by Stephen M. Creel, M.D.
MRS. Charlotte A. Williams, a seventy-twoyear-old widow, was admitted to a large medical center in the Western United States after eight months of “weakness, pallor, and weight loss.” Her case history reports that Mrs. Williams, who lived alone in a small mountain town, apparently did not consult a doctor because none was available in her community. Dr. Lawrence M. Cole, her family physician for thirty years, had died four years before, and no one had come to replace him. Finally, after Mrs. Williams had lost thirty pounds, her daughter became concerned and drove her ninety miles to a large urban center, the location of the nearest general hospital. The medical staff at the diagnostic clinic spoke quietly of “prolonged therapy” and an “uncertain course.” A few months later, she died.
Mrs. Williams could be alive today had she received early treatment. Like thousands of others each year, she was a victim of the doctor shortage. In a society that spent one billion dollars on medical research last year, there are fewer doctors per 100,000 population today than at the turn of the century. In 1900, approximately 150 practicing doctors outside the federal government cared for each 100,000 civilian population. Then, as a consequence of the Flexner report on medical education in 1910, many inadequate medical schools, the so-called “diploma mills,” were closed. By 1931, there were only 118.3 doctors per 100,000 civilians, and in 1959 only 117.7. In 1964, this ratio was still approximately 117, the downward trend having been halted by a more stable population growth, as well as by the yearly licensing of more than 1000 foreign physicians as a stopgap measure to meet current needs. In 1964, only about 80 percent of the 278,000 physicians in the United States were working full time with civilian patients. Most of the rest were in government jobs such as the Armed Forces and the Public Health Service, or in nonfederal teaching and research positions.
While family doctors are in short supply, especially in rural areas, the need for doctors is even greater in hospitals. Eighteen percent of internships and 13 percent of residencies remained unfilled in 1960, even after nearly 10,000 foreigntrained medical graduates were hired to help fill these positions temporarily. Moreover, the 51,800 positions available in hospitals in 1965 represented an increase of 1400 over the previous year.
Our doctor shortage has developed out of an obsolete system of medical education that has not kept pace with population growth or with educational advances in other fields. Medical schools have not expanded sufficiently to meet the increase in demand, and according to the Association of American Medical Colleges, the supply of medical graduates has fallen behind since 1955 despite a 2.7 percent increase in their number.
Moreover, many medical educators are reluctant to overhaul and modernize their training programs. As a consequence, many of the most qualified college graduates are passing up medicine in favor of other, more attractive scientific holds. In 1962, the Association of American Medical Colleges noted that 28 percent of all college graduates entered medicine during the period 1861 to 1880, but only 2 percent did so in 1951-1955. Though the number of college graduates has been increasing, proportionately fewer go into medicine.
A recent upsurge in the popularity of physics, chemistry, and mathematics has grown out of the space-age incentives given these fields by government and industry. Educators have shortened and accelerated their programs, providing more stimulating material and up-to-date teaching methods. As a result, these nonmedical sciences are now attracting the best college science graduates. Capable students can win Ph.D. degrees while still in their mid-twenties, and are well paid in the process.
In contrast, medicine has not progressed since the reform years following the Flexner report when programs were lengthened and made more arduous. Today, medical graduates are thirty-two to thirty-four years old by the time they have fulfilled training and military requirements. They earn only subsistence pay at the hospitals where they train, unless they are in the Armed Services. By graduation day, 60 percent of medical students are married, and many have several children. These families must live frugally, often under a heavy burden of debt. Grants and loans generally offset only about 20 percent of the total expenses of $10,000 to $20,000 incurred by each medical student. Debt continues to grow during the hospital training required after medical school, with interns earning an average of only $3000 per year, and residents averaging $4000 per year.
Because of the high cost, poor families often cannot afford to send their sons through medical training. As a result, a majority of medical students come from homes with yearly incomes of at least $10,000 and usually much higher.
A very small minority of medical educators have attempted to streamline training in order to attract better recruits. They have introduced accelerated pilot programs at such medical schools as Northwestern, Johns Hopkins, and NYU, where students may earn an M.D. degree in about six years instead of the usual eight. Most medical educators resist change. They claim that the accelerated programs produce “inferior doctors,” and steal time from professorial research. The medical faculty pursues research determinedly, often at the expense of teaching.
Professors cancel conferences and ward rounds without notice; students are kept waiting in outpatient clinics for long periods of time while tardy staff members drift in from offices and laboratories. Students listen to what is often pedantic teaching, usually a loose repertory of facts ranging from drug dosages to morbidity statistics or enzyme research figures, without being stimulated sufficiently to remember such information. They are rarely asked, “What would you do in this case?”, and more rarely still do they have any immediate opportunity to put the information into practice.
A SIDE from the disappointing quality of teaching, the traditional system of medical education as it exists today is so obsolete and doctrinaire that it disheartens many trainees. Beginning in college, a young premedical student must labor for four years through a program of difficult “required” science courses, many of which do not interest him and are unnecessary to his medical education. How vital, for example, are invertebrate zoology, comparative anatomy, or general embryology, or even advanced nonmedical chemistry and mathematics? The student’s immediate goal in college is to prove only that he is acceptable for training in a medical school. Many premedical students would prefer to major in the liberal arts, but few do so for fear of jeopardizing their medical school acceptance. Most play it safe by overspecializing in science, hoping thereby to impress medical school admission committees.
If a premedical student gets into one of the eighty-seven medical schools in the United States, he will study subjects more pertinent to his calling, including human anatomy and physiology, medical biochemistry, pharmacology, medical microbiology, biophysics, and pathology. These, known as the “basic sciences,” lay the foundation for further study in medicine. The freshman and sophomore students in medical schools must compete in the same undergraduate atmosphere as in the premedical years.
Although medical students are thus motivated strongly by competition, as well as by their vision of tending and comforting the sick, many medical schools fail to capitalize on such motivation and omit nearly all clinical material from the first two years of training. The students generally have only one semester of physical diagnosis, where they learn to use a stethoscope and look at throats. They spend the rest of their time in the lecture hall and laboratory, where they memorize facts for which they have no immediate use. The absence of a clinical context makes this material less meaningful, and it is, therefore, often poorly retained.
The students’ ambition to be “real doctors” — that is, to work exclusively with patients — comes closest to realization in the junior and senior years of medical school in the form of “clinical clerkships.” At this time they leave formal classroom training and go on hospital wards to serve what some educators have despairingly called an “apprenticeship.” Unlike any other group of graduate students, these junior and senior “apprentices” are no longer judged objectively on mastery of subject matter and examination scores, as in college or the first two years of medical school. Grading now takes on political and subjective overtones. Students must be good-natured, obliging, and gregarious if they wish to excel. Above all, whether they like it or not, they must learn to do exactly what they are told, when they are told to do it. They must follow unerringly the orders of superiors, many of them young men only two to four years further ahead in training. They must learn to live with “scut work,” an endless array of unstimulating hospital chores, including routine laboratory tests, drawing blood, starting intravenous injections, and changing dressings.
Juniors and seniors spend so much of their time as laboratory technicians and orderlies that they frequently lose confidence in themselves as potential creators and innovators. Responsibility and independent thinking are luxuries they can rarely afford. They attend endless conferences, listen to other people talk (“teach”), watch other people do things, and in the end are bored. In their passivity, they are bullied in the operating room and ignored on rounds. Their opinion is seldom sought. Ideally, they become retiring, docile, and obedient.
Medical students must scrupulously avoid personality conflicts with superiors and must refrain from blatant criticism of their training program. Disciplinary action may come in the form of low grades, threats of expulsion, or delay of graduation. Occasionally, a tentative diagnosis of “psychiatric disease” is slapped on a vociferous student, and he is requested to seek “therapy.” Under the scrutiny of a faculty psychiatrist, such an offender is not likely to make further trouble if he wishes to graduate on schedule. I have known students who jest that proof of a perfect record in medical school is when at graduation the dean, on handing a student his degree and announcing the name, wonders, “Who is he?”
Enforced conformity continues into the internship, the first year of postgraduate training. Interns are the hardest-working (usually a 100-hour week) and poorest-paid ($3000 to $4000 per year) drudges in the medical profession. They often find themselves filling jobs as second-class technicians or orderlies. Though they possess M.D. degrees, they are defined by the AMA only as “full-time students.” Yet they have far less freedom than students. They are expected to work obediently around the clock, usually every other night at the hospital. Agitation for more reasonable hours, or even for better pay, is generally discouraged by hospital administrators and medical staff. The average intern has no real job security or collective-bargaining power. He can be hired and fired or denied certification almost at the whim of hospital administrators and attending staff. Personality conflicts with superiors can be disastrous.
The residency, which follows the internship, is the highest stage of medical education. Since residents have much more authority and responsibility than do other trainees, but little more experience, considerable conflict develops when students, interns, and residents are working together. The resident talks; the others listen. Nonetheless, the resident himself is still a “pair of hands” in the serfdom of the medical profession, and many residents say that their programs are too lengthy, that they could learn the same material in half the time.
PUBLIC dissatisfaction with the present system of medical care was one of the reasons for the passage of Medicare. The federal government, with the great momentum gathered in the drive for this legislation, has begun to extend its activities into medical education. In December of 1964, the President’s Commission on Heart Disease, Cancer, and Stroke, composed mostly of eminent physicians, published a report stating broad proposals for improving and expanding medical care for the average citizen. The commission took a critical look at the doctor shortage and recommended that $40 million be spent over a five-year period to provide 5000 additional spaces in medical schools. The commission also recognized that while the number of college graduates has been increasing, proportionately fewer are applying for medical school, a consequence of the high cost of medical education, competition from stimulating careers in the other sciences, and the small number of scholarships and grants now available to medical students. The commission asked that $6 million be spent to advertise medicine as a career in high schools and colleges, and that the Health Professions Educational Assistance Act be amended in order to provide more scholarships. Appropriate bills for all recommended funds were passed by the 89th Congress and signed by President Johnson in October, 1965.
Such measures represent important advances, but they do not change the traditional system of medical education, which has remained unaltered after nearly two generations. Progressive medical educators cannot rest until the system is changed. A revolutionary movement is already taking form in the Association of American Medical Colleges, an organization of medical school deans who seek a more powerful and radical voice in medical education in order to challenge the currently supreme American Medical Association.
Complete reform of the system, however, is improbable in the foreseeable future. Gradual changes would hopefully embody four basic modifications: (1) the high school curriculum could be accelerated and shortened by one year; (2) the traditional four years of college and four years of medical school could be fused into a six-year program that would entail the deletion of many premedical science courses as well as a substantial beefing up of clinical curricula; (3) the internship could be abolished, medical graduates beginning postgraduate training immediately on the resident level, and unnecessarily long residencies could be shortened; (4) continuing education programs for practicing physicians could be made more extensive.
These revisions would serve primarily to reduce the time required for training. The academic pace would be stepped up, resulting in an accelerated program similar to those of the other sciences. More outstanding students could be expected to show an interest in medicine. New medical schools should then begin to offset the doctor shortage.
Ending the monopoly on a student’s time which science studies now hold would make it possible to infuse more liberal arts into an accelerated curriculum. This is lacking at present, except for a uniform language requirement which is generally thought by medical educators to be of particular advantage in developing self-discipline and thoroughness of study habits (medical students typically acquire a reading knowledge of German). In recent years, medical schools have shown more interest in applicants with liberal arts credits, and some schools now list humanities among their scholastic requirements. The University of Colorado, for example, has an English literature premedical requirement, and Stanford has interspersed humanities within its five-year medical school program. Undoubtedly more could be done on a national basis, perhaps through the Association of American Medical Colleges, to require of prospective doctors some knowledge of the humanities. As a beginning, campus premedical advisers (usually faculty members in science departments) could be asked to emphasize the fact that medicine is becoming more tolerant ol the liberal arts.
A final expedient in reforming medical education would be to tighten up the postgraduate program, the internship and residency. The internship today is the remnant of a hard-line medical tradition prevalent up to a decade ago which approved of late marriage and prolonged serflike dedication to the profession, with the financial reward postponed until middle age. The coming of Medicare makes such a philosophy harder to defend. The internship, plus what it stands for, is a deterrent to prospective recruits, and the same can be said for residencies that are too long. The six-year surgery program is a notable example because only the final two years provide sufficient opportunity for a young surgeon to practice his technical skills. An intern could spend his year much more profitably as a first-year resident. He would enjoy greater responsibility, status, income, and stimulation; and with appropriate clinical training in medical school, he should be equal to the task.
Admittedly, there is more to learn in medicine today than there was ten years or even one year ago. A vast improvement in the efficiency of medical teaching is vital to any accelerated program. New knowledge must replace obsolete material; the entire medical curriculum should be kept in a state of constant revision. Clinical studies could be introduced earlier in the program, and basic science courses could be more clinically oriented than they are now. Medical schools should be encouraged to function as teaching institutions, not as research centers. Professors should expect as much advancement from teaching as from research, and teachers should be hired primarily to teach. Students should enjoy greater status, and should expect to have a greater hand in patient care instead of lingering for years on the sidelines. Interns and residents should be granted equal consideration by a hospital’s attending staff. The principal beneficiary of all this effort, of course, is supposed to be the patient, though all participants would share the benefits of an improved medical discipline.
If society is to ease the doctor shortage and at the same time continue to enjoy medical care of high quality, it must look closely at the entire system of medical education. As Hippocrates said, “To heal even an eye, one must heal the head, and indeed, the whole body.”