1069
PROSPECTIVE MEDICAL MANPOWER REQUIREMENTS, BY SPECIALTY AND GEOGRAPHIC DISTRIBUTION* CHARLES D. EDWARDS, M.D. Senior Vice President for Research and Scientific Affairs Becton-Dickinson and Co. Rutherford, N.J.
T HIS meeting is both timely and challenging, because the whole issue of medical manpower and education has been discussed and debated so extensively over the last several years. It would be fairly easy for me to rehash what has been said before, to repeat statistics that most of us probably can recite from memory, to reiterate the by-now well-worn rhetoric about maldistribution, the shortage of primary-care physicians, the underrepresentation of racial minorities and economically disadvantaged students in the medical education process, and the need for changes in curriculum, teaching methods, and teaching environments. Each of these problems and issues certainly demands attention; I would be the last person to suggest that they are not important, indeed, vital to any thoughtful discourse on medical education and physicianmanpower requirements in the years to come. But to retrace that ground would serve little useful purpose. Instead, it is absolutely necessary for the medical profession, the academic community, and the health-policy makers in Washington and throughout the United States to look beyond this kind of parochial descriptive profile, to recognize that the subject of health-manpower requirements and the place of the American medical system in meeting them has implications not just for our own country and our own society, but for the entire world. It is easy, convenient, and conventional to look at health manpower in terms of numbers of people, specialty mix, geographic distribution, and *Presented as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1070
7 1 0 0
C
C. D. EDWARDS D.
.
EDWARDS~~~~~~~~~~~~~~~~~~~~~~~~~
the other customary yardsticks. But the inference to be drawn and the plans based on such a view are likely to be wrong. Clearly, we need to take a fresh view, to begin from a new base. The way to begin is by taking an objective look at the world as it is, not the way we would like to think it is or would like it to be. Something on the order of one billion people in the world are living on annual per capita incomes of $200 or less-often substantially less. While the per capita income in the industrialized nations has been fairly stable, that of the poorest nations has been declining. I cannot help contrasting that information and the tremendous implication it has for the world health scene with the projection that there will be 600,000 active, practicing physicians in the United States by 1990 or 50% more doctors per 100,000 Americans than we have today. It is one thing to ask whether we really need a 50% increase in the ratio of physicians to population-an extremely important question that needs to be looked at critically (I believe that we do not need an increase of anywhere near that magnitude). But the real question is whether we in fact dare allow that to happen. At a time in the history of the world when the gulf between rich and poor nations simply cannot be turned aside, can the United States seriously contemplate a vast and highly questionable increase in the number of physicians we support? Moreover, can we continue to import medical manpower from underdeveloped nations on any scale whatever, let alone at a rate that equals the annual output of all United States medical schools? The average life expectancy in the 30 poorest nations of the world rarely exceeds 50 years; for some it drops below 30 years. Infant mortality rates above 150 per 1,000 are common and rates above 200 per 1,000 are not unknown. Against that appalling picture, the United States attracts and welcomes foreign medical graduates and looks forward to adding more than 200,000 active physicians in the next 15 years. Do we dare allow that to happen? Can we honestly say to the world that our health-care needs are so acute that we simply must devote untold additional billions of dollars to train another 125,000 to 150,000 doctors in the United States over the next 15 years and then pay many more billions to use the services of these and perhaps 50,000 of their foreign-trained colleagues? I certainly would not want to carry that argument before the court of world opinion. I am certain that we shall indeed be called to account if these trends and projections go unchanged.
Bull. N. Y. Acad. Med.
PROSPECTIVE MANPOWER REQUIREMENTS
1071
I shall offer one additional observation on the subject of foreign medical graduates. The argument is often heard that many, perhaps most, of the foreign-trained physicians practicing in the United States simply could not work in their homelands because there are inadequate facilities and other resources to sustain a modern medical practice. That proposition has little merit and less logic. The amount of money that we spend per year to pay for the training of one undergraduate or graduate medical student-probably between $10,000 and $20,000-undoubtedly could support a physician practicing in Asia, Africa, or South America. Now that the federal government is proposing to spend part of its health-manpower funds to upgrade foreign medical graduates' clinical and language skills, the diversion of funds from United States medical education to support foreign health-care activities is not as obtuse as it might seem. We no longer can look on our medical-education objectives and our manpower needs as though they existed in a vacuum. Since nearly half of the physicians entering practice each year in the United States come from abroad, our medical-education objectives must be viewed against a world perspective, against the reality of the world's health-manpower needs. I recognize, of course, that this perspective will be difficult for many to achieve. Faced with an immediate crisis in the world's supply of petroleum, it was, and still is, difficult for most Americans-including business and political leaders-to think of our oil requirements in relation to others' needs. If we have trouble seeing the relations with respect to oil, it will be infinitely more difficult to see them with respect to the supply-and-demand equation in the health-manpower field. We must develop such a perspective and we must do so soon. The underdeveloped nations of the world have demonstrated that they will not quietly accept a state of affairs in which the United States and a few other economic giants enjoy the lion's share of the earth's natural and man-made resources. Health and health resources, including manpower, are among those necessities that we must learn how to share. That simple fact will have to be given substantial weight in our manpower training. Now I shall turn to another set of issues that have not received the sober, candid consideration of those who seek to shape health-manpower programs and objectives. Recently, Dr. Theodore Cooper, the assistant secretary for health of the U. S. Department of Health, Education, and Welfare (HEW), achieved a victory of some significance. He succeeded in reversing the position of the
Vol. 52, No. 9, November 1976
1072
1072
C. D. EDWARDS EDWARDS
Office of Management and Budget with respect to health-manpower legislation, a position that Dr. Cooper and I both believed to be wrong and totally indefensible. As some of you may know, during my tenure as assistant secretary for health of HEW we developed a planning mechanism (the so-called Forward Plan for Health) that would enable HEW to make realistic projections of its long-range responsibilities in helping to resolve a number of core health problems. These included the need for new knowledge in the behavioral, biological, and social sciences, the need to increase the scope and effectiveness of preventive health efforts, the need to prepare for national health insurance, and several other equally complex issues. One of the payoffs of this planning activity obviously would be the ability to assess the need for new federal health legislation and to make a sound case in support of such proposals, both within the executive branch and before the Congress. In view of the fact that major health-manpower legislation had not been adopted, much of our attention was devoted to developing a broad new legislative proposal in this field, based on the extensive planning effort that we had set in motion. In the fall of 1974 our manpower proposal was rejected out of hand by the Office of Management and Budget. In September 1975-largely, I believe, because the planning effort has matured and improved over time-HEW won approval for the health-manpower legislative proposal that had been developed more than a year before. It was presented to the Congress, where it received a warm reception, as indeed it should have. One critical aspect of the proposal (identical bills HRl 119 and S2748) is its intention to continue capitation, rather than terminate it, as the Office of Management and Budget had insisted, and to use this support to address problems of maldistribution. There are other important provisions in the proposal, but the whole proposal would either stand or fall on this provision-and as of now it stands. I shall step back from this legislative initiative for a moment, because I have some serious questions. These are not so much about specific provisions as about the basic philosophy-or, perhaps, lack of philosophy-that supports it. In retrospect, the federal health-manpower initiatives of the last two decades or so have been seriously disappointing, if not fundamentally wrong. You will recall that during the 1950s, particularly in the decade prior to the enactment of federal legislation authorizing direct financial
Bull. N. Y. Acad. Med.
PROSPECTIVE MANPOWER REQUIREMENTS
1073
support of medical education, the federal manpower strategy-if it can be called that-involved pouring vast amounts of money into medical schools to support biomedical research. This was predicated on the belief that it would, as a spin-off, lead to substantial necessary improvements in the quality of medical education and, therefore, in the practice of the physicians trained in these scientifically enriched environments. Part of the conventional wisdom or accepted dogma of those days held that the support of biomedical research not only would lead to important advances in science, but also would turn out physicians who were better able to apply their scientific skills to the care of patients. Needless to say, this health-manpower strategy did not work out. We found, instead, that the number of physicians in the primary-care field moved steadily downward-as it is still doing-and that the number of physicians entering certain highly specialized areas was in no way related to need. Thus, a basic tenet of federal health-manpower strategy-one which the medical schools and the specialties readily approved-not only was failing to work, but was having a negative effect from the viewpoint of the consumers of health care. At about that time, numerous study groups and commissions began proclaiming the advent of a shortage of doctors. As a result, federal health-manpower strategy took a sharp turn, this time with the aid of specific legislation and funding; the goal became not more scientifically trained doctors, but simply more doctors. This time the conventional wisdom held that if we could produce more physicians we not only would prevent a shortage but also could expect to find more physicians entering practice in underserved areas for, by this time, the problems associated with maldistribution also were receiving increasing attention. The successful effort to increase medical school enrollment, like the presumed side benefits of federal support of biomedical research, accomplished little in the way of solving manpower problems. More doctors were entering practice, but still fewer of them had elected primary-care fields, and they were not, by and large, going into underserved areas. Much of this is familiar, but my conclusion has received little, if any, attention. Can we be sure this time that the federal health-policy makers will be right about how to deal with manpower problems? They-and we-were seriously wrong before; are we sure that this time the federal health-manpower strategy is correct? I have some grave doubts, and they are not diminished by thoughts of the results of our actions.
Vol. 52, No. 9, November 1976
1074
1074
D. EDWARDS C. C. D.
EDWARDS~~~~~~~~~~~~~~~~~~
I am afraid that those who have tried to address the health-manpower issue over the last two decades or so-and they have included many dedicated and able people-have failed to look at some of the real issues; indeed, many may not be looking at them even at this late hour. Have we simply witnessed the substitution of a new dogma for an old one? Are we banking on an illusion in assuming that medical students will elect primary-care fields and stick to their decisions? Can we be sure that various financial incentives will entice physicians to practice in underserved areas? Is there not strong reason to believe that career choices of this magnitude are based on additional considerations, as well as those of money and debt? I pose these questions with no sense that they are rhetorical. I frankly do not think we know the answers. If we do not, then the risk of being wrong is great. That is what concerns me. I am also concerned about another aspect of the federal health-manpower strategy, namely, that it is basically a federal strategy, not a strategy developed within or by the academic health system or the medical profession. As one who has spent many years in the federal health bureaucracy, I see, perhaps more clearly than some others, the disappointing failure of medicine to address some of its most urgent problems: manpower needs, quality, costs, the financing mechanisms we employ, and the manner in which they distort and weaken the health-care system. Each of these real and serious problems is being left, begrudgingly but inevitably, to the federal government. It is ironic that some of the professional organizations which could make the greatest contribution to the development of a meaningful and responsible health-manpower strategy have become little more than passive observers of the federal health scene. Perhaps we want this. Perhaps medicine has lost the will and leadership to tackle its own problems. If so, it does not have much longer to go as an independent and honorable profession. It will, instead, become a handmaiden of the federal bureaucracy and, like the railroads, have a glorious past and no future. What I have said may be disappointing and disturbing to some. If so, please forgive me, for what I want to engender is not disappointment but discomfort. The resolution of our health-manpower predicament, no matter how it is measured or described, is steadily being taken out of our hands. That may be occurring because we have lost the ability to solve it. To be
Bull. N. Y. Acad. Med.
PROSPECTIVE MANPOWER REQUIREMENTS
1075
sure, numerous organizations have made invaluable contributions, both to assessing the manpower problem and to dealing with it. The American College of Surgeons, the Academy of Family Physicians, the National Board of Medical Examiners, and a number of other societies and organizations have devoted themselves seriously and productively to the manpower issue; we are all in their debt. But, despite each of these, there is a gaping lack of leadership and creative thinking coming from spokesmen for medical academia and the medical profession at large. The leadership that they should provide is missed sorely, just as their narrow provincialism is far too evident. A tough new federal health-manpower law is about to be enacted which will attach many firm strings to the teaching and practice of medicine, and this is looked upon as an important victory. I cannot help thinking that our greatest problem is a failure of will. Without the will to deal with manpower issues that become more acute year after year, American medicine is relinquishing its right to a voice in its own future. I hope that will not happen. But it will take more than hope to prevent it.
Vol. 52, No. 9, November 1976
PROSPECTIVE MEDICAL MANPOWER REQUIREMENTS, BY SPECIALTY AND GEOGRAPHIC DISTRIBUTION* CHARLES D. EDWARDS, M.D. Senior Vice President for Research and Scientific Affairs Becton-Dickinson and Co. Rutherford, N.J.
T HIS meeting is both timely and challenging, because the whole issue of medical manpower and education has been discussed and debated so extensively over the last several years. It would be fairly easy for me to rehash what has been said before, to repeat statistics that most of us probably can recite from memory, to reiterate the by-now well-worn rhetoric about maldistribution, the shortage of primary-care physicians, the underrepresentation of racial minorities and economically disadvantaged students in the medical education process, and the need for changes in curriculum, teaching methods, and teaching environments. Each of these problems and issues certainly demands attention; I would be the last person to suggest that they are not important, indeed, vital to any thoughtful discourse on medical education and physicianmanpower requirements in the years to come. But to retrace that ground would serve little useful purpose. Instead, it is absolutely necessary for the medical profession, the academic community, and the health-policy makers in Washington and throughout the United States to look beyond this kind of parochial descriptive profile, to recognize that the subject of health-manpower requirements and the place of the American medical system in meeting them has implications not just for our own country and our own society, but for the entire world. It is easy, convenient, and conventional to look at health manpower in terms of numbers of people, specialty mix, geographic distribution, and *Presented as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1070
7 1 0 0
C
C. D. EDWARDS D.
.
EDWARDS~~~~~~~~~~~~~~~~~~~~~~~~~
the other customary yardsticks. But the inference to be drawn and the plans based on such a view are likely to be wrong. Clearly, we need to take a fresh view, to begin from a new base. The way to begin is by taking an objective look at the world as it is, not the way we would like to think it is or would like it to be. Something on the order of one billion people in the world are living on annual per capita incomes of $200 or less-often substantially less. While the per capita income in the industrialized nations has been fairly stable, that of the poorest nations has been declining. I cannot help contrasting that information and the tremendous implication it has for the world health scene with the projection that there will be 600,000 active, practicing physicians in the United States by 1990 or 50% more doctors per 100,000 Americans than we have today. It is one thing to ask whether we really need a 50% increase in the ratio of physicians to population-an extremely important question that needs to be looked at critically (I believe that we do not need an increase of anywhere near that magnitude). But the real question is whether we in fact dare allow that to happen. At a time in the history of the world when the gulf between rich and poor nations simply cannot be turned aside, can the United States seriously contemplate a vast and highly questionable increase in the number of physicians we support? Moreover, can we continue to import medical manpower from underdeveloped nations on any scale whatever, let alone at a rate that equals the annual output of all United States medical schools? The average life expectancy in the 30 poorest nations of the world rarely exceeds 50 years; for some it drops below 30 years. Infant mortality rates above 150 per 1,000 are common and rates above 200 per 1,000 are not unknown. Against that appalling picture, the United States attracts and welcomes foreign medical graduates and looks forward to adding more than 200,000 active physicians in the next 15 years. Do we dare allow that to happen? Can we honestly say to the world that our health-care needs are so acute that we simply must devote untold additional billions of dollars to train another 125,000 to 150,000 doctors in the United States over the next 15 years and then pay many more billions to use the services of these and perhaps 50,000 of their foreign-trained colleagues? I certainly would not want to carry that argument before the court of world opinion. I am certain that we shall indeed be called to account if these trends and projections go unchanged.
Bull. N. Y. Acad. Med.
PROSPECTIVE MANPOWER REQUIREMENTS
1071
I shall offer one additional observation on the subject of foreign medical graduates. The argument is often heard that many, perhaps most, of the foreign-trained physicians practicing in the United States simply could not work in their homelands because there are inadequate facilities and other resources to sustain a modern medical practice. That proposition has little merit and less logic. The amount of money that we spend per year to pay for the training of one undergraduate or graduate medical student-probably between $10,000 and $20,000-undoubtedly could support a physician practicing in Asia, Africa, or South America. Now that the federal government is proposing to spend part of its health-manpower funds to upgrade foreign medical graduates' clinical and language skills, the diversion of funds from United States medical education to support foreign health-care activities is not as obtuse as it might seem. We no longer can look on our medical-education objectives and our manpower needs as though they existed in a vacuum. Since nearly half of the physicians entering practice each year in the United States come from abroad, our medical-education objectives must be viewed against a world perspective, against the reality of the world's health-manpower needs. I recognize, of course, that this perspective will be difficult for many to achieve. Faced with an immediate crisis in the world's supply of petroleum, it was, and still is, difficult for most Americans-including business and political leaders-to think of our oil requirements in relation to others' needs. If we have trouble seeing the relations with respect to oil, it will be infinitely more difficult to see them with respect to the supply-and-demand equation in the health-manpower field. We must develop such a perspective and we must do so soon. The underdeveloped nations of the world have demonstrated that they will not quietly accept a state of affairs in which the United States and a few other economic giants enjoy the lion's share of the earth's natural and man-made resources. Health and health resources, including manpower, are among those necessities that we must learn how to share. That simple fact will have to be given substantial weight in our manpower training. Now I shall turn to another set of issues that have not received the sober, candid consideration of those who seek to shape health-manpower programs and objectives. Recently, Dr. Theodore Cooper, the assistant secretary for health of the U. S. Department of Health, Education, and Welfare (HEW), achieved a victory of some significance. He succeeded in reversing the position of the
Vol. 52, No. 9, November 1976
1072
1072
C. D. EDWARDS EDWARDS
Office of Management and Budget with respect to health-manpower legislation, a position that Dr. Cooper and I both believed to be wrong and totally indefensible. As some of you may know, during my tenure as assistant secretary for health of HEW we developed a planning mechanism (the so-called Forward Plan for Health) that would enable HEW to make realistic projections of its long-range responsibilities in helping to resolve a number of core health problems. These included the need for new knowledge in the behavioral, biological, and social sciences, the need to increase the scope and effectiveness of preventive health efforts, the need to prepare for national health insurance, and several other equally complex issues. One of the payoffs of this planning activity obviously would be the ability to assess the need for new federal health legislation and to make a sound case in support of such proposals, both within the executive branch and before the Congress. In view of the fact that major health-manpower legislation had not been adopted, much of our attention was devoted to developing a broad new legislative proposal in this field, based on the extensive planning effort that we had set in motion. In the fall of 1974 our manpower proposal was rejected out of hand by the Office of Management and Budget. In September 1975-largely, I believe, because the planning effort has matured and improved over time-HEW won approval for the health-manpower legislative proposal that had been developed more than a year before. It was presented to the Congress, where it received a warm reception, as indeed it should have. One critical aspect of the proposal (identical bills HRl 119 and S2748) is its intention to continue capitation, rather than terminate it, as the Office of Management and Budget had insisted, and to use this support to address problems of maldistribution. There are other important provisions in the proposal, but the whole proposal would either stand or fall on this provision-and as of now it stands. I shall step back from this legislative initiative for a moment, because I have some serious questions. These are not so much about specific provisions as about the basic philosophy-or, perhaps, lack of philosophy-that supports it. In retrospect, the federal health-manpower initiatives of the last two decades or so have been seriously disappointing, if not fundamentally wrong. You will recall that during the 1950s, particularly in the decade prior to the enactment of federal legislation authorizing direct financial
Bull. N. Y. Acad. Med.
PROSPECTIVE MANPOWER REQUIREMENTS
1073
support of medical education, the federal manpower strategy-if it can be called that-involved pouring vast amounts of money into medical schools to support biomedical research. This was predicated on the belief that it would, as a spin-off, lead to substantial necessary improvements in the quality of medical education and, therefore, in the practice of the physicians trained in these scientifically enriched environments. Part of the conventional wisdom or accepted dogma of those days held that the support of biomedical research not only would lead to important advances in science, but also would turn out physicians who were better able to apply their scientific skills to the care of patients. Needless to say, this health-manpower strategy did not work out. We found, instead, that the number of physicians in the primary-care field moved steadily downward-as it is still doing-and that the number of physicians entering certain highly specialized areas was in no way related to need. Thus, a basic tenet of federal health-manpower strategy-one which the medical schools and the specialties readily approved-not only was failing to work, but was having a negative effect from the viewpoint of the consumers of health care. At about that time, numerous study groups and commissions began proclaiming the advent of a shortage of doctors. As a result, federal health-manpower strategy took a sharp turn, this time with the aid of specific legislation and funding; the goal became not more scientifically trained doctors, but simply more doctors. This time the conventional wisdom held that if we could produce more physicians we not only would prevent a shortage but also could expect to find more physicians entering practice in underserved areas for, by this time, the problems associated with maldistribution also were receiving increasing attention. The successful effort to increase medical school enrollment, like the presumed side benefits of federal support of biomedical research, accomplished little in the way of solving manpower problems. More doctors were entering practice, but still fewer of them had elected primary-care fields, and they were not, by and large, going into underserved areas. Much of this is familiar, but my conclusion has received little, if any, attention. Can we be sure this time that the federal health-policy makers will be right about how to deal with manpower problems? They-and we-were seriously wrong before; are we sure that this time the federal health-manpower strategy is correct? I have some grave doubts, and they are not diminished by thoughts of the results of our actions.
Vol. 52, No. 9, November 1976
1074
1074
D. EDWARDS C. C. D.
EDWARDS~~~~~~~~~~~~~~~~~~
I am afraid that those who have tried to address the health-manpower issue over the last two decades or so-and they have included many dedicated and able people-have failed to look at some of the real issues; indeed, many may not be looking at them even at this late hour. Have we simply witnessed the substitution of a new dogma for an old one? Are we banking on an illusion in assuming that medical students will elect primary-care fields and stick to their decisions? Can we be sure that various financial incentives will entice physicians to practice in underserved areas? Is there not strong reason to believe that career choices of this magnitude are based on additional considerations, as well as those of money and debt? I pose these questions with no sense that they are rhetorical. I frankly do not think we know the answers. If we do not, then the risk of being wrong is great. That is what concerns me. I am also concerned about another aspect of the federal health-manpower strategy, namely, that it is basically a federal strategy, not a strategy developed within or by the academic health system or the medical profession. As one who has spent many years in the federal health bureaucracy, I see, perhaps more clearly than some others, the disappointing failure of medicine to address some of its most urgent problems: manpower needs, quality, costs, the financing mechanisms we employ, and the manner in which they distort and weaken the health-care system. Each of these real and serious problems is being left, begrudgingly but inevitably, to the federal government. It is ironic that some of the professional organizations which could make the greatest contribution to the development of a meaningful and responsible health-manpower strategy have become little more than passive observers of the federal health scene. Perhaps we want this. Perhaps medicine has lost the will and leadership to tackle its own problems. If so, it does not have much longer to go as an independent and honorable profession. It will, instead, become a handmaiden of the federal bureaucracy and, like the railroads, have a glorious past and no future. What I have said may be disappointing and disturbing to some. If so, please forgive me, for what I want to engender is not disappointment but discomfort. The resolution of our health-manpower predicament, no matter how it is measured or described, is steadily being taken out of our hands. That may be occurring because we have lost the ability to solve it. To be
Bull. N. Y. Acad. Med.
PROSPECTIVE MANPOWER REQUIREMENTS
1075
sure, numerous organizations have made invaluable contributions, both to assessing the manpower problem and to dealing with it. The American College of Surgeons, the Academy of Family Physicians, the National Board of Medical Examiners, and a number of other societies and organizations have devoted themselves seriously and productively to the manpower issue; we are all in their debt. But, despite each of these, there is a gaping lack of leadership and creative thinking coming from spokesmen for medical academia and the medical profession at large. The leadership that they should provide is missed sorely, just as their narrow provincialism is far too evident. A tough new federal health-manpower law is about to be enacted which will attach many firm strings to the teaching and practice of medicine, and this is looked upon as an important victory. I cannot help thinking that our greatest problem is a failure of will. Without the will to deal with manpower issues that become more acute year after year, American medicine is relinquishing its right to a voice in its own future. I hope that will not happen. But it will take more than hope to prevent it.
Vol. 52, No. 9, November 1976
