Three new medical schools are scheduled to open by 2020. Will they help or hurt an already chronic shortage of physicians?
Education Feature — January 2018
Tex Med. 2018;114(1):32–35.
By Sean Price
Spencer Pruitt, MD, had every intention of being a Texas physician.
But despite growing up in Houston and graduating from McGovern Medical School at The University of Texas Health Science Center at Houston in 2010, it hasn't worked out that way so far. He didn't match for a Texas residency and instead did one in Louisiana. Since then, Dr. Pruitt returned to Texas briefly for a fellowship, but he soon left again to pursue a pediatric critical care position in Minneapolis.
While he loves Texas and hopes to return one day, he says losing a residency spot here definitely loosened his professional and personal ties to the state.
"I think if I'd had a residency in Texas, I would have been a lot more committed [to staying in Texas]," he said. "Part of my move to Minneapolis specifically was in regard to my wife and my children and where they wanted to put down roots while I was at the hospital. If they'd had more years in Texas, we would have had that much stronger roots and support structure."
State lawmakers, education officials, and many physicians worry that stories like Dr. Pruitt's are about to become more common. Two public universities in Texas ― the University of Houston and the University of North Texas Health Science Center (UNTHSC), which is partnering with Texas Christian University (TCU) in Fort Worth ― are planning new allopathic medical schools. Meanwhile, Sam Houston State University is planning an osteopathic school in Conroe. (See graphs.)
The concern is that once all these schools are online in 2020, there won't be nearly enough graduate medical education (GME) slots to accommodate the graduates those schools and the current 12 medical schools in Texas produce. That's important because most new physicians set up practice close to the place where they complete their residency. According to the Association of American Medical Colleges (AAMC), Texas retains 80 percent of physicians who complete medical school and residency in Texas and more than 58 percent of graduates from other states who complete residency in Texas.
Maureen Milligan, PhD, president and chief executive officer of Teaching Hospitals of Texas, says GME is currently the "critical choke point" in medical training.
"If you don't have the positions for the residents, the concern is that you invest in them in medical school and then they go to other states," she said. "You not only don't get the physicians that you're looking for, but you've lost some of your state funds [for public medical schools] to other states."
Texas currently spends $369 million per year specifically on medical students, or about $45,000 per student, according to data compiled by the Texas Medical Association.
Building medical schools is attractive for universities because they bring prestige and donations. Medical schools also can serve as economic drivers for local economies.
But some, like Commissioner of Higher Education Raymund Paredes, PhD, at the Texas Higher Education Coordinating Board, say there is not enough money available to fund both state-supported medical schools and new residency positions. These critics argue that the state should focus on creating as many residencies as possible and leave building medical schools to other states.
"I think that the fundamental question is, does the state have sufficient money to do two things at once in terms of medical education ― building new medical schools and building more residencies?" Commissioner Paredes said. "The evidence thus far suggests we don't."
Not surprisingly, the universities working to build medical schools disagree. Stuart Flynn, MD, who is the founding dean for the proposed TCU-UNTHSC allopathic medical school in Fort Worth, says the very growth of medical schools has spurred interest in expanding residencies.
"You can't just pop up GME," he said. "If it were really that easy to do, then Fort Worth would [already] have 500 more residency slots."
Genesis of the Physician Shortage
The touchstone of this problem is the U.S. Balanced Budget Act passed by Congress in 1997. It froze the number of residencies funded through Medicare at 1996 levels. The U.S. population growth since 1997 has contributed to a nationwide shortage of physicians.
AAMC estimated that the nationwide shortage had reached 30,500 in 2015. If current trends hold, AAMC projects it could grow to as much as 104,900 by 2030. Texas is 41st among all states in the number of physicians per 100,000 residents, and it is 47th in the number of primary care physicians, AAMC says.
This physician shortage has spurred growth in medical schools statewide. In 2016, two schools began holding classes: The University of Texas at Austin Dell Medical School and The University of Texas Rio Grande Valley School of Medicine. In 2017, the University of the Incarnate Word, a private Catholic school in San Antonio, opened an osteopathic medical school as well.
In response, the Texas Legislature passed Senate Bill 1066 in 2017. The law, sponsored by Sen. Charles Schwertner, MD (R-Georgetown), says that there must be a corresponding entry-level training position for each new medical school graduate. The Higher Education Coordinating Board has set the state's overall GME target even higher, saying there must be a 1.1 ratio of entry-level positions to medical graduates.
"The extra 0.1 is to say, hey, maybe we can reach out and grab some of these other [medical school graduates] from other states who want to relocate to Texas for their residencies," said Dr. Milligan. It also provides an opportunity for physician retraining.
SB 1066 applies to the three proposed medical schools and any schools that come after. But officials from the new schools say they're not worried about complying with the law. Stephen Spann, MD, the planning dean for the University of Houston medical school, says his university is about to announce agreements with local hospitals. Those hospitals plan to launch GME programs that will cover the school's planned inaugural class of 30 students.
"We certainly intend to meet the new legislation that was passed that will require medical schools to provide sufficient GME positions to accommodate their new graduating class," Dr. Spann said. "That plan is already developed. We agree that we shouldn't train medical students to export elsewhere."
The Higher Education Coordinating Board must approve the creation of any public medical schools. Dr. Paredes, the board commissioner, says that while proposed deals with hospitals are encouraging, none of the three new medical schools so far has presented concrete plans to pay for new residencies.
"I haven't seen a proposal from these institutions about how they're going to do it," he said. "We've had discussions about that, and if they can figure out a way to actually do it, that's great. But until we have explicit plans about how the institutions want to build new medical schools and new schools of osteopathy, then to do it, it's hard for us to judge."
Medical Schools vs. GME
TMA's policy is to support the creation of medical schools and the expansion of existing medical schools, but it places greater priority on GME expansion.
Senate Finance Committee Chair Jane Nelson (R-Flower Mound) says state lawmakers currently are committed to creating GME positions over medical school positions. That was reflected in a joint resolution the Texas Legislature passed in 2017.
"We have been working over the last several sessions to retain more of our medical school graduates by investing in graduate medical education ― which is the most effective way of addressing our physician shortage," Senator Nelson said in an email response.
Dr. Paredes says other large states like California, which budgeted $33 million in 2017 to fund medical residencies in the state's neediest areas, also have focused on creating GME positions as the most efficient use of state money.
"So far, that seems to be the strategy that states find most likely to help them deal with any shortages of physicians," he said.
But Dr. Spann says focusing only on GME is short-sighted for a number of reasons. He pointed out that while Texas has a shortage of physicians, it has a critical shortage of minority physicians. Hispanics make up 40 percent of the overall population, but they make up only 8 percent of the physician workforce, according to the Texas Health Professions Resource Center. Meanwhile, African-Americans make up 12 percent of the population but only 6 percent of physicians. (See "Can Texas Physicians Be as Diverse as Texas?" Texas Medicine, July 2017, pages 29–32.)
Dr. Spann says one of the University of Houston's top goals is to recruit potential physicians aggressively from underrepresented groups ― something that focusing on GME positions cannot provide.
"Our goal is that at least 50 percent of our graduates will come from underrepresented minorities in medicine," Dr. Spann said. "Specifically, our goal is that 40 percent of our graduates will come from the Hispanic population and 12 percent will come from the African-American population."
Because of SB 1066, Dr. Flynn of the TCU-UNTHSC medical school says the creation of schools will simultaneously drive creation of GME. He says that is happening with the school in Fort Worth, which ― like the University of Houston ― is collaborating with local hospitals to create residency positions.
Just as important, he says, creating the schools is also the best way to draw quality candidates for all the GME slots. He says young physicians are going to be most attracted to residencies in areas with established medical schools, where there are colleagues and intellectual peers.
"There's not a physician in this country who didn't grow up [professionally] around an academic setting," he said "[Without a medical school in the area], you've reduced your opportunity to attract substantively from the MD graduates in this country."
Dr. Milligan says the one bright side to Texas' physician shortage and the problems it's caused is that it has highlighted the need for greater GME funding.
"A lot of people think, 'Hey, great, they're done with medical school now ― they're a doctor,'" she said. "And that's really just half the story. And I think the shortage over the last few years has helped highlight the second half of the story."
Sean Price can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.