Think of the nation’s 186 medical schools as a club that just about every institution of higher learning wants to join.
“It’s a time of real expansion and variation in [new] medical schools,” said Barbara Barzansky, PhD, co-secretary of the Liaison Committee on Medical Education (LCME), the body that grants accreditation to allopathic schools. (See “Getting Off the Ground,” page 27.) “If you look across Texas’ existing and developing schools, there’s a huge difference in the focus of the missions and the hopes for the students that they graduate.”
This growth is a direct result of a call by the Association of American Medical Colleges to increase enrollments 30 percent between 2002 and 2015. It’s also the result of a nationwide physician shortage, caused in large part by a 1997 freeze on the number of residency positions funded by Medicare.
Texas has seen three medical schools open since 2016; three more could open by 2021. (See “New Texas Medical Schools,” page 28.) Building even more might seem like an obvious answer to the doctor shortage, especially because medical schools can bring other benefits to a community beyond producing physicians, including prestige, high-paying jobs, and improved health care services.
But not everyone is a fan of the idea, and starting one from scratch is complicated. Some have struggled more than others to get established, mostly because of funding. Colleges and universities that can afford to launch a medical school must jump a series of hurdles for several years before students ever sit down for classes, including getting approval from the college’s board of regents and — for publicly funded schools — from the Texas Higher Education Coordinating Board (THECB).
Another significant demand is the accreditation process through LCME or its osteopathic counterpart, the Commission on Osteopathic College Accreditation (COCA), says John Krouse, MD, dean at The University of Texas Rio Grande Valley School of Medicine, which opened in 2016. Schools face extensive site visits by evaluators and hours of interrogation and paperwork.
“It’s a labor-intensive — but important — process,” Dr. Krouse said. “In a new school with a relatively small faculty, you have to [among other things] submit a document to the LCME that’s about 400 pages, and it goes through over 100 standards that you need to address in detail. You have to draft and implement 100 or more policies that govern operations. … The time requirement for the faculty is immense.”
Preparing for launch
Although allopathic and osteopathic schools are judged by different accrediting organizations, the criteria for accreditation are similar. Both types of schools are required to teach sound, science-based medicine. The accrediting bodies also are similar, being made up mostly of medical education professionals.
When publicly funded schools seek THECB approval, they must meet four criteria:
• Is the school needed by the state or community?
• Does it have sufficient funding?
• Does it have sufficient faculty and resources?
• Does it meet academic standards?
Of those criteria, both THECB and the accrediting bodies look closest at funding because so many other factors hinge on it, says Dr. Barzansky.
“The first thing the LCME looks at when it looks at [the paperwork submitted by a school] is the availability of sustainable funding,” she said. “Does the school have in cash and in kind enough money to keep this program going?”
Funding also is important to THECB because the state has limited money to pay for public medical schools. Currently, the state pays $45,000 per medical student each year, or $330 million annually, according to state budget data collected by the Texas Medical Association.
The Texas Christian University (TCU) and University of North Texas Health Science Center (UNTHSC) joint School of Medicine, which will welcome its first class in July, is both private and public but will not receive any state funding. Meanwhile, the proposed University of Houston College of Medicine, which plans to open in 2020, has requested $40 million in funding from the Texas Legislature over 10 years.
The third proposed medical school, Sam Houston State University College of Osteopathic Medicine, has taken a more unorthodox route to funding for a public institution. Scheduled to open in 2020, the school chose to forego state funding and rely instead on student tuition, says Charles Henley, DO, Sam Houston State’s founding dean.
“When [Sam Houston State President Dana Hoyt] was working with legislators, she was told that there was probably not going to be any money for new medical schools,” he said. “She took that and decided to go with a tuition-based approach.”
That means Sam Houston State will charge tuition of about $55,000 per year, Dr. Henley says. This is roughly the same tuition as the University of the Incarnate Word School of Osteopathic Medicine, a small private school in San Antonio. However, it is much higher than the roughly $20,000 average in-state tuition for state-funded medical schools, according to data compiled by TMA.
Even this tuition-based solution has critics, including THECB Commissioner Raymund Paredes, PhD. That high tuition is “not what public higher education should be about,” he said at the July 2018 THECB meeting.
Tuition-based funding also could greatly interfere with Sam Houston State’s declared mission to recruit primary care physicians for rural East Texas, Dr. Paredes said at the meeting. Medical students graduating with high debt loads are unlikely to settle in poorer, rural areas.
However, Dr. Henley says the high debt can be offset by post-graduate programs that forgive or pay off student debt. More importantly, he says, rural physicians usually make enough money to cover their debt. He cited 2016 data from The Medicus Firm showing that the average salary for family physicians in rural areas was $227,261, 16 percent higher than family physician salaries in urban areas.
TCU-UNTHSC’s medical school and the University of Houston have had few official problems with either their accrediting body or THECB, but Sam Houston State has had trouble with both. THECB approved the school in August 2018 but only by an unusually narrow 5-4 vote after board staff recommended against approval. Likewise, COCA approved Sam Houston State to move through the rest of the accreditation process in January, but only after rejecting its initial application for not meeting newly implemented standards. COCA refused to comment on the specifics of any school’s accreditation.
Still, all three proposed schools are on track to open on time, and each is staking out its identity. Sam Houston State’s mission is to improve rural health care. The University of Houston aims to bring more primary care physicians to underserved urban areas while working to recruit future doctors from underrepresented groups, like African-Americans and Latinos. TCU-UNTHSC’s school has focused on ensuring an optimal student experience, creating a system of mentors or “coaches” — area physicians independent of the medical school who can guide students through their medical training.
The fight at THECB over Sam Houston State’s approval was part of a larger battle over residency slots, which are seen as the key to unlocking the doctor shortage. If Texas does not have enough residencies, graduating medical students will go elsewhere to get the specialty training they need to practice. This would do nothing to help Texas’ doctor shortage — research shows physicians tend to settle within 100 miles of their residency training.
Some, like Dr. Paredes, argue that building new medical schools in Texas diverts funds from what should be the state’s top priority — funding new entry-level residencies. He points out that comparable states, like California, have had success recruiting new physicians with this strategy. Dr. Paredes’ belief is echoed in the Texas Legislature.
“There is a point at which we need to stop building medical schools and start building [residency positions],” State Sen. Lois Kolkhorst (R-Brenham) said at TMA’s Winter Conference in January. Senator Kolkhorst chairs the Senate Committee on Health and Human Services and serves on the Finance Committee.
Not surprisingly, officials at the new schools disagree.
The choice between medical schools and residencies is a false one, says Stuart Flynn, MD, founding dean at TCU-UNTHSC’s medical school. Without medical schools, residency slots would not be created in many cases. There have been plenty of opportunities to create residencies at local hospitals in Tarrant County, where TCU-UNTHSC is located, but nobody did it until the university started its medical school, he says.
“In Tarrant County, we have had such a dearth of [residency positions] that we now have a chance to grow them with an academic medical center and actually change the paradigm,” he said.
State-run medical schools are now required to create residencies after the Texas Legislature passed Senate Bill 1066 in 2017. The law says new public medical schools must develop a plan to ensure there are a sufficient number of residency positions in the state to reasonably accommodate the school’s expected number of medical graduates. While that does not directly affect private schools like Incarnate Word, it does put pressure on them to create slots to keep up with the other schools.
TMA policy supports the creation of medical schools and the expansion of existing medical schools, but it places greater priority on residency expansion. TMA also supported SB 1066.
Despite disagreements about the best ways to create residencies, Texas lawmakers have worked with TMA and have shown an “enlightened” view about funding them, says Robyn Phillips-Madson, DO, founding dean at Incarnate Word’s osteopathic medical school. The state provided $197 million in the 2018-19 biennium to preserve existing residency slots and to hopefully create more; that figure is expected to rise to $262 million in 2020-21, according to the Legislative Budget Board.
“One of the biggest advantages [to opening a medical school in Texas] is the state’s thinking about graduate medical education — the foresight that the state legislature has to fund graduate medical education until we can change the cap at the federal level,” she said.
Dr. Phillips-Madson, who votes on accreditation for other osteopathic schools as a commissioner on the COCA board, says she regularly gets calls from universities looking for advice about starting a medical school. She counsels them about avoiding the pitfalls — having a strong applicant pool, obtaining steady funding, working with an established university.
“It’s just my philosophy, but I believe you need to be called to this kind of work,” she said. “But Texas is a wonderful place to start a new medical school.”
Tex Med. 2019;115(3):26-29
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