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Physicians: Endangered Species

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Sadly, in the ongoing, often vitriolic debates about health care for us all, Americans have lost sight of the iconic importance of our physicians and medical scientists -- the foundation of our medical health care system. Nowhere in these debates is there evidence of any awareness of the societal value of physicians and their massive impact on America. Present debates see physicians at most as robotic deliverers of direct medical services, with cost being the only consideration, the cheaper the better. The necessity of maintaining and improving physicians' numbers, strength and quality are not part of the plans or goals of any public or private organization.

Many of the overwhelming changes in our physical and emotional quality of life, public health, preventative care, and nutrition stem directly from the work of physicians and medical science. The average life expectancy for Caucasian men has increased from 33 years in 1850 to 69.8 years in 2004. Caucasian women and all African-Americans live longer, on average into their late 70s.

The saving of lives in emergency, life-threatening situations, while dramatic and important, represents only a small part of the contribution of medicine. An even greater component of medical effort is devoted to improving the quality of our lives, to preventing or minimizing the poor quality of life associated with chronic disease, to the relief of pain, disfigurement, and disability.

The most important medical advances have been in public health, especially with regard to providing safer water and milk, meat and other foods. The discovery of insulin by Banting, Best, et. al. largely wiped out the scourge of diabetes.

The development of vaccines and immunizations for diphtheria, whooping cough and tetanus, and later polio, measles, mumps, rubella, hepatitis A and B, homophiles influenza and meningococcal meningitis, etc., are estimated by UNICEF to save at least 9 million children and countless adults from death each year.

In 1928 penicillin was discovered, followed over many years until today by numerous other antibiotics that have changed our world forever. Estimates of the number of lives saved each year by these drugs vary, but a commonly-held number is 12 million.

Improved surgical techniques, safer anesthesia, and blood transfusion have further and dramatically altered the landscape of our lives. About 232 million major surgical procedures are performed each year, and 4.5 million Americans will receive blood transfusions this year, using 43,000 pints of blood each day.

Survival rates of almost all diseases have improved dramatically over the past few years. Cancer survival rates in Britain have doubled over the past 30 years. Stroke survival rates in Great Britain have improved 29 percent in the past 10 years.

Very recently at Cedars-Sinai Hospital in Los Angeles, an early example of what will become one of the next great leaps forward in dramatic changes to our health and survival, the use of stem cells for curative-regenerative purposes, has occurred. Human cardiac stem cells were used to correct heart scarring in heart attack victims, scars being replaced by normal heart muscle.

At present the number of physicians in the U.S. totals 954,000. This is 40,000 less than are presently needed, with the deficit rapidly growing as the population grows and more and more medical consumers are added to the rolls of those receiving care. At current graduation and training rates, the nation will face a shortage of 150,000 doctors, and probably more, in the next 15 years, according to the Association of American Medical Colleges (AAMC).

Only four new medical schools have started recently, all with no government funding. As of last October, these four new American medical schools enrolled a total of about 190 students. Twelve other existing medical schools added 150 student positions, amounting to a grand total of 340 new medical student positions (AAMC) on top of the usual 18,000, an 1.8 percent increase. This increase is pitifully small given today's current shortage of 40,000 physicians, which is rapidly growing to 150,000.

Moreover, there is a shortage of medical resident positions, a result of a numerical cap placed by our government in 1996 on resident positions. This cap of approximately 110,000 was born on the wings of governmental fear of the U.S. being overrun by foreign medical school graduates and having a glut of trained but unemployable American medical school graduates. Even though both those fears should have long since disappeared, that cap is still standing. These positions are funded through Medicare with money given Medicare by Congress. (Don't ask me why. That's just how it works.) Doctors' groups and medical schools had hoped that the new health care law, passed last March, would increase the number of Medicare-funded residency slots, but such a provision was removed from the final bill. Therefore, instead of more crucial training positions, we have the same number as in 1996, 16 years ago -- a tragic mistake.

The quality of physicians is decreasing as well. The best and brightest are not entering the field of medicine for a wide variety of reasons. The biggest reason is financial. The cost of training for each would-be physician has soared and financial rewards after training have slumped, both dramatically. The cost of undergraduate/medical school/internship/residency, all mandatory to become a physician, is staggering. For example, a typical non-surgical specialist, a cardiologist, will spend 13 years in training and borrow approximately $500,000-$600,000 for tuition, living expenses, and fees. Further specialty training costs more and takes longer and causes further borrowing. (I, for example, a psychiatrist and psychoanalyst, had 21 years of training: four years at the University of California at Berkeley, four at Tufts University Medical School, one at Children's Hospital of Los Angeles, two as a fellow at the National Institute of Mental Health, three at the UCLA Neuropsychiatric Institute, and seven at the Los Angeles Psychoanalytic Institute. My number of years is unusually high.)

Our best doctors are those with excellent training, years of experience, and usually have specialty board certification. They come from a different era and are older. Back then, they knew after all the training, they would be able to pay back their student loans and be able to support their families. Their tuition was dramatically lower and earnings higher than today. Unfortunately, one-third of the doctors practicing in the U.S. today (315,000 of 954,000), making up a large percentage of our best doctors, are over 60 years of age now and will retire within the next 10 years.

We're losing physicians and the value they bring to all of us left and right. If the old saying, "At least you've got your health" is to continue to have any meaning at all, we need more physicians, more medical scientists, more developments and discoveries, hardly less. For the next 100 years of medical treatment and development to look anything like the last 100, we and our government must not think we can get these at bargain basement sale prices. If we follow that path -- the "cheap and less is best" path -- it will prove to be a monument to our foolishness and shortsightedness and guarantee us poorer health care, profoundly poorer health care. It will also guarantee us fewer and fewer new understandings of our human condition, physical or mental, sick or well. There may be many things we can give up on. We can't give up on us.

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