THE URGENT NEED FOR MEDICAL MANPOWER

...The AMA agreed to a new six-month extension, partly under pressure from the State Department, which expressed concern that a mass deportation might cause widespread resentment abroad...

...To maintain the level of fifty-six dentists per 100,000 in 1975 will require an increase from the present 3,200 to more than 6,000 dental graduates a year...

...But, ironically enough, it is being criticized for the wrong reasons in the dispute over standards in which even the State Department has recently become involved...

...This left 2,000 who flunked and were to be deported after the first of the year...

...Theoretically, the objective of such SELIG GREENBERG, writer on medical problems for the Providence Journal and Evening Bulletin, hat twice been honored by the lasker Foundation for distinguished writing on medicine...

...But so serious is the shortage of doctors that about one-fourth of the hospital house staff positions remain unfilled...

...It's vital to democracy that medical education should be open to any well-qualified person...

...Aside from the threat to our own standards of medical care, there is the moral issue as to whether the wealthiest nation in the world has the right to deplete the thin professional resources of poorer countries...

...It involves four years of college, four years of medical school, two years of hospital internship at low pay, and an additional minimum of three years of residency to qualify for a specialty...

...The AMA has not only vigorously opposed the appropriation of Federal funds for new medical school construction but has blocked legislation to help relieve the financial plight of the existing schools through grants to meet part of their large operating deficits...

...Walter S. Wiggins, Secretary of the AMA's Council on Medical Education and Hospitals, has said, "dwell heavily on public health measures to eradicate contagious diseases such as typhoid and dysentery...

...Whereas the average American visited a doctor 2.5 times a year three decades ago, he is now doing so five times a year...

...But even more disturbing than the quantity of foreign-trained physicians upon whom we have increasingly become dependent is the quality of their medical education...

...One of every three doctors now serving as intern or resident in hospitals in this country was educated abroad...

...The doctor-population ratio figures do not, moreover, tell the whole story...

...In practice, this end is only partially achieved...

...The shortage of physicians is not something which has burst upon us overnight...

...There were fifty-nine dentists for each 100,000 persons in 1930...

...Significantly, state and local hospital associations have strongly resisted attempts to weed out the less competent foreign members of house staffs...

...The reasons are all too obvious...

...The ruling brought such an outcry from hospitals clearly more interested in retaining their manpower than in the caliber of their house staffs that the deadline was promptly extended to December 31...

...Even the AMA, which until recently insisted that there is no shortage of physicians, now concedes that the facilities for medical education must be expanded...

...There are, furthermore, basic differences in health problems in this country and in other parts of the world...

...But as our own shortage of physicians has progressively worsened, a good deal of the original aim has been lost sight of...

...The Urgent Need for Medical Manpower by SELIG GREENBERG Acrucial issue which the Kennedy Administration will soon have to face is the need for a broad expansion of the nation's supply of doctors and other health personnel to meet the challenge of an explosively changing pattern of population, disease, and medical care...

...The obvious reason is that they want to further their medical knowledge in advanced training facilities unequalled anywhere else in the world...

...Fully forty per cent of medical students now come from the eight per cent of the nation's families with annuaflncomes of f 10,000 or more," Dr...

...Hospitals desperately in need of interns and residents have often come to look upon foreign doctors primarily as a source of cheap medical labor...

...There has been an alarming drop in recent years in the number as well as the caliber of medical school applicants...

...This in itself raises extremely serious questions about his ability to give his patients the amount of time they should have for adequate treatment and to have the time to try to keep up with new developments in medicine...

...Much the same ambivalence has been evident on our side, too...

...Just to maintain the present ratio of a little under 141 physicians per 100,000 people, we will need an annual output of 11,000 M.D.s and D.O.s by 1975, or an increase of nearly fifty per cent...

...But so urgent are the medical needs of the new and underdeveloped nations that the availability of Soviet physicians, regardless of their caliber, may become an important weapon against us...

...about half of the more than 20,000 alien physicians admitted to this country have settled here and are in private practice...

...So do all of us as potential patients...

...It is certainly not without significance in the rapidly developing battle for the minds and loyalties of the people of the underdeveloped countries that while we are forced to import substantial numbers of foreign physicians to keep our hospitals going, the Soviet Union already is, or soon will be, in a position to export doctors...

...Those failing to pass the examinations have been allowed to make another try for passing grades...

...It can be extremely hazardous to delegate care of patients to apprentice physicians whose knowledge of English is sometimes so fragmentary that they can neither understand the instructions of their mentors nor communicate with their patients...

...The screening tests are given periodically by the Educational Council for Foreign Medical Graduates, sponsored jointly by the AMA, the American Hospital Association, the Association of American Medical Colleges, and the Federation of State Medical Boards...

...Doctors understandably have a deep interest in maintaining high standards of medical education...

...Measured by American standards, the training received in most of these countries is perfunctory...

...Emphasis on clinical and laboratory training necessarily limits the size of classes in American medical schools...

...The same holds true of dentists...

...Public Health Service, has summed up the issue in these words: "The United States has an obligation to share its opportunities for professional advancement with less favored countries...

...A total of 7,308 foreign doctors took the latest examinations in September...

...Underlying the AMA's opposition to a Federal aid program of wide scope for medical education is its long-standing hostility to any concerted planning for improvement of health services that might become a stepping stone to the bugaboo of "socialized medicine...

...We have to measure these foreign doctors against our peculiar problems, not theirs...

...An entering class of this size, one medical educator has said, "is like attending school in a $2 seat in Yankee Stadium...

...Since then the number of foreign-trained physicians serving in this capacity has more than quadrupled and considerably exceeds the annual output of about 7,000 graduates by our own medical schools...

...The thinking behind the program providing temporary visas for foreign doctors, approved by Congress some years ago, was to make our training facilities available to help lift the standards of medical practice in poorer countries...

...In some cases, American hospitals have been shocked to discover that their interns recruited through advertisements in foreign medical magazines or through travel agents abroad are in reality graduates of native, herb schools in India or Korea...

...The entire teaching program in their medical schools usually is conducted by formal lectures, a type of education discarded in this country fifty years ago...

...The examinations consist of a multiple-choice medical test and an English-language test...

...There are also cultural barriers, particularly in the case of doctors from such areas as the Far East and Southeast Asia...

...But is it in any sense defensible that our rich nation should depend on foreign graduates to meet its own immediate needs for medical manpower...

...Leroy E. Burney, Surgeon General of the U.S...

...But unless the supply of medical school graduates is stepped up beyond anything now contemplated, the average doctor will soon be working from sixty-five to seventy-five hours a week...

...In order to understand the background of this controversy, we must get some idea of the conflicting motivations at play...

...Relatively few of the doctors coming here are from Western Europe or England, where standards of medical education are not far behind our own...

...The average physician now works sixty hours a week and sees more than twenty patients a day...

...The proportion of doctors engaged in private practice has dropped from eighty-six to sixty-nine per cent in the past thirty years...

...The critical nature of this need has long been common knowledge among authorities in the health field...

...The test questions have been devised by a group of prominent medical school teachers and are patterned after those given to American-trained medical graduates by the National Board of Medical Examiners...

...The Russians have been outdistancing us not only in space propulsion but also in the training of medical personnel...

...And the hospitalization rate has jumped three times since 1940...

...The need for safeguards so that the United States will not become a dumping ground for poorly trained doctors is underscored by the sad state of medical education in many parts of the world...

...This has been happening while a variety of factors has combined to build up the demand for medical and hospital care...

...Medical training is far more protracted and expensive than that for any other profession...

...Graduates of schools in the latter category unfortunately predominate among those who have flocked to this country...

...The bulk of the visiting physicians have come from the Philippine Islands, Mexico, Turkey, India, Iran, Korea, Greece, Japan, Spain, Brazil, Argentina, Cuba, Peru, Colombia, and the Dominican Republic...

...Nearly half of these, furthermore, are specialists...

...Ten years ago, there were 143.4 doctors, including osteopaths, for every 100,000 Americans...

...Among these factors have been the steady rise in our standard of living and educational level, the phenomenal expansion of health insurance, and the constant increase in the number of older people, who are the most prone to the chronic diseases and thus require the most medical care...

...Why are so many foreign-trained doctors coming here...

...The result has been that family income is increasingly playing a key role in the decision to enter medicine...

...In the storm which subsequently erupted over whether the drastic surgery might have been averted, the hospital involved conceded that there had been a delay of twenty-three minutes in answering the emergency call, and that the intern had failed to take along his kit of medical instruments or an anesthetic...

...Coming from social environments radically different from ours, these physicians can hardly be expected to display the understanding of their patients' problems so important in medical treatment...

...If the country's future needs for skilled medical manpower are to be met, substantial Federal aid also is needed to provide both loans and scholarships for eligible students not otherwise able to afford a medical education...

...Not only has the overall supply of physicians fallen far behind the sharp rise in population and demand, but more and more doctors are going into teaching, research, hospital practice, public health work, and industrial and military medicine...

...The result is that there are now only ninety-one physicians in private practice per 100,000 persons...

...The trouble is, however, that no such large-scale expansion can take place without massive Federal aid...

...Green's leg was amputated on the spot by an Indian intern who used a pocket knife borrowed from a policeman...

...Our schools of medicine and osteopathy are currently turning out about 7,500 graduates a year...

...It has been building up for years as the output of our medical schools has failed to keep pace with population growth, now proceeding at the rate of three million a year, and the steady expansion of demand for medical services and for research personnel...

...Russian doctors are not so well trained as ours are...

...There are unquestionably many fine foreign medical schools...

...It is true that the AMA must bear much of the responsibility for the shortage of doctors that has forced American hospitals to recruit many of their interns and residents from abroad...

...The proportion of general practitioners—the first line of defense against illness— has declined by more than forty per cent since 1930, so that there is at present only one family doctor for every 1,600 people...

...While some scholarship aid is available, grants are generally lower than those offered for graduate work in other professional fields...

...It is reported there are now 180 Soviet physicians per 100,000 population as against a ratio of fewer than 141 in this country, and the figure planned by the Russians for 1965 is 220 physicians for every 100,000 persons...

...So loud was the new outburst of protests from hospitals and from the foreign physicians themselves—some of whom have charged, without a scintilla of evidence, that the tests were rigged to screen them out of the United States and thus prevent them from competing with American-trained doctors—that still another reprieve was granted...

...Now the ratio is 140.7...

...More than half of the 1959 medical graduates wound up in debt, seventeen per cent of them for more than $5,000...

...training is to enable them to do a better job when they go back to their native lands...

...But authoritative opinion is that there are also many poor ones, some of them little more than diploma mills...

...The problem of the widening gap between our supply of physicians and the need for their services clearly cannot be met by importing ill-trained foreign doctors...

...But in view of organized medicine's record of limiting its professional ranks, there is reason to suspect the motives behind the official line that Federal aid for the expansion and operation of medical schools would lead to undue government interference and an impairment of standards...

...These are no longer major problems here, and we emphasize degenerative diseases of the elderly, such as cancer, heart and arterial ailments...

...But this by no means stilled the protests...

...That's terribly wrong...

...At the present rate of training, there will be only 133 by 1975...

...The skimpy training of some of these doctors was dramatically pinpointed in November, 1959, when Martyn Green, famed British star of Gilbert and Sullivan operettas, crushed one of his legs in an elevator accident in New York City...

...Of these, 3,222 passed with grades of 75 or better and thereby gained the right to remain in the United States for five years...

...Ten years ago American hospitals employed on their house staffs fewer than 2,000 graduates of foreign medical schools...

...There has been increasing awareness of the value of medical care and increasing ability to pay for it...

...An additional 2,084 received grades of 70 to 74, qualifying them to stay here for two more years and to have another chance at the tests for longer extension of their visas...

...But it is an indisputable fact that many doctors are overworked—their crowded offices and general reluctance to make home and night calls are ample evidence that there are not enough of them...

...But nothing has so forcefully focused general public attention on its urgency as has the controversy over the influx of thousands of foreign-trained physicians into the United States in recent years...

...In the meantime, a heated controversy was building up over the requirements for certification of alien physicians established by the American Medical Association and several other professional organizations...

...On the contrary, we should be in a position to send more of our physicians to countries that need assistance in developing their medical education programs...

...Several official study commissions have concluded that from fourteen to twenty new medical schools will have to be provided within the next ten years if the present doctor-population ratio is not to slide still further...

...Today the figure is fifty-six, and it will be down to fifty by 1975 unless there is a broad expansion of dental school capacity...

...Medical schools in many countries," Dr...

...The language barrier alone can become a danger to human life...

...The only difference, according to the Council, is that the questions "are selected as being least likely to confuse those whose command of English is somewhat limited...

...But so high was the rate of failures in the first series of tests that the organizations sponsoring the Educational Council for Foreign Medical Graduates decided that hospitals must stop employing uncertified staff members by last July 1 or face loss of their accreditation...

...It is true that greatly improved diagnostic and therapeutic techniques have raised the efficiency of medical care and enable the average physician to handle more patients...

...Because of growing concern over the qualifications of some of the alien physicians, it was decided in 1958 that the visitors should be required to pass examinations as a condition of being allowed to continue to stay in the United States and to hold their hospital posts...

...He is the winner of the Associated Press Managing Editors Association Award for his series of articles on the problems of the aged...

...But some foreign schools have classes ten times as large as ours—far too large for good training...

...To pay the high tuition—which nevertheless fails to come anywhere near meeting the cost of training—and for other essential expenses, the average unmarried medical student now needs $2,400 a year...

...Lamar Soutter, dean of the Boston University School of Medicine, recently told me...

...Some of them admit as many as 1,600 freshmen...