Texas Faces Severe Primary Care Shortage
Medical Education Feature – December 2011
Tex Med. 2011;107(12):45-58.
By Ken Ortolon
Texas has licensed a record-setting number of new physicians since medical liability reforms were passed in 2003, increasing the ratio of direct patient care physicians per 100,000 residents from 155 to more than 162.
But Texas still lags well behind the national average of 209 physicians per 100,000 population, and physician workforce experts say the state's projected population growth could far outstrip the number of new doctors Texas can train or recruit over the next 20 years.
Those experts say those changing demographics – as well as an aging physician population and declining physician productivity – could lead to serious shortages of physicians, particularly primary care doctors, by 2030.
In a new study published by the American Congress of Obstetricians and Gynecologists (ACOG), William F. Rayburn, MD, concludes that America could face a national shortage of obstetrician-gynecologists of roughly 9,000 by 2030 and nearly 16,000 by 2050.
Dr. Rayburn, chair of the Department of Obstetrics and Gynecology at the University of New Mexico School of Medicine, says the shortage of obstetrician-gynecologists in Texas could be particularly acute. And, he says other primary care specialties, such as family medicine and internal medicine, face similar shortages as Texas' population continues to grow.
"I think we're in for some potential trouble here as it relates to access to care," Dr. Rayburn said.
John Jennings, MD, ACOG vice president and a consultant to the Texas Medical Association Council on Medical Education, agrees.
"Our question, obviously, is who's going to be delivering those babies if we have that kind of shortage?" asked Dr. Jennings, regional dean for the Texas Tech University Health Sciences Center at the Permian Basin. "Who's going to deliver the primary care? We have good data both from the TMA and the Association of American Medical Colleges on what's happening with specialty choice among U.S. graduating students, and they're certainly not going toward primary care specialties."
Fewer Doctors, More Women
In The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011, Dr. Rayburn concluded that the number of obstetrician-gynecologists trained in the United States since 1980 has not increased, while the female population of the country grew 26 percent.
He also projects that as many as 15,000 obstetrician-gynecologists could retire in the next 10 years, and the number of annual retirees will soon equal the number of graduating residents.
In Texas, the current numbers look pretty good. The number of obstetrician-gynecologists per 10,000 adult women in Texas is 2.6, while the state has 5.5 obstetrician-gynecologists per 10,000 women of child-bearing age, both above the national standard, Dr. Rayburn says.
But 159 of Texas' 254 counties have no obstetrician-gynecologists. And Dr. Rayburn says the state is about to face a "perfect storm" of demographic changes that will put serious pressure on access to women's health care.
According to data from the U.S. Census Bureau, Texas is expected to have the largest increase of women in the country between now and 2030, he says. Meanwhile, a large number of Texas physicians are expected to retire during that same period.
Finally, Dr. Rayburn says new physicians entering practice today are less inclined to work 60- and 70-hour weeks the way their predecessors did.
"The current workforce is undergoing fundamental changes that will have important long-term implications on the professional lives of ob-gyns and on the delivery of women's health care services," Dr. Rayburn wrote in the preface to his study.
Dr. Rayburn says several recent trends affecting the workforce and practice patterns include:
- A new generation of physicians, including more women, that places greater emphasis on balancing their personal and professional lives;
- Changing practice patterns, with more flexible schedules;
- Less professional satisfaction among obstetrician-gynecologists;
- Slow or no growth in adjusted incomes; and
- Continued maldistribution of the obstetrician-gynecologist workforce.
"It should be emphasized that these trends are not unique to ob-gyns," Dr. Rayburn wrote. In fact, Dr. Jennings adds, those changes are found across the Texas physician workforce.
The Downward Trend
While Dr. Rayburn's data paint a bleak picture of access to women's health services, other primary care specialties also face shortages in Texas.
Despite record numbers of newly licensed physicians and medical students and residents training in the state, the numbers barely keep up with the state's population. In 2010, there were 27 family physicians, 13 pediatricians, and 20 internists per 100,000 residents in Texas. Those numbers are virtually unchanged from 2007.
Harlingen pediatrician Stanley Fisch, MD, chair of TMA's Committee on Physician Distribution and Health Care Access, says the state's physician workforce definitely got a bump from tort reform. He adds, however, that the physician-to-population ratio is still low.
"The physician-to-population ratio in Texas right now is at 162. That's up from 155 in 2003. That's not a whole lot of change and, in the meantime, the population has grown substantially."
Jon Opelt, executive director of the Texas Alliance for Patient Access (TAPA), says the number of active primary care physicians in Texas continues to grow at rates exceeding population growth for most primary care specialties. According to TAPA, the primary care physician workforce grew nearly 22 percent between 2003 and 2011, compared to a 17-percent growth in population.
That increase includes an 18-percent increase in family and general practice physicians, a 25-percent jump in internists and geriatricians, a 12-percent increase in obstetricians and gynecologists, and 30-percent increase in pediatricians.
Dr. Fisch says another concern is that medical school graduates' interest in primary care specialties continues to be low. He says family medicine programs are continuing to have trouble filling all of their slots on Match Day, even with international medical graduates.
According to a TMA analysis of 2011 national match data, 97.6 percent of primary care residency slots were filled on Match Day this year, including 94.4 percent of family medicine slots filled.
In Texas, 202 family medicine positions were filled. That's up slightly from recent years but below the peak of 225 slots in 1997. In fact, Texas offered only 211 family medicine positions this year because some programs have eliminated slots that were not being filled.
Dr. Fisch says there also is a huge problem in internal medicine. Only a relatively small number of internal medicine residents are going into primary care, he says. The vast majority are choosing to go into subspecialties.
"What we face is a shortage of primary care internists and primary care family physicians to take care of an enlarging population of elderly people," he said. "That is a significant problem."
Texas continues to see a maldistribution of physicians between urban and rural areas. According to a rural physician workforce report presented to the TMA House of Delegates, the percentage of Texas physicians practicing in rural areas dropped slightly from 8 percent in 1999 to 7 percent in 2009.
While the number of physicians, including primary care physicians, in rural Texas grew during the decade, the numbers barely kept pace with the population growth.
"Because both physician supply and population grew at about the same rate, there was no real difference in the ratio of rural physicians per 100,000 population," the report stated. "Although the increased numbers of rural physicians may indicate increased access to care for some rural areas, the rate of growth paled significantly when compared with the state's 77 urban counties."
But TAPA Chair Howard Marcus, MD, of Austin says that is not true in all specialties. "Today, many counties that lacked an orthopedic surgeon, an emergency medicine physician, or a cardiologist now have one," he said. "The number of obstetricians practicing in rural Texas has grown four times faster than the state's rural population."
Stoking the Pipeline
Dr. Rayburn and others say the solution to the projected primary care physician shortages is to train more primary care doctors. But chances of adding a significant number of new primary care residency slots appear bleak. Medicare capped its funding of graduate medical education (GME) more than two decades ago, and the Texas Legislature recently slashed formula funding for GME slots here.
Drs. Jennings and Fisch say the state has put a lot of resources into increasing medical school enrollment over the past decade without adding residency slots to accommodate the increasing number of medical school graduates.
"The disproportionate number of medical school slots without a proportionate increase in GME slots is a critical limitation in the system," Dr. Jennings said.
Texas is a net exporter of medical graduates because other large states offer far more residency positions per capita. According to 2009 data from the Association of American Medical Colleges, New York ranked first out of the 50 states in total residency slots and residents per capita, with 15,679 slots and 80.4 residents per 100,000 population. Texas, meanwhile, had 6,924 resident slots, ranking 23rd out of 50, with 28.5 residents per 100,000 population.
Other large states that ranked higher than Texas included Pennsylvania, which ranked fourth, and Ohio, which ranked eighth. California and Florida ranked below Texas in residents per capita, even though California offered far more residency slots at 9,214 positions.
TMA continues to advocate for commensurate increases in residency positions to better match the high rate of growth in medical school enrollments and to facilitate retention of a greater number of Texas graduates. TMA is working with medical schools and teaching hospitals to identify potential sources of funding for expanded GME.
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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