In 1955 the total college enrollment was 2,755,000. This is expected to rise to 6,443,000 by 1970. Will medical schools be able to squeeze an additional 2,000 students a year out of the increased number of college students?

The answer probably is "yes," but there are grounds for concern.

In 1920 medical schools had 2.4 percent of the total college enrollment. Now, they have 1 percent. It is estimated that by 1965, the figure will be 0.6 percent. It is here that the falling away from medical studies becomes apparent.

There also seems to be a deterioration in the quality of students applying for medical school.

The number of college students entering medical school with grade A averages has decreased from 40 percent in 1950 to 16 percent in 1956, while the number of students with grade B averages has increased from 43 to 70 percent.

The major, privately owned medical schools drawing students from colleges across the Nation have felt no pinch. Theirs is the pick of the crop.

Harvard, for instance, received 10,560 applications last year for the 115 places in its first-year class. As each applicant had filed an average of 7.7 applications to different medical schools, Harvard's share worked out to 1,371.4, or 11.9 for each available place.

Most State schools have geographical restrictions compelling them, either by custom or law, to reserve all or most places to residents.

Medical educators admit that the national average of 1.9 applicants for each available place leaves little room for complacency. It means that too many schools must scrape the bottom of the barrel.

What is keeping good students away from medicine? Any answer involves speculation. Several contributing factors have been suggested, including the following:

The high cost of medical education.

The long grind involved.

The lure of science and industry.

The decline of learning in general.

The insecurity and hardships encountered by practicing physicians.

Racial and religious discrimination.

A medical education is the most expensive. The minimum time required to complete it is 8 years beyond high school, 3 years of college, 4 years of medical school and a year of internship. However, 75 percent of first-year medical students in 1955 had 4 years of college behind them.

A medical education for certification as a specialist may take 12 years or more, for the specialist must normally complete at least 3 years as a resident in an approved hospital.

Eight years of premedical and medical education cost up to $13,000. The median cost of 4 years of medical school is $7,200, and is increasing.

Is medicine, then, a rich man's profession?

Not necessarily, for scholarships and student loans are available at most medical schools. A wide range of employment opportunities exists for students and their wives.

Medical educators are, however, unanimous in the belief that more financial assistance is needed.

A college student with insufficient motivation may be deflected from medicine when he considers the arduous road that leads to distant licensure and certification. Many students and ex-students of medicine insist, however, that medical school may be a most satisfying experience.

LURE OF INDUSTRY

The lure of science and industry does not appear to be as great for the potential medical student as may be thought. The prestige of the physician is not as great as some persons think. The physician's prestige is not exceeded by that of the engineer or industrial scientist. His financial rewards are usually comparable.

Besides, many students choose medicine in preference, not to other scientific pursuits, but to law, theology or teaching. For medicine belongs to the social as well as the physical sciences.

On the other hand, the general softening of scholastic endeavor in high schools and colleges has been as prejudicial to medicine as the basic sciences. It is hard to tell how much native talent and intelligence is lost to advanced scientific studies simply because the groundwork has not been laid.

In 1953,

Yet, despite their complaints, physicians live better than most. the average physician in private practice earned $15,000. For lawyers, the figure was $9,392; dentists, $8,500, and public school teachers, $3,615.

REGARDING DISCRIMINATION

The charge that good students are lost to medicine through racial and religious discrimination in admission policies is hard to substantiate because the discrimination, if it exists, is never admtted.

Two medical schools, Howard in Washington and Meharry in Nashville, Tenn., are primarily for Negroes. The Woman's Medical College in Philadelphia admits only women.

A 1953 study showed that a student wanting to enter medical school in New York State stood a better chance if he was Protestant rather than Catholic, or Catholic rather than Jewish. It was noted, however, that the findings were not proof of discrimination.

Geographical discrimination sometimes works to the detriment of ethnic groups. Many private medical schools make a conscientious effort to achieve national representation in student bodies.

Thus, an applicant from Wyoming or another State having no medical school may be taken in preference to an equally promising applicant from New York. However, the New York applicant is more likely to be a Jew than his competitor from the West.

Discrimination may keep Negroes out of medical school even in the North. Inferior educational opportunities and lack of funds also are factors.

Internship and residency are an essential part of medical education. However, increasing amount of medical care is being dispensed by interns and residents. They constitute the majority of house staffs in the 867 hospitals offering approved internships and 1,202 offering approved residencies.

However, 2,013 of the 11,616 approved internships available in 1955 were vacant. Of the 26,516 approved residencies, 5,091 were vacant.

Without a constant influx of foreign physicians and American graduates of foreign medical schools, the shortage of house staffs would be more pronounced. In 1955, there were 2,293 foreign interns and 5,580 foreign residents in American hospitals.

New York State reported 2,005 foreign physicians serving as interns and residents, about a quarter of the total. In New Jersey, about 68 percent of hospital house staffs were foreigners.

Foreign medical schools as a rule do not come up to American standards. Many patients, therefore, are being cared for by graduates of substandard medical schools. This situation has been described as reminiscent of the diploma-mill era 50 years ago.

The number of graduates of foreign medical schools entering the United States medical profession on a permanent basis increased from 308 in 1950 to 907 in 1955. The latter figure represents the output of 11 United States schools of median size.

In 1955, there were 1,863 Americans enrolled in medical schools outside the United States and Canada. The number of foreign students enrolled in United States schools was 375. The difference represents the capacity of 4 United States schools of median size.

The shortage of medical teachers has become serious. Last year, medical schools reported 331 full-time faculty positions unfilled, a substantial increase over the 251 reported in 1956.

Efforts of several States to encourage young doctors to practice in rural counties testify to the physician shortage in remote areas. In most cases the encouragement takes the form of financial assistance to medical students in return for an undertaking to practice for a specified time.

The physician-population ratios vary greatly in regions and States. The Northeast States, for instance, are much better supplied with doctors than the South.

Among the States, New York has the highest ratio, 1 physician to 485 inhabitants. Mississippi has the lowest, 1 to 1,305.

DISTRIBUTION A PROBLEM

The need for better distribution to help areas not yet adequately supplied has been listed by the Association of American Medical Colleges as a factor calling for an increased number of physicians.

Acute physician shortages also are reported in the medical specialties, especially mental health. State mental hospitals now need more than 3,700 additional physicians.

A similar situation exists in public health. A 1951 study showed 458 medical vacancies in State and local health departments. The American Public Health Association believes the number of vacancies has "substantially increased" since. The available evidence, therefore, suggests that the recent workshop conference erred in stating that the demand for physicians' services and the supply were "about in equilibrium."

The conference conceded, however, that the need for more physicians might exceed the demand.

Federal programs to stimulate new medical teaching facilities and assist medical students have been proposed as a way of increasing the supply of physicians.

Most medical schools have indicated that they would apply for Federal matching grants for expansion purposes if the necessary legislation, now in preparation, were enacted.

Contemplated construction projects, costing about $400 million could then be undertaken over a period of 5 years. About three-fifths of the cost would be

chargeable to teaching and the rest to research.

Schools estimate that expanded facilities may enable them to accept as many as 1,850 more first-year students. This would be a long step in the right direction. However, most medical educators believe a more concerted effort is needed.

Mr. WILLIAMS. We appreciate your appearance and the testimony you have given, Mr. Fogarty.

Mr. FOGARTY. Thank you, Mr. Chairman.

Mr. WILLIAMS. At this time, I am pleased to turn the hearings over to our old friend, Dr. Ward Darley, executive director of the Association of American Medical Colleges, who will act as master of ceremonies in the panel disussion this morning.

Dr. Darley, we are pleased to have you and your associates here. If you will, we would be very happy for you to proceed in your own way after introducing for the record the members of the panel who are present.

Dr. Darley.

STATEMENT OF DR. WARD DARLEY, EXECUTIVE DIRECTOR OF THE ASSOCIATION OF AMERICAN DENTAL COLLEGES

Dr. DARLEY. Thank you very much, Mr. Chairman.

First, we wish to express our appreciation for the hearings that are being held today and tomorrow. I think you will find that the panel will not be speaking to any specific bill, but rather to the principle of extending the Research Facilities Construction Act and, in addition, providing for the construction of educational facilities in the field of health education.

The individuals on the panel this morning can be easily identified, because we have nameplates in front of each one. The first to speak will be Dr. John Deitrich, the dean at the Cornell University School of Medicine. The next will be Dr. Hugh Hussey, professor of medicine at Georgetown University.

Incidentally, Dr. Hussey is the new dean at Georgetown University, beginning July 1, and he is also a member of the board of trustees of the American Medical Association.

Dr. E. L. Stebbins, the dean of the School of Hygiene at Johns Hopkins University.

Dr. Francis Herz, dean of the College of Physicians and Surgeons Dental School in San Francisco.

Dr. Harry Lyons, the dean of the Dental School at the Medical College of Virginia.

And Dr. C. V. Rault, the dean of the Dental College at Georgetown University.

Then, finally, Dr. Wallace Sterling, the president of Stanford University, who is also on the Advisory Council of the Health Research Facilities Council for the National Institutes of Health.

Present in the audience we have certain staff members who will be glad to answer questions that fall in their area.

The panel will assume that everyone is aware of the effectiveness of medical service and health service, and also of the important part that health schools play in the education of practitioners, researchers, and teachers.

Today and tomorrow we would like to speak briefly to 4 points, 3 points today and 1 tomorrow. The points today will cover, first, what the health service schools do; second, the present trends in science and medical care that have significance as far as the effective operation of our health schools is concerned; and finally, the importance of maintaining standards of education for health service. Tomorrow we would like to speak to the fact that teachers and students must have places in which to work; that is, facilities that are needed so that our people may have health service personnel who will be needed in the years ahead.

Each panelist will speak very briefly. After Dr. Deitrick and Dr. Hussey finish, I think it would be good to stop for questions. When Dr. Stebbins, speaking for the public health schools, is through, I think questions would be indicated; questions again when the dentists have spoken; and finally, after Dr. Sterling has made his statement. Dr. Deitrich will speak first.

STATEMENT OF DR. JOHN DEITRICH, DEAN OF THE SCHOOL OF MEDICINE, CORNELL UNIVERSITY

Dr. DEITRICH. Thank you.

Dr. Darley has asked me to speak about the major activities of the medical schools.

The medical schools are the primary educational institutions providing personnel for the health services of this country. At the beginning of the century the production of doctors was their only educational objective. Today, they have assumed or have had thrust upon them the responsibility for either a portion or all of the education and training of those various individuals composing our health teams.

Information illustrating the scope of these educational activities of the medical schools was obtained by a survey carried on between 1949 and 1951. The survey was sponsored jointly by the Association of American Medical Colleges and the council on medical education and hospitals of the American Medical Association. It was undertaken because the schools following World War II found themselves in serious difficulty. In a time of rapidly growing inflation, society was

asking them to provide an increased number and variety of personnel to man the country's health services. As director of the survey, I was given the opportunity to visit and study 41 of the 79 schools in existence in 1949. Information from all 79 schools was obtained by questionnaires.

The first phase of our study was to determine how many and what categories of students received instruction from the faculty of each medical school. The information provided by one privately supported school revealed that in addition to 398 medical students, the faculty gave courses of instruction to 63 dental students, 49 nursing students, and 60 pharmacy students. Twenty-two medical technicians were given all of their training in this school. The professors of the clinical departments trained 131 interns and residents and gave postgraduate courses to 94 physicians.

A second large tax-supported school had assumed even broader responsibilities for educating health personnel. In addition to the medical students, the faculty gave courses to 608 dental students, more than 1,000 nurses, 211 medical technicians, 74 occupational therapists, 87 dental hygienists, 18 speech pathologists, 73 physical education students, 238 pharmacists, 90 embalmers, 93 veterinary medical students, 421 graduate students, 62 interns and residents, and 90 postgraduate students.

In 1957, the medical schools provided some of the instruction for 5,457 dental students, 1,820 pharmacy students, 10,851 nurses, 2,600 technicians, and 5,144 students in the arts and science departments of their universities. They trained 10,967 interns, residents and fellows, and taught 2,537 students seeking masters or Ph. D. degrees in the sciences.

We emphasize this to show the scope and breadth of the educational activities of the health services provided by the medical schools. This huge educational activity requires adequate physical facilities.

In addition to these varied educational activities, the medical schools, as you well know, are engaged in research and service. Between 1940 and 1950, the funds expended on research by 59 of the medical schools increased 9 times. Today it is estimated that the medical schools as a group spend at least $1 on research for every dollar of instructional expense. The research expenditures of the medical school which I represent, Cornell University Medical College in New York, increased 3,200 percent since 1934, and yet we are still housed in exactly the same facility that we began with in 1933.

For lack of research facilities in the school, we have been forced to rent space outside the medical college. Many schools face similar situations and will be deeply appreciative of the Federal research construction grants.

The service activities of a medical school faculty include consultations to local, State, and national health and welfare agencies, and the provision of free professional care to charity patients. In 1949, the value of this free professional care of patients provided on the wards and outpatient departments of the teaching hospitals would have been worth between $90 million and $100 million if paid for according to the scale of fees used by the Veterans' Administration.

In 1949, the combined budgets of all medical schools equaled only $110 million.