First, the good news: While Texas has enjoyed red-hot population growth in recent years, its growth rate in physicians has been even hotter.
“Texas is a great place to practice medicine,” said Dallas anesthesiologist and pain management specialist Kevin Klein, MD, chair of the Texas Medical Association Council on Medical Education. “Historically, TMA’s efforts on tort reform and everything TMA does has helped make Texas a physician-friendly state, and physicians around the country recognize that.”
But even with this dynamic growth, Texas still has a long way to go to catch up with the physician distribution seen in other states, according to a comprehensive TMA report that outlines the strengths of physician workforce growth – and there are many – while analyzing how the state can improve.
For instance, Texas still has a serious shortage of physicians. Despite having 8.8% of the U.S. population, the state has 7.3% of active U.S. physicians, according to data collected by TMA. And Texas’ ratio of 204.6 patient care physicians per 100,000 people is well below the national average of 247.5.
The state’s rapid population growth helps explain why the state struggles in this metric, says Austin emergency physician Robert Emmick, MD, chair of TMA’s Committee on Physician Distribution and Health Care Access, which authored the report. Of the five most populous states – California, Florida, Illinois, New York, and Texas – only Florida and Texas have seen population growth in the past decade. But all five have seen increases in their physician populations.
“It’s hard to move up [against other states] in that situation,” he said.
Change in the Texas physician workforce comes from many directions, presenting many different opportunities and challenges. (See “Texas Physician Workforce,” page 12.)
Still, other gauges of physician population point to the need for improvement.
“Although there has been strong growth in the number of Texas physicians, Texas has far fewer physicians per capita than other states,” the committee wrote. “There is a continued need to expand physician recruitment efforts and to prepare more homegrown physicians.”
And amid all these knowns remains one big unknown – the full impact of the COVID-19 pandemic on physician recruitment and retention. While there are no formal studies or reports yet on the topic, anecdotally, some physicians chose to retire or change careers because of the pandemic, so future data may show a slowdown in Texas’ physician growth, the committee notes.
One of the best ways for a state to boost its physician population is to grow its own, and Texas has done a great job of that, Dr. Klein says.
Since 2016, Texas has launched six new medical schools, nearly doubling the number in the state to 15. Another school, The University of Texas at Tyler School of Medicine, is scheduled to open in 2023. Once that happens, Texas will be tied with California for second place in the number of medical schools, with 16. Both states are right behind New York, which has 17.
“We’re going to be creating a lot of doctors, and some of those schools aren’t even at their maximum [class size] yet,” Dr. Klein said. “They still have room to grow.”
In graduate medical education (GME), Texas has a historic number of residents, and its ratio per 100,000 population is close to the national median. Keeping just-graduated medical students in Texas for residency is important in part because medical students who do their residency training in Texas have a more-than 80% likelihood of staying and practicing medicine in the state, according to the Texas Higher Education Coordinating Board.
Texas has set a target ratio of 1.1-to-1 for first-year residency positions to medical graduates with the goal of retaining these graduates for in-state training and entry into practice. The state’s target ratio was reached in 2018, and it has been maintained ever since.
But Texas will need to add 249 entry-level GME positions to maintain the target 1.1-1 ratio by 2027. For that reason, one of TMA’s top priorities for the 2023 Texas legislative session is to build on the state’s already strong support for funding GME positions, Dr. Klein says.
Since 2014, lawmakers have appropriated $520.5 million for the state’s Graduate Medical Education Expansion Grant Program, which has created and supported 465 first-year GME positions. Programs like that have helped rank Texas fifth in the country for the retention of residents for practice, at 59%, according to the Association of American Medical Colleges.
“We need to continue to increase the number of residency positions to match up with the increasing number of medical school graduates in order to capture those folks and give them the best opportunity for staying in the state,” Dr. Klein said.
As in other states, Texas’ physician workforce is spread unevenly. Big cities tend to have plenty of physicians of all specialties. Some rural counties have none at all.
However, TMA recently discovered that since 2014, the number of health professional shortage areas (HPSAs) in Texas that are lacking in primary care dropped 29%. HPSAs are designated as areas with a ratio of 3,500-people-to-1-physician by the U.S. Department of Health and Human Services.
Not all HPSAs are in rural areas, but the drop in primary care HPSAs probably reflects an improved distribution of primary care physicians in the most underserved areas of the state, Dr. Emmick says. TMA’s Committee on Physician Distribution and Health Care Access is still studying the HPSA data and plans to issue a more comprehensive report in 2023.
“We’ve tried for decades to improve numbers for rural family medicine, and it looks like we may be having success,” he said.
Texas medical education institutions have addressed the rural shortage in several ways. Two new medical schools – Sam Houston State University College of Osteopathic Medicine in Conroe, which opened in 2019, and the soon-to-open University of Texas at Tyler School of Medicine – are dedicated specifically to addressing the shortage of physicians in rural East Texas.
Several Texas medical schools have a mission to improve rural physician distribution, and a growing number are creating rural training tracks, which set up residencies in areas with few or no physicians, Dr. Klein says. Also, loan-forgiveness programs for physicians who agree to work in rural areas appear to be an effective tool in recruiting physicians to underserved areas.
In 2019, TMA strongly supported House Bill 1065 in the Texas Legislature, which established a grant program designed to encourage rural hospitals to set up rural residency programs. Although the bill passed, the state has not yet funded it. (See “Going the Distance,” August 2022 Texas Medicine, pages 20-27, www.texmed.org/GoingtheDistance.)
Improved telehealth services and expedited licensing via the Interstate Medical Licensure Compact have been singled out as part of the solution to shortages in rural and other areas of Texas. (See “All Roads Lead to Texas,” page 19.)
Demographically speaking, Texas’ physician workforce does not resemble the state’s population. But in some ways, it’s getting there.
Among traditionally underrepresented groups in medicine, women have made the most progress. For instance, between 2012 and 2021, total medical school enrollments among women rose from 46.9% to 52.9%.
People in underrepresented racial and ethnic groups have struggled more. Black and Hispanic Texans remain the most underrepresented. However, the number of applicants to medical schools saw a sharp rise in the U.S. and Texas in 2021, according to TMA research. Hispanic applicants rose by 29.8%, and for Black Americans, they rose by 48.9%.
One of the keys to increasing diversity is a strong pipeline for young students to reach medical school in Texas, says Charles Mouton, MD, executive vice president, provost, and dean of The University of Texas Medical Branch (UTMB) John Sealy School of Medicine in Galveston. For the school, that engagement starts as young as middle school and creates relationships that encourage qualified young people to pursue a career in medicine.
Keeping students in the pipeline requires a variety of tactics like educating families about the requirements of medical school, helping students with standardized test preparation, and providing mentorship.
The cost of medical school frequently discourages young people from pursuing a career as a physician, but Texas has an advantage in that area, Dr. Mouton says.
“Texas compared to the rest of the nation has some of the best tuition rates of any state in the nation for health professionals’ education,” he said.
Improving workforce diversity will require policy changes at the state level, Dr. Emmick says. For instance, the Joint Admission Medical Program (JAMP) reserves medical student positions for qualified low-income students – which often include medical students who are Black and Hispanic. JAMP was cut $510,000 in the current budget, despite the recent increase in the number of medical schools.
Diversifying individual physician practices also can be a challenge, but changing practice norms, policies, and working environments all can help, says Adela Valdez, MD. She is a member of TMA’s Council on Medical Education and serves as associate dean for diversity, inclusion, and health equity at The University of Texas Rio Grande Valley School of Medicine.
“A strong indicator of recruitment success is when your recruited physicians become your recruiters,” she said. “When people are happy and content in their work environment, they draw others. A change in culture has the greatest impact.”