Medical Education Feature - March 2010
Tex Med. 2010;106(3):45-48.
By Ken Ortolon
Virtually everyone agrees Texas needs more physicians. The state's physician-to-population ratio is well below the national average, and Texas has shortages of doctors in nearly every recognized specialty.
Yet a proposal to create a new medical school in the Dallas-Fort Worth area is drawing harsh criticism from at least one segment of the medical community.
Some osteopathic physicians strongly oppose a University of North Texas Health Science Center (UNTHSC) proposal to create an allopathic medical school to share facilities and faculty with its existing Texas College of Osteopathic Medicine (TCOM) in Fort Worth.
UNTHSC officials say the proposed allopathic medical school has broad support from area hospitals, civic and business leaders, and the Tarrant County Medical Society. They believe it will not only increase the number of new physicians trained in Texas, but also attract more research dollars for UNTHSC and expand clerkship and residency training opportunities for both allopathic and osteopathic students through new partnerships with Fort Worth hospitals.
However, osteopathic physicians are concerned it actually would drain resources from TCOM.
"Not only are you threatening to take away financial resources from a very good school that has an excellent reputation, by doing that you're going to potentially threaten not only the quality of the education for all students, but the long-term availability of more primary care physicians for Texas," said Laredo family physician David Garza, DO. "It's no secret that TCOM generates a disproportionate number of primary care physicians, many of whom practice in rural and other underserved areas of Texas," said Dr. Garza, a member of the Texas Osteopathic Medical Association (TOMA) Board of Trustees.
Both the TOMA board and the TCOM Alumni Association Board of Directors oppose the new school. UNTHSC officials counter that they have received letters from dozens of supportive osteopathic physicians who believe it will improve TCOM and UNTHSC's ability to train more physicians.
"I now believe that an MD school working with TCOM could provide a healthy partnership," TCOM founder Carl E. Everett, DO, wrote in his letter of support.
The Pros and Cons
UNTHSC began exploring adding an MD degree program to its Fort Worth campus in November 2008, when the UNT Board of Regents authorized a study group to evaluate the likely benefits and liabilities of such a school.
UNTHSC President Scott Ransom, DO, says that decision was a response to interest among Fort Worth community leaders. He says there are several reasons community leaders want the new school, including what he called a desperate need for more doctors in the Dallas-Fort Worth area.
In a resolution supporting the proposed school, the Fort Worth Chamber of Commerce said rapid population growth in both Fort Worth and Texas, "coupled with existing physician shortages, have created a critical demand now and in the future for physicians of all types, both primary care and specialists. An allopathic medical school would supplement the Texas College of Osteopathic Medicine's provision of high-quality health care providers and increase the University of North Texas Health Science Center's ability to retain physicians in Tarrant County."
Dr. Ransom says there's also a "pride issue" involved. Fort Worth is the largest city in the country that does not have an MD-granting medical school, he says.
Former Fort Worth Mayor Kenneth Barr chaired the study group, which included representatives of local hospitals, business groups, the Texas Hospital Association, the Texas Medical Association, Tarrant County Medical Society, TOMA, and others. In its report, presented to the UNT regents in March 2009, the group concluded that adding an MD degree program would help establish additional teaching hospitals to provide clinical education experiences for both MD and DO students. The panel also said it would enable expansion and diversity of graduate medical education (GME) opportunities in Tarrant County.
The study group added that an MD school would increase UNTHSC's competitiveness for grant funding, expand clinical research opportunities, increase the appeal of UNTHSC in recruiting faculty and students, increase the appeal of Fort Worth and surrounding communities in recruiting new physicians, and establish a "new focus of pride" for Fort Worth and its medical community.
UNTHSC hired consulting firm Price Waterhouse Coopers to help develop a business and academic plan for the new school. That plan, presented to UNT regents in November 2009, estimated that creating the new MD program would cost $25 million in start-up funding.
At that November meeting, the regents unanimously authorized UNTHSC officials to move forward with their plans, but directed them to focus on four areas, including developing commitments to TCOM and other campus programs "to make sure we protect and secure the future success for all current programs, schools, and colleges," Dr. Ransom said.
The regents also instructed officials at UNTHSC to develop clinical education agreements with local hospitals, create a more detailed business plan, and raise the necessary start-up funds.
Once UNTHSC officials address those issues, they will seek regents' approval to ask the Texas Legislature to authorize the new medical school in 2011.
Dr. Ransom says an initial class of first-year medical students could enroll as early as fall 2013. Class size likely would be set at 100 students.
UNTHSC's consultants estimate the school needs $6.7 million for the initial planning phase and $14.8 million in actual start-up costs beyond the expected tuition revenue and normal formula funding support.
Another $2.7 million would pay for renovating the existing TCOM classroom building to house the allopathic students. TCOM already plans to move its students into a new 113,000-square-foot building required by recent increases in its class size.
Dr. Ransom says TCOM and the MD program can share the newly renovated anatomy laboratory and a clinical skills lab in the new building.
Further, the new MD school would recruit new faculty to complement existing UNTHSC faculty from departments such as anatomy, cell biology, physiology, obstetrics, and surgery, he says.
Dr. Ransom said the MD school "will establish an independent dean suite that would have a full-time MD school dean and associate deans for student affairs, academic affairs, clinical research, finance, and other normal support personnel, which presents a relatively limited incremental cost." He added that the "substantial cost of a new medical school is facilities and establishing brand new departments and service units from scratch. For the most part, we have the buildings, we have the service units, and we have a strong base of faculty from which to build. We would need to add faculty and staff incrementally to add to these existing infrastructure departments to support the new program and these additional students."
Follow the Money
While start-up expenses may be lower because of the existing infrastructure, opponents of the plan say ongoing costs to train allopathic students are considerably higher than training osteopathic students.
"They say that because they already have basic science facilities, they already have teaching facilities, they already have some faculty that they don't need to spend as much as some other schools," said Dallas orthopedic surgeon and TOMA President George Cole, DO. "The reason they do have to spend that money is because they've got to be accredited by the Liaison Committee on Medical Education, which has extensive requirements for full-time paid clinical faculty to teach those students where we [osteopathic schools] don't." The Commission on Osteopathic College Accreditation accredits osteopathic schools.
Dr. Cole says Michigan State University has both osteopathic and allopathic schools, and the cost of training an MD student there is roughly three times that of a DO student.
Both Dr. Cole and Dr. Garza are afraid UNTHSC will take resources away from TCOM to meet those additional costs. "It can't work financially without taking resources from TCOM," Dr. Cole said.
Some TCOM students also have concerns about potential negative impacts on their school.
"The students of TCOM welcome students of this proposed MD program on our campus and any potential opportunities to work together," said Joanna Gibbons, a member of the Medical Student Government Association. "However, there are student concerns that the addition of an MD program could be at the expense of the potential to expand and improve our current osteopathic school. We are unsure of how such a program could be established on a campus already expanding to accommodate the current student load without utilizing resources that would otherwise go towards TCOM students," she said.
UNTHSC leaders disagree.
"The $25 million start-up support will come from the community and will prevent any resources being diverted from TCOM or any other campus program," Dr. Ransom said. "The new MD school will not require any additional resources beyond normal tuition and formula dollars when a full four years of students are on campus."
If UNTHSC's goal is to train more physicians, Dr. Garza suggests it simply increase class size at TCOM. But Dr. Ransom says TCOM already increased its class size from roughly 125 three or four years ago to 186 this year. And, TCOM hopes to increase that further to 230 within two years.
Dr. Ransom says 230 students per class is about the maximum class size of any large medical school in the nation. Because of that, UNTHSC believes adding an MD school is more viable than continued expansion of TCOM.
Both Dr. Garza and Dr. Cole say there is widespread concern that the traditions of osteopathic medicine will be lost if the allopathic school is created. Those traditions include a focus on primary care and prevention, a "whole person" approach to medicine instead of just treating specific symptoms or illnesses, extra training in the musculoskeletal system, and use of osteopathic manipulative treatment. The fact that community leaders seem to believe having an allopathic school is more prestigious than an osteopathic school already has damaged relationships in the community, Dr. Cole says. "It's a slap in the face to say we want an allopathic school."
Even the report of the UNT study group cautioned that adding the MD school could result in the loss of the traditions of osteopathic health care from UNTHSC's culture.
Opponents also doubt the ability of Fort Worth-area hospitals to develop the necessary residency programs needed to provide postgraduate training opportunities in Fort Worth.
Texas Health Resources (THR) apparently has earmarked $50 million over the next five years to develop graduate medical education programs at its Harris Methodist Hospital in Fort Worth, but Dr. Cole says it may be difficult getting funding for those new GME slots. He says Medicare GME funding at Harris Methodist is capped at three residency slots, meaning the THR would have to raise funding for any new slots on its own.
"They can't expand unless they self fund," he said.
Where's the Confidence?
Dr. Cole says osteopathic physicians in Fort Worth, with the possible exception of TCOM faculty, are almost universally opposed to the new MD school, as are TCOM alumni.
Dr. Garza says the TCOM Alumni Association board voted unanimously to oppose the proposal in February 2009 and again in November 2009. On both occasions, the board also approved a vote of no confidence in Dr. Ransom, said Dr. Garza, the association's immediate past president.
The TOMA board passed a motion to oppose the school in December 2008. The TOMA House of Delegates ratified that motion in April 2009.
Dr. Ransom responded that UNTHSC has received more than 100 letters of support from osteopathic physicians, including many TCOM alums.
And, the proposal does have support from the broader medical community in Tarrant County. In an October 2009 letter to UNT System Chancellor Lee Jackson, Tarrant CMS President Rex Hyer, MD, said increasing the physician supply in the region requires increasing UNTHSC's undergraduate medical education training capacity, as well as expanding GME opportunities in Fort Worth.
"By offering an MD program, UNTHSC will be positioned to partner with community hospitals that are preparing to move forward with ACGME [Accreditation Council for Graduate Medical Education] resident programs," Dr. Hyer wrote, adding that ACGME programs provide flexibility because they accept both MD and DO students.
"Several hospitals have looked to UNTHSC first as a partner and we believe that allopathic residency programs will not detract from the medical school's commitment to osteopathic training but rather advance the vibrant training environment at UNTHSC through DO and MD students working jointly in local clinical training sites," Dr. Hyer wrote.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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