Addressing the physician shortage in Texas

by Tayson DeLengocky, DO

The physician shortage in Texas has commanded an unusual amount of public interest in recent weeks.

The Houston Chronicle (Oct. 17), Star Telegram (Oct. 19) and Fort Worth Business Press (Oct. 27) all devoted space to the growing shortage of physicians in Texas and the steps necessary to correct the problem. The three articles recognized that the availability of residency slots is the determining factor in addressing the physician shortage. This conclusion has been confirmed in numerous national research studies. Residency opportunities are important because physicians often settle in the communities where they complete their residencies. Dr. Gary Floyd, chief medical officer of John Peter Smith, stated that “seventy to 80% [medical residents] will stay within 100 miles of where they are trained.”

In 2010, there are 1,404 medical graduates and 1,390 first-year residency slots in Texas. According to Todd Ackerman from the Houston Chronicle, 45 percent of Texas medical graduates leave the state to pursue out-of-state residencies. Many of these doctors never return to Texas. Therefore, the lack of residency opportunities not only reduces patients’ access to physicians, but it also imposes a steep financial cost. According to estimates from the Texas Medical Association cited in the Chronicle’s article, each Texas medical graduate who completes a residency outside of Texas and does not return to practice costs the state $200,000.

To address this situation, the main priority of Texas is to invest in expanding residency opportunities beyond the number of medical students in Texas. Since physicians often settle in the regions where they complete their residencies, this approach provides the best, most cost-effective return on investment because it would attract more out-of-state medical graduates to Texas and ensure that Texas’ taxpayers benefit from their investment in the education of the state’s medical students.

The UNTMD Plan

However, the University of North Texas Health Science Center (UNTHSC) at Fort Worth will be requesting that the 82nd Texas Legislature approve the establishment of a second medical school — an allopathic (MD degree-granting) medical school, tentatively called UNTMD — on its campus. There are only 2 institutions, Medical Plaza Center and John Peter Smith, in Tarrant County that offer about 70 first-year residency slots. UNT Health Science Center (UNTHSC) already has a state-sponsored medical school, the Texas College of Osteopathic Medicine (TCOM), which is celebrating its 40th anniversary and has produced more than 3,000 physicians with the D.O. (doctor of osteopathic medicine) degree. TCOM has a current class size of 200 students and will increase to 230 by 2014. It is obvious that the priority of addressing physician shortages in the area is to develop new residency opportunities, not increasing the number of medical students. Therefore, the push for a second medical school on campus with a class size of 100 students is a travesty and misplaced effort.

As the state is facing a budget shortfall of $21 billion for the next 2 years, is it fiscally sound for the state to approve the establishment of another medical school in Fort Worth? South Texas is in dire need of a medical school, which was approved at the last legislative session. Funding, however, will not be approved until 2016.

If UNTMD were established, it would make UNTHSC the largest medical school conglomerate in Texas with total annual class size of 330 students per year (230 DO students and 100 MD students). With the addition of UT Southwestern medical students, the Dallas Fort Worth Metroplex would be training 560 medical students per annual class. UNTMD would divert state resources from other regions, including South Texas, which has a greater need and has a greater potential to benefit.

The proponents of UNTMD claim that the MD program will be “at no cost” to the state for the first five years (2011-2016); this was claimed by Drs. Hopkins, Lowry, and Weiss’ editorial in the Star-Telegram, published in October 16th. These founding donors of the new school believed the start-up cost will be fully covered by $25 million in community fundraising pledges and also implied in their naive article that the new school would even waive the state’s usual formula funding appropriation of $50,000 per medical student per year for the first few years (2013-2016). This translates into a waiver of state funding of $30 million for the first three classes of 100 students. That is pretty difficult to believe.

The above contradictory numbers and the low cost estimate of the UNTMD plan raise serious questions about the credibility, vision and nature of UNTMD. In 2004, UNT Health Science Center did a business study for a School of Pharmacy on its campus and the total start-up cost for a pharmacy program, at that time, with a graduating class of 60 students was approximately $23 million. Is it realistic to expect that six years later the start-up cost of a medical school with a class size of 100 students at UNTHSC will be less expensive?

The cost estimate for a new school is far below the cost estimates of other planned or recently-established medical schools in Texas. The Paul Foster School of Medicine in El Paso, which admitted its first class of 40 students in 2009, cost $150 million. It has been recently published and well known that UT Southwestern and Seton hospital system in Austin plan to invest $1.5 billion to establish a medical school and center in Austin. The Texas Higher Education Coordinating Board (THECB) estimates the funding to establish the medical school in South Texas could cost at least $99 million. All of these estimates make the UNT estimate laughable and unbelievable.

A closer analysis of UNTMD business plan shows deliberate omissions. It did not include the cost of renovating its 22,000 square feet of excess building space (which will be reserved for the new MD school). According to the UNTHSC’s new Legislative Appropriation Request (LAR) for fiscal year 2012-13, UNTHSC is asking, rather surprisingly, for $90 million for a new building space of 150,000 square feet in order to increase research space. As a point of reference, the Texas Higher Education Coordinating Board estimates that a medical school with a class size of 60 students typically requires a 160,000 square-foot building. Regardless, why isn’t this cost reflected in the UNT business plan? Furthermore, the business plan does not detail the administrative cost; UNTMD at UNTHSC would obviously have to increase administrative costs beyond their present levels.

UNTMD is simply a duplication of TCOM’s services and capabilities except for the different title degree (M.D.) because it will adopt the TCOM curriculum and, with the exception of some artificial changes, will share a single core of clinical and basic science faculty members. Does it make any academic sense to make UNTHSC a medical school of one body with two heads (two administrative structures)?

In conclusion, the wisdom rests now in the Texas Legislature, which should disapprove an inappropriate request of a second medical school in Fort Worth. In an October 2008 report, the Texas Higher Education Coordinating Board recommended that the Legislature should “fully fund the existing health-related institutions and their expansion efforts before committing additional dollars to new projects.” The Board offered the right prescription in 2008. Using the pledges of $25 million to develop 125 additional residency slots represents a more sensible and cost-effective strategy for responding to the projected physician shortages in Tarrant County. New residency slots could accommodate both MD and DO students in order to better serve patients. The local community should know that there is no requirement that allopathic (MD) residency programs be affiliated with an MD school and that there is no requirement that MD residency programs avoid being affiliated with an accredited DO school.

Several allopathic hospitals and institutions, including UTMB Galveston, John Peter Smith County Hospital, and Texas A&M Health Science Center, have sought accreditation by the American Osteopathic Association through the Texas OPTI (Osteopathic Postdoctoral Training Institutions) for their residency programs in order to better attract DO graduates.

Tayson DeLengocky is a vitreo-retinal surgeon who blogs at Eye Dr DeLengocky.

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