Medical Education Feature - June 2008
Tex Med. 2008;104(6):41-43.
By Ken Ortolon
Texas is licensing new physicians at record rates, yet growth in the state's physician workforce is barely keeping pace with increases in the state's population.
And, despite the expected opening of a new four-year medical school in El Paso in 2009 and planned class size expansion at nearly every other Texas medical school, experts say the ratio of physicians to population in Texas likely will begin to decline by 2015 unless it can find other ways to train or recruit even more doctors over the next several years.
"We're not making much headway despite our really good recruitment efforts," said Hurst pulmonologist Woody Kageler, MD, chair of Texas Medical Association's Committee on Physician Distribution and Health Care Access. Dr. Kageler's committee recently released a report that showed Texas' physician-to-population ratio has remained relatively flat since 2000, despite the fact the state has licensed more than 10,000 new physicians in the past four years, including a record 3,324 in fiscal 2007.
Dr. Kageler and others believe Texas cannot afford to let its physician workforce lag behind population growth for several reasons, including an aging population that will demand more services and a large number of practicing physicians who soon will reach retirement age.
The problem has attracted legislative attention. House Speaker Tom Craddick has directed three different House committees to conduct interim studies of Texas' physician workforce needs. And, Senate Bill 10, passed by the 2007 Texas Legislature, directed the Texas Health Care Policy Council in Gov. Rick Perry's office to examine graduate medical education's (GME's) role in meeting the state's physician workforce.
While medical educators believe the state's current efforts to produce more physicians will play an important role in meeting future needs, they say other efforts will be required.
Nancy W. Dickey, MD, president of the Texas A&M Health Science Center and vice chancellor for health affairs for the Texas A&M University System, chairs the Texas Health Care Policy Council . She says the physician shortage issues facing Texas are really a national - possibly even a worldwide - problem.
"For us here in Texas, population growth and increased intensity of services, as well as the fact that we started fairly down on the list in terms of physicians-to-population ratio, means that we have some catch-up to do," Dr. Dickey said.
According to the report from Dr. Kageler's committee, Texas actually dropped in the national ranking of physicians per 100,000 population in 2006, falling from 42nd to 43rd. In 2007, Texas had 156.7 practicing physicians per 100,000 population - virtually the same number it had in 2000, even though the number of physicians rose by 17 percent during that period. The state's population, however, grew by 16.6 percent during those years.
At a meeting of the Texas Health Care Policy Council hosted by TMA in April, Ed Salsberg, senior associate vice president and director of the Center for Workforce Studies of the American Association of Medical Colleges (AAMC), warned council members that workforce trends indicate the nation likely will face a significant physician shortage in the near future.
"This is, of course, driven by the large cohort of physicians who are approaching retirement age, the fact that the younger physicians demand lifestyles that are highly likely to include working fewer hours, and that demand for services continues to rise," Mr. Salsberg said.
More than 20 states already report shortages of practicing physicians in at least 17 specialties, including emergency medicine, family medicine, geriatrics, neurosurgery, pediatric subspecialties, psychiatry, and others, Mr. Salsberg says.
"This is a very widespread shortage that we're likely to be facing," he said.
According to the TMA physician distribution committee, Texas ranks below the national average in 37 of 40 different medical specialties. American Medical Association data from 2006 shows Texas exceeds the national average only in one specialty - aerospace medicine. It ranks right at the national average in allergy and immunology and colon and rectal surgery.
The lowest is vascular medicine, which stands at 55.5 percent of the national average, followed closely by psychiatry at 56.4 percent. Emergency medicine, internal medicine, and pediatrics all fall between 70 and 74 percent of the national average.
Austin psychiatrist Clifford Moy, MD, a member of the TMA Council on Medical Education, says part of the problem is that Texas does not have enough residency programs in some specialties to keep Texas medical school graduates here for their postgraduate training. For example, Texas has only two residency programs in emergency medicine, says Ben Raimer, MD, chair of the Statewide Health Coordinating Council.
"That was in the top 10 percent of specialties that our students wanted to go into, so they had to leave the state," Dr. Raimer told the Texas Health Care Policy Council.
In addition to emergency medicine, the specialties of otolaryngology, general surgery, preliminary surgery, and orthopedic surgery rank high in terms of the number of Texas medical school graduates who leave the state to pursue those careers, Dr. Moy says.
Despite that, Mr. Salsberg says Texas does relatively well in physician retention. Nearly 80 percent of those who both graduate from medical school and do their residency training in Texas stay here, he says.
Still, more than 20 percent are going elsewhere to practice.
Solving the Shortage
How to solve the looming physician shortage both nationally and in Texas remains the $64,000 question. In 2006, AAMC recommended that medical schools nationally increase their enrollment by 30 percent by 2015. Mr. Salsberg says current projections are that first-year enrollment in allopathic medical schools will stand at about 19,900 by 2012, a 21-percent increase since 2002. He also says enrollment at osteopathic schools should exceed 5,000 by 2012.
Dr. Dickey says Texas is well on its way to meeting that 30-percent increase in enrollment, as well. She says Texas currently graduates about 1,300 new physicians each year. With the class size expansion already under way, Texas should reach 1,700 graduates per year by 2010 or 2012, she says.
But solving the physician shortage will take more than just more medical school graduates. Residency opportunities in the state also must increase. That could be a problem, given current limitations on state and federal GME funding.
"There are numerous problems with graduate medical education funding," Dr. Kageler said. "One problem is the cap that comes from the federal level." Medicare, which traditionally has been the largest source of GME funding, has capped the number of GME slots it will fund for several years.
Another problem, Dr. Kageler says, is that Medicare GME funds have been "almost exclusively linked to hospitals, whereas we really need to be training many of our physicians in ambulatory practice settings for primary care and for nonhospital work."
While Mr. Salsberg says continuing to increase medical school enrollment and residency slots is critical, other steps also can bolster the physician workforce and improve efficiency. They include improving utilization of health information technology, increasing interdisciplinary education, designing a delivery system that is more responsive to the needs and lifestyle demands of younger physicians, and increasing the use of nonphysician clinicians.
Dr. Raimer says allowing nonphysician advanced practitioners to work with physicians in physician-led teams could be important in meeting health care access needs.
"Creating certified health workers who manage chronic illness also provides us an opportunity to assist physicians in their practice, allowing them to take on more complex cases," he said.
Dr. Dickey believes that idea should be considered. There is something about the way we deliver care that should be evaluated for more efficiency, she says.
A more integrated approach blending the talents and training of multiple providers, including nurse practitioners, physician assistants, and technicians, to help physicians care for their patients might allow physicians to focus more attention on "the things they need to do as opposed to the things they have traditionally done," Dr. Dickey said.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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