Many of the facts are carefully documented in the splendid report made by your staff last fall on the current status of medical and related schools. They add up to simply this:

1. Our population is growing and changing. We will have 200 million people in this country by 1970, and more than 300 million by the year 2000. In the years immediately ahead, three-fourths of our population growth will be in the age groups that most need medical and dental care those who are over 65 years of age, and those who are under 20.

2. Even when one takes into account such factors as the increasing urbanization of our population, the advances in the techniques of modern medicine, and the gradual reduction in communicable diseases (all of which may tend to permit the physician or dentist to take care of a few more people on the average than he can today), it is abundantly evident that we are not graduating enough trained people in the health professions now to meet the needs that are predictable in the years ahead.

3. The medical and related schools on which the Nation relies are doing a splendid job. But they cannot turn out many more graduates per year per school and still maintain their high standards. Moreover, with each year that pases, the cost of medical and dental education goes up, and the ability of the school to remain stable without new or augmented support is in ever-increasing jeopardy. Yet, by the year 1970, it is reliably estimated that we will need 2,000 physicians more per year than are now being produced, if we are to maintain, roughly, the same ratio of physicians to patients that we have today, Where will they come from?

I wonder if the present administration is asking itself this question? If so, they ask it in a whisper, and with little apparent expectation that an answer will be forthcoming in the near future.

Yet even if we acted immediately, today, it would be 8 or more years before the first of the additional physicians and dentists and others would be trained and available to care for the health needs of our growing and changing population.

The problem of manpower supply for medical care and medical research and medical teaching is not just one of the construction of facilities. It is a composite of many issues, including many which are apparently not susceptible to Federal action. But the precedent for construction assistance has been long established, and the challenge can be met without the bugaboo of Federal control and without imperiling the principles of diversity in Federal support and stimulation of non-Federal activity-principles on which so much of the progress in the health sciences has been achieved.

The problem of construction of educational and research facilities in the health field can be approached in two ways-ways that are not mutually exclusive, but complement each other. They can be combined in single legislation or made the subject of separate legislation, as long as both are taken into account.

The first approach is to aid and strengthen our present medical schools and related institutions by providing matching grants for teaching as well as research facilities.

The second approach is to provide for appropriate Federal assistance and stimulation for the construction of new schools.

It is my firm conviction that both of these needs must be met. I would like to place in the record at this point a very excellent and comprehensive article by Michael Clark in the New York Times on March 3, 1958. Mr. Clark's summation of the issues leads to the conclusion that "unless a way can be found to recruit and train many more qualified students, medical care a decade or two from now will suffer" and that "the demand for their [physicians'] services already is far greater than the supply."

I have before this committee proposed legislation which would authorize $300 million over a 5-year period to help meet this challenge. The administration's proposed bill calls for less money. Mr. Roberts' legislative proposal makes special provision for new schools. Without going into the relative merits of these or other ways to approach the problem, I would urge the committee to act affirmatively and immediately on the proposal which, although only a first step, has the greatest potential for meeting the needs of the Nation in the years ahead. It is quite evident that the American people are threatened by inadequacies in health services, and that initiative and constructive action on this matter must come from the Congress in a truly bipartisan effort.

(The article from the New York Times of March 3, 1958, referred to, is as follows:)

NATION NEEDS PHYSICIANS TO MEET POPULATION RISE-SURVEY SHOWS THAT THE DEMAND EXCEEDS SUPPLY-DECLINE IN STUDENT ROLLS IMPERILING FUTURE MEDICAL CARE

(By Michael Clark)

The number of physicians in the United States is falling behind the growing population.

The demand for their services already is far greater than the supply, and the gap appears to be widening.

Unless a way can be found to recruit and train many more qualified students, medical care a decade or two from now will suffer, according to the best opinion in the profession.

These are the findings of a survey made by the New York Times on whether enough students are entering the medical profession.

In an attempt to predict future needs, a group of medical educators recently sought advice from Dr. Dudley Kirk, of Population Council, Inc.

With the population at 172 million, he said, the country is growing at a rate of 3 million a year and a reasonable guess of the population in 1980 would be 240 million.

The projected rate of population increase transcends any current projections of the rate of increase in medical school enrollment or physicians.

Medical school graduates have increased from 4,565 in 1930 to 6,796 last year. A record was set in 1955 with 6,977.

By 1962, however, the number is expected to level off at 7,400 a year, with the population curve continuing to rise sharply.

In recent years, the physician-population ratio has remained constant at 1 to 750 (850 if active physicians only are counted). This is exceeded only by Israel, which has 1 physician to 467 inhabitants.

In other words, although the number of physicians licensed each year has been greater than the number who have died, the difference has been just great enough to keep pace with the increment in the population.

It is unlikely that the present ratio can be maintained much longer. Dr. Vernon W. Lippard, dean of the Yale University School of Medicine, estimated last year that if the population reached 220 million in 1975, as predicted, and if the present ratio was to be maintained, the country would have to produce 2,000 more physicians a year.

It is widely felt that any attempt to balloon out the existing medical schools may impair the quality of instruction.

Rolls to increase: A Comparison of actual and projected trends in medical

Ratios compared: In 1955, the United States had 1 physician to 753 inhabitants, with the highest ratio in the Northeast and the lowest in the South. (Data are from the U. S. Public Health Service.)

28728-58-3

ASKS NEW SCHOOLS

According to Dr. Lippard, the United States can avoid a drop in the physicianpopulation ratio only by building 20 to 25 new medical schools of the current median size.

Since a new school normally involves a capital outlay of $50 million, Dr. Lippard was suggesting an investment of about $1,250 million.

His estimates are rejected by those who hold that the physician-population ratio is no key to adequate medical care. They fear that an oversupply of doctors could, in the event of an economic slump, bring great hardship to the profession.

Traditinoally, this has been the position of the American Medical Association. This powerful group has never conceded a shortage of physicians or such a possibility.

According to the AMA, the real problem is distribution, not numbers.

Dr. Frank G. Dickinson, director of its bureau of medical economic research, cites the increased efficiency of medicine as the best argument for rejecting the physician-population ratio as a valid indication of the number of physicians

needed.

He reported in 1954 that only one-sixth of the United States land area, inhabited by one-sixth of 1 percent of the population, was beyond a 25-mile radius from the closest physician in active practice.

His conclusion was that if 361 physicians of the 156,000 then in active practice were relocated, no area would have more than 2,000 inhabitants for each physician in active practice.

Dr. Dickinson put the lowest area ratio at 1 physician to 5,100 inhabitants. However, since 1954, the position held by Mr. Dickinson and the old guard of the AMA has been increasingly beleaguered.

Dr. Kirk delivered a blow when he told the recent Congress on Medical Education and Licensure in Chicago that the profession should prepare for an "enormous increase in the potential demand for medical service."

He did not try to answer the question, "How may doctors are enough?” However, he felt it "fair to say the medical profession has erred in the direction of preparing too few physicians in relation to the prospective needs for their services."

After having heard Dr. Kirk, a workshop conference on population and medical care concluded that the present physician-population ratio should be regarded tentatively as the best available yardstick by which to determine the desirable output of physicians in the immediate future.

TWO DISSENTERS NOTED

The 20 participants in the conference included physicians, sociologists, and businessmen. Only two believed that a lower ratio would be satisfactory. The names of the dissenters were not given, but Dr. Dickinson presumably was one. At a plenary session of the congress, Dr. Dickinson asked if the findings of the conference reflected the official views of the AMA. The answer was "No." It was noted that the conference had not conceded that there was a physician shortage now, but implied that there might be one if the physician-population ratio dropped.

However, the conference gave weight to the recommendations of the Association of American Medical Colleges. At its 1956 annual meeting, the association issued a statement to the effect that more physicians should be obtained by increasing the number of medical schools.

In the opinion of many medical educators, the physician-population ratio must be improved if present shortages are to be overcome and probable future demands met.

When a balance sheet is drawn showing, on one hand, factors tending to improve the efficiency of the corps of physicians and, on the other, factors tending to increase the demand for medical service, it is reasonable to conclude that the saturation point is nowhere in sight.

The following factors make it possible for a physician to see more patients in less time: wonder drugs, improved techniques, faster transportation, group practice, and greater assistance from auxiliary medical personnel.

A case of pneumonia used to absorb 11 hours of a physician's time. the average case occupies him an hour and a half.

Today,

Dr. Dickinson says physicians' services increased at least one-third between 1940 and 1950. Yet there has been no technological unemployment in medicine. Dr. Lippard noted recently that between 1900 and 1950 the number of physicians increased by 58 percent, while in the same period the number of trained health personnel, including dentists, nurses, pharmacists and technicians, rose by 370 percent.

"If this remarkable increase has diminished the need for physicians' services, it has not been apparent," he commented.

Urbanization is another factor tending to increase the demand for medical care, since metropolitan areas always absorb more doctors than rural areas.

In addition, urbanization is accompanied by a general social and economic upgrading of the population. As health consciousness grows, more and more persons can pay for medical care.

This process is accelerated by the spread of prepaid health insurance plans and industrial and union programs. About 123 million persons, three-quarters of the population, are covered by health insurance.

The changing age structure is another factor.

The baby boom of the last few years has widened the base of the population pyramid. However, as life expectancy at birth approaches 70 years, the population is also aging. The median age rose from 23 years in 1900 to 30 in 1950, and there is no reason to suppose that the ceiling of life expectancy has yet been reached.

The implications of these changes are that obstetricians and pediatricians will continue to be in demand and, concomitantly, a growing need will be felt for specialists in the chronic and degenerative diseases of old age.

It has been found, too, that mental and emotional disorders are more prevalent among the elderly and are aggravated by the complexities of urban living.

A specialist estimates that no more than 10 percent of the psychoneuroses, emotional disturbances and disorders of behavior, character, and intelligence are getting competent professional attention.

Medical advances make it possible for a physician to treat more patients in less time, but they also enable him to attack conditions previously thought to be beyond his scope.

As a physician has put it:

"The advent of intrathoracic and intracardiac surgery, new approaches to mental health and the increasing demands for effective control of degenerative diseases impose new demands for the augmentation of health personnel."

The search for an optimum physician-population ratio is hindered by countless unknowns. That is why some physicians and medical educators prefer to look at the problem from a different angle.

Let us forget the ratio controversy and the overall picture, they say, and examine, instead, the measurable shortages as they exist in the supply of medical students, medical teachers, and practitioners in specific areas of medicine.

When this is done, it is seen that in many instances, the demand far exceeds the supply and that virtually unlimited opportunities await the young doctor emerging from internship or residency.

That there is a decline in medical studies can hardly be doubted. This is not necessarily reflected in absolute numbers. Actually, the number of medical schools and students have been increasing.

There are 78 approved, 4-year medical schools in the United States, and 4 approved 2-year schools of basic medical sciences. Three new schools-Florida, Seton Hall in Jersey City, and Albert Einstein in New York-are in the process of development.

A total of 29,130 undergraduates were attending all the schools last year, a record number. The 1956 entering class was the largest ever enrolled, 8,014.

However, medical schools have reported a decrease in the number of applicants. The figure fell from a high of 24,434 in 1950, to a low of 14,538 in 1954, but rose to 15,917 in 1956. The number of applicants for each available place in first-year classes has been at a record low of 1.9 since 1954.

It has been unfortunate for the schools that as the high veterans' demand for medical education subsided in 1952, the small crop of depression babies began to arrive on the college scene.

By 1954 the schools were in the trough of the wave. However, by the mid1960's, when increased enrollments now reported by high schools begin to be reflected in medical school applications, the situation will improve.