Since its inception in 1842, the Naval Medical Corps, through the Bureau of Medicine and Surgery, has constantly supplied that high quality of medical and surgical care to U. S. Navy and Marine Corps personnel that has made our Navy the healthiest in the world. It has upon occasion performed near miracles in reducing the mortality of casualties during World War II, and, again, during the Korean War, when mortality was reduced to the lowest of any war in history.
Today, however, there is a crisis which may take all the ingenuity of the Naval Medical Corps to solve. Crises in the form of inadequate personnel have occurred and reoccurred in the Medical Corps since the end of World War II. At its largest at the end of World War II, the Medical Corps had 14,387 physicians on active duty. Five short years later, just prior to the Korean War in 1950, it had dropped to an alarming 2,755 physicians. These personnel shortages were buffered to some extent in the early 1950s, when a number of recalled physicians elected to remain and make a career of the Naval Medical Corps.
Numerous incentives have been tried to retain career medical officers. Among these have been increased pay for physicians and dentists on active duty, credit for time in medical school for pay and retirement pay, more rapid advancement in rank, shorter tours of sea duty, and opportunities for residency training and specialization. These measures, although they have been beneficial, have failed to fill adequately the growing need for career military physicians.
Now, once again, there is a critical shortage of career medical officers. There were 3,482 medical officers on active duty in March 1964. Of these, 1,303 were reserve officers and 2,179 were regulars. Presumably, over one- third of these officers merely are fulfilling their obligated service with no intention of remaining in the service.
A recent survey of medical officers completing specialized training under naval auspices has shown that approximately 90 per cent have indicated that they intend to quit the service after fulfilling their obligated duty.
These are the highly trained men who were expected to become career medical officers, and function as heads of departments and chiefs of services in the next few years.
The bulk of today’s medical corps captains were promoted to their present rank in 1955, which means that they are nearly ten years in grade at this time. The majority will retire in a few short years, either by choice, because of expected attrition, by being “passed over,” or due to mandatory retirement age. If the majority of the trained younger men also depart, as they have indicated they will, who will fill the career officers’ billets? Must we continue to resort to costly, unfair drafts to fill our needs? How else can we maintain the present high standards of medical care for our servicemen and their dependents?
It is apparent that present methods are entirely inadequate to obtain badly needed, career medical officers. We can no longer talk in platitudes about the insufficient number of regular medical officers. There appears to be only one solution—the establishment of a naval medical school.
The American Medical Association Council on Medical Education points with pride to the fact that the freshman class for 1965 is about 100 more students than that for 1964. This number includes the first year class of one new medical school. Assuming normal attrition of about 10 per cent (the average for the last five years), this means that four years from now about 90 more doctors will graduate than did in the preceding year.
Over the past decade, the average increase in medical school graduates has been about 2 per cent. However, this dropped to 1.4 per cent last year. Thus, it can be seen that since the annual increase in the U. S. population for the last decade has averaged 1.7 per cent, the number of new doctors each year cannot keep up with the population increase, much less alleviate the continuing shortage of career service physicians.
The American Medical Association objects to a service medical school on the grounds that it tends toward “governmental control” of medicine. But, does not the career service doctor actually practice a type of socialized medicine—and by choice? By obtaining sufficient career officers to abolish the draft, would not this possibly prevent socialized medicine from becoming established throughout the nation?
Most medical schools have been receiving federal aid for many years. The American Medical Association therefore has no valid objection to “governmental control.” Forty- six per cent of medical school expenditures in 1962 were paid by federal funds. This compares with only 30 per cent in 1959. Over 13 per cent of all full-time faculty members of medical schools received 100 per cent of their salaries from federal sources in 1963, and more than 40 per cent received some portion of their salary from federal funds.
The accelerated programs during World War II, such as the V-12 and Army Specialized Training Program, proved that good, well trained physicians could be turned out in a three-year program. Many of the career medical officers of today were recruited from these programs. And, these programs, vital during the war years, did not lead to socialized medicine, or government control of medicine.
Another criticism is that a naval medical school would not be sufficient to fill the needs of the service. But what is sufficient? One hundred career officers a year would become 400 in four years. This would better the present number of “regulars” recruited by present methods for long-term tours.
Another objection heard is that additional medical schools will lower medical standards. This need not be true. Last year, over 2,000 U. S. citizens were in medical schools in foreign countries. We must assume the majority, although qualified, could not get into U. S. schools. Last year, 1,700 of these U. S. citizens who had studied abroad were licensed to practice in the United States, which indicates that they are now considered adequately trained.
Where might we obtain enough students of high educational qualifications and motivation for medicine to begin a naval medical school? The A.M.A., as well as state and county medical societies, recognizing the need for enticing able students into the field of medicine and the allied sciences, have several recruiting programs to emphasize the challenges of medicine as a career. The National Opinion Research Center has shown clearly that decisions regarding careers are often made by students as early as in their high school years. By careful selection and recruiting methods, the high schools could become an inexhaustible gold mine of potential medical students for the proposed naval medical school.
There are many outstanding corpsmen and corpswaves in the service today, who have had some college training. Many of them would welcome the opportunity to become doctors, but they are unable financially to attend medical school. Many of today’s career medical officers are ex-corpsmen who left the service after World War II, attended medical school under the G. I. Bill, and then returned to active duty with the full intention of “going for 30.”
The Navy Enlisted Science Educational Program (NESEP) recruits and finances four- year college educations for apt pupils. A similar program for six years would be sufficient to finance a medical education— three years’ college and three years of an accelerated medical school. First-year medical students could also be recruited from the Service academies after the first two years. We can assume that many Academy men (who find themselves not motivated for line officer, aviation or engineering billets) would welcome a chance for medical school. There are career medical officers today who were line officers previously, and who returned to the service after attending medical school.
Preliminary studies indicate that the number of applicants to medical schools in 1965 will increase 15 per cent over 1964. Due to an expected increase in the number of college graduates, we can anticipate that the number of medical school applicants will increase substantially during the next several years. Were a naval medical school to compete with present medical schools many of these applicants could be recruited for a medical career in the service.
Medical students now studying in foreign countries would fill the equivalent of four average-size schools in this country. We must assume the majority of these students would prefer to be trained in the United States, but that they have been rejected by medical schools here for various reasons. Over 20 U. S. medical schools accept less than 10 per cent from outside their individual states. Three schools accept no students from other states, in spite of the fact that all of these schools accept federal aid. Thus, a great many capable students are lost to medicine through these unfair tactics.
About 5 per cent of last year’s graduating classes were women. There are suitable nurses and corpswaves in the service today who are mature, who are oriented toward medicine, and who would make good career physicians, if given the opportunity. The use of more and more women in medicine, civilian as well as military, is undoubtedly one significant answer to the critical shortage.
Approximately one-half of the drop-outs from medical schools occur for other than academic reasons. Identification and correction of these other reasons for drop-out (financial, emotional, motivational) could add considerably to the number of students who graduate.
The problem of selection of suitable medical students for a naval medical school becomes paramount. The credentials committee should scrutinize the qualifications of each candidate carefully, and consider strongly such factors as character, scientific background, motivation, and moral turpitude. College grades, although admittedly important, need not and should not be the deciding factor alone. Last year, 28 schools reported over one-fourth of their students had “C” averages in premedical work, and two reported over 50 per cent with “C” averages. These students undoubtedly will graduate and make good physicians. It thus appears that aptitude and motivation should count equally high with scholastic standards in the selection of students.
The Medical College Admission Test (MCAT), taken by almost all medical school candidates today, has been standardized for at least the last decade. The average score on this test is about 500 points, with the range between 400 and 600 embracing about two- thirds of all candidates. A relatively high score on this aptitude test should be mandatory for selection to a naval medical school.
All applicants should have an extensive personal interview, to determine their suitability for the medical field. During this interview, certain pertinent questions should be dwelt on at length to ascertain that those students selected are of high quality, and well motivated not only for medicine, but for a naval medical career.
In today’s fast-moving world, there appears to be no need for candidates to medical school to have B.S. degrees. Apt students at the third-year college level can survive medical school, as was amply demonstrated during World War II. Accelerated medical school programs have produced fine quality, well trained physicians.
Admission to a naval medical school should be on a strictly competitive basis. There should be no congressional or “political” appointments or appointments of expediency. Service-wide competitions should be held among career enlisted men and women first, and suitable candidates from this group should be given preference over their civilian counterparts. All applicants, of course, should pass a rigid physical examination. Waivers could be granted, however, for certain visual and auditory defects, as well as other minor defects, both congenital and acquired.
Above all, the entrance requirements of the Council on Medical Education and Hospitals of the American Medical Association, and the Executive Council of the Association of American Medical Colleges should be met unequivocally by students seeking admission.
How should these medical students be financed? The American Medical Association Education and Research Foundation (AMA- ERF) reports that one out of every seven students receives financial aid from the Foundation. This is only one source of aid for students —many are financed through other loans, such as the Sears-Roebuck Foundation. Others are supported, in whole or in part, by friends and relatives other than their parents. Thus, we must concede that the financial status of students is a critical factor in determining whether or not they complete their medical training.
A program financed like the ASTP and V-12 programs during World War II has been proven feasible. Civilian medical students could be enlisted at the basic pay rate. Military personnel could be continued at their current rank and pay. This scheme is similar to the one being used with the present NESEP. Books and equipment could be loaned to students, to be returned upon completion of the school year, and thus used for the next class.
Students accepting training would obligate themselves on a year-by-year basis, similar to the obligations of the service academies. Objection has been made that there would be no assurance of retaining these individuals, after completion of their obligated service. However, the same applies to the service academies, who lose a healthy portion of their officers after they complete their four-year obligations. But if these students received training for six years and were then obligated for six years’ service, they would have 12 years longevity upon completion of their obligation. Thus, they will be approaching the 20- year mark and would likely be retained. It is with those individuals who have only six to eight years longevity that the greatest attrition occurs.
The problem of staffing a naval medical school immediately must be faced. The ratio of students to staff varies considerably from school to school. Most schools, however, would settle for a five-to-one ratio of total students to full time faculty. During the first and second years of medical school, basic science teaching is done on a departmental basis. Thus, the student-to-faculty ratio is proportional to the number of members of the particular department, rather than to the total number of basic science teachers. This means that the ratio would be higher for the first two years than it would be for the last two.
Professors for the basic science departments should be recruited from civilian sources. They should have the qualifications and breadth of experience to enable them to organize an effective teaching program. They should have a real interest in teaching and should be willing to give extra time and effort to the educational program. They should be chosen on the basis of ability, aptitude, and interest. Their selection should not be considered as honorary, and there should be no political appointments.
The associate and assistant professors could be obtained from a number of sources. There are many retired service doctors, who would welcome an opportunity for full or part-time teaching jobs at a medical school. In addition, appropriate civilians seeking teaching fellowships or advanced degrees could be hired, if necessary.
The problem of staffing for the third and fourth years of medical school is solved more easily. The A.M.A. states that the majority of medical graduates who are interested in academic careers will continue to seek medical specialty board certification rather than a graduate degree in clinical science programs. We have career physicians who are board certified specialists in all the major specialties. Many of these have proven themselves excellent teachers. Most of the service hospitals are recognized by the A.M.A. and the Joint Commission on Accreditation of Hospitals as teaching hospitals for interns and residents. Given added incentive and prestige, present chiefs of medical services and heads of departments in teaching hospitals could round out the naval medical school staff. As evidence of the acceptability of these men as teachers, it should be pointed out that a larger majority of individuals finishing residency programs in service hospitals successfully pass their specialty board examinations than do their civilian counterparts.
Would the cost for a naval medical school be prohibitive? Not necessarily—yearly expenditures for the various medical schools varied from $379,200 to $8,037,827 in 1962. However, 75 per cent reported expenditures of between one and three million dollars. Admittedly, these schools have buildings, laboratories, dormitories, and other facilities already constructed.
The decision has been made recently to build a new 650-bed permanent type structure hospital at the present site of the U. S. Naval Hospital, Oakland, California. The “temporary type” buildings which were built over 20 years ago, during World War II, have withstood the ravages of time well. At present, however, they are being dismantled gradually and sold for a mere pittance of their value. These buildings would be entirely adequate for use as a nidus for a naval medical school. They can be converted easily into laboratories, class rooms and student dormitories at minimal expense to the government when compared to the cost of entirely new structures. These buildings already contain central steam heat, hot and cold running water, and electricity.
The first two years of basic science could be set up on a trial basis, using existing facilities at Oak Knoll, U. S. Naval Hospital, Oakland, California. Upon completion of the first two-year curriculum, a comprehensive examination similar to Part I of the National Board should be satisfactorily passed by the naval medical school students. If each civilian medical school would accept only one, or at the most two, of these students under a program similar to NESEP, until the complete four-year curriculum could be instituted and approved, personnel benefits to the medical corps could be realized within a very few years.
Any four-year program would have to be acceptable to, and approved by, the Council on Medical Education and Hospitals of the American Medical Association and the Executive Council of the Association of American Medical Colleges, through their liaison committee on medical education.
Various A.M.A. review committees regard the hospital autopsy rate as a most important index of the interest in conducting an educational program with high academic standards. Of hospitals showing the highest autopsy rates, there were 20 federal hospitals last year which showed 86 per cent or over. The U. S. Naval Hospital, Oakland, California, showed an autopsy rate of 95 per cent for last year.
Adequate clinical material for the third and fourth years of medical school also exist at Oak Knoll. Service internships and residencies there are comparable to most and superior to many teaching programs approved by the A.M.A. and J.C.A.H. During the Third Quarter, Fiscal Year 1964, there were 3,960 admissions to Oak Knoll, with an average daily bed occupancy of 643. There were 437 births during this period, with a daily average of 17 bassinets occupied. There were 56,018 outpatient visits for the Third Quarter. For the same period, there were 66,620 X-ray films exposed, 869 fluoroscopic examinations, 109,066 pharmacy prescriptions filled, and 98,809 laboratory tests conducted. These statistics compare favorably with those of most medical school hospitals teaching students today.
It is the author’s firm belief that the entire medical student training program is within the present capabilities of the Services— teachers, facilities and students. The A.M.A. has expressed concern in recent years over the adequacy of the future supply of physicians for a growing population. The increase in future supply is a well-documented necessity, not only for the Services but for the civilian population as well. There is only one answer to both problems—expand present educational facilities, and increase the number of medical students.
People in the medical educational field, including those in A.M.A. and the Bureau of Medicine and Surgery, are afraid of radical changes. They mistrust them. But the need for changes exists, and someone must cast down the gauntlet of challenge to awaken them to the need for a re-evaluation and a change in the archaic thinking of yesteryear.
The program as outlined conceivably could abolish the unfair draft of physicians in a few short years, barring a major war. At the same time, the program would offer some assurance to the American serviceman and his dependents that they would continue to receive what they are entitled to no less than the civilian population—that degree of skill and competence which has always been the backbone of American medicine, the fully- trained, competent, and available physician.
The question then is not why a service medical school—the dire need already exists. The question now becomes why not? The author believes it to be both economical, feasible, and practical.
The gauntlet has been thrown. It remains up to the American Medical Association and the Bureau of Medicine and Surgery, for the good of the Medical Corps as well as for all American medicine, to investigate further the possibility of a naval medical school. The time is short, and we must plug the holes in the Medical Corps before we find it necessary to abandon ship.