The Real Crisis in American Medicine—No Leadership

THE REAL CRISIS IN AMERICAN MEDICINENO LEADERSHIP RICHARD L. LANDAU, MJO* In an era when nothing counts at all unless it is a crisis, it would appear that American medicine has been provided with its fair share of attention. So many people, experts and amateurs alike, have alleged that the physician shortage has reached crisis proportions, that only a brave or foolish person would question this conclusion. However, a careful examination of the data accumulated by the protagonists of doom does not leave all readers aroused by the assumed impending calamity . That certain geographic areas (both urban and rural) are grossly underdoctored, both quantitatively and qualitatively, is undeniable —indeed shameful. But this "crisis" has been with us for at least fifty years. And then there is the pocketbook "crisis"—the cost of medical care. The cost of some items within the total medical care package has certainly risen much more rapidly than the value of the consumer 's dollar has declined, and this has become a "crisis" demanding the verbal attention of our president and other politicians momentarily in responsible positions. It has also been stated that the wealthiest, most powerful nation in the world should certainly have the healthiest, most long-lived population in the world. Since national statistics indicate that we are not the healthiest nation, some feel that we have a health "crisis." This "crisis" is generally explained by the shortage of physicians, the lack of physician availability in many areas, and the exorbitant cost of good care when it is provided. This is a neat construction built on a very shaky foundation. Improved administrative public health measures (housing , nutrition, utilities, education) still offer a greater potential for life extension than does medical care of the ill. But there are more deeply seated "crises" than these! The curtail- • Department of Medicine, University of Chicago. Perspectives in Biology and Medicine · Spring 1972 | 351 ment of federally sponsored biological and medical research is jeopardizing our continuing the rapid advances in medical science of the past thirty years. The loss of federal and other governmental funds for research and training is an important factor in the financial crises being experienced by virtually all of the nation's medical schools, about one fifth of which are said to be struggling on the verge of bankruptcy. Simultaneously, the medical schools are finding themselves beleaguered by the demands of communities, politicians, and naïve medical students that the schools' medical centers accept responsibility for "primary" medical care in neighboring and deprived communities. This is a task which the university-based medical schools can accomplish if they reorient themselves. But the inevitable cost of this change in direction is incalculably immense. The magnificent scholarship and research which have become the internationally recognized hallmarks of American medicine are certain to waste as the limited resources of the schools are diverted to more immediate practical goals. Recognizing the financial embarrassment of the medical schools, generous governmental agencies have offered to bail them out, if they materially increase the size of classes. In many instances this can be accomplished only by a significant dilution in instructional and research effort because the funds offered and contributed are generally insufficient to provide for more faculty positions . These strains on medical school faculties and administration which result from the obviously conflicting demands and aims now threaten to separate the medical schools from the universities which have provided the broad scientific base and the tradition of scholarship from which American medicine has derived its great strength. Such a separation would be a crisis dwarfing all others. Finally, there is a "crisis" in the closely related pharmaceutical industry. With congressional sanction, Food and Drug Administration regulations are threatening the very existence of new drug development and testing in this country. For example, it is now planned to have Americans test oral agents for the treatment of diabetes mellitus on Yugoslavians. The government's motives are commendable. The public must be protected from the hazards of ineffective and excessively dangerous drugs. Both the pharmaceutical industry and the profession have been guilty of quite minor misdemeanors which called for some corrective measures. However, the regulations imposed demand such extravagant preclinical testing that the high...