I urge the Health Subcommittee and the full Labor and Public Welfare Committee to take early and favorable action on this muchneeded measure.

Today, we need approximately 50,000 additional physicians to adequately meet the health needs of this country. Citing the national picture reveals the total problem, but one has to focus on certain communities to really appreciate the critical urgency of the problem and to understand why action by this subcommittee and the Congress in response to the physician shortage problem is called for now.

There are many communities in this country that are one-physician towns, and, even worse, there are communities that right now are nophysician towns. Furthermore, the evidence suggests that tomorrow, many of today's one-physician towns are in danger of becoming nophysician towns. S. 4208, I believe, is a workable and needed response to this problem.

The physician-shortage problem is more than just numbers, although additional numbers of physicians are needed; to solve the problem, we must also deal with the distribution-of-doctors problem so that doctors will go and practice in the areas that need them the most. For example, Los Angeles County has a physician-patient ratio of 1 to 600. On the other hand, in Watts and East Los Angeles, the physician-patient ratio is 1 to 3,000. S. 4208 will attempt to direct doctors into the areas where they are needed the most, whether this area is a poverty area of a large city, a migrant community, or an isolated rural community.

Under S. 4208, scholarships would be provided to young men and women who agree to practice medicine in areas designated as physician-shortage areas, or who agree to serve migrant agricultural workers and their families. For each year of the scholarship, 1 year of service would be required by the student in physician-shortage areas. Intern and residency fellowships would also be granted.

Mr. Chairman, surveys have indicated that over 25 percent of doctors practice in areas in which they were reared. In addition, we know that once a doctor establishes his practice, he is unlikely to move.

Based on this information, I have provided for priorities in awarding the scholarships. These priorities are (1) students from lower income families who reside in physician-shortage areas and who agree to return to those areas to practice; (2) other individuals from physician-shortage areas who agree to return to those areas to practice; (3) persons from lower income families who reside in non-physician-shortage areas who agree to practice in physician-shortage areas; and (4) other individuals who agree to practice in physician-shortage areas. An added advantage, but not the primary purpose of this measure, would be, since lower income students are given priority, the attraction of more minority youngsters into medical schools. I am convinced that if we can attract youngsters from the physician-shortage areas, and provide them with scholarships in return for service in such areas that we will have a big step in solving the the manpower distribution problem.

This measure has the support of the California Medical Association as well as many deans of the medical schools in my State.

There are many health problems in the Nation. One thing, however, is certain. Unless we solve the medical manpower problem, we have

little chance of solving the other health problems of the Nation. That is why action is needed now to lay the groundwork for providing the medical manpower needed to meet the rising health demands of the country.

Mr. Chairman, I have spent a great deal of time and research in this area, and I know time does not permit me to go into all the facts and rationale for S. 4208. I would, therefore, urge that the committee carefully study the complete text of my introductory floor statement of August 10. I would like to ask, Mr. Chairman, that my remarks on that date be printed in the record.

Thank you.

[From the Congressional Record, Washington, Aug. 10, 1970]

S. 4208-INTRODUCTION OF THE "FAMILY PHYSICIAN SCHOLARSHIP AND

FELLOWSHIP PROGRAM ACT"

Mr. MURPHY. Mr. President, I introduce today the "Family Physician Scholarship and Fellowship Program Act." The bill is cosponsored by my colleagues, Senators Prouty, Dominick, Javits, and Saxbe.

Under this measure, family physician scholarships and fellowships would be offered to young men and women who agree to practice in areas designated as physician-shortage areas or to serve migratory agricultural workers and their families. For the first year, approximately 500 scholarships and 200 fellowships would be offered at a total cost of $4.5 million. The number of scholarships and fellowships would be increased until by the 4th year 1,000 scholarships and 500 fellowships would be authorized. In addition to migrant areas, these areas may also be an isolated rural community, an Indian reservation, or a poverty area of a central city. The basic purposes of the bill are:

First, to help with the physician-shortage problem in general;

Second, to encourage and increase the number of individuals entering the family physician specialty in particular;

Third, to attack the problem of the maldistribution of physicians by encouraging the location of doctors in physician-shortage areas;

Fourth, to increase the number of lower income and minority individuals in the medical profession; and

Fifth, to tap the idealism, social commitment, and energies of youth to serve where the medical needs of the country are the greatest.

Scholarships not to exceed $5,000 would be available to individuals agreeing to serve in physician-shortage or migrant areas. For each year of the scholarship, 1 year of service is required in a physician-shortage or migrant area.

Two types of postgraduate fellowships, intern and residency, are also provided. Since attracting medical school graduates into physician-shortage areas for their graduate work is a desirable goal in itself, no additional service requirement is demanded under the fellowship program. The fellowship program, then, will assist in providing needed medical assistance to physician-shortage areas or to the migrant population. Since there is a correlation between practice location and the location of internship and residency programs, this fellowship program should be a positive influence in attracting and hopefully attaching the doctors to physician-shortage and migrant areas.

As an inducement to encourage those who have been in the scholarship program to continue in the fellowship program, a year of their service obligation under the scholarship program is eliminated for those who complete their postgraduate work in this manner.

In keeping with the purposes of the measure, the following priorities for selecting individuals for the scholarships-and fellowships are provided:

First, individuals from lower income families who reside in physician-shortage areas and who agree to return to those areas to practice;

Second, other individuals from physician-shortage areas who agree to return to those areas to practice;

Third, individuals from lower-income families who reside in nonphysicianshortage areas who agree to practice in a physician-shortage area; and

Fourth, other individuals from nonphysician-shortage areas who agree to practice in a physician-shortage area.

PHYSICIAN SHORTAGE PROBLEM IN GENERAL

Mr. President, today it is estimated that the need exists for 50,000 additional physicians. According to the Public Health Service, approximately 297,000 physicians were actively engaged in practice in 1966 and 50,000 were needed to meet increasing demands for health care. This survey estimated that 400,000 physicians would be required by 1975 to meet demands for personal health care, for teaching, research, medical administration, and public health and military service. Yet, the U.S. Public Health Service warned:

"The output of U.S. medical schools at presently planned levels, even with the continued immigration of foreign physicians, will provide no more than 360,000 physicians by 1975, a figure far short of meeting estimated needs."

Mr. President, I ask unanimous consent that a Library of Congress chart illustrating physician needs be printed in the RECORD at this point in my remarks. There being no objection, the chart was ordered to be printed in the RECORD, as follows:

Mr. MURPHY. Mr. President, the National Advisory Commission on Health Manpower in its November 1967 report said this about the physician shortage: "The Commission believes that there is currently a shortage of physicians, and this shortage will worsen in relation to the growing demand, despite the expected shortage in the supply of physicians in the years ahead.

This Commission cited a number of factors responsible for the physician shortage, one of which was the continuing trend toward specialization. As the Commission stated:

"Specialization has decreased the number of physicians available to provide care for the entire family, and has resulted in a reduction of the number of persons seen per family."

FAMILY PHYSICIAN SHORTAGE IN PARTICULAR

Mr. President, my bill responds to these developments. It does not yet respond to the physician shortage problem in general; its focus and thrust is aimed at the family physician shortage in particular. One of the measure's primary purposes is to reverse the alarming decline in the percentage of physicians in family practice. In 1931, 75 percent, or three out of four, of the doctors in the Nation were family practitioners; only 15 percent specialized. By 1949, or nearly two decades later, only 50 percent of the doctors were in general practice with 29 percent specializing. By 1967, again approximately two more decades later, only 21.3 percent, or approximately one out of five of the physicians were in general or family practice. According to figures in the report of the Citizens Commission on Graduate Medical Education, known as the Millis Report:

"In recent classes of medical school graduates, only 15 per cent have planned to enter general practice."

The trend is obvious; in my judgment, it must be reversed, if our health care system is to enjoy optimum health.

Recent testimony before the Senate Health Subcommittee indicated that the family physician "is capable of treating 85 percent of the illnesses that beset mankind." Yet, indications are that only 15 percent of our medical students will become family practitioners. Thus, it seems clear to me that we need more family physicians, capable of treating the "85 percent of the illnesses besetting mankind." Even in this age of specialization, the family doctor is a critical and central figure. I believe these statistics should make that self-evident.

My bill, Mr. President, then would recognize the primary role of the family physician. It seeks to reverse the trend away from family practice by providing scholarships for young people who want to become family physicians. Recent developments, including the following, convince me that we can attract more medical students into family practice:

First. The AMA approved the essentials for graduate training programs in family practice, December 1968;

Second. The American Board of Family Practice was established and approved in 1969 making family practice a specialty;

Third. The American Board of Family Practice offered examinations for cer tification of practice to eligible candidates in March 1970;

Fourth. A Residency Review Committee for Family Practice has been established and has members from the AMA Council on Medical Education, the American Council of General Practice, and the American Board of Family Practice; and

Fifth. Legislation, S. 3418, which has been introduced by Senator Yarborough and cosponsored by me and which will provide grants to medical schools to establish programs in the family practice, was recently reported to the full Senate by the Labor and Public Welfare Committee.

My bill recognizes that there will not be enough graduate programs in the family physician specialty immediately, and therefore properly makes other primary-care physicians-pediatricians, obstetricians, and internists-eligible for the fellowship programs.

MALDISTRIBUTION OF DOCTORS

Mr. President, my measure has a sharper focus than merely providing more doctors, although more doctors are needed. My bill specifically focuses on the family-physician shortage and also addresses itself to the critical problem of the distribution of doctors. Some suburban communities have adequate numbers of doctors, while many rural areas or poverty areas of our cities may not have a single physician. My research reveals that in some areas of Los Angeles near the U.S.C. medical school, the ratio of physicians is one to 3,000 patients whereas the county average is one to 600. This means that in the East Los Angeles area and the Watts area, it is five times as difficult to find a doctor as it is in Los Angeles County. My proposal is an attempt to move doctors into the Watts and East Los Angeles areas and other areas of the country where they are needed the most.

Dr. B. L. Bible, who is on the staff of the Department of Community Health, Division of Health Services, American Medical Association, in a January 1970 article stated:

"Because of the tendency of physicians, like other professionals, to settle in urban areas, and because of the problems in communities and transportation experienced by rural dwellers, rural people, particularly those in isolated areas, have only one-half the access to physicians and other health resources that the rest of the nation has."

The Library of Congress, which has been so helpful to me in gathering background information on this proposal, attempted research on the number of communities across the country without a physician. It reported that:

"Little research has been published on physician-shortage in small communities, and definitive statistics indicating the number of communities across the country without physicians could not be located."

My attention, however, was directed to a 1965 survey of more than 1,600 towns and cities in Minnesota, North Dakota, South Dakota, and Montana. The survey's investigators found that more than a thousand of the towns studied had no physician and 224 towns had only one physician. The physicians were usually older in relation to the rest of the physicians in the State. A median age of physicians in one-physician towns was 55 in Minnesota; whereas the median age of the total physicians in the State was 46.5. In North Dakota the median age of physicians in one-physician towns was 54; the median age of the total number of active physicians in the rest of the State was 41. In South Dakota the median ages were the same. In Montana the median age was slightly younger.

The size of the town and the physician's age were also related. The smaller the town, the older the physician for the most part. In towns of less than 500 in population, the median age of the physician was 58; in towns with population of between 501 and 1,000, the median age was 47; the median age was 44.5 in towns of 1,001 to 1,250 population. This survey not only identified the 1,000 towns without a physician-towns which would soon become no-physician towns as the older physicians die or retire. These communities, unless we provide the incentive, are not likely to attract replacements for their older doctors.

My proposal, as I have indicated, has built-in various inducements to deal with the distribution problem. First, the scholarships are only available to students who agree to serve in physician-shortage and migrant areas. Years of ex

pensive education are thus provided in return for a commitment by the student to serve in these areas. Students are also encouraged to continue their postgraduate service in physician-shortage areas by the offering of competitive intern and residency fellowships.

A recent report published in the Public Health Reports in January 1970 discusses the question, how does the physicians select a location for his practice? It is based on a research project sponsored by the American Medical Association's Council on Rural Health. A random sample was taken of "all physicians in private practice who reside in nonmetropolitan counties of the United States" as available in AMA records. The random sample totaled 2,468 such physicians. Significantly, over 25 percent of the physicians surveyed in response to the question of how they decide upon their present practice location indicated that they were practicing in the area in which they were reared. That is why in designing my priorities, I have given first and second priority to students from physicianshortage areas. The study's results also indicated that "once a physician establishes a practice, he is unlikely to move." The study went on to say:

"At least 63 per cent of the physicians had not moved from their original practice location. This percentage was consistent regardless of community size. A more detailed breakdown of the area showed that about one-fourth of the physicians in non-metropolitan areas had practiced twenty years or more in the same place."

This same report indicated that:

"Physicians who practice in small towns are more likely to have rural rather than urban backgrounds . . . rural physicians have predominantly rural backgrounds and metropolitan physicians generally had urban locations during their youth."

The following hypothesis was offered:

"Physicians who practice in small towns are likely to have rural backgrounds." Statistics from the report indicated that 49 percent of the physicians surveyed who were practicing in communities of less than 2,500 were raised in a small town. Therefore, the study concluded:

"Physician recruitment for rural areas would be enhanced if more young men with rural backgrounds were encouraged to enter the medical profession."

Based on this information, and I believe what commonsense would tell us, I have designed the priorities for the scholarship and fellowship program so that first choices would come to individuals from physician-shortage areas. I believe if we can offer them a scholarship and in turn secure from them a commitment to spend 4 years in an area, they will be more likely to continue to practice in that area after their obligation ends.

Furthermore, we also learned from this information that the longer we can attach a physician to an area, the more likely he is to stay there. Who could be greater motivated than a man or woman from an area to serve the people from the vicinity in which he was reared?

ATTRACTING LOWER INCOME AND MINORITY STUDENTS

Mr. President, there is a need in the country to attract more lower-income and minority youngsters into the medical profession. An additional and attractive feature of my bill is that it would have the effect of attracting more of these young adults into the medical profession.

In its 1968-69 survey of medical education, the American Medical Association asked the medical schools to report the racial origin of its medical students. Ninety-six out of 99 schools replied. Although the results may not be completely valid because most schools do not require their students to report their race, the survey said:

"Of the total medical school enrollment of the 96 reporting schools, 2.2% are Afro-American. Excluding the two predominantly Negro schools, only 0.8% of the total enrollment is Afro-American. Three regions, East North Central, South Atlantic, and Pacific, show a 1% Afro-American enrollment. The Pacific region also has a 6% Oriental enrollment. The Mountain region, which has 0.1% AfroAmerican enrollment, shows a 2% Oriental enrollment. The East North Central region has a 1% Oriental enrollment. Only the West South Central region has as much as 1% Mexican-American student enrollment in its medical schools." President Nixon in his outstanding Indian message of July 8 to the Congress said:

"Almost unbelievable-we are presently able to identify in this country only thirty physicians and fewer than four hundred nurses of Indian descent."