Dr. Leitch, a physician and surgeon, is a member of the editorial staff of “Northwest Medicine” and an active opponent of socialized medicine.
. . . and if so, could federal funds cure it?
How do we get our doctors? Is there a competitive, free market, ideal method of obtaining a supply of doctors in proper ratio to population or demand for medical services? Does the traditional or Hippocratic method approach this ideal? Is it true that we have, or are likely to have in the imminent future, a shortage of medical doctors? If this is so, is there any assurance that any governmental measures thrown into the breach can prevent or correct the situation?
The cry of doctor shortage has been heard for years, but its political origin tended to discount it. Recently, however, such a staid and respected publication as the New England Journal of Medicine observed that medical educators are expressing concern over the decline in number of suitable applicants for medical training, and intimated that some medical schools are already experiencing difficulty filling their classes with suitably qualified students.
Claims of an actual or impending doctor shortage raised by medical educators, and supported by federal politicians anxious to apply the spending treatment at the slightest suggestion of symptoms, would carry more weight if also supported by another party of interest in the matter, the physician in the field who actually delivers our medical care. To date, his voice has been strangely silent. Is he too busy practicing medicine to know there is a doctor shortage? Or is there a doctor shortage? What are the facts?
One test of a doctor shortage would be to poll the patients. Actually, there is a market process whereby supply and demand (as distinct from clamor) work toward a balance. But the opinions of patients will vary. If one has experienced no trouble whatsoever securing the services of a physician, it is difficult for that person to believe a doctor shortage is present or in the offing. But if one has had difficulty obtaining a doctor, perhaps to come to one’s home or at night, no amount of official figures, pronouncements, explanations, or arguments from any source is likely to persuade him that there is not a grave and immediate shortage.
The record shows that current allegations of a doctor shortage trace back to the sound and the fury of the efforts to build what was deceptively termed national compulsory health insurance into increased political power.
For statistical evidence of a doctor shortage, one may look to sources which supposedly are better advised than the doctors and patients directly concerned. This is likely to be a governmental source. Usually cited are figures developed by the Truman-appoint-ed “Commission on the Nation’s Health,” which many physicians hold was not exactly unbiased. Others occasionally quoted are those given by a chairman of the Health Resources Advisory Committee of the National Security Resources Board.
Statistics from the former source indicate that there “might” be a shortage of 22,000 to 45,000 doctors by 1960. Those from the latter source foresee an “estimated” possible doctor shortage of 20,000 before 1960. The hedging represented by careful use of the qualifying “might,” “estimated,” “possible,” and the generous flexibility of the figures, clearly in-dictate there is no precision in them. At best they are only politically flavored guesses.
A different authority, Frank J. Dickinson, chief of the Bureau of Medical Research of the American Medical Association, whose business it is to know what is happening to physicians, concludes differently. Says Dr. Dickinson: “There is no shortage of doctors now, and by 1960 there probably will be a surplus!” (Emphasis added.)
Which is correct? Oddly, both could be. A clue to this seeming paradox lies in the definition and use of the word doctor.
The politicians make their guesstimates in terms of medical school graduates, persons holding the degree of Doctor of Medicine.
There is no question of the existence of a demand for the services of those holding a medical degree. Nor is there any question that the demand will continue as long as there is expanding bureaucratic activity in commercial or governmental matters concerned with health or medical care. But the demand is for persons to accept positions as employees, technicians, etc., in various governmental or commercial segments of our economy having some connection with health matters. What is meant by “doctor” is not a practicing physician, but one whose medical training is sought in industry or government to discharge duties which in many instances could be equally well or better discharged by nonmedical personnel. Immediate or early financial return on one’s medical education is the great lure.
On the other hand, Dickinson clearly refers to practicing physicians. His analysis is based on market areas and reveals some unusual data. One-sixth of the land of the United States lies outside a 25-mile radius of the nearest physician. But only 0.16 per cent (1/6 of 1 per cent) of the population resides beyond this 25-mile radius.
He further states that the output of medical care per doctor, due to such things as automobiles, improved roads and communications, increased medical knowledge and wonder drugs, has markedly increased in recent years. This increased output per doctor more than offsets what may appear to be a physician shortage based on geography.
That many communities do not have doctors cannot be denied. More often than not, this is a matter of basic economics linked with scanty population and applies equally well to lawyers, bakers, jewelers, automobile salesmen, butchers, and undertakers.
There is a single county in Oregon, for instance, which has an area greater than either New Jersey or Vermont, yet can muster only three physicians in the entire county! The reason? The county consists of large stock ranches and there are more cattle and jack rabbits than humans. The chief marketing center of the region, however, is a few miles over the line in the next county; here there are twenty-four well-trained, competent doctors, and a well-equipped modern hospital, capable of catering to all the medical needs of the region. Thus while absence or scarcity of physicians in a specific locality can be presented as a major defect when expressed in geographic terms, the defect vanishes when stated in terms of supply and demand in the market.
There is, however, a true shortage of physicians on which all can agree, a shortage evident when expressed in terms of certain racial minorities. This is a need or desire which medical colleges find it difficult to meet for reasons which go to the very heart of the system which supplies our doctors. There is simply a dearth of candidates from the minorities involved, with suitable scholastic attainments. And scholastic stature is an integral, major part of what it takes to become a doctor capable of furnishing the high quality medical care which is the present fortunate lot of North Americans, regardless of all other considerations.
What is this system whence come our doctors, the system in which scholastic ability ranks so highly? Its comprehensive nature precludes detailed consideration here, but presentation of some aspects bearing on the supply of physicians is pertinent.
The title “doctor” act u ally means “teacher,” and essentially it is the traditional or Hippocratic system. From the days of the apprentice learning from a priest in an ancient temple courtyard, to the resident assisting at a major operation in today’s modern hospital, physicians have held and accepted responsibility for teaching their successors. And they still do, in spite of some efforts to have it otherwise. The traditional nature of the system may be somewhat obscured by the presence of such things as medical school admission standards, medical practice licensure requirements, and delegation of some teaching responsibility to medical educators.
Any mingling of governmental and libertarian forces in today’s world is open to suspicion on the face of it. But any impression that doctors comprising state medical licensing boards, because of deriving their authority from state law, are in cahoots with politicians to entrench physicians in the practice of medicine against cult and undesirable physician competitors, while patients and the public get the short end of the deal, is simply not true.
The record is quite clear that those comprising these quasi-judicial boards are concerned with one thing, and one thing only: protection of the public against incompetent and unscrupulous practitioners of the healing arts by establishing and maintaining minimum standards or qualifications for those who wish to practice medicine.
Any statistician or director of a prepaid medical care plan can substantiate that much more important factors affect the medical care market. These are the general aging of the population, with the greater prevalence of the degenerative diseases, the tendency to seek out medical care because “we’ve paid for it anyway,” and the increasing scientific and technical perfection of our diagnostic procedures. Many of these require most elaborate and expensive equipment of great complexity to furnish dependable results. Herein lies the great unprobed medical problem of the future, but even so it is most likely to be technicians and skilled artisans, rather than physicians, who will be most affected.
That there is trouble in the Hippocratic system which produces our doctors must be evident to anyone who intelligently examines it. But no system of training doctors has been found superior to that of one generation of physicians passing its knowledge and skill to its successors; the difficulties are those of execution rather than fundamental conception. Most expressions of concern relative to the system are heard from professional educators and politicians, rather than from practicing physicians and their customers. The system, of course, does not preclude tampering. And there is ample evidence that it has been and is being tampered with by both politicians and educators, separately and together.
Educational confusion plagues the system because of the fact that in the modern scheme of things physicians have delegated much of their Hippocratic responsibility for teaching successors to professional educators, both academic and medical. But increasing numbers of these educators fail to understand or appreciate the meaning of the word delegate. Instead of concentrating on teaching, they are busily engaged in medical empire building extending their influence and control over as wide an expanse of medical practice and related activities as they can encompass. The story of captive hospitals and institutional aggrandizement in the collectivist manner, while pertinent, is a story in its own right, much too lengthy for inclusion here.
The greatest immediate confusion and danger, however, stems from the doctrine fostered by politicians that intervention by the federal government, directly or through grants in aid, can somehow or other cure all the ills of medical education, and hence of medicine. In spite of the widely demonstrated fact that intrusion of government into any private venture more often aggravates than corrects the presumed shortcomings of private enterprise, the same old vote-charming snake oil is being peddled by the proprietors of the federal medicine show.
In the make-up of each doctor, and therefore in the aggregate of the entire medical profession producing and delivering today’s high quality medical care, three attributes are essential, the three priceless ingredients.
A candidate for the medical degree must have the desire and will to be a physician above all else. He must have the scholastic and other ability to enable him to become a doctor. And he must possess character in its finest sense.
Can government legislate or order character into individuals who lack it?
Can government decree or legislate that individuals must like the practice of medicine above all else?
Can government by the expenditure of funds or by passing a law create the ability it requires to be a doctor where this is nonexistent?
Since answers to all these are in the negative, it is obvious that there must be considerable truth in the plaint of the New England Journal of Medicine that medical schools find a decline in the number of suitable applicants for admission.
Since legislative and other government intrusions are notoriously ineffective and helpless when facing certain characteristics of human nature, it is also obvious that the fascination of the federal authorities with medical education is only incidentally concerned with medicine. Whether those in the political apparatus recognize it or not, their efforts amount to a bid for political power. 
Experience should teach us to be most on our guard to protect liberty when the government’s purposes are beneficent. Men born to freedom are naturally alert to repel invasion of their liberty by evil-minded rulers. The greatest dangers to liberty lurk in insidious encroachment by men of zeal, well-meaning, but without understanding.
Mr. Justice Brandeis
Dissenting in Olmstead v. United States,
277 U.S. 438 (1928)