MEDICINE AND PUBLIC ISSUES
Health Manpower: Numbers, Distribution, Quality ROBERT G. PETERSDORF,
M.D., F.A.C.P., Seattle, Washington
Although the "health care crisis" was thought solvable by simply increasing the number of physicians, this has turned out not to be the case. The major problems in physician manpower are geographic maldistribution with a sparsity of physicians in the rural areas and the inner city and an overproduction of specialists. Certain changes in undergraduate and postgraduate medical education have contributed to this maldistribution. There is good evidence that there is an overproduction of surgeons and of medical subspecialists such as cardiologists. Much of the excess subspecialization can be laid at the foot of graduate training programs. The role of the specialty boards in affecting career choices and with them health manpower is analyzed. Some solutions to solve the geographic and specialty maldistribution problems are suggested. It is clear that more primary care physicians including general internists, family physicians, and pediatricians are needed.
FOR NEARLY A DECADE, the term "health care crisis" has
been bandied about in the United States. The crisis has been defined in various ways: a comparatively high infant mortality rate; failure to extend our normal lifespan to that in a number of other Western countries; and an unacceptably high mortality rate for heart disease, cancer, cerebrovascular accidents and hypertension, and several other diseases. Patients define the health care crisis more in terms of lack of personal service, like being unable to get the services of a physician at night or on weekends; long waits in the office; and high costs that are unaffordable. Although these claims have been disputed, they are all true, at least in part. Less disputable, however, is the inaccessibility to care for many persons in the rural population and even more in the central cities. For many years the remedy for our ailing medical services was thought to be the production of more physicians. This goal was based on the reports of many commissions, advisory bodies, and task forces that had studied the problem during the forties and fifties. In 1969, the claim that 50 000 more physicians would be needed and should be trained by 1980 was put forward by the then assistant secretary for health, and was echoed both by the American Medical Association and the Association of • From the Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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American Medical Colleges. At that time few recognized that simply training more physicians was not the answer because the problem was one of maldistribution rather than absolute shortage. Maldistribution had two forms: maldistribution by location and maldistribution by specialty. Moreover, it seemed reasonable to postulate that with new technology and increasing numbers of non-M.D. health professionals, the productivity of physicians was likely to increase. Finally, only a few pointed out that the usual laws of supply and demand do not apply to physicians because supply begets demand. In other words, availability of a greater number of physicians would increase demands for more health services regardless of need. The Physician-Population Ratio
Despite these early warnings, the numbers game prevailed. Indeed, some of the statistics were persuasive. For example, it was shown that the United States ranked only tenth in the world in the number of physicians per hundred thousand population; our ratio of approximately 150 per hundred thousand was far below that of Israel, Russia, Bulgaria, Italy, and even Argentina ( 1 ) . No wonder we had a health care crisis! What was not appreciated, of course, was that the 10 countries with the leading physicianto-population ratios had health care statistics no better than those in the United States. As a matter of fact, the Netherlands with a physician-to-population ratio of 117 per hundred thousand has had better mortality statistics than countries with nearly twice as many physicians for the same population. The lack of correlation between the number of physicians and the quality of health care is reinforced by the disparity between physician-to-population ratios in several regions in the United States. The Middle Atlantic states have a higher physician per population ratio than any other region ( 1 ) . Yet there is no evidence that the infant mortality rate, general mortality rate, or morbidity rate for chronic diseases is any lower in that region than in the Rocky Mountain area where the physician to population ratio is considerably lower. The same argument can be put in historical terms. In 1900, there were 157 physicians per hundred thousand population in the United States, a ratio comparable to that at present. Moreover, the overall mortality rate has fallen to half the level in 1900. This is not difficult to understand but the data emphasize that the quality of medical care and of health Annals of Internal Medicine 82:694-701, 1975
may have little relation to the number of physicians. Other factors also invalidate the physician-to-population ratio as a simple index to quality of care. These include the basic health of the population, the changing characteristics of some illnesses, and the crossover of both physicians and patients from one neighboring region to another. For example, in the state of Washington, certain counties are said to have very low physician-to-population ratios while their neighboring counties have many more physicians. What happens, of course, is that the patients in the low-ratio counties can easily cross county lines to get health care. The issue may be summarized by saying that the physician-to-population ratio is one of the more fallacious health-care indexes to which we have been subjected. Factors Increasing the Number of Physicians
Despite the strength of these arguments that not all problems in health care could be solved by recruiting and educating more physicians, increasing the number became the modus operandi of the past several years. If the goal of 50 000 more physicians by 1980 were to be attained, it would mean that the physician-to-population ratio would rise to close to 200 per hundred thousand. A number of immutable forces have continued to increase production of physicians. INCREASE IN MEDICAL SCHOOL CLASS SIZE
The institutions of health care learning have jumped into the fray with both feet. Initially, they accepted the data indicating that there was a genuine shortage of physicians. Subsequently, whether they believed the shortage or not, the capitation grant, which was for many schools essential to financial survival, was tied to increasing class size and forced the schools to augment their class size without regard to need or capability. CHANGES IN THE UNDERGRADUATE CURRICULUM
Not only did medical schools increase the size of their classes, they moved rapidly to change their curricula to attempt to increase the number of physicians. Many simply contracted their curricular offerings into 3 years instead of 4. Others changed their curricula and deleted a significant amount of content that they believed should be offered electively or not at all. The net result was that many schools were able to graduate students in 3 years where formerly 4 years had been required. The gain in numbers was small because it would result in the graduation of only one additional class. CHANGES IN POSTDOCTORAL EDUCATION
While curricula were being curtailed and classes were being increased in size, an additional major change affecting medical education was implemented. This was the abolition of the internship that had been recommended by the Millis Commission some years before ( 2 ) . The intent of this recommendation was reasonable enough. It was aimed at providing a continuum of postgraduate education so that the internship could not be offered standing free from further postdoctoral experience. Presumably, the major benefit of this change would be to do away with
a large number of free-standing internships in community hospitals that were staffed primarily by foreign medical graduates, and whose purpose was more to provide service than education. When this recommendation was accepted, several specialty boards including those for neurology and psychiatry, anesthesiology, obstetrics and gynecology, radiology, urology, and orthopedics determined that they would no longer require the internship for entry into residency training. Their belief was that the type of education previously provided by a rotating internship could be integrated into a total specialty residency program. What has emerged instead is the so called "flexible first year," which is no more and no less than a rotating internship attached to a formal residency program. The total number of subspecialty residents has not decreased; in fact, there has been appreciable expansion of many specialty programs. Moreover, the loss of free-standing internships has decreased the number of general practitioners, at least until training programs in family practice graduate enough of their trainees to redress this imbalance. These three alterations in undergraduate and postgraduate medical education are combining to loose a greater number of individuals into the physician manpower pool. It has become clear, however, that the major problem in physician manpower is not the number of physicians but their maldistribution. Maldistribution of physicians has occurred in two dimensions: geographic and professional. Geographic Maldistribution
The problem of geographic maldistribution, in turn, may be divided into two sets: rural and urban. Clearly, rural communities have had considerable difficulty in attracting physicians. The reasons for this are difficult to ascertain. Most physicians choose not to settle in rural areas because the lifestyle there is foreign to them, most of them having not grown up in rural America. There is also a great tendency for young physicians to settle in the cities because of the opportunities for professional stimulation— imagined or real. Many young physicians have a great desire to practice in a community that has a medical school, often the one in which they took the M.D. degree and postgraduate training. The fact that many of them do not interact with the medical school very meaningfully after they go into practice does not seem to enter into the decision. In rural Washington State, for example, there can be more interaction between the medical school and rural physicians (through a mechanism such as WAMI*) or special preceptorships, than between medical schools and urban physicians ( 3 ) . The physician's wife often objects to settling in a rural community. Whatever the reasons, until recently it has been difficult to recruit physicians to rural communities, and most attempts to do so, including subsidization of medical education (with a payback clause) have been unsuccessful. In fact, in some * WAMI (Washington/Alaska/Montana/Idaho) is the acronym for a medical education consortium in which part of the clinical curriculum is taught in community clinical units, by residents assigned to these units and clinical faculty practicing in the community. The community clinical units are generally located in small rural areas. The purpose of the program is to attract physician-trainees and residents to eventually settle in these areas. Petersdorf
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payback programs, many physicians have chosen to repay loans in preference to settling in rural areas. The problem of inducing physicians to practice in center cities is even more complex. In many instances, the lack of modern facilities, inadequate budgetary support, unavailability of other health professionals, and other deficits combine to make this type of practice unattractive. Personal safety of the physician and his staff is a risk. Perhaps most important is the objection of many physicians to trying to care for patients whose social mores lead them to reject the standards of health care that the physicians are trying to promulgate. The problem of rural and urban maldistribution may not be solvable within a social structure that permits free movement of physicians. Moreover, there is some evidence, at least, that health standards in rural America, where the physician-to-population ratio is relatively low, are often better and certainly no worse than in locations that are amply served by physicians ( 1 ) . Maldistribution of Physicians by Specialties
During the past 25 years too many specialists have been trained in the U.S. while the training of primary care physicians has lagged. Recent figures are that the United States has 54 000 generalists and 216 000 specialists exclusive of housestaff and fellows ( 4 ) . Such figures are open to debate because internists and pediatricians, who, to a large extent, render primary care, are classified as specialists. Nevertheless, the available data confirm the contention that we are training more specialists than we need and not nearly enough primary care physicians. The best information available on the excess of specialists has been gathered for surgery and its specialties in the SOSSUS (Study of Surgical Specialties in the United States) ( 5 ) . This study has shown quite clearly that we have an excess of general surgeons as well as of surgical subspecialists. The surgical study gains credibility from the fact that it was conducted by surgical societies themselves. It indicates that not only are too many surgeons being certified by the American Boards of Surgery, Neurosurgery, Ophthalmology, Orthopedics, Obstetrics and Gynecology, Thoracic Surgery, and Plastic Surgery, but that there are in addition to the nearly 47 000 board certified surgeons, 23 500 non-board certified surgeons, 9000 general practitioners, and 1000 osteopaths doing surgery. This means that in this country alone there are about 70 000 full-time and 10 000 part-time surgeons. The problem is complicated further by the large influx of foreign medical graduates into surgical specialties. Foreign medical graduates comprise 17% of all physicians in this country and 14% of all surgeons. The percentage on house-staffs and still in training is even higher. Seventy-five percent of foreign medical graduates who come to this country and 2 1 % of present surgical residents in this country are foreign medical graduates who will remain here. Of the 2000 foreign medical graduates that come to the United States each year in surgery, 1500 remain as surgeons. Four hundred of these become board certified and 700 who are not certified do surgery. The data may be projected to mean that if the present trends continue, there will be a large 696
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surfeit of surgeons in this country for many years to come. Regional Implications of Over-Specialization
Clawson, Bennett, and Steen (6) at the University of Washington attempted an analysis of the number of specialists in the Pacific Northwest. They derived data from existing practitioners in the state of Washington and the WAMI states of Alaska, Montana, and Idaho. They then projected the need for specialists on the basis of the experience in prepaid health care programs: Kaiser Permanente of Southern California, Kaiser Permanente of Northern California, and Group Health Cooperative of Puget Sound. For the state of Washington and the WAMI region, they made the following observations: 1. There is no deficit in the number of primary care specialists; that is, internists, family practitioners, and pediatricians. There also appears to be an adequate number of obstetricians and gynecologists. 2. There is a marked excess of general surgeons right now; this excess will be accentuated by the number of surgeons being trained. 3. Similarly, there is a considerable surplus of neurosurgeons, ophthalmologists, orthopedists, and urologists. Of the surgical subspecialties, only otorhinolaryngology is not in excess now although it will likely become so in the future. 4. Future projections are based on the premise that among the various factors that affect the location of the specialist, the place where he has taken his residency is most important. In the WAMI region, for example, 5 3 % of specialists have been trained in residencies in the region. The site of residency training is considerably more important than the place of birth of the resident (there is little correlation between an individual's place of origin and whether he chooses to practice there) or the place where he went to medical school. An additional factor enters into the picture: in certain states, such as Washington, there is a greater in-migration of specialists than an egress of trainees. In other words, even if all residency programs in the state of Washington were abolished, there would probably still be an appreciable influx of specialists. Thus, if the number of specialists is to be curtailed through control of residency programs, such a scheme is workable only nationally. 5. There is a small deficit of physiatrists in the Northwest region but this should be corrected shortly. Psychiatrists are still in considerable demand, but no more neurologists are needed and dermatologists seem to be in adequate supply. 6. The "service" specialties—pathology, radiology, and anesthesiology—have a considerable excess. Whether or not one considers the number of anesthesiologists excessive depends on whether nurse anesthetists are counted along with physician specialists. While there may be some fault with using prepaid health care systems to judge the need for specialists, this kind of information has considerably more credibility than specialty needs as defined by residency program directors of specialty boards. For example, before the study referred to above, every residency program director of a surgical
specialty indicated a need for more individuals to be trained in his specialty ( 6 ) . An example of having a specialty board determine physician manpower needs is provided by the recommendation of the American Board of Dermatology. This body projected a major lack of dermatologists. They argued that because approximately 10% to 20% of the diseases seen by a general practitioner or internist have dermatologic implications, 10% to 20% of the physicians trained must be dermatologists ( 1 ) . This kind of reasoning implies, of course, that a specialist is required to see every disease, and its application to medicine in general would result in chaos. The implications of training too many surgeons are quite clear. It has resulted in unnecessary operations and in decreased productivity per surgeon ( 7 ) . In the United Kingdom, for example, there are approximately 50% fewer operations per hundred thousand population than in the United States, and these operations are done by approximately 2 5 % the number of surgeons. In other words, each surgeon in the U.K. is approximately twice as productive as is his counterpart in the United States. In the city of Oxford, with a population of 300 000, there are two thoracic surgeons; both are busy but neither is stressed. Moreover, it is likely that most of the excess surgery done in the United States consists of hysterectomies, tonsillectomies, herniorrhaphies, and hemorrhoidectomies. There is painfully little evidence that this type of surgery has improved the general health of the population. Nor should all the rocks be cast at the surgical fraternity. Indeed, they should be congratulated for doing the health manpower study that has clearly indicated to them that they are producing an excessive number of surgeons. Unfortunately, the medical subspecialties have not yet conducted a similar study. However, it is quite clear that, particularly in the attractive urban population centers, the number of medical subspecialists far exceeds the need. The proliferation of subspecialists is a direct consequence of the marked increase in subspecialty training offered by departments of medicine. They have been stimulated by the training programs of the National Institutes of Health which, though intended for research training, served in many instances to support clinical training programs. A study of manpower training and resources in cardiology has been completed recently ( 8 ) . The following data came to light: 1. There are 329 programs offering advanced training in cardiology in approved hospitals in this country. During 1972 and 73, 1278 trainees were enrolled in these programs and 791 completed their training. The number may actually be larger because of trainees completing their training in nonapproved hospitals and those who take additional training (such as residency) outside cardiology programs. 2. As might be expected, graduating trainees practice close to where they trained. 3. A large part of the training is devoted to laboratory diagnostic methods, including angiography and cardiac catheterization. 4. Nearly 4000 full-time equivalent professional staff are engaged in the training of cardiologists, and some
programs expressed a need for more faculty. 5. The average training program did 555 angiograms and 368 cardiac catheterizations per year. Although this report does not comment on the need for additional physicians in cardiology, it is difficult not to conclude that the disgorging of 1000 cardiologists per year into the health manpower pool is excessive. Moreover, most of the cardiology training has been "catheteroriented" and the products of these training programs have prided themselves on their diagnostic expertise using modern technology. These modern cardiologists may be doing cardiac catheterizations and coronary angiograms far in excess of needs for their use. Of course, the proliferation of cardiovascular surgeons has resulted in further excessive use of invasive cardiologic techniques. In the city of Seattle, which draws from a population of approximately 1.25 million people, there are no fewer than five cardiac surgical teams. Each of these is supported by a diagnostic cardiology laboratory. Even in smaller cities in the state of Washington, where the populations barely approximate 100 000, facilities for cardiac catheterization are being planned and cardiac surgeons are planning to set up shop. The inevitable results of such developments is an excessive number of diagnostic cardiologic procedures and an excessive amount of cardiac surgery, both of which have contributed to the marked acceleration in health care costs. It is well known that the proliferation of subspecialists generates an increased demand for health services whether the services are indicated or not. Again, it is easy to point the finger at cardiology because one can easily identify the effects of having a progressively greater number of cardiologists (and, by implication, cardiovascular surgeons) in the community. However, other specialties in medicine have also produced to excess. In Seattle, for example, there are clearly too many hematologists and there is a steadily increasing number of gastroenterologists. In fact, there is not a single subspecialty of internal medicine, possibly excepting infectious disease, that has not caught on as a subspecialty in practice, that is not overrepresented in most communities that provide attractive living, good hospital facilities, and that have a medical school. While it is not hard to pinpoint the effects of an increasing number of specialists, it is more difficult to find the cause of the steady increase. Simplistically speaking, every man has an innate desire for self-advancement, intellectually and financially. In addition, subspecialists seem to have acquired prestige, particularly in medical schools. More than anything else, however, the structure of training programs in medical schools has led to specialization. The reasons for this are as follows: 1. Residents are providers of health-care services at low cost. Hospitals strongly wish to keep costs in bounds, and it is much easier and cheaper to have a resident provide the help than to hire staff physicians. Thus, up to some point, hospitals are motivated to maintain housestaff programs. 2. In medical schools, residents are the "graduate assistants" of the clinical departments and play an important part in teaching. It would be difficult for clinical departPetersdorf • Health Manpower
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ments to meet their teaching obligations, at least without radically altering them, if they did not have an ample resident staff who provide much of the student-subfaculty contact. 3. For reasons that are more difficult to explain there appears to be a great desire for growth on the part of clinical departments. Inherent in this desire is the attitude of academic departments, as well as hospitals, that consider mounting a residency program a "right" rather than a privilege. 4. Another important factor militating against curtailment of specialty training programs is the very increase in medical school graduates generated by the presumed shortage of physician manpower. As more students are graduated from medical schools, they require and expect the opportunity for graduate training. In most specialties, including family practice, this training is now no shorter than 3 years. Thus more residencies have to be created simply to meet the training needs of our medical school graduates. It can be argued that all of these new residents should be in family practice or some other primary care discipline, but as yet the number of training programs leading to certification by the American Board of Family Practice is inadequate, and even if internal medicine or pediatrics could take up the slack, there would still be the need of paying for these additional residency programs. The problem can be summarized by saying that it is difficult to see that there will be a decrease in the number of specialists as long as there are as many clinical fellowships and residencies as now have to be filled. The decrease in the National Institutes of Health training grants may reduce the number of clinical fellowships. The recently announced fellowship program is aimed at training investigators rather than clinicians, because anyone who takes such a fellowship and who enters practice must repay the stipend. However, consider what a lucrative investment it would be for a future cardiologist to receive 2 years of training, even if he has to repay a total of $20,000 plus interest. The answer to the problem of the excessive number of residency and specialty training programs is a substitution of hospital-based staff physicians for residents in specialties that are overproducing. Initially, this may seem expensive because staff physicians require higher salaries than residents. On the other hand, it may pay off eventually because of increased efficiency. Certainly, the large prepayment health plans recognized this principle long ago; programs such as Group Health Cooperative of Puget Sound, Kaiser Permanente, and others have a very modest investment in training compared to full-time staff. The Role of the Specialty Boards
Clearly the specialty boards have done a great deal to maintain quality of residency training programs. At the same time, they have made certification by a specialty board a major goal and have thereby contributed to the imbalance in physician manpower. The American Board of Internal Medicine, the organization with which I am most familiar, is a case in point. Up until 1970, the American Board of Internal Medicine certified to competence 698
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in general internal medicine through a two-stage examination system. The first stage, a written examination, was given at the completion of 4 years of training, at least 2, and usually 3, of which had to be in general internal medicine. Formerly, two additional years of practice or other experience were required before a candidate was permitted to take the examination. In other words, a compulsory period of 6 years of post-M.D. training or experience, or both, was the minimum time that could elapse between the granting of the M.D. degree and the passing of the written examination. Once the written examination was passed, the candidate took an oral examination during the ensuing year. In this examination, he was tested as a "consultant in general internal medicine." Specifically, he was required to examine two patients that were outside the subspecialty of internal medicine in which he had special training and was examined by two examiners outside their own subspecialty. In 1968, the Board analyzed the results of its examination process and found that while the written examination had a good deal of reliability and statistical validity, there was poor correlation in grades between the written and oral examinations. Moreover, there were many differences in grading between examiners on the oral examination. The lack of statistical reliability (along with the logistic problems encountered in mounting oral examinations because of the ever-increasing number of candidates) resulted in the abolition of the oral examination. While the Board was making this decision, it was also confronted with the apparent shortage of physicians. To counter this challenge, it considered an earlier certification of physicians and attempted to steer them toward the practice of general internal medicine. Therefore, the Board decided to permit certification in internal medicine after only 3 years of training. For most candidates, this training would consist of 3 years of general internal medicine; for some only 2 years of medicine and a year of a clinical subspecialty was required. When the Board made this change, it recognized that many of its candidates were, in fact, trained in a subspecialty. In the past, some of the candidates who had advanced training in cardiology, allergy and immunology, pulmonary disease, or gastroenterology went on to take Board examinations in these subspecialties. Recognizing that many persons were training in subspecialties other than the four that had been recognized by the creation of official subspecialty Boards, the Board set up specialty examination committees in hematology, infectious disease, endocrinology, nephrology, rheumatology, and oncology. A candidate was required to have 2 years of training in one of these specialties in order to sit for a subspecialty examination. The subspecialty examination would be taken by most candidates after 5 years of training (3 in internal medicine followed by successful completion of the Certifying Examination and 2 in a subspecialty) and in some instances, after 4 years, 2 years of internal medicine and 2 years of subspecialty. Thus, some candidates could be certified in medicine at the end of the third year following the M.D. degree and in a subspecialty at the end of the fourth year. This second tier of examinations was created to ac-
knowledge the training patterns of present day candidates, most of whom took 1 or 2 years of subspecialty training after 2 or 3 years in general internal medicine. A beneficial side effect of the second tier was that specialty training programs would have to be standardized and that internists would have to have training in institutions deemed to be competent in specialty training for at least a 2-year period before being permitted to be certified in the subspecialty. At the same time, the Board hoped that many candidates would seek no training beyond the initial 3 years of general internal medicine and would, after they were certified, wish to practice "primary care" or general internal medicine. Unfortunately, this hope has not been realized. The subspecialty certification system has tended to drive candidates to further subspecialty training followed by examination. As a matter of fact, there are now some candidates who want to take examinations in more than one subspecialty. The Role of the Medical Schools in Promoting Specialization
Unfortunately, the structure of our postdoctoral training programs in medical schools also promotes subspecialty rather than general training. In departments of medicine, for example, there is a great emphasis on subspecialty medicine; few of our best academic departments have strong programs in general medicine. Thus, the house officers have difficulty in finding appropriate role models of general internists in academic departments. Moreover, the postgraduate curricula in general internal medicine are weak when compared to subspecialty medicine. For example, a resident in cardiology receives experience in reading electrocardiograms, interpreting cardiac catheterization data, doing exercise tests, doing various noninvasive diagnostic procedures, inserting pacemakers, and learning the many other skills of a modern cardiologist. However, how often do programs designed to train general internists include exposure to office gynecology, otorhinolaryngology, psychiatry, adolescent medicine, and community medicine? This weakness in training programs in primary care internal medicine is largely due to the lack of appropriate faculty for teaching general internal medicine. This lack in turn has resulted in failure to design the most appropriate training programs for general internists. A number of chairmen of departments of medicine have attempted to create divisions of ambulatory medicine or general medicine. However, once faculty for these divisions have been recruited, it has been difficult to retain them within the system, to offer them the financial rewards that they would earn in practice, or the academic rewards that come more easily to specialists and, particularly, to clinical investigators. Certain programs such as the Clinical Scholars Program of the Johnson Foundation are attempting to correct these difficulties, but it will be some years before general internal medicine will attain its appropriate role in full-time academic departments. However, this development is absolutely vital for recruitment of the young physicians who must be the general "primary care" internists of the future. The reason for the drive for specialization in internal medicine is not entirely clear. In part, the motivation stems
from the fear that it would be disadvantageous in the future to be certified only as a general internist and not as a subspecialist. With government medicine in the offing, the expectation is that subspecialists will be paid more for their services than general internists. It must be clear, however, that the need in internal medicine is not for more subspecialists. Rather, it is for well-trained general internists who can render primary care to the adult population. This means that the financial rewards for primary care physicians must be at a level equal to that for subspecialists. Factors Affecting the Quality of Postgraduate Education Postgraduate medical education depends, of course, in part on undergraduate medical education. Whether the quality of undergraduate education is improving, or whether it is deteriorating, is a matter of debate. Certainly, students now entering medical school are, in general, better than their predecessors. Many have had a superb science education in high school and in college. They appear to have better grade point averages and MCAT scores than ever before. Partly, perhaps because of the belief that premedical education is much better today than in the past, the scientific content of the medical school curriculum has been abbreviated, and in many schools the curriculum has been shortened from 4 years to 3. While this in-vogue type of curricular innovation has been to the advantage of a few extraordinarily bright students, the average student has had more than his share of trouble coping with the material presented. Perhaps this is the fault of the faculties who have been quite willing to cut the time given to the curriculum without altering the content. While it is difficult to judge the performance of medical students objectively, the only criterion that is available is the scores on the examinations of the National Board of Medical Examiners. When these are examined, the performance of students in many medical schools clearly has deteriorated. It has been argued that this reflects curricular change more than the quality of medical education or the quality of the students. My bias is that the quality of medical education is depreciating mainly because so little time is now allotted to it. Most medical students need 4 rather than 3 years to grow into medicine; a number of students who have done poorly on my clerkship in medicine have more than doubled the quality of their performance by simply repeating the clerkship and thereby getting additional exposure to the material presented. A second factor that will unquestionably affect the quality of physicians, if not as specialists but as broadbased physicians, is the abolition of the internship. The recommendation of the Millis Commission to abolish the internship, while well intentioned, is turning out to be the Gulf of Tonkin Resolution of medical education. Certainly from the point of view of quality of the practitioner, a surgeon who has had some postgraduate training in medicine or pediatrics, or both, is likely to be a better surgeon —at least in judgment—than one who has not. This may be even more true for psychiatric training. Indeed, a good medical, rotating, or mixed internship may be the last exposure to physiological medicine that psychiatric trainees receive! Petersdorf • Health Manpower
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A third factor that will affect the quality of medicine is the accreditation procedures in the medical specialties. Certainly the Residency Review Committee is doing an admirable job in eliminating second-rate residency training programs and in upgrading the ones that are in existence. However, this type of review is not available for programs in the medical subspecialties and in most subspecialties of pediatrics. In other words, there are many subspecialty programs that are not accredited at all. Particularly with the present surfeit of medical specialists, it seems vital that programs approved for medical specialty training be high in quality. Unfortunately, this is not always the case. However, the quality of postgraduate medical education has not deteriorated badly, if at all. For every weak program still in existence, newer and stronger programs are being created. In particular, the upgrading of residency training in family practice must be singled out. The Board of Family Practice has been a major force in upgrading the quality of postgraduate education in that ever-growing specialty. The problem, then, is not so much the quality of the educational process but the system that turns out an excessive number of subspecialists often at the expense of training primary care physicians, and that has not found the answer to distributing its physicians in locations where they are most needed.
Some Possible Solutions
While there are some trends in undergraduate medical education that might compromise the quality of medical graduates, there is little evidence that the quality of the post-M.D. educational process is deteriorating or that, in general, its quality control is faulty. Of the two major problems geographic maldistribution and overspecialization, that of geographic maldistribution defies easy solution. In a free society, and one that is mobile, the only way in which physicians can be induced to go into rural areas is by their own motivation. Certainly, the spectre of not being able to make a living in the cities with large physician populations or the suburbs that are becoming equally overpopulated with doctors may deter some from settling in these locations. However, the law of supply and demand does not apply to physicians. Even in areas that are patently overcrowded, there always seems to be room for at least one more competent doctor. Perhaps one way to improve the lot of the rural physician, or the one in the urban ghetto, is to offer financial inducements. So far, this method has not been very effective. Perhaps the guarantee of programmed postgraduate education for physicians settling in high-need areas would be more attractive. A program could be devised, for example, in which physicians practicing in rural areas would spend at least 2 to 3 days a month engaged in postgraduate education in a major medical center. This might be augmented by periodic stays of longer duration. Improved communications in terms of televised consultations and televised postgraduate courses might further augment the contact between the rural physician and his colleague in the medical center. This type of postgraduate educational 700
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network would require a massive effort and would cost a lot of money. Conceivably, if young medical graduates, most of whom are trained in urban settings and who have become accustomed to them, can be kept in contact with these settings, they would agree to settle in rural areas. Similar opportunities for continuing education must be provided to physicians working in center cities. The alternative, of course, would be to completely nationalize medical personnel and to assign them to posts where they are needed. In a sense, this would put our health care system on a paramilitary footing, and even countries with a totally nationalized health system such as the United Kingdom have not adopted this approach. In fact, even in the United Kingdom, the geographic maldistribution problem has not been solved and many foreign medical graduates populate the rural hospitals in the British Midlands. The issue of maldistribution by specialties also does not lend itself to easy solution but here, at least, we know what needs to be done. The steps to be taken may be summarized as follows: 1. Residency programs must be reduced in number, and the number of graduates of residency programs in overpopulated specialties must be decreased below the rate of attrition until some reasonable balance is achieved. 2. Likewise, specialty training programs need to be curtailed. In academic medical centers, this means that, in the future, specialty consultations and teaching will have to be rendered more by faculty than by fellows. Fellowships should, in general, be reserved for research and not clinical training. 3. In many specialties, the curtailment of training programs will require the hiring of additional full-time staff to render necessary services. While this will initially escalate the cost, in the long run it is the only way to balance the system. In other words, residents must not be used as underpriced labor to provide service. 4. Programs in internal medicine must be restructured so that after the graduates of our programs complete 3 and in some instances 4 years of training, they will be more prepared to practice "primary care" internal medicine than "consultative" internal medicine. It is quite clear that the medical consultant of the future will not be the general internist but the subspecialist. It should be recognized, however, that subspecialty consultations will be needed for only the minority of patients and for these most patients can readily be referred by their family practitioner or primary care internist. 5. While it is desirable that the profession itself police the number of residents and specialty trainees that it produces, my dyspeptic view of the situation is that it will not do so and that we will have to come closer to the modus operandi in the United Kingdom. There, under the National Health Service, the production of specialists has been rigidly controlled by two mechanisms: (a) The number of registrar (residency) positions available in the several specialties is set according to the needs for conconsultants (practitioners) in the specialties. For example, in the field of cardiology, there are very few open registrar positions because there is at this time no great need
for consultant cardiologists. On the other hand, there is still a dearth of anesthesiologists in the United Kingdom and hence it is not too difficult to land a registrar position as an anesthesiologist, (b.) The number of consultant positions is controlled. These positions are offered in parallel to the number of registrar positions. Thus, there are comparatively few new consultant posts being created in cardiology but a moderate number are still being provided in anesthesiology. Because consultant posts are created only in relation to hospital practice, in many instances they are made available only in the comparatively less desirable areas, thus correcting to some extent the problem of geographic maldistribution. In other words, if a man wants to be a consultant in cardiology, he is likely to have to settle in a less desirable community than if he wants to be a consultant in anesthesiology. A byproduct of this system is that a large number of young physicians go into general practice after a year or 2 of training after medical school. They do not want to undergo the long training periods and waits that are inherent in subspecialization with its long-term goal of a consultant post. Instead, they opt for general practice. Moreover, the National Health Service has gone to great pains to make general practice as attractive as specialty practice. The general practitioners in the United Kingdom begin to earn a living much earlier in their careers than their counterparts who prefer to go into specialties. Even after they complete their training and obtain their definitive posts, consultants earn not much more than general practitioners. Thus, the economic incentive that has driven young physicians into the specialties has to a large extent been abolished. These controls do not seem to be unduly oppressive to graduates of British medical schools. About a decade ago, the U.K. had many more registrars than consultant posts available. When a man finished several years as registrar and was unable to find a position, he often emigrated. In recent years, however, the imbalance between registrar and consultant positions has been corrected and much of the
dissatisfaction with the system has been dissipated. It seems likely that some variant of this system will be the only one that will control production of specialists in the United States. Our Goal We should aim to make the practice of primary care medicine—whether it be by family practitioners, general internists, or pediatricians—as attractive, prestigious and rewarding as subspecialty practice. This should be the major goal of medical schools, professional organizations, accrediting bodies, and government. If it can be reached, many of our health manpower problems will be relieved. ACKNOWLEDGMENTS: This paper was prepared for a Commission on Future Physicians sponsored by the Macy Foundation and is reproduced with the permission of the Foundation. Received 19 September 1974; revision accepted 3 January 1975. • Reprint requests should be addressed to Robert G. Petersdorf, M.D., Chairman, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195. References 1. SENIOR B, SMITH BA: The number of physicians as a constraint on delivery of health care. JAMA 222:178-183, 1972 2. CITIZENS COMMISSION ON GRADUATE MEDICAL EDUCATION: The
Graduate Education of Physicians. Chicago, American Medical Association, 1966 3. Report to the Dean of the University of Washington School of Medicine: An Evaluation of the Need for Increased Medical Student Enrollment at the University of Washington. 29 June 1973 4. BEESON PB: Some good features of the British National Health Service. / Med Ed 49:43-49, 1974 5. MOORE FD, BOYDEN CM, SABISTON D, et al: The production,
attrition, and biologic life-time of surgeons in relation to the population of the United States: a look into the future through the clouded computer crystal. Ann Surg 176:457-468, 1972 6. CLAWSON DK, BENNETT RL, STEEN MK: Planning
Residency
Programs Based on Physician Projections. A paper presented to the American Medical Association Symposium on Distribution of Health Manpower, San Francisco, 17 June 1972 7. BUNKER JP: Surgical manpower: a comparison of operations and surgeons in the United States and in England and Wales. N Engl J Med 282:135-144, 1970 8. ADAMS FH, MENDENHALL RC (editors): Evaluation of cardiology training and manpower requirements. Publication (NIH) 74-623. DHEW, 1974
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Health Manpower: Numbers, Distribution, Quality ROBERT G. PETERSDORF,
M.D., F.A.C.P., Seattle, Washington
Although the "health care crisis" was thought solvable by simply increasing the number of physicians, this has turned out not to be the case. The major problems in physician manpower are geographic maldistribution with a sparsity of physicians in the rural areas and the inner city and an overproduction of specialists. Certain changes in undergraduate and postgraduate medical education have contributed to this maldistribution. There is good evidence that there is an overproduction of surgeons and of medical subspecialists such as cardiologists. Much of the excess subspecialization can be laid at the foot of graduate training programs. The role of the specialty boards in affecting career choices and with them health manpower is analyzed. Some solutions to solve the geographic and specialty maldistribution problems are suggested. It is clear that more primary care physicians including general internists, family physicians, and pediatricians are needed.
FOR NEARLY A DECADE, the term "health care crisis" has
been bandied about in the United States. The crisis has been defined in various ways: a comparatively high infant mortality rate; failure to extend our normal lifespan to that in a number of other Western countries; and an unacceptably high mortality rate for heart disease, cancer, cerebrovascular accidents and hypertension, and several other diseases. Patients define the health care crisis more in terms of lack of personal service, like being unable to get the services of a physician at night or on weekends; long waits in the office; and high costs that are unaffordable. Although these claims have been disputed, they are all true, at least in part. Less disputable, however, is the inaccessibility to care for many persons in the rural population and even more in the central cities. For many years the remedy for our ailing medical services was thought to be the production of more physicians. This goal was based on the reports of many commissions, advisory bodies, and task forces that had studied the problem during the forties and fifties. In 1969, the claim that 50 000 more physicians would be needed and should be trained by 1980 was put forward by the then assistant secretary for health, and was echoed both by the American Medical Association and the Association of • From the Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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American Medical Colleges. At that time few recognized that simply training more physicians was not the answer because the problem was one of maldistribution rather than absolute shortage. Maldistribution had two forms: maldistribution by location and maldistribution by specialty. Moreover, it seemed reasonable to postulate that with new technology and increasing numbers of non-M.D. health professionals, the productivity of physicians was likely to increase. Finally, only a few pointed out that the usual laws of supply and demand do not apply to physicians because supply begets demand. In other words, availability of a greater number of physicians would increase demands for more health services regardless of need. The Physician-Population Ratio
Despite these early warnings, the numbers game prevailed. Indeed, some of the statistics were persuasive. For example, it was shown that the United States ranked only tenth in the world in the number of physicians per hundred thousand population; our ratio of approximately 150 per hundred thousand was far below that of Israel, Russia, Bulgaria, Italy, and even Argentina ( 1 ) . No wonder we had a health care crisis! What was not appreciated, of course, was that the 10 countries with the leading physicianto-population ratios had health care statistics no better than those in the United States. As a matter of fact, the Netherlands with a physician-to-population ratio of 117 per hundred thousand has had better mortality statistics than countries with nearly twice as many physicians for the same population. The lack of correlation between the number of physicians and the quality of health care is reinforced by the disparity between physician-to-population ratios in several regions in the United States. The Middle Atlantic states have a higher physician per population ratio than any other region ( 1 ) . Yet there is no evidence that the infant mortality rate, general mortality rate, or morbidity rate for chronic diseases is any lower in that region than in the Rocky Mountain area where the physician to population ratio is considerably lower. The same argument can be put in historical terms. In 1900, there were 157 physicians per hundred thousand population in the United States, a ratio comparable to that at present. Moreover, the overall mortality rate has fallen to half the level in 1900. This is not difficult to understand but the data emphasize that the quality of medical care and of health Annals of Internal Medicine 82:694-701, 1975
may have little relation to the number of physicians. Other factors also invalidate the physician-to-population ratio as a simple index to quality of care. These include the basic health of the population, the changing characteristics of some illnesses, and the crossover of both physicians and patients from one neighboring region to another. For example, in the state of Washington, certain counties are said to have very low physician-to-population ratios while their neighboring counties have many more physicians. What happens, of course, is that the patients in the low-ratio counties can easily cross county lines to get health care. The issue may be summarized by saying that the physician-to-population ratio is one of the more fallacious health-care indexes to which we have been subjected. Factors Increasing the Number of Physicians
Despite the strength of these arguments that not all problems in health care could be solved by recruiting and educating more physicians, increasing the number became the modus operandi of the past several years. If the goal of 50 000 more physicians by 1980 were to be attained, it would mean that the physician-to-population ratio would rise to close to 200 per hundred thousand. A number of immutable forces have continued to increase production of physicians. INCREASE IN MEDICAL SCHOOL CLASS SIZE
The institutions of health care learning have jumped into the fray with both feet. Initially, they accepted the data indicating that there was a genuine shortage of physicians. Subsequently, whether they believed the shortage or not, the capitation grant, which was for many schools essential to financial survival, was tied to increasing class size and forced the schools to augment their class size without regard to need or capability. CHANGES IN THE UNDERGRADUATE CURRICULUM
Not only did medical schools increase the size of their classes, they moved rapidly to change their curricula to attempt to increase the number of physicians. Many simply contracted their curricular offerings into 3 years instead of 4. Others changed their curricula and deleted a significant amount of content that they believed should be offered electively or not at all. The net result was that many schools were able to graduate students in 3 years where formerly 4 years had been required. The gain in numbers was small because it would result in the graduation of only one additional class. CHANGES IN POSTDOCTORAL EDUCATION
While curricula were being curtailed and classes were being increased in size, an additional major change affecting medical education was implemented. This was the abolition of the internship that had been recommended by the Millis Commission some years before ( 2 ) . The intent of this recommendation was reasonable enough. It was aimed at providing a continuum of postgraduate education so that the internship could not be offered standing free from further postdoctoral experience. Presumably, the major benefit of this change would be to do away with
a large number of free-standing internships in community hospitals that were staffed primarily by foreign medical graduates, and whose purpose was more to provide service than education. When this recommendation was accepted, several specialty boards including those for neurology and psychiatry, anesthesiology, obstetrics and gynecology, radiology, urology, and orthopedics determined that they would no longer require the internship for entry into residency training. Their belief was that the type of education previously provided by a rotating internship could be integrated into a total specialty residency program. What has emerged instead is the so called "flexible first year," which is no more and no less than a rotating internship attached to a formal residency program. The total number of subspecialty residents has not decreased; in fact, there has been appreciable expansion of many specialty programs. Moreover, the loss of free-standing internships has decreased the number of general practitioners, at least until training programs in family practice graduate enough of their trainees to redress this imbalance. These three alterations in undergraduate and postgraduate medical education are combining to loose a greater number of individuals into the physician manpower pool. It has become clear, however, that the major problem in physician manpower is not the number of physicians but their maldistribution. Maldistribution of physicians has occurred in two dimensions: geographic and professional. Geographic Maldistribution
The problem of geographic maldistribution, in turn, may be divided into two sets: rural and urban. Clearly, rural communities have had considerable difficulty in attracting physicians. The reasons for this are difficult to ascertain. Most physicians choose not to settle in rural areas because the lifestyle there is foreign to them, most of them having not grown up in rural America. There is also a great tendency for young physicians to settle in the cities because of the opportunities for professional stimulation— imagined or real. Many young physicians have a great desire to practice in a community that has a medical school, often the one in which they took the M.D. degree and postgraduate training. The fact that many of them do not interact with the medical school very meaningfully after they go into practice does not seem to enter into the decision. In rural Washington State, for example, there can be more interaction between the medical school and rural physicians (through a mechanism such as WAMI*) or special preceptorships, than between medical schools and urban physicians ( 3 ) . The physician's wife often objects to settling in a rural community. Whatever the reasons, until recently it has been difficult to recruit physicians to rural communities, and most attempts to do so, including subsidization of medical education (with a payback clause) have been unsuccessful. In fact, in some * WAMI (Washington/Alaska/Montana/Idaho) is the acronym for a medical education consortium in which part of the clinical curriculum is taught in community clinical units, by residents assigned to these units and clinical faculty practicing in the community. The community clinical units are generally located in small rural areas. The purpose of the program is to attract physician-trainees and residents to eventually settle in these areas. Petersdorf
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payback programs, many physicians have chosen to repay loans in preference to settling in rural areas. The problem of inducing physicians to practice in center cities is even more complex. In many instances, the lack of modern facilities, inadequate budgetary support, unavailability of other health professionals, and other deficits combine to make this type of practice unattractive. Personal safety of the physician and his staff is a risk. Perhaps most important is the objection of many physicians to trying to care for patients whose social mores lead them to reject the standards of health care that the physicians are trying to promulgate. The problem of rural and urban maldistribution may not be solvable within a social structure that permits free movement of physicians. Moreover, there is some evidence, at least, that health standards in rural America, where the physician-to-population ratio is relatively low, are often better and certainly no worse than in locations that are amply served by physicians ( 1 ) . Maldistribution of Physicians by Specialties
During the past 25 years too many specialists have been trained in the U.S. while the training of primary care physicians has lagged. Recent figures are that the United States has 54 000 generalists and 216 000 specialists exclusive of housestaff and fellows ( 4 ) . Such figures are open to debate because internists and pediatricians, who, to a large extent, render primary care, are classified as specialists. Nevertheless, the available data confirm the contention that we are training more specialists than we need and not nearly enough primary care physicians. The best information available on the excess of specialists has been gathered for surgery and its specialties in the SOSSUS (Study of Surgical Specialties in the United States) ( 5 ) . This study has shown quite clearly that we have an excess of general surgeons as well as of surgical subspecialists. The surgical study gains credibility from the fact that it was conducted by surgical societies themselves. It indicates that not only are too many surgeons being certified by the American Boards of Surgery, Neurosurgery, Ophthalmology, Orthopedics, Obstetrics and Gynecology, Thoracic Surgery, and Plastic Surgery, but that there are in addition to the nearly 47 000 board certified surgeons, 23 500 non-board certified surgeons, 9000 general practitioners, and 1000 osteopaths doing surgery. This means that in this country alone there are about 70 000 full-time and 10 000 part-time surgeons. The problem is complicated further by the large influx of foreign medical graduates into surgical specialties. Foreign medical graduates comprise 17% of all physicians in this country and 14% of all surgeons. The percentage on house-staffs and still in training is even higher. Seventy-five percent of foreign medical graduates who come to this country and 2 1 % of present surgical residents in this country are foreign medical graduates who will remain here. Of the 2000 foreign medical graduates that come to the United States each year in surgery, 1500 remain as surgeons. Four hundred of these become board certified and 700 who are not certified do surgery. The data may be projected to mean that if the present trends continue, there will be a large 696
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surfeit of surgeons in this country for many years to come. Regional Implications of Over-Specialization
Clawson, Bennett, and Steen (6) at the University of Washington attempted an analysis of the number of specialists in the Pacific Northwest. They derived data from existing practitioners in the state of Washington and the WAMI states of Alaska, Montana, and Idaho. They then projected the need for specialists on the basis of the experience in prepaid health care programs: Kaiser Permanente of Southern California, Kaiser Permanente of Northern California, and Group Health Cooperative of Puget Sound. For the state of Washington and the WAMI region, they made the following observations: 1. There is no deficit in the number of primary care specialists; that is, internists, family practitioners, and pediatricians. There also appears to be an adequate number of obstetricians and gynecologists. 2. There is a marked excess of general surgeons right now; this excess will be accentuated by the number of surgeons being trained. 3. Similarly, there is a considerable surplus of neurosurgeons, ophthalmologists, orthopedists, and urologists. Of the surgical subspecialties, only otorhinolaryngology is not in excess now although it will likely become so in the future. 4. Future projections are based on the premise that among the various factors that affect the location of the specialist, the place where he has taken his residency is most important. In the WAMI region, for example, 5 3 % of specialists have been trained in residencies in the region. The site of residency training is considerably more important than the place of birth of the resident (there is little correlation between an individual's place of origin and whether he chooses to practice there) or the place where he went to medical school. An additional factor enters into the picture: in certain states, such as Washington, there is a greater in-migration of specialists than an egress of trainees. In other words, even if all residency programs in the state of Washington were abolished, there would probably still be an appreciable influx of specialists. Thus, if the number of specialists is to be curtailed through control of residency programs, such a scheme is workable only nationally. 5. There is a small deficit of physiatrists in the Northwest region but this should be corrected shortly. Psychiatrists are still in considerable demand, but no more neurologists are needed and dermatologists seem to be in adequate supply. 6. The "service" specialties—pathology, radiology, and anesthesiology—have a considerable excess. Whether or not one considers the number of anesthesiologists excessive depends on whether nurse anesthetists are counted along with physician specialists. While there may be some fault with using prepaid health care systems to judge the need for specialists, this kind of information has considerably more credibility than specialty needs as defined by residency program directors of specialty boards. For example, before the study referred to above, every residency program director of a surgical
specialty indicated a need for more individuals to be trained in his specialty ( 6 ) . An example of having a specialty board determine physician manpower needs is provided by the recommendation of the American Board of Dermatology. This body projected a major lack of dermatologists. They argued that because approximately 10% to 20% of the diseases seen by a general practitioner or internist have dermatologic implications, 10% to 20% of the physicians trained must be dermatologists ( 1 ) . This kind of reasoning implies, of course, that a specialist is required to see every disease, and its application to medicine in general would result in chaos. The implications of training too many surgeons are quite clear. It has resulted in unnecessary operations and in decreased productivity per surgeon ( 7 ) . In the United Kingdom, for example, there are approximately 50% fewer operations per hundred thousand population than in the United States, and these operations are done by approximately 2 5 % the number of surgeons. In other words, each surgeon in the U.K. is approximately twice as productive as is his counterpart in the United States. In the city of Oxford, with a population of 300 000, there are two thoracic surgeons; both are busy but neither is stressed. Moreover, it is likely that most of the excess surgery done in the United States consists of hysterectomies, tonsillectomies, herniorrhaphies, and hemorrhoidectomies. There is painfully little evidence that this type of surgery has improved the general health of the population. Nor should all the rocks be cast at the surgical fraternity. Indeed, they should be congratulated for doing the health manpower study that has clearly indicated to them that they are producing an excessive number of surgeons. Unfortunately, the medical subspecialties have not yet conducted a similar study. However, it is quite clear that, particularly in the attractive urban population centers, the number of medical subspecialists far exceeds the need. The proliferation of subspecialists is a direct consequence of the marked increase in subspecialty training offered by departments of medicine. They have been stimulated by the training programs of the National Institutes of Health which, though intended for research training, served in many instances to support clinical training programs. A study of manpower training and resources in cardiology has been completed recently ( 8 ) . The following data came to light: 1. There are 329 programs offering advanced training in cardiology in approved hospitals in this country. During 1972 and 73, 1278 trainees were enrolled in these programs and 791 completed their training. The number may actually be larger because of trainees completing their training in nonapproved hospitals and those who take additional training (such as residency) outside cardiology programs. 2. As might be expected, graduating trainees practice close to where they trained. 3. A large part of the training is devoted to laboratory diagnostic methods, including angiography and cardiac catheterization. 4. Nearly 4000 full-time equivalent professional staff are engaged in the training of cardiologists, and some
programs expressed a need for more faculty. 5. The average training program did 555 angiograms and 368 cardiac catheterizations per year. Although this report does not comment on the need for additional physicians in cardiology, it is difficult not to conclude that the disgorging of 1000 cardiologists per year into the health manpower pool is excessive. Moreover, most of the cardiology training has been "catheteroriented" and the products of these training programs have prided themselves on their diagnostic expertise using modern technology. These modern cardiologists may be doing cardiac catheterizations and coronary angiograms far in excess of needs for their use. Of course, the proliferation of cardiovascular surgeons has resulted in further excessive use of invasive cardiologic techniques. In the city of Seattle, which draws from a population of approximately 1.25 million people, there are no fewer than five cardiac surgical teams. Each of these is supported by a diagnostic cardiology laboratory. Even in smaller cities in the state of Washington, where the populations barely approximate 100 000, facilities for cardiac catheterization are being planned and cardiac surgeons are planning to set up shop. The inevitable results of such developments is an excessive number of diagnostic cardiologic procedures and an excessive amount of cardiac surgery, both of which have contributed to the marked acceleration in health care costs. It is well known that the proliferation of subspecialists generates an increased demand for health services whether the services are indicated or not. Again, it is easy to point the finger at cardiology because one can easily identify the effects of having a progressively greater number of cardiologists (and, by implication, cardiovascular surgeons) in the community. However, other specialties in medicine have also produced to excess. In Seattle, for example, there are clearly too many hematologists and there is a steadily increasing number of gastroenterologists. In fact, there is not a single subspecialty of internal medicine, possibly excepting infectious disease, that has not caught on as a subspecialty in practice, that is not overrepresented in most communities that provide attractive living, good hospital facilities, and that have a medical school. While it is not hard to pinpoint the effects of an increasing number of specialists, it is more difficult to find the cause of the steady increase. Simplistically speaking, every man has an innate desire for self-advancement, intellectually and financially. In addition, subspecialists seem to have acquired prestige, particularly in medical schools. More than anything else, however, the structure of training programs in medical schools has led to specialization. The reasons for this are as follows: 1. Residents are providers of health-care services at low cost. Hospitals strongly wish to keep costs in bounds, and it is much easier and cheaper to have a resident provide the help than to hire staff physicians. Thus, up to some point, hospitals are motivated to maintain housestaff programs. 2. In medical schools, residents are the "graduate assistants" of the clinical departments and play an important part in teaching. It would be difficult for clinical departPetersdorf • Health Manpower
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ments to meet their teaching obligations, at least without radically altering them, if they did not have an ample resident staff who provide much of the student-subfaculty contact. 3. For reasons that are more difficult to explain there appears to be a great desire for growth on the part of clinical departments. Inherent in this desire is the attitude of academic departments, as well as hospitals, that consider mounting a residency program a "right" rather than a privilege. 4. Another important factor militating against curtailment of specialty training programs is the very increase in medical school graduates generated by the presumed shortage of physician manpower. As more students are graduated from medical schools, they require and expect the opportunity for graduate training. In most specialties, including family practice, this training is now no shorter than 3 years. Thus more residencies have to be created simply to meet the training needs of our medical school graduates. It can be argued that all of these new residents should be in family practice or some other primary care discipline, but as yet the number of training programs leading to certification by the American Board of Family Practice is inadequate, and even if internal medicine or pediatrics could take up the slack, there would still be the need of paying for these additional residency programs. The problem can be summarized by saying that it is difficult to see that there will be a decrease in the number of specialists as long as there are as many clinical fellowships and residencies as now have to be filled. The decrease in the National Institutes of Health training grants may reduce the number of clinical fellowships. The recently announced fellowship program is aimed at training investigators rather than clinicians, because anyone who takes such a fellowship and who enters practice must repay the stipend. However, consider what a lucrative investment it would be for a future cardiologist to receive 2 years of training, even if he has to repay a total of $20,000 plus interest. The answer to the problem of the excessive number of residency and specialty training programs is a substitution of hospital-based staff physicians for residents in specialties that are overproducing. Initially, this may seem expensive because staff physicians require higher salaries than residents. On the other hand, it may pay off eventually because of increased efficiency. Certainly, the large prepayment health plans recognized this principle long ago; programs such as Group Health Cooperative of Puget Sound, Kaiser Permanente, and others have a very modest investment in training compared to full-time staff. The Role of the Specialty Boards
Clearly the specialty boards have done a great deal to maintain quality of residency training programs. At the same time, they have made certification by a specialty board a major goal and have thereby contributed to the imbalance in physician manpower. The American Board of Internal Medicine, the organization with which I am most familiar, is a case in point. Up until 1970, the American Board of Internal Medicine certified to competence 698
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in general internal medicine through a two-stage examination system. The first stage, a written examination, was given at the completion of 4 years of training, at least 2, and usually 3, of which had to be in general internal medicine. Formerly, two additional years of practice or other experience were required before a candidate was permitted to take the examination. In other words, a compulsory period of 6 years of post-M.D. training or experience, or both, was the minimum time that could elapse between the granting of the M.D. degree and the passing of the written examination. Once the written examination was passed, the candidate took an oral examination during the ensuing year. In this examination, he was tested as a "consultant in general internal medicine." Specifically, he was required to examine two patients that were outside the subspecialty of internal medicine in which he had special training and was examined by two examiners outside their own subspecialty. In 1968, the Board analyzed the results of its examination process and found that while the written examination had a good deal of reliability and statistical validity, there was poor correlation in grades between the written and oral examinations. Moreover, there were many differences in grading between examiners on the oral examination. The lack of statistical reliability (along with the logistic problems encountered in mounting oral examinations because of the ever-increasing number of candidates) resulted in the abolition of the oral examination. While the Board was making this decision, it was also confronted with the apparent shortage of physicians. To counter this challenge, it considered an earlier certification of physicians and attempted to steer them toward the practice of general internal medicine. Therefore, the Board decided to permit certification in internal medicine after only 3 years of training. For most candidates, this training would consist of 3 years of general internal medicine; for some only 2 years of medicine and a year of a clinical subspecialty was required. When the Board made this change, it recognized that many of its candidates were, in fact, trained in a subspecialty. In the past, some of the candidates who had advanced training in cardiology, allergy and immunology, pulmonary disease, or gastroenterology went on to take Board examinations in these subspecialties. Recognizing that many persons were training in subspecialties other than the four that had been recognized by the creation of official subspecialty Boards, the Board set up specialty examination committees in hematology, infectious disease, endocrinology, nephrology, rheumatology, and oncology. A candidate was required to have 2 years of training in one of these specialties in order to sit for a subspecialty examination. The subspecialty examination would be taken by most candidates after 5 years of training (3 in internal medicine followed by successful completion of the Certifying Examination and 2 in a subspecialty) and in some instances, after 4 years, 2 years of internal medicine and 2 years of subspecialty. Thus, some candidates could be certified in medicine at the end of the third year following the M.D. degree and in a subspecialty at the end of the fourth year. This second tier of examinations was created to ac-
knowledge the training patterns of present day candidates, most of whom took 1 or 2 years of subspecialty training after 2 or 3 years in general internal medicine. A beneficial side effect of the second tier was that specialty training programs would have to be standardized and that internists would have to have training in institutions deemed to be competent in specialty training for at least a 2-year period before being permitted to be certified in the subspecialty. At the same time, the Board hoped that many candidates would seek no training beyond the initial 3 years of general internal medicine and would, after they were certified, wish to practice "primary care" or general internal medicine. Unfortunately, this hope has not been realized. The subspecialty certification system has tended to drive candidates to further subspecialty training followed by examination. As a matter of fact, there are now some candidates who want to take examinations in more than one subspecialty. The Role of the Medical Schools in Promoting Specialization
Unfortunately, the structure of our postdoctoral training programs in medical schools also promotes subspecialty rather than general training. In departments of medicine, for example, there is a great emphasis on subspecialty medicine; few of our best academic departments have strong programs in general medicine. Thus, the house officers have difficulty in finding appropriate role models of general internists in academic departments. Moreover, the postgraduate curricula in general internal medicine are weak when compared to subspecialty medicine. For example, a resident in cardiology receives experience in reading electrocardiograms, interpreting cardiac catheterization data, doing exercise tests, doing various noninvasive diagnostic procedures, inserting pacemakers, and learning the many other skills of a modern cardiologist. However, how often do programs designed to train general internists include exposure to office gynecology, otorhinolaryngology, psychiatry, adolescent medicine, and community medicine? This weakness in training programs in primary care internal medicine is largely due to the lack of appropriate faculty for teaching general internal medicine. This lack in turn has resulted in failure to design the most appropriate training programs for general internists. A number of chairmen of departments of medicine have attempted to create divisions of ambulatory medicine or general medicine. However, once faculty for these divisions have been recruited, it has been difficult to retain them within the system, to offer them the financial rewards that they would earn in practice, or the academic rewards that come more easily to specialists and, particularly, to clinical investigators. Certain programs such as the Clinical Scholars Program of the Johnson Foundation are attempting to correct these difficulties, but it will be some years before general internal medicine will attain its appropriate role in full-time academic departments. However, this development is absolutely vital for recruitment of the young physicians who must be the general "primary care" internists of the future. The reason for the drive for specialization in internal medicine is not entirely clear. In part, the motivation stems
from the fear that it would be disadvantageous in the future to be certified only as a general internist and not as a subspecialist. With government medicine in the offing, the expectation is that subspecialists will be paid more for their services than general internists. It must be clear, however, that the need in internal medicine is not for more subspecialists. Rather, it is for well-trained general internists who can render primary care to the adult population. This means that the financial rewards for primary care physicians must be at a level equal to that for subspecialists. Factors Affecting the Quality of Postgraduate Education Postgraduate medical education depends, of course, in part on undergraduate medical education. Whether the quality of undergraduate education is improving, or whether it is deteriorating, is a matter of debate. Certainly, students now entering medical school are, in general, better than their predecessors. Many have had a superb science education in high school and in college. They appear to have better grade point averages and MCAT scores than ever before. Partly, perhaps because of the belief that premedical education is much better today than in the past, the scientific content of the medical school curriculum has been abbreviated, and in many schools the curriculum has been shortened from 4 years to 3. While this in-vogue type of curricular innovation has been to the advantage of a few extraordinarily bright students, the average student has had more than his share of trouble coping with the material presented. Perhaps this is the fault of the faculties who have been quite willing to cut the time given to the curriculum without altering the content. While it is difficult to judge the performance of medical students objectively, the only criterion that is available is the scores on the examinations of the National Board of Medical Examiners. When these are examined, the performance of students in many medical schools clearly has deteriorated. It has been argued that this reflects curricular change more than the quality of medical education or the quality of the students. My bias is that the quality of medical education is depreciating mainly because so little time is now allotted to it. Most medical students need 4 rather than 3 years to grow into medicine; a number of students who have done poorly on my clerkship in medicine have more than doubled the quality of their performance by simply repeating the clerkship and thereby getting additional exposure to the material presented. A second factor that will unquestionably affect the quality of physicians, if not as specialists but as broadbased physicians, is the abolition of the internship. The recommendation of the Millis Commission to abolish the internship, while well intentioned, is turning out to be the Gulf of Tonkin Resolution of medical education. Certainly from the point of view of quality of the practitioner, a surgeon who has had some postgraduate training in medicine or pediatrics, or both, is likely to be a better surgeon —at least in judgment—than one who has not. This may be even more true for psychiatric training. Indeed, a good medical, rotating, or mixed internship may be the last exposure to physiological medicine that psychiatric trainees receive! Petersdorf • Health Manpower
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A third factor that will affect the quality of medicine is the accreditation procedures in the medical specialties. Certainly the Residency Review Committee is doing an admirable job in eliminating second-rate residency training programs and in upgrading the ones that are in existence. However, this type of review is not available for programs in the medical subspecialties and in most subspecialties of pediatrics. In other words, there are many subspecialty programs that are not accredited at all. Particularly with the present surfeit of medical specialists, it seems vital that programs approved for medical specialty training be high in quality. Unfortunately, this is not always the case. However, the quality of postgraduate medical education has not deteriorated badly, if at all. For every weak program still in existence, newer and stronger programs are being created. In particular, the upgrading of residency training in family practice must be singled out. The Board of Family Practice has been a major force in upgrading the quality of postgraduate education in that ever-growing specialty. The problem, then, is not so much the quality of the educational process but the system that turns out an excessive number of subspecialists often at the expense of training primary care physicians, and that has not found the answer to distributing its physicians in locations where they are most needed.
Some Possible Solutions
While there are some trends in undergraduate medical education that might compromise the quality of medical graduates, there is little evidence that the quality of the post-M.D. educational process is deteriorating or that, in general, its quality control is faulty. Of the two major problems geographic maldistribution and overspecialization, that of geographic maldistribution defies easy solution. In a free society, and one that is mobile, the only way in which physicians can be induced to go into rural areas is by their own motivation. Certainly, the spectre of not being able to make a living in the cities with large physician populations or the suburbs that are becoming equally overpopulated with doctors may deter some from settling in these locations. However, the law of supply and demand does not apply to physicians. Even in areas that are patently overcrowded, there always seems to be room for at least one more competent doctor. Perhaps one way to improve the lot of the rural physician, or the one in the urban ghetto, is to offer financial inducements. So far, this method has not been very effective. Perhaps the guarantee of programmed postgraduate education for physicians settling in high-need areas would be more attractive. A program could be devised, for example, in which physicians practicing in rural areas would spend at least 2 to 3 days a month engaged in postgraduate education in a major medical center. This might be augmented by periodic stays of longer duration. Improved communications in terms of televised consultations and televised postgraduate courses might further augment the contact between the rural physician and his colleague in the medical center. This type of postgraduate educational 700
May 1975 • Annals of Internal Medicine • Volume 82 • Number 5
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network would require a massive effort and would cost a lot of money. Conceivably, if young medical graduates, most of whom are trained in urban settings and who have become accustomed to them, can be kept in contact with these settings, they would agree to settle in rural areas. Similar opportunities for continuing education must be provided to physicians working in center cities. The alternative, of course, would be to completely nationalize medical personnel and to assign them to posts where they are needed. In a sense, this would put our health care system on a paramilitary footing, and even countries with a totally nationalized health system such as the United Kingdom have not adopted this approach. In fact, even in the United Kingdom, the geographic maldistribution problem has not been solved and many foreign medical graduates populate the rural hospitals in the British Midlands. The issue of maldistribution by specialties also does not lend itself to easy solution but here, at least, we know what needs to be done. The steps to be taken may be summarized as follows: 1. Residency programs must be reduced in number, and the number of graduates of residency programs in overpopulated specialties must be decreased below the rate of attrition until some reasonable balance is achieved. 2. Likewise, specialty training programs need to be curtailed. In academic medical centers, this means that, in the future, specialty consultations and teaching will have to be rendered more by faculty than by fellows. Fellowships should, in general, be reserved for research and not clinical training. 3. In many specialties, the curtailment of training programs will require the hiring of additional full-time staff to render necessary services. While this will initially escalate the cost, in the long run it is the only way to balance the system. In other words, residents must not be used as underpriced labor to provide service. 4. Programs in internal medicine must be restructured so that after the graduates of our programs complete 3 and in some instances 4 years of training, they will be more prepared to practice "primary care" internal medicine than "consultative" internal medicine. It is quite clear that the medical consultant of the future will not be the general internist but the subspecialist. It should be recognized, however, that subspecialty consultations will be needed for only the minority of patients and for these most patients can readily be referred by their family practitioner or primary care internist. 5. While it is desirable that the profession itself police the number of residents and specialty trainees that it produces, my dyspeptic view of the situation is that it will not do so and that we will have to come closer to the modus operandi in the United Kingdom. There, under the National Health Service, the production of specialists has been rigidly controlled by two mechanisms: (a) The number of registrar (residency) positions available in the several specialties is set according to the needs for conconsultants (practitioners) in the specialties. For example, in the field of cardiology, there are very few open registrar positions because there is at this time no great need
for consultant cardiologists. On the other hand, there is still a dearth of anesthesiologists in the United Kingdom and hence it is not too difficult to land a registrar position as an anesthesiologist, (b.) The number of consultant positions is controlled. These positions are offered in parallel to the number of registrar positions. Thus, there are comparatively few new consultant posts being created in cardiology but a moderate number are still being provided in anesthesiology. Because consultant posts are created only in relation to hospital practice, in many instances they are made available only in the comparatively less desirable areas, thus correcting to some extent the problem of geographic maldistribution. In other words, if a man wants to be a consultant in cardiology, he is likely to have to settle in a less desirable community than if he wants to be a consultant in anesthesiology. A byproduct of this system is that a large number of young physicians go into general practice after a year or 2 of training after medical school. They do not want to undergo the long training periods and waits that are inherent in subspecialization with its long-term goal of a consultant post. Instead, they opt for general practice. Moreover, the National Health Service has gone to great pains to make general practice as attractive as specialty practice. The general practitioners in the United Kingdom begin to earn a living much earlier in their careers than their counterparts who prefer to go into specialties. Even after they complete their training and obtain their definitive posts, consultants earn not much more than general practitioners. Thus, the economic incentive that has driven young physicians into the specialties has to a large extent been abolished. These controls do not seem to be unduly oppressive to graduates of British medical schools. About a decade ago, the U.K. had many more registrars than consultant posts available. When a man finished several years as registrar and was unable to find a position, he often emigrated. In recent years, however, the imbalance between registrar and consultant positions has been corrected and much of the
dissatisfaction with the system has been dissipated. It seems likely that some variant of this system will be the only one that will control production of specialists in the United States. Our Goal We should aim to make the practice of primary care medicine—whether it be by family practitioners, general internists, or pediatricians—as attractive, prestigious and rewarding as subspecialty practice. This should be the major goal of medical schools, professional organizations, accrediting bodies, and government. If it can be reached, many of our health manpower problems will be relieved. ACKNOWLEDGMENTS: This paper was prepared for a Commission on Future Physicians sponsored by the Macy Foundation and is reproduced with the permission of the Foundation. Received 19 September 1974; revision accepted 3 January 1975. • Reprint requests should be addressed to Robert G. Petersdorf, M.D., Chairman, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195. References 1. SENIOR B, SMITH BA: The number of physicians as a constraint on delivery of health care. JAMA 222:178-183, 1972 2. CITIZENS COMMISSION ON GRADUATE MEDICAL EDUCATION: The
Graduate Education of Physicians. Chicago, American Medical Association, 1966 3. Report to the Dean of the University of Washington School of Medicine: An Evaluation of the Need for Increased Medical Student Enrollment at the University of Washington. 29 June 1973 4. BEESON PB: Some good features of the British National Health Service. / Med Ed 49:43-49, 1974 5. MOORE FD, BOYDEN CM, SABISTON D, et al: The production,
attrition, and biologic life-time of surgeons in relation to the population of the United States: a look into the future through the clouded computer crystal. Ann Surg 176:457-468, 1972 6. CLAWSON DK, BENNETT RL, STEEN MK: Planning
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Programs Based on Physician Projections. A paper presented to the American Medical Association Symposium on Distribution of Health Manpower, San Francisco, 17 June 1972 7. BUNKER JP: Surgical manpower: a comparison of operations and surgeons in the United States and in England and Wales. N Engl J Med 282:135-144, 1970 8. ADAMS FH, MENDENHALL RC (editors): Evaluation of cardiology training and manpower requirements. Publication (NIH) 74-623. DHEW, 1974
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