A godsend.
That’s how Celeste Caballero, MD, describes the physician student loan repayment program that encouraged her to set down roots in San Angelo twice as long as the repayment terms required. Doubling down on her four-year commitment to practice in the area stemmed from Dr. Caballero’s loyalty to her patient families, compassion for the need she saw in the area, and awareness of the shortage of physicians regionally.
In the 200-mile radius I was practicing [in], there were very minimal pediatricians,” she said. Patient families would tell her in visits “we prayed for you to come here,” before thanking her.
“It almost felt like a calling,” said Dr. Caballero, the vice chair of the Texas Medical Association’s Council on Legislation, “I took it very seriously.”
The health professional shortage area (HPSA) in which Dr. Caballero worked in San Angelo didn’t qualify for federal repayment programs, despite her employment by a federally qualified health center. But she did qualify for the state program.
“It was just that impetus to stick around and stay,” she said, adding she “felt empowered that I was a young physician, saving and investing” in her community.
Dr. Caballero’s yearslong sojourn in San Angelo shows in miniature how Texas has made valiant strides in growing its ratio of physicians per state residents, even amid headwinds of record-setting population growth relative to other states. Texas has regularly added more people than any other state in decennial and annual censuses since 2000, TMA’s 2025 Physician Workforce Update shows, and still succeeded in growing its ratio of direct patient care physicians to the population. Still, shortages in some specialties persist, and access to care continues to be a challenge in rural areas.
Despite the state’s vastness, adding as few as 80 primary care physicians to the workforce in the right places could remove all whole county primary care HPSA designations, according to a recent TMA analysis of U.S. Health Resources and Services Administration data.
TMA’s 2025 Physician Workforce Update captures the interplay of these dynamics and other complexities impacting access to care in Texas and delves deep into the data that undergird pipeline trends, including licensure statistics, medical student enrollment numbers, and residency slot availability.
One of the report’s boldface findings is Texas’ historic number of newly licensed physicians – 7,609 in 2024, 549 more than in the preceding year. That momentous count stands to potentially make inroads in fields with shortages identified by TMA’s report, including pediatric subspecialists, a thorny recruitment challenge due to longer training and often lower pay than general pediatricians. The state trails national totals in its ratio per 100,000 children for every pediatric subspecialty.
These and other nuanced data points cataloged in TMA’s report capture a state workforce in flux, meeting the moment in important ways, with gaps still to fill.
“We have lots of new physicians coming into Texas, and that’s a great thing,” said Stephen Whitney, MD, immediate past chair of TMA’s Committee on Physician Distribution and Health Care Access, which authored the report. “The new graduate medical education (GME) programs are helping us to have at least a projected path forward to come closer to meeting our needs … Many of the newer schools are emphasizing direct care … [and] tend to turn out more people by percentage of their class [relative to institutions that are more research-oriented] that will go into direct patient care and more directly address that need.”
The retired Missouri City pediatrician is optimistic overall about the future of physician practice in Texas and, at the same time, supports TMA’s continued advocacy and watchfulness. The influence of Texas’ landmark 2003 medical liability reforms, which TMA helped achieve, reverberates in the context of today’s physician workforce in Texas, he said, having “increased the number of physicians wanting to practice in Texas. We were considered a safe haven from the malpractice crisis back when that was first passed. And it’s a continuing, ongoing draw to get people here.”
In addition, the new crop of medical schools in the state, with at least seven institutions enrolling inaugural classes since 2016, stands to improve Texas’ ratio of direct patient care physicians to residents amid the state’s phenomenal population growth and its expected continuation, he says.
The importance of a strong physician pipeline also undergirded TMA’s successful arguments against scope-of-practice expansions that patients, no matter where they live, deserve high-quality, physician-led care.
Dr. Caballero’s trajectory is emblematic of the type of progress brought about by TMA’s workforce wins this legislative session, including increased funding for a state GME expansion grant program, per-medical student and per-resident formula funding, and new money for training programs in family medicine-obstetrics – all opportunities to support a robust, resilient physician workforce in Texas.
Those funding gains are also grounded in longstanding TMA initiatives. Past comments from the association’s members and staff helped define some of the parameters of the Texas Higher Education Coordinating Board’s (THECB) Physician Education Loan Repayment Assistance Program in which Dr. Caballero participated.
“We tried to think of ways to incentivize physicians to stay in underserved areas for longer periods of time,” said Marcia Collins, TMA’s associate vice president of medical education. “By using a repayment process that uses incremental increases over the four-year obligation period (instead of four equal repayment amounts), we felt this would incentivize physicians to stay longer, set down roots, and hopefully, remain after their service obligation,” she said.
Rodney Young, MD, who worked with Ms. Collins to communicate those recommendations to THECB, says a continuing big win for TMA at the state level is increased funding this year for the GME expansion grant program. Amid Texas’ booming population, he calls the $304 million allotment – a 30.5% increase for 2026-27 – critical to keeping the state’s ratio of residency slots to medical school graduates at the state target of 1.1 to 1 or higher.
“We’ve got positions that both need to start up and need to be maintained,” the family physician and TMA board trustee said. “With our population growth, we would not have any luck of keeping ahead [otherwise].”
The state has beaten the odds and exceeded the state target with its projected ratio of 1.2 to 1 for first-year Texas residency positions in the 2025 National Resident Matching Program relative to the projected number of 2025 Texas medical school graduates, according to calculations based on data analyzed by TMA staff. Staff projections indicate that ratio will slip to 1.1 to 1 from 2026 through 2029 if the number of entry-level residency positions remains stable while graduates are projected to increase.
“The strongest predictor of where people will end up practicing is where they complete their training. Residency positions are pivotal,” said Dr. Young, past chair of TMA’s Council on Medical Education.
A 2024 report by the Association of American Medical Colleges (AAMC) maps neatly onto that wisdom, with findings that 58.6% of physicians who completed training in Accreditation Council for Graduate Medical Education-accredited programs between 2014 and 2023 now practice in the same state where they completed residency.
‘Biggest return on investment’
In Texas, the numbers are even higher, at 67% of physicians remaining in state to practice after residency, according to the American Medical Association. Capitalizing on this momentum could yield big returns, says Dr. Young, who teaches at the Texas Tech University Health Sciences Center School of Medicine in Amarillo.
“If we can get them here for residency training and keep the ones that we invest the dollars in to educate them in medical school to the greatest extent possible, then the state of Texas gets the biggest return on investment.”
One statistic that crystallizes the state workforce’s progress and complexity is the ratio of direct patient care physicians to 100,000 residents, at 202 currently, up from 177.4 in 2015, according to TMA’s analysis. In that sense, the ratio is robust.
“Our rate of growth in our physician workforce has bested the population growth. That’s an important metric,” Dr. Young said. On the other hand, “our challenge is that we were historically behind in terms of our physician-to-population ratio.”
That trend has proved tough for Texas to shake, as the state now ranks 42nd out of the 50 states in this respect, with the U.S. ratio at 254.
But it’s not an apples-to-apples comparison.
“[Other states] generally have had a lot of legislative success getting funding at the federal level for a GME infrastructure, which has been like a backbone to their system … we have not had the same treatment historically,” Dr. Young said.
Recent legislative wins, including modest increases in per-resident formula funding and a new funding artery for expanding obstetrical education for family medicine fellows, shouldn’t be discounted, he said, rather seen as “part of an ongoing effort that matters.”
GME is a community good, Dr. Young says, and its infrastructure should be invested in and built out accordingly. TMA’s legislative advocacy to keep the state’s investment in it “front and center, so that they understand every session how it makes a difference, and how we measure those differences – that’s critical for us.”
Likewise, the state’s brand-new budget allocation this biennium of $200,000 for an OB-gyn workforce study stands to potentially shed light on some of the factors that underlay Texas’ maternal care deserts – 47% of the state’s counties.
Funding for medical education infrastructure has steadily increased in recent years, with an augmented $122 million allocated this session for per-medical student funding.
“We have now had a track record of several sessions in a row where [lawmakers] have paid attention to the need for expanding the medical workforce in Texas,” Dr. Whitney said.
While encouraged that trend might hold, he cautioned medicine must continue to make its voice heard on a number of fronts. Loan repayment and loan forgiveness are critical, he said, as are “continued diligence on the [medical liability] front, to make sure that any of the recurring attacks on [liability] reforms don’t proceed, and continued funding for new programs.”
Jonathan MacClements, MD, University of Texas at Austin Dell Medical School senior associate dean of graduate medical education, lauds the state’s forecast progress in maintaining its heightened proportion of residency slots to medical school graduates, with a slight caveat.
“It’s fantastic that we’re predicting to have sufficient GME capacity through the end of the decade, but with the knowledge of course that our workforce is aging,” the Austin family and adolescent physician and consultant to TMA’s Council on Medical Education said.
AAMC reports U.S. physicians aged 65 or older are 20% of the clinical physician workforce, and those between age 55 and 64 are 22% of the clinical physician workforce.
While the projected residency slot ratios through 2029 are positive, medical schools are identifying areas of opportunity locally for new training programs and fellowships for specialties with physician shortages. Dell Med, for instance, is focusing on expanding primary care specialties and developing specialty programs where community needs remain high.
The rationale for many new medical schools starting up in Texas, Dr. MacClements added, is a recognized need in regions and cities of the state “to recruit, train, and retain colleagues in their community who then become very familiar with what the community needs [and] adapt their tactics and operations to ensure that their communities are receiving the quality of health care they need.”
Medical schools are also finding ways, for example, to serve uninsured and low-income residents via safety net programs, as Dell Med does in its partnership with Central Health’s Medical Access Program in Travis County.
“What we’re looking to do is try and augment the quality of care here in Central Texas so that a number of our patients don’t have to travel greater distances that they’ve been doing in the past, to other metropolitan areas like Houston, Dallas, San Antonio – to get some care that ultimately new specialty hospitals and trainees will be able to provide for us in Central Texas.”
“The good news for us is that we seem to be attracting a lot of colleagues from outside of the state, and they’re moving to Texas,” he said. “That’s fantastic. It makes me proud to be a Texan. The one thing I’d like to do is see how many of our own medical students and residents we can continue to retain.
“What we’re trying to do is train the future physician leader who not only will have the skills to be an outstanding, consummate physician, no matter what their specialty is, but also be able to be thoughtful [about how] to transform the health care environment and lead a health care team to maximize efficiency and maximize quality care.”