The Medical Brain Drain

WASHINGTON–On June 4, 1973, Caspar Weinberger, Secretary of Health, Education and Welfare, was angry over a report on foreign medical graduates and American medicine. First, he didn’t like the conclusions of the study by Dr. Rosemary Stevens of Yale University made under a contract with his Department. Second, he wanted his subordinates to understand that any release of the report should plainly state on a revised title page that the Department is not to be associated with it in any way.

In a private memo to Assistant Secretary for Health, Charles Edwards, Weinberger emphasized: “Before we publish this, I want a Departmental statement that this report is the result of a contract we awarded some time ago and that it does not represent the views of the Department, particularly when the report says we ‘perpetuated the brain-drain’ and that we are vulnerable to criticism of being ‘imperialistic’ and ‘grabbing.'” Just what did the Stevens report conclude? Basically, these points were made:

1. Foreign Medical Graduates (FMGs) now constitute one-fifth of U.S. physicians and about one-third of hospital based physicians. This had two important consequences, she stated. It has postponed constructive criticisms of the utilization and distribution of American trained physicians. And, the influx amounts to a “reverse foreign aid” and a brain drain from poorer countries in great need of physicians for their people. The report goes on to assert that the U.S. has perpetuated this brain-drain partly through its educational exchange program.

In addition to discussion of language problems and different standards than those provided for American graduates, Dr. Stevens urges a rethinking of what the best interests of needy countries and our national health policies and manpower should be in the light of this critical reliance on FMGs.

By May 1973, about 100 copies of the Stevens report were circulated to a select list of recipients. Yet, remarkably enough, Assistant Secretary Edwards was offering
Weinberger options which included restricting the report as being too controversial and inconsistent with “public positions of the Administration.”

In a confidential memo to Secretary Weinberger last May, Dr. Edwards proposed three options: “prohibit dissemination of the report “; “provide copies of the document upon request but do not routinely disseminate”; or “routinely disseminate the document with a disclaimer that the views and opinions expressed are those of the author and not the federal government.”

Dr. Edwards recommended the third option – to disseminate routinely the report on request. He observed that his lawyers advised him that “the Freedom of Information Act would preclude any attempt to withhold the report from the general public. In addition, a much greater public controversy would develop if we attempt to prohibit release.”

Why such-agonizing at such high Departmental levels over a seemingly straightforward report? The issue of the number of FMGs practicing medicine in the U.S. is part of a highly controversial Departmental debate over the alleged doctor shortage and the question of continuing massive federal funding of medical education and health manpower generally when the present law expires on June 30, 1974.

Dr. Edwards believes that such support should be curtailed, that there may be a surplus of doctors in the next fifteen years and that such a surplus may create more demand and higher prices for health care. In a candid address last November to the Association of American Medical Colleges, he took medical schools to task for not responding adequately to the “uneven quality in the services that physicians and others provide” and to the “serious imbalances in supply and demand that leave someareas with far too many resources and others literally with none.” He was presumably referring to the overabundance of certain specialities such as general surgery and the low numbers of family practitioners and internists, for example, as well as the virtual absence of physicians in some small towns or city slum areas.

On the other hand, Dr. Kenneth Endicott, the Administrator for the Health Resources Administration, disagrees and opposes reduction of the Department’s national health manpower expansion program. He does not expect oversupply of manpower to develop and that it is not “good public policy” to continue relying on “very large numbers of foreign medical graduates to meet national needs for physicians” for reasons similar to those in the Stevens report. He recommends reduction in the admission of FMGs over the next decade.

Congress, particularly Cong. Paul Rogers who leads health policy in the House of Representatives, will take up these contrasting views soon. It is a debate of spreading consequences to national health policy generally and citizens may wish to participate by obtaining some basic information from Cong. Rogers and his Subcommittee on Public Health and Environment.

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