December 29, 1970
Page 43986
HEALTH CARE CRISIS DOCUMENTED
HON. EDMUND S. MUSKIE OF MAINE IN THE SENATE CF' THE UNITED STATES Tuesday, December 29, 1970
Mr. MUSKIE. Mr. President, the grave problem of deficiencies in all areas of health manpower in our Nation must be met quickly. It is a complex area, involving numbers and distribution, as well as possibilities of new kinds of health workers.
Two papers dealing with these problems have recently come to my attention. One is an article appearing in the November issue of Medical Opinion and Review by Dr. George James, president of the Mount Sinai Medical Center and dean of the Mount Sinai School of Medicine of the City University of New York. The other is a speech by Dr. Joseph English, president of the New York City Health and Hospitals Corp., which earned him a standing ovation from members of the Association of American Medical Colleges at its annual convention.
Dr. James' article deals with some of the problems of health manpower, and points at the serious difficulty facing medical schools because the Federal Government has not kept its earlier promises of financial aid to institutions and students. He also suggests a number of interesting approaches to the problem of distribution of manpower.
Dr. English's speech deals with the present administration's lack of leadership in the field of health. It documents the fact that the Congress has taken the leadership to press for increased appropriations so desperately needed by medical schools, and also for increased funding for loans and scholarships for medical students.
I hope my colleagues will study these two documents. They provide excellent background material as we prepare to act on extending the Health Manpower Act of 1968 due to expire next June. Mr. President, I ask unanimous consent that the text of both appear in the RECORD at this point.
There being no objection, the article and speech were ordered to be printed in the RECORD, as follows:
A MATTER OF OPINION: CRITIQUE OF SEVERAL PROPOSALS FOR INCREASING THE NUMBER OF PHYSICIANS
(By George James, M.D.)
There has been fairly general agreement that we need more physicians as soon as possible. The single most important cause of this need is the growing willingness of the people to pay for medical care, through tax funds, or third-party payment systems, or directly through fee-for- service payments by individuals. The physician shortage is an effect of marketplace events, not an expression of an unmet health-need of the American people.
Nevertheless, the nation could profit from a large increase in the number of physicians. Large sections of the population do not have physicians at all, and there does not appear to be any surplus of physicians waiting to enter these areas. Of course, training more physicians does not automatically increase their numbers in medically deprived areas; however, it seems a necessary first step, if we are ever to bring physicians to where we are needed most, that there be more of us.
The only question is: whence will they come? Importation is not the answer. "Theft" or "enticement" of physicians from foreign countries, when their physician shortages far exceed ours and when we obviously have at our disposal other means of solving our problem, offends our better senses of national responsibility in the world community of man and brings forth strong objections, of course, from the foreign nations.
A better idea is that we create many new medical schools within our own borders.
Unquestionably, there are a great number of universities that could sponsor medical schools, and there are a large number of well-organized hospitals that could, with some additional effort, become the teaching institutions for these schools. But the big problems here are cost and time.
Starting a medical school today costs in the range of 100 million dollars, and it is usually eight to ten years from the university's first acceptance of the idea to the entrance of the first class. This process might be telescoped somewhat, but, even if there were the greatest determination on the part of state, federal, and local governments, with almost unlimited funds available from government and private sources, we could not expect to reduce the lag to less than ten years from decision to first graduating class. And the accelerating demands for physician care will not wait even that long.
NECESSARY INTERIM MEASURES
This does not mean that the effort to start new schools should be abandoned. I believe very strongly that it must not. The momentum that was developed in the past decade, during which twenty new schools were begun, is not exhausted; some additional schools will be founded in the next few years. Unless the program is renewed by the federal government, however, it looks as though there will be a definite slowdown in the rate of new school development – and the federal government has not seen fit to invest any new, large sums of money in this direction. Other methods for increasing the number of physicians in the interim are essential, but, without concurrently establishing new schools, we only delay an inevitable hiatus.
The other major method that has been energetically supported is expansion of classes at existing medical schools. There is little doubt that the medical schools could expand, given the inducements and the help, but many persons who urge this expansion do so too glibly, without considering all the facts. Some have accused medical-school faculties of not wanting to expand because it would require increased effort on their part. Others have denounced modern training of medical students as too elaborate and have proclaimed that, if we redirected existing resources, we could train twice as many students as we do now – and at less cost. Each of these viewpoints is partially correct, but in the main, a program for increasing the size of classes should be designed on the basis of sound analysis of all the facts and problems – not by accusing medical educators of lack of initiative.
For example, there are hidden costs in the enlargement of the student body. One of the most important of these concerns faculty. We are told that since the medical school plant operates primarily in the daylight hours, we ought to develop a night shift. Obviously, this would require an entire new faculty; we could hardly ask existing daytime faculty to serve both day and night.
But I know of no medical school in the country that has evidence it could recruit high-quality faculty to work a steady night-shift. If any group feels this is feasible, they should make it part of a demonstration program. Presumably, if they succeed – making student body and faculty content with the system – this model could be rapidly adopted in the rest of the nation. Certainly it is a simple way to meet the problem in the basic years. In any case, however, where are the funds to come from to pay two full faculties?
STUDENT MAINTENANCE COSTS
Another problem is that, unless one wants to attract students only from the wealthy portion of the population, extra funds have to be garnered to pay that portion of the cost of a medical education that reasonable rates of tuition do not meet. Tuition now covers, on average, one-sixth of the cost of education. Moreover, since the trend is to recruit more students from minority and deprived groups (roughly in proportion to their numbers in the total population), it is frequently necessary that even the tuition must be met by institutional funds. At the present time, my medical school has one-third of its tuition payments met through scholarships. In addition, many of our students, particularly those from the black minority group, need assistance for living quarters and a stipend for food and other personal expenses. We pay subventions for students' apartments, furniture, and some other items. We buy some expensive study equipment outright and rent it to the students for a nominal charge. If the number of students increases, our costs go up, and out situation is, certainly not unique.
SCHOOLS RISK A DEFICIT
As far as I know, no one has yet done a solid investigation of all the hidden charges and made that the basis of recommendations for giving medical schools the inducements to increase their student bodies. The federal government's program of inducements has ignored the fact that medical schools even now receive insufficient funding to meet costs. Offering a medical school with a teaching program running a deficit of one or two million dollars a year, a sum of money to cover admission of new students, so that the deficit will increase, is at best anachronistic. And the school risks still greater deficit in the event the federal program that induced them to take on more students should be phased out in subsequent years, as so many support programs have been. As things stand, without such long-range programs or commitments, an individual institution increases its own commitment only at great peril.
Consider what happened with the scholarships and student loans from the federal government: HEW stimulated recruitment of minority students by offering these grants. The stimulus worked, and the number of such students increased because of it; but the number of grants has remained constant, and the burden has fallen on the schools to fill the gaps. I think it must be said that, if there is to be any major increase in the number of new students by this route in the next few years, then we need a vast transfusion of federal funds across the land to meet the true costs of education for the additional and traditional numbers of students. If this were done, then most of the large medical centers could boost the number of students they train, and could do so quickly.
A corollary exists in the plan to enable the undergraduate colleges to expand some of their science departments to include the basic-science courses of the first two years of medical school. This would be an amazingly effective way to cut back the need for new construction. If undergraduate departments of biology, chemistry, physics, etc., expanded and developed new courses in physiology, anatomy, pharmacology, microbiology, etc., and each admitted a small group of students – say, ten – an enormously enlarged crop of students would be made available for studies of clinical medicine. Here the delay would be only two years – just time enough for the medical schools to gear up for the admission of vastly enlarged third- and fourth-year classes. Planned properly and well-supported by federal funds, this approach would be eminently feasible.
CAN ANY PLAN WORK?
A few programs of this type are already in trial. The State of Indiana is supporting the teaching of such basic sciences to several students at Purdue and at Notre Dame. These students will eventually take their clinical studies at the university of Indiana School of Medicine. A similar program is being set up by the State of Illinois. If this became a nationwide project – with, say, 700 colleges each giving preclinical course work to only four or five potential medical students – 3,000 additional students would be readied for the existing clinical-teaching plants of the nation, and without expansion of facilities. And yet the existing 100 or so medical schools could not now comfortably absorb into their clinical-teaching programs more than about one-third of this total.
In other words, without adequate supports at all levels, even the most economical plan cannot be made to work. And, of course, because the States haven't the resources to do this job alone, it is up to the federal government.
Ideas for increasing the physician population are often tied to a plan to train more general practitioners and fewer researchers, academicians, and specialists. The feeling is that the American people want family doctors, that what the urban ghettos need are GPs, and that we are wasting a good deal of manpower on training cardiologists, neurosurgeons, and so on, when what we really need are first-level, primary physicians. Advocates of this approach have recommended that many of our community hospitals could serve excellently as training points for clinical medicine. Elaborate classroom training, such as only the large university medical center can readily provide, is not needed, it is said. We teach too much biochemistry and anatomy anyway, while the real need is for a turn toward the apprenticeship method of learning clinical medicine.
All of these suggestions are intriguing and stimulating; they are even relevant. But they are very dangerous if taken at face value, without comprehensive analysis. I won't attempt that now, but I will point out that, for example, contrary to widespread opinion, GPs are not reproducing themselves.
PRESSURE FOR GENERAL PRACTICE
Despite their great interest in humanistic medical care, students are still flocking to the specialties. Various methods – some of the penalty type, some of the coercion type – have been suggested for reversing the trend. Some suggest that every physician be required to spend two years in general practice before he can undertake specialty studies; others, that certain medical schools be supported by state and federal funds only if they promise to produce GPs either primarily or exclusively. One state had before its legislature a measure that would deny a license to an MD unless he had spent at least six months in an internship assigned by the Commissioner of Health; presumably this was to force him into some rural area or urban ghetto in a community hospital not generally recognized as having teaching excellence.
But if the nation agrees that it needs more general practitioners, penalty systems are not the answer. I see no value in a school professedly training as GPs those students who enter that school only because they can be admitted easily, but who promptly after graduation lay out their plans for specialization. I also do not think it wise to create a double standard in medical-school status – one class being more academic, more high-powered, more specialization-oriented, and the other less sophisticated and earning a reputation for having received something less than excellent training to make them adequate, but not top-flight, general practitioners. Far wiser, it seems to me, is that each school provide many tracks for its students, including a strong GP track – one that is competitive, in terms of inducements and attractions, with those of the specialties.
In the meantime, we need a better set of models of how GPs are going to work after they are trained. It may be that the pattern of general practice we usually have in mind is no longer viable, or won't be in the coming years. The GP of the future will presumably be involved with complex arrays of equipment and with extensive follow-up procedures that engage the services of many allied health professionals.
RESTRICTION OF FIELD
Perhaps what we need, after all, are more GPs of this kind who will work in teams and go periodically from more central headquarters (possibly with elaborate mobile equipment) to serve an area for a period of months and then circulate back to the parent program. If this is to be the case, I think it would be much easier to recruit students to the general-practice track. And still, in this era, one cannot neglect the ladder effect of career development. One would not want to recruit a man into a form of medicine from which he had no escape should he change his mind.
As for the role of the community hospital in teaching, it is extremely important that the medical student learn not only the facts of present medicine, but also the basic mechanisms of health and disease. Medical school must prepare him for the dual responsibility of practicing medicine as he has learned it and continuing the learning process throughout his life, so that he can always be relevant. Medicine is changing so rapidly that students must be graduated from school with the ability and motivation for self-teaching and the undertaking of postgraduate education. It is still to be determined whether an apprentice-type program in a community hospital, without a strong relationship between classroom and bedside, and often without full-time chiefs of service (or with part-time chiefs whose primary dedication might be to activities other than teaching), can achieve this kind of graduate. Also, the community hospital often operates as a series of separate clinical departments in loose confederation around a non-medical administrator who maintains the budget and who administers, but who does not accept the responsibility of leadership for the academic and clinical program. High-quality medical education still requires total orientation to education and leadership from a staff so oriented. Then, too, community hospitals are built for service; tooling up for education would be, again, a costly and lengthy procedure.
People who can think back to the Flexner Report of 1910 do not believe it would be desirable for us to lower standards of medical education now in 1970. We want to maintain quality even while we pursue quantity. The problem of overtraining can be handled by allowing students to elect various tracks of specialization, including general practice. I believe that we can't force or coerce students into general practice, but I also believe that, if the medical school is associated with good medical-care practice models for rural and urban health, its students will see opportunities in these clinical fields.
ASSISTANCE IN ALL AREAS
One way, therefore, that the government could provide significant aid would be by investing heavily in helping medical schools establish practice-models for the distribution of care to the community. In fact, such support should help each school serve several communities – rural, urban, labor union, industrial-plant, and so on. Each such community demands first-level applied medicine. But, precisely because we cannot lower standards, cannot coerce students, and cannot regiment physicians, the increase of any group of physicians necessitates increase of all. And if we have more students and, eventually, more medical schools, we will certainly need more teachers. They have to be produced now. Were the government to provide assistance in all areas – including continued support of research, and a working program of inducements, to universities to expand their basic-science departments; plus long-range planning and methods of upgrading the community hospitals within a reasonable period of time – then all of the problems we find today would be capable of resolution.
REMARKS BY JOSEPH T. ENGLISH, M.D.
To the country as a whole, the health care crisis was identified as such, on July 10,1969 when President Nixon spoke to the issue as follows:
"This Nation is faced with a breakdown in the delivery of health care unless immediate and concerted action is taken by Government and the private sector. Expansion of public and private financing for health services is far in excess of the capacity of our health system to respond. The result is a crippling inflation in medical costs, causing vast increases in government health expenditures with little return, raising private health insurance premiums and reducing the purchasing power of the health dollar of our citizens."
Disturbingly, this description of a basic imbalance between the financing of health care services and the capacity of the health care system to respond is no less accurate today than it was a year and a half ago. How have we come to this point? What is being done about it today? What must be done in the future?
The lessons of recent years have sharpened our focus and perspective. Our nation has come to recognize two important myths – myths which impede our efforts toward progress in meeting the health needs of our people.
The first myth held that a major investment of money and talent in bio-medical research would result in advances that would be automatically transmitted throughout the health care system to the benefit of all. The investment was made. Dramatic advances were the result. We saw progress in every field of medical science and technology, making our nation's centers of medical excellence second to none in the world.
But the translation of these advances into the day-to-day practice of medicine did not occur.
Rather, the gap widened between the best which medicine could offer and what was available to vast numbers of our people. Committed to the important work of advancing medical knowledge, our medical schools became over-dependent upon Federal research support for other important activities, such as education and community service.
The second myth held that a mainstream of American medical care existed, and that the only barrier between this mainstream and millions of our people was the lack of money to pay for these services. It was assumed that if these citizens were provided a money ticket into the system, they would then be able to partake of quality medical care. This assumption was seldom questioned, and the great national debate centered on whether the money ticket was to be from public or private resources.
The result of the economic and ideological dialogue which ensued was the enactment of the Social Security amendments of 1965, creating Medicaid and Medicare. A significant step forward was taken in the development of a financial structure to support health services. But only recently have we begun to understand how incomplete a strategy this legislation was.
What have been the consequences of an incomplete strategy based, to some extent, on a series of myths? First, the demand for health services has reached an unprecedented scale. Medical progress in the past 30 years has increased realization of what the physician can offer. Health services are perceived as related to the right to life itself. Provided with real purchasing power, the American health consumer has placed enormous stress on the capacity of the American health enterprise to respond.
This strain has been compounded by the maldistribution of health manpower, particularly physicians, who are moving away from the rural areas of our country, away from the urban core, and into the suburban communities surrounding our great cities. In 1943, the doctor-patient ratio in the inner cities was one to 500, and in the surrounding suburban communities was one to 2,000. By 1968, it had become one to 10,000 in the urban core and one to 500 in the suburbs. So much for the myth of the mainstream.
It has been in the cities of our nation, where the majority of Medicaid beneficiaries reside, that increased demand for health services has been most pronounced. It is in the cities where our capacity is most severely strained. In one 55-block area of Harlem recently studied, 50 physicians served 25,000 residents 25 years ago. Today, five physicians struggle to serve a population grown to 50,000. A physician in a situation such as this often bears double and triple the load he carried before, and inevitably finds difficulty in providing every patient with the highest quality care.
The sheer number of patients seeking his attention forces him to put those who are really ill into hospitals. Many of these patients might have been otherwise cared for outside of the hospital. This strains our already over-taxed hospital resource. This is further aggravated by financing mechanisms which support hospital care far better than out-patient care.
In the South Bronx of New York, the 346-bed Lincoln Hospital now serves as primary health resource to some 350,000 of New York's most medically needy citizens. In its tiny emergency room, now the third busiest in the nation, some 500 patients a day are seen in a facility and by a staff never intended to bear such a load. In these situations we risk dilution of the quality of care. Further, we find increasing inequities and indignities in the human relationships involved in health services. The personal and human attention so basic to the healing process becomes progressively more difficult to assure.
In the rural areas of the country, the problem is no less acute. In rural counties physicians lost through death and retirement are not being replaced. Over 412,000 people in 115 counties scattered through 23 states do not have any physicians poviding patient care in their counties. There is no place at all to cash in the money ticket.
Faced with an increased demand, and dilution in the quality of services for a major portion of our population, inflation in health costs has increasingly attracted the attention of Americans and their congressional officials. Last year public-private expenditures for health services in this country exceded $63 billion. Inflation in this massive segment of the economy has exceeded that in any other. The nation's medical bill has increased 500% during the past twenty years. Health insurance premiums have been increasing at the rate of 10% a year. Hospital costs have increased 82% in the past five years. In the last fiscal year the federal contribution to the $63 billion enterprise was $18 billion – a figure larger than the national budget of all but five countries in the world. Of this $18 billion, $14 billion was devoted to the financing of health care – to the issuing of money tickets.
These are the elements of the health care crisis we face today. The growing reaction of an aroused public is the major new factor. In the halls of Congress and in the headlines of our national press we see the stirrings of a public now questioning those in whom they had placed their trust for the assurance of accessible, high-quality health services. The health professions, and medicine in particular, are receiving increasing public scrutiny. I would suggest that, unless we respond by effective action in the public interest, the reaction of an increasingly concerned public will eventually impose drastic changes which will work neither to the benefit of the patient nor the provider.
There are several major issues which must be confronted.
First, the national shortage of health manpower and institutions is real. But beyond the training of larger numbers of health professionals, the means must be developed to deal with the serious maldistribution of health manpower and resources.
Second, pouring resources into payment for health services without comparable investment in our capacity to respond to increased demand produces staggering inflation. A qualitative balance in the Federal health investment must be struck. This has not been done.
Third, important advances in medical research and technology still have not reached the public at large. Effective incorporation of new discoveries into the daily delivery of health services must be assured.
Fourth, medical schools are vulnerable today because of their over-dependence for many functions on federal research dollars. Realistic financing for the educational and service responsibilities of medical schools must be guaranteed.
Finally, the system through which health services are organized and delivered has serious inadequacies requiring effort on many fronts. New organizational models for health care delivery must be supported, studied and compared. Incentives both for consumers and providers of health services must be developed and tested. In order to be sure that the vast talent of the nation's medical schools contributes to these efforts, departments of social and community medicine must be supported. It is here that the vital union of education, service, and research can be directly focused on solving some of our most severe problems.
At a time when the health professions are entering what could be the most critical decade of the century for the future of our nation's health effort, at a time when public unrest is moving us toward new approaches to the problem which would have been unthinkable ten years ago, what kind of leadership and response are we getting from Washington?
This is the saddest fact of all. The evident lack of attention to the health needs of the American people is a matter of public record:
(1) The nation's number one health official has had to publicly lament his exclusion from the decision-making process in the White House.
(2) The new Secretary of HEW was not consulted by the White House staff before the Presidential veto of a major piece of health legislation: the Hill Burton Program.
(3) At this very moment, it is still impossible to identify anyone on the largest White House staff in history who has responsibility or competence in this major segment of our economy and national life.
(4) In a year which the Administration itself defined as one of major crisis, there was no Presidential Health Message.
Meanwhile, the Federal Government will quantitatively increase its expenditures for health next year by $2 billion in a way which contributes to the present inflationary spiral. But it has developed no strategy for making this increase produce the qualitative impact so needed if the public interest is to be served.
Despite the urgent need for investment in increasing our capacity to respond to new demand, it is in this area where the administration seeks false economy.
It has been the Congress this year which pressed for an increase of $411 million over the administration's budget for support a bio-medical research, medical education, comprehensive health planning and health services research and development.
It has been the Congress which pressed for increases in expenditures for medical facilities construction, the Regional Medical Programs, mental health, and communicable diseases control.
Despite drastic inequities in our medical educational system in which 40% of the nation's medical students come from families in the top 5 % income bracket, the Administration cut back financial aid programs for medical students last year. It has been the Congress, with the encouragement of this Association and the Student American Medical Association, which pressed the administration for an additional $18 million for student assistance this year.
When a score of our medical schools are on the verge of financial collapse, it is again the Congress that takes the initiative in pressing an administration, deaf to its own health officials, for an additional $16 million for institutional support and an additional $24 million for health research and education facilities.
I would contend that this not-so-benign neglect of a $63 billion segment of our economy can do nothing but further cripple our capacity to provide services important to life itself, and to aggravate the reaction of a frustrated public.
But perhaps the most insidious aspect of the current situation is the fostering of a climate which could divide into meaningless competition the three inseparable parts of our health effort: research, education and service. When resources are scarce, individuals and institutions whose primary commitment has been to one of these areas may fall into the easy trap of attempting to protect their interests at the expense of other equally vital areas. In the face of famine, there is a temptation towards cannibalism. Only the most simplistic analysis of the current crisis would allow such a course.
Research has led and will continue to lead to heightened medical capability without which the whole medical enterprise will wither and die. All our efforts will be futile if our capacity to produce increased numbers of physicians and other health professionals is not assured. Without financing mechanisms which at once remove monetary barriers for those who need health services and provide incentives for the more rational organization and delivery of health care, we can never meet our responsibility to the American public.
I would suggest that the callous indifference at the highest levels of our government to the health crisis in America exposes above all our own inability to organize effectively and to argue persuasively for the rational support of the American health enterprise. This indifference requires that we rise above our more parochial concerns to organize an effort in the public interest which combines our forces more effectively.
In the past there has been ample evidence of the leading role that medical educators and schools of medicine can play in such an effort. .
Tufts University School of Medicine moved to sponsor two of the pilot Neighborhood Health Centers in cooperation with the office of Economic Opportunity. These centers, established in the Columbia Point section of Boston and in Mound Bayou, Mississippi, served as early models of the effective social involvement of medical educational institutions in the health problems of the poor.
When government confronted the problems of the Watts community here in Los Angeles, the University of Southern California School of Medicine, then under the direction of Dr. Roger Egeberg, took the initiative to accept major responsibility for the medical aspects of that task. Today over half the nation's medical schools are involved in the operation of Neighborhood Health Center programs.
Early in the '60's the municipal hospitals of the City of New York were faced with the serious consequences of a failure to attract enough house staff and attending physicians. The City's commitment to provide health services to the medically indigent was in danger of breach. Under the brilliant leadership of Dr. Ray Trussell, then Commissioner of Hospitals, the affiliation plan was born. Through this plan, the City contracted with medical schools and voluntary hospitals for the provision of professional services. Since 1961, the medical schools of New York have helped to provide quality care to millions of New Yorkers while leading in the development of some of the nation's finest physician training programs. We are now involved, through the newly created New York City Health and Hospitals Corporation, in efforts intended to further develop this public-private partnership. But this example reminds us that in a time of great need, the medical schools of the City responded with energy and responsibility in helping with that health care crisis.
Today the Albert Einstein College of Medicine, an institution nationally known for its high standards of academic excellence and its contributions to basic bio-medical research, has begun to rise to the new challenge. At the Lincoln Hospital which I mentioned earlier, the school is developing training programs for students and house officers which will assure medical excellence but which will also deal realistically with the needs of a hospital and a community where health conditions are in a state of near disaster. Beyond its concern with the South Bronx, the College is moving toward an holistic approach to health problems and is taking a leadership role in the development of a more rational planning of health services for the entire Bronx. The College's response to the basic needs for health care of this community, to the needs for new models of physician and health professional training, and to the need for participatory planning involving the community, is most encouraging. Albert Einstein is but one example of many such initiatives underway by major medical centers in our city and throughout the country.
The major challenge of this decade will be to stabilize the support of our institutions of bio-medical excellence while we create the new institutions of equity. The task is to share the fruits of our achievements with 200 million people, to share our excellence with equity, efficiency and respect for human dignity.
This will take institutional development as did the challenge of the last two decades. And the development of the new institutions of equity will require the leadership of medical research and education in the same way that the development of our institutions of bio-medical excellence did in the past. If we do not forge this partnership in the '70's, then all of the American health enterprise will suffer, but especially the consumer.
With this partnership, the Administration will not be able to ignore our Federal health leadership. If those of us committed to new knowledge, new manpower and better service join forces in the coalition which the times demand, we shall be heard. It must be a coalition of teacher and student, of provider and researcher. It must include those interested in the old as well as the young; of those interested in the treatment of disease as well as the protection of health. It must be a public-private partnership, and most importantly, it must include the consumer.
The time is late. The public need is great. Let us get on with the work.