WHERE ARE TOMORROWS DOCTORS?

U.S. Medical Education Is Lagging

In 80 medical schools this month, 7,000 graduates will don academic hoods (green, for herbs) and receive the degree of Medicinae Doctor. After internship, the vast majority will be licensed to practice as physicians, swelling the nation's total to almost 250,000. The big round number looks impressive. But in fact, if the proportion of doctors in the community is to be kept from slipping dangerously during the population growth of the next ten to 20 years, the output must be upped by more than 40% -- to 10,000 a year.

The U.S. is facing a crisis in both the quantity and quality of its medical care. The twin problems are a shortage of man power and a drop in its caliber. The questions are multiple. Where will tomorrow's doctors come from? Where will they be trained? How good will they be? What sort of medicine will they practice -- coldly scientific or warmly human?

Last week in Washington, the Association of American Med ical Colleges gave a subcommittee data on shortages in man power and money, offered a partial solution. With the annual output of new M.D.s averaging 90 per medical school (the range is between 40 and 190), the goal of 10,000 a year by 1975 would require adding the equivalent of 30 new schools. The gap is being narrowed by expansion of existing schools, and half a dozen entirely new schools are in the building or planning stages. But the remaining shortage is equal to the capacity of 20 more schools -- which as yet are not even a gleam in the eye of medical educators.

The A.A.M.C.'s proposal, incorporated in a bill sponsored by Rhode Island's Democratic Representative John Fogarty: raise $325 million in the next five years, half to come from the federal Treasury, half from matching funds provided by the schools themselves, for modernization. This way, it is esti mated, 1,100 new freshman places could be created. The Fogarty bill also proposes a $2 billion program to build 20 or more new schools, with the Government putting up two-thirds.

Emphasizing the need for a bold program are more chilling statistics. It takes at least three years to plan, build and staff a medical school, and there is a lag of five more years before its first graduates can hang out their shingles. A new school may cost anywhere from $10 million (if laboratory, classroom and dormitory facilities can be hooked on to an existing hos pital) to $50 million (if a big general hospital, essential for teaching bedside medicine to the upper classes, has to be built from the ground up).

Two-Year Bargain? Besides the 80 schools in the conti nental U.S. (plus one in Puerto Rico) producing M.D.s this year, there are four "junior colleges" which teach the basic medical sciences for two years, then send their diploma-holding graduates to enter four-year schools as juniors. This is a vital and valuable service to the four-year schools. Most of their dropouts, averaging 10% (but ranging as high as 19%, depend ing mainly on the thoroughness of their preadmission screen ing), are in the first two years. The result: vacancies in the upper classes, with only 90 M.D.s graduated for every 100 freshmen. There are an estimated 800 such vacancies now, of which fewer than 150 can be filled.

There were ten two-year schools before World War II, but several have become four-year schools. West Virginia's (Morgantown) graduates itself this year, will admit its first juniors in the fall. This leaves three: Dartmouth (Hanover, N.H.), North Dakota (Grand Forks) and South Dakota (Vermillion). Dartmouth, the nation's fourth-oldest medical school (1797), cut itself back from four to two years in 1914, has long enjoyed a cozy symbiotic relationship with Harvard Medical School, the nation's third oldest (1782).

Harvard's energetic, extravert Dean George Packer Berry invites all Dartmouth's two-year men (recent classes have averaged 24) to apply for admission to Harvard as juniors. Most of them do. Dartmouth has now become so secure in its role of primary supplier that it is undertaking a vigorous expansion program, is putting up a new $3,200,000 building, plans to double its enrollment to about 50 a year.

Two-year schools, say their advocates, offer the U.S. a bargain in medical education. They can be put up for $7,000,000 to $8,000,000, or less than one-third the average cost of a four-year school. If there were enough of them, they could fill nearly all the upper-class vacancies.

More & Better. But the idea of cutting more physicians' training into two-year bites at two schools raises controversy about the basic aims of medical education and how to achieve them. The nation's population is growing not only in numbers but in sophistication about medical matters, and is willing to pay increasing sums for more and better care. What sort of doctors does the public want?

The U.S. went through a similar soul-searching in the early igoos, after the A.M.A. launched a crusade to put cheapjack, quick-quack medical-diploma mills out of business. This culminated in the famous Flexner Report of 1910, made by the late Abraham Flexner for the Carnegie Foundation. In a year and a half, Flexner visited all 155 so-called medical schools in the U.S. and Canada, found that many were flagrant frauds. Within a few years, more than half were put out of business.

Flexner went over to the Rockefeller boards, which put up $30 million in 16 years to build up some of the world's finest schools (Vanderbilt University alone got $15.3 million). The prototype and ideal was "the Hopkins," created for Johns Hopkins University in the 18903 by such brilliant men as Sir William Osier, on two revolutionary principles: 1) medical education should be under university control and pursued for a full four years (many schools were then graduating M.D.s after two years, and some within a year); and 2) faculty members should be fulltime employees, dividing their time between teaching, research and treating patients in university hospitals.

By chance, emergence of Hopkins as the model, backed by Rockefeller millions, coincided with the rise of modern scientific medicine. The Osier leadership froze this into the curriculum. Applicants for the medical school had to have some years of college, including such "pre-med" courses as biology, physics and chemistry. Then they got more of this in a horizontally stratified med school. Such fundamental subjects as anatomy and physiology were taught in big, solid blocks in the first year, and pathology in the second. Not until two years or more after he had dissected his first cadaver did the student get to see a breathing patient, and edge slowly toward the bedside.

With minor variations, the Hopkins white coat became a straitjacket in nearly all the most prestigious U.S. medical schools. Virtually all the deans and heads of departments now in office were mentally corseted in it. For all its virtues and its undeniably great superiority over what had gone before, the Hopkins plan helped to saddle the U.S. with at least two generations of physicians and surgeons to whom the practice of medicine was more a science than an art. The quality of medical care came to be judged by the number and complexity (and often the cost) of the batteries of laboratory tests that the doctor ordered. The horse-and-buggy doctor, ill-trained as he often was, carried a priceless remedy in addition to the simples in his black bag: a personal interest in his patients as people.

Stomach in Parts. If the future physician is to treat patients as individual human beings rather than numbered cases, say some educators, he must get the habit of thinking and feeling that way from the first day in med school. At Cleveland's Western Reserve University, sparked by the then dean, Joseph T. Wearn, a bold experiment began in 1952. The faculty, armed with a grant from the Commonwealth Fund, staged a curricular earthquake and turned the strata vertical. A first-year Western Reserve student gets the anatomy, physiology and biochemistry of, say. the stomach, in a single block of time, and starts seeing gastritis patients at once. He is also assigned to a family; through his four years, it is his duty to be in the clinic or at the bedside whenever any member of that family needs care. Many families come to prefer their constant student physician to his seasoned seniors, call him "our doctor," though he may be years away from his M.D.

Western Reserve finds it virtually impossible to take replacements from two-year schools for its upper classes, says its new dean, Psychiatrist Douglas D. Bond, because, of necessity, they have been taught horizontally stratified basic medical sciences. And Dr. Bond insists that medical education in the future is going to be more nearly vertical.

If he is right, the vast majority of U.S. deans and professors who serve as department heads have not got the word. Last week, one after another dismissed Western Reserve's experiment as too radical. Some said that they could not afford to try it if they wanted to--which they did not. Others claimed to have anticipated it in their own curriculums. Harvard's Berry, who can pick admissions from the top 5% of pre-med students, said that the Western Reserve plan was "far more extreme than necessary," but took credit for it as the product of Harvard-trained professors. However, Dr. Bond can also feel self-satisfied. Harvard, widely rated as the world's best med school, gets 900 to 1,000 applications for 115 places in its freshman class: Western Reserve now gets 1,100, "attracted by its exciting new curriculum." for 80 places.

One school that has adopted much of the Western Reserve plan is the University of Oklahoma. There, Hopkins-trained Dr. Stewart Wolf, professor and head of the department of medicine, says: "We have what you might call a diagonal plan, and it is working well for us. But the quality of the student and faculty is far more important than the curriculum. You could work with the world's most moss-backed curriculum and make out all right if you had a good intellectual atmosphere."

But, medical statesmen complain, what is clearly most lacking in U.S. med schools is "a good intellectual atmosphere." Dr. Ward Darley, head of the A.A.M.C. and himself a former dean (University of Colorado), says: "Stuffing students with facts is training them, not educating them. And it produces unnecessarily narrow-gauge physicians."

Academic Achievement. A second, and almost universal, complaint has to do with academic achievement. Each year, to fill 8,000 freshman places, more than 15,000 men and women make out 60,000 applications. (Many, especially members of minority groups who fear discrimination, fill out a dozen or more.) As recently as 1951, applications included 40% straight-A students, 43% B and 17% C averages. Latest figures show that, while Cs have declined three points, there has been a precipitous drop in A students to 16% while B types have zoomed to 70%. Why?

In most of the U.S., and among most social groups, the medical profession and the physician himself have lost much of their old glamour. The family doctor used to be an authoritarian but friendly figure, dispensing medicine that was more art than science and had (in its hieroglyphic prescriptions for compounding herbals) an important element of magic. Today, though most Americans have a high regard for their own family doctor, the magic is gone. They see the doctor more as a technician, making his diagnosis on the basis of lab tests, and prescribing a single wonder drug which they think they know all about--and which the druggist merely counts from a big bottle into a little bottle. According to polls, the public sees the profession generally as still authoritarian, but less friendly and more aloof--and less interested in making house calls.

Educators find that youngsters are influenced deeply by current cultural heroes. There has been a drop in applicants to medical schools since rocketeers and nuclear physicists have held the spotlight. Other major factors dimming the attractiveness of a medical career are economic. Doctors' incomes used to be relatively better than they are today, when men in other professions can earn as much and with a far shorter education. At least 75% of all U.S. physicians go through four years of undergraduate college, then four years of med school, plus at least a year's internship, before they can make a nickel. To specialize, they need a hospital residency of two to five years, still with little chance to earn money. At best they are nearing 30 before they can support themselves and a family. By then they may be loaded with debt.

In contrast to this prolonged apprenticeship and hardship, students of the physical sciences can make a fair financial showing by age 25, and big business unabashedly uses this bait to hook promising high school and college science students.

State Chauvinism. Overall, med schools report that an increasing proportion of students are from the better-heeled social strata, with 43% coming from the best-off 11% of the population. But this varies widely between states and between different med schools. Sixty percent do some outside work all year round, and 10% work a full 40-hour week on top of a crushing schedule of classes and clinics. Some of the most expensive schools, e.g., Harvard, have such generous scholarships and loan funds that they attract more impecunious students than do more modest schools with less endowment. Virtually all state-supported schools enroll 90% of their classes from residents of the state. Partly because of this chauvinism, three states that now have no schools of their own are planning them.

Such foreseeable additions to the nation's plants for producing physicians will not be enough. For 20 years there has been a fairly stable ratio of 132 M.D.s to 100,000 people, or one for every 758. This is a crude statistic, because thousands of doctors have given up practice, or are in fulltime jobs in drug and insurance companies, administration, or concentrating so heavily on research or teaching that they never treat a patient. The ratio of general practitioners, virtually synonymous with "family doctors," and the people's first line of defense against illness, has been dropping fast because of increased specialization: from one for every 1,100 people in 1941 to one for every 1,600 today.

U.S. medical care is generally rated as good as any in the world and often proclaimed as the best. It will not hold this rating, the experts warn, if the doctor-patient and G.P.-family ratios fall farther. Says Dr. Darley: "The big problem is how to preserve a personalized type of medical care in the face of all the forces that tend to depersonalize it." One plan for which he has high hopes is to develop the practice of "family medicine" itself into a specialty. Pilot programs to do this are beginning, with A.M.A. backing, at Johns Hopkins, Indiana, Kansas and Northwestern. The question is not one of increasing the number of either specialists or "generalists" at the expense of the other. Dr. Darley holds: "We have to have more of both, because the increasing body of medical knowledge has to be broken down into learnable parts. I know it sounds paradoxical, but training the general family doctor to take care of patients as individuals, in their particular family and social settings, represents the ultimate in specialism."

Serious Crisis. None of the panaceas proposed by self-appointed healers of the medical profession offer much hope. Mechanization and automation with punch cards and computer diagnoses might help a physician to treat more patients, but not the way they want to be treated. Crash programs for research intensify the problem. Dr. Joseph C. Hinsey, a former dean (Cornell) and now director of the New York Hospital-Cornell Medical Center, points out that proposals to appropriate billions for research may dry up the supply of physicians to apply the research findings--because the men siphoned off into "pure" laboratory work would otherwise be in medical schools and combining research with the teaching of future doctors.

Experimental programs to shorten the time between high school and shingle from nine to seven years are under way at the University of Vermont, Johns Hopkins and Northwestern. If such plans work well enough to be widely adopted, they should make preparation for the career of medicine less onerous and therefore more attractive. But nothing can be accomplished overnight or by fiat.

The needs of the times add up to an ominous challenge. "The crisis we are approaching," says Dr. Darley, "is the most serious that medical education has faced since the Flexner Report."

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