Medical Teacher
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
The Great American Dream Shrinks a Little To cite this article: (1979) The Great American Dream Shrinks a Little, Medical Teacher, 1:2, 93-93 To link to this article: http://dx.doi.org/10.3109/01421597909019399
Published online: 03 Jul 2009.
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The Great American Dream Shrinks a Little American Government thinking about the future of medical education was outlined by Joseph Califano, Secretary of the US Department of Health, Education and Welfare, addressing the American Association of Medical Colleges meeting in New Orleans. Health care is America’s third largest Industry. In 1978 it used some 180 billion dollars and almost six per cent of the national work force; by the year 2000 health costs are expected to reach one trillion dollars and 12 per cent of the entire gross national product. And the decisions taken by individual physicians account for 70 per cent of all such expenditure. Califano’s first message was clear-“The men and women you train today and tomorrow will make decisions governing several trillion dollars of our Gross National Product over the next two decades”.
Oversupply of Physicians Imminent The number of US medical school graduates has virtually doubled, from some 8,000 in 1963 to more than 15,000 in 1978, in response to concern during the early 1960s about an impending physician shortage. With the influx of foreign medical graduates, the number of doctors in active practice increased by 46 per cent between 1960 and 1975, the ratio of doctors to population increasing from 143 to 177 per 100,000 people. Califano stated that the first tenet of national policy in this area is that an oversupply of physicians is immi-
Medical Teacher Vol 1 N o 2 1979
nent. Depending on how one estimates need for physicians, an excess of 23,000 to 150,000 doctors is predicted by 1990, with 594,000 active doctors in practice, 242 per 100,000 of the population. The second major problem is that “we are producing too many medical specialists and subspecialists, such as surgeons, and there is a corresponding and disturbing decline in the proportion of primary care physicians”. Califano concluded, from a number of studies, that “as the number of surgeons rises in an area, the number of operations also goes up-with no clear evidence that all this extra surgery is necessary”. The USA has twice as many surgeons as England and Wales, for instance, and twice the surgery rate. In some parts of Maine where the ratio of surgeons to population is highest, the number of gall bladder operations is more than double the number performed in other parts of the State. Other studies suggest that the greater the number of surgeons in an area, the higher the surgeon’s fees. Califano voiced his concern about the decline in primary care. In 1931, fully 94 per cent of practising doctors in the USA were in full-time primary care. By 1975 that proportion had fallen to 38 per cent, compared with 72 per cent in West Germany and 60 per cent in Canada. Despite considerably greater efforts to reduce this trend in the last decade, it seems that only 35 to 40 per cent of doctors now in training in America are completing residency programmes in primary care fields. Distribution problems abound. Despite the “excess medical manpower”, more than 25 million Americans live in underserved areas with fewer than one doctor for every 2,000 people. The percentage of doctors practising in such areas actually fell between 1963 and 1976. In the areas with excellent doctor/ patient ratios (better than 1 to 300) the percentage increased sharply. So the rich get richer and the poor poorer. Britain, Germany, and Canada are experiencing similar problems. The next major problem Califano identified was the need for medical schools to be far more active in making physicians responsive to
demographic, social and economic changes -the ‘graying’ of America (the increasing proportion of the population over 65 years old); the need for greater emphasis on chronic and long-term rather than acute conditions, on palliative and rehabilitative rather than curative practice; the increasing importance of emotional and psychosocial problems; the need to learn to work with other varieties of health care personnel and to be more sensitive to ethical issues.
Action t o Deal with Problems Califano proposed action to deal with these problems. Federal funding and incentives will be realigned. Schools will be encouraged to reduce gradually the size of classes. It is extremely unlikely that new schools will be created, and strong opposition to the admission of foreign graduates will be continued. Efforts to increase the production of primary care physicians will gain more support, and Departments of Family Medicine can expect more funding and encouragement. Geographic maldistribution will be tackled by increased support and scholarships for the National Health Service Corps (an internal-service version of the Peace Corps); by encouraging the admission to medical school of students from underserved areas; and by clinical rotations in community health centres during training. Psychosocial, ethical and economic aspects of health care should receive more emphasis, too. Califano’s news may not have been uniformly welcome to all who heard him, but he is to be commended for his directness, his realism and his optimism. “We are approaching the day” he said “in health care as in the field of energy when we simply cannot sustain the costs of chromefinned, gas-guzzling, option-rich technology. ” At long last, it appears that we are talking about planning medical education on the basis of a realistic assessment of health care problems, apart from a few romantic rhetorical flourishes. 93
ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20
The Great American Dream Shrinks a Little To cite this article: (1979) The Great American Dream Shrinks a Little, Medical Teacher, 1:2, 93-93 To link to this article: http://dx.doi.org/10.3109/01421597909019399
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 9
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imte20 Download by: [Deakin University Library]
Date: 08 November 2015, At: 17:47
CONFEKENCE REPORTS
Downloaded by [Deakin University Library] at 17:47 08 November 2015
The Great American Dream Shrinks a Little American Government thinking about the future of medical education was outlined by Joseph Califano, Secretary of the US Department of Health, Education and Welfare, addressing the American Association of Medical Colleges meeting in New Orleans. Health care is America’s third largest Industry. In 1978 it used some 180 billion dollars and almost six per cent of the national work force; by the year 2000 health costs are expected to reach one trillion dollars and 12 per cent of the entire gross national product. And the decisions taken by individual physicians account for 70 per cent of all such expenditure. Califano’s first message was clear-“The men and women you train today and tomorrow will make decisions governing several trillion dollars of our Gross National Product over the next two decades”.
Oversupply of Physicians Imminent The number of US medical school graduates has virtually doubled, from some 8,000 in 1963 to more than 15,000 in 1978, in response to concern during the early 1960s about an impending physician shortage. With the influx of foreign medical graduates, the number of doctors in active practice increased by 46 per cent between 1960 and 1975, the ratio of doctors to population increasing from 143 to 177 per 100,000 people. Califano stated that the first tenet of national policy in this area is that an oversupply of physicians is immi-
Medical Teacher Vol 1 N o 2 1979
nent. Depending on how one estimates need for physicians, an excess of 23,000 to 150,000 doctors is predicted by 1990, with 594,000 active doctors in practice, 242 per 100,000 of the population. The second major problem is that “we are producing too many medical specialists and subspecialists, such as surgeons, and there is a corresponding and disturbing decline in the proportion of primary care physicians”. Califano concluded, from a number of studies, that “as the number of surgeons rises in an area, the number of operations also goes up-with no clear evidence that all this extra surgery is necessary”. The USA has twice as many surgeons as England and Wales, for instance, and twice the surgery rate. In some parts of Maine where the ratio of surgeons to population is highest, the number of gall bladder operations is more than double the number performed in other parts of the State. Other studies suggest that the greater the number of surgeons in an area, the higher the surgeon’s fees. Califano voiced his concern about the decline in primary care. In 1931, fully 94 per cent of practising doctors in the USA were in full-time primary care. By 1975 that proportion had fallen to 38 per cent, compared with 72 per cent in West Germany and 60 per cent in Canada. Despite considerably greater efforts to reduce this trend in the last decade, it seems that only 35 to 40 per cent of doctors now in training in America are completing residency programmes in primary care fields. Distribution problems abound. Despite the “excess medical manpower”, more than 25 million Americans live in underserved areas with fewer than one doctor for every 2,000 people. The percentage of doctors practising in such areas actually fell between 1963 and 1976. In the areas with excellent doctor/ patient ratios (better than 1 to 300) the percentage increased sharply. So the rich get richer and the poor poorer. Britain, Germany, and Canada are experiencing similar problems. The next major problem Califano identified was the need for medical schools to be far more active in making physicians responsive to
demographic, social and economic changes -the ‘graying’ of America (the increasing proportion of the population over 65 years old); the need for greater emphasis on chronic and long-term rather than acute conditions, on palliative and rehabilitative rather than curative practice; the increasing importance of emotional and psychosocial problems; the need to learn to work with other varieties of health care personnel and to be more sensitive to ethical issues.
Action t o Deal with Problems Califano proposed action to deal with these problems. Federal funding and incentives will be realigned. Schools will be encouraged to reduce gradually the size of classes. It is extremely unlikely that new schools will be created, and strong opposition to the admission of foreign graduates will be continued. Efforts to increase the production of primary care physicians will gain more support, and Departments of Family Medicine can expect more funding and encouragement. Geographic maldistribution will be tackled by increased support and scholarships for the National Health Service Corps (an internal-service version of the Peace Corps); by encouraging the admission to medical school of students from underserved areas; and by clinical rotations in community health centres during training. Psychosocial, ethical and economic aspects of health care should receive more emphasis, too. Califano’s news may not have been uniformly welcome to all who heard him, but he is to be commended for his directness, his realism and his optimism. “We are approaching the day” he said “in health care as in the field of energy when we simply cannot sustain the costs of chromefinned, gas-guzzling, option-rich technology. ” At long last, it appears that we are talking about planning medical education on the basis of a realistic assessment of health care problems, apart from a few romantic rhetorical flourishes. 93
