A great enterprise is glutting the market with expensive products, and although sales keep dropping, the output continues at the same level.
Harsh as that sounds, that's an apt description of the medical-education industry, a nationwide collection of 125 medical schools that continues to train and turn 'em out at a rigidly changeless pace, although rising joblessness has become a realty in the once-golden profession of medicine.
The number of applicants for admission to medical schools has dropped for the second straight year, but still exceeds the number of slots by nearly 2.4 to one. A reduction in Medicare funds for medical education, dictated by the balanced-budget amendment, now threatens the stability of the system, as Herbert Pardes, dean of the Faculty of Medicine at Columbia University's College of Physicians and Surgeons, warned recently in a Sept. 3 op-ed article, "Save the Med Schools."
Financial first aid surely is warranted to avoid catastrophic disruptions. But a long-term solution requires recognition of a medico-economic reality: We have too many medical schools for the nation's needs.
In 1981, 121 medical schools enrolled a student body of 65,497. In 1985 the American Medical Association reported a "surplus of physicians, regardless of specialty . . . in most areas of the country" and recommended cutting enrollments. By 1998, with a net gain of five schools in the national total, enrollments climbed to 66,489. Studies futilely have urged large-scale shutdowns of medical schools.
Several schools are near bankruptcy and a couple have merged, but like unneeded military bases, they're tough to kill. Although tuition is sky high in the private schools, it covers only a small portion of medical-education costs. The balance largely comes from taxpayer support and payments for patient care. As magnets for money during the heyday of unrestrained medical spending, medical schools and their associated hospitals experienced enormous staff growth, much of it financed by Medicare and rapid increases in federal research funds.
In 1987 the schools employed 66,798 full-time faculty and enrolled 65,742 students. By 1998 the faculty had grown to 98,202 while student enrollment remained almost unchanged, at 66,489.
Managed-care companies, seeking the lowest prices for hospital services, have worsened the financial plight of medical education by shunning high-cost university-related hospitals. Worsened by Medicare reductions, the financial crisis shows up most acutely in the hospital-based training of residents -- of whom there are too many because of the unceasing output of the medical schools.
Meanwhile, the unbalanced nature of medical-school finances shows up in the politically popular boom in health research. As Pardes notes, the National Institutes of Health, which spends most of its money in medical schools, got a record $2 billion increase last year and may be bound for another big helping. But as he also points out, "Biomedical research laboratories in much of the country are old, outmoded and inadequate to handle the prospective NIH increases."
Why, then, is NIH pouring money into ramshackle laboratories?
Because the expanded platoons of researchers in medical schools live off that money, even if they can't make optimal use of it in their outmoded and inadequate laboratories. Bountifully supported, research prospers while teaching scrapes for money. The general hope in the medical-education industry is that sufficient howling will lead to a fix here and there and, as in past crises, the system will muddle through without any schools going under or any reductions in enrollments or employment.
The odds are that some relief will be provided from the stringencies of the balanced-budget amendment. It should be provided, because medical education is too important and fragile to be subjected to financial battering. But, on the long road to catastrophe, the basic problem persists: too many schools turning out too many doctors.
Politics only timidly recognizes that reality, while the Association of American Medical Colleges, the education industry's well-heeled lobby, blithely contends that if we just end further admission of foreign-trained physicians, all will be well. Few acknowledge what's really needed: mergers, closures and fewer doctors.
Daniel S. Greenberg is a science journalist.