need for doctors or of the opportunities present in the study of medicine. Moreover, certain barriers and prejudices which limit enrollments could be removed. The financial barriers which face many prospective students could be overcome by more adequate scholarships or by loan funds. Some qualified students cannot gain admission to medical schools because of tacit racial or religious discrimination. Lastly, there is a great untapped source of future doctors among the women of the Nation. We are unable to discover any compelling reason for the failure of this country to utilize its womanpower to prevent what is claimed to be a serious future shortage of physicians. Other nations have done so; we have simply never tried.

TRAINING FOR DEMOBILIZED PHYSICIANS

The quality of medical education in this country for the past two decades has been very high. The medical schools have rendered outstanding service in the war by increasing the annual output of physicians 30 percent despite serious depletion of faculties and unpredictable Army and Navy policies. But the accelerated undergraduate courses, and the shortened internships and residencies, will make it necessary to provide further supervised training for many recent graduates unless the future quality of medical and dental practice is to be jeopardized. Most of the young graduates are well aware of this. A majority of the replies to a questionnaire recently addressed to medical officers of the Army and Navy indicated a desire for refresher and advanced courses in medicine after the war. Neither the need nor the demand for postwar advanced medical training can be met with the graduate teaching facilities and staffs now available in medical schools. Expansion of such facilities through increased provision of teaching hospitals and medical centers, as part of the program hereinafter described and recommended, will therefore be required.

Many thousands of physician veterans will receive post-graduate training at Government expense under the terms of the G. I. Bill of Rights. Additional financial assistance will be necessary for many of those eligible if they are to avail themselves of training opportunities offered. For example, it is unlikely that a doctor with a wife and two children could maintain himself very long on $75 a month.

DISTRIBUTION OF MEDICAL FACILITIES

The quality of American medicine at its best is very high. Unfortunately, American medicine at its best reaches only a relatively small part of the population. One of the greatest benefits of medern, scientific medicine is the early detection of conditions which, if neglected, may become seriously incapacitating or even fatal. Vast improvement is needed in the application of known diagnostic procedures. Only a negligible proportion of people get a periodic physical check-up. Fifty-five percent of all cases of tuberculosis admitted to sanatoria are in advanced stage of the disease at the time of first admission. In mass chest X-ray studies of presumably healthy workers, at least one in every hundred is found to have significant tuberculosis. Many patients have cancer for months, or even years, before the disease is discovered, and a substantial number of cases remain undiagnosed until cancer has caused death. There is widespread neglect of prenatal care by which both maternal and infant death rates could be considerably reduced.

The reasons for the failure of medicine to apply more widely the known diagnostic and preventive techniques are many and complex. The economic barriers to care are discussed later. Another very important reason is the lack of physical facilities and equipment in many parts of the country. Good medical practice today requires a concentration of skilled personnel and equipment that is found only in good hospitals, medical centers, or group clinics.

Whereas the national ratio of general hospital beds was 3.4 per 1,000 population in the years just before the war, the ratios in such States as Mississippi and Alabama were less than half that. According to the Surgeon General of the United States Public Health Service. 40 percent of our counties, with an aggregate population of more than 15.000,000, have no registered hospitals. Many of the counties with hospitals have poor ones, even though they are registered.

A study conducted by the American Medical Association showed that only 2 percent of the population did not reside within 30 miles of some hospital. Such a study, however, does not indicate the size or quality of the institutions, whether or not they have vacant beds, whether or not patients are financially able to use them, or whether racial barriers or legal requirements concerning residence prevent their utilization by all who live in the vicinity.

DISTRIBUTION OF PHYSICIANS

Shortages of doctors, dentists, nurses, and other medical personnel are marked in many communities, and, in general, medical personnel are inequably distributed throughout the country. For example, in 1944 Massachusetts had about 3 times as many active physicians in proportion to population as did South Carolina. Similar disproportions exist between other States and between local areas within the same State. Counties with more than 5,000 population may be without a single physician, while other counties in the same State may have 1 active physician for each 1,000 people.

Extensive studies conducted by the United States Public Health Service show that the distribution of physicians is influenced by several interrelated factors, among which are community purchasing power, adequacy of hospital facilities, degree of urbanization, proximity to medical schools and teaching hospitals, and presence of professional colleagues. Of these factors, the first three are probably the most significant, and community wealth is probably the most important of all. In 1938, counties with per capita income of more than $600 had eight times as great a proportion of physicians to population as did counties with per capita income of less than $100.

Rural areas are generally less well supplied with physicians than urban areas. Strictly rural counties in 1938 had only about one-third as many physicians in proportion to population as did urban counties. Recent data supplied by the Procurement and Assignment Service show that the 81 counties reported to have no active physician, as well as the 141 counties reported to have more than 5,000 inhabitants per active physician, were practically all rural. The wealthier rural areas are better supplied than are the poorer rural areas, but even the wealthiest group of rural counties in 1938 had 30 percent fewer physicians in proportion to population than urban areas with the same per capita income.

The shortage of physicians in rural communities is not due to less need for medical care than in cities. Studies made by the Farm Security Administration suggest that the burden of illness in rural areas is the same as, or greater than, in urban centers.

SITUATION GROWS STEADILY WORSE IN RURAL AREAS

Despite this need, medical graduates have shown increasing reluctance in recent decades to settle in rural communities. In North Carolina, for example, the number of doctors in strictly rural areas fell from 1,125 in 1914 to 719 in 1940, although the population in such areas increased from 1,960,000 to 2,597,000 in the same period. In 1940, 73 percent of the population of the State lived in rural areas, although such areas contained only 31 percent of the State's physicians. The burden of caring for rural patients falls increasingly on the old practi tioners who, despite sometimes heroic efforts, are frequently unable to do the work demanded of them.

There is no doubt that lack of hospitals and diagnostic facilities is one of the most important factors in keeping doctors away from rural practice. In fact, the presence of hospital facilities alone, independently of such factors as community wealth and size of population, appears to attract physicians. This is suggested by a United States Public Health Service study which shows that among counties with per capita income of less than $300, those with no general hospital beds had 60 percent fewer doctors in proportion to population than did those with 250 or more general hospital beds.

Many crowded war-industry and extra-cantonment communities are also suffering from a severe shortage of doctors. In some places shortages have been relieved by relocation of physicians through the Procurement and Assignment Service of the War Manpower Commission, but in others the situation remains critical and without hope of relief except through assignment of Public Health Service physicians, a proposal which Congress has rejected. Data submitted by the Procurement and Assignment Service show that at the end of 1943, 553 counties had more than 3,000, 141 counties had more than 5,000, and 20 counties had more than 10,000 people per active physician in private practice. In addition, 81 counties, 30 of which had populations of more than 3,000, had no praeticing physician.

The wartime shortages are merely sharper manifestations of the long-standing and steadily growing maldistribution described above. There is every indication that maldistribution will become even more marked after the war unless effec tive steps are taken to reverse the trend. As the older physicians who remain

in rural communities die or retire the situation becomes increasingly critical. Polls of the opinions of young Army and Navy doctors show that the vast majority want specialist training and practice, preferably with a group. Only 122 percent indicated a desire for rural practice. We may therefore expect the younger doctors and dentists to continue to shun the countryside unless they are offered good professional surroundings, including modern hospital facilities and an opportunity to earn a good living. Without such positive incentives the opportunity for better distribution presented by release of medical personnel from the armed services will be lost. More uniform licensure laws are also needed.

THE MEDICAL CENTER IDEA

Hospitals were formerly considered only as places in which to care for the seriously ill, and even today many hospitals are nothing more than that. Modern programs of hospital construction should have as their aim the ample provision of a more inclusive type of hospital service. The subcommittee has studied with interest the growing trend toward utilization of a relatively new type of facility called a medical center, which combines and coordinates the three major aspects of modern medical care-the preventive, the diagnostic, and the therapeutic services. The medical center brings together doctors' offices, diagnostic and laboratory equipment, hospital beds, and preventive work. It furthers group practice by physicians, surgeons, and dentists; encourages experimentation and research; and stimulates dissemination and exchange of medical knowledge.

This principle of combining the preventive, diagnostic, and curative services of medicine into a single functional unit, here called the medical center, has been advantageously applied on a large scale in certain great university centers and in the Mayo, Lahey, Crile, Ross-Loos, Scott-White, and other group clinics. It is also applicable, however, to the smaller-scale needs of rural communities throughout the Nation. The establishment of a network of "outpost clinics," to use the phrase of a representative of the American Medical Association, the creation of "diagnostic centers," as urged by the Surgeon General of the Navy, and the "expansion of the present functions of the hospital," advocated by the spokesman of the American Hospital Association, appear to be expressions of the same basic aim the provision of facilities suited to the practice of modern, scientific medicine.

PLANNED NETWORK OF FACILITIES URGED

Terminology in this field is far from uniform. The Surgeon General of the United States Public Health Service urged development of a coordinated network of four basic types of medical center facilities-the small neighborhood or community "health center," the "rural hospital," the "district hospital," and the large "base hospital." (See cut facing p. 92.)

The physical structures required for many of these four basic types of units already exist in many areas. Here the primary need is for regional planning and organization of the existing facilities so that they might function in a coordinated manner, rather than for the construction of new buildings. In some places, minor alterations, renovations, or addition of new wings, might suffice to convert existing public or voluntary institutions into units of the coordinated regional plan.

The smallest unit, the health center, might include offices for local physicians and dentists; facilities for emergency medical and surgical work; a small number of beds for obstetrical care; laboratory facilities for X-ray, blood, and bacteriological procedures; and health department offices and clinics where these are not otherwise provided.

The rural hospital, located within easy reach of several health centers, would be larger than the health center and would provide additional basic medical, surgical, obstetrical, and laboratory services. The size of the rural hospital would depend upon the needs of the area it served, but it should be a modern hospital in every sense of the word.

Many of the health centers and rural hospitals probably would serve areas which could not support specialists' services of their own. Therefore, such services would be provided through district hospitals, located so that they could conveniently serve several rural hospitals. Local needs and preferences might determine whether the patients from the rural areas were transported to the district hospitals or whether the specialists from these hospitals visited the small units periodically. In most instances the district hospitals would provide nurse training and instruction for interns, including discussion of complex cases and of medical advances.

BASE HOSPITALS

Finally, as the hub of each major medical service area, there would be a large base hospital. In most cases the major service area would be a State, though some States might have more than one major service area, and in some instances a base hospital might serve two States or sections of two States. The base hospital would be a teaching hospital, staffed with experts in every medical and surgical specialty, equipped for complete diagnostic services, and designed to conduct extensive postgraduate work and research. Besides its general hospital beds, it would have, either on its premises or nearby, facilities for institutional care and study of tuberculosis, nervous and. mental disease, contagious disease, and orthopedic and chronic disease. The benefits of the research carried on in the base hospital would be passed on to the smaller units in the network, and there would be constant back-and-forth referral of patients and diagnostic information, as well as interchange of personnel, between the large center and the smaller institutions.

With such graded networks-the health center, the rural hospital, the district hospital, and the base hospital-covering the entire country, facilities would be available through which every person, regardless of where he lived, might receive (a) immediate diagnosis and care for the common, relatively simple ailments and (b) easy access when necessary to the more complicated types of medical service. The development of such a network of medical centers would constitute a great step toward the goal of providing a high quality of medical service everywhere in the Nation. It would enable communities to cope much more adequately with the medical needs of war veterans and their families. It would also create opportunities for group and individual practice for the 40,000 medical and dental officers who will return from the armed forces, as well as for returning nurses and other health personnel.

HEALTH DEPARTMENT CENTERS

Local health departments should be moved from the musty basements of county courthouses and city halls to modern, well-equipped buildings where the health officer and his staff could efficiently carry on their very important activities.