Texas First

Legislature Preserves Training Spots for Texans

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Tex Med. 2013;109(10):49-53.  

By Amy Lynn Sorrel 
Associate Editor  

Texas medical students come first. That's what the Texas Medical Association and the state's medical schools told the 2013 legislature. Lawmakers heard them and passed legislation barring foreign medical schools from buying up core clinical training spots at Texas teaching hospitals and institutions.

Those clerkships are reserved for third- and fourth-year medical students to begin their clinical training. With most of them at or nearing capacity, however — and a queue of new students as Texas medical schools expand enrollments — there's little room to spare for foreign medical schools to scoop them up, says David Wright, MD, chair of TMA's Council on Medical Education.

Yet that's what one Caribbean medical school tried to do in Texas. The American University of the Caribbean (AUC) — a for-profit medical school owned by DeVry, Inc. on the island of St. Maarten — pitched the move to lawmakers to bring more physicians to Texas. That's because like many offshore schools, it lacks the facilities to offer the clinical training on site. According to its website, the school offers core clerkships through hospitals in six U.S. states.

But Dr. Wright said the proposal came "at a time when Texas medical schools are just so overwhelmed right now trying to keep their heads above water, to take on anything additional would cause them to go under and drown." He said the legislation ensures that "all of our students who need certain clinical experiences get them, and not just get them, but have good quality experiences."

The threat to that education was imminent: Following a 2011 recommendation by its Strategic Planning and Policy Committee, the Texas Higher Education Coordinating Board (THECB) was poised to grant a certificate of authority to AUC. It would have allowed the school to offer courses leading to a medical degree in Texas and to contract with Texas hospitals and other health care facilities for clinical training spots. A November 2012 opinion by the state attorney general's office reinforced the board's authority to grant such certification.

"It's important to recognize that this almost happened," said Sen. Judith Zaffirini (D-Laredo). She and fellow Senate Higher Education Committee member Sen. Robert Duncan (R-Lubbock) originally coauthored the prohibition as Senate Bill 301, which later passed as an amendment offered by Rep. John Zerwas, MD (R-Simonton), to Senate Bill 215. "I believe strongly we precluded a problem from happening. Our Texas medical students should be prioritized, and we must ensure they have access to those clinical rotations without doing anything to jeopardize that. They are our investment. [The state] invests in medical education, and we have to protect that investment."

Avoiding a Bidding War

THECB was ready to allow AUC to buy a limited number of core clerkship spots in Texas training facilities. Before the proposal was finalized, however, TMA and Texas' medical schools intervened to put the brakes on the decision over fear it would displace Texas medical students.

Adding foreign medical students while Texas enrollments continue to grow could exacerbate the shortage of clinical training space and spark a bidding war for the spots, which publicly funded medical schools could not compete with, wrote then-TMA Council on Medical Education Chair Cynthia Jumper, MD, to THECB in 2012. The amount of money the state invests in Texas medical students far outweighs any bid foreign schools' could offer, she added.

In addition to voicing their opposition to the AUC plan to the coordinating board, TMA let key lawmakers Sens. Zaffirini and Duncan know what it would do to all of the state's medical schools.

"And all of that impact was more or less going to be a negative impact," said Dr. Wright, director of The University of Texas Medical Branch's family medicine clerkship program at Austin's University Medical Center Brackenridge Hospital. "Of all four years [in medical school], the third is the most critical because that's when students gain clinical exposure" in various specialties: psychiatry, family medicine, internal medicine, surgery, pediatrics, and obstetrics/gynecology. "That's how they are going to learn medicine," he said, adding that overcrowding those clinical rotations would dilute the quality of students' education.

Legislature Steps In

Meanwhile, unconvinced of THECB's authority to allow foreign medical schools to operate in Texas, Senator Zaffirini asked the board to seek an opinion from the state attorney general and to further study the capacity issue. "What we asked for was time to investigate the issue."

In his legal opinion, however, Texas Attorney General Greg Abbott said state law at the time gave THECB the discretion to decide whether foreign-based institutions may offer courses leading to a medical degree in the Lone Star State. State law contained "no geographic requirements or restrictions" that prevented THECB from granting or denying a certificate of authority to a foreign medical school "that otherwise satisfies the statutory and regulatory criteria for issuance of such a certificate."

Lawmakers disagreed with that interpretation, which led them to take up the issue during this year's legislative session.

Meanwhile, THECB in January released the results of a survey of the state's medical schools that received mixed interpretations. According to the board, because "the number of students at a particular clerkship site is fluid … it is difficult to adequately assess the clinical capacity within a particular clerkship site."

But Dr. Wright says the survey was quite clear in that medical schools unanimously agreed the clinical training sites they work with could not accommodate more students. At Brackenridge, he has about 35 medical students from UT. For the past four years, the school asked him to accept additional students and for the past four years he turned them down because "I don't have the capacity, faculty, or resources." Meanwhile, struggling hospitals have had to downsize, and many students have to travel across the state to find clerkships. 

Kenneth I. Shine, MD, then-executive vice chancellor for health affairs of the UT System, testified on behalf of the state's medical schools that they, too, are scrambling to find enough third- and fourth-year clerkships to keep pace with an Association of American Medical Colleges recommendation to increase enrollments 30 percent by 2015. That was before two new medical schools were approved in Texas.

Even though THECB's plan pertained only to a single foreign school, it could open the door to others, he warned. "The fact is there are 35 English-speaking medical schools with thousands of students in the Caribbean alone," he told the Senate Higher Education Committee in April. Even if they were barred from clerkships, however, qualified foreign medical school students could continue to apply for electives and residencies in Texas.

Medical schools also spend considerable effort developing clinical rotation sites, extensive faculty training, and infrastructure for libraries and simulation centers, for example, Don Peska, DO, dean of the Texas College of Osteopathic Medicine, told the Senate committee. Offshore schools do not bear those expenses, he noted.

Warning Shots From New York

While the issues TMA and the medical schools raised were not realized in Texas, they were not unfounded, Dr. Wright says. All lawmakers had to do was look east to see that the stakes were high.

Five years ago, New York City Health and Hospitals Corporation signed a 10-year, $10 million exclusive contract with the Caribbean offshore school St. Georges' Medical School. The for-profit school pays $400 per student per week for training slots under that agreement.

Initially, the move did not drastically impact medical schools' relationships with teaching hospitals, says Jo Wiederhorn, president and chief executive officer of the Associated Medical Schools of New York. Then, several other offshore schools followed suit. "All of a sudden it became much more of an issue," she said. In 2009, the state education department reported that about half of the 4,000 medical students doing third- and fourth-year rotations in New York State were from offshore medical schools.

"It is displacing our students," as hospital use the funds paid by off shore medical schools to supplant low Medicaid payment rates, she said.

The diminution of the quality of students' education also is bearing out.

On one hospital rotation, 25 students from an offshore school replaced five New York students. Because Liaison Committee on Medical Education (LCME) accreditation standards require all students from a medical school to receive an equivalent education, regardless of where in the state they train, some New York schools pulled out of certain hospitals with relationships with foreign medical schools. They feared jeopardizing their accreditation because they could not guarantee an equivalent educational experience for their students.

 A 2010 Government Accountability Office report on foreign medical schools found that between 1998 and 2008, $1.5 billion in federal loan money went to U.S. students studying at foreign medical schools. Pass rates on the U.S. Medical Licensing Exam (USMLE) improved for all international medical graduates, but still lagged behind those of U.S.-educated graduates. While a majority of foreign medical schools met the 60-percent pass rate requirement in 2008, very few would likely meet the new 75-percent rate enacted in 2010. 

 The big question, said Ms. Wiederhorn, "is what percentage of those students are able to come back here and actually get a residency" to be able to practice medicine in their home states? (See "International Medical Graduates on the Rise.")

Texas Takes Priority

Back in Texas, the answer to that question remained unanswered.

AUC's chief academic officer Bruce Kaplan, DO, told the Senate Higher Education Committee the school sought a collaboration to help "ease the [physician] shortage in your state."

The school boasted an above-average USMLE pass rate of 96 percent and said it worked with THECB to address the concerns raised by limiting the number of students it would send to Texas for core clerkships.

AUC also said an extensive review by THECB staff and outside consultants determined that the school demonstrated LCME equivalency.

THECB spokesperson Dominic Chavez confirmed that in addition to agreeing to the conditional plan, AUC met the same standards it applies to Texas medical schools seeking a certificate of authority to operate in the state. They include the quality of the faculty, availability of library and curriculum resources to support the learning environment, student performance on key exams, and accreditation.

"This was an entirely unique situation. Nobody here on staff can remember getting such a request to seek this type of program. We went through the normal review process for similarly situated programs because when we looked at it, there was no prohibition in the law saying we couldn't," Mr. Chavez said. Board staff took into consideration the various concerns raised in crafting a limited agreement. "But from our standpoint, we felt [AUC] met the standards in place at the time and after our review, our staff put together a recommendation that it be approved because we found no reason why it shouldn't be."

Ultimately, he says, the board deferred to the legislature's request to weigh in on the matter.

TMA officials said foreign medical schools are not held to the same rigorous standards as U.S. medical schools.          

In addition to concerns over accreditation, Senator Zaffirini said that "if the [offshore school's] argument is about a shortage of physicians, then we should bring in physicians," not students.

Senator Zaffirini says the new law closes the door on the attorney general opinion and any potential action the board may have taken on the AUC agreement. "This time, the legislature made our intent very clear."

In July, THECB adopted emergency rules to implement the new law by Sept. 1. Formal rulemaking was expected to take place at the board's October meeting, and Mr. Chavez said he doesn't anticipate any major changes. "It's pretty clear to us what our charge is, and we are going to execute [this law] as intended by the legislature."

But Dr. Wright was careful to clarify what the law is not about: Texas-born students in foreign medical schools looking to return to their home state to practice medicine "have something to contribute. This is not to say we do not want to help figure out a way to repatriate all of those students," he said. "But it has to be done in such a way that does not compromise the education of our students. This is about prioritizing Texas medical students. The state puts money into those students. They take precedence. And we do have an obligation to them." 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

 SIDEBAR 

International Medical Graduates on the Rise 

Medical school enrollments continue to grow at a faster rate than entry-level residency positions in the United States. Meanwhile, of all applicant groups* to the U.S. National Resident Matching Program, U.S.-born international medical school students and graduates showed the largest increase at 19 percent in 2013. The 5,095 U.S. citizen international medical graduates were 50 percent more than in 2009. About half of U.S.-born students who went to foreign medical schools matched into U.S. residency programs in 2013, compared with 94 percent of U.S. allopathic seniors who matched. 

*Applicant groups with more than 100 applicants

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