Medical Education Feature – August 2010
Tex Med. 2010;106(8):43-45.
By Ken Ortolon
As a fourth-year medical student at The University of Texas Health Science Center at Houston, Spencer Pruitt, MD, had hoped to train in obstetrics and gynecology at a residency program in Texas. But when the Match Day results were announced in March, he found himself among roughly 1,100 U.S. medical school seniors who did not match to a residency program.
"I was definitely disappointed that I didn't match in my specialty," Dr. Pruitt said. "I had a good curriculum vitae, and I interviewed well. But there just aren't enough spots in the whole country."
That left Dr. Pruitt searching for a residency position in "the scramble," where unmatched medical graduates contact residency programs with unfilled positions looking for any spot they can get.
Dr. Pruitt was lucky. He found a position in pediatrics, which was his second choice. Unfortunately, the position is at Our Lady of the Lake Regional Medical Center in Baton Rouge, La.
"They're a great program," said Dr. Pruitt, a former medical student representative on the Texas Medical Association Board of Trustees. But it's not in Texas.
"My experience with the Texas Medical Association working with physicians, and just in general working with the physicians at school, has shown me how great an environment Texas has for physicians," he said. "That's the reason that physicians are coming into Texas and out of other states. Plus, I grew up here. So I think those two factors make me want to come back after residency."
Dr. Pruitt is among a growing number of medical graduates in the country, particularly in Texas, who find it hard to match in their preferred specialty. While medical educators say there are a variety of reasons for that, almost all point to a growing imbalance in the ratio of medical graduates to residency slots.
That imbalance is particularly apparent in Texas, where the state offered fewer first-year residency positions in 2010 than it had medical graduates.
Ben Raimer, MD, senior vice president for health policy at The University of Texas Medical Branch (UTMB) in Galveston, says sending young residents such as Dr. Pruitt to other states to train is a losing strategy for Texas.
"When we send young men and women to another state to do their residency training, we lose the investment that we've made in many of those students," Dr. Raimer said. "We must have enough graduate medical education (GME) slots in Texas for Texas students to match to or we lose our investment in those students."
Those concerns have prompted TMA to launch an effort with the medical schools to make GME funding a priority in the next session of the Texas Legislature.
Where Are the Slots?
Data from the National Resident Matching Program show that the number of U.S. medical school seniors who go unmatched each year has been trending upward over the past several years. In 2000, only 4.6 percent of medical graduates failed to match. This year, that number was 5.9 percent.
Also, the number of students who matched to their first choice of specialty has been going down. In 2005, 59.3 percent matched to their first choice. In 2010, that number dropped to 52.7 percent.
Most graduates who did not match found positions through the scramble, but Association of American Medical Colleges (AAMC) spokesperson Jamila Vernon says roughly 200 were left without a slot even after the scramble.
While final Texas data from the 2010 match was not yet available, medical educators say it appears Texas is following those trends.
"We know from our meeting with the Texas Council of Deans that all of the schools found more students this year who didn't match," said Steven Berk, MD, dean of the Texas Tech University Health Sciences Center School of Medicine in Lubbock.
For example, 12 of 140 (8.6 percent) of Texas Tech graduates and 11 of 215 (5.1 percent) of UTMB graduates did not match. Dr. Berk says most of those Tech graduates found a position in the scramble. Dr. Raimer says all but one of the UTMB graduates found a slot, with that one student deciding to defer residency to pursue an advanced degree in public health.
Dr. Berk says there are various reasons for the rise in unmatched graduates. One is the "incredible competitiveness" in some specialties, such as dermatology and orthopedics.
But a big problem is that the number of residency slots across the country has remained relatively flat while medical schools boosted class size and new schools opened.
Texas added a handful of residency slots this year, but that was largely due to UTMB restoring 29 entry-level slots suspended in the wake of Hurricane Ike. According to estimates by TMA and outcomes from the National Resident Matching Program, Texas had 1,404 medical graduates in 2010 but offered only 1,390 first-year residency slots.
And the ratio of graduates to slots is only likely to get worse. The Coordinating Board projects that by 2013 Texas will graduate 1,544 new physicians. Without new residency positions, 154 Texas medical graduates will have to go out of state for their training even if they want to stay in Texas.
Finding More Slots
But medical educators say creating new residency programs is difficult. Medicare pays for a large percentage of residency training, but Medicare funding for existing residency programs was capped in 1996 under the Balance Budget Act.
John Guest, executive director of Teaching Hospitals of Texas, says teaching hospitals have used their own money to add some residency positions despite the cap. But other experts point out that those positions usually are in a limited number of specialties that the hospitals believe will generate revenue. Few of those residency slots have been in critically needed primary care specialties, they say.
Educators hoped the health system reform bill would provide some new funding for graduate medical education, but they say there was very little real help on that front.
Mr. Guest says about the only good news in the health reform bill was creation of a new system of identifying and redistributing unused residency slots at hospitals under the Medicare cap. The system identifies residency programs that have closed or slots that have gone unfilled and reassigns those slots to states with high health care professional shortage areas.
The bad news is that Texas got none of the 300 or so slots that AAMC estimated to be available, despite having a significant number of medically underserved areas.
Still, there are some efforts under way to develop new residency programs in Texas. The University of Texas System recently announced that it was developing a partnership between Good Shepherd Hospital in Longview and The University of Texas Health Science Center (UTHSC) at Tyler to launch a new internal medicine residency program.
David Coultas, MD, vice president for clinical affairs at UTHSC Tyler, says that program will be able to draw down Medicare funding because Good Shepherd has never had residency programs before and, therefore, is not subject to the Medicare cap.
They hope to enroll their first class of 18 residents in July 2012.
Dr. Coultas says UTHSC Tyler also has been talking to East Texas Medical Center and Trinity Mother Frances Health System in Tyler about establishing additional primary care residencies. East Texas also would be able to get new Medicare funding, but Mother Frances is under the cap.
Scott Ransom, DO, president of the University of North Texas Health Science Center, says his institution also has been "very aggressive in seeking partners and creating solutions to add residency programs in Fort Worth and North Texas, as well as through partnerships across the state. We do have a number of possibilities in the pipeline."
Dr. Berk also says Texas Tech is exploring opportunities to partner with federally qualified health centers to establish residency programs. Marcia Collins, director of TMA's Medical Education Department, says some funding in the health reform bill might allow those centers to add programs.
More Money Needed
Despite those and other efforts, medical educators say Texas can't develop the residency programs it is going to need without additional state funding. Lawmakers have appropriated additional formula funding for graduate medical education in recent sessions. Educators say those funds help pay faculty salaries but are insufficient to allow them to add slots.
What's worse are the concerns that the looming $18 billion budget shortfall might prompt the legislature to cut GME funding in next year's session.
TMA officials recently began plotting a strategy designed not only to protect both graduate and undergraduate medical education funding next year, but also to lay the foundation for expanded GME funding.
Darren Whitehurst, TMA's vice president for advocacy, says the association wants to make sure that TMA and the medical schools "are on the same page relating to educating legislators about priorities in medical education. The budget environment in the state highlights the fact that we are going to have to work very hard to ensure that we are turning out the number of undergraduates and graduates in medical education that we need to provide for the state in the future."
And educators add that health system reform is only going to accelerate the need for more physicians as tens of millions of Americans gain new health insurance coverage.
"Clearly, we need more doctors based on our current health care needs and the current paradigm of medicine right now," Dr. Ransom said. "But as the Obama health care reform plan moves forward, the need and the demand on health care providers are expected to dramatically increase."
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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