That Was Then, This Is Now

Demographic Changes Force TMA to Alter Medical School Policy

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Medical Education Feature -- June 2003

By  Ken Ortolon
Senior Editor

When several proposals were floated in the Texas Legislature in 2001 to create new four-year medical schools or increase enrollment at existing medical schools, the Texas Medical Association did not support them. The demographics, TMA officials said at the time, simply did not support adding more medical school slots.

Two years later, however, the association has done an about-face. Based on new studies that show that fewer physicians are moving to Texas and that physician shortages are growing in certain specialties, the TMA House of Delegates in April voted to revise association policy against expansion of medical school opportunities in Texas.

But some TMA and state higher education officials say expansion of existing programs should be a priority over creation of new medical schools. And, any expansion in the legislative session that just ended was considered a long shot given the severe budget woes lawmakers were attempting to resolve. Some medical school officials say just maintaining current programs will be difficult with the almost-certain budget cuts the schools will face.

"During this session it seems very clear that we're going to take a [budget] cut," James Guckian, MD, acting executive vice chancellor for health affairs at The University of Texas System, said while lawmakers were still meeting in April. "If we increase class size, the question before all of us is, 'Can we afford to do that, given that our medical schools are going to receive less funds?' The question is almost moot."

Facing the New Reality

The change in policy approved by the House of Delegates in April was based on recommendations developed by the TMA Committee on Physician Distribution and Health Care Access and the Council on Medical Education. In a workforce report presented to the House of Delegates, those panels concluded that workforce projections simply did not come to pass.

"The projected oversupply of physicians by the year 2000 by leading national physician workforce planning groups proved to be an inaccurate prediction," the report stated. "Instead, a growing number of medical specialty shortages are being seen across the country and in the state."

Among the specialties of particular concern are anesthesiology, pediatric subspecialties, and cardiac surgery.

Houston emergency physician Diana Fite, MD, chair of the Council on Medical Education, says three main factors influenced the decision to recommend adding medical school slots in Texas. First, she says, is the consistent increase in population in Texas, particularly in heavily Hispanic areas such as the Texas-Mexico border, "where we do not have a high distribution of physicians, by any means."

Second, she says, the number of international medical graduates (IMGs) seeking certification to enter U.S. graduate medical education programs has declined significantly since the Educational Commission for Foreign Medical Graduates began requiring IMGs to pass a clinical skills assessment examination in 1998. Since then, the number of IMGs seeking certification has dropped by more than 40 percent, while the number of certificates issued annually has decreased from between 9,000 and 12,000 during 1995-1998 to fewer than 6,000 during 1999-2001.

The number of IMGs entering the United States also has been impacted by thefederal government's decision to temporarily suspend the J-1 visa waiver program due to post-Sept. 11 security concerns. That program allowed many IMGs to set up practice here. Dr. Fite says the program has not been canceled outright, but it is much harder to get a visa, thus the pipeline of IMGs has been severely restricted.

Finally, fewer U.S. medical graduates are coming to Texas. That, Dr. Fite says, can be attributed both to the current liability crisis and to the increased penetration of managed care in the state that has made Texas less attractive to physicians seeking to avoid the hassles of managed care.

"So you add those three things together, and the Texas State Board of Medical Examiners definitely reflects a decrease in the number of physicians licensed over the last year or so," she said. In fact, Texas is experiencing a 10-year low in the number of new licenses issued.

"Based on the numbers, based on the need, we felt like we're actually facing a shortage here in certain specialties already," added Mexia family physician Ron Stephens, MD, immediate past chair of the Committee on Physician Distribution and Health Care Access. "And we think that problem is going to be magnified over the next few years."

The new policy, which was adopted with little debate by the House of Delegates, deletes the old language that neither the addition of new medical schools in Texas nor an increase in enrollment at any of the state's eight medical schools is needed.

The new policy states: "Given current physician shortages in some medical specialties, projected state demographics, the professional liability crisis, and the decreasing number of out-of-state physicians moving into the state, Texas is approaching a physician shortage. This evidence supports a need to consider enhancement of the physician pipeline through expansion of Texas medical school and residency program slots, with more immediate attention needed to expand resident slots."

Former TMA President Tom B. Hancher, MD, was a staunch opponent of medical school expansion when he was president during the 2001 legislative session. However, he supports the new policy.

"We always committed ourselves to continuing to study the manpower needs of the state of Texas," he said. "With the updated report from the physician distribution committee, we can see that the logistics have changed in the past two to three years."

Some physicians did raise objections to the new policy, pointing out that the number of physicians in Texas grew at twice the rate of increase in the general population. But Dr. Stephens says the ratio of physicians per 100,000 population in Texas still is well below the national average. In addition, an aging population, combined with the fact that younger physicians are working fewer hours than their older colleagues, means the demand for physicians will continue to grow, he says.

"The underlying problem is that as the baby boomers get into the Medicare age group they are going to demand much more health care. So the demand actually is going to continue to increase even if we have more physicians," he said. "Also, a majority of the physicians we're training now tend to not desire to work the 60-to-70-to-80-hour weeks that some of the older physicians work."

Joining the Parade

TMA's new policy closely follows recommendations issued by the Texas Higher Education Coordinating Board in July 2002. In a report, "Projecting the Need for Medical Education in Texas," the Coordinating Board concluded that "over time" the state should increase its in-state production of physicians to meet the increasing demand for medical services.

That should be accomplished, the board stated, by increasing class sizes at smaller existing medical schools -- including Texas Tech Health Sciences Center, the Texas A&M University System Health Science Center, and the University of North Texas Health Science Center -- and by "carefully considering the creation of an additional school or schools."

The board also recommended increasing the number of residency slots because that "would probably yield additional numbers of physicians choosing to practice in Texas -- whether they attended medical school in the state or elsewhere."

Marshall Hill, PhD, the board's assistant commissioner for universities and health-related institutions, says that in reaching their conclusions, board members looked at the need for medical services and for opportunities for Texans to become physicians.

"When we looked at all sorts of demographic trends, at the number of physicians that we have relative to our population, at their distribution around the state, at the opportunities that Texas residents have to attend Texas medical schools, we concluded that additional physicians were probably going to be needed," Dr. Hill said.

Dr. Hill says the board believes increasing the number of residency slots and the class sizes at existing medical schools is the "cheapest and easiest" way to raise the number of physicians the state is producing.

"The bottom line is that we probably need to increase residency programs, increase the size of the existing smaller schools, and then maybe create additional schools," he said.

At least one school, Texas A&M, already has asked the Coordinating Board and the Liaison Committee on Medical Education (LCME) to approve a class size increase. If it receives approval, A&M would increase its class size from 64 to 80 next fall and to 100 in either 2006 or 2007, says Nancy W. Dickey, MD, president of the Texas A&M University System Health Science Center.

In 2002, the University of North Texas Health Science Center also was working on an enrollment increase proposal, and Texas Tech had been granted legislative authority to seek LCME and Coordinating Board approval to phase in an increase from 124 to 200 students per class.

Bricks or Bodies?

If new schools are to be created, they probably should go in underserved areas, namely the border region, Dr. Hill says. That's good news for supporters of proposed four-year medical schools in El Paso and the Rio Grande Valley.

In 2001, state Sen. Eliot Shapleigh (D-El Paso) introduced legislation to expand Texas Tech University HSC in El Paso from a regional academic health center (RAHC) training third- and fourth-year medical students into a four-year medical school.

That legislation was not refiled this year, but Tech officials included funding for the proposal in their budget request to the legislature, and Senator Shapleigh was attempting to add the funding request to the appropriations bill late in the session.

Manuel de la Rosa, MD, regional dean at Texas Tech HSC in El Paso, says the school's proposed budget requested $45 million for a new building, $5 million to hire basic sciences faculty, and a special line item in the budget as a "placeholder" for future funding. Tech was not optimistic that any of that funding would be approved.

Physicians in El Paso are staunchly supporting the Texas Tech proposal. "You can see a significant need for more doctors along the U.S.-Mexican border," said El Paso nephrologist Manny Alvarez, MD, chair of the Border Health Caucus. "The current graduates certainly are not fulfilling the needs in these areas. If we can train people who are interested in border issues and try to keep them in the border areas, we certainly would improve access to health care for this population."

Meanwhile, Sen. Eddie Lucio (D-Brownsville) filed Senate Bill 1586 to turn the UT System RAHC in the Rio Grande Valley into a full-fledged health science center. That bill was referred to the Senate Education Committee in March but it had not been acted upon as of late April.

It will be an uphill battle for either facility to get the funding necessary to expand while existing medical schools are looking at significant budget cuts. Both the TMA workforce report and the Coordinating Board recommendations say new medical schools should not be created if doing so would jeopardize funding for existing programs. Dr. Hill says graduate medical education alone could face up to a 10-percent cut.

And, Dr. Guckian says the Rio Grande Valley RAHC may not be able to maintain its current operations under funding levels approved by the House in April, much less expand. That facility admitted its first group of third-year medical students from the UT Health Science Center in San Antonio last July and is scheduled to add a second class this summer.

Dr Guckian says the funding cuts may threaten accreditation of the Valley RAHC by compromising the quality of education being delivered there. UT may be forced to rotate students between San Antonio and the Valley rather than permanently assigning them to the Valley RAHC, he says.

Dr. Hancher says "throwing bricks" at the physician shortage problem is not the solution.

"The logic of that is quite clear," he said. "The cost of medical schools is in establishing an adequate infrastructure. Once you have that in place, increasing class size is much easier to adapt to the dynamic needs of the state than to simply build new schools and throw bricks at the problem."

A third proposed medical school at the predominantly African-American Prairie View A&M University appears to have given way to a more modest proposal to create a premedical school academy. Dr. Hill says the bill, filed by Rep. Ruth Jones McClendon (D-San Antonio), grew out of a Coordinating Board feasibility study on creating a Prairie View medical school. After looking at the hurdles to creating the school and the potential costs, the Coordinating Board determined the choices were "very daunting," Dr. Hill said.

Operating on the assumption that the purpose of creating a medical school at Prairie View was to increase opportunities for minorities to become physicians, the board then looked at other alternatives.

"One alternative was to aggressively recruit and improve the pre-med capabilities at high-minority-enrolling universities," Dr. Hill said.

Dr. Dickey says the academy would be a joint activity of her institution and Prairie View and would result in a "center of excellence for premedical education, enhancing the competitiveness of students in the academy in terms of application to professional schools."

Both A&M and the UT System have endorsed the bill. The TMA House of Delegates took a similar action during TexMed 2003.

Ken Ortolon can be reached at (880) 880-1300, ext. 1392, or (512) 370-1392; or by email at Ken Ortolon.

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