465
WHAT THE FEDERAL GOVERNMENT EXPECTS* KENNETH M. ENDICOTT, M.D. Administrator, Health Resources Administration Public Health Service U.S. Department of Health, Education, and Welfare Rockville, Md.
T HIS year's topic-The Medical School and Its Surrounding Community-is especially close to my heart on two counts: I am deeply concerned about the present and future course of medical education and I am deeply troubled about the response of our communities to the professional schools of medicine. As you know, Congress has passed new health manpower legislationthe long-awaited revision of the legislation that expired two years ago. It is a massive authorization bill which says that it is the sense of Congress that the United States should spend some $2.11 billion between 1978 and 1980, in addition to the $587 million for fiscal year 1977. Whether or not all that money will ever actually be appropriated-and, if appropriated, whether it would ever be released-is, of course, another matter. Nevertheless, we do have new and more carefully drawn authority for supporting the education and training of the health professions. However, in the very first statement of "findings" in the new lawt the Congress has stated flatly that "there is no longer an insufficient number of physicians and surgeons in the United States such that there is no further need for affording preference to alien physicians and surgeons in admission to the United States under the Immigration and Nationality Act." In other words, Congress believes that for the past 10 years or so the medical schools of the nation have done what people of the United States hoped they would do: end the physician shortage. Whether or not you agree with that interpretation of the last decade's effort, the Congress does, and the president, however reluctantly, has signed it into law. The second bold statement of "Findings and Declarations" follows hard *Presented as part of a Symposium on the Medical School and Its Surrounding Community held by the Committee on Medical Education of the New York Academy of Medicine October 14, 1976. tHealth Professions Educational Assistance Act of 1976 (P. L. 94-484), Sec. 2(c).
Vol. 53, No. 5, June 1977
466
K. M. ENDICOTT
466K.
M.
on the heels of the first. While there may be enough physicians and surgeons to go around, the Congress asserts that these are distributed badly according to geography and specialty. The specifics of the new legislation use grants, loans, scholarships, and other subsidies to redress what is generally recognized to be a profession in a state of imbalance. We probably shall be able to live with the new legislation, but this law should not be used to denigrate the past. The record of the health profession may be mixed, but there clearly are some positive aspects to keep in mind. For example, it is useful to remember that the nation's health professions and nursing schools are producing more than 80% more graduates today than in 1964. Since that time the health profession has helped build 21 medical schools, eight dental schools, one school of osteopathy, and one school of veterinary medicine. Since 1965, 215 nursing schools have received federal grants to help build new facilities or renovate existing ones. Since 1964 the federal government has pumped about $4.6 billion into health-manpower programs, excluding programs for research and psychiatric manpower. I submit that this record has been impressive, expensive, and moderately effective in addressing the major objectives of our health-manpower authorities, particularly that of increasing the supply of health professionals. A closer, more analytical look at the manpower effort will show how some of our present troubles developed. This is particularly true of the training for primary care or family medicine, an area being examined by other speakers at this symposium. Between 1963 and 1973 the number of physicians in general practice decreased by 12,000; the percentage of all physicians engaged in primary care decreased from 48% to 44%, while the percentage of surgeons and other specialists increased by 2% each. In retrospect, our experience with medical education in the first major round of health-manpower programs has been frustrating. It is generally true that the health-manpower authorizations enacted before 1971 focused primarily on increasing the numbers of health-care practitioners. However, the 1971 legislation provided some additional, important authorizations which enabled the health profession gingerly to approach the issue of what constitutes an appropriate mix of professional services. In 1970 there were only 131 first-year residents in family-practice programs. In 1971 the Congress authorized direct support for developing additional residencies in family practice. With the aid of this federal Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS
467
support we now have more than 1,600 first-year residents in family practice. Of today's 278 family-practice programs, 143 are receiving federal support. Other provisions of the 1971 law have permitted us to address the various issues of primary care directly: funding has been provided for prototype programs in primary care, internal medicine, and pediatric education. In fiscal year 1975 about $3.3 million was awarded to support seven model residency programs in primary care at both private and public institutions. Special-project grants also were awarded for undergraduate programs in family medicine. The authorization has been used to support the development and expansion of new undergraduate training programs in family medicine since fiscal year 1972, when undergraduate programs in family medicine were among the seven special-project areas for funding by the Bureau of Health Manpower.* Fourteen grants totaling $2.2 million were awarded to 13 institutions that year to support training programs in family medicine. All these programs emphasize the delivery of comprehensive, continuous care and most of them involve training experience in a model family practice unit or in the office of a family practitioner. This kind of practice is received very positively by the community-at least in concept. Our 11 area health-education centers also have encouraged and supported increased training opportunities in primary care for medical, osteopathic, nursing, and allied health personnel. Training health professionals in primary care is one option for the plan which medical, osteopathic, and dental schools must submit to qualify for capitation grants. And, of course, our programs to support health-care extenders also are stressing primary care. About 3,000 persons are enrolled in federally assisted programs to train physician assistants and expanded-function dental auxiliary personnel; these produce more than 750 graduates per year. The majority of these graduates are returning to work with primary-care physicians in medically underserved areas. The training of physician assistants in primary care also is encouraged under a capitation-grant bonus. More than 1,100 physician assistants are being trained at institutions receiving this kind of support. However, despite this kind of activity, as I have noted, we have a sense * Health Resources Administration, Public Health Service, Department of Health, Education, and Welfare, Bethesda, Md.
Vol. 53, No. 5, June 1977
468
K. M. ENDICOTT
of frustration. This is because the basic trend among physicians continues to be toward greater specialization. The percentage of active physicians engaged in primary care was about 48% in 1963, dropped to 44% in 1970, and is expected to decline to about 41 % in 1980 and 39% in 1990. There now is virtually unanimous agreement that a continuation of the present specialty-distribution pattern is unacceptable. The Congress put this succinctly into the opening section of the new health-manpower legislation and, of course, the president signed it. Among the specific mechanisms in the new legislation designed to deal -with specialty maldistribution are the requirements for schools of medicine and osteopathy to have affiliated residencies in primary care in order to receive capitation grants. The law suggests that by 1980 these schools should have half their residencies in the field of primary medical care (obstetrics and gynecology are not counted). Dental schools applying for capitation grants would have to show that 70% of their residencies were in either general dentistry or pedodontics. Another mechanism is the special project grant. The new law would increase the money available for special projects in family medicine and general-practice dentistry from $40 million in fiscal year 1978 to $50 million in fiscal year 1980. Additional grants under this heading of special projects would be available for instruction in family medicine, general pediatrics, and general internal medicine. Student assistance has the same obvious string tied to it. Students receiving a National Health Service Corps scholarship could repay the government by practicing in a designated health-manpower shortage area. The penalty for default now is three times the amount owed plus interest, payable within one year of default. Additional grants would be available to former members of the National Health Service Corps who elect to stay on in the shortage area in their own private practices. The escape route of personal bankruptcy is closed by law. One suggestion made on Capitol Hill-that students who received assistance and then refused to practice in an underserved area would have to pay back the capitation a school earned on their behalf-was eliminated from the final version of the bill. That was a bit too Draconian for a majority of congressmen. At first these proposals met some resistance in Congress and were debated with some heat within the executive branch also. Of more concern, however, is the resistance that primary care has encountered within the health-care community itself. Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS
469
A recent report titled Trends Affecting the U.S. Health Care System, * prepared for the Health Resources Administration by independent investigators, has warned us that "...in pressing for greater emphasis on training for primary care, the Government is moving against the current in the medical profession and is likely to encounter resistance....When the Government lavished funds on health research, the results were dramatic because the Government and the medical profession were pushing in the same direction. Now, however, the Government is trying to promote primary care while the medical profession still tends to be oriented toward specialized care and research." Change is frequently uncomfortable, perhaps because of our reluctance to abandon approaches that have served us well in the past. Hence, there are those who are reluctant to deemphasize, let alone abandon, those activities which received substantial federal support when the National Institutes of Health and biomedical research were ascendant. However, I hope it is apparent to everyone connected with health-manpower education that the federal health-manpower dollar will be directed to those programs which improve the geographic and specialty distribution of personnel. Primary care is where federal dollars will be allocated. If for no other reason than income, therefore, it would be wise for medical education-its planners, governors, teachers, and treasurers-to pay far more attention to education and training for primary care than has been the case thus far. Progress is slow and the unsteady flow of federal funds has not been helpful. I shall be among the first to acknowledge the unhappy effect an unpredictable federal policy can have upon higher education. But, failing any real chance to control the authorization and appropriations process fully for 100% reliability, we simply have to enlarge our respective capacities for flexibility-both at the institutional and at the federal level. The goal remaining is that of expanding primary-care education and training and encouraging the broader distribution of primary-care physicians throughout the country. It is now in order to discuss the other half of my opening statement: the response of the community to the efforts of medical schools and federal health organizations such as my own. Frankly, the response of the community is becoming increasingly negative. Here I am speaking of the *Trends Affecting the U.S. Health Care System. DHEW Publications No. HRA 76-14503. Rockville, Md., Health Resources Administration, Bureau of Health Planning and Resources Development, 1976, p. 85.
Vol. 53, No. 5, June 1977
470
470
K. ENDICOTT M. ENDICOTT K. M.
community in the broadest sense, with regard to what local citizens are thinking and talking about relative to the health profession. The front-page stories in major American newspapers continue to deal with physicians who have been made millionaires by Medicare and Medicaid, who have opened up so-called "Medicaid mills" in order to get more than they deserve of the $16 billion spent on Medicaid each year. Another story that continues to appear is that of medical malpractice-expressed in articles about huge judgments awarded by the courts to injured patients or their families. The continued presence of these stories on the front pages of our daily papers only serves to fasten deeper in the public consciousness the idea that the medical profession is not to be trusted. Is this unfair? Maybe so. I am certain that the overwhelming majority of practicing physicians put in a long workweek, provide the best patient care they can, and keep only half or a third of the money they gross; the rest of their income goes to maintain their practice and their own support personnel. But I am afraid that we have passed the time when we could defend ourselves by pointing with pride to an overwhelming majority of physicians. The plain fact is that a significant minority is playing havoc with the profession of medicine: exploiting the sick and the poor, squeezing the pockets of black and Hispanic Americans, and drawing off tremendous sums from state, municipal, and federal treasuries. Most frightening of all, there are still physicians practicing medicine who are not competent, who make more mistakes than the profession can forgive, and whose personal lives are so chaotic that they are only capable of producing tragedies among their patients. At first, a cadre of local consumer advocates charged the medical profession with being too protective of the incompetents in its midst. Those advocates were shrugged off too easily by medical societies that preferred-literally-to carry on business as usual. Today the attack is being mounted by state and local governments which cannot afford to reimburse unconscionable fees to local physicians. Insurance companies are becoming exasperated with a profession which will not clean its own house. Labor and management are voicing displeasure at hammering out wage and benefits contracts that eventually benefit a few local physicians rather than union members and the employing company. Through their taxes the people of the United States have contributed rather handsomely to medical education-more than $4.6 billion in the past 12 years, as I have mentioned. Now they continue to support those Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS
471
same licensed physicians through tax dollars spent in medical-care programs and they pay again in their fees for personal or family health care. I submit that a major shift away from specialty training toward training for primary care by itself is not enough to ease the minds of the nation's taxpayers and legislators. I expect the community response to be something like this: "If the doctors are going into family medicine, there must be more money in it for them." As I have stated, from the point of view of the medical school, primary care is where the federal dollars will be spent in the months and years ahead. There is a special message here for medical education. The medical schools have not yet absorbed into their curricula an understanding and respect for the peer-review and utilization-review programs in the real world of practice. The whole concept of medical accountability, painful as it may be for some established members of the profession to accept, is a concept whose time has come. It is incumbent upon schools of medicine, nursing, osteopathy, dentistry, and all the other health professions to make sure that their students graduate with a firm, respectful understanding of the present and future climate of public accountability in medical practice. This is more than just a matter of taking out a bigger insurance policy or securing the services of a crackerjack lawyer. We are talking now about the bedrock strength of the practice of medicine: public trust. Without that trust, medicine is not practiced, it is gambled. Our medical schools are stewards of a great tradition, several thousand years old, by which men and women take upon themselves the tasks of healing and caring, of ministering to the flesh, the spirit, and the mind, and of being responsible for the well-being of their fellow human beings. Medicare-reimbursement procedures have not changed that tradition and Medicaid loopholes must not defile that tradition. Ambivalence or lack of courage on the part of medical societies must not vitiate that tradition. In other words, the federal government at the urging of taxpayers and concerned citizens in many quarters of our society-will be forced to become the steward of the tradition of medicine if the schools and the profession itself will not fulfill that function. I do not think we have to worry about the prospect of federally regulated medicine. That is a convenient bogey for certain political demagogues to wave about at an appropriate moment, but there is little substance to it. Rather, I have complete faith that physicians themselves finally will come to terms with the demands of society for trust and accountability. Medical Vol. 53, No. 5, June 1977
472 472
K. M. ENDICOTT
schools should take the lead in shaping that development. The new doctors, nurses, dentists, and others-those who want to practice in a profession that gives them a continuous sense of pride-are going to demand the best thinking and the best instruction to help them attain their goal of pride in their chosen profession. Students in the health professions are going to expect that kind of concern, but the government expects that kind of concern now. If we can iron out our problems in Congress, stabilize the flow of federal funds, increase interest in primary care, and encourage more physicians to practice in remote, medically underserved areas, then we shall have accomplished much-but not enough. Still ahead of us will be the departure of those persons who see medicine as a way of getting rich quickly, confounding the public interest, preying upon the weak, and defying the innate decency and honesty of the medical profession. Such a task is what the community now asks of medical education. For the community, the accomplishment of this task-the implanting of trust and accountability within medical practice-will lead to better medical care at reasonable costs. We in medicine can ignore such a community desire only at our peril. It was not my intention to be a Cassandra, to dampen your spirits or your enthusiasm for your work. But I would be less than candid if I neglected to tell you what I see before us all, in both public and private medicine. I hope my remarks are accepted in that spirit and that we can mark this meeting as another milestone in which medical education perceived the reasonable expectations of government and sought to satisfy them. *The source of most of the statistics in this paper concerning expenditures, enrollment figures, and other data on health-professions schools and medical education is A New Bureau, A Sharper Focus, Annual Report of Fiscal 1975 Activities. DHEW Publication No. (HRA) 76-9. Public Health Service, Health Resources Administration, Bureau of Health Manpower.
Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS* KENNETH M. ENDICOTT, M.D. Administrator, Health Resources Administration Public Health Service U.S. Department of Health, Education, and Welfare Rockville, Md.
T HIS year's topic-The Medical School and Its Surrounding Community-is especially close to my heart on two counts: I am deeply concerned about the present and future course of medical education and I am deeply troubled about the response of our communities to the professional schools of medicine. As you know, Congress has passed new health manpower legislationthe long-awaited revision of the legislation that expired two years ago. It is a massive authorization bill which says that it is the sense of Congress that the United States should spend some $2.11 billion between 1978 and 1980, in addition to the $587 million for fiscal year 1977. Whether or not all that money will ever actually be appropriated-and, if appropriated, whether it would ever be released-is, of course, another matter. Nevertheless, we do have new and more carefully drawn authority for supporting the education and training of the health professions. However, in the very first statement of "findings" in the new lawt the Congress has stated flatly that "there is no longer an insufficient number of physicians and surgeons in the United States such that there is no further need for affording preference to alien physicians and surgeons in admission to the United States under the Immigration and Nationality Act." In other words, Congress believes that for the past 10 years or so the medical schools of the nation have done what people of the United States hoped they would do: end the physician shortage. Whether or not you agree with that interpretation of the last decade's effort, the Congress does, and the president, however reluctantly, has signed it into law. The second bold statement of "Findings and Declarations" follows hard *Presented as part of a Symposium on the Medical School and Its Surrounding Community held by the Committee on Medical Education of the New York Academy of Medicine October 14, 1976. tHealth Professions Educational Assistance Act of 1976 (P. L. 94-484), Sec. 2(c).
Vol. 53, No. 5, June 1977
466
K. M. ENDICOTT
466K.
M.
on the heels of the first. While there may be enough physicians and surgeons to go around, the Congress asserts that these are distributed badly according to geography and specialty. The specifics of the new legislation use grants, loans, scholarships, and other subsidies to redress what is generally recognized to be a profession in a state of imbalance. We probably shall be able to live with the new legislation, but this law should not be used to denigrate the past. The record of the health profession may be mixed, but there clearly are some positive aspects to keep in mind. For example, it is useful to remember that the nation's health professions and nursing schools are producing more than 80% more graduates today than in 1964. Since that time the health profession has helped build 21 medical schools, eight dental schools, one school of osteopathy, and one school of veterinary medicine. Since 1965, 215 nursing schools have received federal grants to help build new facilities or renovate existing ones. Since 1964 the federal government has pumped about $4.6 billion into health-manpower programs, excluding programs for research and psychiatric manpower. I submit that this record has been impressive, expensive, and moderately effective in addressing the major objectives of our health-manpower authorities, particularly that of increasing the supply of health professionals. A closer, more analytical look at the manpower effort will show how some of our present troubles developed. This is particularly true of the training for primary care or family medicine, an area being examined by other speakers at this symposium. Between 1963 and 1973 the number of physicians in general practice decreased by 12,000; the percentage of all physicians engaged in primary care decreased from 48% to 44%, while the percentage of surgeons and other specialists increased by 2% each. In retrospect, our experience with medical education in the first major round of health-manpower programs has been frustrating. It is generally true that the health-manpower authorizations enacted before 1971 focused primarily on increasing the numbers of health-care practitioners. However, the 1971 legislation provided some additional, important authorizations which enabled the health profession gingerly to approach the issue of what constitutes an appropriate mix of professional services. In 1970 there were only 131 first-year residents in family-practice programs. In 1971 the Congress authorized direct support for developing additional residencies in family practice. With the aid of this federal Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS
467
support we now have more than 1,600 first-year residents in family practice. Of today's 278 family-practice programs, 143 are receiving federal support. Other provisions of the 1971 law have permitted us to address the various issues of primary care directly: funding has been provided for prototype programs in primary care, internal medicine, and pediatric education. In fiscal year 1975 about $3.3 million was awarded to support seven model residency programs in primary care at both private and public institutions. Special-project grants also were awarded for undergraduate programs in family medicine. The authorization has been used to support the development and expansion of new undergraduate training programs in family medicine since fiscal year 1972, when undergraduate programs in family medicine were among the seven special-project areas for funding by the Bureau of Health Manpower.* Fourteen grants totaling $2.2 million were awarded to 13 institutions that year to support training programs in family medicine. All these programs emphasize the delivery of comprehensive, continuous care and most of them involve training experience in a model family practice unit or in the office of a family practitioner. This kind of practice is received very positively by the community-at least in concept. Our 11 area health-education centers also have encouraged and supported increased training opportunities in primary care for medical, osteopathic, nursing, and allied health personnel. Training health professionals in primary care is one option for the plan which medical, osteopathic, and dental schools must submit to qualify for capitation grants. And, of course, our programs to support health-care extenders also are stressing primary care. About 3,000 persons are enrolled in federally assisted programs to train physician assistants and expanded-function dental auxiliary personnel; these produce more than 750 graduates per year. The majority of these graduates are returning to work with primary-care physicians in medically underserved areas. The training of physician assistants in primary care also is encouraged under a capitation-grant bonus. More than 1,100 physician assistants are being trained at institutions receiving this kind of support. However, despite this kind of activity, as I have noted, we have a sense * Health Resources Administration, Public Health Service, Department of Health, Education, and Welfare, Bethesda, Md.
Vol. 53, No. 5, June 1977
468
K. M. ENDICOTT
of frustration. This is because the basic trend among physicians continues to be toward greater specialization. The percentage of active physicians engaged in primary care was about 48% in 1963, dropped to 44% in 1970, and is expected to decline to about 41 % in 1980 and 39% in 1990. There now is virtually unanimous agreement that a continuation of the present specialty-distribution pattern is unacceptable. The Congress put this succinctly into the opening section of the new health-manpower legislation and, of course, the president signed it. Among the specific mechanisms in the new legislation designed to deal -with specialty maldistribution are the requirements for schools of medicine and osteopathy to have affiliated residencies in primary care in order to receive capitation grants. The law suggests that by 1980 these schools should have half their residencies in the field of primary medical care (obstetrics and gynecology are not counted). Dental schools applying for capitation grants would have to show that 70% of their residencies were in either general dentistry or pedodontics. Another mechanism is the special project grant. The new law would increase the money available for special projects in family medicine and general-practice dentistry from $40 million in fiscal year 1978 to $50 million in fiscal year 1980. Additional grants under this heading of special projects would be available for instruction in family medicine, general pediatrics, and general internal medicine. Student assistance has the same obvious string tied to it. Students receiving a National Health Service Corps scholarship could repay the government by practicing in a designated health-manpower shortage area. The penalty for default now is three times the amount owed plus interest, payable within one year of default. Additional grants would be available to former members of the National Health Service Corps who elect to stay on in the shortage area in their own private practices. The escape route of personal bankruptcy is closed by law. One suggestion made on Capitol Hill-that students who received assistance and then refused to practice in an underserved area would have to pay back the capitation a school earned on their behalf-was eliminated from the final version of the bill. That was a bit too Draconian for a majority of congressmen. At first these proposals met some resistance in Congress and were debated with some heat within the executive branch also. Of more concern, however, is the resistance that primary care has encountered within the health-care community itself. Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS
469
A recent report titled Trends Affecting the U.S. Health Care System, * prepared for the Health Resources Administration by independent investigators, has warned us that "...in pressing for greater emphasis on training for primary care, the Government is moving against the current in the medical profession and is likely to encounter resistance....When the Government lavished funds on health research, the results were dramatic because the Government and the medical profession were pushing in the same direction. Now, however, the Government is trying to promote primary care while the medical profession still tends to be oriented toward specialized care and research." Change is frequently uncomfortable, perhaps because of our reluctance to abandon approaches that have served us well in the past. Hence, there are those who are reluctant to deemphasize, let alone abandon, those activities which received substantial federal support when the National Institutes of Health and biomedical research were ascendant. However, I hope it is apparent to everyone connected with health-manpower education that the federal health-manpower dollar will be directed to those programs which improve the geographic and specialty distribution of personnel. Primary care is where federal dollars will be allocated. If for no other reason than income, therefore, it would be wise for medical education-its planners, governors, teachers, and treasurers-to pay far more attention to education and training for primary care than has been the case thus far. Progress is slow and the unsteady flow of federal funds has not been helpful. I shall be among the first to acknowledge the unhappy effect an unpredictable federal policy can have upon higher education. But, failing any real chance to control the authorization and appropriations process fully for 100% reliability, we simply have to enlarge our respective capacities for flexibility-both at the institutional and at the federal level. The goal remaining is that of expanding primary-care education and training and encouraging the broader distribution of primary-care physicians throughout the country. It is now in order to discuss the other half of my opening statement: the response of the community to the efforts of medical schools and federal health organizations such as my own. Frankly, the response of the community is becoming increasingly negative. Here I am speaking of the *Trends Affecting the U.S. Health Care System. DHEW Publications No. HRA 76-14503. Rockville, Md., Health Resources Administration, Bureau of Health Planning and Resources Development, 1976, p. 85.
Vol. 53, No. 5, June 1977
470
470
K. ENDICOTT M. ENDICOTT K. M.
community in the broadest sense, with regard to what local citizens are thinking and talking about relative to the health profession. The front-page stories in major American newspapers continue to deal with physicians who have been made millionaires by Medicare and Medicaid, who have opened up so-called "Medicaid mills" in order to get more than they deserve of the $16 billion spent on Medicaid each year. Another story that continues to appear is that of medical malpractice-expressed in articles about huge judgments awarded by the courts to injured patients or their families. The continued presence of these stories on the front pages of our daily papers only serves to fasten deeper in the public consciousness the idea that the medical profession is not to be trusted. Is this unfair? Maybe so. I am certain that the overwhelming majority of practicing physicians put in a long workweek, provide the best patient care they can, and keep only half or a third of the money they gross; the rest of their income goes to maintain their practice and their own support personnel. But I am afraid that we have passed the time when we could defend ourselves by pointing with pride to an overwhelming majority of physicians. The plain fact is that a significant minority is playing havoc with the profession of medicine: exploiting the sick and the poor, squeezing the pockets of black and Hispanic Americans, and drawing off tremendous sums from state, municipal, and federal treasuries. Most frightening of all, there are still physicians practicing medicine who are not competent, who make more mistakes than the profession can forgive, and whose personal lives are so chaotic that they are only capable of producing tragedies among their patients. At first, a cadre of local consumer advocates charged the medical profession with being too protective of the incompetents in its midst. Those advocates were shrugged off too easily by medical societies that preferred-literally-to carry on business as usual. Today the attack is being mounted by state and local governments which cannot afford to reimburse unconscionable fees to local physicians. Insurance companies are becoming exasperated with a profession which will not clean its own house. Labor and management are voicing displeasure at hammering out wage and benefits contracts that eventually benefit a few local physicians rather than union members and the employing company. Through their taxes the people of the United States have contributed rather handsomely to medical education-more than $4.6 billion in the past 12 years, as I have mentioned. Now they continue to support those Bull. N.Y. Acad. Med.
WHAT THE FEDERAL GOVERNMENT EXPECTS
471
same licensed physicians through tax dollars spent in medical-care programs and they pay again in their fees for personal or family health care. I submit that a major shift away from specialty training toward training for primary care by itself is not enough to ease the minds of the nation's taxpayers and legislators. I expect the community response to be something like this: "If the doctors are going into family medicine, there must be more money in it for them." As I have stated, from the point of view of the medical school, primary care is where the federal dollars will be spent in the months and years ahead. There is a special message here for medical education. The medical schools have not yet absorbed into their curricula an understanding and respect for the peer-review and utilization-review programs in the real world of practice. The whole concept of medical accountability, painful as it may be for some established members of the profession to accept, is a concept whose time has come. It is incumbent upon schools of medicine, nursing, osteopathy, dentistry, and all the other health professions to make sure that their students graduate with a firm, respectful understanding of the present and future climate of public accountability in medical practice. This is more than just a matter of taking out a bigger insurance policy or securing the services of a crackerjack lawyer. We are talking now about the bedrock strength of the practice of medicine: public trust. Without that trust, medicine is not practiced, it is gambled. Our medical schools are stewards of a great tradition, several thousand years old, by which men and women take upon themselves the tasks of healing and caring, of ministering to the flesh, the spirit, and the mind, and of being responsible for the well-being of their fellow human beings. Medicare-reimbursement procedures have not changed that tradition and Medicaid loopholes must not defile that tradition. Ambivalence or lack of courage on the part of medical societies must not vitiate that tradition. In other words, the federal government at the urging of taxpayers and concerned citizens in many quarters of our society-will be forced to become the steward of the tradition of medicine if the schools and the profession itself will not fulfill that function. I do not think we have to worry about the prospect of federally regulated medicine. That is a convenient bogey for certain political demagogues to wave about at an appropriate moment, but there is little substance to it. Rather, I have complete faith that physicians themselves finally will come to terms with the demands of society for trust and accountability. Medical Vol. 53, No. 5, June 1977
472 472
K. M. ENDICOTT
schools should take the lead in shaping that development. The new doctors, nurses, dentists, and others-those who want to practice in a profession that gives them a continuous sense of pride-are going to demand the best thinking and the best instruction to help them attain their goal of pride in their chosen profession. Students in the health professions are going to expect that kind of concern, but the government expects that kind of concern now. If we can iron out our problems in Congress, stabilize the flow of federal funds, increase interest in primary care, and encourage more physicians to practice in remote, medically underserved areas, then we shall have accomplished much-but not enough. Still ahead of us will be the departure of those persons who see medicine as a way of getting rich quickly, confounding the public interest, preying upon the weak, and defying the innate decency and honesty of the medical profession. Such a task is what the community now asks of medical education. For the community, the accomplishment of this task-the implanting of trust and accountability within medical practice-will lead to better medical care at reasonable costs. We in medicine can ignore such a community desire only at our peril. It was not my intention to be a Cassandra, to dampen your spirits or your enthusiasm for your work. But I would be less than candid if I neglected to tell you what I see before us all, in both public and private medicine. I hope my remarks are accepted in that spirit and that we can mark this meeting as another milestone in which medical education perceived the reasonable expectations of government and sought to satisfy them. *The source of most of the statistics in this paper concerning expenditures, enrollment figures, and other data on health-professions schools and medical education is A New Bureau, A Sharper Focus, Annual Report of Fiscal 1975 Activities. DHEW Publication No. (HRA) 76-9. Public Health Service, Health Resources Administration, Bureau of Health Manpower.
Bull. N.Y. Acad. Med.
