Curing the Doctor Shortage

It usually takes at least eight years before a U.S. college graduate can practice medicine on his own. As a result, the world's best medical training has a serious flaw: the U.S. has only one physician for every 650 people, compared with the Soviet ratio of one to 400 and the Italian figure of one to 580. One out of 50 Americans has no access to a doctor under any circumstances. To cure the shortage, the nation's chief health officer, Dr. Roger Egeberg, prescribes an immediate injection of 50,000 new physicians --a 15% increase in those now practicing. Last week the Carnegie Commission on Higher Education produced a plan that could fill this prescription.

Educational Overkill. The Carnegie report is the most revolutionary look at the education of American physicians since the Carnegie Foundation's Abraham Flexner studied the problem in 1910. Because students could then enter medical school directly from grade school or high school, Flexner urged a sharp increase in scientific training and no student contact with patients until the final two years of study. The ultimate result has been a kind of educational overkill. After pre-med courses in college, medical students often spend unnecessary and repetitive hours in classroom work. Although the system has created an extremely high level of academic medicine and research, it needlessly prolongs medical training and restricts the doctor supply at a time when the demand is greater than ever.

The situation is likely to get worse. Convinced that the U.S. will adopt some kind of national health-insurance plan, the Carnegie Commission views the current problem as "a mere ripple in comparison with mounting waves of problems to be faced when the financial barriers to health care are lowered." To meet a demand for ever more doctors, it urges medical schools to update the Flexner plan and to adopt a program that it says could fill the physician gap by 1980. Among its recommendations:

> Four-year medical-school programs and three-year residencies should each be shortened by one year. The goal: much earlier clinical practice. Medical schools should also institute a two-step degree system. After completing basic requirements, students could graduate with a new degree called bachelor of medicine or master of human biology, which would qualify them for research and teaching. Those interested in practicing medicine would be required to go on for an M.D.

> Medical schools, which now accept 52% of all applicants, or 10,800 a year, should increase their admissions and take at least 16,400 students by 1978. A substantial number should be women, who now constitute only 7% of the U.S. doctor force, and blacks, who make up only 2%. Community colleges should undertake programs for training medical assistants to relieve physicians of many routine tasks (see box).

> Nine new medical schools should be established in urban areas with populations of 350,000 or more, each forming the nucleus of a university health-science center. The goal is a nationwide complex of 126 health centers, combining schools and hospitals and located within an hour's drive of 95% of the population.

> The Federal Government should provide grants of up to $4,000 a year for low-income medical and dental students. It should also underwrite 75% of the cost of building or expanding health-science facilities. The estimated federal bill: $1 billion by 1980.

Several medical schools are already moving toward the Carnegie Commission's goals. Dartmouth is developing a three-year program leading to an M.D. degree. Case Western Reserve has long encouraged clinical experience by assigning each first-year student to follow one family's health problems throughout his four years of medical school.

Obstacles to Reform. Dr. Carl Ruhe, director of the American Medical Association's Division of Medical Education, notes that his organization is on record as favoring health insurance for all Americans, and he terms the Carnegie report's emphasis on community needs "consistent with the A.M.A.'s feelings and beliefs." Yet the obstacles to reform remain formidable. A significant number of academic doctors are quietly opposed to any changes that stress clinical training at the expense of their pet research projects. Many medical schools lack funds or facilities to increase their enrollments.

Federal help, on which the Carnegie recommendations rest, is not likely to be forthcoming in the near future. A tax-supported national health-insurance program could supply the Government with the money necessary to train doctors, but the Administration has shown no disposition to adopt such a plan.

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