The Plethora of Doctors

IN a paper in the Atlantic for June, I discussed at some length the development in America of the ideal training of the physician. In the present article it is my purpose to deal with the actual conditions in the medical profession of the country, with especial reference to the number of doctors we are now endeavoring to support. The problem involved in reaching a satisfactory physical adjustment is practical, not academic; and taking economic and social conditions as they are, its solution will depend upon the widest possible distribution of the best possible type of physician. For an intelligent consideration of the question, it is fundamental that we understand the statistical aspects of medical education in America so far as they are immediately pertinent to the question of reform.

Professor Paulsen, describing in his book on the German Universities the increased importance of the medical profession, reports with some astonishment that the number of physicians has increased with great rapidity, so that now there is, in Germany, one doctor for every 2000 souls, and in the large cities one for every 1000.’ What would the amazed philosopher have said had he known that in the entire United States there is already on the average one doctor for every 568 souls, that in our large cities there is frequently one doctor for every 400 persons¹ or less, that many small towns of less than 200 inhabitants have two or three physicians each!

Overproduction is stamped on the face of these facts; and if, in its despite, there are localities without a physician, it is clear that not even long-continued overproduction of cheaply-made doctors can force distribution beyond a well-marked point. In our towns health is as good, and physicians are probably as alert, as in Prussia; there is then no reason to fear an unheeded call or a too tardy response if urban communities support one doctor for every 2000 inhabitants. On that showing, the towns have now four or more doctors for every one that they actually require, — something worse than waste, for the superfluous doctor is usually a poor doctor. So enormous an overcrowding with low-grade material decreases both relatively and absolutely the number of well-trained men who can count on the profession for a livelihood. According to Gresham’s Law, which, as has been shrewdly remarked, is as valid in education as in finance, the inferior medium tends to displace the superior. If then, by having in cities one doctor for every 2000 persons, we got four times as good a doctor as now when we provide one doctor for every 500 or less, the apothecaries would find time hanging somewhat more heavily on their hands. Clearly, low standards and poor training are not now needed in order to supply physicians to the towns.

In the country the situation follows one of two types. Assuming that a thousand people in an accessible area will support a competent physician, one of two things will happen if the district contains many less than a thousand. In a growing country, like Canada or our own Middle West, the young graduate will not hesitate to pitch his tent in a sparsely settled neighborhood, if it promises a future. A high-grade and comparatively expensive education will not alter his inclination to do this. The more exacting Canadian laws rouse no objection on this score. The graduates of McGill and Toronto have passed through a scientific and clinical discipline of high quality; but one finds them every year draining off into the freshly opened Northwest Territory.

In truth, it is an old story. McDowell left the Kentucky backwoods to spend two years under Bell in Edinburgh; and when they were over, returned contentedly to the wilderness, where he originated the operation for ovarian tumor in the course of a surgical practice that carried him back and forth through Kentucky, Ohio, and Tennessee. Benjamin Dudley, son of a poor Baptist preacher, dissatisfied with the results, first of his apprenticeship, and then of his Philadelphia training, hoarded his first fees, and with them subsequently embarked temporarily in trade: he loaded a flat-boat with sundries which he disposed of to good advantage at New Orleans, there investing in a cargo of flour which he sold to the hungry soldiers of Wellington in the Spanish peninsula. The profits kept Dudley in the hospitals of Paris for four years, after which he came back to Lexington and for a generation was the great surgeon and teacher of surgery in the rough country across the Alleghanies. The pioneer is not yet dead within us. The self-supporting students of Ann Arbor and Toronto prove this. For a region which holds out hope, there is no need to make poor doctors; still less to make too many of them.

In the case of stranded small groups in an unpromising environment, the thing works out differently. A century of reckless overproduction of cheap doctors has resulted in general overcrowding; but it has not forced doctors into these hopeless spots. It has simply huddled them thickly at points on the extreme margin. Certain rural communities of New England may, for example, have no physician in their midst, though they are in most instances not inaccessible to one. But let never so many low-grade doctors be turned out, whether in Boston or in smaller places like Burlington or Brunswick, that are supposed not to spoil the young man for a country practice, these unpromising places, destined perhaps to disappear from the map, will not attract them. They prefer competition in some already over-occupied field. Thus, in Vermont, Burlington, the seat of the medical department of the University of Vermont, with a population of less than 21,000, has 60 physicians, one for every 333 inhabitants; nor can these figures be explained away on the ground that the largest city in the state is a vortex which absorbs more than its proper share; for the state abounds in small towns in which several doctors compete in the service of much less than a thousand persons. Other New England states are in the same case.

It would appear, then, that overproduction on a low basis does not effectually overcome the social or economic obstacles to spontaneous dispersion. Perhaps the salvation of these districts might, under existing circumstances, be better worked out by a different method. A large area would support one good man, where its separate fragments are each unable to support even one poor man. A physician’s range, actual and virtual, increases with his competency. A well-qualified doctor may perhaps at a central point set up a small hospital, where the seriously ill of the entire district may receive good care. The region is thus better served by one well-trained man than it could possibly be, even if overproduction on a low basis ultimately succeeded in forcing an incompetent into every hamlet of five-and-twenty souls. This, however, overproduction cannot compel. It cannot keep even the cheap man in a place without a ‘chance’; it can only demoralize the smaller places which are capable of supporting a better trained man whose energies may also reach out into the more thinly settled surrounding country. As a last resort, it might conceivedly become the duty of the several states to salary district physicians in thinly settled or remote regions — surely a sounder policy than the demoralization of the entire profession for the purpose of enticing ill-trained men where they will not go. These officials would combine the duties of county health officer with those now assigned in large towns to the city physician.

We may safely conclude that our methods of carrying on medical education have resulted in enormous overproduction at a low level, and that, whatever the justification in the past, the present situation in town and country alike can be more effectively met by a reduced output of well-trained men than by further inflation with an inferior product.

The improvement of medical education cannot therefore be resisted on the ground that it will destroy schools and restrict output; that is precisely what is needed. The illustrations already given in support of this position may be reinforced by further examples from every section of the Union: from Pennsylvania, with one doctor for every 636 inhabitants, Maryland with one for every 658, Nebraska with one for every 602, Colorado with one for every 328, Oregon with one for every 646.

It is frequently urged that, however applicable to other sections, this argument does not for the present touch the South, where continued tolerance of commercial methods is required by local conditions. Let us briefly consider the point. The section as a whole contains one doctor for every 760 persons. In the year 1908, twelve states showed a gain in population of 358,837. If, now, we allow in cities one additional physician for every increase of 2000, and outside of cities an additional one for every increase of 1000 in population, — an ample allowance in any event, — we may in general figure on one more physician for every gain of 1500 in total population. I am not now arguing that one physician to 1500 persons is the normal or correct ratio; that is a point that need not even be raised. What I contend is that, as such a ratio has proved more than satisfactory elsewhere, it will at least serve for further increase of our population.

A country, in other words, which now has one physician for every 568, will be amply supplied for a generation at least if it produces one additional physician for every 1500 additional persons. On that basis in 1908 the South needed 240 more doctors. In the course of the same year, it is estimated that 500 vacancies in the profession were due to death. If every vacancy thus arising must be filled, conditions will never greatly improve. Let us agree to work toward a more normal adjustment by filling two vacancies due to death with one new physician, — once more a decidedly liberal provision. This will prove sufficiently deliberate; it would have called for 250 more doctors by the close of the year. In all, 490 new men would have amply cared for the increase in population and the vacancies due to death. As a matter of fact, the Southern medical schools turned out in that year 1144 doctors; 78 more Southerners were graduated from the schools of Baltimore and Philadelphia. The grand total would probably reach 1300, —1300 Southern doctors to compete in a field in which one third of the number would find the making of a decent living already difficult! Clearly the South has no cause to be apprehensive in consequence of a reduced output of higher quality. Its requirements in the matter of a fresh supply are not such as to make it necessary to pitch their training low.

The rest of the country may be rapidly surveyed from the same point of view. The total gain in population, outside of the Southern states already considered, was 975,008, — requiring, on the basis of one more doctor for every 1500 more people, 650 doctors. By death, in the course of the year there were in the same area 1730 vacancies. Replacing two vacancies by one doctor, 865 men would have been required; in most sections public interest would be better cared for if the vacancies all remained unfilled for a decade to come. On the most liberal calculation, 1500 graduates would be called for, and 1000 would be better still. There were actually produced in that year, outside the South, 3497, that is, three times as many as the country could possibly assimilate; and this goes on, and has been going on, every year.

It appears then that the country needs fewer and better doctors; and that the way to get them better is to produce fewer. To support all or most present schools at the higher level would be wasteful, even if it were not impracticable; for they cannot be manned. Some day, doubtless, posterity may reëstablish a school in some place where we now recommend the demise of a struggling enterprise. Toward that remote contingency nothing will, however, be gained by prolonging the life of the existent institution.

The statistics just given have never been compiled or studied by the average medical educator. His stout asseveration that the country needs more doctors’ is based on ‘the letters on file in the dean’s office,’ or on some hazy notion respecting conditions in neighboring states. As to the begging letters: selecting a thinly settled region, I obtained from the dean of t he medical department of the University of Minnesota a list of the localities whence requests for a physician have recently come. With few exceptions they represent five states, and judging from these states, the general distribution shows that overproduction prevails in new communities as well as in old ones.

Fifty-nine towns in Minnesota want a doctor, but investigation shows that these 59 towns have already 149 doctors between them! Ten of the 59 are without registered physicians; but of these ten, two are not to be found on the map, while two more are not even mentioned in the Postal Guide; of the other six, four are within easy reach of doctors, and two only, with a combined population of 150 souls, are out of reach of medical assistance. Forty-one places in North Dakota apply; they have already 121 doctors. Twentyone applications come from South Dakota, from towns already having 49 doctors. Seven come from Wisconsin, from places that had 21 physicians before their prayer for more was made. Six come from Iowa, from towns which had 17 doctors at the time of application.

It is manifest that the files of the deans will not. invalidate the conclusion which a study of the figures suggests. They are more apt to sustain it, for the requests in question are less likely to mean ‘no doctors’ than ‘poor doctors,’ — a distemper which continued overproduction on the same basis can only aggravate, and w hich a change to another basis of the same type will not cure.

As to general conditions, no case has been found in which a single medical educator contended that his own vicinity or state is in need of more doctors; it is always the ‘next neighbor.’ Thus the District of Columbia, with one doctor for every 262 souls, maintains two medical schools of low grade. ‘Do you need more doctors in the District? ’ I asked one of the deans. — ‘Oh, no, we are making doctors for Maryland, Virginia, and Pennsylvania,’ — for Maryland, with seven medical schools of its own, and one doctor for every 658 inhabitants; for Virginia, with three medical schools of its own, and one doctor for every 918; for Pennsylvania, with its eight schools, and one doctor for every 636 persons.

With the overproduction thus demonstrated, the commercial treatment of medical education is intimately connected. Low standards give the medical schools access to a large clientèle open to successful exploitation by commercial methods. The crude boy or the jaded clerk who goes into medicine at this level has not been moved by a significant prompting from within; nor has he, as a rule, shown any foresight in the matter of making himself ready. He is more likely to have been caught drifting at a vacant moment by an alluring advertisement or announcement, quite commonly an exaggeration, not infrequently an outright misrepresentation. Indeed, the advertising methods of the commercially successful schools are amazing. One school, for example, offers the bonus of a European trip to any graduate who shall have been in attendance for three years. Not infrequently, advertising costs more than laboratories. The school catalogues abound in exaggeration, misstatement, and half-truths. A few instances may be cited at random.

The catalogue of the medical department of the University of Buffalo states that ‘the dispensary is conducted in a manner unlike that usually seen. . . . Each one will secure unusually thorough training in taking and recording of histories.’ There are no dispensary records worthy the name.

The catalogue of Halifax Medical College assures us that ‘first-class laboratory accommodation is provided for histology, bacteriology, and practical pathology.’ One utterly wretched room is provided for all three.

The catalogue of the medical department of the University of Illinois claims that ‘the University Hospital . . . contains 100 beds, and its clinical advantages are used exclusively for the students of this college.’ Over half of these beds are private, and the rest are of but limited use.

In the catalogue of the Western University of London, Ontario, we find under the heading Clinical Instruction: ‘The Victoria Hospital . . . now contains 250 beds, and is the official hospital of the City of London.’ On the average, less than 30 of these beds are available for teaching.

The deans of these institutions occasionally know more about modern advertising than about modern medical teaching. They may be uncertain about the relation of the clinical laboratory to bedside instruction, but they have calculated to a nicety which ‘medium’ brings the largest ‘return.’ Their dispensary records may be in hopeless disorder, but the card-system by which they keep track of possible students is admirable. Such exploitation of medical education, confined to schools that admit students below the level of actual high-school graduation, is strangely inconsistent with the social aspects of medical practice.

The overwhelming predominance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its own highest purposes, not a business to be exploited by individuals according to their own fancy. There would be no vigorous campaigns led by enlightened practitioners against tuberculosis, malaria, and diphtheria, if the commercial point of view were tolerable in practice. And if not in practice, then not in education. The theory of state regulation covers that point. In the act of granting the right to confer degrees, the state vouches for them; through protective boards it seeks still further to safeguard the people. The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action.