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MANPOWER REQUIREMENTS IN THE U.S.A.
41 LENGTH OF STAY OF PSYCHIATRIC PATIENTS IN A DGH UNIT
revealed
a
substantial
excess
of
physicians,
and
specialists
in
particular. 5-9** Mullan’s second point relates to inappropriate geographical may well be that here, too, there is no shortage of physicians but rather a lack of access to medical care in rural areas or urban ghettos which do not attract practitioners. The solution may not be training more doctors but ensuring access to care; this care may or may not be best delivered by
distribution; it
a
physician.
Department of Research Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, U.S.A.
BERNARD S. BLOOM
SEAT-BELTS can be few medical practitioners who, from reading or from their direct experience in accident departments and operating-theatres, are not convinced of the value of seat-belts. To them the recent decision by the Minister of Transport not to introduce legislation to make seat-belt wearing compulsory must be seen as a devastating act of irresponsibility. However, the response from the profession and its official representatives has been minimal. Mr Lewis Carter-Jones, MP for Eccles, asked the Minister of Transport in a Parlimentary question what representation he had received from the medical profession about wearing of seat-belts in the light of his policy not to proceed with legislation to make the wearing of seat-belts compulsory. In a written answer on Tuesday, June 19, Sir George Young, replying on behalf of the Minister of Transport, stated. that only
SiR,—There
their
example of duck-weed multiplying on the surface of We are not sure what an appropriate analogy would be in the case of patients losing their psychiatric disability -ice melting on the same pond?
been the a
pond.
Department of Psychiatry, St. Mary’s Hospital, London W9 3RL
R. G. PRIEST P. RAPTOPOULOS M. L. CHAN
MANPOWER REQUIREMENTS IN THE U.S.A.
SIR,-Idespair that in 1979 a senior U.S. Civil Servant should contend that the United States has had at any time during the past decade a shortage of physicians. Dr Mullan also noted that the U.S. has an uneven distribution of physicians, a less questionable thesis. Mullan’s opinion that the U.S. was short of doctors in 1970 is, like nearly aH major physician manpower reports on this shortage over the past two-and-a-half decades and the expansionist recommendations which have followed them, based on opinions of commission members, mainly academic physicians and deans. The first Carnegie report, cited by Mullan, recommended a 50% increase in medical-school output.2 A second Carnegie report, issued just six years later, also based mainly on opinion, concluded that there might be too many physiciansIt seems odd that the U.S. went from shortage to excess in just six years. The recommendations of the first report had barely been implemented and the first classes could only have been part way through their training. U.S. manpower commissions, without hard evidence, have been recommending expansion since the 1940s.4 Recommendations for expansion were usually based only on opinions. Every commission has urged greater increases than did the one before. One fundamental problem of U.S. physician manpower policy is that responsibility for manpower recommendations is divorced from payment for the consequences. An additional problem may be that the U.S. health-care system is informally organised with little comprehensive policy planning and health goal-setting. Better health is the implicit goal, but the objectives and methods by which this goal is to be reached are not made clear. "More physicians" thus becomes a goal in itself. In future we will need to ensure that the consequences of different policies are debated publicly and explored fully before decisions are made. Manpower policy must be based on sound evidence. Starting in the early 1970s several well-designed, executed, and analysed manpower studies were done: they all 1. Mullan F. The National Health Service Corps. Lancet 1979, i: 1071-1073. Commission on Higher Education. Higher education and the nation’s health. New York: McGraw-Hill, 1970. 3. Carnegie Council on Policy Studies in Higher Education. Progress and problems in medical and dental education. San Francisco: Jossey-Bass Pub-
2. Carnegie
lishers, 1976. 4. Bloom BS, Peterson OL. Physician manpower Ann Intern Med 1979; 90: 249-256.
expansionism: a policy review
letters had been received from individual doctors in favour of the compulsory wearing of seat-belts and none from professional organisations. I trust that individual doctors and those who represent them will make the most vigorous representations to the Minister to get him to introduce this most simple piece of preventive medicine and to demonstrate to the public that we really are concerned for their health and safety.
two
Department of Surgery, University of Manchester, Hope Hospital,
MILES IRVING
Salford M6 8HD
M.R.C. TREATMENT TRIAL FOR MILD HYPERTENSION a paper given on June 13, 1979, at the sixth scienmeeting of the International Society of Hypertension, the Management Committee of the Australian National Blood Pressure Study reported results which have led them to stop
SiR,-In
tific
their randomised controlled trial for the treatment of mild hypertension. Some of your readers may want to know how this will affect the somewhat similar M.R.C. trial in Britain. The entry criteria in the two trials differ in an important way. The Australian trial included men and women aged 30-69 with screening pressures within the 95-109 mm Hg diastolic (V) range. Randomisation to active or placebo tablets was determined by their blood-pressure measurements recorded at a subsequent entry examination, when all with pressures of 95 mm or over were eligible. At that stage 16% 5. Clawson DK, Denton TJ. Orthopædic manpower study: phase IV. Chicago: American Academy of Orthopaedic Surgeons, 1975. 6. Adams FH, Mendenhall RC, ed. Profile of the cardiologist. Am J Cardiol
1974; 34: 389-456. 7. Hauck WW Jr, Bloom BS, McPherson CK, Nickerson RJ, Colton T, Peterson OL. Surgeons in the United States. JAMA 1976;236:1864-1871. 8. Nickerson RJ, Colton T, Peterson OL, Bloom BS, Hauck WW Jr. Doctors who perform operations. N Eng J Med 1976; 295: 921-926, 982-989. 9. Glenn JF. Urologic manpower and training program survey. J Urol
1977, 119: 137-139.
revealed
a
substantial
excess
of
physicians,
and
specialists
in
particular. 5-9** Mullan’s second point relates to inappropriate geographical may well be that here, too, there is no shortage of physicians but rather a lack of access to medical care in rural areas or urban ghettos which do not attract practitioners. The solution may not be training more doctors but ensuring access to care; this care may or may not be best delivered by
distribution; it
a
physician.
Department of Research Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, U.S.A.
BERNARD S. BLOOM
SEAT-BELTS can be few medical practitioners who, from reading or from their direct experience in accident departments and operating-theatres, are not convinced of the value of seat-belts. To them the recent decision by the Minister of Transport not to introduce legislation to make seat-belt wearing compulsory must be seen as a devastating act of irresponsibility. However, the response from the profession and its official representatives has been minimal. Mr Lewis Carter-Jones, MP for Eccles, asked the Minister of Transport in a Parlimentary question what representation he had received from the medical profession about wearing of seat-belts in the light of his policy not to proceed with legislation to make the wearing of seat-belts compulsory. In a written answer on Tuesday, June 19, Sir George Young, replying on behalf of the Minister of Transport, stated. that only
SiR,—There
their
example of duck-weed multiplying on the surface of We are not sure what an appropriate analogy would be in the case of patients losing their psychiatric disability -ice melting on the same pond?
been the a
pond.
Department of Psychiatry, St. Mary’s Hospital, London W9 3RL
R. G. PRIEST P. RAPTOPOULOS M. L. CHAN
MANPOWER REQUIREMENTS IN THE U.S.A.
SIR,-Idespair that in 1979 a senior U.S. Civil Servant should contend that the United States has had at any time during the past decade a shortage of physicians. Dr Mullan also noted that the U.S. has an uneven distribution of physicians, a less questionable thesis. Mullan’s opinion that the U.S. was short of doctors in 1970 is, like nearly aH major physician manpower reports on this shortage over the past two-and-a-half decades and the expansionist recommendations which have followed them, based on opinions of commission members, mainly academic physicians and deans. The first Carnegie report, cited by Mullan, recommended a 50% increase in medical-school output.2 A second Carnegie report, issued just six years later, also based mainly on opinion, concluded that there might be too many physiciansIt seems odd that the U.S. went from shortage to excess in just six years. The recommendations of the first report had barely been implemented and the first classes could only have been part way through their training. U.S. manpower commissions, without hard evidence, have been recommending expansion since the 1940s.4 Recommendations for expansion were usually based only on opinions. Every commission has urged greater increases than did the one before. One fundamental problem of U.S. physician manpower policy is that responsibility for manpower recommendations is divorced from payment for the consequences. An additional problem may be that the U.S. health-care system is informally organised with little comprehensive policy planning and health goal-setting. Better health is the implicit goal, but the objectives and methods by which this goal is to be reached are not made clear. "More physicians" thus becomes a goal in itself. In future we will need to ensure that the consequences of different policies are debated publicly and explored fully before decisions are made. Manpower policy must be based on sound evidence. Starting in the early 1970s several well-designed, executed, and analysed manpower studies were done: they all 1. Mullan F. The National Health Service Corps. Lancet 1979, i: 1071-1073. Commission on Higher Education. Higher education and the nation’s health. New York: McGraw-Hill, 1970. 3. Carnegie Council on Policy Studies in Higher Education. Progress and problems in medical and dental education. San Francisco: Jossey-Bass Pub-
2. Carnegie
lishers, 1976. 4. Bloom BS, Peterson OL. Physician manpower Ann Intern Med 1979; 90: 249-256.
expansionism: a policy review
letters had been received from individual doctors in favour of the compulsory wearing of seat-belts and none from professional organisations. I trust that individual doctors and those who represent them will make the most vigorous representations to the Minister to get him to introduce this most simple piece of preventive medicine and to demonstrate to the public that we really are concerned for their health and safety.
two
Department of Surgery, University of Manchester, Hope Hospital,
MILES IRVING
Salford M6 8HD
M.R.C. TREATMENT TRIAL FOR MILD HYPERTENSION a paper given on June 13, 1979, at the sixth scienmeeting of the International Society of Hypertension, the Management Committee of the Australian National Blood Pressure Study reported results which have led them to stop
SiR,-In
tific
their randomised controlled trial for the treatment of mild hypertension. Some of your readers may want to know how this will affect the somewhat similar M.R.C. trial in Britain. The entry criteria in the two trials differ in an important way. The Australian trial included men and women aged 30-69 with screening pressures within the 95-109 mm Hg diastolic (V) range. Randomisation to active or placebo tablets was determined by their blood-pressure measurements recorded at a subsequent entry examination, when all with pressures of 95 mm or over were eligible. At that stage 16% 5. Clawson DK, Denton TJ. Orthopædic manpower study: phase IV. Chicago: American Academy of Orthopaedic Surgeons, 1975. 6. Adams FH, Mendenhall RC, ed. Profile of the cardiologist. Am J Cardiol
1974; 34: 389-456. 7. Hauck WW Jr, Bloom BS, McPherson CK, Nickerson RJ, Colton T, Peterson OL. Surgeons in the United States. JAMA 1976;236:1864-1871. 8. Nickerson RJ, Colton T, Peterson OL, Bloom BS, Hauck WW Jr. Doctors who perform operations. N Eng J Med 1976; 295: 921-926, 982-989. 9. Glenn JF. Urologic manpower and training program survey. J Urol
1977, 119: 137-139.