vrth the chiefs of the services and the commanding officer in nn advisory capacity, Fh.il e the most cordial relations hi p has been maintained with consultants, th- suggestion of The Surgeon General regarding more frequent get to gathers is thoroughly concurred in. -"re have invited these men to .loin our officers' club; most of them have joined it. Fany of them wo call by their first’names and they call our men by their first n-mes. So. there has been very close personal relationship with practically all of them. The consultants hove also been helpful in injecting the hospital Personnel into the affairs of the community. They have encouraged attendance at the founty kodica] Society meetings and other professional gatherings. It is bel"eved that they should encourage and assist medical officers in presenting oarers at professional meetings and in writing papers for publication. Through these undertakings wo can better put across to the civilian community what actually is going on in our training hospitals. Just next-week Dr. Fathewson.has arranged for an 39 invitation for Colonel Heaton, the chief of th< surgical service, to go to Los Angeles and ores on t a neocr to a very select grout) of Pacific Coast surgeons. He does .it because he wants to further Heaton's refutation in the community, evaluation of Professional personnel by consul tants has been conducted in an informal manner, he talk about those men a good deal, but a formal statement from, consultants is now being roouired. In reviewing the grades of student officers, the education committee has given full consideration to'the opinions of the attending staff members. The third feint that General Armstrong asked me to discuss was their use as ai dos in the procurement program and in the maintenance of good relations with civilian medicine. It is difficult to evaluate at this time the aid consultants have rendered in the procurement Program, Hr. Pathewson informs mo that medical students care already asking him for advice as to the Army and, what the I my has to offer. It is becoming known to students through their contact with consultants that the Army has a training program!, and it is believed that as time goes on more and more of the students will manifest an interest and be advised to take advantage of it. In lino with one of the remarks that General Armstrong made, Hr. f'athowson said that some former young officers seeking civilian hospital residencies arc reported to have rejected any suggestion for the pursuit of an Army career because of unfortunate previous assignments to duties which they felt might just as well have been performed by administrative off?,cers. And he cited several cases of which he has personal knowledge. It is believed that the consultants will Drove a valuable aid to Procurement as our Program becomes more firmly organized and our consul.tants more completely sold on the idea and convinced of the sincerity of the Army in making a professional career possible. The fourth point was any suggest! ons you might have relative to improving the Program including measures of economy that might be taken without jeopardizing the program. In this connection the appointment of one consultant as coordinator should be dis- cussed, ire]i , I. think one way we can improve this Program is to go along with those in the hospitals right now, but I think we must be sure we assign chiefs of services who are teachers and .are interested in teaching; net just good operators. Try to,make these residency assignments as permanent as possible so that the man doesn't get just one year and is then interrupted. Establish formal teaching programs in all hospitals, Everybody is familiar with the tremendous “'mount cf clinical material that we have wasted in our Army hospitals, I am guilty myself over many year's. We had a little two by four teaching program, but 40 we didn't actually have a formal program, As a measure of economy it might be well for the education committees to review the con- sultant staff from time to time with the idea of eliminating same consultants in sub-specialties and employing those remaining to better advantage, ‘’during the oast year considerable pressure was nut on hospital commanders by The Surgeon Sonera! 1s Office to Increase the number of consultants. Tt is possible that this b-'s brought about an excessive number in a isolated instances. The appointment of one' consultant as coordinator is not considered favorably. This opinion is based on the difficulties which would be cncounf red because of Personality clashes, the existence of civilian cliques, the extreme individuality common to doctors, and the fact that consultants at least in certain instances are drawn from two rival school faculties, It is further felt that the coordination of consultants is inherently a responsibility of the commanding officer of a military hospital. It is believed that the chief of service should act as the coordinator of the consultants on his own service. In conclusion, may I with propriety make these observations. It is net believed that the utilization of civilian consultants should be permitted to inhibit initiative and direct decision on the part of Army medical officers, radical officers must be alert to maintain responsibility for the care of patients and not be expected or permitted to delegate this to consultants, be died officers should be encouraged to maintain reliance in consultation between staff officers and not permit this important staff coordination to suffer as a result of extra-staff contri- butions, And finally, it is felt that the Army must stand on its own feet in any program. This can be accomplished and the important contribution of civilian consultants fully utilized provided harmonious consultant relationship is maintained. Teaching staff officers should avoid board fever in their relation with consultants and should preserve the dignity of Army medicine by a receptive attitude and by an attitude of eauality in any discussion. I believe that most of the con- sultants subscribe to and promote the above as a basic concept. 41 DISCUSSION GElTHBA? BUSS; Colonel Winn has said an enormous amount there and when this is transcribed it will give us one of the •‘most excellent programs that is going'on-in any of our general -hospitals and I hone that you will all it carefully. The program which is on at letterman is ■ excellent in evevy' way share and manner. C0L0~:BJ CTTF.: This very fine report which Colonel irrinn has read of the activities of the consultant program at letterman Hospital needs no discussion, I think it is a very good exannle of the nrogram; he has covered everything in almost minute detail. And as General Bliss said, when thi.s is Printed it will bo well worth reading by everyone connected with this consultant nrogram. There are one or two questions though that I would like to touch on. One is.the nroblem of anpointing consultants direct from this office. As far as 1 know, in surgery there have been two direct appointments made to, Letterman Hospital from, this office. One was by order of The Surgeon General himself, the previous one, and the other because we- wanted to hold him for an overseas assignment where wo are now processing to send him in the very near future. As I said before, it has been the policy of the consultants’ branches in this office not to appoint consultants to any installation tntil that installation comes forward with a recommendation. We have tried to live up religously to that. In the beginning.there were some exceptions to it because we had‘to work rather rapidly and.had to pick up consultants where we could get them and take whom we could get. But I think now you’ll find that practically all, with reser- vation—because occasionally we get one for whom we receive a direct order to report—are appointed only on the recomrendvti on of the hosnital. But that Is a very exceptional case. General Bliss, there have been two of our gentlemen on the program this morning who have stated that they don’t think that consultant should be appointed to administer the work of the consultants, so with that in view I think wre shall have to leave thpt question-oben for discussion at a later time or until such time .as the decision can be arrived at on that particular Point, Colonel Winn brought up in his.paper that there are consultants who have been appointed and who haye been carefully checked by the commanding officer and his educational committee, but who during the course of the year are found not to ’’fill the bill” for which they wjere appointed. It is rather difficult to come out in the middle of the. year and tell Dr. Smith, ’’Well we. don’t want you as a consultant anymore”. He’ll wan't to know why and you’ll have to tell him, which will break down all the good feeling w;hich we have built up. So at the end of the year, as I have stated in my previous talk, when recommendations are asked from the hospitals and the army areas as to the names of those consultants w/ho are now on their staff 42 •whom they wish reappointed, that is the tine to state that so-and-so is not recommended for reappointment, Thus we can drop him out with- out too much trouble, and it will be handled from this end without any reflection on your department. There was another thing brought up which has been touched on once or twice and that is the evaulation of the residents each quarter, or each time they are evaulated, This has been done by, the educational committee with the commanding officer of the hospital on the recommendations of the consultants and the recom- mendations of the chiefs of services* It is believed by Col. nuke of the Education and Training Division here that an additional evaulation should be made by the consultant involved* For instance, if we have a resident in orthopedic surgery, an individual evaluation should be made by the consultant who has had this man under close observation during the period that this report covers. That would be sent in through the education committee, be evaulated by them, and be an additional, evaulation sent iri with those made by the committee, ' I think Colonel Winn is very fortunate, in his geographical position because there .are two very fine medical schools from which he can draw consultants. Most of our general hospitals have .one, some of them none, and it is extremely difficult in some of our station and general hospitals to get qualified teaching consultants locally. They just aren’t the :, We have to draw them from over a great distance. Colonel Finn has two fine schools to draw from; Fitzsimons has one; and Walter Reed has two here. Brooke has none. It is extremely difficult in those Places where there is not this abundance of. material on Which to draw to get the type:of consultant whom we wish to carry on this program. ■COIONFI WINN: I didn’t mean in my remark to cast aspersion on mhe’ Surgeon General’s office, I still think that’s a bad idea to come from any other source but local. In reference to personal relationships with these consultants I would like to add that it is my, practice to have everyone of. these new,consultants come to see me- and we can'go-over this program, very carefully. They are made to understand that as far as possible they are members of our staff, and we expect thorn to consul t with us,’With me, and with the chief of the service,; to come in and make any comments or sug- gestions they want arid we will, give these every consideration. Occasionally, if you keeP your ear to the ground,’ you will hear stories going around. Someone Was quoted as saying that something is wrong with our medical service progbam, ;but.he hadn’t come in and told me anything about it. As soon as I heard that I sent for this gentleman and sat down and told him again what we expected from him in the way of cooperation, that we don’t want him to be dissatisfied and spreading news around that things aren’t exactly as they should be. It -is through these personal conferences and in my meeting them around the. hospital, shaking hands with them, and asking-them, about various things that we keep very close contact with them, , The meetings that were proposed in a letter that recently came from this office and which I think were all right, are■ goipg to take the place of this activity which I’ve described as personal t relationship. As to .the consultant coordinator, it was the consensus of all of the consultants with whom I’ve talked that this would not be a good idea. They thought that it ;would create friction and destroy some of the good morale we nowr held. There are some people there who don't get along well together and a lot of things that have to be straightened out. We have for instance, a very fine blood vessel surgeon. Freeman—none better in the country. When a child comes there with patentductus arteriosis he’s the one I’m going to have,..:; operate. I’m not going to get the chest surgeon because he goes in,, and takes out a lung just because this phenomenon is in the chest have him do the, surgery; but you'd be surprised to find out that he's a. little jealous. He vaunts to know why he didn’t get to see that patient and operate on him, I think that this is something for the chief of service and myself, if necessary, to handle and not some- one ho doesn’t like whom I’ve decided to make coordinator of the program, * GENE R AI HE IS S: I think our thoughts on that coordination are just about the same. Colonel Winn has the greatest coordination.-out • there among his consultants that you’ve ever seen, but it happens to be done, by the executive officer together with the chiefs of . services. It’s, certainly coordination, which is what we are aiming for, whatever you call the personnel. There is a little more time for some of these other hospital commanders to get up there and talk, GENER/JL QUAPE: I agree top' that the appointment of a consultant coordinator might be embarrassing to the men and I think the coordination can bo done by the chiefs of services and the committee. Each of our chiefs of services is preparing‘a proposed sketch for the consultants use for the whole year, and- ; I think that will be the answer to the question of coordination. There were several consultants who have been approached on this overseas proposition. They raised the question of nay’and mode of travel,-and one of them who happens to bo a reserve officer’ also wondered if he could be called to active , duty for that period and travel by boat, GENERAL BLISS: Colonel Cole will answer all of those questions, GENERAL QUAPE: There is a question I’d like to ask y°u, if the legislation proposed mil permit the use of retired officers on the consultant staff? GENERAL' BUSS; Yes , COLONEL DUKE: This nolicy of appointing. chief consultants and coordinators originated when T)r. Bowers ’■ group went on an in- spection of teaching hosoitsl, They came back and unanimously felt that the consultants’" organization had to teach the hospital what to do. They thought that a closer organization would he best and that a coordinator, through which each one of the consultants had access to the commanding officer, shoiild be one of their own group. •' At Brooke General Hospital—I think Colonel Streit mil bear me out here—he had his group appoint the consultant themselves. It was agreed that that was the "best way to organize., COLO MET. RUTOIPHt’ ’’■’hat is the relationship, if' any, of the army area consultant to the teaching consultants of a general hospital withln the army area? ' COIONEL COLE; I’ll try to answer that question first. The. recently promulgated policy formerly set up in this office with the consultants belonging to the army surgeon is that they have ■ no connection with the teaching hospitals, Nov/, if you have a consultant in your area that the teaching hospital wishes, and they contact you, you can lend this man, but as far as sending your consultants out to inspect the general hospitals or to make . rounds in them, I believe the policy is that they shall not do that. Teaching consultants will be: appointed for these, particular hospitals. Teaching hospital consultants.will carry, on the teach- ing there'and not the consultants in the army area. .... * • * ’ 1 . * ' l* . . ; . There has been considerable discussion, and we have had several staff meetings with General Armstrong, or, at least, I talked to him recently during the absence of General Bliss regarding overseas consultants'. This is the condition we are • faced with in sending consultants overseas—if we send civilian consultants overseas, they will be paid the usual consultant’s fee, plus $7 per diem while traveling without the U. S,, in comparison with G6 a day while traveling within the- U, S, Many • of these consultants have come back and said, that they would go over provided they could take their wives or other dependent members of their families with them, and they want,to travel by boat. This is the proposition: If v/e send these people by boat, it means that we have to send them over on a commercial boat with their wives which would require about 12tdays, This means that their pay and their transportation will have to bo paid on a commercial basis, which would amount to about $300 each way, adding to, roughly, about They get a day while they're on the boat, for about 12 days each way, which makes another si*600. 45 and it runs up to “1,200 to get a roan over there and back without doing any work... .Now, th’ey are ordered over for approximately, ■ 30 days, When we have a man over -there for only 14 days, to do' the work which we require him to do, at #50 a day for the, 14 V days it runs up to about another *£700, so you :cap see that ‘ ' #1,200 plus $700 makes it approximately $1,900 in figuring the cost when we send thd consultant over in this-manner. If we can ' send him by Air Transport Command, and that’s the way v/e are contemplating sending them, they Will leave Wcstover Field, if they’re going to Europe, in the evening and arrive at Frankfort, Germany, the next'day. This takes one day at-$50, -end no trans- portation charge. Then 'we have the use'of that roan over there for approximately 28 days, and he comes back on the next day. In order to .cover about two general hospitals and about twelve station hospitals, it will require about 28 .days* A man can’t cover that many hospitals in 14 days. In order,to work done and to accomplish the mission which we feel wo are attempt-'' ' ing to do, we think that these consul tants should go in this way. It will do two things: first, give us the man’s services for a longer period of time, and second, cut down the cost tremendously.' General Bliss, X' wPuld like to introduce, at this time Dr, Henry L. Thomas, of Baltimore, who is one of the consultants to the Secretary of the' Army, and I believe he has a few words that would be of benefit to all of us in regard to this program prior to making the final summary. Dr, Thomas. COLONEL THOMAS, PROCUREISENT BRANCH, G-l, GENERAL , STAFF: General BTIss , it’s been a’ real' privilege to be. allowed to listen to this conference. When General Bliss invited me, I was very pleased to: come, and I realized that he was’extending.an unusual invitation to a person .who hasn’t even got 'a caducous -on, and X feel very’’ strange about that, and I can only say to you-that I am still a consultant and I suspect that my rating as a procurement officer will be good or poor. However, I Wasn’t expected to really procure medical officers in a short period of five weeks, but I suspect that I have fulfilled the mission that General Paul had in mind which was to educate one more-civilian doctor, and I, have really been educated, ip these five weeks, and it’s been extraordinarily interesting, I'have been educated because- of the enthusiasm and interest that I’ve found all through the. .army in the present medical program,’ and that^s not only in my travels to several medical installations, but also up in the General. Staff, This was, I must say, quite a surprise to me, but I find that it’s not a surprise to the officers here'in The Surgeon General’s Office, where they .realize the interest and cooperation that is, being" given them in their efforts, I remember the Consultant system when it was just getting started. In fact, when I went down to Atlanta, .in. August,of 1942, 46 if Colonel Winn thinks that they put on their system by a method of trial and error, he should have seen me in August, 1942, There was no blueprint by which to go then, and in listening to Colonel Winn, I suspect that his scheme has been about 99 percent trial and one percent error,. I think mine may have been the other way ’round. However, it was a beginning, and it was a very inter- esting beginning. The thrilling thing now is•to see this group of officers of the Medical Corps setting the pattern for the activities of the consultants, and to me that's been the interest- ing thing that I’ve gotten this morning. Whereas when we were turned loose at first, we didn’t know what to do and the officers under whom we served didn’t know what to do, I’m sure that Colonel French had no more idea what I was supposed to do or how I could do it when 1 reported to him than the man in the moon, and I had* not that much, either,. However, he was splendid in helping, and we gradually worked out places where we could be useful, and the interesting thing now is to hear the thrilling reports of General Denit, Colonel Winn, and Colonel Cole about the program.and to see the way in which the thinking about the future is going, I don’t think I can add anything constructive at this time to the dis- cussion of this over-all program. I am vitally interested, I know what a consultant is confronted with. However, I see no con- flict between the way the expression of thinking this morning is set up and the activities of the individual consultants. I have derived a somewhat different point of view since this past five weeks, and I’d like to say just one or two words about my differ- ences of thinking now, than five weeks ago. Colonel Winn stressed one point which I don’t think anybody else has mentioned and that is that he insists on the Regular Array chiefs of services taking an active professional part in all of the exercises on their services. I think this is of great importance, I can see hoy/ a clinician in administrative work, five or six years away from any clinical work, will feel rusty. Those of us who are in different work, and were- in tropical medicine when v/e came back to our old kind of medicine, v/ere rusty. I remember seeing Hugh Morgan shortly after he went back to civilian life and he said he had never studied so hard in his life. I can understand any officer feeling diffident about expressing his opinion on a clinical subject that he has been out of five or six years. However, I think it is of utmost importance, and it will be one of my ob- jectives to explain to the consultants I see from now on to make it a joint effort between the chief of the service and the con- sultant who happens to be there that day. General Denit spoke of the 'cordial relationships and the methods of maintaining them. All of you who know General Denit t who have had the pleasure of serving with him know that that’s no trouble to him if ho can got at the officer, and apparently he is making it his duty to get at the officer. Well now, I feel that I can go back to the consultant committee and explain to them that 47 this is part of their duty ’as well;’that they must go all-out in their effort -to maintain this cordial relationship which is so beneficial to both. Colonel Colo said one thing too along this same -line and that is that the consultant system as set up now is a gigantic scheme, a very expensive scheme; one involving a great many civilian consult- ants. , • My visualization is that year by year more Regular Abrny’ ‘ officers in medical surgery and psychiatry and in' the■specialties will be available just as two of General Denit’s officers now"are serving as consultants. This number will increase year by year and the number of civilian consultants will diminish. That is as it should be. I hope*however, that all of the officers here will try to maintain some close contacts with those of us who are really interested in the Army Medical Corps and its future.' And it seems . to me that there can always be important relationship and exchange of ideas back and forth, I had no speech prepared when General Bliss said that he was going to ask me to talk, so you will have bo forgive me for not making a formal talk. I just want to say that. I am going to take back to the meeting of the Consultants’ Committee which.acts in an advisory capacity to General Bliss as much as I can of.what was said this morning, "COLONEL COLE: This will be only a short talk and it will be the .final summary of the .things that have been brought up this morning and this afternoon. I want to personally thank Dr, Thomas for his observations and for transmitting to you gentlemen the observations he has made relative to this program. In making appointments of civilian consultants, an application is sent in hero and the applica- tion is cleared - • . Me have had three questions asked and'I’d like tc -'answer those now, and also give you a few suggestions that'may help in making your relations with tie consultants a little more pleasant, not that they have indicated that ti cy arc not, but anything that we can do to be cf better service to them and to you is cur air... You have been, using the consultants con- siderably more this year than any previous year. Their excepted appoint- • ments are for ninety work days. Se me instances may occur where you want to use these consultants for mere than the appointed period. Their ninety day appointment can be extended, but not tc exceed one hundred and eighty days in any one fiscal gear, and where it is necessary or desirable to use a consultant for longer than his initial appointment, a request to this office, prior to his use, will make his services available to you for a longer period. Please do net make the mistake . of working; him in excess of the ninety days and then ask for prior approval retroactively. This cannot be given, little planning will make these men available to you for additional tii.je* There is n-.. curtailment of their services contemplated due to a lack of funds during the current fiscal year, nor is there a curtailment anticipated future. For the and the station hospital consultant, if the surgeon of the Army will see that the certificate of services rendered accompanies the travel voucher for the consultant, if there is to be a claim for travel reimbursement, it will speed up the settlement of their claim. Me are experiencing seme instances where they7- arrive separately", When- ever you separate two documents that are necessary for one action, an unnecessary delay is occasioned. Some cf your consultants travel a short distance. This is true of both the and t! e general hospital consultant. He makes frequent trips, but each amounts to very little as far as reimbursement is con— 56 cerned. It has been ycur practice. t;o subnit one certification each, month for services rendered, but you have been submitting, an individual travel reimbursement voucher, for each of these little trips, when it amounts to,maybe a dollar or two. In those instances, you can save yourself, the consultants, and all concerned who handle those vouchers if you will likewise consolidate these vouchers for reimbursement for travel. There has been in one of the areas a close reading of the regulations governing travel, and payment for travel by privately- owned automobile on a mileage basis has been denied. This matter cane to our attention yesterday, and, on bringing the particular case to the office of the Chief of Finance, they could not disagree with the local finance officer, so I carried it further, to the Office of the Secretary of the Rmy, who wrote the regulation. They agreed that it was the wrong interpretation of the regulation, *,t least, it wasn't their intent to limit the travel of consultants to prevent travel in their own automobiles on a mileage basis, ks a result, they told me yesterday afternoon that I could pass the word on to you that travel by privately-owned automobile as limited by Civilian Regulation 155.2-5b was being amended retroactively to September 1946 to comply with Public Law 644, which authorizes travel on a mileage basis. So if you are experiencing difficulty with any other fiscal office in processing re- imbursement L r travel by privately-owned automobile by a consultant on a mileage basis, just held it for a while, and an authorization will be published by the Secretary of the Gray to authorize payment on a mileage oasis. Colonel Cole this,- morning 'mentioned the practice cf- reappointment at the end of each fiscal year. I just want to add a little bit to that. Last year, when we asked who should be reappointed and who were net to be reappointed, these lists get into_ this office, I fear, without the commanding officer personally seeing what was included and who was to be eliminated. In a few instances, errors wore made because of that oversight, so I would like to recommend that when these lists requesting reappointment or nenrdappeintwont leave your command near the end of this fiscal year, you personally review them so that we will not embarrass you, The burgeon General, or the consultant,. If there are any administrative problems that you have that we do not know about, and you think we can help you with, we will be only too happy to. discuss it further either here or with you individually as you get an opportunity to, come by the personnel office. 57 H, ATOMIC ENERGY....... .Colonel James P,'Cooney General Bliss, hospital commanders. Army surgeons, visitors, it is a great honor and pleasure to be here this afternoon.' I appreciate the opportunity, I thought it might bo of interest to you to know what we have done thus far, in so far as atomic energy and atomic warfare are con- cerned, and what we anticipate doing in the future. During the war, no Regular Army Medical Corps officers were assigned to the Manhattan Engineering District.. The medical staff was composed entirely of Reserve officers. Therefore, after the war and Operation Crossroads (Bikini), our good friends, who, incidentally, did a very excellent job, returned to their .civilian duties and the Regular Army was calle d Upon to take over. My first assignment was at. Bikini, where I was liaison officer for the Office of The Surgeon General, From there I was sent to Hiroshima and Nagasaki for a brief study of thb casualtied one year following the detonation. I returned to Wash- •ington and was assigned to the Manhattan Engineering District, My first duty was to visit the plants throughout the country and ask questions. Individuals working in the plants wore so security conscious that it was extremely difficult to find out much concern- ing the medical problems on my first visit. However, after becoming, better acquainted, I found everyone most helpful and anxious to- advise me as to the medical problems. It appeared that the best -solution toward becoming acquainted with the many and varied problems was to start an on-the-job training, program. The Armed Forces Special Weapons Project under General Groves and the Atomic Energy Commission were both very cooperative. They gaie us everything that we asked for. He wore able to place one Regular Army officer at Dayton, Ohio; one at Hanford, Washington; four at Los Alamos, New Mexico, as well as three ASTP’s at Los Alamos, and one at Oak Ridge, Tennessee; one at the University of California for training as a radiochemist; and throe are now stationed with the Armed Forces Special Weapons Project and one with The Surgeon General, He organized a five-day indoctrination course to be given to members of the Army, Navy, Public Health Service, Veterans Administra- tion, and Air Force, We started this course in May 1947, and hope to continue it until such time as every doctor, in the above-mentioned services’has been able to attend. Beginning in December,. 1947, we invited the deans of the seventy-two class A medical schools in the United States to send a representative from their teaching -staff to attend this course. As of the February course we anticipate having from sixty to sixty-five representatives from the above-mentioned medical schools. The course is very elementary, and its purpose is to give the average doctor some idea of the problems that will con- front- him in case of war when an atomic casualty is admitted to the hospital for treatment. Our instructors serve on a voluntary basis and are furnished by the Army, Navy, Veterans Administration, and U.S. Public Health Service. In addition to the above short course, the Armed Forbes Special Weapons Project made possible our arranging with the University of Chicago to give a six months’ course to prepare National Defense officers for training which will enable them to advise higher- echelon commanders in time of war. We anticipate'expanding this-course to nine months next year and also have a similar course at the University of Rochester, New York. At the termination of the 9-month academic training, these men will have three months on-the-job training at Los Alamos, Hanford, and Oak Ridge, Thus far we have not decided how much training will be necessary in order to acquaint a'medical officer with all the problems with which he will be faced, but personally, I would like to have fifty officers receive high level training during the next two. years. Unfortunately, this seems bo be impossible as we do not have the personnel nor* the facilities to care for them, I be- lieve that on-the-job training at such places as Los Alamos and Sandia will be far more valuable than a straight academic course in some university. However, we will probably have to have a combination of the two in order to get the complete realization of all the problems concerned, ‘ • v ' What are some of the problems that will face the medical officer in time of war? He must be acquainted with the hazards-of radiation and the methods for detection of such; the problems of instrumentation; developing and handling of film badges; diagnosis and treatment of radiation casualties; and laboratory techniques associated With determination of the excretion of radioactive elements deposited in the bo.dy. At the time of the detonation of the bomb, some thirty radioactive elements are liberated as a'result of fission. In addi- tion to these being a hazard externally, they may be' absorbed into the body by inhalation, ingestion, or through an abrasion in the skin, A groat number of these elements are bone seekers and become deposited in the bones. ‘They rdmain there a long time, depending upon their half-life, and thus may cause problems similar to the radium dial workers who ingested radium by tipping their brushes in their mouths and later died of osteogenic-sarcoma as a result of the radium deposited in their bones. It will be‘necessary to examine all patients who’have been injured by an atomic bomb to determine whether or not radioactive elements are deposited in their body. This will be needssary before such individuals will be able to obtain life insurance. At the present time we are training two medical officers and six noncommissioned officers at Los Alamos, New Mexico for the purpose of establishing a school for enlisted personnel at Brooke Army Medical Center, This school will cover the problems of radiation detection. 59 instrumentation, handling of contaminated casualties and developing of film badges, and' laboratory procedures connected with excretions of radioactive materials. It will be given to the medical, surgical. X-ray, and laboratory technicians. As to the problems of radioisotopes, I know that you are all anxious to have an isotope program established at your hospital, However, I ask you to be patient, as we will have to wait until we have a, sufficient number of• people trained in the hazards of handling radioactive materials before such programs can be established. The handling of radioactive materials is a hazardous procedure, YoU all had friends who were injured in the early days by injudicious use of X-ray, Those men were martyrs to science. T/e must profit by their sad experience, otherwise their sacrifice will have been in vain. At present we are using isotopes at Letterman General Hospital with the help of the trained personnel at the University of California, As of October 1948, we hope to establish an isotope program at the Army Medical Center, Washington, D.C, If in the future it becomes nec- essary to have isotopes in all general hospitals, we will do so, but we are going to proceed cautiously. I. PHYSICAI ■ FEEICINE It. Ol. Benjamin A. S.tricklapd, Jr. • First vf. all I w uld like-V- express the keen appreciation • of... everyone who' is engaged in physical • medicine, both in civilian •.and military 'circles,- the. splendid support which all of you have given this now specialty. Because of the efforts.of General Kirk, the / my was the first of the •governmental medical services to establish Physical medicine•as a separate and distinct specialty. As established by F, P, Circular 349, dated 28 November 1946, the physical medicine service in Army general h soitals consists of ■ physical therapy, occupational therapy and physical recondition- ., ing, The newness of the Physical medicine servioC has led to some lack af understanding as V its exact purpose and manner o£ function. In Army hospitals there are certain services that literally ”serve” all the other services engaged in actual care and treat- ment of patients. These three are the laboratory, and the physical medicine services. Just ..as the laboratory service is called.on to serve every patient-in the hospital, for the purpose of laboratory testing and diagnostic procedures, the x-r.?y service functions .as an adjunct for diagnosis and treatment, when roent- genograms are required or x-ray therapy or radium therapy is necessary; in like manner does the physical medicine service provide definitive therapeutic treatment, certain diagnostic assistance, and dynamic convalescent care whenever requested by the surgeon, the internist, the neuropsychiatrist, etc. These three adjunct services can be said figuratively to ”cut across” all the other services and sections in a general hospital that are engaged in patient care and treatment in that their work cones from all the other clinical branches, the services encaged in the treatment of patients. Thirty years ago, the specialty of orthopedic surgery was experiencing severe growing pains. Some general surgeons felt that orthopedic surgery was their responsibility per so, and could see no use for the development of orthopedics as a distinct specialty. Twenty years ago, anesthesiology was just beginning to attract doctors of medicine as a specialty, Fany surgeons still felt that the nurse-anesthetist was all that was really necessary. Put now, the best informed operating surgeons insist on o trained anesthesiologist who is an FT), Physical medicine ins advanced tremendously during the oast ten years, but still finds itself in a situation somewhat reminiscent of the development of both orthopedic surgery and anesthesiology, Fany orthopedic surgeons still feel that there is little to physical medicine beyond heat and massage, and that they can get along perfectly well without a doctor trained in physical medicine being interposed between himself and the 61 physical therapist. They forget that only three decades ago many general surgeons regarded'them .as interlopers, when they set themselves up as being particularly qualified in bone and • joint surgery, .aIt. is of unique note that it was a well-known orthopedic surgeon, namely, Doctor Frank Ob'er, professor of clinical orthooe h.es at Harvard .Medical School who in 1943 stated-: "The 'first World T%restablished orthopedic surgery as a specialty of medical practice an 1 I believe that this war will do the same thing for the field of Physical medicine’1.. That the physlean trained in Physical medicine is now firmly established and has a real service to offer his colleagues is attested to by the establishment taring 1947 of the American Board of Physical. Medicine, This n'-w specialty board has the considered approval of the Council on Medical Education and hospitals .of the American Medical Association, of the Advisory Board of Medical Specialties, of the American College of Sur- geons, and of the American College of Physicians. Now, what is. the Present status of Physical medicine in Army general hospitals'? A Physical medicine service is at present functioning in the thirteen named general hospitals and this service is headed by trained medical officers. Sixteen Regular Army medical rorns officers, all of whom, requested assignment in physical medicine, are engaged in this specialty. Contrast this, if you will, with the number assigned to Physical medicine on 1 September 1946, which was a dismal, two. Likewise the number of A. U. S. officers assigned to physical medicine has increased from 13 to 38. The question probably arises in your minds as to what pro- fessional training these medical officers had had. Thirteen of the Regular Army medical officers have received six months’ post-graduate courses in civilian institutions, and three are now assigned to approved residencies in physical medicine. In October 1947, out of the 550 A. S. T. P. medical corns officers who comprised the October increment at the T . F. S. 3. 26 of these young doctors requested training and assignment in physical medicine, all voluntarily. Three months’ courses are being given these’26 young A. S. T. P. medic'1! officers at five general hospitals. Upon completion of this three months’ on-the-job course, these medical officers will* be classified in the MOS 31S0D, which is Medical Officer, Physical Medicine ■ and assigned as requisitioned to assist the Regular Army medical officers who are chiefs of physical medicine service. I would like to say a few words about Physical recon- ditioning. Host physicians '-an'1, surgeons are so completely absorbed and preoccupied jn getting their patients ovor the '’.cute stage of their illness or injury, that oftentimes they 62 lose‘sight of the importance of the period of convalescence* During the recent, war several controlled studies ■were conducted on' the problem,of convalescent management. One of these comprised several hundred cases of virus Pneumonia, which were divided into two squad groups for the purnos of this study* One group was given an active program of Physical reconditioning. The other group, under the same condition, identical type of management, etc., was given no convalescent exercises but allowed to engage in normal activity d-orlng convalescence. Of the former group, that is the group treated with physical reconditioning, only 3 percent had complications or recurrences of their disease. Of the group that did not receive physical reconditioning, 30 percent had complications or recurrence. Furthermore, the average hospital stay of the group that did not receive physical reconditioning was forty-five days. The average length of the hospital stay of the group that did receive physical reconditioning was thirty-one;days. Other studies of similar significance have been reported. It would appear that in peacetime radical Department activities, a more extensive use and 'exploration of the•Possibility of Physical reconditioning are indicated. The utilization of certain therapeutic procedures in the realm of Physical medicine are worthy of discussion. One tvf these is-fever therapy. Fever therapy has been authorized for use at ten of the named general hospitals, TTpdical officers trained in this technique are assigned to Physical medicine at these hospitals. Therapeutic fever by means of a Kettering hynertherm type of fever cabinet has certain advantages over fever induced by inoculation with malaria, or injection of typhoid vaccine or sterile milk. The most'important of these is that the fever can be controlled perfectly at all tires,’ It is induced from outside-to-within or produced externally, and complete control is possible at all times. The days are gone when therapy was used at .temperatures of 106 and above, /• s mos t of you will remember, this was the technique used in the treatment of sulfa-resistent gonorrhea. This technique is about as outmoded today as blood-letting. Fever therapy has been found to be extremely useful in certain . oothalmological conditions. Thousands of treatments have been done at the eLley Forge General Hospital mainly in, cases of iritis, iridocyclitis, keratitis, and other opthalmological conditions. Extremely remarkable results have been obtained. The patients prefer it to injection of typhoid vaccine or to injection of steri]e milk. Another utilization of fever therapy is in certain cases of neurosynhilis. It is borne in mind, of course, that many neuronsychiatrists still prefer, when treating neurosyphilis, to use malaria. But recent studies, a notable one of which was made by Seaton of FcGill 63 University Medical School in Canada, indicate that properly combined chemotherapy Tilth mechanical!)y-induced fever gave a high percentage of remissions and euros in neurosyphilis than malaria. Certain types of arthritis also are quite amenable to fev r t her cany. Thin Kayo Clinic and certain other leading civilian institutions are utilizing this treatment in certain tynes of nanarthritis at the present time. A greater utilization of.occupational therapy is in obvious need. Probably the specialist who is most cognizant of this is the neuropsychiatrist. But more an~1 more the orthopedic surgeon is becoming fully aware of the possibilities that occupational therapy has to offer in contributing to functional restoration, to motivation, and to stimulation of recovery. These mimeographed sheets which have been passed around . list certain suggestions regarding imrorving the therapeutic effectiveness of the physical medicine service in Army hospitals. It 5s hpped that.you will see fit to give them a trial and when you do, the Physical Medicine Consultant's Division in this office will bo extremely grateful for your reactions, Suggestions for increasing the therapeutic effectiveness of the Physical Fedicine Service: 1. Adequate number of medical officers assigned to the Physical Fedicine Service, Minimum needs have boon determined to be: 2 Medical' Officers in General Hospitals of 500 beds 3 Medical Officers in General Hospitals of 1000 bods 4 5 edicsl Officers in General Hospitals of 2000 beds 2. Medical officers assigned to the Physical redicino Service should npt be given so many additional duties of an administrative nature that they d0 not hawe sufficient time to carry out essential examinations, prescriptions and consultations on all patients referred to and being treated by the Physical Fedicine Service. All three sections of the Physical Medicine Service, in order to have therapeutic value, require the active and close supervision of a medical officer with special train- ing, 3. A continuing orientation program of the entire hospital staff concerning Physical Reconditioning. (See TF 8-292). 4. Individualization of the Physical Reconditioning program for bed patients. Rather than conducting a program of calisthenics on the wards. Physical Reconditioning instructors 64 should spend 20 mi nut os '*aily with each individual bed patient in vfoora Physical Reconditioning is indicated, 5. Fullest possible utilization in actual Physical Reconditioning of patients of all 'personnel trained in Physical Reconditioning and hoi ’ing a primary FOS In Physical Reconditioning. (At some installations, skilled Physical. Reconditioning personnel are being used only 60 per- cent of their time in Physical Reconditioning,) 6. A continuing' orientation program aimed at familiarizing-ward officers with the value of Physical Therapy in definitive medical care, mth equal emphasis on the limitations of its applicability, 7. Close cooperation between the Physical Medicine Service and the Convalescent Services Section with the common goal of a dynamic regimen for all patients during convalescence, 8. The extension of Occupational Therapy to all patients who will be benefited by it. Fary general hospital patients, because of a lackadaisical attitude of the ward officer toward Occupational Therapy, are retarded in their convalescence by this unawareness on the part of their doctor to the functional restoration, motivation and stimulation available through medically prescribed and. supervised Occupational Therapy regimens, 9. An indoctrination of nil medical officers that the Physical Fedicine Service is set up to provide a professional type of medical care and treatment, particularly applicable during the usually protracted period of convalescence; ’ that its coordinated and integrated utilization has real therapeutic value; an-*1 that it has much more to it than simply "keeping the patient busy". 65 J. MODERNIZATION OF EQUIP7 ENT. Colonel Si] ar P. Hays ....... .Colonel Clifford V, Morgan I wi3] discuss very briefly .the urogram that is underway on modernization of hosni Mis, TV Surgeon Gene ral feels that Army and Air vorce hospitals should be as well, if. not. better, equipped than comparable civilian, Navy, and Veterans'.Administration hospitals. Forking.with General Grow, he has appointed a committee to survey all medical installations of the /'■ rry and- Air Forces in the United States to determine what modernization equipment is required. This survey will probably take all of the calendar year of 1948. It will give us information with which we can go f to the Bureau of the Budget and to Congress and request money for ‘future years, lie find ourselves now in the position in this office of not knowing the exact condition of equipment In the various hospitals. This survey team is comprised of Army and Air Force members. Colonel Morgan, Beauty Post Commander of the army Medical Center, whom most of you know, is the chairman end Colonel William Lawton from the Mr Force is the vice-chairman. All medical instal- lations will bo surveyed, last year we could n't get personnel to do this work and as a result, wo sont rut two men who did some superficial work in general hospitals only, Fn]jowing that, we spent approximately a million dollars for equipment, I feel that our money was not as well spent as it could have been had we been able to grn at the thing with better qualified personnel and in a more systematic manner as we have this year. Colonel T organ wall tell you of the work that his committee will do, COLONS! (-RG M: Colonel Hays has outlined for you the mission in the program. I want to say that the committee has already been organized consisting of ab ut eight members and we've laid the ground work and the educational surveys during the past two months. Me are nrw ready to start on the program of covering about 210 medical installations in the Zone of the Interior, The committee consists of rne representative fr m supply, two nurses, an engineer who has experience in teaching repair of utilities at Ft. Pelvoir, and three officers from the Air Surgeon's office, Fe are trying to cover the south in the next two. months and the whole United States, I believe, possibly within eight months. I think we can cut the time of me year a little short. There are two things I would like to request the hospital commanders to be prepared for. One is to know what they want when the team gets there. A1so J feel that they should have the inventories and their stock record cards on medical supplies available. It would, bo well if they had available the memorandum receipts to some of the clinics, operating rooms, and the central supply. So as the team goes through, they won't waste a lot of time ving an inventory job. Then if any requisitions are prepared, they sheuld be available to the team, 'Mo report op the team will be routed through the 66 station commander in order that he may roconrr,ond changes, if desired, either deletions, additions nr changes in nileriti.es• The rcrorts will also be rented through the i.rrnv Surgeon,, or the Air Command, or in the case of Class TI installations sent directly t<' The Surgeon General rs Office, One copy v/ill be furnished for the- files ~f the station surveyed. Now the see nd important, point, I believe, is-to- have the post engineer avail able when the team comes. We anticipate considerable difficulty in getting-installation made on equipment. Some things like x-rays may need lead-lined rooms, or sterilizing equipment may need walls knocked out, or other modifications may be in order, Vo have found in a few surveys•already made that we have been able to gain the cooperative spirit of the post engineer: by having him‘present, I think it will help build up your rela tions with him if that can be accomplished. K. RESIDENCY TRAINING PROGRAM, Colonel Raymond E, Duke I’m net going tc confine my remarks to the residency training program as outlined, on the agenda, but rather I’m going to cover briefly the over-all training activities of The Surgeon General’s Office, because you are all more or loss concerned with all of our training activities. In formulating plans for training of our medical officers, obviously the first thing we should have is a very clear conception .of ’.That are*re trying to accomplish. The Medical Department, I believe, has two missions to accomplish in the training of medical officers. • • : . • .- Our first mission, I believe, is tc be prepared for mobilization and war. Surely our mission as part of the cannot be different from that cf the itself. ; The large number of civilian doctors- who come into the -my during wartime, with some exceptions, are neither interested in nor trained for the purely military aspects of the medical service. The regular corps, must always furnish the bulk of leadership in this field. So I feel that the great majority of cur regular medical ccrps officers, regardless cf what they do in peacetime, regardless of how much professional work or professional achievement, they must receive sufficient tactical, administrative, and staff training so that if necessary, during wartime, they may be capable staff officers, medical planners, and commanders of Medical Department units, .Now our second mission, and surely this second mission is very close to the first one, is that wo should be able to provide the ■ highest standard cf medical care for a peacetime Army and dependents. There must be developed and maintained in the regular corps an adequate number of officers who are professionally qualified tc accomplish this second mission. I think that each individual must bo afforded the opportunity to reach the highest level of professional attainment for which he is physically or mentally capable. In formulating a plan to meet these two missions, we must first know our numerical requirements. How many officers do we need, hew many officers do we need in the various- categories, and how many do we have on hand at the present time, I’d like just briefly to review these requirements with you because our whole training plan is based on them. May I have the first slide please. Now our Personnel Division and our Resources and Analysis Division tolls us that this ' is the number of officers■that we will need in a peacetime Army, The Department right now says that our peacetime **rmy is going to be 875.000, That of course is subject to congressional action but at least we’ll have to have a planning figure. If we have an army of 875.000, we’re going tc need a total of 16,771 officers in the Medical Department, and 4,771 of those must bo Medical Corps officers or doctors; 1,833 must be Dental Corps, 500 Veterinary Corps, 2,706 Medical Service Corps, 5,912 Army Nurse Corps, the Dietitians 331, Physical Therapists 283, and Occupational Therapists 233. The figure I want you to remember right now is that we will have to have 4,771 doctors. 68 At the present time, rr you know, we, nave authority for %000 doctors in the Regular Army. They expect us to make up the other 1,771 by reserve officers on active duty, Nov/ about the 1,771 medical officers; how must they be utilized? Next slide. Our Resources and Analysis Division says that of the 1,771 doctors, one out of ten, or 111 will have to fill administrative staff and command positions. One out often in a peacetime Army. 119 on staff jobs, and 292 in command jobs makes up the HI. of the 1,771 we must have 1,719 for general duty—general duty or general practice officers. Of the 1,771 we must have 2,$81 or over one-half as experts. Now by experts, I mean men with some degree-of professional specialization. No?/ how about.these professional experts. In which specialties must they be qualified? This next slide will show you that of the 2,581 our Personhel Division says that-we must have 709 A and & men—that's professional classification; In other v/ords we must have 709 who have- the qualifications equivalent to certification, by American Specialty Boards. We must have lj122*0 men, men who have had at least two years of training in a specialty; and 750 D men, men with one year of training. Of those totals, 2,581, $61 must be ip surgery, 780: in medicine, 26'3 in neuropsychiatry, and so on. And that gives you a general picture of how these 2,581 experts must be utilized in the’peacetime Array. The figure that I would like you to remember is 709, a total of 709 in the Regular Army in a peacetime Army who must have the qualifications equivalent to board certification. All right new, what do we have on hand at the present time? We have.28 in the medical specialties, 25 in the surgical specialties, 48 in other Specialties, or a total of 101. In other words, generally speaking, it's true to say that we have- about one-seventh the number that we need. We are almost in the same position, professionally in the 0 and D classification. Now that's the status of cur regular corps at this time to accomplish that second mission Which I mentioned—that of providing the highest standard"of’medical care for a peacetime Army and dependents. This actually is the starting point in our professional training' program.■ Now what about the qualifications of our Regular Corps as it exists today to-accomplish the first mission, that cf being ready for mobilization?- As you know, almost 100 percent cf the Regular corps, of necessity, during the war period of four to six years, had to fill staff and administrative assignments. A few months ago, the War Department required that all technical services make a survey of the existing Regular corps, and this survey was for the purpose of awarding what they call a "constructive school credit." We had to survey every officer in the Medical Department, and, depending on that man's ago, his length of service, the schools which he had attended, .and the assignments' which he had held during the war, he w,as awarded a constructive school credit. The next slide. Here, are the results of' this survey as far as the Medical Department is concerned, The, 69 military school system is arranges as fellows, first our basic course, our advanced course, Command and General Staff College, Armed Forces College, Industrial College, and National War College. Whe'n thisd survey.was made we had 1,110 officers in the Medical Corps, Regular Army, and this was about three months ago. Of the Regular corps, 140 had the age and the experience which would give them credit for the basic course. We had 275 whose age, length of service, schools they had attended, and their assignments during the war g-ve them the equivalent bf the advanced course. But notice this—that 5B2 or more than one-half the corps had the experience and military education equivalent to graduation from the Command and General Staff College, So we must agree, that over one-half the corps either had attended the Command and General Staff College or held assignments during the war which gave them the experience equivalent to the education pro- vided by the Command and General Staff College. Seventy—two were given credit for the"Armed Forces Staff College, 15 for the Industrial College, and 26 for the National War College, It is generally felt here that the majority of our officers can successfully fill a staff or command assignment in the Medical Department during the war, having gone no further than the advance course. We’re not going to have to send every Medical Officer to the Command and General Staff school. So you see that for this second mission, the Medical Corps as it exists today is very well trained, with over one-half of the entire corps having the military education equivalent to graduation from the Command and General Staff College. So at the present time we’re very well qualified from the military or administrative standpoint, but we’re woefully short as far as our professional qualifications are concerned as brought out in the previous slide. This is the reason why, for the last two years, we have stressed professional training. We feel that we must correct this imbalance in the qualifications cf the Regular corps, Before I go on, I want to inject one thought. That’s a word concerning the American Specialty Boards and professional specializa- tion in general, I know that many of us are allergic to the mention of the word American Specialty Board. I know that there is certainly some difference of opinion with respect to this marked trend toward specialisation. .1 frankly admit that we here in the office are somewhat allergic to certain actions .of the American Specialty Boards. Of course the pendulum has swung far .toward specialization in American medicine. As General TTillis and his crew down at Medical Field Service School say so many times, "Don’t fight the problem." Let’s not fight this problem of specialization, '"bother we like it or net, whether we a6ree with it or not, the yardstick of professional attainment in American medicine today is certification by an American Specialty Board. , Tie outlook and attitude if the medical student is different'from what it used to be. The peak or goal when we graduated from medical school was graduation from a four year course in an accredited school, a one year internship, and then the practice of medicine. That’s no longer the peak and the goal of the medical 70 graduate today. His peak or goal has been elevated about three or four years. Graduation from the medical school and a one year rotating internship, he considers merely a stepping-stone toward three or four'years more of training toward specialization and board certificationr This - is a truth—a fact—let us not fight it, but accept it as a truth and fact. Unless we can convince the medical school graduate today that, the Army has and can provide training toward specialization and board certification, you’re never going to get him in the Army. Let’s realize and accept this. vro have the means to provide that training. Let’s take advantage of it, We’re beginning to see reactions now against specialization. As I say, the pendulum has swung far, out -we’re beginning to see some reactions. Indiana, for instance, has set up its own State Board for general practitioners. Just recently there has been organized along with other academies, an Academy of-General Practitioners. That’s spon'serb’d by the American M^didal”Association. The University of Colorado Medical School has recently organized a three year residency training program for the general .practitioner. Very shortly, we in the Army will have our own three year training ■ program for general prac&ice. This marked trend towards specializa- tion is certainly a matter of great concern today of American medicine and of the American Medical Association and the Specialty Boards. When it comes time for this pendulum to swing back, I’m sure that the Army. Medical Department will be right there and lend its weight to bringing that pendulum back to a neutral or normal position. But for the time being, regardless of our personnel views, let’s accept these truths and facts as something beyond,cur control. Let us not fight it but rather make our plans and solve our problems accordingly. MEDICAL DEPARTMENT EDUCATIONAL SCHOOL SYSTEM Not/ after a“study of these requirements which I just outlined in these slides, The Surgeon General’s Office formulated a post-war educational school system for medic:! officers. Most of you are familiar with it and Jim going over it just briefly. Tab No. 1 is a diagram of this system. As I say.most of you are familiar with it and I’m going over it very briefly, because I’m going to* spend most of my time on the Residency Training Program, This system is now about 75 or 80 percent in operation. The newly commissioned officer will come in the service, and, he will first be sent to a Medical Field Service School for a four months' basic branch course. This course in general will correspond to the old prewar course which was conducted at Carlisle,and with which you are all familiar. There are two reasons why w.e have not started this course as yet. First, we haven’t had anyone'to put in the course and second, we still have a few ASTP officers to train. Y'e have a class at Brooke now, and we’re getting our last group of ASTP officers in the service in July. That will be the end of the ASTP program. The first peacetime’ four month class will be in September of 19A9, and. the individuals to go in that class will be those of the 108 interns who we're getting in July of 71 this year for our Army hospitals, who elect to .inter the regular service. On completion of their internships they will be sent to this first course at Brooke in September 194-9. Now after that course, a man may go to one of several places. Ha may'go out to his first duty assignment, \ r he may into the professional . training, pro gram as a resident in a specialty. Some of the MSG officers may go directly into supply training, which is in operation at the present time at the Army and Navy Medical Procure- ment Office. Incidentally, our first basic science course began last week, I will have more to say about that in a moment. A few of the Me ical Service Corps officers may go directly into,our opticians course, VTe conduct this course every seven months. The next class begins the 5th of April; this course has been continued in operation from wartime. All of the Veterinary officers, after ,. they finish the basic branch course, will go thethe Meat and Dairy Hygiene Course at Chicago, This ?s a three months' course, and we conduct the course every three months, at the present time. The Army, Navy Medical Equipment Maintenance Course is conducted at the. . St, Louis Medical Depot. This is a six months’ course and has been continued in operation since the war. The course in Hospital Administration we’re conducting at the present time at the Brooke Army Medical Center. The next course will begin on the 10th of May. I’ll have more to say about civilian institutional training in a moment. We keep from two to thr.;e hundred officers at all times in civilian institutions for both professional and administrative training. Now the advanced branch course, Te have a technical and• administrative phase of the advanced course. That’s a four months’ course, required of all Medical Department officers somewhere between the third and tenth year of their service. Our first class in that course will be conducted in August of this year. You recall on the chart that I showed you up here on the board, a minute ago, we had 140 officers who were given the constructive school credit . of only the basic course. Those are the individuals who will attend our first advanced course to begin in August of this year at the Medical Field Service School, Not all of the officers will take" b,' the professional phase of that course.. The Veterinary officers will go to the advanced Veterinary medical course which will be here at the Army Medical Center. That course has not begun. The Laboratory • Medicine course will be held here at the Medical Research and Development School We’re going to scratch preventive medicine for the time being. We are not going to attempt to duplicate the training that is being given by civilian institutions in preventive medicine. We have sent 51 officers to civilian schools for a one year course in Public Health and Preventive Medicine in the last three years. We’re sending now from ten to twelve every year. We’re going to continue to send doctors to the civilian schools for that training. Advanced dentistry wall be here at the Army Medical Department Research and Graduate School, and the first course is to begin in September of 72 this year. Now the other trainin ' included on this chart is'our administrative and technical training at the Command and General Staff school, the.Armed Forces College, National War College, and Industrial College, At the present time we have seven men in the Command and General Staff school. Te can get all the officers who can be made available fcr training in the Command and General Staff School at the present time. The Armed Forces Staff College is a course that1 s conducted twice a year, and we.’ve been sending two to three officers to;each course. Quotas are very limited, but we have been sending either one or two officers to the war college each year. To Industrial College we’ve been sending from two to.four Officers each year.. Now that, in brief, is the overall Medical Department school system. As I say, the system is about 75 to 80 percent in operation,, the purely military training is represented in the basic branch course, the tactical and administrative phase of the a civ: need course, and the service schools at the top right-hand corner. RESIDENCY TRAINING PROGRAM Now I’d like to discuss cur residency training program. As you know, after the war as officers were returned from overseas and units were inactivated, and officers could be made available for training, wo put them into the general hospitals, in That we call refresher training. For one year this refresher training went on, and about 400 officers took part in it. Miring this year, the possibility was explored of establishing within-the Army, permanent, formal, approved, residency training. Te’went to the American Medical Association and to the American Specialty Board, and it was decided about a year and a half ago that we could establish and support adequate residency training, Tre started this program one year ago this month in eight •of our permanent general hospitals. The American Medical Association and the American Specialty B w.rd have been quite surprised and pleased with the progress that we have made during this year in conducting and operating teaching hospitals. The American Medical Association sent out a warning last summer that residency training in American medicine was far over-extended. There -are three times the number of men in residency training today as there were before the war. They sent out the 'warning that there were too many residents in many hos- pitals, many of the hospitals could not meet the standards that they required, and so wo thought it was a good time to take inventory—check up and see what we were doing and how good our own hospitals were. We invited a group of 27 civilians, all of whom were medical educators, men who were' well acquainted with residency training, and asked that they go out in teams of three to these eight hospitals and stay there at least a week and clearly evaluate the training program in that hospital, compare it to the residency training that they knew back at their own civilian hospitals, and give us their advice, ve asked that they survey the hospital from every angle, from the amount and variety of clinical material, the physical plant, the instructor or 73 permanent staff, the attending or consultant staff which we had there. They came back and all sent in a very long, detailed report. These reports were analyzed and finally at a meeting of the executive council of that group with representatives of The Surgeon General’s Office, it was decided to contract somewhat in our residency training program. It was decided to discontinue residency training at Beaumont. It was decided to put Madigan and Percy Jones on a standby basis. It was decided to not open Valley Forge, at the present time, for residency training. This is no reflection at all on those hospitals that were closed or placed on a standby basis. They simply did net have suffi- cient clinical material in enough specialties or they didn’t have sufficiently highly qualified instructor personnel, and there is nothing that The Surgeon General’s Office can do about it at this time. They were just not available and those hospitals were so located geographically that it was somewhat difficult for them to get suffi- cient consultant time. That in general was the reason for putting these hospitals on a standby basis or closing them. Just as soon as we are able, and I think we’ll be able to within one year, a year and a half, possibly two, we will go into Valley Forge,as well as Percy Jones and Madigan, and establish residency training. ' e hope we can do it within one year. (Now will you turn to Tab No, 2 please). That’s the status of our present program with regard to approvals in the residencies, ’'lien we discontinue these hospitals and put them on a standby basis, that leaves us five teaching hospitals in this country. That’s Brooke, Fitzsimons, Letterman, Oliver, and Valter Reed. We’ve added Gorges to the list because Gorges is approved, and we have seme residents training there, I might mention here a word about the Tripler General Hospital, As soon as the New Triples Hospital is open we’re asking the American Medical Association to send Doctor Reed over to inspect this hospital for residency training, and we’re sure that we can set up Tripler for training both for interns and residents. Now that’s the present status. The P means that that residency is permanently approved by the American Medical Association and the respective Specialty Bo-rd. The T or temporary approval means that it was iven full approval and that our men are getting credit, but the hospital is subject to a final inspection at a later date. Frankly, that time is whenever the American Medical Association can get to it. However, our men in all those residencies where you see a P and T, are getting full credit by the board. The R means that the residency has been recommended by the American Medical Association for approval to the American Specialty Board, but we do not have the final action on it. Now in that program you’ll notice that there are 71 residency training programs in our five teaching hospitals. Fifty-seven of them have permanent or temporary approval and Li have been recommended. You can rest assured that we’re working on those 14 and have been for some time. It takes just about a year to get a residency approved, because the application goes from the hospital to the American Medical Association. They get out when they can to inspect the hospitals; then their recommenda- tions gO"to the Specialty Board. The Specialty Beard meets once a 74 year or sometimes twice a year, so on the average it takes us about a year to-get one approved. Tab No. 3 will give you a further status of the residency training program. As to whether nr not it's approved ~ or for how many years. They recommend a residency for one year • approval, two, or three years. In other words, you can train a- man just his first year, e sure, be absolutely certain, that these interns get a good, well rounded internship. Frankly, several of the deans of the medical schools have told us that they will form their opinions ,of an Army inoernship after they hear from these men, It!s exceedingly important that you give them an excellent internship. If you will do this, I believe that in the future, we wall not have any difficutly at all in ,etting all of the interns we can possible use, from the upper and middle third of the graduating classes, and I»ra sure that if you give them a good internship, we will not have any difficulty in keeping a relatively high percent of them in the Regular Army. The great majority of these individuals will report on 1 July 1948. There are a few schools still on the accelerated program, 4 or 5 schools that j raduated medical students in February and March. rre are discouraging any of those interns to come on duty in April, Tre would much rather they come to the hospital in July because of administrative difficulty later on when we get out group next year. However, we have told them that their internship will begin in'July. Of these that graduate in I.ferch or April, and wo are requesting that they bo sent to their internship in wo are granting this, so you nay expect a few, not more than two or three at each hospital in April, A groat majority of then will cone to you in July, and if they cone to the hospital and talk to you about it, discourage their coning on duty in *.pril; however, if they insist upon it, we will grant thoir request, TRAINING FOR 04,Ant.L PRACTICE New a word about training for general practice: All I can tell you now is that we are at the present tine drafting a three—year residency training program designed to train a good general nan—a general practician, he don’t like the word general practitioner. In the main this training will be at general hospitals other than cur five teaching hospitals. In other words.we arc going to call upon Valley Forge, Percy Jones, .iadi ,an, Beaumont, Murphy, Tilton, McCornack, and nrny & Navy to conduct this training for general practice. It is possible wo nay use the larger station hospitals 78 in this program, V/e vdll have that pro gran out within about a month* ]j'q will be down to soo you and outline it and so on. It is hoped that we will be able to interest quite a few of the regular corps or quite .a few of the youngsters coning into the regular corps in tliis training program. The University of Colorado is just beginning a similar course this year, .and Dr. Jenson who is head of the pest graduate school told us'that ho has more applicants for the training than ,he can accommodate. Three years training for'general practice. Vie hope to interest some individuals .in it, • BASIC SCIENCE TRAINING .Tab No, 8—'that’s basic science. Practically all of the ioaorican Specialty Boards require some training in the allied or basic sciences, They are very indefinite or hazy about what they require as to whether it should be a full tine course or part'.tine course, .or whether it should be taught on the ward .and sc one. There is considerable di- vergence of opinion right now in American medicine as to how you should conduct basic science training, The medical schools, a few of"then, in the, last t?iro or throe years have organized courses in basic science instruction. Wo have sent, as you know, quite a few officers to those courses. In the main it has"been a repetition of first year anatomy, physiology, and pharmacology. It’s frowned on in general by the Speciality Boards, There are several schools of thought on the subject. The tiling has never jelled at all as far as American medicine is corn- corned, At a meeting of the Speciality Board and the innerican Medical Association—the advisory council cf the Speciality Board—-they spont one whole day last year in Chicago discussing this very problem and they all expressed their views and the conference, ended right where they started, .Jeout a year ago we invited Dr, Irvin Paige to cone and help us on this problem. Dr, Paige is director cf Research and Laboratories of the Cleveland Clinic, he came in and we discussed basic science training with him. He- had a few revolutionary ideas in basic science instruction with reference to how you should teach the basic science as applied to clinical medicine, he have been working about a year on the thing now and finally we decided that we could conduct our own course in basic’science, and Tab No, 9 will give you the approach that ’ire are taking. First, teach Category I subjects. Teach those:subjects which the body utilizes as a whole and metabolizes. That is the essential substances such as water, electrolytes, carbohydrates, proteins and so on. Then teach the aberration in handling these substances that is effected by modifying agencies such as bacteria, virus, necplasans, cold andheat and so on. Third, teach the study of the different-.systems; gastrointestinal system, nervous and renal system in their normal and abnormal handling of the basic substances as a result cf your category.2 subjects. Now that is sort of a now philosophy in teaching basic sciences, Ae had to have a faculty so Colonel ifoursund who has charge of that program spent six months in going all around the United States, and with Dr, Paige’s help picked out 55 of the top notch men in th«ir subjects. 79 In ether worts he picked the man who knew the most about the metabolism of water in-the country regardless of v/ho he was, Alien Colonel Joursuni presented this problem to these 55 men, alnost without exception they were very enthusiastic about it sc much that they agreed to cone to Washington to spend four or five days of their tine to teach their particular part of this course. The course began last 1.1cnday at the *or.iy Research and Graduate School, 7e have 27 officers enrolled in the course. This course is an experiment, ,c hope and believe that it will bo a successful one, he have invited the medical schools and all are sending representatives to it. he think that there is a possibility that it may become the .accepted method of teaching basic science. If it is successful we will conduct the course every year. The tabs that I mentioned will give you a com- plete background for it. They are tabs 8 and 9, Tab Me, B gives you the complete background of the course and Tab No, 9 gives you an hour by hour breakdown of the subjects. So much for basic science, CIVILIAN INSTITUTIONAL TRAINING: Since all of the necessary training in the Medical Department of the urny cannot be conducts by the Army, we have made use of training in civilian institutions, During the last fiscal year we sent some 304 medical Department officers out to civilian institu- tions, I can show you on this chart, I realize that you can't see the details on this chart, but at least we can see the trend. In January of 1946 we had 26 officers out in civilian institutions, Mo immediately set up more courses and encouraged our officers to apply for these courses, and you can see how it went up from 26 to a peak, during February 1947, of 272, The number came down a little here in June, July, and August of 1947, because there are few courses given during the summer months and; another reason was that wo ran out of money at the end of the fiscal year, be received our new appropria- tion and the number has gone back up now tc around 200 officers in civilian institutions at all times. During the month of December there were 197 officers in civilian institutions. The;/ have included courses for medical officers, dental, veterinary, Army Nurse Corps and so on. Each corps has received its share of the available funds in accordance with its needs and availability of its personnel for training. The courses for medical officers have covered the entire field of medicine; the courses for dental officers has been mostly orthodontia, periodontia and oral surgery; courses for the Medical Service Corps have been hospital administration, business administra- tion, sanitary engineering;, and nutrition research, As I said a moment ago, during the last three years, we have sent 51 officers to take the full one-years' course in public health, mostly at Johns Hopkins and Harvard, although wo are branching out now at Columbia and the University of California for this instruction. Gentlemen, wo are still getting too many personal letters asking for civilian institu- tional training, acquaint your personnel with Circular No, 32. 80 Circular No. 32, dated 7 March- 1947, goes, into detail and tells how a man applies for a course in a civilian institution. There is a definite reason why it has to be done that way. To send a man to a civilian institution we have to know almost two months in advance; we have to go to the War Department, they go to the Army, and the Army has to go ‘to the institution to draw up a writ-ten contract—whether it costs us any money or whether it’s no cost agreement. There1s only one mistake in Circular No. 32, Applications should come into this office, Attention; Personnel Division, not Education and Training, as is stated here. So acquaint your people with that. 'We are having less trouble but still too many personal letters to The 'Surgeon General or to General Armstrong or to chief of Personnel, or chief of Training, asking that ”1 would like to have such and such a course on such and such a day, the chief of service says it's o.k, and concurs," but that's not enough information. Obviously, it should go through channels. We have to know whether you have to have a replacement during the time the man is gone and so on; so acquaint your personnel with Circular No. 32. R.D.T.C. PROGRAM The last thing that I want to discuss is the R.O.T.C. program. Before the war we had authority for only 23 Medical R.O.T.C. units,* and year before last that's all wo had authority to reactivate; just 23, We reactivated 20 of the 23 schools. The Surgeon General .at that time felt that we could not afford regular officers for this assignment so we recalled to active duty reserve officers and sent them out as HIS and T’s. This program worked just fairly well. This year or last year I would say, we convinced the War Department that to fulfill the requirement of the Regular Army and the Reserve we would have to have R.O.T.C. in all 66 accredited, medical schools. We surveyed the 66 schools; we approached the dean pith a new proposition, and most of you in the Army are well acquainted with it—that if they would accept an R.O.T.C. unit, we would pick out a young enthusiastic regular offi- cer and send him there as PIS and T for a minimum of at least two years, and we asked that the .school or affiliated hospitals train trial, officer in one of the specialties. . We attempted to combine our professional training, our residency, with R.O.T.C. R.O.T.C..is not a full time job in the Medical Department. There is a maximum of four lectures per week. I realize there are some other duties that take more than four hours, but that's the maximum number of lectures. We approached the deans with this proposition and 43 of the.66 were very enthusiastic and accepted R.O.T.C. units. Our personnel Division selected 42 of our most able young regulars, men who are interested in professional work, men who had combat experience, who would be a good professor of military science and tactics, and put them out into these assignments for two years. We brought them all tp Washington here for a three-day conference to orientate them in their job, orientate them with personnel problems, our professional training program, internship problems, and so on. Tills program has worked out beautifully, so much that we have 81 9 schools now that have written to The Rurgeon General’s Office asking that we talk to them with a view to establishing H.O.T.C. units in their schools. That’s quite different from two years ago when many of them 'would hardly consult with us at all. Now the results of this so far is that we have doubled our schools this last year and we have tripled our enrollment. Last year as I said earlier we had only 50 applications for internships, this year we have 322 applications. These results, I am sure, were due mostly to these eager, young BIS and T’s out there presenting the Army’s problem, presenting our training pro- gram, and so on to the medical students. I think that the Armies are doing an excellent job in operating these R.O.T.C. units. Turn to the last two Tabs 10 and 11. Tab No. 10 will give you the names of the A3 medical schools in which we now have an R.O.T.C. unit, also the name of the RTS and T and the specialty in which he is being trained by the school or affiliated hospital. Turn over to the last page of Tab No. 10, please. Now, there will give you the dental R.O.T.C, schools con- templated for this year, 1918; there are 19 of them. It will also give you the veterinary R.O.T.C. units now contemplated for 1918 of which there are 6, and pharmacy schools contemplated of which there are 1. We do not have, as yet, the authority of the Department of the Array to activate these new units. We expect to get it this week. Do not con- tact these schools yet. We have the understanding with the Ground Forces that representatives from The Surgeon General’s Office with a representative from the Array Area Surgeon’s Office will make the initial contact. We have definite reason for that; because the BIS and T has to be assigned from here. It has to be determined in what specialty they can provide training; then we go to personnel Division and find out if they have such a man available, and so on. So we’ll make initial contact with the school with a representative from your office. After we once get the units established, then of course, we’ll turn it over to the Army area to operate. Tab No. 11 is just a brief summary. There are 67 approved four-year medical schools here in this country. There are six in ’which wo are not particularly interested. Alabama, Albany, Bowman-Gray and Utah have a very small enrollment. Some 50 or 60 students in the entire school. It is not economical to put an R.O.T.C. into these schools, Tennessee and Southwestern are both schools still on the accelerated program where their students get no summer vacation but go to school all year for three years; there- fore they can't attend the R.O.T.C, summer camps. That makes six that are unacceptable. Twenty were established in 19A-6; an additional 23 in 19A7, so that leaves 18 units remaining. The first fifteen are the ones we are primarily interested in. Rochester, College of Medical Evangelists, and Maryland are still somewhat in doubt. We must clear up certain points on these three before we approach the school. CONCLUSION Gentlemen, I have presented here the basic framework of the education and training program for officers. I think that by taking 82 full advantage of these training opportunities} we can, within a period of eight to ten years, develop and maintain a group of regular medical corps officers who will be professionally capable of rendering the higher standard of medical care and who in the event of another war will be capable staff officers. I am sorry we have no time, for questions. We’ll be here all day tomorrow and Saturday, so if any of you have any problems or questions I would welcome a visit from each one of you to the Training Division to discuss any phase of the training program. I would certainly appreciate your opinions and recommendations on it. 83 L. GENERAL DISCUSSION OF PERSONNEL SITUATION..Colonel Paul I. Robinson General Bliss, Army surgeons, hospital commanders, most of the morning is to be devoted to personnel matters. Following my remarks. Colonel Amspacher will discuss, at some length, the present procurement program and what we are trying to do. Then Colonel Epperly, Colonel Maley, Colonel Goriup, and Colonel Vogel vail discuss special problems in the Dental Corps, the Army Nurse Corps, the Medical Service Corps, and the Aomen’s Medical Specialist Corps, respectively. Colonel McCallam will discuss veterinary personnel matters and make remarks on other matters. We have not included anything on our program today with regard to the enlisted personnel program. The question as to whether or not it is about time for the Medical Department to again get its own medical enlisted corps, as it had before the war, and as the Navy Department now has in its Hospital Corps, has been raised. The Plans Division has a study on its agenda and of course you all will hear more about that at a later time. Civilian personnel problems have also been eliminated from our agenda today. We feel, in general, that everyone is handling his civilian personnel problems in.a very fine manner. We realize that the different shifts that we have had- from enlisted personnel to civilian personnel, and vice versa, have been tremendously annoying. I think that you will all understand that these things are without our control and we hope, as you do, that they’ll all be stabilized as soon as possible. Also we have not included on this program today any special section for our career planning. However, on the wall in back of General Willis, there are a number of career programs posted so that any of you may look at them and see what we arc trying to do. I feel that during the next conference of this type, the Personnel Division will devote its entire time to career management which will be well under way by that time. Furthermore, we are not going to talk today about Reserve problems. We are worrying about the number- of resignations that are coming in from the Reserve Corps. We have no really good method of evaluating what these resignations mean. However, I am sure that within a very few days a letter will go out either to the Armies or direct to as many Reserve officers as we can reach to try to stop these resignations, We think that probably a number of Reserve officers are remembering that they came in as 1st Lieutenants, whereas there were men that were not in the Reserve Corps that came in as Major and they feel that possibly the best thing to do is to get out of the Reserve Corps at an early date. We are not going to discuss that problem today. The acute problem that the Medical Department is involved in now is the matter of procurement of officers. We are going to hear from tho Dental Corps and the Nurse Corps, who also have acute shortages. For that reason, my remarks will be limited to the Medical Corps. I have a. .chart here that will indicate what the general situation is to be over the next two years. You can't easily read the chart, but it really matters not at all. This is the stage we are now in as of January 1948. The blue is our Regular Array, amounting to a little over 1,100 doctors. The green is volunteers, in other words, Category I, VII or VIII officers. This yellow group i.s- the ASTP group, or the non- volunteers, Category V. You'll notice.this little oit of blue up here on top—that is the surplus that we have been discharging from the ser- vice during December—1,300 ASTP's. In other words, as the Training Division says, it costs a medical school more to educate a student than he nays in tuition, so for every one who comes into the Federal service, why should not the Federal Government pay to that school a certain sum of money calculatedto be the difference between the cost of his edu- cation and the tuition he has paid in. This plan is thought of because it will cause the deans of the schools and the instructors in the schools to be interested in having some of their graduates go into the Federal service. All of these plans have difficulties. In the first place, they would all require legislation, and anything that requires legislation encroaches on our time. Another scheme that has been suggested to cover the period un- til something can be done to get more medical officers available is to employ civilian doctors on a part time or full time basis. This plan certainly is one that we must have to cover the emergency period, which we arc bound to have no matter ho; good procurement becomes. General Bliss mentioned yesterday that that part of the previous bill which was not passed last year has already been re-submitted to the Department of the Army for re-submission to the Congress at the present session. However, there are a few things that are wrong with that scheme also. The bulk of doctors that are available for employment under this scheme are now with the Veterans Administration, and it would place us more or less in a position of being an encroacher on the Veterans Administra- tion, another Federal service, if we go into employment on any large scale. You will note that the Regular Corps has barely held its own. In- tegration has just about balanced separations, Tf this situation is not corrected in the next fifteen months, all able-bodied medical officers must be sent overseas, and the hospitals and medical installations in the United States must be almost entirely staffed with civilian doctors on part time or consultant basis. Our experience in the past few months indicates that we cannot in- terest enough doctors in Array medical service to fill this deficit by the ordinary methods of procurement, A program has, therefore, been evolved, all of which has not yet been approved by The Surgeon General, It has been discussed with several General Staff officers in Personnel and Administration GSG, and would probably be sanctioned by them. It 85 includes: 1. Commissioning in the Regular Army 200 to 300 doctors oer year in 1943 and 1949 who are in residency programs in civilian hospitals, allowing them to remain in their civilian residencies, even allowing them to compete for another year of formal training in civilian hospitals, while on active duty status. 2. Commissioning in the Medical Corns Reserve 200 to 300 interns per year in 1943 and 1949 in civilian hospitals, allowing them to finish their internships on active duty status and to compete for and accent residencies in civilian or Army hospitals, provided they come into the Regular Army, 3. Obtaining 130 residencies in civilian hospitals throughout the United States and having them reserved for Army use, 4. Procuring 400 to 500 officers per year in 1948 and 1949 from civilian, AST15, and Army intern sources, allowing them to compete for the 130 Army and 130 civilian residencies. 5. Requiring every participant in this program to serve as a duty officer in the United States Army one year for each year of formal post- graduate training, whether in a civilian or Army institution, 6. Endeavoring to commission 100 to 300 mature, well-trained doc- tors directly in the grades of Major, It, Colonel, and Colonel, 7. Expanding the post-graduate teaching program as rapidly as possible, both in the United States and overseas, so the Medical Depart- ment will have to depend on civilian institutions only for exceptional training; 8. A general improvement of medical service in the Army, includ- ing the providing of living quarters, human understanding, social events, and high standards of medical care, 9. Advertising continuously for doctors to do one or two years of duty in specific jobs, vr9% or 159 officers; Physical Therapist Section, or 136 officers; Occupational Therapist Section, 28% or 114 officers. Officers required in these sections in excess of the minimum number.will be members of the Women's Fedical Specialist Corps Section of the Officers' Reserve Corns, which was also authorized by this law. After the inte- gration has been completed, all future appointments in this corps will be made only from individuals otherwise qualified who are members of the Officers' Reserve Corps. This law provides, as stated by Colonel Faley, that the integration must be completed by 15 Anril 1948, Defer- ment under certain conditions has been authorized by The Adjutant General, but in no case will deferment be extended beyond 15 March 1948. To date, there have been three increments, totaling 61 die- titians, 53 Physical therapists, and 54 occupational therapists nominated. As of this date, 33 dietitians, 35 physical therapists, and 10 occupational therapists have accented commissions. Since all of the applications have not yet been received in this office, there is no information available at this time as to the number which may be expected to be integrated into each of these sections. Regulations concerning the general provisions of the Women's Fedical Specialist Corps are in the process of publication and should be available from The Adjutant General cabout the 1st of February, There seems to be considerable misunderstanding regarding the F0S and the abbreviation designation for these officers. In accord- ance with. Department of the Army Circular 17, 9 October 1947, the abbreviation authorized for the Women's Fedical Specialist Corps is WFSC, not W S as was previously announced. The abbreviation for dietitian is DIET,, not HD, and for physical therapist it is PT, not PTA as was the case in the AUS status. The F0S designation for occu- pational therapists will appear in the revised edition of TF 12-406, which is now in the process of amendment. In the meantime. The Adjutant 110 General has approved the job description and HOS of 34-16 for occupation- al therapists. In.addition, the I'OS of 4114 may be us_d by hospital food supervisors who are the chief dietitians in general hospitals. In regard to the insignia, I just have one point to add. Occu- pational therapists who are commissioned at the present time have no distinctive insignia. They arc therefore authorized to wear the insignia, of the physical therapists pending the approval and avail- ability of the insignia for the "ISC which is a silver caducous with letters IIS superimposed. The general remarks made by Colonel Haley regarding separation of nurses on the 30th of April are also applicable to members of the women’s radical Specialist Corps. At the present time this office has no information as to how many officers in this corps may be expected to apply for commissions in the Officers' Reserve Corps with request for.extended active duty. ’Vo should like you to urge the members of this corps to apply for commissions in the Officers’ Reserve Corps, bearing in mind that any officer who has'been on active duty or who is now on inactive status may apply. In addition, it is hoped that regulations will soon be published that will concern the commission- ing of civilians wrho have had no previous military service. In this connection, it is anticipated that all officers appointed in this corps who have had no previous military service will be ordered to the Brooke Army Medical Center for the basic course, following which they ’.111 be assigned to general hospitals for further experience. After those officers have served on extended active duty.for a sufficient period of time to accomplish an evaluation of their professional ability, they may, if they .desire, then apply for a commission in the Regular Army, provided they meet all requirements and have not passed the ago of 28 years. The procedure for appointment in the Regular Army will then be accomplished the same as for other officers. As soon as this regulation is published, we shall call on you to follow through on the publicity program, suggested by Colonel Anspachcr. It is anticipated that training programs for the throe sections of the corps will bo established at the Brooke Amy Medical Center on the 1st of September 1948. If the plan is approved, an applicant, other- wise qualified,- who has submit a written statement to the effect that she will apply for a commission in the Regular Army upon completion of the training program, will be commissioned in the TIonen’s Medical Specialist Corps Section of the Officers’ Reserve Corps. The education- al requirements for such appointment will be: (1) for dietitians—a bachelor’s degree from a college *or university acceptable to The Surgeon General, with a' major in foods and nutrition or in institution manage- ment: (2) for physical therapists—completion of a college or universi- ty acceptable to The Surgeon General, with emphasis on physical education; and (3) for occupational therapists—completion of four years of didactic training in a course of occupational therapy acceptable to The Surgeon General. Details regarding the procedure for making application will be 111 published in a Department of the Circular in the very near future. The career program for ..omen’s Medical Specialist Corps Officers has-been'given serious consideration and study. In the past it has been noted that some officers have spent their entire military service in a station hospital, while others have been assigned only to general hospitals. It is recommended that specialization of these officers not begin until the third or fifth year. It is anticipated that a limited number of graduate courses in civilian institutions, some of which will lead to the master of science degree, will be available before the end of 194-8. Instructions regarding the qualification of applicants and the method of making application will be published soon. Refresher courses in those specialties in selected general hospitals are also being planned. It is proposed that assignment's of individual officers will be on a planned, rotating, and progressive pattern through station and general hospitals, in accordance with the demonstration of increased ability and acceptance of responsibility. However, it is not anticipated that the complete professional training program for the '.1130 will be implemented until it is known how .any officers have been integrated into the Regular Army. The organization of. the corps is still in a formative stage. It is hoped, however, to establish an organization that will be capable of ready expansion in the event of an emergency, but which at the same time will constantly be working toward improved standards of professional performance and advancement in those specialties, 1'ith this as our goal, wo hope that the contribution of these groups to the Medical De- partment "will be even mere effect .,e in the future than it has been in the past. R. CLASS 3 INSPECTION AND VETERINARY PERSONNEL Brigadier General James A. HcCallam General Bliss, gentlemen, I am glad of the opportunity to appear before you this morning and convey briefly some information pertaining to the veterinary service, particularly regarding inspection at origin, the veterinary personnel situation, and one or two other items. Class 3 or inspection at origin is the most important of the several inspections with which the veterinary service is charged, not only relative to determining the soundness of the food item and its processing under sanitary conditions, but to insure that the quality of the product complies with the specification and the purchase in- strument, thus insuring that the food is nutritiously acceptable. Inspection at source or origin is a policy of the Department of the Army. Under the provisions of LX) Circular 138, 1946, and LD Circular 47, 1947, the army commander is responsible for the accom- plishment of inspection at origin of all foods of animal origin in the army area except in those metropolitan areas where general depots are located, and such depots are expressly charged with the procure- ment of foods. Then this inspection in the metropolitan area is charged to the veterinary service at the depot. This arrangement has not been entirely satisfactory from the standpoint of command, administration, supervision, and economy and efficiency in the utilization of personnel, T7e will take the San Francisco area as an illustration. There were two veterinary units in that area, one an Army unit at the presidio, and one assigned to a class II quartermaster installation. The one at the Presidio did no inspection within the San Francisco area but operated in con- tiguous areas, while the veterinary personnel assigned to the class II installation in San Francisco had no business outside the metro- politan area, and, in fact, could not inspect outside the San Francisco area. This division of responsibility caused so much confusion and lack of efficient over all operation that the Veterinary Division, Surgeon General’s Office, initiated a letter to the Manpower Control Group, Department of the Army, recommending that the veterinary personnel assigned to the Quartermaster class II installation bo transferred to the Sixth Army, thus ...king that army responsible for the veterinary service in the San Francisco Area, The Quartermaster General and the Sixth Army concurred and the transfer was effected. The conditions cited existed to a lesser extent at two other places and were corrected by the tr.xnsfer of the personnel to Army jurisdiction; in one case the Amy headquarters initiated the request. Emphasis is placed on this situation because it is our firm belief that all veterinary personnel, including veterinary officers doing this type of inspection assigned to Air Force stations, engaged 113 in the inspection of food at origin should be under the control of the Army, or at least under the technical supervision of the army veteri- narian through the army surgeon. This is for economy and efficiency in operation and for the most efficient utilization of available personnel. In this cpnnection, it should be remembered that the veterinary service at general hospitals, ports of embarkation, and class II installations is under the Amy. Until such tine as a further revision of Circular 138 (1946) is made, we are accomplishing it piecemeal, as mentioned above, 1 want you to know our policy regarding the subject and that several members of the Manpower Control Group, Department of the Army, with whom we have talked agree. That is why the several transfers of veterinary units have passed from ;;lass II to Army class I control, VETERINARY PERSONNEL A condition causing us increasing concern and in which you have an interest is the inability to meet requisition requirements for veterinary personnel (officers and enlisted) in the zone of the interior and overseas. Since June 1946, a shortage of veterinary officers has existed, becoming more acute with each separation be- cause of expiration of term of service or otherwise. This shortage has not only resulted in spreading those available rather thinly in attempting to accomplish our mission and assigned tasks, but it has retarded the Veterinary Corps in the development of its training program and research activity, lie were unable to take full advantage of authorized available vacancies for specialized training in civilian institutions. Nor have we been in a position to assign officers for specialized training in advanced courses given at Army schools. The present authorized strength of veterinary officers, regular and temporary, is 575. VJith a current strength of 398, we are 177 under the authorized ceiling. Between now and 31 December 1948, 90 category V officers will be separated because of expiration of service, leaving the Veterinary Corps with an aggravated • shortage,’ A logical question would be, f*Mhat have you done about it?n Over a year ago we started a program in our attempt to get officers to come on active duty for a period of two years. Me went to the associations, had articles written in the periodicals, and wrote to the deans of colleges, but we haven’t had much response. Replacements have been negligible in spite of everything that we have attempted,_ There is one thing that did help us somewhat—our authorized ceiling of Regular Army was set at 186, With the backing of The Surgeon General, a paper was prepared and presented to the Staff, requesting that we be authorized a temporary increase in order to take advantage of the experience of the limited number of officers that desired to come into the Regular Army. The Staff agreed to this, and we were able to obtain about twenty additional officers. Since then we have had some 114 losses, retirements, and declinations. I think we made a net gain of fifteen. This overstrength, however, will be absorbed by attrition when Regular Army colonels leave on retirement. Therefore, our records on officer personnel indicate that the situation will become , increasingly critical with the passing of each month in 1948 and will seriously impair the efficiency of the service, which.we are expected to give, through, our inability to provide adequate direction and supervision by officers. Another point I should like to make is the need for the army veterinarian to make inspections of his area from time to time, I think it’s especially important at t*iis time that many of the younger officers who are in the field receive adequote supervision by the army veterinarian under the jurisdiction of the army surgeon. The army veterinarian should get out and check his workload in that area, resolve any difficulties that may arise, and provide uniformity of inspection regardless of the inadequacy of personnel strength, 17e will appreciate your assistance-In-this matter, I want to say a few words on the question of inspection of .fruits and vegetables at. general hospitals, 1 ie have been asked on several occasions why veterinary personnel assigned to general hospitals do not inspect fruits md vegetables on receipt, especially for condition and soundness. Although the veterinary service is specifically charged by regula- tions with the inspection of foods of animal origin, it is not limited to the inspection of such foods at post, camps, or stations. In some places the inspection of fo.ois of other than animal -origin is being accomplished. by veterinary personnel. In fact. The Quartermaster General wants the Army veterinary service to perform the inspection of all foods purchased by the Army, including laboratory examination. We are not in-a position at this time to take on the vast volume of work such inspection would involve. However, it is our policy that destina- tion-inspection of all foods may be accomplished' at’ posts, camps, and stations as' far as veterinary personnel’are available at. such places for this work, particularly with reference to the.condition and sound- ness of such food items. mention this phase-of inspection at. general hospitals because we were informed recently that in some places,- dietitians were: spending two or three hours on such wurk and were queried whether veterinary personnel could assist in or perform such inspection. It is your prerogative as commanding officer to utilize veterinary personnel on such work at the hospital. I believe that one or two of the hospitals are doing this. There are no veterinary personnel at Beaumont,.but veterinary technicians from the station are doing the work. ltfs also being done at several posts and stations. The only request we make is that in performing such work, it does not interfere, with the primary mission of inspect- ing foods of animal origin, particularly if the officer or enlisted man is doing inspection work at ciuss 3 or point of origin. At most 115 general hospitals the latter would not be the case, as a meat and dairy technician is assigned the hospital to accomplish destination, storage and inspection prior to issue. DISCUSSION COLONEL' ROBINSON;. General Bliss, Colonel Doan has given us . the rest of the morning for discussion and I'm sure it -will be all right with you. , GENERAL BLISS; Yes, this can be taken un with discussion now by anyone or everyone- on the nersonnel .oroblems, I thought perhaps I could inject some kind of a note into this about statistical nersonnel, I am per- fectly aware that hosnitals are not run by statistics and these figures that I'm giving you now have to do with operating Personnel in general hospitals covering a period from January to November 1947. It has been a very interesting experience, going down from some 200,000 patients in our hospitals to 16,000 now in our general hospitals,'and following the curve of personnel. As you know, we are checked very carefully by the Fanpower Board, by the Bureau.of the Budget, and by all the agencies in the Department of the Army, Our calculations are made on the total Army strength. The Army strength is much below what we contemplated it would be, ! The health of the Array happens to be the best that it ever has been in the history of the Army, We have fewer patients. However, w e get some figures that are interesting anyway and sort of mitigate terrific arguments by us for getting more personnel at times, I'm always willing and in favor of personnel when we need them. We have this analyzed, by personnel per hundred authorized beds, personnel per hundred patients remaining, personnel per hundred beds occupied. The types of personnel are male officers, female officers, enlisted personnel, and civilians. We authorized a certain number of beds. The beds have gone down in authorization from 35,000 in January 1947 to 25,000, At thfe beginning of the year we had 75.5 per cent personnel per hundred authorized beds. At the end of November, we had 98.4- percent per authorized beds. This probably doesn't pertain to any one hospital here as these are statistics from all general hospitals. We had an increase of 30 per cent in the number of personnel per beds. In personnel furnished by The Surgeon General, we had 60,2 per cent per hundred authorized bods at the beginning of the war. Wo now- have 74 Per cent, an increase of 23 Per cent. It has been a big complaint all the way through that the Armies were-not- furnishing their number. They start out with 15 per one hundred beds at the beginning of the year and end up with 24 which is an increase.of 60 per cent. With male officers we started out with 6,6 and nowr have.9.3 an increase of 60 per cent. The female officers decreased; they started w/ith 8 per hundred beds and ended up with 7.0. The enlisted personnel started at 37 and ended at 42 an increase of 14 per cent. Civilians, and! realize that there is a difference between graded and ungraded civilians, I realize all the implications there arc with reference to all these things, started out at 24 Per hundred beds and ended up at 39, Now; to analyze that further in personnel per hundred patients remaining I'm just 117 giving the increases, if you mil, in total they came up from 62,7 people per hundred patients remaining, to 139.8 an increase of 69 per cent. Those furnished by The Surgeon General increased 59.5 per cent. Those furnished by the Armies increased 106,5 per cent. They started out with 16.B people Per hundred patients remaining and went up to 34.7, an increase of 106,5 per cent. The officers increased by 81,9 Percent; female officers for each 100 patients remaining were increased in the year by 29,9 per cent; enlisted personnel 47.4 per cent and civilians 112.7 per cent, The personnel per 100 beds occupied. These are comparable figures that they use in all the government services. Some of them figured the beds occupied and some of them patients remaining and some of them total beds, he have them all. At the beginning of the year'we had 26,886 patients in occupied beds and at the end of November 13,765 in occupied beds. The percentage increase in people nor 100 beds occupied was all the way through 82 per cent, 72 per cent, 122 per cent, male officers 97 per cent increase, female officers 39 Per cent, enlisted Personnel 59 per cent and civilians 129 per cent. So at least statistically we were better off. According to these statistics, the standards of many of our general hospitals would appear to have been improved as far as numbers are concerned, I hope that it will all be brought out in the discussion as to why you are short and if you are short all right, but it has actually increased that number since the first of January until the last of November according to very carefully analyzed and detailed statistics, I know that some of the big cuts in perconnel came after November and later figures may show a different story, but at least through November the figures are encouraging, I’d like to say one thing about the insignia that was rather interesting to me. It came up two or three times during the war and since the wat, I believe that it is impossible to got an insignia which is approved by anyone except one person. I’ve never seen any two people agree on an insignia, I hope the new one will be nice, C0I0NEI HDBINSON: I have a few notes handed to me to announce. First, the Army Surgeons should note that the Public relation officers throughout the Army are being notified of the Army Nurse needs. In other wbrds, they will be told that 25,000 nurses mil be granted commissions in the officers’ reserve corps. Four thousand of those will be permitted immediate active duty in Army general hospitals. They will publicize the fact. They wall very likely come to your surgeons in your stations for further information. Anything that you can give them will be acceptable. Also,, another note is to the effect that General Dalhquist is very much interested th'at all of those officers who are eligible’ for promotion get promoted promptly. Please get their recommendations in in the ordinary way. That includes all corps of the Medical Department, and, the criteria are all published. We would like now for our procurement program to be thoroughly criticized by you, I know* Colonel Gorby wants to say something. 118 COLONEL GORBY; General Pliss, I would like to t)rnsont the problem of the Army surgeon from, my standpoint which I believe is equally applicable to the other -'rmy surgeons on an area basis, I’ve had a. little personnel study made in ry Sixth Army Area and in trying to invision the requirements at a certain date, the material I ha ve to work with, and then listening to these stories I am a little pessimistic. T'e have to get some answers. As an example, I would just like to cite one or two things—I go down in medical corps officers from an assigned 234 on an authorized 205 at the present time to 133 following the April exodus and down later in the year to 94* Of those, 25 are assigned to T/O units. And of the remainder, some 15 are at present on duty supporting class II installations which are isolated, and which have to be covered, Y.hen you subtract the 20 which are with.the 2nd Division and the Engineers Special Brigade you don’t have much left for your own requirements. Of those that remain, I don’t have qualified personnel to cover what I consider the primary mission of the Medical Department—service to the lino in its field operations and training. And this takes no cognizance of the UMT program which I think we all have to consider, Be are exploring contract dentists which I hone they will give us; exploring contract surgeons as to their Probability, but we need some help for a pa rt-time contract surgeon or a little more for day-time contract surgeons does not solve our situation now with the present price of things outside, I think that some legislation should be inaugurated to change that so wre can offer them something and got qualified personnel, I think that we can make out in certain of our station hospitals where we have a residential responsibility if we are given some qualified personnel to head up the major services. That is, a man that can serve as the chief of medicine, the chief of surgery in say a AOO-bed hospital. One that we can depend on in evaluating the officers, leading these ASTP’s, etc., contacting them and interesting them in the Army. Y.re have quite a few other officers at Biggs Field .and I think contact with them or competent personnel of that nature is import-o nt, I have no other comment, I would like to assure you that no one is any more interested than I am in seeing that we get this training program completed, but as I listened to cur program hero, which is fine, I can’t see. where we are going to get the personnel to cover the Army requirements and I’m sure that this applies equally to all the other 'rmies, C0I0NEL ROBINSON: with regard to Colonel Gorby’s question about hiring civilian physicians, I stated in rry original talk that that legislation has gone to the Department :of the Army, and that it is expected it will be proposed at this Congress, As to the other question of Colonel Gorby’s specific needs in the Sixth Army I 119 think that it would bo much bettor for that to be discussed in our Division with ny officers, I'd still like to have my procurement program torn to Pieces. COLONEL WI1 LIMITS: I have one question on my mind reference to procurement of personnel. We are all aware, and have been for some time, that we are progressively losing'officers. As we get vacancies, we will requisition on this office for replacements. You will be unable to fill all those requisitions, I request that when you do have a replacement that you teletype'us the necessary information on the individual and let us decide where he will be assigned. The picture mil be changing so constantly that only the Army surgeon will be in a Position to know where the need is most acute and where the man should go, CO 10NET. ROBINSON: Colonel Bramlitt will you make a note of that information for further use. COLONEL BIESSE: I think we ought to consider a bit-more the use of the Eedical.Service Corps, In the past, tic never .have given that proper consideration, yet that is the one place whore we can hope to get substitutes for the medical officers who are not on purely professional status. It seems to me, as we go over our T/O's, we can so‘frequently substitute if we can get the right kind of a man, Ye had difficulty with the old administrative corps because they were taken in in a haphazard manner. We had some good men; .'we. gat a lot of poor ones.- Then there was the proper assignment arid training for that assignment before the man went out. You've all seen them come into a general hospital for instance, and maybe have the) post* exchange thrown at them or various things. I've seen some have three or four jobs thrown at them immediately without any training whatsoever. We had some TTSC officers that we threw in with tv- basic course at Carlisle at that time, if they-were convenient in that general vicinity, and so on, Wq didn't give those people the proper chance, I think that we can, with better selection now- and with still more emphasis on.good selection, study the qualifications of these men, I think we will find that there are some that will definitely show up badly if you put them in an office when-they are entirely qualified in a- different fiold. Others again will show a special'line, I think training should bo sot up to make them possible substitutes in some of these places; I'm referring to the fie]d.of preventive ■ medicine. - There probably are a great many installations that have to do with water purification, waste disposal and everything else. There are many of those jobs that could be handled by trained ESC officers* By trained I don't mean the courses—-which' ! there seem3 such a tendency to put out today—ten.days, thirty days and so' of them aren't worth the time, the travel, and the expense* I believe, however, if you would put these selected men in training in preventive medicine, they could qualify. 120 We plan to do, that in battalions especially by giving a battalion surgeon's, course. We put them in during the w;ar and w;here they wore properly selected, it worked out very well. In some instances it didn't, because they hadn’t been properly ; ■ selected and trained. There are other conditions—the courses -■ must be of sufficient length, duration, and enough thought put into them to qualify the man for the job, I think as wo look over the various T/O’s we can still find a good many places to save medical officers. If we do that, our nroblem of course will be the err. .agency problem, I don’t know whether we wall have time to work up this training to a point where a nan w/ill qualify. In peace tine, I don’t see w;hy there should bo any problems. It is possible that training could be worked up so that in an emergency we could still qualify a sufficient number of FSC officers to take over a great many of these other jobs on which we are not using medical officers, COIONEL ROBINSON: I'm certain the Training Division has representatives here wtio wall take cognizance that, GENERAL DENIT; I've got a lot to say but I'm not going to say it, but I do want to say that I’m opposed to any idea of subsi- dizing anybody. That has been studied by me for over a year and one-half and for-two years' I have been thinking about it in a larger sense, I hone.we don't go along with the Navy with any idea of subsidizing the individual. In the first place, medical schools can’t take them; they,can’t take anybody else, but you all know; my view/s on that, I m not sure, but I think this contract surgeon business at $150 a month w;as started back in the Spanish American War and it is the most ridiculous thing I’ve ever heard of in ny life—$150 a month] I think-that whole thing ought to be wiped out, I think that law and regulation, I think the w;hole thing ought to be wiped out. It’s merely an insult. Now, this thing that Colonel Williams has been talking about has caused me serious concern, so much so, that I waote a letter the other day to every one of my hospital commanders and told them that the show must go on, whether Helen Hayes played the leading, part or not. Somebody has got t take her place. Therefore, if Helen can’t act in the show;, they must take these youngsters and start to train them right this minute to take their place, -We'll have to go back to the days where boys w;ere told that they must understudy some one for EENT and some one for this, etc. We have no idea in the First Army of dissipating our forces. We expect and hone to keep one or twro station hospitals at the highest level possible. We are going to put on this soring a command post exercise on which w;e are making studies now; ■with the-Air Corps, We are 121 going to utilize cub planes and motor bouts for evacuation of our patients around Jay, you knor we are on an island there, and some- times you can’t get out because of fogs. I ’vq talked it over with, not the fir Corns, but the officers that fly, Wie flying officers that are on that fiel d there and we are going to out on these exorcises to see if we can bring patients into Jay and over to Totten, etc., by plane for necessary work. The Question of whether we can have dependents on the plane has come up and we have decided that dependents ;were going to be cabled an emergency. If they need surgery,, it is an emergency* That's how seriously ,we regard the situation. Now I just want to say one more thing—I certainly cbn't want to see anybody subsidized, CO 10MEL ROBINSON: General. Denit, I would like to,t ask you a question. Do you consider commissioning a resident in his civilian residency and ;al lowing him to stay there as a subsidization? , GENERAL DENIT; No sir, I think that is a fine thing. There is no more reason .why we-sh.ouldn't do that than why a boy should graduate from West Point and go to the University of Virginia,- to study law. I'm delighted with the idea and I'm not criticizing any of your program* The thought I am criticizing is any idea of taking up boys out of high school end subsidizing them to nine years of school;, then you have an indentured slave* It’s the same old in- denture, We have found out after long experiences that this in- denture problem, is no'good. We eon't want anyone in the Army except the people that want to come in. GENERAL QUADS; I have a question here with reference-to this Circular 79 on the senaratioh of officers by 30 April, There is no reference made to-patients, irrhet are we going to do for example with a nurse patient who is in the hospital awaiting disposition? CO LONEI LORI NSC N: 1'r,re have proposed'a change in that circular already and I wonder if any of my division—"Is Major.Mackin here—did you write that?” ■ / MAJOR FACKIN: Yes sir, but the Adjutant General is sending out a radiogram’thatwill be back to usotpday for concurrence which will allow the commissioning of oil people in the detachment of patients in the "Honorary-Reserve.” They wi}.l be retained on duty in their AUS status until they have completed their hospitalization, • at which time, if they are physically qualified, they wall be com- missioned in the active Reserve, if not they will not be commissioned in'the. Reserve, GENERAL QUADEt Will that apply to nurses? MAJOR MACKIN; Yes sir. The matter cf nurse ray, however, after 122 1 July will, I imagine, have to be covered by a separate directive to finance officers to assure their payment, but we will follow up on that too, sir, GENERAL QUADE: The other question I have is in reference to the Secretary of the Army’s orders which seems to provide overtime on the regular basis, rAJOR MACKIN: We'll have to take that up with civilian personnel, GENERAL QUADE: One other statement that was made by Colonel Maley that I didn’t understand. She made some reference to not being able to use a reserve officer in a grade of Major which would call her back as a grade of Can tain, I don’t understand that, COLONEL ROBINSON; Will you talk to the Nursing Division about that? COLONEL RUDOLPH: I have no particular comments about the procurement program. Of course, we all realize the urgent necessity for getting people and when I look at my loss figures here for the past two months and a half, it's very startling. The figures are, of course, the same as those of the Sixth Army and the Fourth Army, Here’s one matter of Personnel though that I would like to mention, and that is the policy of using hospital beds in station hospitals as a yard stick for the allotment of personnel, I find that 50 to even 75 per cent more of our medical effort on our stations is exclusive of the people occupying hospital beds and I hope that something can be done about it, COLONEL RDPINSON; Colonel Thomas would you like to make a remark? CO LONEL THOR AS: * I have been learning a lot about these problems and I must say that I think that I have been influenced by my trips around to take a much more cheerful attitude than the talks this morning, I think perhaps I shouldn’t say that, because I think everydoby seems to.be taking it as seriously as they possibly can, and there seems to be no danger that anybody will overlook■the' gravity of the situation. However, I do think that it’s worth saying that the bottom has been passed and that there is- a very great interest in Army medical careers, I think the AS TP boys are taking a different attitude and it took a little while to1 get over the Niagara valls of the people rushing away from the Army, the medical officers trying to get back home. Now that's over and I honestly believe that the tough spot has been passed. Of course, that doesn't take care of this immediate critical period of two years that Colonel Robinson is so much worried about, but I cb feel more cheerful about it because I think the Army Medical Corps is in perfectly wonderful shape, I think that the Staff— everybody that I talked to up there is interested. They realize 123 these personnel problems were foreseen in The Surgeon General's Office back in 194-3 and 1944, and the requests for action at that time were denied the Medical Department by the Army, Now their attitude is very different. The only thing that I really want to say is that I believe personal approach in orocurement of medical officers is very important. However, how we can ~ot the people to_ approach these doctors—civilian doctors—with our present shortage, is of course the whole catch. We would all like to go out .and spqnd our time talking to people who are interested. There are certain ways, and that is being thought of very carefully, I believe that is the thing that I would like to leave with all the visiting officers which is their opportunity to do the final pair up which is the por so nal anpreach. GENERAL HIISS; I want to say ,iust a word. I hone the Personnel Division is doing that and that it will show up in time, I have found in my traveling around that the medical officer wants to know ,That you have to offer him, definitely and specifically. We have gone out now in Europe, ETO, and we have heard that they need 143 key men, and they say where these key men will be assigned and what they will do. They also told us that the key men which we will send-ever can take their families with them on the; boat and so forth. I hone that personnel is going on that basis in the United States as well as in ETO, We are approaching every single doctor in the country. Colonel Amspacker didn't mention that. He has written to the deans of every medical school and every hospital and all of the consultants to approach those doctors all over the country—offer them definitely something that they can do in Germany at the present time for a year, I am certain that, properly approached, a great number of these ASTP men who are now being di schargod, who could bo promoted to Major after two years '-s service, and are told, that they wculd go to a specific place for a yr a, would go there. As far as the contract of course that’s actually obsolete, but personnel, Civilian 'Personnel, has told me that we can, at the present time, hire doctors under Civil Service on full or part time basis. The administrative procedure is difficult but it can be done if you know someone who wants to come. If yr u can get him to come in, the arrangements can be made that they will come on at a specific salcry for as long as you want them—about a day. GENER/ L ARMSTRONG; I think you all kn°w Harold Glattly, Hal is a medical officer op detail with the Inspector General’s Department, He came down the other day and asked me if .1 would ask the hospital commanders if they would be interested in selecting from their staff a medical service corps officer, who, perhaps, they are now utilizing 124 as a hospital inspector, and request that ha be detailed to the Inspector General’s Department, It is the-opinion of The Inspector General ~fficers with vhom he has talked up there that it would increase the stature, so to speak, of this officer, would give him a direct channel to The Inspector General. He’s still your man. It seems to me on the face of it, that it might be a good deal more valuable to you than just to designate him,in a hosoital order. Think about that daring the lunch hour and I'm going to ask for a show of hands before we break up this afternoon, GENERAL VVI7.IIS; I would like to interrupt this meeting a minute just to say that at the present time with the 23 or 26 whatever it is that we have as FMS and T's for the medical schools, we have, generally speaking, the cream of our crop of officers on that duty. Those that I know are tops—they are the very best that we have. Certainly those that went from Brooke Army Medical Center are just the tops of our officers, I think more publicity might be obtained through the American Medical Association and certainly through the secretary, who is one of us, I also think there should be perhaps a more liberal policjr of authorizing and ordering officers and even the younger officers on the professional service, at government expense, to attend the medical conventions. I think there they will get the contacts and can sell a great deal for the Medical Department. Of course, the promptness in processing of those applications that do come in is of inestimable In connection with the attending of these conventions, societies and so forth, to got many of them to present papers as possible, I think that will be good for us, I was talking with an officer just recently, at noontime, and it seems that there is a possibility of some of the better ones of these ASTP's being promoted. If we can promote some of those who are going out next April or March to a majority, that gives them a pretty good increase in pay. To do that, they will have to volunteer for a year's service and then be eligible for the $100 a month extra. Some of them mil want to stay, .Also I would like finally to give the experience that we have had in bringing the Medical Corps as a career to the attention of the young officer. If you get them all in a room like we all are here, and talk to them about coming into the Army, you don't get any response, ItTs just like a man getting religion. It’s something of his own, and he doesn't want other people to bo talking to him about it until he has made up his mind. We got nowhere when we talked en masse so we put a notice on the bulletin board that any officer interested in the Regular Army could contact by phone, give him a phone number, plan that there would be an officer to talk to him privately, The officers that talked to him privately was Colonel Streit, General Martin, the assistant commandant of the school, and myself, and we got a tremendous response to that. They would come up for interviews and we got a good many applications from that way of handling. 125 GENERA! A HI* STRONG: Thank you very much. Those are fine suggestions, I hone some of your crew will take them down. I saw Hal Thomas writing back there. Did you, get them all? I think they are fine, C010NKL GENTZKOW: Speaking of the FMS and ,T* s at Valley Forge, we have already contacted the throe at the schools dn Philadelphia where there are R'S and T* s and have arranged for a clinical afternoon, a visit to the hospital, dinner at the officers* club for the junior class now engaged in ROTC some time in March or April as soon as the weather opens up, I throw that out as a little advertising slant. 126 S. HOSPITAL ADMINISTRATION PROBLEMS Colonel Uilliam D. Graham Colonel Achilles L. Tynes- >• Major Helen C. 3urn3- COLONEL GRAHAM; General Armstrong and gentlemen, I have placed'on each uray surgeon’s tablet a request for specific information about station hospitals. A copy of that has also boon put on General Grow’s place and I am urgently in need uf getting this Information so that I can proceed with studies for the Hawley Committee and for a Congression- al investigation and study. I would like to have this as soon as you can possibly get it together for me as I need it on the 26th of January. If this is too big a job, please give it to me as soon after that as possible’ but let me know when X may expect it from you. I realize that asking you for this information which should be secured through other channels is requesting a favor, but it is one which is of the utmost importance to the Medical Department and I feel sure that you can contact mo personally with the information. ‘ rRRD SERVICE CHARGES - DEPENDENT CARE The care that is rendered to dependents by the Army Medical Department is considered to be legally authorized by the phraseology of the Act of 5 July 1884 (10 USC, Section 96),.the pertinent portion of which reads, "medical officers of the Array and contract surgeons shall, wherever practicable, attend the families of officers and soldiers free of charge," There have been many rulings which have supported the rendition of care to dependents provided that faci- lities are considered by the hospital commander to be available. Military personnel are not entitled to the medical care of their dependents at the direct expense o't appropriated funds, but their ■ dependents may bo given such care, and only such care, as is available at Array medical installations. It has always been the policy -of The Surgeon General of the Army to render as complete medi- cal service to military personnel and their dependents as has been possible. Prior to the war> the wording of the Medical and Hospital Department appropriation directed that the monies authorized by the Congress for the medical care of the Array were appropriated, "for the medical care of officers ana soldiers," and this wording had been identical for many years. It was, therefore, considered proper and was construed to be legal to make additional charges for various expensive medicines and for blood usod for transfusion in the treat- ment of dependents, and charges were also authorized in many medical installations-, which when deposited in the’hospital fund, made avail- able to the hospital commander additional monies with which to defray the salaries of a few maids or female attendants for the care of dependents. In 1944 the wording of the M and HD appropriation was changed to read so that the annual military appropriations act pro- vided funds for, "medical care and treatment of patients’ when entitled thereto by law, regulation or contract," Since by derivation from the law of 1884, medical care could legally be given dependents when 127 practicable, and since by recent law monies are appropriated for the care of such patients, the collection of ward service charges at the present time would be an operation specifically prohibited, both by presidential directive'and congressional action. Both the President and the Congress have indicated that it is illegal to supplement appropriated monies“to perform functions for which appropriated monies have been made available. The Medical Department budget is established'on statistical,data derived from experience as to the number of patients who will require medical care. Dependents are included in the total, and when the various factors are applied to set up the budget, sufficient money is included in the budget to provide for the care of dependents. In a similar way, beds authorized for operation meet a total that includes the requirement for depend- ents. In spite of the frequent reductions in personnel made available to general hospital commanders and to station surgeons, the number must either be considered to be adequate for the care of all patients, or dependent care must be curtailed. The entire problem of dependent care might seem to be capable-of solution were the Army to request legislative action similar to that recently obtained by the Navy. However, when the Navy law is analyzed, it dees not afford as great potentiality, either for the care of the dependent or for freedom of action by the Medical Department of the Navy, as existing policy and law offer to the Army# There are at present a number of plans in effect in various places that directly or indirectly embody the collection of ward service charges from dependents. Some of these have been established because the allotment of personnel to operate the hospital has been so reduced that dependents’ wards cannot be staffed, and the post commander has, notwithstanding this shortage, directed the surgeon to render complete care to dependents and has approved or directed a per diem charge. In other instances, dependents, have organized themselves into a type of ’’blue cross" organization, and by paying dues have guaranteed that maids and female attendants can be empljyed to care for them in the post hospital when they become ill. Undoubtedly, by the variations inherent in these various systems, complaints will be made to The Inspector General by individuals who do not desire to participate or who refuse to pay. The Inspector General wL II again- ■ ■ indicate that procedures of this type are improper and must be- immediately discontinued, as was done in 1944,' The bnly solution I can suggest under the present situation is that army surgeons explain the background of dependent care-to the army commanders and then attempt to insure that all funds of the Medical and Hospital r Department appropriation that are allotted to the army commanders are' suballotted to those stations that are so in need o-f them. The Army Surgeon should then make every effort to guarantee to 'the station •* surgeons that personnel authorization in sufficient hufciber, both civilian and military, will be given to operate' the station-hospital. Following this, it is essential that the personnel actually be made ; 128 available bo fill the allocations. ■ < \ CARE OF NAVY DEPENDENTS Since the passage of the Unification Bill, numerous problems have arisen with respect to the xaeuical care of members and of dependents of the three armed forces, and a tremendous amount of pressure is being applied by congressmen and others for an immediate s elution. This has been particularly true in the case of the authorize ticm to dependents of the Navy for a'Amission to Army hospitals. The entire problem is being referred to the Secretary of Defense by the secretaries of the three services with recommendation for mutual eligibility of the’dependents of all services. It appears reasonable that the matter will be referred to the Hawley Committee for consider- ation. As you know, the Army has for many years rendered courtesy type medical care to Naval dependents in many instances. This has been a great contribution by the i,ray in the past in view of the fact that at that time the Navy could not hospitalize its dependents. Immediately before the appointment of the Hawley Committee, informal approval had been given for the extension of dependent privileges wherever practicable to the dependents of the Navy and at the same charges, namely, subsistence only, but formulation of the approval appeared to be precluded by the establishment of this com- mittee. No definite decision can, therefore, be given at this time. It is certainly in keeping with our past policy that we should make every effort to give as much care as possible to dependents of Navy personnel, if facilities can possibly be construed to be available, and v/hen such care involves hospitalization and can be given to Army dependents, it should be given. This is being carried out of nec- essity in medical installations of all services in isolated areas, such as the overseas theaters, and in certain places in the U.S. It is obvious that with the personnel situation as it is, there may have to be curtailment of the entire dependent care program, but while possible if should be given under the provisions of AR 40-590, construing dependents to include those of the Navy as well as those of the army until a final decision has been approved by Mr. Forrestal. SICK LEAVE Discounting the statistics that result from the large amount of sick leave given before and during the Christmas season, figures available in the office indicate that approximately one patient out of every five on the rolls of the general hospitals is absent from the hospital on sick leave. There are about 2,000 veterans in these hospitals and 2,500 dependents and other civilians. Sick leave is not granted to patients in these categories. Therefore, when 129 the total patients remaining are adjusted by subtraction of veterans and the dependents, it appears that one out of every three military patients has been granted sick leave, and this figure is maintained throughout the year except for the tremendous increase at the Christmas season. Further analysis of the data indicates that only three percent of patients in station hospitals are granted sick leave, but of the station hospital-type patients treated in general hospitals, approxi- mately fifteen percent are given sick leave. Professionally indicated sick leave has been, and must continue to remain, a prerogative of the Medical Corps, It is only by the careful screening of all requests for sick leave .on a professional basis that we can hope to retain this authority. During the war, both because beds were needed and because it was essential for his morale, the patient was allowed to spend time on sick leave, even though it might prolong his ultimate disposition. It is the current practice to permit patients who are awaiting administrative action on retiring boards to be absent from the hospital on sick leave because there is no other administrative category, such as administrative leave, in which they can be placed. Because of the interpretation of the wording of the Armed Forces Leave Act, as amended, it is highly probable that the granting of sick lep,ve to these individuals mil very shady be prohibited, and it will be required that these patients utilize their accumulated leave during the waiting period. This action has tnus far been forestalled by this office by the representation that these patients would refuse to take accumulated leave for this purpose and would remain present in the hospital with the inevitable results of violation of regula- tions and disciplinary problems. However, it is immediately apparent to anyone receiving Medical Department statistical reports that we are granting sick leave to approximately 4,000 out of 17,000 patients, and this large number comes up for constant justification. T7e urgently recommend, therefore, that requests for sick leave that in any way prolong final disposition and are not thoroughly based on professional requirements be disapproved, .HOSPITAL FOOD SERVICE MAJOR BURNS: After the speech just presented by Colonel Collins, I’m afraid ray talk will- seem a little dull, but to us Hospital Food Service is important, I should like to give you a little of the thinking that wo are doing here in the office and that we are trying to get out to the dietitians. . The aim of the Hospital Food Service is to provide nourishing and appetizing food for the patients, person- nel, and the staff of an hospital. The purpose of the Hospital Food Service is to accomplish tills work with efficiency by means of well thought out plans of operation and the use of personnel and 130 material. All of our hospitals haven’t as yet accomplished the organization set-up we would like .to see--that is, one which will work more or less like clockwork. There should be a maximum economy through firmly established administration methods of control in planning and use of materials. Then we need to have organized training, he are progressing toward these goals, and we hope with specialized personnel that we will soon reach them. Everyone of us agree that the food service suffered mure with the change of person- nel than any other department. During the war most of the hospitals had trained civilians. Then we were told that this group had to go and their places would be filled by enlisted men, he were rather happy to see it, because I think we all like our GI cooks. However, we found the men coming in were untrained youngsters. It was nec- essary to start from scratch and train them as best we could. In some hospitals they were just sort of dumped in on the department; therefore, the organization that h d been set up broke down. That group has gradually been replaced by civilians, and the organiza- tions arc on the upward trend. • You probably wonder what your chief dietitians have been gaining in the symposiums and institutes that they have been attending, when you probably felt that it would be much better if they had stayed at the hospital where their assistance was needed, I think if they got nothing else from attending those meetings they did get away from their jobs long enough to see the 'apartment as a unit. Too many of them had been so close to the job itself that they hadn’t been able to see the over-all problems. They als'o exchanged ideas with other chief dietitians—which is always good. Stress was raid on the need of having a definite plan of operation, fixing responsibility through established lines of authority, systematizing the work, and establish- ing operating rules and regulations. In order to accomplish this the dietitian will have to have certain “tools,” and wo are trying here in the office to help her out with these. It is realized that in the hospital the dietitian doesn’t have time to do-much of this detail v/ork. A film strip, which will be entitled '‘’Training Hospital Food Service Personnel,” is now under way. This film strip'we expect will be'broken down into four parts. The first part will be on “Indoctrina- tion of Personnel Assigned to the Hospital Food Service.” The second part will be on “The Operation, Care, and Maintenance of Hospital Food Service Equipment.” ’Te realize that much of the equipment is the Engineers:’ responsibility; but yet we’re using it, and we have to get the maximum use out of it. By instructing our personnel, I think we will accomplish this. The third part concerns “Serving of Food to Patients.” That will take in the dining room and the wards. The fourth part concerns “The Preparation of Special Diet Food.” ie haven’t cleared all of these with The Quartermaster and other services, so there may'have to be some changes, T,7e need an active training program for all of our employees. 131 particularly now with so many new ones being employed. During the war we did have a good training program set up, . ,ith the large number of replacements being made, it has been necessary to do most of the training on the job. This is good training, but time should be.taken to give reason for instructions in order to gain the desired results. Dishwashing is a good example of that. One can go in time and time again and tell the men not to stack the dishes, but invariably t.he bowls, cups, plates, and.everything else are in one box. It takes time to stop and show them that you have a reason for the separation of dishes and if done properly it will not be nec- essary to send thorn back the second time. The results are usually better. .It is believed the film mentioned above can be used for training new personnel and refreshing the memories of our old person- nel. TTe appreciate the fact that the dietitians have been given the opportunity to discuss their problems with the commanding officers or the executive officers. This is one of the things that we ran into so much in making inspections. The dietitian didn’t feel that she could go up to the front office .A oh her problems. rJe, who have been in the urmy, knew that that was not so, but there were many coming in who weren’t acquainted with the ways of the Army, These conferences have been most helpful. You probably wonder about the menus that are being sent in—why wo have them, be like to have them in case any. questions come up regarding the items 'used. And wo are constantly getting questions. That .brings up reports that we are asking for. . be will try to keep these to a minimum, as we know that you have many other problems to deal, with. In order to make intelligent studies of the requirements of the Hospital Food Service Department, it is necessary to know the number of main kitchens in operation. No two of our hospitals are the same. The, number of diet kitchens serviced is also required. It is not possible to assign one dietitian to one hundred patients; because, while in one hospital the proportion of one to one hundred would be fine, in another, where the setup is quite different, it might take one to seventy-five, or in still another you could probably use one to one hundred and fifty. Much depends on the physical set-up. Too often we are told by other services that there is no ■ difference in the feeding of troops and patients, TTe know there is, but some tangible information must be made available to show this difference. Charts for. the food service set-up of all general hospi- tals have been made; and, with very little information from time to time, it should not bo too difficult to keep them up to date, I understand that some of the hospitals have a very long and lengthy report to make out, particularly those in the Sixth Army. It so happens that this form is one that the Sixth Army Headquarters sent out. The Food Service Section i' the Office of The Quartermaster General has been, working on one. It is understood that when it is 132 put into use. The Surgeon General will send out his own instructions as to its use and the information desired. There is much of it that is of no value to us, and it was difficult to get this point across. Again, other services fail to realize the difference in the food service in the hospital and the food service in the field. Gradually, we are getting very good cooperation from.the market centers. It was necessary to go out--and thanks to the commanding officers for their support--and show the market center personnel just what was needed in the hospitals. There vail be other problems on -which your coopera- tion will be needed, ’7e know there are still some weak points in our food service program, but we shall continue to work until it is the very best, be are always willing to help, and it is hoped that any problems concerning which this office can give assistance will be stated to us. CENTRAL HOSPITAL FUND PROJECTS COLONEL TYNES; General Armstrong, gentlemen, I am sure each of the hospital 'commanders here today is wondering what has become of his "letter to Santa Claus" requesting free projects to be financed from Central Surplus Hospital Funds, as outlined in b.D. Memo, 40-590-10. You also were probably disappointed when Christmas came around and you found your stockings still empty. You will recall that all projects were to be submitted to The Surgeon General prior to September 15. By request from a great many of the hospitals, this was extended, first to October 15, and later, to November 15. A number of hospitals still have not submitted proj- ects, but are no longer considered eligible under this memorandum. This office did not publish the amount of surplus central hospital funds available under this program, but rather directed that, in accordance with the memorandum from the ,ar Department, the program be limited to approximately 060 per authorized bed for each station and Air Corps hospital, and $100 per bed for general hospitals. It was decided that, in view of the uncertainty of the cost of labor and materials, it would be wise to withhold approximately 20 percent of the total funds available to serve as a contingency fund to individual projects that might cost more than the estimated amount. This, in view of the fact that no additional funds will be made available to the project. Accordingly, a sum of $3,200,000 was declared available to finance the individual approved projects in this program. In spite of instructions to •; contrary, the total cost of projects submitted amounts to over .',11,000,000, SS&P directed that the entire program 1~>e consolidated and sub- mitted in such a form that it could be approved with available funds. 133 The task of consolidating this program and reducing it from |ll,000,00p to.a.little over 05,200,000 without.hurting any individ- ual hospital or showing favoritism has been tedious and painstaking. The program from one hospital only, and that from an overseas theater, was divorced from the program and sent up to SS&P separately last fail. This project required approximately sixty days for clearance. Because of this fact we worked directly an 1 closely with SS&P in summarizing and clearing the rest of the program in order that it. could bo pre- sented in such a form that its clearance would be only a matter of form. Many widely divergent cost estimates were submitted by different hospitals on exactly the same items. These had to.be rationalised before SS&P would give blanket approval to the program. For example, the cost estimate for the diet kitchen renovations, including only cost of the stainless steel dish t ;ble and installation of free issue equipment supplied by the Government, ranged from’a'low of $207 to $3,500.for general hospitals-, and as high as $5,200 for station hospitals. It was found that the most reliable bid for. this item of equipment based on acceptable standards, was made 'by S. Blickman, Inc. Blickman’s cost Tor the dish table amounted to $1,100 as an average. Installation of all free issue equipment amounted, as an’average, to an additional $700, including $200 overhead for the Corps of Engineers. Accordingly, since The Surgeon General desires that the renovation of diet kitchens be given a high priority in this program, a fixed amount of $1,800 per diet kitchen is being set aside for each.hospital where such have been requested. In view of the above factors, please bear with us and understand first, the necessity for the delay in processing this program in accordance with criteria set up by SS&P, and second, realize that when a Christmas program is cut from $11,000,000” to slightly over $3,200,000, the presents will not be quite as many or just exactly in accordance with your letter to Santa Claus, In spite of this, however, each of you can hope to get the projects that you have counted on most, and if they are financed in accordance with your original estimates you may expect additional items from surplus funds that were originally withheld as a contingency fund. SS&P, with whom we have worked very closely, informs me that there need be little or no delay in this program in view of the Care- ful screening already given. Each of you will be advisee shortly, through means of a form letter of the projects that have been ap- proved, giving instructions for future action on your part. ’There TTrD.Fom 5-25 has already been’ completed in full, it will be necessary only to inform this office that no change has been made either in the estimated cost or plan for the project before authorization is given to proceed.. If b.D. Form 5-25 and supporting plans and specifications have, not been previously presented, these must be executed in accord- ance with original W.D. Memo 40-590-10. ’' • • In closing, let me again repeat that your program, as presented*, has been consolidated and reduced from $11,000,000 to slightly over $3,200,000.' A 20 percent contingency fund has been withheld in this office to take care of unexpected emergencies and cost increases. All of these funds will eventually be expended for some of the items now included in the original program. 135 T. INFLUENZA VACCINATION. Colonel Tom F. Whayne General Armstrong and gentlemen, I want to take just a very few minutes to advise you of the influenza situation. I know that many of you must have had some criticism of the supply of influenza vaccine. I want to toll you the reasons back of that and ask your cooperation in certain plans we have for further study of the vaccine. Now as most of you know, we were advised by the Army Epidemiological Board at its annual meeting last April to include in the vaccine the FM-1 variant of the A strain. This is the strain that was isolated at the Army Medi- cal School from specimens from Fort Monmouth..-hence the FM-1. In starting on the program as late as April, and considering the fact that the contracts had to be let and that production of egg-type vaccines throughout the summer months is difficult, the manufacturing company had great difficulty in adapting this new strain to and obtaining good growth in eggs. We thought that it had been thoroughly adapted to eggs. It had to be taken out of eggs, run through mouse brain‘passages, and back into eggs. They actually were not in production until the end of the summer. We had hoped to have the vaccine ready to go by that time. They have continued to have some technical difficulties from time to time, and therefore we'wore delayed in the distribution of the vaccine until the end of December, I understand that some of you have received your vaccine only recently. That is the background of the slowness with which the vaccine has reached you. In addition to that, the quantity of vaccine the Lederlo people were able to produce, much as they had thought they would be able to give us any quantity that we wanted, by reason of the technical difficulties noted, was greatly reduced. Hence we had to cut the requisitions for vaccine by 25 percent. We did feel, however, that there had been some over-requisitioning, and that most of you would be able to vaccinate adequately your personnel under circumstances. If there is any shortage of vaccine, go ahead and re-requisition your actual needs, because we do have vaccine in the depot at the present time. Back orders also will be filled. However, I ask your cooperation in look- ing over the requisitions for vaccine, and make them as practical and as near to your actual needs as possible. There are reasons to be- lieve that the FM-1 component of the vaccine may not be as well worked out as we had hoped. We have asked the Supply Division to limit the contract on the vaccine so that we will not have any great amount left over next year. As to the nature of the vaccine itself, we fully realize that with our present stage of knowledge, we do not know enough about it. We have in it the B strain and variants of the A strain. As our experience last year demonstrated, we may at any time encounter another strain or other strains for which these components are not protective. As a matter of fact, the 1946 vaccine did not afford protection against the type of influenze we had last year due to the absence of the FM-1 strain. We know full well that that could 136 happen again, and so we are constantly searching for additional strains or, better still, for an antigenically broad strain that could offer protection for the several of the known strains and those that have not yet been recognized. In order to set up an evaluation program at this time, we have had the assistance of the Army Epidemiological B )ard again, and, under the general direction- of Dr, Thomas Francis of the University of Michigan and Dr. Jonas Salk of the University of Pittsburgh, we have set in motion a program for the evaluation of the influenza vaccine, be have set up at Fort Dix separate groups in which we are observing the effects of the old type vaccine, which does not have the FM-1 component and the new type vaccine. By cooperation with the Navy we have,observations going on at the Quantico Marine Barracks with an unvaccinated group in comparison with Fort Belvoir, also a school with almost the same population, which is a vaccinated group. This is only the beginning of an evaluation study that we anticipate will take several years, be hope next year to obtain permission to conduct observations on vaccinated and unvaccinated groups in the Army, be may be asking assistance from some of you to help in setting up that program. There is only one other point I' want to cover. I think from the clinical point of view the inclination on the part of the hospital physicians is not to consider the diagnosis of influenza in mild upper respiratory conditions. The A strain of influenza produces a mild disease and even in our experience this year in the outbreak in California, the diagnosis of actual influenza was at least two weeks late because consideration was not given 'directly to the .diagnosis of influenza. I would ask your cooperation in surveying very care- fully each upper respiratory outbreak, and, if the rate is rising rather rapidly despite the mildness of the disease, we request that you have ward surgeons send in the specimens to the Army area labora- tories, each of which has a virus section capable of diagnosing the disease. This is particularly important in isolating additional strains, because we don’t know from what part of the country new strains present themselves. The virus sections of the laboratories are sending in specimens from all virus material to the Army Medical School virus laboratory for recheck, In addition to that, the Army Medical School forwards part to a strain center located in the labora- tory of Dr, McGill in New York, who is highly expert in isolating and identifying new virus strains. The matter of sending prepared speci- mens to the laboratory is of great importance to us not only in the diagnosis of influenza in your own Area, but possibly in helping us to identify new strains that may influence component parts of our future vaccine. 137 U, CLINICAL PHOTOGRAPHIC LABORATORIES *.Dr. Edward M. Gunn, M ♦ D. General Armstrong, hospital commanders and Army surgeons. I’ll speak on clinical photographic laboratories and the Army Medical Illustration Service. Today, medical illustration, defined in its broadest sense, is a necessary requirement and an integral part of any properly developed program concerned with medical practice, education, and research. The Army Medical Department has been a leader in this specialty field for many years--it has contributed Substantially to the development and advancement of techniques in medical cinematogra- phy, photomicroscopy and color photography. It is our intention that its enviable position of prestige be not only maintained but furthered. The Army Medical Illustration Servicej an organic component of the Army Institute of P-.thology, is charged with txio responsibility of collecting medical illustration material and supervising clinical photography and medical arts for the Army, (AR par 3c)* Poli- cies and procedures have boon established and published relative to the operation of clinical photographic laboratories in general hospitals; hospitals authorized such laboratories have been designated; and authorized equipment and supply levels have been set. forth. References to this are in SGO Circulars No, 75, 10 June 1947 and No. 129, 10 October 1947; and SGO Circular No. 2, 5 January 1948, For your information, laboratories are presently authorized at the following general hospitals; i\vmy & Navy, Wm. Beaumont, Brooke, Fitzsimons, Lettermah, Madigan, McCornack, Murphy, Oliver, Percy Jones, Walter Rood, Tilton and Valley Forge, and a central laboratory is authorized for the Army Institute of Pathology. This service activity is of great importance to every member of the Medical Department and to the Army. It should be a source of considerable pride for all of you to know that members of the medical profession and of allied scientific fields from all parts of the world correspond with andv-isit the Army Institute of Pathology to secure information and material for which it is recognized as being the outstanding source. You no doubt will also be interested to learn that the film loan program, which has recently been decentralized to the control of Army Surgeons for the local professional benefits to be derived therefrom, has grown from nothingness in about eighteen: months to the point whore there - are no’w approximately 2,000 names on an approved mailing list of unsolicited extra-military users. PMS&T’s at several of the medical R0TC units are already taking advantage of the resources to be found in this central facility. Those few facts certainly demonstrate the tremendous opportunity which exists for disseminating information in a discrete manner to those of the professional and allied scientific fields, whom the Medi- cal Department wishes to impress favorably with the high standards adhered to in the service. From recent experience I am convinced that 138 there is relatively little known by the military of these facilities which exist for its benefit. It is sincerely hoped that you will add this information to your armamentarium. A large central library of documented medical illustrations con- sisting of case entities and medical subjects is maintained by the Army Medical Illustration Service, at Institute. The documented illus- trations in this library, which are collected from the aforementioned clinical photographic laboratories at the general hospitals, the Army Institute of Pathology, and many other sources, are for the use of the entire military establishment wherever and whenever needed. Such materials may also be made available to other federal agencies, civi- lian teaching institutions, hospitals, and qualified civilian scientists for study, research, teaching, and preparation of medical publications, under such policies as may be established by The Surgeon General. The standard operating procedures for these laboratories described in the recent SGO Circular No. 2, 5 January 1948, are intended to facilitate, the collection and classification of illustration material at contributing sources; to facilitate its transmittal to the Army Institute of Pathology; and to facilitate correlation with the central files of the Army Medical Illustration Service. Certain factors covered in the circular are distinctly new and rather definite--all arc based on lossons learned during the past, World War II, and the post-war period. The "why" behind some of the newer details is naturally not included in the directive, however, it has been suggested that you should be informed, hence I make reference to a statement that reads to the effect--"All clinical photography and medical arts pro- duced by and for the Army Medical Department is the property of the United States Government and is subject to the restrictions and regula- tions pertaining thereto." Such statement is enunciated and emphasized to forestall any future unpleasant incidents. I believe you all have at least heard of this regulation being violated., Frankly much valu- able material has been lost by the Medical Department to individual collectors. Further, it is stated--"No clinical photography is authorized without prior completion of a request slip and a release f form in duplicate." This serves your interest, since the review of the slips by you or anyone else will show exactly the type and amount of photography being accomplished and they will substantiate the re- quired requisitions and reports. The release form will help to protect the Army and those individuals, who display photographs at a later date, against legal suits from those pictured, who feel tneir rights of privacy have been violated. Further, a case or subject which warrants the use of color film is to be photographed twice. Cue original is retained by the con- tributing station and one is forwarded to the Army Medical Illustra- tion Service. This action meets the needs of the station and also provides the original material required by the Army Medical Illustra- tion Service to answer adequately all other requests. 139 Further, because of the bas.is upon which these laboratories are authorized, only the following categories of subject matter can be photographed; cases of unusual medical and surgical interest, oc- casional representative cases of ordinary or routine medical interest, new and unusual medical procedures and/or equipment, ■subjects re-- quastod by the Army Medical Illustration Service, now modifications of routine medical procedures, original medical research work and/or significant medical, statistical analyses, gross pathologic and anatomical specimens, and photomicrographs. May I invite your atten- tion to the fact that so-called "legal,” ’’public relations," "lAE," and other similar types of photographs are not common error found in reports submitted to date. Please make certain the reports contain accurate figures and that they are, for the approved medical categories only. Further, it states--”All motion pictures will be photographed at sound speed, (24 frames per second). Immediately upon completion of the photographic assignment, all motion picture footage will be sent for processing and marked for return to the Chief, Army Medical Illustration Service, Army Institute of pathology, Washington, D.C., where arrangements will bo made for duplication, editing, and con- version of this footage into official Army films. A complete written description of subject material, contributing unit, camera- man, location, footage, date when film was taken, and descriptive scenario, including names of patients, names of medical officers, history of case and description oi action will also be forwarded directly to the AMIS* A duplicate will be sent to the contributing station providing a request for such material is submitted to the Chief, Army Medical Illustration Service at the time the footage is sent to the laboratory for processing." These are basic principles of professional photography and arc required by the Signal Corps. The color originals must not be projected (run), because the footage becomes scratched and permanently damaged with each running. The dupes are used for projection, editing, study, etc. The original is used only for final match cutting md then as the color master from which official Army release prints are produced, vfe will furnish the dupes to meet your early needs at the contributing stations and all footage which is photographed by the Army Medical Department is to be used ultimately as source material for the production of official films if it is approved as containing The Surgeon General’s doctrine. Lastly, there are now only two reports required, both are sub- mitted quarterly. One, the Medical Illustration Quarterly Report, Reports Control Symbol MEDEM-96, a new form; the other, the Signal Corps Still Photographic Laboratories Production Report, W.D. AGO Form 11-18. The data submitted in the so reports and that submitted in connection with supply requisitions should be correlated. To date, in mopt instances, any connection between them has been purely coinci- dental . 140 This presentation of facts is made to give you current information on if little-known but active and valuable Medical Department activity; to acquaint you with the need that exist-s for careful 'command super- vision, rational utilization of facilities, and the efficient usage of scarce and valuable supplies; so that we may always justify beyond all question the photographic facilities. The. Array Medic,al Illustration Service, will exert every efforti in your behalf, will assist your workers in overcoming technical problems, and will maintain training facilities to which you are invited to send one representative at a time for consultation and on-the-job training. 141 GENERAL kW'STRONG: Thank you doctor Gunn, I’d like to say that the work Dr, Gunn has done and; is doing is deserving of the ver?/ highest praise. He is making a, very, very fine contribution to the Nodical Department, V. PROGRESS IN THE DEVELOB'ENT OF AIRBORNE HOSPITALS It, Colonel Carlos Schuessler General Armstrong, hospital commanders, and army surgeons. We appreciate the opportunity afforded us at this meeting” to present some of our air force views and thoughts on light weight medical field equipment. General Grow has often pointed out to us that during the war the aim force was frequently called on to transport gasoline, various supplies, and even evacuation hospitals from one spot to another. He also observed that it took a relatively laerge number of airplanees to do this, pointing out, for instance, that nineteen C-17's wore required to transport one platoon of a field hospital at its nresent weight. About a year ago, the general charged the School of Aviation Medicine with the task ef developing an airborne field hospital that could bo easily and readily trans- ported by air. Our first step was to have one Platoon of a field hospital shipped to us; we noticed that the bill of lading indicated a weight of 60,000 rounds. After uncrating the numerous items and making an initial survey, we were convinced that radical revision' would be required in making the assembly reasonably air trans- portable, With some thirty tons of hospital equipment at our disposal, we organized the undertaking into three phases to permit an intelligent approach to the problem. Phase one was. designated the elimination phase; Phase two, redesign or substitution; and phase three, packaging* We have practically completed phase one. To accomplish this, we laid the equip- ment out on tables in a large building and invited our staff, members of the Brooke General Hospital Staff, and civilian professional people who had wide experience during the war in field work, to indicate which items were, in their opinion, nonessential, ib our amazement, a great many items were considered nonessential or obsolete; but at the same time a good many other items were recommended for Inclusion, and in the end we found our list was more extensive than in the begin- ning, This didn't make us particularly unhappy in that we discovered a general interest in lighter components permitting us to make substitutions which would tend to reduce weight, yet permit satisfying individual idiosyncrasies. The suggestions served the further purpose of enabling us to select and re- design equipment in a manner to assure the end product being the best that could be devised for the purpose. We recognized the necessity for completeness, simplicity, and functional ability of the components to eliminate the need for impro- visation by the ultimate using agency. Some of you may recall 142 that during the war.it sometimes became necessary to improvise a table, etc., and when a move became necessary, your trans- portation Problem had increased correspondingly. We are presently engaged in Phase two and three. The unnecessary items have been eliminated and we are now going over some of the heavier items such as beds, autoclaves, arid operating room tables, and are redesigning them along aircraft construction lines, vie are convinced that over—engineering should be avoided. If a bed, fori instance, is to carry the weight of one or perhaps two men, we feel it a waste to construct it solidly enough to support a'truck. Ye further feel that field equipment need not have a life expectancy of twenty years; this medieval thinking still plagues us in the form of World War I equipment which we still have in our stores. We have developed an operating room table which, with a packing container that serves as two instrument tables, weighs 32 pounds as compared with the present field operating room table weighing about 160 pounds or the latest Carlisle model that weighs 200 pounds. It has no fancy elevating gadgets, yet its design permits easy and ready lift to any of a variety of positions. In that way, we have eliminated considerable weight. Wo have used tubular construction, magnesium, and aluminum and believe we have a fairly, serviceable, light weight operating room table. We have several of the items on exhibit here and will appreciate your examining and criticizing them, giving your frank opinions. In establishing the characteristics of u airborne hospital, we emphasize certain specific features. The first of these is lightness; it must further be made up of small units that can be expanded; for instance, the laboratory eauioment is contained in one chest, designed for use in a dispensary dr a small hospital; its adaptation to a large hospital would reouire only an additional supplemental chest. Ward equipment will be similarly designed and packaged—the basic ward equipment being contained in a minimum number of standardized containers, A surgical ward would be readily available by addition of a supplemental chest. As previously indicated, this hospital must be functional and not dependent on the ingenuity of the staff for workability and adaptability. Ye propose to design all containers to servo as furniture upon being emptied. We illustrate this with some of the chests on display here. We, of course, propose to include the latest developments in medical equipment. This, we feel, is essential. Our largest problems center around the really heavy items such as electrical generators, housing, laundries, etc., which may be the responsibility of another agency or technical service. These items are necessarily bulky and heavy; however, it is-‘ our feeling that considerable reduction in weight can be e’ffc-ctod. Wo would like very much to develop some of these things ourselves, but are, of course, unauthorized to enter these fields; consequently, our recom- mendations will bo submitted to the nroner agencies. We feel that adoption of 400 cycle electrical current for field use would be a definite advantage. By using 110 volts with 400 cycles, weights can be cut three-fourths• A quarter horse motor of the conventional tyne, for instance, weighs annroximately 32 nounds; a comparably 400 cycle motor weighs 9 nounds and is eaually or jt»o* '■ efficient, v:o> feel this is a field worthy of serious consideration. Since most units furnish their own electricity, we foci a conversion to 400 cycles has definite merit. Incidentally, such a change-over affect only motors and transformers and has no effect on light bulbs, toasters, sterilizers, etc. X-ray equinment would require re- design. In thinking of an airborne hospital, we feel that the aviation industry is in a good position to render valuable service by virtue of their knowledge of light metals. Their years of' experience in air-lift problems especially qualifies them to develop light weight yet durable equipment. The feasibility of letting a contract to an airplace manufacturer to produce a prototype of an airborne hospital, strikes us as having considerable merit. We feel that in this manner the present 75-bed field hospital could be redesigned to permit its air carriage to a theater with a few modern cargo planes, rather than 19# I am sure there is little doubt in anyone’s mind that in a future war, the air Place will afford a prime transport medium. As a result, the factor rf weight and cube will be of great importance. Our aim, as far as medical equip- ment is concerned, is to keep both weights cand cubages to an absolute minimum without sacrificing e.fficioncy. The air- plane manufacturer certainly can give good advice and service toward that end, I could continue at length on this airborne field Hospital; however, I foel that I shouldn’t take up more of your time and think we could put our print '"rer to you a little better by actually examining the exhibits. You wall notice wjg have a hospital be —an ordinary wrard bed—that weighs approximately the same as the old Army folding canvas cot; its advantages over a cot should be readily apparent, b'0 have a fracture bed which weighs a pound more than the old Army cot. Since I am a dentist, I naturally devoted extra effort to the dental equipment, Yr,u will see that the method of packaging wre propose to adopt for this whole hospital is a functional method whereby the things needed first are on top, things used less often are down at the bottom, etc. You also will notice that the method of packing assures orderly arrival at the ultimate destination. Repacking is also greatly simplified. DISCUSSION GENERAL ARI-iSTi-QNG:. Thank you very ranch Colonel Scheussler, I could sit for hours and listen to the Chief Surgeon of the Air Forces and his ideas on non we are going to avoid the great wastage of time and medical person- nel in the future, I find that he and his assistants, like Colonel Scheussler, arc Just,about tuo jumps and ten years ahead of the rest of us in his and their thinking, I think it would bo remiss on my part if I didn’t ask General Grow to make some brief comments on this picture, GENERAL GROM: First of all I want to express appreciation fch the en- thusiastic and fine work which Colonel Scheussler has done. I started on this thing without any particular authority for research and design, I thought we would work on a few little medical items and see how we made out and I got a little research money which I could use, I looked around for somebody with a gadgeteer complex. Someone said that this fellow Scheussler-had it. It was difficult for him, being a dental officer, to know exactly what the medical service required. So I thought that by starting this thing at the,school we would have the advantage of the Brooks Field Staff to advise us along those lines, I want to again ' emphasize the fact that the aircraft people have been a lot of help to us. They have struggled, and you'd scarcely realize, unless you were close to aviation engineering, the great stress that has been put on them by the aircraft designers to cut wastes. That same stress is put on the Signal Corps in putting in various'types of signal equipment, on the Ordnance, etc. Things arc figured down to ounces and all of that 'goes into the ultimate performance of the aircraft. For these reasons I felt that in our first approach possibly the aviation industry would be better equipped with their engineering staffs to tackle these problems of engineering in the light weight metals. as the thing went on, as Colonel Scheussler said, I got into items which were not my business but the business of engineering, and it is now a bit difficult to get the -whole thing coordinated. It is also quite an expensive project, and I don’t know how I am going to carry on from this point—when I get into such things as dishwashing machines, sterilizers, and items of heavy equipment, we have all of the Technical Services mixed up in this project and so I brought some of them into my office and dis- cussed these things with them, I can new see where wo are up against a bit of a block, I can also see where we are going to need a little bit of help from The Surgeon General’s office. The Marine Corps and Navy are very much interested in this project from a standpoint of amphibious operations. Maybe by getting everybody together and in back of’us perhaps wo can put it across. The Air is interested first of all from a standpoint of medical service; secondly, it is interested because it decreases the demands for cargo aircraft, I think some of you who were in ETO will remember when General Patten was up across the Rhine; the bridges were down; the railroads were out; it was very difficult to supply him with gasoline, ammunition and food. So the Troop Carrier Command was called upon in a period when they ’./ere not getting Air Force troops and they did quite a big 39b of resupplying. Well, about that time, the boys in the Army wanted to move an evacuation hospital too big for a troop carrier. It was pretty evident.that that equipment was very heavy and very difficult tw move and so that was the double-edged sword of helping the Air Force a bit and also I believe it-will help us in any future operations; so I received support on this project from the Air Force, I think I can visualize the next t/ar as anyone can and especially you people who were in the Southwest Pacific where you were jumping from island to isalnd, I believe you will admit that if wo can reduce the overall weight and construct this airborne equipment in a way that it can bo quickly set up with things available, I believe it is a worth-while effort for the men in the field, GENERAL ARMSTRONG: Thank you very much, General Grew. I believe that that takes care of all thq formal papers. I’m not going to sum up this meeting, with any degree of detail, because in the first place, Pm net capable of it and secondly we haven't time. I'm certain that everyone hero has other things which .they would like to bring cut, but I believe it, is not feasible, I know that we deeply appreciate your c. ming, and the enthusiasm and patience that you have exhibited, I feel certain that we will all gain from this meeting. When we will have the next one I am not prepared to say, I suspect that it-■'./ill be in November of this year. The reason I say that is that I'm going to put a plug in for the Association of military Surgeons, Those of you who attended the meeting in Boston last fall, I think had the idea correctly, that the Association of military Surgeons has had a rebirth. There were- over 600 registered. The attendance was' excellent and it is felt by the present officers, that probably, and the announcement is not yet official, in vie?/ cf the fact that since there has net been a meeting cf the Association for a long tine in the southwest part'of the country the next meeting will be in San Antonio, I 0on11 want to bo quoted on that because it has not been off A suggestion was mado-and I'm not sure whether it was made by General Grow, General Hawley or who it was—the idea was that from time to tine various people have meetings. General Grow probably has meetings cf his key surgeons, v/o have meetings such as this. Admiral Swanson has his meetings and the Director of the Medical Department cf the VA has his. Now the idea is that next year the chiefs will plan meet- ings of this sort so that they will be hold at San Antonio o it her just prior cr just after the date set for the Association rf Military Surgeons which will in itself give a great impetus to the next-meeting. If it is at at San Antonio we can t-kc advantage ex Brooke Army Medical Center and the general hospital in the center and Randolph Field, I think we could put on a good show. I'll collect on that from brother Hume who is the new president of the Association, I would like- to emphasize the in- vitation of Colonel Scheusslcr; I think that no one in this room, with exception perhaps some of the clerical personnel, should miss seeing the exhibit after wo are through. Colonel Duke has an analysis to' rnnke.