Encouraging Exports?

GME Cuts Could Send Texas Graduates Elsewhere

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Medical Education Feature – September 2011

Tex Med. 2011;107(9):45-47. 

By Ken Ortolon
Senior Editor

Texas medical schools are graduating record numbers of new physicians, but an increasing number of them likely will head out of state for residency training because of huge cuts in graduate medical education (GME) funding the legislature passed earlier this year.

In its budget for 2012-13, the legislature slashed formula funding for residency slots by 33 percent and cut funding for a family practice residency program run by the Texas Higher Education Coordinating Board (THECB) by 75 percent. Lawmakers eliminated funding for another primary care residency program THECB operates and all money for a primary care preceptorship program.

State officials and residency program directors say the cuts almost certainly will abolish some residency slots, particularly in the primary care specialties. And some residency programs that relied heavily on the THECB funding may close.

"When you don't have the money to support those residents, we may well see residency programs reducing the number of residents they support or shutting their doors," said Stacey Silverman, PhD, senior director for academic research and grant programs in THECB's Academic Affairs and Research Division.

Some medical educators say the decision to cut GME funding at a time when Texas needs to be training and retaining more doctors is shortsighted.

"The case will be made that they were penny-wise and pound-foolish – or whatever other adage you want to use – by cutting this type of training funds when what they really need is to be expanding them," said Roland Goertz, MD, president of the McLennan County Medical Education and Research Foundation and chair of the THECB Family Medicine Residency Program Advisory Committee. "We're spending so much money on medical students who now have no place to stay in the state and end up having to leave."

Cutting to the Bone

While higher education funding saw significant cuts across the board, GME was hit particularly hard. The legislature cut formula funding to state health-related institutions that support GME faculty costs and development of new GME positions from $6,653 per resident per year to $4,436. That's a reduction of $25 million for 2012-13.

Funding for the THECB's Family Practice Residency Program was cut from $21.2 million for fiscal years 2010 and 2011 to $5.6 million for the next two years.

The board's $4.99 million Primary Care Residency Program saw its funding wiped out and the Graduate Medical Education Program and State Preceptorship Program also were zeroed out, losing $600,000 and $904,289, respectively.

And, the Joint Admission Medical Program (JAMP), which encourages disadvantaged students to go to medical school, was cut from $10.6 million to $7 million.

Dr. Silverman says the Family Practice Residency Program funds 29 nationally accredited family medicine residency programs across the state. Under the current budget, those programs get roughly $13,000 per resident. Under the 2012-13 budget, that will be cut to about $3,900, she says.

The Primary Care Residency Program supports 23 of 41 primary care residency programs in the state, including programs in internal medicine, pediatrics, and obstetrics/gynecology. Those programs now will receive no state funding.

Dr. Silverman says the Graduate Medical Education Program, which also was eliminated, provided supplemental funding for 15 independent primary care residency programs that are not affiliated with state medical schools and, therefore, do not receive GME formula funding.

"Most of those programs also received funding under either the primary care or family practice residency programs," she said. "So those programs are going to be hit pretty hard."

Finally, the preceptorship program provided funding for students to shadow rural primary care physicians in the summer after their first or third year in medical school to encourage them to select primary care specialties. The family medicine preceptorship program had been in place since 1979.

"I've heard several students say it's the first time they ever saw someone born or die," Dr. Silverman said. "It's a pretty powerful experience that's been taken away from those students."

Reducing Slots

While some residency program directors were still trying to assess the impact the budget cuts will have on their programs, Dr. Goertz says it is almost certain that some programs will have to cut slots and some programs may have to close.

His advisory committee surveyed family practice residency program directors during the legislative session, and seven said they might have to shut their doors if the family practice program was zeroed out, as originally proposed in the House version of the budget bill. That did not happen, but Dr. Goertz says there is still a threat that between two and five of those programs might have to close even though they still will get some THECB funding.

Officials declined to name the programs, fearing that doing so could hurt their ability to fill slots in the next match.

Edward J. Sherwood, MD, vice dean for graduate and continuing medical education at Texas A&M University Health Science Center College of Medicine, planned to meet with affiliated residency program directors in mid-July to determine the impact of the cuts on those programs. A&M sponsors a family medicine program in Bryan and has affiliated programs in Sugar Land, Corpus Christi, Killeen, and Temple.

"One of our affiliated program directors told me today that he was looking at almost a half-million dollar cut," Dr. Sherwood said. "A half-million dollar blow is huge. Unless that money can be found from some other source, that will almost certainly result in a reduction in program size."

Gary Floyd, MD, chief medical officer for the John Peter Smith Health Network, says residency programs there will lose between $800,000 and $1 million, but the network does not plan to cut any residency slots.

"We feel they're very important, and if we can train them here, we'll keep most of them here," Dr. Floyd said. He says they plan to juggle operational funds to plug the funding gap. "We're just going to try to be smarter in how we manage our resources."

Dr. Goertz also says the family medicine program run by his foundation also will be able to maintain its residency slots despite losing as much as $390,000 per year in state funding.

"We're fortunate that our center is a large center and a foundation-supported center," he said. "Our clinical board, which is the entity that funds whatever deficit might occur, has made a commitment to the educational programs. We are big enough now that hopefully it can get us through to the next legislative session."

            Tom Blackwell, MD, associate dean of graduate medical education and vice chair for graduate medical education at The University of Texas Medical Branch (UTMB), says UTMB does not plan to cut any of its 570 residency slots in 48 different programs, even though it will lose several million dollars in funding. Instead, UTMB will cut in other areas, such as reducing the number of conferences residents attend, eliminating some rotations at hospitals in Houston, and other cost-cutting measures that could impact the residents' education experience.

Jonathan MacClements, MD, director of medical education and chair and program director of the Department of Family Medicine at the UT Health Science Center in Tyler, runs a 24-resident family medicine program. He says the cuts will amount to almost 20 percent of his budget, which he thought was going to force some serious cutbacks in residency slots.

Fortunately, UTHC Tyler President Kirk A. Calhoun, MD, "is absolutely committed to making sure that primary health care moves forward," Dr. MacClements said. "I'm going to be in a lot better shape than a lot of my colleagues. Sadly though, a further unforeseen casualty from these cutbacks will be the reduction in faculty development programs, like the Waco Faculty Development Center, that were partially supported by these state educational funds. It takes resources to develop physicians as educators who can train the next generation of physicians."

Dr. Goertz says his program has hosted that faculty development center for 33 years to help junior faculty members become better teachers.

Exporting Physicians

Even if many primary care residency programs can find other funding to allow them to maintain residency slots, medical educators say the cuts will devastate efforts to train more homegrown physicians in Texas. In 2010, Texas graduated 1,404 medical students and offered 1,390 first-year residency slots. THECB projects that in 2013 Texas will graduate 1,544 new physicians. Without new residency slots, 154 new physicians would have to leave the state to complete their residency training.

"We've been expanding medical school class size in Texas, and we have exceeded the number of PGY-1 [post graduate year 1] residency positions," said Dr. Sherwood. "So we're now a net exporter of new doctors trained to a significant extent at taxpayer expense. That's not sound public policy, and it certainly does not address the needs for the future physician workforce to take care of Texans."

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 email.

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