The Doctor Shortage: An Economic Diagnois.

Dr. Fein's book projects the future demand for physicians' services and the future supply. He uses both 1975 and 1980 as dates for the projection. He concludes that we will indeed face a shortage of doctor services and, although he calls his book an economic diagnosis, he does not shrink from prescribing several means of dealing with the problem. These include the growth of group practice and the greater use of auxiliary personnel including assistant physicians-both as ways of achieving greater productivity of the doctor-and he does not overlook the role of financing. Dr. Fein points out that without means of assuring delivery of service merely increasing the number of physicians is only a partial fulfillment of government's growing commitment in health, and also that a surge in financing arrangements often stimulates necessary improvements in supply. The book explores a number of issues in a reasoned and interesting way; it is not always clear which factors are being emphasized. Because of this low-key approach and the range of considerations surveyed, the book stimulates discussion, and in fact such is the author's intention. One of the problems in reorganizing the practice of medicine so as to extend the benefits of the doctor-hours available is that traditions of doctor autonomy and leadership of the team may influence both rate of acceptance of change and the economic framework of the new approach. Specifically, if doctors' duties are reallocated to semiprofessional others at lower supply cost will the doctor captain or his group continue to be reimbursed as before? (A look at dentistry indicates that an affirmative answer is realistic.) If the answer is yes, society may still gain in that more health services for which an unsatisfied demand existed can be produced and exchanged for payment. A financing problem for the community or for the marginal solo patient may be the residual, however. The method used by Dr. Fein to estimate the effect of income on future demand for care is to assume that families move up one income class (in the five-step classification used by the National Center for Health Statistics). He then tries alternative assumptions about the number of physician visits to be expected for an age-sex group, based on recent national data by income class. One problem in considering aggregate visits is that use of specialists has been income-sensitive and that the nature of the relationship of utilization to income will be affected by the growing proportion of specialists. A look at population movement between income classes in a recent decade (1955-1965) shows great upward mobility and suggests the possibility of unstable utilization patterns, and of receptivity to new ways. Future exploration will be useful. CHARLOTTE MULLER