Part 19

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 Blanket authority for field transfers from one district to another has been entirely withdrawn, and District Officers must either place immediately in an authorized hospital in an adjacent district, as specified in General Order No. 59, or, having placed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.

PSR/jcs L 10–DMO

District Manager, District No. 1, U. S. Veterans’ Bureau, 101 Milk Street, Boston, Mass.

Dear Sir:

Referring to General Order No. 26 and to Paragraph No. 2, which reads as follows: