Thanks in Part to Several Legislative Victories, Texas Is Finding Innovative Ways to Chip Away at Physician Shortages in the Nation's Fastest-Growing State.
Cover Story — March 2016
Tex Med. 2016;112(3):24-33.
By Amy Lynn Sorrel
West Texas is known for its oil fields, but one of its boomtowns is building a new kind of pipeline to stream a steady supply of primary care physicians to the largely rural and underserved area. Midland sits atop one of North America's largest oil reserves, the Permian Basin, but local educators and hospital leaders say convincing doctors to stay in the patch is often a bust.
To prime the pump, Midland is looking to its own community. The new well: community college students with an aptitude for a medical career.
"This really is my story," said Lisa R. Nash, DO, a family physician and associate dean for educational programs at the University of North Texas Health Science Center (UNTHSC) Texas College of Osteopathic Medicine (TCOM) in Fort Worth. She graduated from the medical school after starting her education close to home at Weatherford College and Texas Christian University, then entered rural practice in West Texas postresidency.
"We now understand very well the challenges for rural Texas in recruiting physicians, and predictors for who might really go into rural practice or underserved areas that are not necessarily rural but where there's need. And one of the best ways to get people into those communities is to train people from those communities because they are the ones most likely to go back there," she said.
UNTHSC and TCOM are partnering with Midland College and Midland Memorial Hospital on an innovative program designed to grow and keep its own crop of future doctors in the area. The Primary Care Pathway identifies interested, high-achieving community college students likely to be successful in medical school and guarantees them an accelerated pathway to a doctor of osteopathic medicine (DO) degree, focusing earlier and more intensely on primary care. The targeted program allows students to get their undergraduate and medical degrees in seven years versus eight; the first crop of eight students enrolled last fall.
Community college students have valuable experience that doesn't always make up the typical application sought by medical school admissions committees, Dr. Nash says. But local ties, combined with early exposure to primary care training, create what she describes as a natural fit.
"This is really done in cooperation with the local community and what their needs are in terms of medical services, and we can predictably say in pretty much all of rural Texas the most acute need is primary care," she said. "It's just a natural extension taking it back in the pipeline. And if this works, it could be a model replicated many places across the state."
Thanks in part to several victories the Texas Medical Association and Texas medical schools won over the past two legislative sessions to increase medical education funding, Texas is finding ways to chip away at primary care physician shortages in the nation's fastest-growing state. More than 5 million Texans — 20 percent of the state's population — live in designated primary care shortage areas, according to federal statistics. (See "Texas' Primary Care Profile.")
The Pathway launched in October 2015 with help from a $350,000 primary care innovation grant, one of several grant programs the 2013 and 2015 legislatures approved to expand availability of undergraduate and graduate medical education (GME) across Texas. In 2015, lawmakers also revived the decades-old Texas Statewide Primary Care Preceptorship Program, a mentorship program that, like the Pathway, gives interested medical students early exposure to primary care by matching them with internists, family physicians, and pediatricians. (See "Medical Education Wins Big.")
"Our need is so great that meeting that need is a goal that is still out there," said Stacey Silverman, PhD. She is deputy assistant commissioner for academic quality and workforce at the Texas Higher Education Coordinating Board, which oversees the state grants.
The Pathway program, for example, not only shortens the physician pipeline and promotes primary care, but it also "does outreach to a sector of higher education not really picked up yet. We have so many students starting out in community college we need to reach, and this sets a new pathway for community colleges to follow, making it a really innovative model," Dr. Silverman said. At the same time, she adds, the preceptorship program has shown over the years that early exposure to primary care plays an important role in swaying medical students' decisions to choose the specialty.
"It's a long road, but certainly these programs help us get further down that road in having a positive effect on the physician workforce and education in our state," Dr. Silverman said.
The Pathway model seeks to provide additional opportunities for students from historically underserved communities to attend and succeed in medical school. Selected students enter the pipeline program in their first year at Midland College and benefit from shadowing and mentoring experiences in primary care in the area. After successfully completing an enhanced three-year premed curriculum, students would have automatic admission to TCOM.
The basic program structure includes:
- Two years of full-time study at Midland College;
- One year of full-time study at UNT Denton; and
- Four years of study at TCOM.
Two summer clinical internships after their first and second years at Midland College give students firsthand training outside the classroom.
TCOM Dean Don N. Peska, DO, says a number of puzzle pieces fell into place to launch the Pathway.
A Midland County judge who was a member of UNT's Board of Regents caught wind of the new medical education grants and pushed the idea of partnering with Midland Memorial Hospital on an initiative to get more doctors to the area. Around the same time, Dr. Peska noticed a significant number of applicants who did a portion of their undergraduate education at community colleges around the state. Meanwhile, leadership at Midland Memorial — already a teaching hospital — had close connections to Midland College.
"We saw we had all the components we needed other than putting a medical school there, and we felt we had an opportunity to bring the whole community into this initiative," Dr. Peska said. "We felt the more we use the community for this, the more successful we would be."
Some hurdles were encountered in developing the curriculum. For medical schools to maintain their accreditation, for example, students need at least 90 credit hours to begin their training. Midland College offers only 60 credit hours toward an associate degree and didn't have the advanced science courses required for TCOM admission.
"But of course, we have an undergraduate school. So we said we could take candidates coming out of Midland, and UNT [Denton] could give them the additional 30 credit hours in coursework we design to be successful in medical school," Dr. Peska said. "To get into medical school, you don't need the bachelor's degree. You just need the 90 credit hours."
TCOM also agreed to waive the Medical College Admission Test for Pathway students.
"We don't want students to take the exam and fail because their preparation is different, and we recognize and are fairly comfortable with the correlation with Scholastic Aptitude Test [SAT] scores," Dr. Peska added. "Midland College doesn't require either, but for this program we ask students who want to enter to take the SAT so we can predict how they will perform on standardized academic exams."
To secure admission to the DO program, the premed students must maintain a 3.5 grade point average — with no grades below a B — in a prescribed curriculum that is heavy in math and science.
In the heart of oil engineering country, Midland College already had a nationally recognized science program, says Margaret Wade, dean of math, science, and kinesiology. In formulating what she describes as a targeted premedical curriculum, "we looked at very standard requirements for medical school," which include the general biology, anatomy, and organic chemistry courses. From there "we pared down the first two years by giving students the option not to take certain core courses [for an associate degree], like government or history, and enabled them to take more science."
A faculty member from Midland College's biology department spends about 10 hours a week identifying and recruiting students to the program. "We want to look for students who've already proven they know how to study, took rigorous courses in high school, and can handle heavy loads. We won't eliminate anyone, but that's our target audience," Ms. Wade said, adding that the college has a track record of identifying, mentoring, and transferring successful engineering students to Texas Tech University to complete their studies.
Dr. Peska acknowledges accelerated medical degrees — with mixed success over the decades — are nothing new, and only time will tell if the Pathway strategy works.
A September 2013 New England Journal of Medicine commentary cautions that shortening medical education could mean shortchanging students and the public, but agreed that medical education reforms are necessary. According to the article, in 1974, 33 medical schools had three-year MD programs, most of which disappeared until now as a growing number of schools across the country experiment with the model. The University of Texas System, for instance, is piloting a Transformation in Medical Education (TIME) initiative that aims to better coordinate students' transition from college to medical school and shorten that total time in school by one to two years. The reasons for creating such programs decades ago were the same that some schools put forth now: addressing predicted physician shortages. Nationally, the Association of American Medical Colleges predicts a shortfall of 90,000 physicians by 2025.
"You can get into some maturity issues when you accelerate too quickly. But we know there have been [accelerated programs] that do just fine, and that's the reason accrediting bodies don't require a bachelor's degree for entry into medical school, just a credit-hours minimum," Dr. Peska said. Nor is the program for everyone, "but we have a lot of confidence in the rigor they will be facing at Midland College, and we know of no other program anywhere like this."
Keeping Close to Home
Throughout the entire pipeline from undergraduate to medical school, students leave their local community for only three years, Dr. Peska explains. "We want to get them back into the community as quickly as we can because we know the longer we take them out, the more risk of them not coming back."
UNTHSC also is working with the hospital to develop a primary care residency program to host the students once they graduate.
In addition to helping students save on education costs with a shortened pathway, educators say the grant money provides some enhancements to help meet community college students' unique needs and improve their likelihood of success. The funds primarily support tuition scholarships, travel, stipends, and program coordination staff, in particular an advisor dedicated to coaching and encouraging the premed students when things get difficult.
Such support, combined with local recruitment and getting students back to their community as quickly as possible, is key to solving some of the challenges Texas faces in getting physicians into rural practice, Dr. Nash says.
From the get-go, rural students face several disadvantages just because they choose a particular educational pathway.
"The challenges are, like me, students don't come from wealthy families. Most of them have to work and pay their own way through college, so they stay close to home. For a lot of them, that means community college first, followed by a four-year university. And that's not necessarily the background most medical school admission committees consider the strongest," Dr. Nash said. Medical schools also look for things like volunteer experience, "which is great. But it takes a lot of time, and most of these kids work through school."
That doesn't mean their experience isn't valuable, she says. But another obstacle is convincing rural students that medical school is an option in the first place.
"Nobody in my family was a doctor, and nobody from my school had gone to medical school. I just remember since I was a little kid wanting to be a doctor," Dr. Nash said.
After starting at Weatherford College, she got a scholarship to TCU and continued to work on average 24 hours to 30 hours per week, and 16 hours per week through her first year of medical school "until I couldn't do it anymore. When I graduated, I did a family medicine residency in Fort Worth and went into rural practice and ultimately ended up choosing an academic career and still finding ways to work on rural medicine issues. But for a lot of kids, it never crossed their mind they could do this."
Seven of the Pathway's inaugural students are recent high school graduates, and one is an older student who worked after high school. Many of them would be first-generation college graduates, let alone doctors, "which is exciting," Ms. Wade added. "You'd be amazed at the community college level at things as simple as, 'I don't have gas money for the end of month.' Now we can step up to the plate with funds, but too often we don't know about it."
Educators also agree exposing students to primary care early — and often — is an important factor in their decision to choose the specialty.
In addition to the academic curriculum, for instance, Pathway students complete two summer internships: The first summer, between their first and second years at Midland College, students participate in a clinically oriented program at Midland Memorial to introduce them to basic medical practice and concepts like professionalism and teamwork. The second summer program, when students transfer to UNT Denton, offers hands-on training in clinical skills labs to learn things like how to assess vital signs.
"These are things we expect all applicants to do somewhere along the line, and we are creating the experience for [Midland College students] so they don't have to go find it," Dr. Peska said.
In addition to the opportunity to shadow physicians, for example, Midland Memorial is working with the West Texas Area Health Education Center to create a community health coaching program, modeled after a joint project between Angelo State University and Shannon Medical Center in San Angelo. Under supervision of a physician assistant, premed students visit chronically ill patients in their homes, for example, to check on their health status and quality of life, identify possible needs, make sure patients get to their appointments, and report back to the doctors and nurses who coordinate their care.
"We'll work with premed students at Midland, get them acclimated to a medical environment, and they'll have some contact with people in the community so when they come back to Midland as a DO, they've already gained some valuable experience. And it might help us reduce readmissions in the process," said Bob Dent. A nurse by trade, he is senior vice president and chief operating officer at Midland Memorial and past dean of Midland College's Health Sciences Division.
Wanted: Primary Care
Oil drilling in Midland may be cooling off, Mr. Dent adds, but the boom over the last several years — and Midland's overall boom-and-bust history — has transformed the once tumbleweed town now in need of more doctors to keep up with the economic and population growth that brought an influx of new workers and businesses. According to U.S. Census data, Midland County's population increased 10.7 percent from 2010 to 2013, compared with a 5.4-percent population increase for Texas as a whole. Twenty percent of the county's population lives in rural areas.
"Our problem is two-fold, and we have to figure out which comes first: making sure the community truly understands the value and importance of seeing primary care doctors on a regular basis and making sure we have enough primary care providers to meet that demand. [The Pathway program] is one way to try and hit all the angles and meet the long-term need of the community," Mr. Dent said. "People from the big city — West Coast, East Coast — get here, and it's not what they are familiar with, so they end up leaving. But we've found in our medical staff and other clinical staff that if they have a connection to Midland — a family or they were raised here — they stay much longer."
Embedded in DO training is early and frequent exposure to primary care, a big reason 65 percent of TCOM's students go into primary care specialties like family and internal medicine and pediatrics, Dr. Peska adds. Large classrooms, divided into small groups, feature advisors largely in primary care. An even larger percentage of students enrolled in TCOM's rural training track — where Dr. Peska says trainees "really see the diversity of primary care" — go on to choose the specialty.
As a teaching facility, Midland Memorial already hosts an internal medicine residency program through Texas Tech University Health Sciences Center, making it ripe training ground for Midland College students when they return for their clerkships in the final two years of medical school.
Although still early — seven years out — UNTHSC is exploring sponsorship of residency pipelines within the hospital so graduates can stay in Midland. Some hurdles may lie ahead.
For guidance navigating accreditation and challenges with facilitated entry into residency, Dr. Nash plans to reach out to Texas Tech, which offers a Family Medicine Accelerated Track that guarantees students who choose the specialty a residency slot and shaves one year off of their medical school training. The program also won a state primary care innovation grant from the Texas Higher Education Coordinating Board.
National Resident Matching Program rules "require you to be all in: If you are going to participate in the match, then all of your positions have to be in the match. The [Pathway] residency is probably going to have to be bigger than what we can fill with local kids," Dr. Nash explained. The program likely could take advantage of one or more of the GME expansion grants the legislature authorized to promote and support such residency programs, "but there will have to be other spots to comply with accreditation rules and also assure these [Pathway] kids have a spot."
The Statewide Primary Care Preceptorship Program meanwhile has shown that mentorship and early exposure to primary care specialties have a positive influence on students' decisions to go into the field.
The program places first- and second-year medical students with practicing internists, family physicians, and pediatricians across the state to immerse them in one of these medical specialties for a summer. The medical students work in practicing physicians' offices and experience the daily life and work of participating mentor physicians — known as preceptors — who provide direct experience and insight into the clinical and administrative aspects of practicing primary care.
The statewide program cleared a major hurdle, winning back a three-fold increase in funding after the legislature defunded it during a 2011 budget crisis. Lawmakers put $3 million into the program for 2016 and 2017, up from $904,000 the last time it was funded in 2010–11.
Houston internist Robert E. Jackson, MD — one of more than 1,400 preceptors — says students get much more out of the money than a summer stipend, as does Texas, which ranks among the bottom states with the fewest number of primary care doctors serving the population. He is a former governor of the Texas Chapter of the American College of Physicians and a member of TMA's Council on Legislation.
"We are the front lines, and the legislature woke up and realized how important it is to have enough primary care doctors, and that you can't just snap your fingers and become one," said Dr. Jackson, pointing to program data showing participants in the preceptorships tend to choose primary care residencies at higher rates.
Over the past decade or so, the internal medicine and pediatric preceptorships have shown that as many as 38 percent of participating students choose the specialty, compared with national residency entry rates of 9 percent to 24 percent. The family practice preceptorship — the longest running of the three programs, since 1979 — has attracted as many as 28 percent of participating Texas medical students to the specialty over the years versus 16 percent of nonparticipants.
First-year medical students typically have not decided on a specialty, "and they have really not yet been exposed to that much clinical medicine. What we as mentors try to demonstrate is the joy of the practice of medicine and the breadth and depth of primary care," Dr. Jackson said, likening the process to detective work. "Patients — all kinds — come to me with a whole bunch of complaints, and it's so much fun to take care of them, plus it's an honor and privilege."
That kind of enthusiasm rubbed off on Navy reservist John DeMis. He knew he wanted to serve his country but, like most medical students, wasn't sure what kind of doctor he wanted to be when he started at The University of Texas Health Science Center at San Antonio. An internal medicine preceptorship gave him the answer.
"What really struck me was the relationships my mentor had built with his patients. The bread and butter of primary care was made more inspiring by seeing the compassion and empathy you share," Mr. DeMis said.
His preceptor was a career internist and nephrologist who, from day one of the program, told the students they would be working through lunch. It wasn't long before Mr. DeMis figured out why: Whether in the dialysis unit, hospital, or clinic, patients brought homemade food and vegetables from their gardens.
"And now that I'm in my third year, I can't overstate the importance of being able to constantly change gears from different settings. It was so helpful to be exposed to that early on, and it made me better in third year," Mr. DeMis said.
Beyond the lessons on labs and charting, however, during those car rides and long days, his mentor also imparted life lessons.
"When you spend this much time together, you don't just talk about medicine. We talked about things like having a family and making enough money. And I thought, 'Hey, I can do this,'" Mr. DeMis said. "That was more useful than anything because so often in medical school you're learning curriculum and diseases and drugs. But you don't get to take a step back and see what your life is going to be like. This program totally changed my outlook and made me much more determined in my path to primary care."
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
Medical Education Wins Big
Building on 2013 successes and recognizing physician workforce shortages, the Texas Legislature gave another significant boost to undergraduate and graduate medical education (GME) funding in 2015, including:
- $53 million for new GME expansion grant programs, a $40 million increase over 2014–15 funding levels;
- $7 million for primary care physician pipeline programs: $4 million — or 31 percent — above current funding for the existing family medicine residency program, and $3 million to restart the Statewide Primary Care Preceptorship Program;
- A $20 million, or 22-percent, increase in biennial per-resident, or "formula," funding;
- Steady funding for the primary care physician workforce innovations grant program;
- An additional $53 million, or 3-percent biennial increase, in medical student formula funding;
- Maintained funding for the State Physician Education Loan Repayment Program;
- A new loan repayment program for psychiatrists and other mental health professionals; and
- Additional money for mental health workforce training programs in underserved areas.
For more information on the GME expansion grants, visit tma.tips/GMEgrants.
Texas' Primary Care Profile
State Population: 26,956,958
Population in Primary Care Shortage Areas: 5,211,605
Active Physicians: 57,502
Primary Care Physicians: 19,234
Active Patient Care Physicians per 100,000 Population
State Rank: 42
Active Patient Care Primary Care Physicians per 100,000 Population
State Rank: 47
Total Residents/Fellows in ACGME Programs per 100,000 Population
State Rank: 22
Total Residents/Fellows in Primary Care ACGME Programs per 100,000 Population
State Rank: 32
Note: Texas' rankings are compared with the other 49 states. A No. 1 ranking goes to the state with the highest value.
Sources: U.S. Health Resources and Services Administration, Association of American Medical Colleges 2015 State Physician Workforce Data Book
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