Helping Prepare for Texas' Health Care Future
Symposium on Medical Education — February 2016
Tex Med. 2016;112(2):62-67.
By Betsy Goebel Jones, EdD, and Steven L. Berk, MD
Meeting Texas' future health care needs will be challenging, including the goal for a physician workforce more balanced toward primary care. To help expand the primary care physician workforce, Texas Tech University Health Sciences Center (TTUHSC) School of Medicine developed the Family Medicine Accelerated Track (FMAT), a three-year curriculum that culminates in the MD degree and links medical students to family medicine residency programs at TTUHSC campuses in Lubbock, Amarillo, or the Permian Basin (Odessa and Midland). Twenty current family medicine residents are graduates of the FMAT program, and 30 medical students are enrolled in the program, which is charting a path for curricular innovation in medical education that will be increasingly competency-based.
Forecasting the future is always a challenge. Management consultant Peter Drucker is widely quoted as having said, "Trying to predict the future is like trying to drive down a country road at night with no lights while looking out the back window." Available data, however, do provide some reliable indicators for the road ahead. Texas' Office of the State Demographer projects a 2050 Texas population of 40,502,749 — almost doubling the 2000 census numbers of 20,851,820 and a significant increase over the 2014 population of more than 26.5 million.1
Meeting health care needs of an expanded population will be challenging. Writing in the pages of this journal in 2009 (and before the passage of the Affordable Care Act),2 T. Samuel Shomaker predicted that, in the face of already low physician-to-population ratios, "shortages of primary care physicians (PCPs) will continue to worsen in Texas, especially in the rural and border areas." More recently and post-ACA, research conducted by Petterson et al found Texas would need an additional 6,250 PCPs by 2030 to meet the needs of population growth and insurance expansion, citing the state's poor PCP-to-population ratio.3
In an effort to reflect the current "state of the union" of the medical profession in Texas in 2015, a Merritt-Hawkins analysis of the Texas physician workforce, prepared for the North Texas Regional Extension Center, also found shortages of primary care physicians, with Texas ranking 47th in the nation in active PCPs per 100,000 population (63.3 vs. 80.7 nationwide).4 Interestingly, their research found PCP shortages in Texas' five most populous counties, which are "top heavy in specialty care." Also noted in the report — and publicized in the national press — were the 35 counties with no active physicians.5
However, given the current expansion in the state's medical schools — with 12 active medical schools as of fall 2016 — but no corresponding increase in graduate medical education positions or programs, the Merritt-Hawkins report noted, "Texas will be challenged in 'growing its own' primary care physicians" in coming years.
In the face of these insistent calls for an expanded primary care workforce and a rebalanced physician workforce in favor of primary care,6-11 Texas Tech University Health Sciences Center (TTUHSC) School of Medicine developed the Family Medicine Accelerated Track (FMAT), a three-year curriculum that culminates in the MD degree and links medical students to family medicine residency programs at TTUHSC campuses in Lubbock, Amarillo, or the Permian Basin (Odessa and Midland).12,13
The purpose of FMAT is to prepare primary care physicians more efficiently and with less cost. To meet this purpose, FMAT focuses on family medicine (FM), specifically, rather than primary care more broadly: Nationally, more than 90 percent of FM residency graduates remain in primary care, and almost 40 percent do so in communities that are otherwise medically underserved. In contrast, only about 20 percent of internal medicine graduates and 40 percent of pediatrics graduates choose primary care careers.6,14 The TTUHSC FM residency programs, in particular, have been especially successful in training primary care physicians for West Texas, a region that remains medically underserved. Of the 108 counties in TTUHSC's catchment area, 98 are rural and 25 are among the 35 that lack even one active physician.4
Accelerated Training as a Pathway to Family Medicine
Despite steady growth in the number of FM positions offered in the National Resident Matching Program (NRMP) — rising from 2,708 in 2011 to 3,195 in 2015 — the percentage of FM positions relative to other specialties has remained constant at about 11.7 percent of all positions offered in the match.15 While 95.1 percent of the 490 U.S. FM residency programs filled in the 2015 match, only 44 percent of the filled positions were with graduates of U.S. medical schools, one of the lowest percentages across all specialties.
Several theories have been proposed to explain the low number of students choosing FM. The most common explanation is financial, related both to student debt loads and to the disparity in compensation between primary care and subspecialty physicians. Recent scholarship has looked at the role of student debt on career choice, concluding students are keenly aware of potential earning capacity among medical specialties and that their own debt ultimately drives their career choice — especially away from primary care.16-19
Among the recommendations made by Petterson to bolster a primary care pipeline is to provide medical school student debt relief.3 The FMAT program takes on this challenge directly; FMAT students receive one year of scholarship support during medical school, and they begin to earn a residency salary one year earlier, effectively halving the cost of tuition and fees.
In addition to debt relief,20 TTUHSC's decision to develop the FMAT program was driven by recognition of several benefits to accelerated training. Accelerated programs shorten the time and narrow the gap between medical school and practice. Surveys of our students tell us they are most often drawn to FMAT because it provides an earlier career start, which is especially appealing to older students who come to medicine as a second career and often have spouses and children.21 With full institutional and leadership support, accelerated training programs enjoy enhanced and visible status within the institution, which accrues to all stakeholders — departments of FM, faculty, and clinical systems that provide training, and most especially to the students selected for the programs. As a result, an accelerated training program that targets FM has the effect of increasing the status of FM (and probably other primary care fields) across the institution.
Accelerated training functions within tradition-bound medical education as a disruptive innovation, a term used by Hwang and Christensen to describe a process that creates change in established systems via products and systems that are simpler and more affordable22 — an obvious example is a three-year MD degree whose owner has less debt to repay.
Description of the FMAT Program
For both three- and four-year programs, TTUHSC medical students (currently 180 in each class) complete their first two years of training in Lubbock and are distributed for MS3/MS4 years among two campuses in Lubbock (at the TTUHSC and Covenant Health System campuses, about 57 percent of the class), Amarillo (30 percent), and the Permian Basin (13 percent). Similarly, FMAT students spend two years in Lubbock, followed by at least four years on the campus (which may include Lubbock), where they complete the final year of medical school and three years of FM residency training. The FMAT curriculum, approved by the Licensing Committee for Medical Education (LCME) in 2010, is covered in an equivalent of 149 weeks, compared with the 160 weeks of the four-year program.
Specially developed FMAT courses include an eight-week systems-based experience in the summer between students' first and second years of medical school, team-taught by family medicine and basic sciences faculty; an eight-month family medicine clerkship that students complete during their second year, concurrent with MS2 basic science courses; and an eight-week capstone experience in May and June of their MS3 year that includes hospital-based FM sub-internship and ICU experiences.
FMAT Student Selection
The TTUHSC School of Medicine fills FMAT positions both during the pre-matriculation process and in the fall semester from the sitting MS1 class. Students are selected based on academic performance, interest in FM, and an interview with the FMAT committee. Factors that affect class size (typically eight to 15 students) are available residency slots, faculty capacity, and student interest.
Transition From FMAT to Four-Year Curriculum
Students may choose to return to the regular four-year curriculum at any time before January of their MS3 year, when final residency numbers are due to the NRMP. They may do so for any number of reasons, but typically they have decided not to pursue residency in FM. They are also given the option of going through the match, rather than using the "all-in exception" (described below) to transition to a TTUHSC-FM residency program.
In addition, because the accelerated nature of the program does not allow time for remediation or delays due to personal or academic reasons, students may be counseled by the School of Medicine to return to the four-year curriculum. For example, students who do not pass the U.S. Medical Licensing Examination (USMLE) Step 1 exam or who delay taking that exam based on predictive exam scores require additional curricular time that the FMAT program cannot accommodate.
Transition to Residency
FMAT students register with NRMP and the Electronic Residency Application Service during the fall, but this program also qualifies for the Family Medicine Accelerated Program's exception to the NRMP's all-in policy, which allows early placement in participating FM programs by reducing the number of residency positions in the Match.
FMAT Program Outcomes
In addition to providing an educational experience for our FMAT students that is comparable to the traditional four-year curriculum, our intended outcomes for the program are:
Meeting FMAT Program Outcomes
Program Recruitment and Retention
FMAT training began for the first class of students in June 2011; those first eight students graduated in May 2013, began residency the following July, and completed their third and final year of FM residency in June 2015. To date, 20 students have graduated from the program and begun FM residency (classes of 2013, 2014, and 2015); 31 additional students are currently in training as medical students (classes of 2016, 2017, and 2018), and recruitment is ongoing for the class of 2019. (See Table 1.)
For the NRMP matches in 2013-15, TTUHSC successfully took advantage of the FM accelerated track exception and thus far has placed 19 FMAT graduates in two TTUHSC programs. One additional FMAT graduate participated in the match and is now completing residency in another FM program in Texas.
Overall, program retention has been high. As of November 2015, of the 48 students who had begun training in the FMAT program, three students have chosen to return to the four-year curriculum — two to consider residency training other than FM and one in anticipation of a couple's match in 2017. In addition, four students transitioned to the four-year curriculum by the School of Medicine to provide additional time for academic preparation. Significantly, interest in FM remains high among students who return to the four-year curriculum, with two students who began the program in the classes of 2013 and 2014 ultimately matching with FM residencies when they graduated in 2014 and 2015, respectively.
Increasing Numbers of TTUHSC Students Choosing FM
In the NRMP matches for 2011 and 2012, the two years before our first FMAT graduating class, 15 and 14 TTUHSC School of Medicine students, respectively, chose FM residencies. In the three matches since, those numbers have risen to 21, 23, and 20, respectively. (See Table 2.)
While we would expect a bump in numbers for the first class, which included four-year and three-year program graduates, the numbers have remained strong. Thus, we do not see that the three-year program has become the dominant route for FM residency at TTUHSC but has allowed a parallel pathway for mature students able to make early decisions about residency and specialty and receive incentives, mentoring, and support for doing so.
Moreover, in an increasingly competitive match environment, FMAT students rate highly the importance of the TTUHSC medical school-to-residency program link as a motivator to participate in the program.
While the percentage of TTUHSC School of Medicine students matching with FM in 2011 was 11.9 percent — close to the national average of 11.4 percent — by 2015, TTUHSC's average had risen to 15.4 percent, while the national average remained at 11.6 percent.15 Certainly, the factors influencing students' residency choices are complex and involve national trends related to reimbursement, more intense competition for positions, and the vagaries of medical student interests, and can be considered limitations to drawing conclusions about student numbers. But the strong visibility of the FMAT program in particular and family medicine in general across our institution cannot help but affect those numbers, as well.
Indeed, our own evaluation has revealed the draw of an earlier beginning to a medical career is the most powerful factor in students' decision to apply for the FMAT program, with the effect of recruiting students who "might not otherwise have considered family medicine" as a specialty choice.21
Increasing the Percentage of U.S. Graduates in FM Residency Programs
Using a similar baseline of the pre-FMAT 2011 and 2012 years, we have experienced a dramatic increase in the percentage of U.S. graduates in our own programs, commensurate with the increases in TTUHSC School of Medicine match numbers. The same limitations listed above apply to conclusions about spikes in the percentage of U.S. graduates in TTUHSC's FM residency programs, but both programs that have received FMAT students into their residency programs (Amarillo and Lubbock) have experienced meaningful increases in the number of graduates of U.S. medical schools — even a 10-fold increase in the case of Amarillo's program, from 0 percent in 2011 to 100 percent in 2015. (See Table 2.) We anticipate the Permian Basin program will receive FMAT graduates in 2016, as well.
FMAT Graduate Performance in Residency
How have FMAT students, with one fewer year of medical school, performed as residents? They have done well, by qualitative and quantitative measures. In their first and second years of residency, as a group, members of the FMAT class of 2013 performed above their non-FMAT peers in Amarillo and Lubbock and well above the national average on FM in-training exams (ITEs), as well as the USMLE Step 3 exam.
Members of the FMAT class of 2014 also performed above the national average on their PGY1 ITE. Using the milestones developed to assess residents' performance, FMAT graduates have been assessed as performing at or above performance levels of their peers from four-year programs. While we anticipated some adjustments as FMAT graduates became residents after three years, those adjustments have been minimal. Indeed, those students' familiarity with clinical and hospital facilities, their ongoing relationships with faculty and other residents, and their commitment to become family physicians of at least three years' standing has served them well in making an early transition from student to resident. Even with one more year to go before the residency graduation of our first FMAT class, we have seen a number of FMAT graduates in all classes (including some still in medical school) sign contracts to practice in smaller towns in Texas where family physicians are most needed.
The TTUHSC School of Medicine has clearly developed a national reputation for innovation in medical education to address physician shortages and specifically for accelerated training. Dean Steven Berk, MD, has been interviewed by The New York Times,23 Washington Post,24 U.S. News & World Report,25 and the NBC Nightly News26 because the FMAT program is considered a national exemplar for dramatic action and positive impact on the advancement of physician training.
We field questions regularly from other interested schools, and we are working closely with a consortium of nine other medical schools (including New York University; Medical College of Wisconsin; University of California, Davis; University of Louisville; Penn State; and others) that are engaged in implementing and assessing the benefits of accelerated training as a way to reduce student debt and provide more direct pathways for needed specialty training, including in psychiatry and general surgery.
Challenges and Lessons Learned
FMAT Program Challenges and Pleasant Surprises
The challenges we've experienced thus far have been few but real. Befitting a program with the word "accelerated" in its title, the most common and demanding challenges are related to time. FMAT's fast pace allows no time for remediation of courses or exams, delays due to illness, or other personal issues or experiences that otherwise enhance medical school, such as electives and global health activities. Similarly, the truncated schedule, especially in students' MS3 year, when residency positions are set and a number of exams are taken, allows little time for faculty and administrators to identify students at academic risk for not passing those exams.
Additional challenges for TTUHSC have been related to determining the best balance between FMAT and other graduates within residency programs and how best to deploy the FM positions available across all of our campuses. Nonetheless, students are willing to make the trade-offs, and each year has brought additional data to help refine schedules, policies, and decisionmaking. Finally, to this list of challenges, TTUHSC administrators might add the loss of formula funding, at least as a hard programmatic cost. Again, we have determined that this cost, though significant (at least $45,000 per student, not including tuition) is justified by the program's ultimate measure of success: increasing the primary care physician workforce in Texas.
What has not been challenging — despite our early concerns about opt-out or burnout — is encouraging student interest in the program or retaining them once enrolled. As noted above, factors that lead to students' residency selection are varied and span well beyond one medical school, but pleasant surprises have included continued high interest in FM (even among students who leave FMAT), increasing interest in FM from non-FMAT students (which we hypothesize is related to FM's higher status and visibility within the School of Medicine), and the ability of our FM programs to recruit top candidates from the non-FMAT applicant pool. Nor have we encountered resistance from TTUHSC faculty, including those outside the FM department. Most satisfying has been the level of performance FMAT graduates have demonstrated as they transition to residency. They are confident, familiar with inpatient and outpatient settings, and cognizant of their roles as ambassadors for the program.
Conclusion and the Road Ahead
TTUHSC's early adoption of an accelerated pathway has opened a new road for the institution as a leader in curricular innovation that will be increasingly competency-based.27 The road ahead for medical education is likely to be linked less to time than to demonstrating proficiency in communicating with and caring for patients, and FMAT is one vehicle on that road. Indeed, we do not argue that FMAT or any accelerated program is for every student, or even for most students, destined to FM or primary care careers; rather, it is one pathway for mature and capable students who clearly see their futures as family physicians and are ready to take their place in Texas' primary care physician workforce.
Betsy Goebel Jones, EdD, is professor and chair of the Department of Medical Education and professor of family and community medicine at Texas Tech University Health Sciences Center (TTUHSC) in Lubbock.
Steven L. Berk, MD, is executive vice president, provost, and dean of the TTUHSC School of Medicine.
Note: TTUHSC's FMAT program is supported by a 2010-16 predoctoral training in primary care grant from the Health Resources and Services Administration.