Medicine: Med Schools’ Troubles

Said President Eisenhower in Manhattan last week, at a dinner for the National Fund for Medical Education: “There is on all sides a mounting demand for health services by our communities. Under these demands, the medical schools in America today face inherited responsibilities beyond what they are financially able to meet. The medical progress of which we are so justly proud has involved them in a struggle for solvency and survival.”

Behind the struggle lie serious problems without a single, simple answer. The U.S. has 218,000 active physicians, but many of these (in full-time teaching, research, insurance, hospital or executive posts) treat no patients. The bulk of patient care is performed by 90,000 general practitioners, 67,000 specialists, 18,000 hospital residents—a total of 175,000, or one for every 983 population (proportionately more than in any country except Israel).

How Many Graduates? Eisenhower’s forecast that the U.S. will have 228 million population by 1975 means that to maintain the present patient-doctor ratio the nation will need new doctors at a rate increasing from about 12,000 a year now to about 15,000. U.S. medical schools simply cannot turn out that many. Last summer 76 schools with full (four-year) curriculums produced 6,796 graduates. Canadian schools and some in Europe, all with A.M.A. approval, supply about 2,500 more. So this year’s deficit is around 2,700. As in several postwar years, the deficit will be made up by immigrant doctors, many of them trained in schools not approved by the A.M.A.

New schools are being opened; by 1963 seven more will be graduating doctors. Even with these additions U.S. schools will not quite catch up with the demand. Bigger classes, sometimes suggested as a solution, are not feasible because in the final years students need detailed, bedside instruction by physician-professors. Although there are 90 students in the average class, usually there is room for no more than three or four students at a bedside. To increase the student enrollment would require a proportionate increase in faculty, which the schools could not afford even if the necessary teachers were available. As it is, in a mediocre medical school, there is one teacher* for every student; in the best schools there are two.

How Much Money? The cost of educating a doctor in the U.S. may range from $10,000 to $40,000. Operating budgets for all the 82 med schools (including six two-year schools) in the last academic year totaled $111 million, an average of $16,000 per graduate. Of this, the students pay no more than $20 million (18%) in tuition fees. Where does the other $91 million come from?

Half the U.S. medical schools are run by states and cities; government funds to the tune of $53 million a year make up nearly all these deficits. The other half are private, rely on income from endowments and general university funds for a total of $20 million. To balance, the schools need $18 million in gifts and grants. Research grants are no answer; usually given for men and materials only, with no provision for overhead, they may make a medical college’s fiscal problems worse.

How to Find Teachers? Biggest headache is finding and paying the faculty to teach bedside medicine in the last two years. Salaries are low: for full professors rarely as much as $20,000, nearly always much less than a first-rate physician could earn in private practice. Some schools settle for second-rate teachers. Others compromise by taking on professors halftime, leaving them half a work week to make a living in private practice. Since this leaves no time for research, the best schools insist on a hard core of full-time faculty members. Even so, these are outnumbered by part-time specialty teachers, often unpaid. There are now 331 full-time budgeted positions open in U.S. medical schools, with no qualified takers.

Although he pays less than a fifth of the cost of his professional education, the medical student does not have it easy either. With the price of a microscope (range: $500 to $1,000) added to what he pays for tuition, books and living expenses, he cannot hope to get by for less than $1,600 a year at an out-of-the-way state school, closer to $3,000 if he goes to a private school in a big city. Then, with a minimum of a year’s internship at niggardly pay, he loses five years (beyond college) during which he might have been earning money. For the schools to raise tuition fees would bear heavily on the already hard-pressed student, and would do little to close their budget wounds. Upshot: despite heavy contributions, notably those raised by the Fund for Medical Education that Ike praised, the schools still need $10 million a year to break even.

* Teachers include, besides physicians engaged in all 19 medical specialties, instructors and technicians in such subjects as anatomy, physiology, biochemistry, pathology, microbiology, parasitology, pharmacology, physical medicine and rehabilitation, X rays, physics, electronics, psychology and sociology.