The Medicalization of Health
Rick Carlson, in his much-praised The End of Medicine, written in 1975, prescribed cutting the number of physicians in half and shifting the distribution heavily toward primary care. 1 The resources released could make a greater contribution to health and life in other employment. He must be surprised to note that in fact the number of physicians has almost doubled, and has further skewed toward specialists, and that the health care industry has far surpassed his feared 10 percent of GNP. How did this come about? We have reviewed the facts about the vast expansion of supply. But how did everyone manage to keep busy?
The medical profession has succeeded so far in increasing the demand for its services to such an extent that a near-doubling of the ratio of doctors to population since 1960 has not resulted in a surplus of M.D.s in general or in almost any specialty (in the sense that incomes fall, or prices fall, or M.D.s are unemployed, although many specialists have more leisure time than they should have). This was accomplished in part, as previously indicated, by overtesting and overtreatment. Comparison of rates in the United States with rates in other advanced and wealthy countries gives an indication of oversupply in many services: caesarian sections, coronary bypasses, surgical rates in general, therapy for high serum cholesterol, high blood pressure treatment, and a wide variety of diagnostic and screening tests. For that matter, comparisons of rates in different regions within the United States give the same indication: the more surgeons per capita, the more surgical procedures; the more hospital beds, the higher the rate of hospital admission relative to populations. We are not suggesting that low rates are necessarily appropriate and that high rates constitute overuse. But the lack of evidence that outcomes are better in the high-rate areas and countries does suggest overuse.