Postgraduate Medicine

ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage:

How Many is too Many? Allan J. Ryan To cite this article: Allan J. Ryan (1979) How Many is too Many?, Postgraduate Medicine, 66:2, 18-19, DOI: 10.1080/00325481.1979.11715212 To link to this article:

Published online: 07 Jul 2016.

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Date: 13 August 2017, At: 04:59




HOW MANY IS TOO MANY? Downloaded by [Australian Catholic University] at 04:59 13 August 2017

Allan J. Ryan, MD

In a recent essay in the New England Journal of Medicine (300: 1047-1049, 1979) Donald B. Louria, MD, has addressed the question of the impending oversupply of physicians in the United States. He






points out that "Between 1960 and 1990, the American population is expected to grow by 35 per cent, whereas the medical-school output should increase by 152 per cent." Every physician is, or should be, familiar with the fact that the great increase in our ratio of physicians to

population (from 1:735 in 1950 to an estimated 1:500 in 1980) is due to two factors: ( 1) an increase in the number of medical schools and size of classes and (2) a heavy influx of foreign medical graduates (FMGs). Two of Louria's five recommendations for controlling the available supply of physicians make good sense, but the other three are împractical, unwise, and even contradictory. In regard to his first suggestion, it is logical to reduce class size in US medical schools, even though the demands for admission continue to exceed by far the number of available places-in spite of the tremendously high cost to the individual aspirant. Interestingly, the federal government has indicated that it would look favorably on modest class-size reductions even though it mandated increases in exchange for capitation grants only a few years ago. Also of interest is the fact that neither faculty nor supporting facilities to accommodate these increases have grown proportionately in most cases. As for another of Louria's suggestions, it is reasonable to discuss the possibility of coming to an agreement on what might be an appropriate ratio of physicians to population for the United States in the future. There should be sorne way to determine a figure that would recognize the increase in the average age of our population, the potential for Cl· continued


Downloaded by [Australian Catholic University] at 04:59 13 August 2017

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using physician extenders, and advances in medical technology. The new figure may never find favor with physicians, or with anyone else for that matter, but the ratio we have now does not make rouch sense either. lt does not follow, however, as Louria further suggests, that it would be possible to establish limits on the number of Americans trained in foreign medical schools who could be licensed. There is no way to force registration of such students or legally to limit the number of returning graduates who could be licensed each year. The fiasco that resulted from the attempt to force our medical schools to admit a certain number of foreign medical students of US origin to advanced standing should be proof enough of that. Sorne schools are admitting more of these students, but on the schools' own terms. It makes even less sense to talk about encouraging more residency training of FMGs, as Louria advocates. These physicians are currently required to return to the country of their origin, but a high percentage do not do so. Special legislation and other legal maneuvers make it possible for them to stay. Laws and regulations are regularly circumvented to allow many FMGs to return to the United States after a brief visit to their homeland. This is winked at, if not actively encouraged, by the administrators of medical schools and hospitals anxious to

till their more than 60,000 residency positions. The principal justifications for a sizable number of residency programs in both teaching and nonteaching hospitals are the desire for prestige and the ability to attract grant support, rather than a proven need for more graduates trained in sorne of the various specialties. Louria's least palatable recommendation, summarized simply in the words "no further increase in osteopathy students should be permitted," without any further expianation, is a calculated insult to the community of osteopathie physicians who have worked so hard in the past two decades to advance the standards of training in their field and to support better education and research, in their new schools and elsewhere, for and by members of their profession. The steps that can and should be taken immediately to stabilize the ratio, as unpopular with sorne parties as they may be, are the reduction in size of medical school classes and the phasing out of a substantial number of residency training programs.


Wilfiam H. Rorer, lnc. Fort washington, PA 19034


How many is too many?

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