dispensing of drugs and in his relationship to the pharmaceutical industry.

Some might question the need for this legislation since one would hope that no medical practitioner would ever place himself in the position of directing patients to utilize services or purchase commodities in which the practitioner has a financial interest.

Yet, I welcome the concept of this bill because as a law it says in print what we expect to be true in the practice of medicine, and by innuendo, in other areas of professional and business life. Simply stated, we do not establish relationships, procedures, or practices, either consciously or unconsciously, which will clearly place in conflict the standards of one's profession and culture against pure personal gain.

This bill simply reiterates this concept in one small area, supports the practices of most medical practitioners, and will stand as a warning to those who fail to meet these standards.

I would now like to comment on the bill specifically and indicate: (1) where it might be expanded,

(2) whether it will serve its purpose, namely, reduce the cost of pharmaceuticals to the patient;

(3) whether it might have some deterimental effects.

If the committee has as one of its goals a reduction in the cost of medical care then I believe that the provisions of the bill should be expanded to include, as mentioned in the bill:

"(1) All medical practitioners unless they are in a geographic area where the pharmaceutical, commodity or service is not available". and this is mentioned in the asterisk at the bottom-"exception to line 15-17, page 2."

(2) Restriction of the percent-ownership of publicly offered companies "exception to line 1-5, page 5."

I believe that the bill mentions that if the company stock is offered publicly this would exempt the physician from being covered by the bill, and I feel it should also mention the percentage of the ownership in the publicly offered company, because a small company could be offered with a physician having major ownership, and therefore I suggest that the bill should restrict ownership to less than 1 percent ownership or some similar small figure.

Furthermore, there are several other medical businesses that should be legally incompatible with the primary role of a medical practitioner. I think from the standpoint of the cost of the savings to the country, these areas are much more important, and would actually elevate the level of medical care more significantly than the points. mentioned in the bill already. I would restrict partial or sole ownership in (1) laboratory services; (2) hospitals; and (3) nursing homes.

Having a financial interest in these areas of the health care industry. places the medical practitioner under an unfair burden of having to consciously or unconsciously choose between the patient's welfare and his own income.

How can a medical practitioner admit a patient to a nursing home or a hospital that he partially owns without being aware of the fact that a higher occupancy directly affects his income? How can a medical practitioner decide rationally on the number of laboratory tests his patient needs, if he has a direct financial interest in that laboratory business?

Even more important, physicians who have multiple financial interests in the health care industry are going to be less willing and less able to change it.

Actually, the physicians should be leading the way. This leadership would be more readily forthcoming if the physician's allegiance to the health care industry was dependent solely on the efficiency and quality of the delivery of health care.

Will this bill, in its present form, if enacted, reduce the cost of drugs and medical commodities? I think it might make a small dent in the total drug bill of this country. Because although you hear a lot of anecdotes about the improper dispensing of drugs, and the number of physicians that own pharmacies or dispense drugs, I think the members of the American Pharmaceutical Association and the committee would recognize that these instances involve a small percentage of physicians, and therefore the savings that would occur is not in the area of hundreds of millions of dollars, as are the savings that could be generate by improvements in other areas of the health care system.

I believe there are other reasons for the present level of drug costs of this country. This bill will not prevent the overutilization of medications by the medical practitioner and the demand for medication by the patient. I would estimate that 75 percent of all the antibiotics used in this country are unnecessarily prescribed, and that in many instances vitamins and medications used for symptomatic treatment are not indicated at all. There are several antibiotics that are used routinely in this country that our pediatric department rarely uses because they are minimally effective or not indicated. There are medical, scientific groups now working on this problem, and hopefully information will be developed that can be utilized by the public, the medical professions, and the FDA to decrease the use of unnecessary drugs.

I do not want this statement to be interpreted as an indictment of the pharmaceutical industry, for it's their job to develop new and useful drugs and they have performed well in their role.

It is the FDA's and the medical profession's job to approve and utilize drugs that are effective and use them only when they are

necessary.

I might expand upon the phenomenon in the United States of the demand for drugs by the public, especially in the middle and upper classes; it is not uncommon that a drug is prescribed due to the fact that the patient expects it and most physicians are unable to resist this pressure.

Furthermore, there are numerous anecdotes that could be used to describe the overuse of antibiotics. When the physician diagnoses a virus infection and prescribes antibiotics, this is usually bad medicine and a waste of medicine. The figure of 75 percent of antibiotics is probably low since more than 95 percent of respiratory infections are viral.

Senator Moss. Isn't this partly due to the fact that everybody has been educated to the fact that there is a pill for everything? If you have a little discomfort, you take a pill and right away you feel a hundred percent?

Dr. BRENT. We have become a drug-oriented culture, and I don't know where the input has to go to reverse this, but I think television is partly at fault.

We have a tremendous number of ads on television-Preparation H-and most of these medications are innocuous and ineffective. There is a whole world of television medicine that has to be changed.

But there are other committees that are interested in television's effect on the population, but there is no question about the fact that television plays an important part in the overutilization of drugs in this country.

It is not one single groups fault. The physician is at fault, but the public also is at fault. It's part of our culture, and we have to be constructive and creative in trying to change the direction of our culture and not by attacking one person or one group. This is another problem.

My last point deals with the-in a sense I might put detrimental in quotes the detrimental aspects of the bill, because as a physician, and one who is very dedicated to the principle of medicine and enjoys the practice of medicine, and one who is also at a medical school and knows the variation in qualities of the applicants to medical school, I am worried about the effect of this bill if it stands alone.

I think the bill is a good bill, and, in fact, I have suggested areas where this bill might broaden the areas where the medical practitioner should be separated by law from some of the business aspects of delivering health care.

I reiterate that this bill only echoes the ethical and moral standards that we expect of medical practitioners.

By the way, I don't think you need anecdotes to support this bill. If the American Pharmaceutical Association's presentation didn't have one anecdote, it wouldn't make any difference. When a bill reflects the ethical standards of a culture, anybody who is honest shouldn't be particularly against it, because when a bill says this the way we expect people to function, anybody who functions that way should welcome the legislation.

I am worried because so much attention is being given to the transgressions of a few in the medical profession and that similar legislation is not enacted for lawyers, congressmen, and businessmen who also have conflicts of interest between their professional, public, and personal activities.

I might point out that the medical profession has suffered through many image-tarnishing years. And much of the tarnish is welldeserved. The loss of image plus restrictive laws singling out the medical practitioner alone might have a detrimental effect on the quality of men who choose medicine as their profession.

Remember, that the quality of the applicants determines the quality of the doctors who take care of you. Remember that the physician's training period is the longest and most expensive. Remember there is no professional or nonprofessional group other than the physician that is subject to service in the Armed Forces until age 35, or that has anywhere near the percentage of its ranks having served under some form of conscription in the Armed Forces. Let me say that these are not attractive aspects of the medical profession.

Remember that 10 years ago, when engineering, physics and space were attracting our best students, there were many medical schools that could not find qualified students to fill their classes. I was speaking to a dean in Philadelphia who reminded me that 10 years ago, in August, they were 30 students short of filling the class. He worked the

whole Labor Day weekend calling students they had thought unqualified to ask them to come and fill the class. This is past history, and it is possible that history may repeat itself. The change in priorities and the Vietnamese war has changed this situation dramatically, namely the number of qualified applicants that apply to medical school, but it could change again.

In summary, I would point out that there are many other methods of reducing the cost of medical care and pharmaceuticals and have so testified before Senator Hart's Subcommittee on Antitrust and Monopoly on May 19, 1970. Again, I state that I support this bill and recommend certain extensions.

Furthermore, I endorse the clear implication of the high ethical standard that this bill reflects. In order that the bill, 1575, which might be labeled the hypocratic bill, not be labeled by some as the hypocritic bill, I would suggest that legislation be enacted to reflect these same high ethical standards with the aim toward eliminating areas of conflict of interest that apply to lawyers, legislators, other professionals and businessmen.

Thank you.

Senator Moss. Thank you very much, Dr. Brent, for your good testimony. I, of course, would agree with you heartily that the same standards of eliminating conflicts of interest and being in a position where one, through his professional activities, can gain or be in a position, anyway, to have personal gain from a sideline such as we are talking about here in the medical profession, ought to be applied to any profession, all the way across.

I don't know that it's practicable to insert, in this bill dealing with this specific problem, lawyers and congressmen and professionals and others in there. But the principle is certainly valid.

Dr. BRENT. That is why I support the bill, because I feel that if you expect individuals to attain this level of standards, it isn't long before the hypocracy of other areas of our culture becomes well known, if not to the old at least to the young.

I might make some comments on the testimony of our previous representatives, because I think their testimony was good.

I think it was sound. I, for one, on the other hand, never am able to accept anecdotes because they give me no denominator on the instances, and they know perfectly well that when you deliver testimony like that, you create the aura that one profession lacks ethical standards and the others are angels. And we know that people who become doctors come from the United States of America, they reflect a cross section of the people of the United States of America, they reflect the ethical standards of those people. If we have cheats and crooks and disreputables in the medical profession, it only means that we have those same types as plumbers, and pharmacists, and lawyers. There is no reason why a special breed of people go into medicine. In fact, if you could document it, you would find that the ethical standards are a little bit higher. But that's not important.

I don't think anecdotes are necessary to support this bill. I could give you 20 anecdotes on pharmacists and what they have done when I have sent patients with prescriptions. We send out a prescription for a cortizone ointment and the patient comes back and says the prescription ran out, and the pharmacist had given him a sample. That

doesn't damn the pharmaceutical profession because of one dishonest pharmacist, and it is not a cause for legislation.

But the principle of high standards, and that's what we want all people to attain is a basis for this legislation. In fact, the previous presentors bring up a good point with regard to the fact that samples are a problem, and should we allow samples to be distributed. Physicians get tremendous numbers of samples.

Physicians get samples and some sell them as pharmaceuticals, and so do some pharmacists get samples and sell them. I just wonder if this is something the committee ought to look into because one of the reasons why a physician could even think about making a profit is that he does get a substantial number of drugs free, and put that together with a little bit he buys from drug firms we might eliminate the beginnings of a business. This legislation could eliminate the business totally.

But they made a good point about the purchase of pharmaceuticals by physicians from these large-I guess you would call them jobbers— who will sell you drugs at low cost that you aren't certain about the quality of the drugs.

Senator Moss. I suppose those samples are sent out by proprietary drug companies hoping the physician, by handing out the samples, could carry on, and therefore prescribe them thereafter for his patients?

Dr. BRENT. I can be honest with you-being in a pediatric clinic, we depend on samples, but we give them away. There are many patients, because of State laws, who will get complete pharmaceutical support in a certain income group, and as soon as they go $20 beyond that income group, they have to buy their own drugs. So that group of patients is in a tight spot, and we save them medication costs with samples.

Many physicians give away samples for nothing, but that is not a responsible way, and I am sure the APhA would rather see all patients go to the drugstore and if they can't afford it, they can get proper financial aid from insurance or government.

There are a lot of points that I made and that the APhA made that are peripheral to this legislation, but in order to make this legislation work these other suggestions might be implemented.

Senator Moss. That's a very good point. You indicated, of course, the feeling of physicians that perhaps they are being targeted by this bill. Do you have any estimates of how many of them generally would support the provisions of this bill and how many, perhaps out of resentment or for other reasons, would resist the bill?

Dr. BRENT. I think it would go by age and place. I can't imagine a physician at one of the 100 university medical centers in the United States even thinking about this bill one way or the other.

In fact, most of them would say, I don't understand what you need it for. Most good doctors are so busy reading and trying to be good doctors, they can't get involved in other businesses.

If you talk to the man who is doing it, it is easy to build up a defense mechanism-he's doing good, saving the patient a trip, all kinds of plusses.

But again, I don't like to go on percentages that we guess at, and anecdotes. The bill is good in principle and reflects the ethical standards we expect from the physician. It is impossible to learn all the