“I regret very much that Colonel Patterson cannot be here today, because
he had some very definite statements to make about the dispensary
problem of the Veterans’ Bureau. It was only last night that his
physical condition warranted his telephoning to the Bureau his
impossibility to come. In his absence I shall attempt to give you
briefly a plan of the dispensary service of the U. S. Veterans’ Bureau.
The Veterans’ Bureau plans to establish a chain of dispensaries
throughout the United States, located in the fourteen District Offices
and in the hundred and twenty six sub-offices.
This is a new idea but is the logical result of past experience in
furnishing service to the patients of the Veterans’ Bureau and in
providing adequate medical facilities. It may not be amiss to trace the
development of this idea from the time when the Veterans’ Bureau was in
its infancy as the Bureau of War Risk Insurance and when the problem of
securing examination reports on claimants for compensation and providing
treatment to patients amounted to a grave emergency.
No ready made medical service existed to which the Bureau could turn for
its needs. The problems of demobilisation confronted the Army and Navy.
The Public Health Service was presented with the needs of the Bureau of
War Risk Insurance and undertook the difficult task of forming a medical
organization throughout the Country to meet these needs. The United
States was then divided into fourteen districts with the District
Headquarters and a medical officer of the Public Health Service in
charge, called a “District Supervisor”, who was directly responsible for
the organization of a medical staff throughout his District. The first
plan for medical service was the appointment of physicians as designated
medical examiners on a fee basis wherever there were claimants of this
Bureau to be examined and treated, the ultimate object being to have at
least one designated examiner in every county of the United States. By
January of 1920 this object had been attained and designated medical
examiners had been appointed in every city and town and in almost every
village of the county.
The District Supervisors soon found this a most expensive method of
accomplishing the work. The Bureau concurrently found it increasingly
unsatisfactory in its result—an army of physicians widely scattered,
whose work was difficult to control and well nigh impossible to
standardize. The requirements of the Bureau were very definite. As a
result, the Public Health Service developed the _medical unit_ plan of
organization, which, in brief, was the formation of groups of physicians
in the larger communities to make complete general and special
examinations and to give careful study to cases requiring treatment. The
results were so far superior to any previously obtained that the Bureau
of War Risk Insurance urged the District Supervisors to complete the
organization of their Districts along these lines and to use the
designated medical examiners as little as possible.
The next step in the development of the dispensary idea was the
establishing in the District Offices of large examining clinics staffed
by officers and appointees of the Public Health Service devoting their
entire time to this work and reinforced by the consultant services of
the best specialists which the cities afforded.
The growth of the District Offices had passed all expectation and a
serious problem faced the Public Health Service in enlarging these
offices in accordance with this plan. However, there was no question of
the wisdom of establishing in the District Offices adequate facilities
for making examinations, as this feature was one of vital importance to
the Bureau because on the accuracy and completeness of the examination
reports depended the award of disability and the determination of
compensation.
The Public Health Service faced this problem squarely and, loyally
supported by the Bureau of War Risk Insurance, demonstrated the wisdom
of this move. The Surgeon General went even further and established real
outpatient dispensary service in connection with certain examination
clinics in the District Offices and hospitals of his Service.
The Bureau of War Risk Insurance then assumed direct control of the
entire District organization and the Director, Colonel Forbes, after an
extended survey of this organization and the methods of furnishing
service to his patients, which took him into practically every District
Office and many of the larger cities served by medical units, evolved
the plan of extending dispensary service to every section of the
Country. With his keen insight into organization problems, one of his
first moves was to obtain Congressional authority to further divide the
Districts into sub-districts. He appreciated that each sub-district
office was a potential dispensary, the examination clinic in each
District Office and the medical unit at each sub-office being the
nucleus upon which to build a U. S. Veterans’ Bureau Dispensary Service.
Under the terms of the Veterans’ Bureau Act, the Director is charged
with the responsibility for proper examination, medical care, treatment,
hospitalization, dispensary and convalescent care, necessary and
reasonable after care, welfare of and nursing service to beneficiaries
of the Veterans’ Bureau, and since he is so charged, the manner in which
dispensary and reasonable necessary after care can be afforded is a
matter of immediate importance. It is therefore proposed to establish in
each District Office and sub-district office a dispensary of standard
type which will vary only in size according to the amount of work in the
city and surrounding territory which it serves. It is proposed to
establish a type of dispensary to be used as a standard which will
provide facilities for a medical clinic, a tuberculosis clinic, a
neuro-psychiatric clinic, a surgical clinic and an eye, ear, nose and
throat clinic. In addition, there will be a dental unit, primarily for
the purpose of making accurate dental examinations, and secondarily for
the purpose of furnishing dental treatment. It is proposed to establish
an X-ray laboratory and a small clinical laboratory and pharmacy. These
are the facilities of the standard type of dispensary proposed.
In the District Offices, and in a few of the largest Sub-offices, this
standard type will be developed to the greatest extent as these offices
bear the greatest burden of making examinations and furnishing
out-patient treatment. In addition to the clinics above mentioned these
Offices will be equipped with complete Physiotherapy Clinics.
The initial expense involved in establishing dispensaries will
necessarily be large, but once established, will not only furnish
medical service of the highest type to patients of this Bureau, but
will, it is believed, result in an actual economy when compared with the
present method of providing similar medical service practically on a
contract basis. X-ray service alone costs the Government large sums
annually which, with the establishment of the dispensary, can be
practically eliminated. Laboratory service is also an expensive item of
out-patient service when performed by contract, which can also be
eliminated. Dental treatment to which patients of the Veterans’ Bureau
are entitled under the law, is a matter of grave concern as it is
handled at the present time on account of the great expenditure
involved. This expense can be very materially reduced if the Bureau
establishes its own dental dispensaries where careful examinations can
be made and definite determination of the dental disability can be made
by trained examiners. Treatment to which the patient is entitled can
then be furnished either by the dispensary or performed by contract
under close supervision.
Every medical officer in charge of a hospital is faced with the problem
of de-hospitalization of patients of this Bureau who have reached the
maximum amount of recovery afforded by hospital treatment. I believe
there is not a medical officer here who is not facing this problem at
the present time and who knows that patients are in hospital not
actually requiring further hospital treatment but who do need further
medical attention and careful medical observation to enable them to make
a complete recovery.
It is believed that the dispensary with its trained professional staff
to render medical treatment and to provide medical follow-up and after
care during that period when the patient is undergoing the final stage
of his physical recovery and is making his social and vocational
recovery to a life of usefulness in the community, will meet a long felt
need. It is believed that the period of hospitalization can be
materially shortened if the patient can be discharged directly to a well
organized out-patient dispensary where his treatment will be continued
and his social and industrial rehabilitation made under the careful
surveillance of trained medical groups. The effects of hospitalization,
prolonged after the maximum benefit has been received, are injurious to
the average patient and if continued, soon makes of these patients
domiciliary charges upon the Government. This is to be deplored and
prevented.
As soon as the dispensaries are established, this Bureau is, and will
continue to place them more fully at the disposal of the hospitals for
the purpose of shortening hospitalization and hastening his physical and
social recovery. This is one of the most important functions of
dispensary service.
The Director is charged, under the law, with not only providing
treatment for compensable claimants of this Bureau, but he is also
charged with maintaining the physical condition of claimants who are
undergoing vocational rehabilitation during the period of their
training. The dispensaries have been located as far as possible to serve
the greatest number of trainees and will provide medical service to take
care of the so-called intercurrent diseases and accidents from which the
trainee may suffer as well as furnish him treatment for diseases or
disabilities connected with his service. With the increasing number of
claimants availing themselves of vocational rehabilitation, the problem
of medical service is one of no small import and it is believed that the
dispensary furnishes the best solution of this problem.
There is another class of beneficiary of the Veterans’ Bureau who is
entitled, under the recent Veterans’ Bureau Act, to medical
treatment—namely, those claimants whose disability is not sufficient to
warrant an award of compensation. Heretofore only patients who were
compensable were entitled to medical treatment and the claimant must
have a disability of ten percent or more to entitle him to compensation.
Under Section #13 of the Veterans’ Bureau Act, a patient with any degree
of disability is entitled to treatment for a disease or disability,
which is connected with or aggravated by service. This adds a class of
patients to whom the Veterans’ Bureau must provide treatment now and in
the future. The dispensaries, it is believed, will meet this demand.
The establishing of dispensary service by the U. S. Veterans’ Bureau is
therefore the logical outcome of past experience in the examination and
treatment of its patients. The Director is also enjoined by the
Veterans’ Bureau Act to furnish adequate medical care including
dispensary service, follow-up and after care to claimants of this
Bureau. The matter has been given and is being given careful
consideration in this Bureau and it is hoped that in the near future the
dispensary service of the U. S. Veterans’ Bureau will extend throughout
the United States, for the convenience of all disabled veterans of the
World War and for the betterment of the treatment which this Bureau is
endeavoring to give.”
COL. FORBES: stated that it was believed that the dispensary was the type
that could do everything but put the man to bed; that it was decided
that it would require an appropriation of seven million dollars to put
over the dispensary program; that the Bureau has a dental bill of 435
thousand dollars; that the dental work is one of the big items, as is
the x-ray service under the present contract system; that heretofore the
examiner was the workman; that the patient would go for examination, and
the examiner would say: “You have two teeth out on this side, and it is
no use to put one in on this side unless you have the other two put in
also; that the bureau has had bills come in for dental service for one
mouth in the amount of $350.00; that that service has been abused; that
x-ray bills for one mouth have ranged from $15 up; that $3.50 was
decided upon as a general figure.
“We shall now have a half hour’s discussion of the topics presented in
today’s program so far.”
DR. LAVINDER: suggested that explanation be made to the officers present
concerning out-patient relief, stating that shortly the Veterans’ Bureau
will assume entire responsibility in that connection.
COL. FORBES: repeated the statement that the Veterans’ Bureau will assume
the entire responsibility.
COL. EVANS: Called attention to the part of General Sawyer’s address which
summarized the personnel for a 200–bed hospital, and stated that he
believed there was an error in the numbers as he had formerly compiled
them;—that 14 people would be sufficient to cover the three phases of
work (Occupational Therapy, Social Service, and Vocational and
Prevocational Training).
GENERAL SAWYER: stated that the correction would be made.
SURGEON CHRONQUEST: asked if the personnel just mentioned applied to all
types of hospitals, general, T.B., and N.P.
COLONEL FORBES: stated that they do.
SURGEON BAHRANBURG: stated that he thought there must be an error in the
figures as given; that at St. Louis they have a 650 bed hospital, with
an average of 600 patients; and that with the use of aides in greater
proportion than here mentioned, they cannot do as much work as is
required of them in that line.
COL. FORBES: asked for his recommendations concerning additional aides.
SURGEON BAHRANBURG: suggested 12 as the number of physio-therapy aides; and
the same number for occupational aides. He added a few words concerning
the clinic at St. Louis, stating that they had 162 cases last month;
that they have an x-ray laboratory, etc., and that the cost of operation
of the dental clinic was a little over $8000 a month.
SURGEON YOUNG: inquired as to the basis on which were derived the figures
for total per diem cost.
COL. FORBES: that the Bureau has a complete analysis of the cost of
operation, and that this matter would be discussed later in the
conference.
DR. SANFORD: stated that he was interested in the dental clinic in Denver,
and remarked that the dental clinic was the hardest to handle. He added
that their dental bill for one month was $3760, but that their expenses
in that connection were much less now; that they have a personnel of
eight full-time doctors—three men in the laboratory; and that the clinic
there is a complete one.
COL. FORBES: “There is no question but what the fee basis is costly. Our own
clinics are the most economical.”
COL. BRATTON (Army & Navy Gen. Hosp.): asked how long this expense for
dental treatment was to continue,—if it were to continue during a man’s
life.
COL. FORBES: stated that the law provides that any man who has 8% disability
has a dental disability; that the x-ray is largely responsible for this
dental treatment; that the matter is one to be adjusted by those present
who are responsible for having the x-rays made and for prescribing
dental treatment.
SURGEON McKEON: made reference to Colonel Patterson’s paper and the
necessity for removing men from hospitals as soon as the need for
hospital treatment ceases to exist. He stated that men are retained in
hospitals longer than is necessary, due largely to the fact that they
want to take up vocational training. He recommended that the
Rehabilitation Division make a survey of a patient about three months
prior to discharge, so that when the patient is able to be discharged
from the hospital, he may enter training at once.
COL. FORBES: Read Section 2 regarding vocational training; but added that in
the rearrangement of the Veterans’ Bureau now in process there will be a
closer liaison between the Rehabilitation Division and the Medical
Division, and the Rehabilitation Division will be represented in the
hospitals.
COL. EVANS: stated that a recommendation is to be presented to Col. Forbes,
for his approval or disapproval, to the effect that the educational
director in a hospital will be the Bureau’s representative there in
regard to rehabilitation work and will furnish data regarding the man as
to what he has done and what he can do.
GEN. SAWYER: said he understood that this representative was accounted for
in the list presented formerly by Col. Evans.
COL. EVANS: answered that that was the provision made.
COL. FORBES: said that he believed that the rehabilitation proposition is
much more of a medical problem than an educational one; that there must
be a closer medical observation of the men and not quite so much
education; that if the physical disability can be removed first, then
the man is better equipped for vocational work; that the man should have
the maximum of hospital treatment before he is put into vocational work;
that the problem is 90% medical and 10% educational.
SURGEON DEDMAN (Greenville): stated that his place had adopted the system of
sending a copy of the physical report of the Board of Medical Officers
to the social welfare part of the Red Cross, and one copy to the
educational department of the Veterans’ Bureau so that the Bureau might
be in constant touch with the man’s physical condition. He recommended
that there be in the sub-offices experts on T.B., etc., and thereby
eliminate the sending of men to hospitals when they have no trace of
such disease.
He expressed appreciation of the work of the Red Cross in his community.
COL. FORBES: added his appreciation of the splendid service rendered by the
Red Cross, and stated that that organization had recently made available
to the Bureau $175,000 for recreational purposes.
SURGEON STITES: stated that the educational director at the Alexandria
hospital is kept in constant touch with every patient there,
particularly those approaching discharge. He also stated that he was
particularly impressed with what was contained in General Wood’s paper
with reference to the care and treatment of disabled veterans whose
disability is in no way connected with the service; that there are
veterans in his community who need treatment, but whose disability is
not connected with service.
COL. FORBES: emphasized the fact that the law provides that the disability
must be in line of duty or during the period of military service.
COL. FORBES: in answering a conferee, stated that the law providing for
admission to Soldiers’ Homes was amended to apply to veterans of the
World War; and that all that is required of the man is to make
application to any National Soldiers’ Home and present an honorable
discharge from the service.
SURGEON MILLER: expressed his interest in Dr. White’s address; that it
called to mind a condition which exists at some of the T.B. hospitals.
He said that a case of Dementia Praecox is often found with active T.B.,
and that where such a patient is accustomed to taking convulsions, it is
very disturbing to the other patients at the hospital.
COL. FORBES: said that the N.P. cases could be sent to Marion, Indiana.
SURGEON MILLER: said he had a telegram saying that admittance was refused to
active T.B.-Dementia Praecox cases.
COL. FORBES: recommended that he take this up with his Surgeon General.
SURGEON WILBOR: spoke concerning the patients at Gulfport, and stated that
many of these men lack confidence in themselves as regards training and
have to be encouraged. He recommended that the men be given a partial
course of training in the hospital, after discharge, in order to give
them sufficient confidence.
COL. FORBES: said that he believed that if a man were able to pursue six or
seven hours of educational activity, he should not be hospitalized; that
heavy machinery, etc. should not be in hospitals.
COL. FORBES called upon Captain Blackwood, U.S.N.
CAPTAIN BLACKWOOD: stated that he did not have anything special to say, as
he had intended reserving his remarks until later. He said that he was
discouraged at hearing so many exaggerated adjectives used by the
conferees; that it should be realized that the patients came from all
walks of life; that the physical examination upon entering the service
was superficial in many cases, and the men are only now being examined
as thoroughly as they should have been before; that they are now
receiving better treatment than they would in civil hospitals, as the
Government is trying to eliminate the possibility of the patient’s
having a disease of which he is not aware, and thereby save future
trouble and expense for the Government.
COL. FORBES: “Would you say that in all cases of medical doubt, a man should
be x-ray’d?”
CAPTAIN BLACKWOOD: “Yes.”
CAPTAIN BLACKWOOD: stated, in addition, that he considered the matter of
dispensaries a very good one.
He also recommended that the amount of paper work for medical office be
reduced, as it seemed that the work they are trying to do in medical way
will be subservient to the clerical work. He stated that he had
reference to both Navy and Veterans’ Bureau papers.
COL. FORBES: asked for his recommendation in this connection.
CAPTAIN BLACKWOOD: replied that he could not make any sweeping statement.
COL. FORBES: called upon Colonel Kennedy, U.S.A.
COL. HANNER: represented Colonel Kennedy.
COL. FORBES: inquired as to the number of patients at Letterman Hospital.
COL. HANNER: answered that they have 84. He inquired concerning a few
patients sent to them by the proper authorities, where the disability
has no connection with the service.
COL. FORBES: inquired as to what had been done in such cases.
COL. HANNER: replied that the men had been taken in and that some of them
had been hospitalized and some not—pending authority from the District
Manager to discharge them from the hospital.
COL. FORBES: stated that if there is a question of doubt, the man is to be
given the benefit of the doubt and his hospitalization continued; that
if it believed that the disability is not due to service, the officer is
to be guided strictly by Regulation 27, and he should inform the
District Manager; that the Sweet Bill provides very liberally for the
care and treatment of ex-service men, and that he would see that
everyone present received a copy of the Sweet Bill, a copy of the
Vocational acts, and the original War Risk Act and its amendments; that
he wanted all to read them very carefully. He added that it is the
medical advice and decisions that the Bureau has to depend upon
regarding the care and treatment of the men.
DR. SNELL, (N.H.D.V.S.) asked if a man should be hospitalized if he
presented himself to Dwight, Illinois, for example, but his disability
was not of service origin.
COL. FORBES: said that the man is to be hospitalized, and his case
determined later; that is he has a contagious disease the city will take
care of him.