If, after written notice has been given, any institution furnishing
medical care and treatment to patients of the United States Veterans’
Bureau fails or refuses to make reasonable effort to meet the foregoing
requirements, such institution will be deemed to be rendering
unsatisfactory service, and if under contract with the United States
Veterans’ Bureau, such contract may be cancelled, and the Director will
refuse to make contracts when the care and treatment offered do not
substantially meet the requirements specified herein.
[Illustration:
LEON FRASER
Acting Director,
U. S. Veterans’ Bureau.
]
SENIOR SURGEON B. J. LLOYD, (U.S.P.H.S.,(R)): presented the second paper,
entitled “Admissions to, Transfers and Discharges from Hospitals of
Beneficiaries of the U. S. Veterans’ Bureau,” which is given below:
“I do not often speak in public. Occasionally I attempt to speak
extemporaneously, but today I shall claim your indulgence and confine my
remarks strictly to what is written in this manuscript, for the reason
that if taken in a disconnected sense some of the things I shall say
might sound sensational, whereas if taken in a connected sense and in
the way I shall say them, I think you will agree with me that there is
absolutely nothing sensational in my remarks.
Attendance at this conference is indeed both a privilege and an
opportunity. To be asked to address this gathering is a distinction
worthy of the best that can be said on the topic assigned.
I take it that you are already familiar with the rights and benefits to
which the disabled ex-service man is entitled; that you are familiar
with the usual routine of paper work and other procedures in admitting,
transferring and discharging, and I shall therefore omit some of the
more or less definitely settled, fixed policies in this discussion.
I fully realize that my subject is an extremely important one and that
it is in a measure connected with nearly every benefit extended to the
ex-service man or woman, and with every service that is rendered in his
or her behalf. On the intelligent administration of the functions of
admission, transfer and discharge to, or from our hospitals, as the case
may be, depends, in great measure, not only the economical and efficient
administration of our entire hospital program, but in equal measure the
recovery, the health, the happiness, the future usefulness, even the
very lives of men and women, many of whom have made great sacrifices and
passed through great agonies.
When I make these assertions, do not think for a moment that I am
comparing these functions with the actual volume of work that is done in
the hospitals, with the relief that is given therein, nor with the
benefits which accrue to the patient, but, just as victory in a great
battle may depend on the placing of the right troops in the right place
at the right time, so victory, in the struggle of the disabled
ex-service man for rehabilitation, for health, or for life, may depend
on his being sent to the right hospital at the right time. Neither must
he be discharged too soon, nor kept too long, and when he is transferred
from one hospital to another there should be sound medical reasons
therefor, barring those unfortunate cases, where the beneficiary may be
transferred to a hospital near his home when it is seen that death is
inevitable.
Going back now to the contact which hospitalization makes, or should
make, with the other benefits extended to the ex-service man, let me
picture to you the state of our past, and to a great extent, our present
organization, by recalling to your minds the old story of the six blind
men of Hindustan who went to see the elephant, each trying to tell what
the elephant was like. The first man got hold of the elephant’s ear and
said that the animal was very like a fan; the second got hold of his leg
and said, “No, I can’t agree with you; this elephant is like a young
tree.” The third man got hold of the elephant’s trunk and said, “The
elephant is like a snake.” The fourth man grasped a tusk and said that
the elephant was like a spear; the fifth fell against his side and said
he was like a wall; and the sixth got hold of his tail and said he was
like a rope. Now all were partly right and each was mostly wrong, and a
somewhat similar condition exists with regard to our work.
This meeting, gentlemen, is an attempt to further co-ordinate the
efforts of all the agencies that are at work for the ex-service man.
Ours is a tremendous responsibility, both from the standpoint of our
duty to the ex-service man and of our duty to the taxpayer as well.
No man except the man in the field knows better than I do that you have
been circularized and regulated and instructed and uninstructed,
informed and misinformed, ordered and dis-ordered, until I have no doubt
you have been tempted to slam your fist down on your desk and say,
“Well, for Heaven’s sake, how many bosses have I, anyway, and which lead
had I better follow.” And as for reports, no doubt you have wondered,
“Well, what _will_ they want to know next?” And yet there has generally
been a fairly good reason for every question you have been asked and a
reasonably intelligent, honest, and often an enthusiastic, and sometimes
an efficient man or woman behind the interrogation point.
In addition to having all these things done to you, I suspect that you
and your colleagues in the hospitals, some of you at least, feel that
you have been libelled and slandered by newspapers whose editors thought
they were telling the truth, and by newspapers whose editors probably
did not stop to consider whether they were telling the truth or not. You
probably feel that you have been libelled and slandered, unintentionally
of course, by men inside of legislative halls, and also, again perhaps
unintentionally, if carelessly, by men and women outside of legislative
halls, and by men and women both inside and outside of well-meaning
civic organizations. And, I may say that in the Arlington Building in
this city there are reams of evidence which might be cited in support of
your beliefs, and at “C” Building at 7th and B Streets, there are
tri-remes of such evidence, and these reams and tri-remes of evidence
have cost the Government of the United States thousands, tens of
thousands, yes, hundreds of thousands of dollars for investigations,
when, as a matter of fact, the majority of the complaints that have been
filed against hospital administration need never have been investigated
by the Government at all if the individual who submitted the complaint
had taken the trouble to do a little honest investigating on his or her
own account.
The fact that these statements have been made with the best intentions
in the world does not lessen the injustice contained in many of the
charges, nor does it remove the sting which has accompanied these
charges, and you, gentlemen, have listened to the soft pedal on the
inside and to jazz on the outside until you have probably said, “For the
love of justice, is there not some man who has grit enough to get up in
public and tell the truth and say what he thinks?”
But, gentlemen, it will not always do to talk back. Actions speak louder
than words, even though they do not make as much noise, and Solomon was
right when a few centuries ago he remarked that “A soft answer turneth
away wrath.” We must _always_ maintain a courteous, gentlemanly,
dignified attitude. We must never for a moment allow our sympathies for
the deserving unfortunate ex-service man to become in the least
weakened, and we must continue to give him the benefit of the doubt in
border-line cases, and finally we must maintain our equanimity under the
most trying circumstances.
And now that we have you here, we are going to ask you some more
questions, and I hope you know the answers, because I don’t know the
answers to some of these questions myself, nor do I intend to answer
them.
In passing, I might remind you of the fact that in times past we have
spent money very freely on our hospital program, and that while we still
desire to give our beneficiaries what is perhaps a little more than
reasonable medical and surgical care and treatment, at the same time we
must be able to show Congress that we are operating economically under
present conditions, and certainly, when not in conflict with the
patients’ rights or interests, the question of economy of administration
must be considered in admitting, transferring and discharging. Are we
giving this question of economy of administration the proper
consideration in performing these functions, and if not, what are the
reasons? We want to know. This I will label “Question No. 1,” and let
you think it over for a while. It is perhaps not the most important
question I shall ask but it is important.
Now, having delivered myself of this question, and not having answered
it, I suppose you are ready for Question No. 2. Well, I am not. I want
to talk a little before I spring the next question. Of course we all
know that the primary object in placing a man in a hospital is to give
him a chance to get well, or as nearly well as possible. This, however,
is not the only thing to be accomplished in the hospitalization of
patients of the Veterans’ Bureau, and, if I may speak frankly, I may say
that, while theoretically, hospitalization, rehabilitation, and the
awarding of compensation ought to dovetail into each other without any
overlapping or getting in each other’s way, as a matter of fact they
won’t do it,—at least they haven’t done it so far; but, nevertheless,
we’ve got to make the best possible connection between these functions.
Let us hark back to Regulation No. 57 of the old Bureau of War Risk
Insurance, which gave temporary total disability to the beneficiary
whose disability showed Service connection, together with compensation
at this high rate as soon as the man entered the hospital, and which cut
down this compensation anywhere from $80 per month to nothing at all as
soon as the beneficiary left the hospital. Although this Regulation has
been somewhat modified recently, it is still a very strong incentive for
men to seek hospitalization. It takes an unusually patriotic citizen to
take $30 to $60 a month or less when he can get $80 a month and board
and lodging if he can remain inside of a hospital.
Apropos of this provision, I recall the circumstances of a young man who
came to me quite some time ago, having left the hospital at Fort
McHenry. He presented himself in a courteous, dignified way, was
perfectly serious and absolutely frank. He began the interview by
handing me the card of a U. S. Senator. Then he told me his story, and
it was a good story. I shall try to recall it as nearly in his own
language as possible. “Doctor”, said he, “I have just left your hospital
at Fort McHenry. I do not like it. I realize that the Public Health
Service is not to blame for conditions which I found there. It is not
suited for a hospital. It is badly located. There are odors which it
seems impossible to overcome. The walls and floors are dingy, and while
they are clean, they cannot be made to look clean.
“I was shot through the stomach by a machine gun. Here are the scars. If
I do not work hard I feel fairly comfortable, and yet I am not well, I
receive $30 a month when I am outside the hospital, I receive $80 a
month and my board and room when I am in the hospital. Personally I
would much prefer to remain at home, but when I work hard enough to make
a living I break down. I have seen so many men in the hospital who are
receiving their board and lodging and their $80 a month who are not as
deserving of this as I am that I do not propose to remain at home and
work on my present compensation, and I would just like to see you keep
me out of a hospital. And furthermore, I demand to be sent to the
hospital of my choice. What are you going to do about it?”
I replied, “Young man, you have been unusually frank in what you have
said. I shall be equally frank with you. If I had been wounded as you
have, and if I had the information which you have gained from your stay
in different hospitals, I should probably make the same demands. You can
have your transportation whenever you want it.”
I saw this young man later at No. 38 in New York and he told me that he
was about to get what he considered a satisfactory rate of compensation,
and that as soon as he could get it he would go home.
Question No. 2. How many men are there in our hospitals today who would
voluntarily leave if we did not, by providing total disability rating
and compensation while in the hospital, place a premium on their
remaining there? How many of those who would leave really ought to
leave? What can be done to correct the defects in the operation of
Regulation No. 57, modified as it has been? Perhaps you think I am
giving you several questions in one, but we will still label if
“Question No. 2.” I am not alone in desiring to know the answer to that
question.
Before I go any further let me say that I regard admissions, transfers
and discharges as such closely related operations that I shall not
attempt to treat them separately, but shall discuss them in any sequence
that may be convenient.
I assume that all of you have been advised that under General Order No.
59, the allocation, distribution and transfer of patients of the
Veterans’ Bureau are functions and prerogatives of that Bureau.
Theoretically, none of the Services has anything to say about these
matters. Practically, if I have not misunderstood the intent of this
General Order, it does not mean that, altogether. The actual authority
for and the right to refuse transfers certainly is vested in the
Veterans’ Bureau and its representatives, but the Veterans’ Bureau and
the District Medical Officers and District Managers depend on you to
tell them when you think transfers ought to be made. Admission to a
given hospital is the prerogative of the Veterans’ Bureau within certain
limits; that is, the Service concerned must be able to take and care for
the class of patient sent by the Veterans’ Bureau.
With regard to the discharge of patients from hospitals, the Veterans’
Bureau is continually encroaching, perhaps unavoidably, on what was once
the prerogative of the Medical Officer in Charge and the Service which
operated the hospital. Blanket authority for field transfers from one
district to another has been entirely withdrawn, and District Officers
must either place immediately in an authorized hospital in an adjacent
district, as specified in General Order No. 59, or, having placed for
observation or diagnosis a patient in a hospital within their own
districts, must apply to the central office if it is desired to transfer
later. It is, or should be, understood that under the present regime,
that Medical Officers in charge of hospitals who regard transfers as
necessary must request the District Office to make these transfers if
within the district, and must request the District Offices to obtain
authority from the Central Office if it is desired to transfer outside
of the District.
Several questions suggest themselves with regard to General Order No.
59, and perhaps I should label this series of questions “No. 3.”
(a) Has General Order No. 59 lessened the number of ill-advised and
unnecessary transfers, which is one of the objects, I believe, that were
intended to be accomplished.
(b) Has General Order No, 59 caused any marked fluctuation in the
patient personnel of any of the hospitals? I notice, for example, that
Public Health Service Hospital No. 53, Dwight, Ill., has recently
dropped from occupied beds to 65 in number, giving a surplus of 165
unoccupied beds. Houston, Texas, has dropped from occupied beds to
443 beds, giving a surplus of 528 unoccupied beds. At No. 32, Mount
Alto, Washington, there is a ward for colored patients which will
accommodate 30, in which there are only 6 colored patients at the
present time. Are these fluctuations coincidences or are they the effect
of the Veterans’ Bureau having assumed the functions under discussion.
Of course if we could be sure that these reductions in-patient personnel
are going to be permanent it would not make any difference. We could cut
down our working personnel at a hospital like Houston, Texas, and with
the consent of the Veterans’ Bureau we could close a hospital like
Dwight, Ill., but will the pendulum swing in the other direction again,
and what advance information can the Veterans’ Bureau give these
fluctuations and of their approximate duration?
(c) Have you received very many patients who, owing to their condition
or to the nature of your facilities, or both, should never have been
sent to your hospital?
(d) Has General Order No. 59 tended to delay the turnover in those
general hospitals having special wards for psychoneurotic and psychotic
patients, who are detained for a short time only until they can be
otherwise disposed of?
(e) Should General Order No. 59 be modified, and if so, in what
particulars?
Having delivered this third volley of questions, I shall talk a little
more. I have no idea what opportunities you gentlemen have had to become
familiar with the facilities at hospitals other than your own. I have no
idea what information District Managers and District Medical Officers
have of hospitals and conditions in Districts other than their own.
General Order No. 59 of course attempted to convey some idea of the
facilities in all of the hospitals used by the Veterans’ Bureau, but it
was impossible to incorporate anything like a comprehensive statement
with regard to these facilities. Quite recently, at the request of Dr.
Guthrie, and with the assistance of men in both Bureaus, I prepared a
questionnaire for all the hospitals, asking what your general conditions
and facilities were like. Most of the hospitals have answered this
questionnaire, and the information obtained is exceedingly valuable.
Practically without exception the answers have been concise, complete
and exactly what was asked. Those of you who have not answered please do
so as soon as you can. I wish it were possible to print or mimeograph
these reports and distribute them. Certainly anyone who is charged with
the responsibility of placement and transfer of patients should have
access to these reports.
While I am on this subject of facilities, let me invite attention to the
fact that there are marked differences in the kinds of facilities
offered by different hospitals and by the hospitals of the different
Services. Let me also invite attention to the fact that we have patients
who, if properly distributed, would fit into these different
institutions possibly in a much more satisfactory way than at present
and at a smaller expense. Particularly I suspect that there are many
patients in Public Health Service hospitals that do not need the highly
specialized and necessarily expensive care that these hospitals are
giving, and I also suspect that there are many vacant beds in our
Soldiers’ Homes where these patients can be given all they need at a
much less expense than is possible in the highly developed hospitals of
the Public Health Service, and possibly those of the Army and Navy as
well. Why would not this be a good time to arrange for the prompt
transfer of such patients? Europe has found the Convalescent Home to be
an economical institution, being much less expensive than the hospital.
Why may not our Soldier’s Homes be used for convalescents and those who
need relatively little medical care and treatment, but who are still not
well enough to be thrown on their own resources? These questions I shall
not number. They just crept in.
There is one class of beneficiary that none of the Services seems to be
prepared to handle satisfactorily, possibly due to the fact that
legislation is needed to deal with this class. There may be a solution
other than legislation but none of us has thought of it as yet. I refer
to the drug addict who is entitled to hospitalization for some Service
connected disability. We haven’t any place to put such patients and we
do not know what to do with them after we put them there. We do manage
to take care of some of them but at great inconvenience, and without
being able to treat them for their own best interests. We cannot get
them admitted as irresponsibles by the Courts. We have no such thing as
involuntary commitment, and if one of them desires to walk out of the
hospital, out he walks if he is persistent enough about it, and we
cannot stop it. This is a good time to say something about what we might
to with these cases.
I have said very little about discharges for the reason that
disciplinary discharges are to be treated by another speaker, and
Regulations Nos. 26 and 26–A, bearing on this subject are to be
discussed by Doctor Guthrie, who follows me on the program. I will say,
however, that this subject is an important one and I can easily
understand that from the standpoint of the man in charge of a hospital
present procedures with regard to discharges are unsatisfactory. On the
other hand, I can understand that when a man is in a hospital it affords
an excellent opportunity to settle once and for all his claims for the
various benefits provided by law, and yet I think it is right that the
Veterans’ Bureau should accomplish these objects before the man is ready
to be discharged. As yet this is not being done.
In conclusion, Gentlemen, I may say that as I see it, those of you who
are in charge of hospitals are, if you will pardon the expression,
between the devil and the deep blue sea. You are told one minute that if
you exceed your allotment you will go to jail, and in the next breath
you are told to go the limit if it is for the ex-service man. You have
been told that there is room for improvement in your hospitals. No doubt
there is, but in my humble opinion there is also room for improvement in
the laws providing these benefits, in the orders, regulations and
procedures designed to administer these laws, and last but not least,
there is a crying need for some means of creating a sane public
sentiment that will enable the public servant to discriminate between
the man who really has a serious disability which he got in the Service
who deserves our help and our sympathy, and to whom you and I would give
the shirts off our backs if need be, and the man who spent a few days or
a few weeks in camp who is not really disabled but who proposes to live
at the expense of the tax payer just as long as he can get away with it.
We, Gentlemen, are not responsible for the law, nor is the Director, and
the Director has men who tell him what the law is and he has to obey it
and so do we, but it is our duty to point out defects in the law and try
to get them remedied.”
SURGEON M. C. GUTHRIE (U.S.P.H.S.) had for his subject, “Discussion—General
Order No. 26”, and spoke as follows:
“The subject assigned to me for discussion is General Order No. 26. This
refers to U. S. Veterans’ Bureau General Order No. 26, dated September
6th, 1921, the subject of which is: “Admission to and Treatment in
Hospitals of the U. S. Veterans’ Bureau Beneficiaries.” You are
doubtless all familiar with the general provisions of this order.
It goes without saying that any definite order or instruction which
effects the policies and functions of the U. S. Veterans’ Bureau and
which may be issued to the field is sure of a series of return
re-actions from various parts of the country, both as to the manner in
which such an order is applied and as to the consequences of its
application. These reactions are naturally good, bad, and indifferent;
exact and truthful statements or colored as to the manner in which they
affect the various individuals in its application, but coming from all
parts of the United States they afford many valuable and effective
criticisms of the order in question and are illuminating as to the
original intent of the order and the amount of deviation or variation
from its original purpose brought about by the manner in which it is put
into effect.
The criticisms of General Order No. 26 had to do very largely with the
“Four Days’ Notice” clause, and because of the fact that large numbers
of beneficiaries in hospitals were being discharged without provisions
having been made for out-patient care, dental care, physiotherapy, or
other treatment where such was indicated and necessary; that patients
were being discharged without having proper arrangements made for
vocational training where the patient in question was feasible for some
kind of training and was anxious to get it; that many such patients had
to leave a hospital when they were receiving no compensation or where
adjustments or readjustments of matters related to compensation needed
to be carried out here.
These were the dominant and outstanding criticisms which followed the
issuance of General Order No. 26, and as a result of these criticisms,
it was considered advisable to issue a supplemental order correcting the
defects complained of. Accordingly General Order No. 26–A came out under
date of November 17, 1921.
The re-actions to General Order No. 26 were as I have just stated and
came largely from the Bureau beneficiaries, from friends, relatives, and
allied agencies working in the field. The criticisms of General Order
No. 26–A, however, came largely from the hospitals and the District
offices, the hospitals particularly. There was an apparent contradiction
between the two orders. No. 26–A seemed to largely or entirely
contradict the provisions of the original Order No. 26. General Order
No. 26 stated that patients not requiring further hospital treatment
should be given four days to complete personal arrangements and then be
discharged.
General Order No. 26–A requires that before a patient is discharged from
hospital it should be determined whether or not he is in further need of
out-patient care; whether or not he is feasible and eligible for
vocational training and if he wanted training, that this should be
arranged before he is discharged, and that the necessary adjustments or
re-adjustments of all matters pertaining to a claimant’s compensation be
entirely completed by the time of his discharge from hospital; and
further it must be distinctly understood in carrying out all of this
that no unnecessary delay in discharge of patients would be allowed. A
pretty complex and contradictory situation you might say. However,
between the time of the issuance of General Order No. 26 and of General
Order No. 26–A—to be exact, on October 14, 1921, a general order was
addressed by the Medical Division of the U. S. Veterans’ Bureau to the
several Government services—the Surgeons General of the Army, Navy, U.
S. Public Health Service, the Superintendent of the National Homes for
Disabled Volunteer Soldiers, the Superintendent of St. Elizabeth’s
Hospital, and to the fourteen District Managers. The essential parts of
this letter are as follows:
October 14, 1921.