THE PRESIDENT of the Association of American Medical Colleges was quoted the other day as saying that in its treatment of the nation's medical schools, the federal government is "like the fellow who gets the girl pregnant, then walks away claiming it's no longer his responsibility."
What he was referring to in that bit of rhetorical dash is that, with the urgings and aid of Washington, the medical-education enterprise was vastly expanded over the past two decades, to the extent that the output of physicians has approximately doubled, to about 16,000 a year. Having encouraged this phenomenal growth with a variety of financial inducements, the Congress, a couple of years ago, noted that doctors per 100,000 of population would rise from the then-current 180 to 240 by the year 1990. And though what constitutes enough in medical manpower is a disputed matter, the Congress suddenly announced that it "finds and declares that there is no longer an insufficient number of physicians and surgeons in the United States." Not long afterward, President Carter and his cost-containing Secretary of Health, Education and Welfare, Joseph Califano, concluded that, if that's the case, there is no justification for continuing general subsidies for medical education.
Accordingly, they have been snipping at several federal programs of assistance, particularly the "capitation" scheme, which provides medical schools with a payment for each enrolled student. The payments are relatively small -- $1,400 each last year, against the $17,000 that is estimated as the true annual cost of educating a medical student -- but every bit counts in the fragile economics of higher education. Students, of course, pay only a portion of that $17,000, with the rest coming from endowment, research grants, gifts and other sources. Even so, the financial load on the students can be staggering. At Georgetown University, which does not benefit from the assistance that most medical schools receive from state or local governments, tuition will rise next year to $13,500.
With medical schools regularly swamped with qualified applicants, it is obvious that the cost is not an impediment to obtaining a sufficient number of recruits for medical training. Loans and various government programs of scholarships in return for service do, in fact, enable students to meet the costs. But we don't think the success of these various patchwork schemes should be permitted to deflect attention from the fact that our booming medical-school system -- made up of 124 separate institutions -- is storing up troubles that sooner or later will have to be contended with.
For example, opinions may differ on how many doctors are enough, but at the rate at which new M.D.s are now being minted, saturation will eventually occur; some contend that it's already happening in some of the cities that young professionals find attractive. When the long-predicted doctor surplus does finally arrive, it will become politically difficult to sustain direct or indirect subsidies for medical education. The burdens will then shift toward student tuition payments -- which means that, increasingly, medical-school recruits will come from the ranks of those who can pay their own way. That shift may already be happening, according to analyses of the financial arrangements of recent classes of medical students. Is that a desirable trend?We think not.
Another matter that might be considered in connection with that gusher of new doctors is that -- as many studies have shown -- doctors do manage to keep busy with doctoring and the earning of fees that accompany their work, regardless of whether their area has a high or low ratio of doctors per population. Rather than being a humanitarian blessing, the present massive output of physicians could turn out to be an economic catastrophe -- Mr. Califano's yearnings for cost containment notwithstanding.
What this all comes down to is that, regardless of whether the federal government did right or wrong in its romance with medical education, attention now has to be directed to the problems of the future. And the biggest and most unpalatable of these, quite simply, is whether this country needs all of its 124 medical schools and 16,000 new doctors a year. Medical educators and politicians might start thinking about that.