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13  We Need More and Better Docs
    The Washington Post, Sunday, October 16, 1966

     "To Most Americans, medical education is as remote from everyday
life as the Ecumenical Council's deliberations of decide," said
Greer Williams of the Rockefeller Foundation in a discussion on how
to fill the physician gap which appeared in Science magazine recently.

     Certainly, while the simile is ironic, the effectiveness of
medical education has the most direct impact on the health and
happiness of everyone.

     Do we need more doctors?  Williams faults "the health manpower
experts (who) have begged the question of shortage."  But everyday
experience has proved the point, not only because medical progress
saves lives of people who then need more care, but especially
because our standards of scientific precision in medicine and health
and longevity have constantly risen.

     "If the entire Nation were as well supplied as New York,
California and Massachusetts, we would need over 400,000 doctors,
higher by nearly 50 per cent than the 275,000 we have now.  But
the figure is perhaps meaningless without an analysis of what
kinds of doctors are needed," Williams said.

     The last point is obscured by his criticism of an "ivory-tower
conception of scientific education in medicine, a setting in which
scholars investigate the diseases of their patients and render their
greatest service through the discovery and imparting of knowledge
helpful to humanity."

     This quotation is, in fact, the ideal image of several of the
university-centered schools, particularly private institutions, that
by general consensus set the Nation's standards in medical education;
Johns Hopkins, Harvard, Stanford, Yale, Michigan and others.

     Williams criticizes this concept for neglecting the obvious
requirement for craftsmen of medicine -- the troops on the front
line -- who are so badly needed to bring the existing art to the   
healing of the lame and diseased.  He proposes that the excellent
institutions exploit the economies of scale that might make it
cheaper to expand existing schools than starting new ones.

     His approach is already embodied in the guidelines of existing
Federal legislation, which provides a token start to support 
facilities for medical education.  The peril is, of course, the
erosion of quality for the sake of numbers -- the willingness to
be contented with some of the "good" (as opposed to excellent)
candidates that Williams feels are now deprived of a place in
medical classes.

     It seems to me that Williams has contradicted himself.  He
emphasized that the physician gap consists of several distinct
problems, but then pressed for the solution to the one problem
of overwhelming numbers as a way to solve most of them.

     Much disease now is iatrogenic, actually a backwash of excessive
and imperceptive use of drugs.  Many of my colleagues wonder, then,
whether we do not have too many physicians -- too busy and
preoccupied, to evaluate the churning battery of drugs thrust at
their attention via the glossy trade journals.

     We should increase the numbers of doctors, if that would give
back to the individual physician the time he needs to follow his
conscience in constantly relearning contemporary medicine.  This is
surely a better answer than making the Food and Drug Administration
the doctor's parole officer.

     We must be careful to recognize that providing medical education
causes several problems.  Different institutions must innovate their
styles and find their roles if the system is to remain intact.  The
coexistence of an elite Harvard College and huge state universities
creates no paradox.  The smaller institutions can set standards,
experiment with new forms and provide academic leadership for the 
rest of the system.

     Open debate on the goals and principles of medical education
is overdue, if only for public understanding.  It may also help to
expose some of the rigidities that historical guild attitudes have
imposed, which interfere with the discrimination now needed for
application to the wide variety of functions for which medical
training is relevant.

     The diversification of style and goal among different
institutions is probably the most effective way to pursue this
inquiry.

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