If You enter an American hospital tomorrow, the chances are better than one in four that the resident physician who admits you will be a foreigner. Of the 22,000 resident doctors in American hospitals today, 8,000 are foreigners here on temporary visas. Hospital administrators now advertise regularly in foreign medical journals and send representatives abroad to recruit doctors. Even so, many thousands of hospital positions remain unfilled, and this year between 5,000 and 6,000 doctors are expected from outside the country. But this is only one of the many serious consequences of the present shortage of physicians in the United States.
According to a recent report of the President’s Commission on the Health Needs of the Nation, this country needs at least 25,000 more doctors than it now has. Instead of graduating 7,000 doctors a year as we do at present, we should graduate 10,000 if we mean to keep the gap between need and supply from growing even larger.
Dr. Willard C. Rappleye, dean of Columbia University’s medical school, considers the present influx of doctors from abroad “reminiscent of the diploma mill era of fifty years ago,” since most of these doctors come from schools that are not approved by the Council on Medical Education of the American Medical Association. The majority of state medical boards consider graduates of unapproved foreign schools ineligible for licensing examinations. But neither a medical board license nor graduation from an approved domestic or foreign medical school is a necessary requirement for a resident physician at an American hospital.
What makes the whole situation bitterly ironic is that there are and have been more than enough American college students fully qualified for a medical education, and eager for one, for whom there just isn’t any room in our medical schools. Shortage of trained manpower in other fields usually reflects a lack of qualified applicants. We would graduate more engineers and more science teachers if more young people were both willing and qualified to pursue these careers. But it is only because we fail to provide enough facilities to train the number of doctors we need that we are reduced to the anomalous expedient of recruiting special-purpose doctors from abroad who, more often than not, happen to be unqualified by our own standards.
In other countries, anyone with the necessary qualifications can study medicine. In the United States, not everyone able to meet the requirements can do so. In each of the past twenty-five years at least two qualified candidates have presented themselves for each place at a medical school. Only a few years ago, between three and four qualified students were competing for each place—which is a state of affairs we are likely to face again in the near future. True, this situation has permitted American medical schools to be selective to a degree unparalleled elsewhere. But this advantage has not outweighed all the liabilities that go with it, since selectivity has been achieved at the cost of human welfare.
Our medical societies do not accept the shortage of doctors as sufficient reason for recruiting thousands of doctors from abroad to man our hospitals. Nor, for that matter, do they agree with the recent report of the President’s Commission on the Health Needs of the Nation that there actually is such a shortage. The American Medical Association has, for one, long been against any increase in the facilities for training physicians. In 1933, when the low earnings of doctors began to worry the AMA, it was decided that there was an over-production of physicians and the Association’s Council on Medical Education advised that the number of doctors graduated annually should be “drastically curtailed.” In a 1955 report, the AMA insisted that the “needs for additional facilities for the education of physicians are exceedingly difficult to determine,” and while proposing “constant study and analysis,” it questioned whether such needs could ever be accurately predicted.
In 1955, at a hearing before a Senate committee considering Federal aid to increase medical school facilities, Senator Lehman asked the American Medical Association for its estimate of the number of additional physicians the country needed. Dr. F. J. L. Blasingame, the AMA’s representative, replied that the question was “somewhat unanswerable,” and went on to observe: “I jokingly say sometimes the number of physicians, to answer the question, is sort of like answering your wife the question of how many dresses she should have. She can always use one more good dress.” He added that it was the effective use of physicians, not their numbers, that should determine an estimate of need; the telephone, the automobile, more hospitals, and new auxiliary services had increased the individual doctor’s usefulness. In short—according to Dr. Blasingame—technological progress was reducing manpower requirements in medicine as in other fields.
The actual facts, however, do not bear him out. Despite heavy recruitment of foreign physicians, 28 per cent of approved interneships and 25 per cent of approved residencies in American hospitals remain unfilled today. Twenty per cent of the budgeted positions for doctors in city and state health departments are vacant, and this has discouraged the execution of many plans to expand public health service.
The discovery of antibiotics and other recent scientific advances in medicine, said Dr. Howard A. Rusk of the New York University College of Medicine at the same Senate hearings, were swelling the need for doctors instead of lessening it, because the better standards of care they encouraged required the physician to spend more time on each of his cases. Dr. Rusk pointed out that within the past five-year period ten years had been added to the life expectancy of the average American, but it was a question whether the health of the physicians themselves had benefited by medical advances—a recent study had established that their average work week in active practice was sixty-nine hours. Overwork, Dr. Rusk suggested, had much to do with the fact that doctors had a higher coronary rate than any other professional group.
Over the past fifteen years medical training facilities have increased by 15 per cent, while the population of the country has increased by 25 per cent. We now have a higher proportion of older people, who generally require more medical care. Rising standards of living have also increased the demand for medical service.
The Bureau of Census estimates that by 1970 our population will be between 24 and 30 per cent above the 1955 figure. The report of the President’s Commission on the Health Needs of the Nation estimates that the country will need 330,000 physicians by 1970, which means a two-thirds increase over the present figure of 192,000. This would seem to call for a “crash” program to expand our medical school facilities. Yet organized medicine still appears to think otherwise.
Our medical schools are now superior to those of any other country, thanks to the elimination of the “diploma mills” that used to furnish most of our doctors up to fifty years ago. The inferior teaching standards and inadequate clinical facilities of these schools were exposed in a study that Dr. Abraham Flexner made for the Carnegie Foundation in 1910. By 1925 only 71 out of the 160 medical schools functioning in 1910 were still in existence. At present there are 82 approved medical schools in the country; these admit 7,800 freshmen, and graduate 7,000 doctors, annually. The average medical school enrolls about 90 new students each year; the two largest schools, those of the universities of Michigan and Tennessee, admit 200 new students a year. Foreign medical schools observe no such limitations: the University of Paris’s medical college has a total enrollment of 7,000 students.
It costs about $12,000, in addition to tuition, to train a doctor at an American medical school. Or so it is claimed, and this is offered as a reason for the reluctance to establish new medical schools. In actual fact, the cost is less than half the figure given. Medical school budgets have become a catchall for activities having nothing to do with the education of doctors. A committee of the American Medical Association that surveyed current medical education reported recently that stated costs were “misleadingly high.” A typical two and a half million dollar budget for a high-cost private medical school whose total enrollment was 231 students gave an expenditure of over $10,000 annually per student. Yet that school’s faculty was paying for itself in the free hospital services its members provided to the community, and their salaries were not really a charge against the budget in which they were entered.
Medical service is not at all the same thing as medical education, and should be financed separately. Research expenses—which are valuable in the training of doctors but not directly related to it—accounted for more than half the total budget of the above-mentioned school. Its instruction and operational costs, moreover, covered a total of 1,248 students of whom only 231 were preparing for medical degrees. Among the other students were 225 nurses, 150 nonmedical graduate and public health students, and 642 physicians doing part-time postgraduate work. Only half of this school’s budget was directly applied to the training of new doctors. Thus the financial obstacles to the expansion of our medical training facilities turn out to be far less formidable than they are made to appear.
Nor are we using the relatively few medical schools we have to train all of the best qualified applicants. Half the places in our national medical training establishment are in state-supported medical schools. Save for rare exceptions, these limit enrollment to residents of the state. A few accept students from neighboring states without medical schools, and are financially compensated by these states. Hardly a private medical school, on the other hand, imposes residential requirements. The result is that the standards of admission to state medical schools are quite different from those of admission to private schools.
Within their residential restrictions, some states have a wide choice and others an extremely narrow one, depending upon their populations and the number of students in each state interested in becoming doctors. Accordingly, the chances a student has of gaining admission to a medical school very often depend more on where he happens to live than on his aptitude for medicine. New York State, for example, has one medical school applicant for each 8,000 residents, while Iowa has one for each 18,000. The same number of places in residentially restricted medical schools receive about one-third the number of applications as do those in schools not residentially restricted. And, naturally, where there are more applicants to choose from better qualified ones can be selected. The result is a significant difference in caliber between the doctors produced by residentially restricted schools and those produced by schools not so restricted.
The qualifications of medical school applicants all over the country can be compared on the basis of the results achieved in the Medical College Aptitude Test, which is taken by almost all of them. The average score fixed for the MCAT is 500, and 68 per cent of applicants have in the past fallen within the 400-600 range, with 16 per cent above and 16 per cent below this figure. The average MCAT score of applicants accepted by the residentially restricted medical schools has been 509; the average score of those accepted at the unrestricted schools is 550. An intelligence quotient of at least 125 is considered desirable by most educators for medical students. Out of 161 freshmen at the University of Texas’s medical college in 1954, only 52 had an I.Q. score of 125 or over; five scored under 100. Of course, I.Q. scores are not the only measure of ability; some “lows” at the University of Texas got by academically, while some “highs” with serious emotional difficulties flunked out. But a generally high positive correlation has been shown between I.Q. scores and the results of the Medical College Aptitude Test; moreover, the latter have been demonstrated to furnish an excellent basis for predicting achievement at medical school.
The shortage of doctors is what is mostly responsible for the residential restrictions imposed by state medical colleges. Tennessee, for example, feels that the best way to remedy its shortage is to admit Tennesseeans alone to its medical school, on the assumption that they will practice after graduation in their home communities, or at least within the state’s borders. Nevertheless, out of more than 2,500 physicians graduated from the University of Tennessee, only about 900, or 35 per cent, have remained in Tennessee to practice. The previously mentioned AMA survey of medical education established that 61 per cent of the graduates of residentially restricted medical schools-were practicing in their home states, while 50 per cent of those who attended medical schools without residential restrictions were doing so.
Thus the residential limitation has done only little to attain its objective. And it would be seen to have done even less if those few states with geographically restricted medical schools, like California and Texas, which retain almost all their graduates, had been left out of the accounting.
It is not only with respect to state residence, however, that medical schools impose restrictions. There is also the “quota” system, which this writer discussed in “Medical School Quotas and National Health” (COMMENTARY, January 1953). Considerable improvement has been achieved in this matter, but not such as to have eliminated all the serious problems.
The “quota” system was devised more than thirty years ago, when medical schools first began to get more applicants than they had room for. A rather odd rationale was then developed according to which each religious or ethnic group in this country was to be accorded a “quota” of doctors proportionate to its numerical ratio to the total population. The dean of one eminent medical school stated at that time that “the representation of the various social and religious groups in medicine ought to be kept fairly parallel with the population make-up.” Specifically, this practice was aimed at cutting down the number of Jewish medical students, which otherwise exceeded the Jewish “quota.”
Dean Ladd of Cornell University Medical School, Which is located in New York City, described the arithmetic of the “quota” system as it was applied by his school in 1940. He said that his school’s quota was based on the proportion of Jews in the population of New York State, which was between 10 and 15 per cent. Out of 1,200 applicants for the 80 places in Cornell’s medical school in 1940, 700 were Jews and 500 Gentiles. Ten Jews and 70 non-Jews were admitted, in strict adherence to the quota Dean Ladd had announced. A Jewish applicant to his school had therefore one chance in seventy of admission, a Gentile applicant one chance in seven. Many Jewish students with superior grades were turned down, while Gentile students with lower qualifications were accepted. A national count in 1933, after the “quota” system had been in effect for a while, showed that 912 Jews had been admitted to medical schools all over the country in that year. In 1936, with the total number of medical school admissions about the same as in 1933, Jewish freshmen had dropped by almost one-third, to 617.
The first real break in the “quota” system came during World War II under the influence of the general discredit into which anything smacking of official anti-Semitism had fallen. This attitude has carried over into the postwar period. Nonetheless, it required strong public concern to effect the change. In 1947 one Presidential commission investigated the effects of discrimination in the field of civil rights, and another such commission investigated it in higher education, including the medical schools. Legislation prohibiting discriminatory practices was enacted in three states, New York, Massachusetts, and New Jersey, and was considered by many other state legislatures. The medical school “quota” system was not completely done away with by dint of all this publicity and public pressure, but to the extent that it survived it did so underground, so to speak.
At the same time, however, that medical schools were revising their admission practices, they were hit by a tidal wave of applicants for which they were totally unprepared. This undoubtedly delayed further relaxation of their discriminatory practices. In 1941 there had been 12,000 applicants for 6,800 places in the medical schools; in 1948 there were 24,000, or twice as many. But in the intervening seven years, only 140 places had been added in the medical schools of the country! Yet the “quota” system continued to give ground, despite the vastly increased number of candidates for medical training.
Admissions to the College of Physicians and Surgeons at Columbia University reflected the change. In 1920 more than 40 per cent of its students were Jewish. In 1924, the year in which the College introduced its Jewish “quota,” Jews formed only 25 per cent of its first-year students, and ten years later only 10 to 15 per cent of its total student body. (Columbia, obviously, based its quota on the proportion of Jews in the population of New York State, just as Cornell’s medical school did, and the dean of Columbia’s medical faculty advanced the same justification for this measure as had Dean Ladd of Cornell.) But in 1948 the proportion of Jews entering the College of Physicians and Surgeons had climbed back to about 25 per cent.
Yet discrimination dies hard. “Personality,” instead of arithmetical quotas, is the device many medical schools have now resorted to in order to continue discriminatory admission practices. Grades alone, it is said, are not enough upon which to base a sound decision; now it must be determined whether the candidate for medical training has the right kind of “personality” for a doctor.
Application to medical school is usually made about a year in advance. A January deadline is generally set, although by that time most medical schools have already chosen their entering students for the next academic year. The typical applicant’s file includes his secondary school records, the official transcript of his college record, his completed application form with information on his extracurricular activities, honors, and awards, and a statement as to his reasons for wishing to study medicine. Letters from character references are also included. Some medical schools prepare checklists of qualities or characteristics on which the applicant is to be rated. Pre-medical or college advisors provide an evaluation which is often given considerable weight, especially when the medical school has confidence in the person making the evaluation. A recent trend in many undergraduate colleges is to furnish the medical school with an evaluation prepared by a special faculty committee; this tends to reduce the factor of individual caprice or bias.
Medical schools that do not impose narrow residential restrictions receive about ten applications for every place they have available; this is because each candidate usually applies to several medical schools at once. One or more members of each school’s admissions board go over the applications and throw out immediately applicants found unqualified solely on the basis of their records. Ordinarily, a subcommittee reviews the remaining applications and decides which candidates will be interviewed. The criteria according to which this is done have never been clearly ascertained for any given medical school. Students with top academic honors are often rejected without an interview. When one is granted, it is necessarily brief, and the resulting appraisal is often based on the degree of nervousness or poise shown by the applicant. The final decision is made by the medical school’s faculty committee in consultation with its admissions officer.
The purpose of this tortuous process is said to lie in the estimate of personality and scholarship it makes possible. Personal traits and character have an obvious bearing on the applicant’s future both as a student and as a practitioner, but while the measurement of scholastic ability is fairly simple and objective, the appraisal of character can under no circumstances be either of these. The report of a recent conference of the American Psychiatric Association that dealt with the personality criteria involved in the selection of medical students states that the difficulty lies in the fact that “we do not as yet know what special qualities make a good medical student or a proficient physician.” Grades, the report holds, will remain the best criteria for selection until reliable personality criteria can be developed.
The personal qualities that Flower Hospital Medical School in New York deems essential to the physician are “diction, voice, physical appearance, and grooming.” Sir William Osier, the great English diagnostician, once said: “There are only two sorts of doctors; those who practice with their brains, and those who practice with their tongues.” The clear effect of “diction-grooming” criteria like Flower’s is to favor the latter kind of doctor.
In 1952 the New York Board of Regents-reported on the admission practices and methods of personality appraisal of nine medical schools in the state, noting: “Admissions policies emphasize personality and character, but admissions practices neither shed light on their nature nor breed confidence in the methods of their measurements.” The report states that personality is understood by many medical schools largely as a matter of poise, appearance, and so forth. But these things hardly furnish the basis for a competent evaluation of an individual’s aptitude for medicine.
The Board of Regents report goes on to say that “factors of dress and manner, of the skill and neatness and grammatical correctness with which application forms are filled out apparently have some effect on admission. Chance comments as to character traits, or as to their manifestation in extracurricular activities or recreation or hobbies, not only seem to influence admissions officers, but to produce different value judgments in different officers.” Decisions are swayed “by the personality and mood (and possibly the bias) of the examining officer himself.” Under such circumstances prejudice and discrimination inevitably enter into admissions decisions. Certain cultural traits that are regarded negatively and ascribed to the members of certain ethnic minorities become a significant element here; even where the “quota” system does not operate, decisions on Jewish applicants for medical training depend often on the presence or absence of assumed “Jewish” traits.
How far from the actual character of the applicant’s “personality” an evaluation can range was revealed indirectly in the Regents study—it found much less discrimination against Jewish medical applicants with both parents born in the United States than against those with one or both parents born abroad. This factor and others related to it were particularly significant in the treatment of applications of Jewish students whose grades were average or below. Those whose families were long settled in this country fared more than twice as well as those whose families were relatively new.
In any case Jewish applicants of average scholarship did only about half as well as Protestants and non-Italian Catholics whose grades were no better. It is clear, moreover, that medical schools make a sharp distinction between Italian and other Catholics. Non-Italian Catholics did about as well as white Protestants in gaining admission to medical schools, while Italian applicants fared about as poorly as Jewish applicants did. This is the kind of data which led the Regents study to conclude that “a combination of cultural traits perhaps related to stereotypes in the minds of some admissions officers, are of considerable consequence in the selection of candidates.”
Discrimination by medical colleges against Negro applicants has not been established. On the contrary, there is evidence that special consideration is given Negro applicants by some non-Southern medical schools. The New York State Regents study observed that “there is no intimation of discrimination on the basis of race at the point of admission to medical schools.”
The problem reflected in the fact that only two and a half per cent of our doctors are Negro, as against 10 per cent of the population, begins with the small number of qualified Negro medical school applicants. Nor has there been much improvement in this respect over the past twenty-five years; 108 Negro doctors were graduated in 1931, only 173 in 1956. Part of the trouble lies in the poor quality of the pre-medical training provided at most Negro colleges in the South, which are attended by about two-thirds of all Negro college students in the country. Equality of educational opportunity for Negroes needs to begin long before medical school. Desegregation at public school and college levels, Negro medical educators believe, will eventually insure a greater number of qualified Negro applicants to medical schools. Court decisions requiring desegregation in higher education have affected the admission policies of Southern medical schools. Today there are 39 Negro medical students in Arkansas, Kentucky, Maryland, Oklahoma, Texas, and Virginia; in 1948 there was none.
The record shows that “personality” criteria have had much less effect than arithmetical quotas in implementing discrimination and prejudice in the admissions practices of medical schools. In 1940, for example, a Jewish applicant to Cornell’s medical school had only one-tenth the chance of getting accepted that other applicants had. In 1952, according to a sampling given in the Regents report, of 63 Jewish applicants to Cornell with good or very good grades, nine were accepted; of 34 non-Jewish applicants with the same grades, ten were accepted. The sample included four applicants with straight “A’s,” three of whom were Jewish and one Protestant. The Protestant was the only one of the four that Cornell accepted. Nevertheless, the difference between the one-to-ten chance a Jewish applicant had in 1940 and the one-to-two chance he had in 1952 represents a highly significant change. Over twice as many Jewish applicants were accepted by Cornell in 1952 as in 1940.
Many medical schools, while giving some weight to “personality” qualifications, base their admissions mainly on scholarship. In the sample reported on in the Regents study, the New York University College of Medicine, for example, accepted every pre-medical student with “excellent” grades who applied to it, and three out of four of those with “very good” grades; Jews were admitted in about the same proportion as Gentiles, all other qualifications being equal.
Top scholarship students are in any case seldom rejected by medical schools that stress grades. Of 66 top scholarship Jewish applicants in 1952, in another sampling given in the Regents report, 63 were accepted at some medical school, and the non-Jewish applicants with equivalent grades who were studied in this same sampling had a similar ratio of success. “Personality” emphasis may limit the choice of medical schools for top Jewish and Italian applicants, but obviously it does not completely bar them.
For applicants with grades below the top the “personality” factor does tend, however, to be decisive. Sixty-four per cent of Jewish applicants with “good” grades were successful in gaining admission to a medical school, as compared with 82 per cent of all other applicants with similar grades. In the “average” and “below average” groups, the differential becomes even more marked; 29 per cent of Jewish applicants with average grades got into a medical school, as against 46 per cent of Gentile applicants with average grades. In the “below average” group, 7 per cent of Jewish applicants and 21 per cent of all others gained admission. These differentials were almost entirely due to the resistance Jewish applicants met at medical schools where “personality” was a controlling factor in admissions decisions.
The Regents report from which the above data are taken concluded that questions of personality were at the “crux of the issue of discrimination” in admissions to medical schools. And it recommended that basic studies of the “personality” factor be undertaken as a contribution to counseling and to “humane intergroup relations.” In response, the Education Testing Service of Princeton, New Jersey, has begun research to establish the traits of personality most suitable to success in the medical and other professions. Objective criteria for “non-intellectual determinants,” as they are called, have already been successfully established for some fields, and it is likely that further research will bring similar results for medicine.
Despite the amount of bias in admissions still shown in the Regents study for 1952, 57 per cent of Jewish applicants got into a medical school in New York State in that year, as compared with 50 per cent of all other applicants. This paradox is explained by the high grades of the average Jewish applicant, coupled with the emphasis on grades at many New York State medical schools. The average Jewish applicant obtained a score of 589 on the Medical College Aptitude Test as against an average of 500 for all other applicants. If Jewish applicants had conformed to the 500 average, only 32 per cent of them, instead of 57 per cent, would have been admitted to a medical school, according to the pattern indicated in the Regents study. Of the Italian applicants, whose average grades were around 500 and who faced the same kind of discrimination on the “personality” count as Jews, only 35 per cent were successful.
The traditional interest of Jews in medicine may be a factor here. In the past, some of the best Jewish talents have been attracted to medicine, since it has always been one of the “free” professions where one could rise by personal merit, and where bias could not operate as broadly as in other fields to block advancement and even employment. Undoubtedly, the realization that a Jewish applicant qua applicant has to have a good deal more than the next fellow in order to offset the effects of discrimination has been another factor contributing to a special selectivity among Jewish students who seek medical careers.
One effect of these selective circumstances is the unusually high proportion of medical discovery and research contributed by Jewish doctors. Fortune recently reported, in a study of outstanding American scientists under forty, that over half (52 per cent) of the country’s leading medical scientists in this age group were Jewish.
The traditional Jewish interest in medicine is beginning, however, to show signs of flagging as discrimination against Jews in such fields as engineering and industry relaxes. In 1940, Dean Ladd of Cornell stated that of around 1,200 applications received annually by his medical school, about 700, or 58 per cent, were from Jews. In 1952, the figure dropped to 41 per cent, according to an estimate based on the above-mentioned study of the Board of Regents. (In that year applicants to medical schools in New York State were no longer required to state their religion on their application forms.) Despite the encouragement to Jewish applications given by Cornell’s abandonment of the “quota” system, a reduction of one-third in the proportion of Jews applying to Cornell has probably taken place since 1940.
Another significant change became apparent in 1952 and has continued through the 1956 freshman classes in American medical schools. For the two decades before 1947, there was a fairly consistent national average of about two applicants for every place in a medical school. This was the heyday of the quota system, when everything seemed calculated to discourage Jewish applicants. The abrupt postwar rise in applications—to over 24,000 in 1948—increased the number of applicants for every place from two to four. In 1950, when over 22,000 young people sought admission to medical schools, the ratio was still more than three to one, since there had been only a negligible increase in medical training facilities in the interim. But in 1952 the tide receded perceptibly, the number of applicants dropping to about 16,000 (with New York State sharing proportionately in the downward trend).
This decrease in applications was accompanied by further significant decreases in discrimination. The 1952 New York Regents study, which showed a clear picture of biased practices, had been preceded by a 1950 study in which the effects of discrimination were even more pronounced. In 1950, 35 per cent of Jewish graduates of New York State colleges applying to New York State medical schools were accepted, as compared with 45 per cent of all others. The figures in 1952, it will be recalled, were 57 per cent acceptance of Jewish applicants and 50 per cent of all others. In other words, decreased pressure for admission had in two years brought about a 22 per cent increase in acceptance of Jewish students as against a 5 per cent increase in acceptance of all others.
An important factor in this rise in Jewish admissions was that the average score for Jewish applicants in the Medical College Aptitude Test remained the same in 1952 as in 1950, while the average of all other applicants fell 10 points. Decreased admission pressure brought with it a considerably smaller proportion of applicants with “A” college grades. In 1950, 40 per cent of the first-year students in all American medical schools had “A” averages; in 1952, the percentage had dropped to 18, where it has stayed since. Thus the shrinking of competition now generally assures top students of a medical education, whatever the ethnic or religious group to which they belong.
Statistical studies of medical school admissions since 1952 have not been made, but there is evidence to show that a plateau has been reached in the matter of discrimination. A New York census of the religious distribution of students in the nine New York State medical colleges established that the situation in 1953 and 1954 remained almost the same as in 1952.
Since 1952 the annual number of applicants to medical schools has dropped further, from 16,000 to somewhere between 14,000 and 15,000, and stayed there. Columbia’s medical school enrollment of Jewish students, which was between 10 and 15 per cent during the “quota” era, rose to 25 per cent in the postwar period, then to 35 percent in 1952, and to 40 per cent in 1953 and 1954.
The reasons for the rise and fall in medical school applications over the past decade have not been fully investigated by the medical schools themselves. The Journal of the Association of American Medical Colleges attributed the postwar upsurge to “a large foot-loose age and educationally eligible population.” In spite of the fact that college enrollment, far from falling since the immediate postwar boom in education, has even risen, the number of students who take undergraduate degrees has decreased. This is accounted for by dropouts and by the junior colleges, which do not grant bachelor degrees. In 1949, 435,000 bachelor degrees were awarded, but only about 300,000 in 1952 and in each year since then. From 5 per cent to 7 per cent of the annual crop of college graduates have applied to medical schools over the past ten years. When degree-takers numbered 400,000 there were over 24,000 applicants; but now that graduates number only 300,000 annually there are only about 15,000 applicants.
However, according to the Association of American Medical Colleges, applications to medical schools can be expected to rise again after 1959—and sharply. This will be brought about by the first contingent of college graduates from the higher birth-rate years that began in 1939. Now that over 30 per cent of those of college age attend college in this country, as against 15 per cent in 1940, with the proportion continuing to rise, it is foreseen that by 1966 the higher wartime and postwar birth rate—combined with anticipated attendance by 50 per cent of those of college age—will send college enrollment up to five or six million. It is now three million, and in 1940 was one and a half million.
By 1965, the United States Office of Education predicts, over twice as many students as in 1955 will be receiving bachelor degrees: 600,000 annually. If they apply to medical schools in the present proportion of 5 to 7 per cent, 30,000 to 42,000 candidates for medical training can be expected by 1965.
We now have room in our medical schools for 7,800 freshman. This includes almost 300 places in three new medical schools: Seton Hall in Jersey City, Albert Einstein College of Yeshiva University, and the University of Florida (all three schools, however, remaining without formal approval from the AMA until they graduate their first classes).
A bill to provide Federal aid as an emergency measure for the creation of additional medical training facilities has been pending in Congress for over two years now. It provides $250 million for this purpose, with a requirement that additional expenses be shared by medical schools themselves, and envisages a five-year program in which $50 million may be spent by the government each year. The result, it is estimated by the Association of American Medical Colleges, will be to add about 850 places for first-year medical students. This means that there would be about 8,650 places in all within1 a space of five years if this bill were adopted.
These additional places will hardly suffice to maintain the present ratio of physicians to the total population of the United States. Nor does anyone even pretend that 850 new places would substantially narrow the present gap between demand and supply in medical care. The American Medical Association, as we have seen, insists that no real shortage of physicians exists at present, and is backing the proposed bill only because it admits that the population is growing, but other authorities maintain that by 1970 the demand for medical services will be 66 per cent higher than it is now.
On the basis of the projected figures, the current ratio of two applicants for each place in our medical schools will rise to four for each place by 1965. The situation will then be one in Which, while the country will still be short of doctors, the number of those willing and qualified to study medicine will be greater than ever. A likely result of the increased competition for medical school places that will then ensue will be the tightening up again of restrictive admission policies both through residential limitations and through ethnic and religious quotas.
In the final analysis, the question of who shall be our doctors ought to be answered by an informed public. Engineering societies do not lay down the number of engineers we require, nor do other professional groups presume to set limits to the number of recruits to their callings. The quality and scale of tomorrow’s medical care will be determined by what is planned today. Though a “crash” program for the expansion of medical school facilities would seem to be clearly indicated by the size of the present gap between supply and need, little is being done about it. This makes medical education a matter of very serious concern to every American, and not merely a special interest of the medical profession.