It Took Decades for the Rio Grande Valley to Get a Medical School. Now It's Working to Improve the Region's Health as It Trains the Next Generation of Physicians
Education Feature — September 2017
Tex Med. 2017;113(9):47-52.
By Sean Price
The streets in Indian Hills, a colonia in Hidalgo County, are a great proxy for the area's health care needs. Some of the streets haven't been paved in a while and contain massive, axle-cracking potholes along with wavelike dips in the pavement where neighborhood dogs like to rest. Some streets have a recent layer of blacktop, but they reek of tar in the Texas sun. This is actually a big step up from May, when these roads flooded in the spring rains and turned into quagmires.
Indian Hills is about 30 miles from Edinburg, home of the nearest campus for The University of Texas Rio Grande Valley School of Medicine. Yet it ― and the 15 other colonias in the area ― already have had an outsized influence on the school, which launched its inaugural class of 55 students in 2016. Colonias are unincorporated neighborhoods that typically have poor infrastructure, low-incomes, and large Hispanic populations.
John H. Krouse, MD, the school's new dean and vice president for health affairs, said the colonias and other underserved areas in the Rio Grande Valley were a major factor in persuading the Texas Legislature to create the school.
"The Rio Grande Valley is home to a unique population that has had poor access to care traditionally," he said. "There is a poor physician-patient ratio, so there are a number of people who live in this area who simply have not had the access to care that they might have in other cities. It's an opportunity to build a community-based practice, to increase the primary care in the area, to look at some innovative programs in how you deliver care to the communities."
One of the first of those innovative programs has been a mobile clinic ― partly staffed by first- and second-year medical students ― that delivers health care to areas that are critically underserved, including Indian Hills. Eron Manusov, MD, is chair of the Department of Family and Community Medicine, and he oversees the clinic program. He says the clinic, which was recently lauded by the Association of American Medical Colleges as a novel way to address medical needs, helps educate students while serving the community.
"[The students] are going into colonias where there's a high rate of obesity, poverty, low education, substance abuse," Dr. Manusov said. "The students actually get to learn about the people here. Also, we are addressing not only health care but the social determinants of health and those things that can raise people out of poverty, like education, jobs, getting insurance. What we're trying to do is give tools to new physicians and students who can change the way we provide care in a more sustainable way."
Carlos J. Cardenas, MD, TMA president and one of the driving forces behind the medical school's creation, says the school faces many of the same obstacles all new medical schools expect: recruiting faculty, developing more residencies, improving funding sources, and raising its profile. But he says the school is trying new things, including innovative ways of teaching medicine and reaching out to neighboring areas. That's created a lot of enthusiasm and support.
"An individual who's looking to practice here and/or to teach student residents here has a blank canvas to innovate and create programs and look at medical education in ways that maybe haven't been thought of before," Dr. Cardenas said. "There's tremendous opportunity, and at the same time an opportunity to do an awful lot of good."
SIDEBAR - Eye on Education
Watch this video to see how UTRGV’s future physicians interact with patients early in their education, and hear officials discuss the school’s health care outreach across the Valley.
Long Time Coming
People in the Rio Grande Valley waited decades to get a medical school. The first bill calling for a medical school was filed in the Texas Legislature in 1947, but authorization for the school didn't take place until 2013. During the 65 years in between, the people in the lower Rio Grande Valley ― which is made up of Cameron, Hidalgo, Starr, and Willacy counties ― often had to travel hundreds of miles to see a physician.
State Sen. Eddie Lucio Jr. (D-Brownsville), who worked with Sen. Juan Hinojosa (D-McAllen) on the bill that finally created the school, remembers having to drive his father to a Veterans Administration hospital in San Antonio in the 1980s because there wasn't adequate care in the Valley. When he became a state legislator in 1986, people constantly reminded him of the need for more hospitals and health care.
"That was always on my mind," he said.
Just driving through it, the Rio Grande Valley can feel like any other region of Texas, with pleasant suburbs and sleek office buildings. But this region is also one of the poorest in the country, with an average per capita income of $30,179 ― far less than the national and state averages of roughly $53,000. In 2015, the four counties that make up the region had an average poverty rate of 35.9 percent, more than twice as high as the Texas rate of 15.9 percent and the national rate of 13.5 percent. More than 38 percent of people in the region are uninsured. The overall rate for Texas, which has the highest percentage of people without health insurance in the country, was 17 percent
Dr. Cardenas, who helped found Doctors Hospital at Renaissance in 1997 in Edinburg, says the topic of a medical school came up constantly at community meetings. The school was seen as a way to boost health care and the region's economy, he says. Civic leaders in the Rio Grande Valley wanted to mimic the success San Antonio enjoyed after its medical school started graduating physicians in 1966. Today, the Joe R. and Teresa Lozano Long University of Texas School of Medicine at San Antonio is the hub of an estimated $30 billion in life science research in the San Antonio area.
"To have a professional school in our community that could make use of the raw brain talent and just brain power that exists down here ― that would be the whole thing ― the piece of the puzzle that would make the area grow," Dr. Cardenas said. "San Antonio was a shining example for what can be done when a medical school comes into your community. We wanted the same thing for the Rio Grande Valley."
A New Direction
When Texas lawmakers approved the UTRGV medical school in 2013, the school's administrators decided quickly to dispense with traditional curriculum, says Leonel Vela, MD, senior associate dean for education and academic affairs. Since the early 1900s, most medical schools have followed the same template: two years of basic sciences followed by two years of clinical work with patients. Class time consists of lectures … and more lectures. Out-of-class time is often consumed by memorization.
UTRGV wanted its students in the community right away ― partly to get them involved in area health care and partly to improve their medical education. That meant leaving behind the typical lecture-memorization routine, Dr. Vela says. "That is not how we wanted [students learning] simply because that is not the real world," he said. "The real world is one that is much more complex."
Instead, UTRGV students are much more responsible for asking questions and solving problems. Whereas traditional medical students consume hours of lecture a day, UTRGV students might get an hour or so in the morning. And even then, lectures involve a lot of back-and-forth between students and lecturer. At the beginning of each week, small groups of students are given a case to study, and it's up to them to solve any puzzles it presents.
"In anatomy, we don't just have one block where we learn all of the anatomy at once," second-year student Leah Bryan said. "It's actually put longitudinally through the first two years. So whatever module we're learning about, say we're doing cardio, then we're doing heart anatomy at that time. And then when we go to lungs, we learn lung anatomy."
Students also are quickly immersed in clinical work in the community. The school of medicine's programs include the Community-University Partnership, which operates in six colonias within three South Texas counties. Medical students team up with students from other UTRGV colleges to determine health needs and work with community leaders to solve them.
The centerpiece of this work is Dr. Manusov's specially equipped van, or "Unomovil," which is funded by a grant from the United Health Foundation. The van is about the size of a small school bus. It contains an exam room, another room with a chair for either dental or gynecological checkups, and a small passageway full of supply cabinets. The van also includes electrocardiogram and ultrasound equipment.
"On the first day of class, we practice [patient interviews] with our peers," said Amanda Arreola, a second-year student who is also a winner of TMA's Minority Scholarship. (See "TMA's Minority Scholarship Program Is About More Than Just Money.") "[By] the second week or third week, we were in a bus on the road to a colonia."
Students are supervised by faculty as they work with patients to conduct interviews, take blood pressure, and do eye exams. Later, the students move on to more complex procedures like hernia checks and rectal exams. Dylan Lopez, a second-year student, says the experience has helped students gain confidence in dealing with patients.
"That's exactly why I chose to go to this medical school," he said. "I feel like I get to actually contribute to the care of the patient early on rather than having to wait for a clinical year. I would call and tell my other medical school friends [at different schools], and they'd be like, 'Wait, you actually got to do that?'"
Dr. Manusov says the van is being used to set up a system of permanent health care hubs around the region where the need is greatest. Many of the patients who come to the van have no insurance and have not seen a physician in months or years. The most common problems are tied to vision, dental, mental health issues, and diabetes. But the Valley's subtropical climate and its widespread poverty make it susceptible to diseases usually found in poorer countries.
"I used to be in the military, and I see more here than I did in the Philippines," Dr. Manusov said. "We have leprosy here. Dengue fever is endemic. We have typhus. We have parasitic diseases. We have cancer at age 22 [and] metastatic breast cancer at 30. [We have] severe diabetes ― uncontrolled with complications. So we have things here in the Valley that you don't get to see anywhere else."
Dr. Krouse, who took over as dean in July, says the biggest challenges the school faces are financial. UTRGV had hoped to get local support to create a hospital district in Hidalgo County. The taxing authority of such a district could provide millions of dollars yearly for the school and give it a shot at more federal funds.
But voters have turned down the district twice. This means the school has had to rely more heavily on money from the legislature, which lately has been cutting funding for higher education. In the regular session that ended in May, lawmakers granted the school $54.1 million for the next two years, about $7.2 million less than the last biennium.
Dr. Krouse says the loss of state money will not cause cuts, but it will force the school to be "very strategic" about where it expands. He says public-private partnerships can help fill the funding gap. He pointed to the $60 million gift the Michael and Susan Dell Foundation provided to The University of Texas at Austin Dell Medical School, which opened at the same time as UTRGV. So far, he says, UTRGV has not received that kind of donation.
"But long term, for sustainability, we need a local hospital district," Dr. Krouse said. "It's something every other academic medical center has in the state."
Dr. Cardenas believes local attitudes will turn around as more people see that the school is an economic driver in research and attracting other health-related industries. That is already taking place with the creation in 2014 of the South Texas Diabetes and Obesity Institute, which is part of the medical school. It started with a 22-member research team and $12 million in federal funding. It since has acquired an additional $9.7 million and increased its team to 52.
"There will be people who make their careers here," Dr. Cardenas said. "They're going to make discoveries that are going to make a huge difference in how we're going to tackle certain illnesses. Things with diabetes are already changing. We're already making links and discoveries about cancer that are coming out of the populations that are being studied here. So we're just scratching the surface."
The school also should finally bring more physicians and providers to the region, Dr. Cardenas says. He pointed to studies that find that residents tend to stay within 100 miles of where they train. UTRGV medical student Sonya Rivera, who grew up in Brownsville, is likely to be one of them.
"I was born and raised here," she said. "This [school] was my first and only choice. I do truly plan on staying here. This is where my family is, and I do see great need."
And the need is not just medical. Fifty-five percent of UTRGV's inaugural class came from underrepresented racial and ethnic groups, far higher than the 13 percent national average, according to the Association of American Medical Colleges. Its second class of 56 is similarly diverse. Ms. Arreola, who is from El Paso, says that when she first arrived she was pleasantly surprised that people looked up to her as a role model.
"I've had people tell me, my daughter is 10 and she's going to go to medical school, and there's never been a medical school here before," she said. "It's just amazing to be a part of that."
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.
TMA's Minority Scholarship Program Is About More Than Just the Money
Growing up in El Paso, Amanda Arreola always perceived medical care as a luxury. Her family didn't have much money. Both of her parents had only high school degrees; both of their parents were immigrants. "So going to the doctor was not a thing, unless it was an emergency. And if you were to go see a doctor, El Paso was too expensive, so you went across the border to seek medical attention in Mexico."
Not until she arrived at Baylor University in Waco did she realize "the normal average person doesn't do that. There's no border in the middle of Texas. The disparities were very apparent once I moved. That had a lot to do with why I chose medicine."
However, excitement over her acceptance into the inaugural class at The University of Texas Rio Grande Valley (UTRGV) School of Medicine in 2016 soon turned to worry over how she could afford it. An email from the Texas Medical Association announcing she had won TMA's $10,000 Minority Scholarship "was the first step for me that this was actually going to happen. It's an amazing feeling, and I am so grateful to TMA for that."
Since 1999, TMA has offered scholarships to first-year African-American, Hispanic, and Native American medical students. TMA selects the scholarship recipients from a competitive pool of applicants. TMA's 2017 Minority Scholarship Program is made possible with a grant from the TMA Foundation thanks to the TMAF Trust Fund of Dr. Roberto J. and Agniela (Annie) M. Bayardo; the TMAF Patrick Y. Leung, MD, Minority Scholarship Endowment; and generous gifts from H-E-B, and physicians and their families. To make a tax-deductible donation to the TMA Minority Scholarship Program, visit the TMA Foundation webpage.
Read more about how the TMA Minority Scholarship Program has helped Ms. Arreola and other students like her.
The Geography of the UTRGV School of Medicine
The University of Texas Rio Grande Valley (UTRGV) School of Medicine is divided among three campuses. Medical students spend their first two years at the university's main Edinburg campus and move to the Harlingen campus for their third and fourth years. The Brownsville campus is used mostly for research.
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