STATEMENT OF DR. ROBERT C. BERSON, MEDICAL COLLEGE OF ALABAMA, BIRMINGHAM, ALA.

Dr. BERSON. Thank you.

Mr. ROBERTS. Doctor, it is certainly a personal pleasure on my part to have you appear before us today. We from Alabama are certainly grateful to you for the fine work you have done and are doing in establishing our 4-year medical college, and the possibilities for a medical center which we need there, and we are very grateful to you for coming.

Dr. BERSON. Thank you, sir.

I think you have already adequately identified me. Today I am here to speak on behalf of the Association of American Medical Colleges as well as myself and my institution. I am a member of the executive council of that organization, and my mission is to speak primarily to the scholarship bill.

I have a written statement that I would like permission to introduce into the record and then make my verbal statement very simple and short.

Mr. ROBERTS. Without objection, that will be done. (The document referred to follows:)

STATEMENT REGARDING THE NEED FOR SCHOLARSHIPS FOR MEDICAL STUDENTS SUBMITTED TO THE COMMITTEE ON HEALTH AND SAFETY OF THE HOUSE OF REPRESENTATIVES ON INTERSTATE AND FOREIGN COMMERCE ON BEHALF OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES

For the record, I would like to identify myself as Robert Berson, dean of the medical college and vice president for health affairs of the University of Alabama. I am here to speak on behalf of the Association of American Medical Colleges in support of legislation to provide scholarships for medical students. With the permission of the chairman I would like to submit a written statement which contains some relevant figures I believe will be useful and interesting reading and to make a brief statement.

It is a pleasure to appear before this committee whose chairman and members have done so much to encourage the Congress to provide the encouragement and support which have been so important in the tremendous advances in scientific knowledge and improvement in health during the recent past. The fact that you are now considering a program to provide scholarships for medical students as a step toward assuring an adequate supply of physicians to apply this scien tific knowledge for the benefit of future patients is further proof of your thoughtful and farsighted concern for the future health of all the people of this country and indeed of the world. The Association of American Medical Colleges believes such a scholarship program is of prime importance for a number of reasons.

In the first place there is general agreement that the growth of population in this country in the 1960's and 1970's will produce a decline in the ratio of physicians to population unless substantial steps are taken to increase the supply of physicians. This phenomenon has been well documented in the report of the Bane committee1 in the fall of 1959 and the report of the Committee of Consultants on Medical Research under the chairmanship of Dr. Boisfeuillet Jones in May 1960.

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While the question of how many doctors per 100,000 people there should be in an ideal situation does not lend itself to a precise answer, I know of no thoughtful individual or organization who would dispute the statement that

1 Physicians for a Growing America Report of the Surgeon General's Consultant Group on Medical Education-U.S. Department of Health, Education, and Welfare, Public Health Service, October 1959.

2 Federal Support of Medical Research-Report of the Committee of Consultants on Medical Research to the Subcommittee on Departments of Labor, and Health, Education, and Welfare of the Committee on Appropriations, U.S. Senate, 86th Cong., 2d sess., May 1960.

the medical needs of our people will be less well met than they are at the present time if there is a decline in the present ratio of approximately 140 physicians per 100,000 people.

The second major point I want to emphasize is that the indispensable ingredient in the supply of physicians is the competent student entering medical school and successfully completing the educational program. The modern medical school is a complex organization which carries on a number of activities of great value to society. The educational program is somewhat involved and quite exacting because the body of scientific knowledge potentially useful in the care of patients is enormous. But unless the medical schools, individually and collectively, admit an adequate supply of competent students they will not be able to maintain their present output of physicians much less increase that output to meet the growing needs of our country.

At the present time the number of students applying for admission to medical schools in the country as a whole is declining and has declined for 10 years to such a point that in the class entering in 1959 there were only a total of 1.8 applicants for each place in the medical schools of this country. This phenomenon is unevenly distributed with some schools popular with students continuing to receive a large number of applications but with other quite adequate schools having such a small number of applicants as to make it doubtful whether they can or should fill their entering classes. It is worthy of emphasis that any college student may apply for admission to medical school whether he has taken the required courses, has been a competent college student, or has shown any evidence of the interest, dependability, and intelligence obviously necessary for a future physician. For this reason, the total of 1.8 applicants for each place in the medical school entering class includes a considerable number of people obviously unsuited.

In the third place there is a good bit of evidence that substantial numbers of students who would do well in the study of medicine are being attracted into competing careers in other fields of science and that financial support provided by agencies of the Federal Government is an important factor in this trend.

For example, the Federal Government now provides scholarships for every field of higher education in the sciences except medicine. During the coming year approximately 10,000 predoctoral fellowships in the physical, life and social sciences, psychology, engineering, the arts, the humanities, and education will be awarded by four Federal agencies-the Department of State, the National Science Foundation, the Office of Education, the National Institutes of Health. These fellowships give the graduate student free choice of the institution in which he will study; they provide him a stipend of $1,800 to $2,500 with a $500 allowance for each dependent, plus travel allowance; they pay full tuition and in some instances they provide an additional subsidy to the institution. A great many universities provide other types of fellowships and scholarships for Ph. D. candidates in the scientific fields, and many of them obtain part-time jobs as assistants on research projects or laboratory assistants in the scientific departments. These jobs fit into their training and usually do not interfere with their progress toward a degree. The successful candidate for Ph. D. has good job opportunities available immediately upon graduation.

In contrast the Federal Government makes no fellowships available to medical students. The medical schools themselves have but little scholarship support to offer students. Most of the jobs that medical students can hold while in school do compete seriously for the time and effort they should be putting into their studies.

For these reasons a good college student has a choice between undertaking graduate study in one of the scientific fields with immediate financial support and good job opportunities, as soon as he has received his Ph. D. degree, or entering medical school where he will receive little if any financial support, will incur expenses ranging between $9,000 and $16,000 during the next 4 years and when he receives M.D. degree entering a further period of training as an intern and resident for from 3 to 5 years. During this latter period the financial support he will receive averages less than that available to graduate students through Federal programs immediately after graduation from college. Under these circumstances it should not be surprising that the number of graduate students is increasing rapidly-68 percent in the last 6 years, while the number of applicants to medical schools is declining.

The point is sometimes made that a medical student can look forward to such a large financial return as a practicing physician that he should be willing to

make considerable sacrifices if necessary to obtain a medical education. While it is true that a successful practicing physician earns a substantial income from the time he becomes well established and successful until he begins to slow down because of age, illness, or the increasing success of other physicians, there are two important qualifications. In the first place the typical student entering medical school has never had a chance to hold a fulltime job, so his resources at that time of life are limited to those his family can make available. Families of very limited means simply cannot provide the money their children would need to study medicine whatever the incentive of future success may be. In the second place one out of five physicians in this country is engaged in teaching, research, the Armed Forces, State-supported hospitals for mental illness or tuberculosis, departments of public health, and similar service activities of the greatest importance to the health of the Nation, but activities which provide very modest financial returns throughout the doctor's career. There is at the present time

a desperate need for more physicians in these activities and this need is likely to grow.

For these reasons the Association of American Medical Colleges believes it is in the public interest for the Congress to adopt legislation that will provide financial assistance to medical students. It believes that this program of financial assistance should, (1) leave students free to select the school of their choice, (2) impose no obligation upon the student's postgraduate training or practice prerogatives, (3) be sufficient so that the student is not forced to turn to extra-curricular work to the detriment of his studies, and (4) be sufficient so that on graduation his accumulated debt does not unreasonably hamper his further education or his choice of a career in the public interest, although it may provide only a modest financial return to himself.

The association would also urge that the program of financial assistance provided by Congress follow the pattern established by the National Science Foundation to support training in the biological sciences, rather than requiring matching funds provided by each of the States. Not quite half of the medical schools in this country are State supported. The medical schools are very unevenly distributed among the States-nine States having no schools and several States having more than one-and we are convinced that the interest and ability of the States to provide such matching funds and programs are also very unevenly distributed.

Within a few years the increased birth rate which began during World War II will be reflected in a great wave of young people sweeping into our colleges and universities. If at the same time the opportunity to study medicine can be offered to students even though their families may be of modest means and a greater effort can be made to present to young people in the high schools and colleges information concerning the opportunities for service, the challenge, satisfactions, and rewards of careers in the medical field, the number choosing medicine as a career can be expected to increase.

In our opinion this scholarship program is a sound and fundamentally important step toward providing this country with an adequate supply of doctors to bring the great advances in science to the aid of individual patients.

Dr. BERSON. You can take the view that the object of research is to produce knowledge that will be useful in helping the general public with its health problems. The fact is that in our country we face a shortage of physicians as the population increases. Every projection of the increase in output of medical schools indicates that it is going to fall far shorter than the increase in the population as a whole. The fundamental point is to get a good physician at the end of the educational term. There has to be an adequate supply of competent students entering the program.

In our country the number of people applying for admission to medical schools has been declining for 10 years and is still declining. In this year the total number of students applying is 1.8 applicants per place in all of the schools of medicine. This shortage of applicants is very unevenly distributed. Some of the popular schools have a very large number of applications from good students, and some other schools that are really perfectly adequate have such a small

number of qualified applicants that there is a serious question as to whether they should fill their class in the fall.

Out of the total number of people who apply for admission, not nearly all of them are well prepared. Some of them have been very poor college students. Some have not taken the proper courses that are required, and some of them have not demonstrated the characteristics of intelligence and diligence, the personal attributes that everyone knows is needed in a physician, so that right now we have gotten to the point where the supply of good students entering medical schools is barely adequate for the present output.

If we are going to keep up, if we are going to keep the present supply of physician-population, there is going to have to be an increase in the capacity of the schools, and fundamental to this is an increase in the number of good applicants.

In the same period an increasing number of talented young people have been attracted into graduate study in scientific disciplines, and some of the programs of the Federal agencies have certainly played a part in this. In the last 6 years the number of people studying for Ph. D's in scientific disciplines has increased by 68 percent, and next year 4 agencies of the Federal Government will offer 10,000 fellowships to graduate students that pay them from $1,800 to $2,500 a year plus $500 per dependent, some travel allowance and tuition. In addition to this, many universities and other agencies also offer scholarships, fellowships, for graduate study in the scientific fields, and it is not surprising that a good many talented young people in college, considering the choice between becoming a graduate student and having this sort of financial support at once or the alternative of going to medical school, facing personal expenditures of between $9,000 and $16,000 in the 4-year period, at which they end up as an intern or a resident at very low remuneration, a number of these young people are deciding on graduate study.

The position of the Association of American Colleges is that it is in the national interest to establish a scholarship program so that talented young people whose families may not be well off can have the option of studying medicine if they so desire and if they are considered suitable.

The association, rather than talking to the specific bills, would like to urge that the scholarship program leave the student free to select the school of his choice, impose no obligation upon his postgraduate training or practice prerogatives, be sufficient in amount so that the student is not forced to turn to extracurricular work in order to keep alive, and be sufficient so that upon graduation he won't be so deeply in debt as to hamper his opportunity to choose a career in the public

interest.

Sometimes the point is made that a practicing physician does so well financially that a medical student should be willing to go through a period of economic hardship. This should be qualified to some

extent.

In the first place, the student at the time he goes to medical school typically has never had a full-time job. Therefore, the only resources he has are those that his family can provide, and families in very limited circumstances simply cannot put up the kind of money that it takes.

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Another point is that a very substantial number of physicians are not engaged in private practice which is very rewarding, but are engaged in activities of great importance to the public good, in the armed services or the Federal programs, in health departments, in mental and TB hospitals, in teaching and research, and they are badly needed in many other positions that are not very rewarding to the individual personally at any stage in his career.

So, for these reasons, the association and I think the scholarship program is of fundamental importance.

The need will increase in our opinion, and it would be logical for the Federal Government to institute programs that do provide this type of financial support.

would be happy to try to answer any sort of questions you would like to ask.

Mr. ROBERTS. Thank you, Doctor.

I want to express the appreciation of the subcommittee for your statement. You made a very fine contribution to the work of our committee.

You mentioned the cost, and I would like to know if you are prepared to give us some figures of what a medical education costs.

Dr. BERSON. Yes. Actually, the association has conducted some studies and compiled a great many statistics from the graduates of medical schools last year. Of course, it makes a lot of difference whether the student is married or single. A great many students are married.

The cost ranges between $9,000 in the 4-year period for the typical unmarried student to $16,000 in the 4 years for the typical married student.

Mr. ROBERTS. Of course, that assumes that he comes to the school ordinarily with an A.B. degree?

Dr. BERSON. Yes. Actually, almost all of the students now enrolled have a bachelor's degree although some medical schools will accept students after 3 years of college and without a degree.

Mr. ROBERTS. What do you estimate as the additional cost that that would add to this $9,000 to $16,000?

Dr. BERSON. Getting his A.B. degree? I don't have very firm figures on that. I think it is less expensive in that earlier 4 years and that the range is wider because the cost in some colleges is substantially more than others.

Mr. ROBERTS. And then, of course, after the 4-year period he becomes an intern and then goes through a period of residency usually at a local hospital. How much more time does that take?

Dr. BERSON. The internship is 1 year. The average young physician spends 3 years in hospital training, some completing their training in 1 year or going into practice after 1 year, and, of course, others go through much longer periods of training.

Mr. ROBERTS. Of course, then, if he goes into private practice, he has to equip his office for that purpose, and that is an expensive operation, in itself.

Dr. BERSON. That is correct, and there are some types of private practice that are much more rewarding financially than others.

The picture of the prosperous physician has really been produced by the successful, mature, well-established practitioner, and in any com