Made for each Other  and Texas Physician to Patient Ratio is Third World

Imagine a time, back two generations, before the nuclear age, moon walks, internet, cable, cell phones. Sit yourself in a movie house. A talkie comes on with high tech drama, for then, and romance. The film is contemporary for depression years just before World War Two. It’s 1939 and Jimmy Stewart, a young Wall Street lawyer, marries Carole Lombard the same day he meets her. Let’s call the movie, Made for Each Other, and watch, and listen, as the newly weds manage their New York apartment, his career, and her insecurities. Throw in a Mother in law who is aghast at her impetuous son’s selection.  Since it is years into the depression, the young father’s,  – Stewart’s -,  requests for raises, at his Wall Street law firm, are not only rebuffed, but, Stewart takes a cut and is glad to even have a job at all. They make room for a baby, and then suspense. After a New Year’s winter holiday party, the parents return home to find the baby figuratively ‘burning up’ with fever. The doctor makes his house call and rushes the baby to the hospital. Pneumonia! Might as well be a death sentence. Only a new wonder drug, discovered a decade before, and recently commercialized and available, will save the child. The drug is called penicillin. Very high tech. Brand new. Very very expensive.  Outside a snow storm rages. Inside the hospital, the doctor is phoning for the drug. More high tech, as the telephone system has wired a nation only in the same generation as the parents’ lives. No penicillin is to be had in Manhattan. Call Boston.  Call Philadelphia, Baltimore, Washington D.C. No hospital on the east coast can spare even one dose for a baby, wheezing, crying, dying. The fever is high. The pulse is slowing. The infection can’t be stopped. What good is the magic bullet, a new discovery, if you can’t get it in time?  Then good news. Doses of Penicillin, are available in Salt Lake City. But the train, going night and day, will take 3 days, and some mountain passes over the Rockies are snowed in. A train will never make it in time, the Doctor laments. The father is frantic crazy for his boy. What about an airplane? More high tech. It has only been 4 years since the Civil Air Board was formed. And yes, yes! A pilot and plane, in Utah,  will hazard the trip over the Rockies, and  across the country. But its dangerous. Even deadly. The price for a special air delivery is five thousand dollars, half paid in advance, the other half upon delivery. In 1939, an ante bellum house and lot in New Canaan Connecticut could be purchased for about five thousand dollars, which antique house would sell for more than a million, maybe two million, 66 years later.  The father, unable to get a raise, barely able to hang onto his junior associate position, doesn’t care about his job. He rushes over to the only person he knows with that kind of cash, his boss. After screams, and sobs, and threats, and pleas, the Wall Street “name” lawyer understands his employee’s baby’s risk, need, and desperation, and guarantees the money. Even writes out the check.  The airport in Utah is notified, and the pilot starts out. The whole American continent is a cloud cover.  Remember it is the first week of January.  There is no air traffic control. Before radar. The pilot has just a radio, lights, and compass.  The plane gets iced up, and the pilot reaches outside of the plane, with his glove, to scrape ice off the wind shield to see. See what? It’s night. The baby is dying. The pilot has the precious penicillin wrapped in a container and strapped inside his coat.  The wind blows. The propellers strain. The pilot checks his compass as the only means of navigation.  Counting the hours, estimating his fuel, nursing the engine, the plane covers mountains and plains, rivers and cities. The pilot has no rest, no place for a break. No place to land and refuel. The radio goes out, and no one has communication.  Might as well have been war combat. The family is helpless, and so is the doctor.  The plane begins to lose altitude, but can’t land without a runway or airport. The pilot knows the plane won’t last, and finally the engine catches fire. The pilot bails out over, who knew what or where?  It was New York! And a farmer family, hearing the plane engine over head, go to inspect the noise, even the crash, and find the pilot and parachute. The pilot is taken to their farm house, and inside his coat is the package, worth the value of a nice estate in New Canaan, with instructions to rush the medicine to the Doctor at the Mercy hospital in New York City. The farm family calls the hospital, arrangements are made with the police for a police car escort.  Another chase scene,  and the medicine arrives, and is given to the baby. It works. The baby starts pulling through. The recovery is complete, the baby is saved, the family saved, and a happy ending for all. That is the plot of the movie. But this was not just Hollywood’s creation.  David O. Selznick, wealthy Hollywood film Producer of Made for Each Other,  wrote that the plot of desperately searching for the serum and flying it from Utah in a storm for a critically sick baby was a real event in his family.   The emergency actually happened.

Can we conceive of a time before there was amoxicllin or penicillin, with sufficient doses, and doctors available for round the clock treatment? Before the Salk or Sabine shot for polio? Before small pox was erased?  There will not be a word about health insurance in the entire story.  Money could buy a plane and pilot who would risk his all, but only after the diagnosis was made, and the medicine was found. Sir Alexander Fleming had discovered the penicillin cure about 1929; but even a decade later it’s manufacture was so limited, only a few doses would be distributed around the largest cities in the country, and none in the rural areas.

As of 2006, some spoke of a health crisis, wherein 5.94 million Texans lacked health insurance[i] with an average annual cost of Texas health insurance at $4,000.[ii] Consider that Texas had 9 medical schools[iii] but 55 Companies[iv] with Approved Consumer Choice Benefit Plans, just one of dozens of health insurance plans. Are the values misplaced to have six times the number of health plans as compared to medical schools? If that is not a wake up call, maybe this is. Texas had 1,987 listings on the authorized insurance company list.[v] Another 118 HMOs were listed by the Department of Insurance.[vi] So it appeared there were over 200 insurance companies for every medical school. But have you ever seen an insurance policy deliver a baby, make a diagnosis, give a shot, remove an appendix, set a broken arm? If so, it would make the Guinness book of Weird world events, if there were such.

There is one physician for every 657 Texans, compared to the U.S. average of one physician for every 454 Americans.[vii]   

But, recalling the movie Doctor in  New York City making the house call for the sick baby, there is only one primary care physician for every 1,408 Texans, compared to one primary care physician for every 1,234 Americans.[viii] Texas can’t even train its own quota of physicians. 44% of Texas’ physicians went to medical school in Texas, about a fifth of the physicians were trained overseas (international), and a third from the rest of the U.S.[ix] Texas has about 1355 resident positions per year, fed by the medical schools.  Texas, with 32 Congressman (2006), Texas has 1200  first years medical students, and California, with 54 congressmen, has 1,000 first year medical students.[x] Texas expands its residency to 110% over its home taught med students, while California balloons to 227%, picking up medical students for graduate education from out of state schools.   The annual cost of faculty to train 6150 residents is $92 million (apparently Texas funding), or only $15,000 per resident. Medical students’ cost is about $47,000 each.

    Texas has about 35,000 physicians. Assuming 3% retire, quit or die each year, the replacement number would be 1,039 new physicians.   Consider other statistics, the Veterans Administration maintains a ratio of about 60 patients per physician. Stamford and Greenwich Connecticut have a ratio of about 250 people per physician, between two and three times more available physicians than Texas has available. Connecticut has five congressmen and two medical schools.[xi]

Texas has twice the number of practicing lawyers (70,000)14 as physicians (35,000).    Texas has the same number of law schools (9), as medical schools (9). But in 2005, Texas had 2,845 new attorneys pass its bar exam,[xii]  or nearly three times the

number of its medical students.   The thesis of this paper is that the ratios, should be reversed. Texas should have twice the number of physicians, as lawyers. If Texas can afford 70,000 lawyers, it should have 140,000 physicians.

Physician training, or lack thereof, impacts immigration. Immigrants are one in four of U.S. physicians,[xiii] and one in four physician immigrants are from India.[xiv] Immigration policy encourages intake of doctors, nurses, health professionals from other countries, and such are given a fast track for American visas and green cards.   Sucking the brains out of the rest of the world, even the third world, is not a sustainable policy when it comes to health care. Remember the frantic father whose baby is dying from pneumonia? He will do anything to get the medicine. Not for him, but his son. The thoughts jump out, “who do I gotta kill?”  That line was not in the movie, but in the acting. Jimmy Stewart, the actor in Made for Each Other, was very persuasive.

Compared to a century ago, Texas medical school training is disappointing. About the turn of the 20th century, a hundred years ago, America had 166 medical schools.[xv]    America now has 145 schools.[xvi] which means, there were more then in 1900, than now. I don’t have immediate information on how many medical schools were in Texas about 1904-1906, but probably more then, than now.   Compare that to the growth in legal education. In 1900 the Association of American Law Schools recorded 32 charter members.[xvii] Today, there are 180 ranked law schools,[xviii] plus 18 more accredited[xix] and dozens unaccredited.[xx]

 ‘In 1900, the census reported 3 million Texans.[xxi] In the 2000 census, there were 17 million Texans.[xxii] You can see that while the legal education, and population, has grown in a century,  there are six times the laws schools nationally, medical education has shrunk.

When compared to other recorded health care, Texas’ patient to physician ratio is high. As noted, the Stamford Greenwich Connecticut ratio is one physician per 250 residents, and for the Veterans Administration, the Veterans Administration  has a goal of  one physician for 60 veterans. The availability of physicians, determines access to regular checkups for health maintenance, timely intervention, crisis care, expert diagnostics, and specialty care. Compared to Connecticut, Texas is trying to set 3 riders on a horse, and expecting the horse to travel as far and fast. That expects a lot from the horse, and a lot from the Texas physicians. Compared to the Veterans Administration, Texas is trying to push 10 pounds of potatoes into a one pound sack. Of course the rest of the potatoes fall on the floor, assuming the sack doesn’t break so that the whole crop isn’t in the dirt.   It can’t be done.

When compared to the third world, Texas physician patient ratio is disappointing. Texas ratio of one physician for 657 Texans is about the same as Kuwait.[xxiii] If I had the statistics, I would expect that North Dallas, Austin, Waco, and cities around the 9 medical schools, would have more physicians for fewer patients which all would agree would enhance health care from the patients’ point of view.  As for rural counties, they might expect a very unfavorable ratio, of few physicians and many more patients. Intuitively, specialists will not be practicing in rural areas. Taking the ratio of one primary care physician for every 1,408 Texans, Texas looks more third world, ranking under Algeria, (1 physician for 1190 population.)   American Samoa (1 physician for 1282 population.),  Andorra, Argentina (1 physician for 303 population),   Armenia,32 Australia,33

measures of quality described here. Specialty rankings are based on nomination by legal educators at peer institutions.” See http://www.usnews.com/usnews/edu/qrad/rankings/about/index brief.php.

Austria, Azerbaijan, Bahamas (1 physician for 952 population),  Bahrain, 37 Barbados, (1 physician for 833 population.) etc.[xxiv]  Notice that Texas has a better ratio of physicians than India, because about 40 thousand Indian trained physicians are practicing in the United States, or five percent of the American total. The assumption must be that there are so many Indians, forty thousand Indian physicians more or less won’t be missed.

Now, I agree that the World Health Organization listings of physicians does not entirely take into account education, skills, experience, and a host of infrastructure, Americans are used to when receiving health care. But all the great hospital buildings, and insurance policies, and medical devices and insurance policies, and wonder drugs, still won’t help until the patient can be seen, examined, diagnosed, treated, reexamined, and cured. A theatre line a thousand patrons long is long enough.  After Disney took moved to New York City,  I saw Michael Eisner, then CEO, virtually swallowed up in the seats of the New Amsterdam theater in Times Square, noting there were 1,356 or so seats That is where the Lion King is performed, and was the theater for the   1920’s Ziegfeld follies. It looked like a lot of seats, but still fewer than each primary care physician is to care for the population of Texas.

Everything that is said for physicians, could be said for nurses, dentists, pharmacists, etc. The health care professional to population ratios are high (that’s bad), the professionals are immigrating from their native countries (that’s bad for their native countries), their patients then want to immigrate here to follow their professionals (that’s bad), and so it goes.

How did the health industry so lack behind the growth in America? Was it too great a reliance on government to pay for everything? Probably thousands and millions of decisions, hour by hour, day by day, decade by decade, created the present situation. But the reliance on government is misplaced.

Note this comment by Dr. Thomas Coburn, one of two physicians who served in the U.S. Senate from Oklahoma, about events when he was a Congressman (1993-2001):

“One of the best example of the disconnections between an organization’s goals and the goals of its lobbyists was the American Medical Association (AMA) and their role in the patients’ bill of rights debate. The AMA failed, in my opinion, to play a constructive role in that debate because their lobbyists were completely out of touch with the needs of doctors and patients. The battle was ironic because the lobbyists were – with rare exception – lawyers, not doctors, and the doctors that did have influence over the lobbyists rarely practiced medicine. So here I was, a congressman who was actively practicing medicine and a member of the AMA, arguing back and forth with lawyers from the AMA who had never had one experience with Health Maintenance Organizations or managed care firms that eliminate necessary and adequate care for patients. The AMA’s chief goal was to get the deal done and look good to the board of the AMA. It seemed they could have cared less if the bill actually helped or hurt doctors or patients. From my vantage point, internal politics, not the needs of patients or doctors, were driving their position. The AMA instructed its lobbyists to avoid any compromise that might alienate doctors in Texas or Georgia, states that had already passed a patients’ bill of rights that protected the right to sue in state courts.

The  Lesson I learned from my experience from the AMA patients’ bill of rights debacle [was] … Don’t trust what anyone says in Washington because more often than not a political calculation will undermined their commitment. One of the first things I did when I retired from Congress was to cancel my membership in the AMA.    It was clear from working with the AMA in Washington that they do not represent most physicians but rather the ruling political elite in medicine, and as a consequence, they harm the interests of patients.”[xxv]

So, I take it that no one in the past century has been watching these misallocation or reduction  of physician resources as they develop. When presented with the need to have more medical students, I have heard some express the belief  there are no more students, i.e. students have chosen other career paths or don’t want to prepare for med school.  That assumption isn’t true, because for each round of testing, the number of pre-med college students taking the MCAT, which tests on microbiology, chemistry, and physics, is usually double the number of medical school seats available.  Students know this. The half who don’t get into American medical schools have other limited choices. Some choices are to go overseas (such as the Grenada medical school which was rescued during President Reagan’s term), or try a peripheral career, such as Psychology, medical technician, therapy, etc.  Many pre med students, if they are unable to get a  medical student seat, drop out of health care education altogether.

       How many medical students would it take to staff the needed physicians? How much would it cost? Pick your level of care.  If you want to replace the ones that are retiring or dying each year, estimate 3% of the total. Texas is not even replacing these to maintain an equilibrium with present levels. If you want the nearly 6 million uninsured Texans treated at a Third world health level, a pretty low bar to step over,  i.e. one physician for Fourteen hundred patients, then Texas needs about 4,200 more physicians, or 3 times the number of  its annual medical school seats.  As it takes 8 years, after college, to train the physicians, doubling the seats now would provide the extra 4,200 physicians about the year 2024.  If Texas wants to raise its health care standard to those of Greenwich-Stamford Connecticut,  i.e. one for 250 patients, Texas needs about 91,000 physicians, or two and a half times the present number.  If Texas wants a Veterans Administration ratio, i.e. one physician for 60 patients, Texas needs 380,000 physicians.  These numbers are to meet current Texas population, and does not consider estimates that Dallas Fort Worth, alone, plans to add five million population within the next 20 years.

Apparently, to meet physician gaps,  California adopted an interesting approach.  After Medical School grants the Doctor of Medicine degree, usually after 4 years or about 160 college hours of credt, further training begins in residency programs in hospitals, called internships or fellowships.  The residency training are for specialty  education and continue the medical education in a clinical setting. California  offers three times the number of residencies for graduate medical education, than the seats it fills from its own California located medical schools. California’s policy of luring graduate medical students away from out of state medical colleges they attended, is economically doubtful, if not damaging, to those states or nations where the students went for medical school. If Texas wants to grow its physician force, and not expand its medical school seats, Texas will have to do the same, i.e. fund residencies and lure into Texas, out of state newly graduated medical doctors.

This analysis has mentioned physician resources in several states, including Texas, California, and Connecticut. The same physician shortage applies throughout the United States.  Big states have  big shortages, and small population states have even bigger shortages, as physician to patient ratios in rural areas  have even more patients needing care, than urban areas.

Recalling Jimmy Stewart’s anguished cries in his movie, consider the plot that one child is diagnosed with pneumonia on New Year’ s day, and there is not a single dose to spare anywhere east of the Rocky Mountains. And, furthermore, to get it in time will require the risk of pilot and plane, and the cost of a house. Were not there other children with pneumonia among the ten of millions in New York, and the millions in Boston, Philadelphia, Baltimore, Washington, Chicago, Pittsburgh, Cleveland, St. Louis, Atlanta, ore Miami? Yes, there were, and presumably, they suffered and many died. Too bad. Not a feel good ending.

            What is needed?  An increase of many Tens of thousands of medical school seats.

Copyright 2006. John Choate is a member of the Federalist Society, and retired Air Force Lieutenant Colonel. He is also a past member of the Federal Bar Association’s National Council and past President of the Tulsa Chapter Federal Bar Association.  He is also past Executive Committee for the Federal Administrative Law Judge Association,  as class agent for his Yale Law School class, past member of  the National Transportation Bar Association, and  past Chair of the Taxation section of the Association for American Law Schools.

[i] [2005 census estimate of 22,859,968 Texas population per U.S. Census Bureau times 26% uninsured from InsureMe, citing the Texas Department of Insurance],

[ii] Ibid.

[iii] [Baylor College of Medicine, The Texas A&M University System Health Science Center College of Medicine, Texas Tech University Health Sciences Center School of Medicine, University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine, The University of Texas Health Science Center at Houston Medical School, The University of Texas Medical Branch at Galveston, The University of Texas Medical School at San Antonio, The University of Texas Southwestern Medical School, The University of Texas Southwestern Medical Center at Dallas]

[iv] http://www.tdi.state.tx.us/company/lhccbp 1st incl.html

[v] Ibid

[vi] Ibid

[vii] [ Physicians /100,000 TX 152 US 220, Primary care/100,000 71 TX 81 US -http://www.utsystem.edu/News/2004/BORMay2004-Presentations/GradMedEdPresentation05-13-04.ppt#291,6,Physician Workforce   (2003)]

[viii] [Presentation  to  the Board of Regents  Health Affairs Committee,   By Kenneth  Shine,   M.D.   May  12,   2004]

[ix] Ibid.

[x] Ibid. The references to number of Congressmen, which representation is based on population, is given for general comparisons.

[xi] The   Fairfield  County  Weekly     News&Commentary.htm.   Letters   05/23/2002. The   Republican   Platform  on  Health  Care.

[xii]

[http://www.texasbar.com/]

[xiii]  http://www.ama-assn.org/ama/pub/category/print/211.html

[xiv] Ibid.

[xv] http://en.wikipedia.org/wiki/Flexner_Report#School_closures

[xvi] http://www.usnews.com/usnews/edu/grad/directory/dir-med/dirmedindex_brief.php       America’s   Best   Graduate   Schools   2007, Medical  School  Directory.   “The medical school directory lists the 125 schools offering M.D. degrees that are accredited by the Liaison Committee on Medical Education, plus the 20 schools that offer the D.O. degree and are accredited by the American Osteopathic Association.”

[xvii] AALS – The Association of American Law Schools

… The AALS holds an Annual Meeting every year in January and five or six workshops and conferences throughout the year. The AALS publishes a Directory of Law Teachers and a quarterly newsletter, as well as other publications. Much of the learned society activities are done by the 85 AALS Sections, which plan programs at the Annual Meetings and publish newsletters throughout the year. History The AALS was founded in 1900 with thirty-two charter members. Professor James Bradley Thayer, Harvard Law School, was its first president. Professor Michael H. Cardozo of Cornell University Law School became the Association’s first Executive Director in 1963 and established the Association’s national office, From a full-time staff of two in 1963 (including the Executive Director ), the AALS full-time staff has grown to approximately 20, including the Executive Director, Deputy

Director …

http://www.aals.org/zoomSearchEngine/search.php?zoom_query=1900+&zoom_per_page=10&zoom_and=1&zoom_sort=0

[xviii] http://www.usnews.com/usnews/edu/grad/rankings/law/brief/lawrank  brief.

php U.S. News and World Report, Top Law Schools.” The rankings of 180 law schools accredited by the American Bar Association are based on a weighted average of the 12

in California,    and 14 more registered,    and 15 institutions offering law study   for at least 227 American law schools.

[xix] http://www.usnews.com/usnews/edu/grad/rankings/law/brief/lawrank  brief.

php U.S. News and World Report, Top Law Schools.” The rankings of 180 law schools accredited by the American Bar Association are based on a weighted average of the 12

in California,    and 14 more registered,    and 15 institutions offering law study   for at least 227 American law schools.

[xx] Law Schools in California accredited by the Committee of Bar Examiners fCALS), See http;//www.calbar,ca,gov/state/calbar/calbarmgeneric,jsp?cid=10115&id=5128,

Correspondence Law Schools Registered with the Committee of Bar Examiners, Ibid, Unaccredited Law Schools in California

[xxi] 3,048,710        Texas   –   TEXAS

Population  of  Counties  by   Decennial  Census:   1900   to   1990 Compiled  and  edited  by   Richard  L.   Forstall   Population   Division  US Bureau   of   the   Census   Washington,    DC   20233. http://www.census.gov/population/cencounts/tx!90090.txt

[xxii] NATIVITY AND PLACE OF BIRTH         Total population. 16.986.510 Table DP-2. Profile of Selected Social Characteristics for Texas: 1990. See http://www.census.gov/Press-Release/www/2002/dptables/90smp48.xls.

[xxiii] http://www.who.int/qlobalatlas/dataQuerv/reportData.asp?rptType=1

Global Atlas of the Health Workforce

[xxiv] ibid.   Belarus 1/222, Belgium 1/239, Belize 1/96, Bosnia and Herzegovina 1/751, Brazil 1/487, Brunei Darussalam 1/1,000, Bulgaria 1/295, Canada 1/478, Chile 1/917, China 1/609, Colombia 1/740, Costa Rica 1/584, Croatia 1/421, Cuba 1/169, Cyprus 1/335, Czech Republic 1/291, Democratic People’s Republic of Korea 1/336, Denmark 1/273, Dominican Republic 1/531, Ecuador 1/680, Egypt 1/473, El Salvador 1/787, Estonia 1/316, Finland 1/322, France 1/303, French Polynesia 1/591, Georgia 1/256, Germany 1/277,

[xxv] Breach of Trust, How Washington turns outsiders into insiders, pg. 44-45. WNDBooks.com

Copyright JIMC

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