Symposium on Medical Education — February 2016
Tex Med. 2016;112(2):68-70.
By Nancy Dickey, MD
Texas ranks 43rd in the country in ratio of physicians to patients. Recruiting and encouraging in-migration of physicians, although strengthened by the 2003 liability reforms and streamlining of the licensing process, remain inadequate in keeping up with the state's continuing population growth. Identifying effective mechanisms to retain the young men and women who graduate from medical school in Texas for their graduate medical education (GME) is an important goal. To meet its physician workforce needs, the state must provide adequate opportunities for college graduates to enter medical school, enough GME positions for any medical graduate who chooses to remain in the state for graduate training, and adequate numbers of fellowship programs.
Texas is one of the fastest-growing states in the nation and has one of the lowest ratios of physicians to patients of any state in the country, ranking 43rd in the nation. Over the past five years, Texas has added the largest number of new physicians at any time in its recent history.1 Population growth has outstripped that of physician workforce growth, however, leaving the physician-to-population ratio at the bottom of the performance ladder. That combination makes it imperative that Texas continue to implement plans and strategies to attract physicians to the state.
Certainly, the effective work done on liability reform in 2003, followed by streamlining of the Texas licensing process, helped to create the significant influx of physicians that occurred in the past five years. Being home to a number of practice types and a variety of recognized group practices like Baylor Scott and White, Austin Regional Clinic, and Kelsey Seybold, as well as internationally renowned centers like MD Anderson Cancer Center, also helps attract physicians. But with the continuing population growth of the state, recruiting and trying to encourage in-migration of physicians has proven inadequate to keep up with the state's population.
Fortunately, a substantial percentage of physicians in Texas received some or all of their medical training in Texas and either returned to the state or remained in the state to practice. Thus, identifying effective mechanisms to retain the young men and women who graduate from medical school in Texas for their graduate medical training becomes a particularly important goal. Retention of these graduates is also important for the taxpayers of the state who invest substantial dollars in the process of educating and training physicians ($168,000 per graduate, or $30.2 million annually); retention of graduates is a good return on the taxpayers' investment.1
In the early part of the 21st century, experts began to change their predictions from a looming surfeit of physicians for this country to a likely significant shortage of physicians and other health care professionals.2 National organizations made recommendations to increase the number of medical school graduates through increasing class size and creating new schools. In addition, they recognized that if the number of medical graduates was to increase, the number of entry-level, postgraduate positions would have to increase, as well. Texas responded to the recommendations in a prompt and comprehensive manner.
The recommendations for growth led to numerous actions over the course of the next several legislative sessions. The actions increased medical and osteopathic school graduation numbers, increased the number of graduate medical education (GME) training programs and positions, and created enhancements to encourage graduates of these education programs to stay in the state.
The legislature passed laws that increased medical school class size in existing schools and approved creation of three new medical schools. The state grew from eight medical schools with approximately 1,300 graduates per year in 2008 to an anticipated 11 medical schools (the last one is moving through accreditation cycles) and approximately 1,700 graduates per year. In addition to addressing graduate numbers, Texas legislators and educators have expanded substantially along the Texas-Mexico border — one of the most underserved areas of the state.
Noting that increasing the number of physicians graduating annually was only part of the solution, the state increased support of existing and new GME. In 2011, Texas had more than 550 residency programs, offering a total of 6,788 residency positions. Only 22 percent (1,494) of those positions were first-year entering residents, and the ratio of first-year entering residency positions to allopathic and osteopathic graduates was close to 1 to 1, with 1,494 first-year entering residency positions for the 1,458 medical school graduates.
But in 2013, the Texas Legislature increased GME funding and again in 2015 infused $53 million (an additional $40 million over 2013) into expanding residency training. The anticipated goal is an additional 200-plus training positions.3 Without increases in the number of first-year residency positions, beginning in 2014, at least 63 graduates of Texas medical schools would not have had an opportunity to enter a Texas residency program. By 2016, 180 graduates would have had to leave the state for their first year of residency training due to the lack of residency positions.1
In addition to funding to increase positions, the legislature increased the formula funding for existing programs with a 22-percent increase in per-resident formula funding, totaling $20 million. The expanded funding will expand programs or fund existing, unfilled entry-level residency slots in primary care and a variety of specialties, continuing positions started with 2014-15 grant funding, or planning brand-new programs.
In addition to the above funding for GME program support, the Texas Legislature:
- Created primary care physician pipeline programs with a $7 million investment ($4 million, or 31 percent, increase over current funding) for existing family medicine residencies and $3 million to restart the Statewide Primary Care Preceptorship Program.
- Allocated funding for the primary care physician workforce innovations grant program.
- Maintained funding for the Texas Physician Education Loan Repayment Program and created a new loan repayment program for psychiatrists and other mental health professionals.
All of those efforts have been advanced with the goal of creating adequate entry-level training positions to meet the 1:1 to 1 ratio of graduates to entry residency positions, or 10 percent more first-year positions than graduating medical students.1 That goal would assure every graduating Texas medical student could stay in the state if he or she so desired, as well as allow programs to recruit outstanding graduates from schools across the country.
The efforts of the legislature demonstrate a notable commitment to addressing the issues of adequate physician workforce in Texas. However, there have been actions in the past that raised support for similar programs only to see the enhanced support disappear through lack of funding in subsequent legislatures. Because one of the biggest barriers in terms of creating additional slots is financial, Sen. Jane Nelson (R-Flower Mound) passed a bill establishing a permanent GME account in the treasury. That account will be funded by annually transferring Joint Underwriting Association funds in excess of their operating revenue into the permanent GME account. Creation of this fund helps assure continuity of the plan so funding will not be dependent upon biennial budget status.3
Creation of new spots in medical schools and adequate opportunities in GME do not guarantee newly minted physicians will remain in Texas. But according to the Texas Health Care Policy Council, Texas ranks second in retention of physicians who complete medical school in Texas (58.6 percent), seventh in retention of physicians who complete GME in Texas (56.4 percent), and fifth in retention of physicians who complete medical school and GME in Texas (79.5 percent). And according to a survey by The University of Texas Southwestern Medical Center, up to 40 percent of students who leave Texas for GME training would have preferred to have stayed in Texas if spots had been available.4 Clearly, in a state that needs to grow its physician workforce and one that has significant loyalty of graduates, the solution of increasing the number of individuals who complete medical education and GME in the state seems to be a particularly important step.
Even while working to increase support for GME, discussions continue about where that support is most needed. Like virtually every other state, Texas has a need for primary care growth. However, surveys of those who leave the state for GME training (and are therefore statistically less likely to ultimately practice in Texas) show the most common training programs being sought (and not adequately available in Texas) were in otolaryngology, general surgery, emergency medicine, preliminary surgery, and orthopedics. In addition, Texas has critical shortages in psychiatry and the pediatric subspecialties of radiology, orthopedics, emergency medicine, and psychiatry. The 2015 legislature made some progress in creating a process to direct funds to those areas and specialties most in need in the state.
Consideration also has to be given to fellowship training, or subspecialization training that occurs after completing GME. Many physicians go on to train in a subspecialty. More than a dozen new specialties have joined the National Resident Matching Program Specialties Matching Service in the last few years. The number of fellowship positions nationally has been on an upward trajectory for 15 years.
The American Board of Medical Specialties noted that from 2003 to 2015, specialties and subspecialties certified by the association expanded from 113 to 161. The increasing number of fellowships is driven partially by the expanding science and technology but also by the desire for better jobs and lifestyles. In 2015, the fellowship appointment process placed a record-setting number of fellow appointments, following what was to date the largest ever Main Residency Match.5
The growth in fellowships feeds into the information about training opportunities because fellows, like residents, tend to practice near where they do their final training. According to Christian Cable, MD, a member of the Texas Medical Association Council on Medical Education and director of the hematology-oncology fellowship at Baylor Scott & White in Temple, "All postgraduate education is growing and has been growing, and what we are seeing now is fellowship catching up with residencies. It's in our best interest to find room for all of our high-quality graduates, or we risk losing them to other states."5 However, none of the funds noted above can be used for fellowships. But because fellowship directors tend to be more comfortable with residents from their own residency programs as those individuals have had essentially a three-year audition, keeping Texas graduates in the state means being sure there are adequate residency slots and adequate fellowship slots.
Though Texas already performs exceptionally well on retention, many programs have been designed in an effort to expand access to medical training for particular populations. These efforts have been an attempt to address issues of minority and ethnic disparities in medical schools, as well as to help address intrastate physician workforce distribution issues. For example, the Joint Admission Medical Program (JAMP), created in 2001, supports and encourages highly qualified, economically disadvantaged students pursuing a medical education. It is limited to residents of the state; for those accepted into the program, it offers scholarships, summer internships, and guaranteed acceptance into a Texas medical school upon successful completion of JAMP.
Texas also created one of the first of its kind Physician Education Loan Repayment programs for physicians completing their GME and entering practice in a medically underserved area. Currently, 33 states have created similar programs.4 In the 2015 legislature, additional funds were added to the program to expand the number of individuals who could benefit from loan repayment by practicing in underserved areas.3
From having adequate opportunities for college graduates to enter medicine to creating enough GME positions for any medical graduate who chooses to remain in the state for graduate training to assuring good numbers of fellowship programs, Texas is committed to "growing its own" physicians to meet the workforce needs of the state's population. Ongoing attention to creating and protecting a satisfactory environment for the practice of medicine will not only help keep Texas graduates in the state but will also facilitate continued efforts at in-migration. In addition to actions taken to date, the state needs to address some of the recognized challenges, such as high rates of uninsured and low reimbursement rates for Medicaid.
Solutions should come not just from the state legislature. Recruiting is a challenge to many locales and for many specialties. Recruiting physicians with ties to the state or to a region within the state is often helpful. Many locations highlight the advantages they offer and use physician preferences to attract the needed workforce. For example, communities that have good hunting and fishing may target individuals who like the outdoor life. Communities with exceptional school systems may tout the extraordinary value for young families with children. Having communities get involved in recruitment can lead to other incentives like aid with education bills or providing income guarantees for early years of practice.
Fortunately, Texas historically has done a better-than-average job of retention of those who are trained in the state. The state appears to be giving high attention to issues of recruitment and retention. With a variety of organizations, systems, and processes all addressing Texas' needs, reaching an adequate physician-to-population ratio seems to be a reachable goal.
Nancy Dickey, MD, is president emeritus of Texas A&M University Health Science Center and professor of family and community medicine at the Texas A&M College of medicine.
- Texas State Health Plan Update 2013-2014. Austin, TX: Texas Statewide Health Coordinating Council. http://www.dshs.state.tx.us/chs/shcc/reports/Texas-State-Health-Plan/. Accessed Sept. 13, 2015.
- Iglehart JK. Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med. 2008;358(16):1741-1749.
- Health Care and the 84th Texas Legislature: Outcomes for Texas Hospitals. Austin, TX: Texas Hospital Association; 2015.
- Physician Workforce and Graduate Medical Education in Texas. Austin, TX: Texas Health Care Policy Council; December 2008. http://gov.texas.gov/files/thcpc/Physician_Workforce_and_GME_in_Texas_12-2008.pdf. Accessed Sept. 1, 2015.
- Sorrel AL. Choosing fellowship: as medicine becomes more specialized and competitive, career decisions become more complex. Tex Med. 2015:111(7):39-45.
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