The MacNeil/Lehrer Report; Too Many Doctors?

JIM LEHRER: Good evening. The nation`s medical profession was given the blunt new word today. As a matter of policy the federal government now believes there is an oversupply of doctors in this country, that they`re poorly distributed and overspecialized, that the country just can`t afford it any more and something`s going to be done about it. Joseph Califano, Secretary of Health, Education and Welfare, was the bearer of these tidings, in a speech this morning to the American Association of Medical Colleges meeting in New Orleans. Califano said his agency would begin immediately to realign its various incentive programs to cope with the oversupply problem; specifically, he said, there would also be some changes in HEW policy.

JOSEPH CALIFANO, Secretary, HEW: We will no longer discourage schools from reducing student bodies if they wish. It is our hope, indeed our objective, that over the next several years the medical schools will gradually reduce the size of their classes. The federal government will not encourage or assist the creation of new medical schools except under the most compelling and extraordinary circumstances. And finally, we will continue our strong opposition to the admission of foreign medical graduates and we will seek ways to deal with the growing problem of American students who return from training abroad.

LEHRER: On overspecialization, the decline in primary care or general practice physicians, Califano called the situation wasteful and dangerous, and urged the medical schools to exert leadership in making general practice more appealing. He said the government would also do its part.

CALIFANO: We will review our reimbursement formulas, which presently discourage ambulatory care, to determine whether they are discouraging students from choosing to involve themselves in primary care. We will seek to institute programs of support for departments of family medicine and other disciplines stressing primary care. We will seek ways to support more residencies in primary care fields and investigate providing other incentives to encourage primary care.

LEHRER: Tonight, the pros and cons of Secretary Califano`s diagnoses and cures. Robert MacNeil is off; Charlayne Hunter-Gault is in New York. Charlayne?

CHARLAYNE HUNTER-GAULT: Jim, the source of Secretary Califano`s concern is money. Within the past ten years health care has grown into the third largest industry in America. In fiscal 1978 health care costs amounted to $180 billion, compared with $69 billion in 1970, and there are predictions that by the year 2000 that figure will reach a whopping one trillion dollars. At the same time, the ratio of doctors to population has been steadily increasing. In 1966 there were 156 doctors for every 100,000 people in the United States. By 1976 the rate had grown to 194, and according to Secretary Califano, by 1990 the rate will reach 242 doctors for every 100,000 people.

Ironically, there is scarcity amidst all this abundance. The number of physicians engaged in primary care -- that is, the kind given by a general practitioner -- is declining, down from ninety-four percent in 1931 to thirty-eight percent in 1975. And fewer than forty percent of new physicians are entering that area. This comes at a time when a severe health manpower shortage exists in many areas of the country, particularly among the urban and rural poor. And that`s what a lot of the fuss is about. Jim?

LEHRER: First let`s flesh out the basic government-Califano position with Dr. Henry Foley. Dr. Foley, a medical economist, is in charge of HEW`s Health Resources Administration, which monitors things like doctor supply, distribution and specialization. Dr. Foley, what`s the basis for concluding that the current supply of doctors is in fact an oversupply?

HENRY FOLEY: Well, we find that the indications of good health care in this country have not improved significantly with the increase of manpower. About ten years ago we invited the medical schools of this country to expand their student bodies so that we would produce enough physicians to serve people in rural and inner city areas as well as other parts of the country. What we found instead is we`ve produced a lot of extra specialists, surgeons, and other subspecialties, and been decreasing in that process the production of basically people who provide basic health care services, physicians in communities, within a reasonable time frame. We`ve compared the results of the health care status in this country with other countries in the Western world, and we found that the increased numbers of the types of physicians that we`ve produced in this country -not the total number but the kinds -- have not resulted in any better health care status and in fact we are finding the number of physicians not increasing in the inner city and rural areas significant to the need.

LEHRER: What is the basic harm in simply having too many doctors?

FOLEY: Well, we found that it`s the type of doctors that we have, more than just the number; that if you have too many surgeons there is a tendency in the system itself to have too many elective procedures, too many different types of surgery and types of special services. And at the same time we`re finding in the medical profession a turndown in the number of hysterectomies and appendectomies and tonsillectomies, and what the Secretary of HEW, Joseph Califano, is addressing is our willingness to work with the health professions, particularly the medical schools, so that those trends would continue and they would begin to redirect the training of the medical students in terms of the role models for those students so that they would practice in these other areas, and basically, when they reach complicated situations, refer those to the specialist but reverse the ratio that we`ve developed in this country. Now we have one in every three doctors providing basic health care-family practice medicine; the other two out of three basically practice special health care services or specialty services. That`s the reverse, as you`ve indicated, from 1931, where the majority of the physicians provided what we call basic first-line services to the American population. We`d like that proportion to swing in the direction of....

LEHRER: Is this oversupply of doctors as you just defined it also costing money, and if so how much?

FOLEY: Well, we estimate that the average figures that have been thrown around is that an average physician will generate $300,000 in expenditures each year. What`s deceptive about that is, it`s not any type of physician. For example, a neurosurgeon will generate much more expenditure than a family practice physician, or a cardiac specialist will also. And so it`s the type of procedures that we find generate high cost, particularly in the hospital sector, and we are concerned about that and are working with the American Association of Medical Colleges to try to encourage physicians to perform the best type of clinical care and reduce the numbers of unnecessary surgeries in the country and other types of subspecialty services.

LEHRER: All right, thank you. Charlayne?

HUNTER-GAULT: Now let`s hear from the source of all this concern, doctors. Leonard Fenninger is a vice president of the country`s leading medical organization, the American Medical Association. Dr. Fenninger, do you agree with HEW that we are facing an oversupply of doctors in this country?

Dr. LEONARD FENNINGER: This is one of the most difficult questions to answer in any society about anything, because what we`re really talking about is the availability of services to people at the time they need the services, so that the services can be given effectively and successfully. We`re dealing with one small variable when we talk about the number of physicians in the whole issue of health. First of all, the responsibility for health is primarily with the individual himself, and physicians have as their chief function in society dealing with illness, the amelioration of pain and sickness, rehabilitation of people who have become ill, together with prevention; but they cannot substitute for the responsibility that the individual has.

HUNTER-GAULT: Right. Well, how do you assess the supply of doctors that we do have, do you think it`s adequate, or just what?

FENNINGER: Well, this is why I spoke to services. There are places where services are needed where they cannot be obtained, either from physicians or other people in the society who assist in helping people get well, because the care of illness and the maintenance of health are by no means limited to physicians. They have a special part to play in it, but they are not the sole actors, nor are they the sole providers of these services.

HUNTER-GAULT: Well, how severe do you think is the problem of maldistribution, that is, doctors being not necessarily in the right place at the right time?

FENNINGER: Well, again, this is difficult to speak to because it depends somewhat on the level of understanding and the demands made by a population in any given area, it depends a great deal on the transportation, the degree of education.

HUNTER-GAULT: Well, in terms of urban and rural, for example, do you feel that there is an adequate supply of doctors in most urban and rural areas?

FENNINGER: From the point of view of numbers of people who are available to give services, by the very standards that have been used, it would appear that the number of physicians may be relatively close to the number of medical services that are required, but as I say, this is appearance only because these are not matters of absolutes; the economy of the nation, the interest of people, the level of education all affect greatly their demand for medical services, whether they be from physicians or other kinds of people, and the economy of the nation greatly affects this also. If, for example, the price of oil were to change significantly, the demand for medical services would immediately be influenced.

HUNTER-GAULT: All right. How about in terms of primary care? Has there been a trend away from primary care into more specialization, in your view?

FENNINGER: Specialization is inevitable as knowledge and technology increase. And one of the major federal investments, one of the major social investments, was made just before World War II and increased very rapidly from 1948 through 1965 in the funding of research by the federal government. There were tremendous advances in knowledge, there were tremendous advances in technology which required more and more skilled people to deal with more and more complicated problems. And one of the reasons that costs have gone up is that whereas it used to be inexpensive to be unable to treat, it is now expensive to have the armamentarium necessary to deal with illness and to correct it; so that much of the cost is due to the inevitable specialization, which incidentally was greatly fostered by federal programs through the National Institutes of Health.

HUNTER-GAULT: In a word, do you think it`s desirable to try and reverse that trend?

FENNINGER: Well you see, I think the trend has always been reversible and flows back and forth, because the fundamental responsibility of the physician is to respond to the need and the burden which the patient brings to that physician, and the patient comes because he can no longer bear that burden himself. So that all physicians give first-call care, all physicians, if the patient comes to him first. And the artificial separation of primary, secondary and tertiary care really gets in the way of both social solutions and political solutions, and it gets in the way of the concept of human beings as being whole creations.

HUNTER-GAULT: All right, we`ll come back; thank you. Jim?

LEHRER: Whether it`s through government programs or other means, it`s the young medical school graduates, the interns and the residents, who must be persuaded if there`s going to be any change in the distribution or specialization of doctors. Dr. Jay Dobkin heads the Physicians National House Staff Association, an intern-resident union. Dr.. Dobkin led a committee of interns and residents in New York City which held strikes in 1975-76 to protest working conditions and patient care. Doctor, do you think there are too many doctors in this country?

Dr. JAY DOBKIN: Well, it`s getting confusing for us. As a young physician when I started medical school ten years ago, the gospel was there were too few doctors and the more that could be trained and the faster, the better. It`s certainly clear now that there are still major deficiencies in terms of health services, and in many cases it seems that there`s an oversupply or services or an over availability in other areas. And assuming an imbalance -- and that, I think, no one can question -the problem now is, I think, again that the issue has been put in terms of economics, that health care is costing too much and we`re starting to clamp down. But the reversals in policy year after year are beginning to get confusing.

LEHRER: But what is your feeling about whether or not there are too many doctors in this country right now?

DOBKIN: Well, I think if we take that simple assumption we`re going to make another mistake perhaps, just as we did when we took the simple assumption that there were too few. The problem, to begin with, was that there was an inadequate supply of health services in certain areas, and I think that still exists. And I think the solution should be at the level of health services and health financing rather than at a manpower level.

LEHRER:I see. What`s your assessment of why young doctors aren`t interested in general practice medicine?

DOBKIN: Well, I think in many cases recent experience has shown that they are. A new family practice emphasis, family practice training programs, was instituted in the last few years, and contrary to expectations, people have flocked into these programs, they`ve been oversubscribed. However, in some cases they`ve been underdeveloped; people have found that there was not an adequate training program awaiting them. Beyond that, people find when they are interested in primary care that the facilities and the services, the setup that`s available to them to practice this kind of medicine is similarly inadequate. We think that the...

LEHRER: Well, what kind of special equipment does it take to practice general family medicine?

DOBKIN: Well, it`s not just a question of equipment, but we find that when the economic incentives are less, when the type of practice is more difficult or ...

LEHRER: You mean you can`t make as much money at it, is that...?

DOBKIN: Well, that`s one point, but what we find is that the whole deck is stacked against primary care, and probably the most important aspects are the ones that are receiving the least attention. The style of practice and the quality from a professional point of view in many primary care settings is really inadequate, and that is not being addressed.

LEHRER: Who stacked the deck?

DOBKIN: I think this is something that`s developed over the years by natural processes and has been aggravated, to be frank, by the policy interventions that have taken place.

LEHRER: You mean by Dr. Foley and his friends in the federal government?

DOBKIN: Well, I think that may have been in previous administrations, but the idea always seemed to be in place that this was a problem that medical schools and teaching hospitals could solve, and in fact it`s not that kind of problem, it`s a problem in terms of what kind of practice awaits someone in a small town or an urban inner city area, and that`s got to be changed. People would go to those places. We`ve found, through our work with the National Health Service Corps, that young physicians are very much interested in going to those places but it`s too much to expect them to go if they`re going to work harder and make less under those circumstances and face becoming medically obsolete within five years. So we think that the kind of practice has got to be changed.

LEHRER: All right; thank you. Charlayne?

HUNTER-GAULT: The two institutions that would immediately be affected by any changes in HEW policy are hospitals and medical schools. One man who wears hats for both is Dr. Thomas Chalmers, president of the Mt. Sinai Medical Center and dean of the lit. Sinai School of Medicine. Dr. Chalmers, are medical schools producing too many doctors?

Dr. THOMAS CHALMERS: I must say, I`m pleased to be agreeing with Dr. Dobkin after having disagreed with him so violently when he was heading up the New York organization with which we were having able negotiations. I don`t think we know whether there are too many doctors or not, and I think I would like to respectfully suggest to Secretary Califano that before you can treat a disease you need to make the proper diagnosis, and before you can treat it you need to understand what`s causing it. We don`t know whether there are going to be too many doctors ten years from now or not because we don`t know what sort of health care delivery system we`re going to have. If we have a drastically different system such that doctors are working on a salary, if we did have something like that we would certainly have far too few doctors, because doctors now work sixty, seventy hours a week and there would be a great shortage if they were to reduce their time to the amount of time that people in other professions often work. There may be changes in medical care of new diseases which will lead to increased or decreased numbers; and finally, I believe that we really have not an adequate idea of how many people are getting good medical care now, and it may be that if we deliver the kind of good care to the poor that we now are giving to doctors in suburbs, we will find that we have a shortage of doctors.

HUNTER-GAULT: This year some 15,000 students graduated from medical school compared with some 8,000 in 1963. Do you see this trend continuing?

CHALMERS: Well, I think probably most of us agree that 15,000 is an optimum number until we find out for sure how many we`re going to need.

HUNTER-GAULT: But it`s not going beyond that, as you see it right now.

CHALMERS: I would agree with him that we should not expand the numbers further; I would not agree with him that we should start to cut back, because I don`t think we have the proper data.

HUNTER-GAULT: What effect do you think a cutting back of the nature that he proposed would have, say, on newcomers like minorities and women?

CHALMERS:I don`t think it should have any effect, in the sense that the same trends will occur, with hopefully more minorities getting into medicine, more women getting into medicine. I don`t see that that should make a difference.

HUNTER-GAULT: Do you do anything special in your medical school to encourage the medical students to service these so-called unserved areas?

CHALMERS:I think so. We have a large department of community medicine, which spends a lot of curriculum time with the students impressing them with the needs of the poor; we are right on the edge of a large urban ghetto and we are the family doctor for that population in New York, and I think our students have a large amount of exposure to it. But that doesn`t make them settle there.

HUNTER-GAULT: You say you`re the family doctor. Does that encourage your students more to get involved in primary care as opposed to specialization?

CHALMERS:I think we need to straighten out some definitions. You in your introduction equated primary care with general practice; we don`t believe they should be equated. We think that general practice is an anachronism; I think I`m giving the general opinion of my own faculty that medicine is too complicated for the same physician to take care of the pregnant woman, deliver the baby, take care of the possibly sick or dangerously borderline neonatal problem...

HUNTER-GAULT: Well, I guess I meant a general as opposed to special...

CHALMERS: What we do believe that we should have more of is primary care specialists who will not specialize, in other words, in family practice or in general practice but who are trained in internal medicine, trained in pediatrics, trained in obstetrics, and to whom patients can turn when they have appropriate illnesses but not try to force the same man to do all things, because he will do it badly.

HUNTER-GAULT: I see. Thank you. Jim?

LEHRER: Dr. Foley, if I`ve counted correctly, I think it`s three against one, three of them against you and Mr. Califano. So let`s go back to some of the points. First of all, all three of them are saying that you and your boss are oversimplifying the problem, the diagnosis is premature and it is premature to say that the oversupply of doctors is causing the health care problem in this country. How do you respond to that?

FOLEY: Well, I`m not quite sure I agree with you that all three of them were against my own position. I was very specific, saying that I think we have overproduced and the data indicates too many sub specialists in the country. I think the Secretary has thrown out a challenge to the medical schools, suggesting that if in fact the professors of medicine can establish a role model in which students will be encouraged to practice family medicine -- and as Dr. Chalmers referred, obstetrics and pediatrics -- that we would then look also to be sure that that number of physicians can practice ire areas that are both now currently being served and the areas that are undeserved. It`s hard for us to tell the American people, when one out of six Americans has very little access to any physician at all at any level, that there are too many doctors. What we`re saying is there are too many of the wrong kinds of doctors practicing at the wrong places at the wrong time. I think that what Jay said to us is correct; we have to work out our reimbursement policies and other types of programs as we`ve done with states like Washington and Montana and Idaho and Alaska, in which the idea for how those physicians will have support and keep up the professional relationship comes from the universities and we have to support that and then the states support it; and basically we move to a situation where Americans are able to receive the care when they need it and where appropriate. I think the Secretary`s really subtly challenging us all, not about just a total number but the total number of the kinds of physicians that we have rather than that we resolve the total problem.

LEHRER: Dr. Fenninger, would the medical profession meet that challenge?

FENNINGER: Well, the medical profession, as a matter of fact, has been very concerned about the availability of services to people which meets their needs, which is what most people define primary care as being. In fact, it was the report of one of the commissions appointed by the American Medical Association that first established the percentage of half of the graduates of medical schools going into the various primary care specialties, which include internal medicine, pediatrics, family medicine and obstetrics and gynecology. Now, one of the problems in meeting such challenges is that, as I said earlier, medicine is part of a society. And just as specialization occurs everywhere else and just as reimbursement systems pay more for high degrees of technology, as do all other aspects of the society, simply saying the medical profession now would like to change people`s attitudes and their views obviously isn`t going to accomplish it.

LEHRER: What is, Doctor?

FENNINGER: Well, I think a variety of things. One is the recognition by the medical profession and continuing, shall I say, encouragement and education of people entering medicine -- of teachers, faculties, the students themselves, and the public itself -- in the advantages of having a generally educated man who then superimposes special knowledge and technology on general understanding. I might say...

LEHRER: I was just going to go to Dr. Dobkin on that. From your point of view, does that make sense? Would that take care of your problem and the concerns that you have about why young residents and interns and young medical school graduates do not want to into primary care right now -- general practice, whatever you want to call it?

DOBKIN: Well, I think I agree, it`s a case of applying a treatment that may be a nice treatment, namely supporting medical schools and supporting hospitals, to a problem that`s not related to that treatment. I think what we`ve got to do is address the kind of practice that`s available, the kind of reimbursement for services that`s available, so we get away from the system, for instance, where a surgeon can make a thousand dollars an hour but a pediatrician can make twenty dollars an hour.

LEHRER: What are you going to do about that, Dr. Foley?

FOLEY: We in the department are now working on an appropriate strategy around reimbursement, as Jay is indicating, suggesting that it should be the whole class of types of physicians that we`re looking at. For ex ample, if we`re looking at a subspecialty like neurosurgery, we might consider, as other countries have, a lower reimbursement and upping the reimbursement for the family practice physician, being sure that we get more equity in the system and drive the incentives in such a way that physicians will want to continue in family practice, which now is only one in three.

LEHRER: Let me ask you, Dr. Chalmers, do you feel that this kind of thing is in fact the responsibility and the job of the federal government?

CHALMERS: I think the federal government has got to exert some leadership, certainly; but I want to object to Dr. Foley`s constantly referring to family practice, I think what he should be saying is primary care that we`re concerned with. Secondly, there`s no doubt about the fact that the thing that lures a physician into going into the specialties rather than primary care is the increased income, and one of the causes of the need for increased income is the federal government and others` attitude towards the costs of medical education. Students are graduating from medical schools now with somewhere between ten and forty thousand dollars in debts. They`ve got to get that money back, pay it back reasonably soon; they can`t entertain the possibility of an unlucrative kind of family care which would take them five to ten years to be reaching a, reasonable income when they can go into a specialty and be making a good salary in a much earlier time after they finish their training. We`ve got to find some way to finance their education so they don`t end up in debt, so they don`t have that incentive to be making more money. I`m assuming that we can`t correct the situation in the opposite way, which I think we can`t completely; specialization will always pay a little more than family care.

LEHRER: Is HEW prepared to do that, Dr. Foley?

FOLEY: I think that what we`re working on is basically the reimbursement side, the end product, so that if in fact a physician, a student that is going to become a physician, is looking at what his debt will be and how it will be basically paid for, he will see a reimbursement structure that`s fairly equitable that will pay for that.

LEHRER: Whether he`s a specialist or a general practitioner.

FOLEY: And what that may indicate, with the high costs that we have, is that one must come down and one must come up to arrive at greater equity in that distribution.

LEHRER: And one must say goodbye, because we`re out of time. Gentlemen in New York, thank you very much. Good night, Charlayne.

HUNTER-GAULT: Good night, Jim.

LEHRER: Gentlemen here, thank you. We`ll see you tomorrow night. I`m Jim Lehrer. Thank you and good night.