Medical Education Feature - May 2010
Tex Med. 2010;106(5):55-57.
By Ken Ortolon
Houston family physician Tricia Elliott, MD, says a community-based residency training program she runs at Kelsey-Seybold Clinic with Baylor College of Medicine has been in difficult financial straits since its primary teaching hospital, St. Luke's Episcopal Hospital, cut its stipends by 50 percent a few years ago. St. Luke's decided to put that money into neurosurgery residencies instead of family medicine.
Despite reducing their residency slots from six to four per year and Kelsey-Seybold's best efforts to find alternate funding, the program will close next year. The last class of residents will complete their training in June 2011. Those currently in the first year of the program had to find other training opportunities, Dr. Elliott says.
"What is so unfortunate is that this comes at a time when we absolutely need to build our primary care workforce," she said. "We can't have residency programs in family medicine closing."
Texas faces shortages in virtually every recognized medical specialty, but experts say the need for primary care doctors is particularly critical. Texas medical schools expanded their enrollment over the past several years, but residency slots for Texas graduates remain relatively flat.
The need to grow the physician workforce, however, has not escaped Texas lawmakers' attention. In February, the Senate Health and Human Services Committee began a study of the current and long-range need for physicians and other health care professionals in the state.
Texas Medical Association officials say that study is definitely timely, but fear there may be little opportunity to expand training for physicians due to the state's projected budget shortfall. (See " Prescription for Public Health Disaster .") In fact, Michael Ragain, MD, chair of TMA's Council on Medical Education, says state graduate medical education (GME) funding actually may be at risk when the Texas Legislature convenes in January 2011. (See " Coordinating Board Proposes Education, Loan Repayment Cuts .")
He expects "a redux of 2003" when lawmakers drastically cut Medicaid funding for GME as part of their effort to resolve a multibillion-dollar budget shortfall. "I'm afraid that's where we may be headed."
Growing Physician Workforce
The Senate Health and Human Services Committee held its first hearing on the physician workforce issue on Feb. 23. The issue is part of a broader charge from Lt. Gov. David Dewhurst to study the state's current and long-term need for physicians, nurses, dentists, and other allied health and long-term care professionals before next year's legislative session.
Lieutenant Governor Dewhurst requested that the committee recommend ways to ensure sufficient numbers of health care professionals, focusing on medically underserved and rural areas, as well as the border region.
The charge also asked the committee to consider health care delivered by advanced practice nurses, potentially setting up a scope-of-practice confrontation over independent prescriptive authority for nurse practitioners.
Physicians say the examination of health professional workforce issues couldn't be timelier. Ben Raimer, MD, chair of the Statewide Health Coordinating Council , testified at the hearing and says Texas is much better off than it was 10 years ago in terms of its health professional workforce, but it is not anywhere near where it needs to be.
"We certainly are doing a better job in educating, in particular nurses, for that workforce," Dr. Raimer said. "But we still face some major problems with physicians and the entire allied health professional work field."
Despite a significant influx of physicians from out of state following enactment of medical liability reform in 2003, growth in the physician workforce barely keeps pace with population growth in Texas.
Dr. Ragain, who also is professor and chair of family medicine at Texas Tech University Health Sciences Center in Lubbock, says the state currently has shortages in 37 of 40 recognized medical specialties.
Dr. Raimer, senior vice president for health policy at The University of Texas Medical Branch in Galveston, says the increase in specialty physicians in Texas is growing faster than the population, but the numbers of primary care doctors - family physicians, pediatricians, internists, and obstetrician-gynecologists - are increasing more slowly. Also, he says, there still is a significant maldistribution of doctors, with the bulk of physicians practicing in metropolitan areas, leaving rural and border areas underserved.
"We are not growing the physician workforce that's probably most critical and the most needed to serve Texans from all walks of life and all geographic areas," he said. "We are facing, in short, a major primary care shortage and a major shortage in the allied health sciences and the mental health areas in Texas. Those are going to really create a major challenge for us in the future."
Where's the Money?
Dr. Raimer says the state's first priority should be investing in more residency training positions.
"For return on investment that would actually keep doctors in Texas and improve the likelihood of Texas graduates staying in Texas and taking care of Texans, I would create more GME slots, particularly in primary care and the specialties in which we have the greatest shortages," he said. Those specialties include pediatric and geriatric subspecialties, he adds.
However, other physicians say the projected budget shortfall for the next biennium - estimated to be anywhere from $11 billion to $19 billion - will make it hard to ask for additional GME funding next year.
"When you give a senator the choice of cutting benefits to a Medicaid beneficiary or supporting doctor training, you know what they're going to pick," Dr. Ragain said. "It's a hard sell."
Sen. Jane Nelson (R-Lewisville), chair of the Health and Human Services Committee, says increasing spending for any programs will be tough in 2011, given the budget situation.
"The appropriations process is never easy because there are many good ideas out there competing for the same dollars," she said. "This year it is going to be particularly difficult - not only because of the budget situation but because of an ongoing shortfall in Medicaid. We will have to make a very strong case for every penny we spend next session. We will probably know sometime in January exactly how painful the budget situation is going to be."
Get on the Fast Track
While winning additional GME funding will be difficult, TMA supports several initiatives that could fast track new physicians through the educational pipeline.
In his testimony before the Health and Human Services Committee, Dr. Ragain encouraged lawmakers to maintain stable funding for both undergraduate and graduate medical education, as well as recently expanded physician education loan repayment programs.
In addition, he suggested lawmakers consider a "bridging" program that could put midlevel practitioners who already have some education and training into a streamlined medical degree program. The idea would be to recognize prior training and skills of physician assistants and nurse practitioners, get them into an accelerated medical education program, and steer them toward community-based primary care residencies, he said.
"I think there are other ways to be efficient within medical education," Dr. Ragain added. One is a current initiative at Texas Tech that will cut one year off medical training for some students interested in primary care.
Under the Tech plan, recently approved by the Liaison Committee on Medical Education, the school would use an accelerated curriculum to graduate some students in three years rather than four. Students in the program would be guaranteed a slot in a Tech primary care residency program.
Another idea, Dr. Ragain says, is an initiative in internal medicine to shorten residency programs from three to two years for those planning to enter subspecialties.
"Rather than having three years of residency and three years of fellowship, you would have two years of residency and three years of fellowship," Dr. Ragain says.
One idea that came out of the February hearing that TMA likely will not support is independent prescriptive authority for advanced practice registered nurses.
At the hearing, representatives of the Texas Coalition for Nurses in Advanced Practice suggested that granting nurse practitioners independent authority to diagnose and prescribe could improve health care delivery for Texas families. They also said nurse practitioners would be more likely than physicians to practice in underserved areas.
While Dr. Raimer says the Statewide Health Coordinating Council supports examining that issue, he says the data does not support the nurse practitioners' contention that midlevel practitioners will flock to underserved areas.
"We certainly need more nurse practitioners," Dr. Raimer said, "but we need something that puts them into the rural and underserved areas where they're needed. Most nurse practitioners, the statistics tell us, will gravitate to a metropolitan area."
Dr. Ragain says independent prescriptive authority for nurse practitioners might be an "expeditious solution" to workforce needs but not necessarily a good one.
"We need to talk about supporting the collaborative model in which the physician is overseeing the practice of the physician extender," he said. "That type of oversight is effective and efficient. Independent practice opens the door significantly to concerns about quality."
In the past, TMA has aggressively opposed another suggestion discussed at the February hearing: repealing the ban on hospitals directly hiring physicians. TMA negotiated extensively in the 2009 legislative session on a bill that would have allowed small rural hospitals to directly employ physicians. But the association has maintained its opposition to a repeal of that ban for large metropolitan hospitals, which TMA believes have no trouble recruiting staff physicians.
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 .
Funding for medical education programs would drop almost $9.2 million this year and next under a Texas Higher Education Coordinating Board proposal.
The reduction is in response to a request from Gov. Rick Perry, Lt. Gov. David Dewhurst, and House Speaker Joe Straus that all state agencies cut their budgets by 5 percent because of an expected budget deficit next year.
The budget cuts would total:
The coordinating board noted that the proposed reduction to the Family Medicine Residency Program "may result in fewer first-year residents invited to train in Texas family practice residency programs and may negatively affect the number of medical school graduates who remain in Texas for residency training."