Texas medical education’s sickening situation
State soon might not have enough residencies
Envelope in hand, Reginald Lloyd walked off the stage Friday morning and approached a map of the United States, where he placed a sticker on San Antonio.
Lloyd had just announced to a boisterous crowd gathered at John T. Floore Country Store in Helotes for national “Match Day” that he would be doing his residency training in psychiatry at the same place he had just finished medical school: UT Health San Antonio.
He will join 16 percent of the school’s 2019 graduating class to remain in San Antonio for the next step in their medical training.
Forty-two percent of the class is staying in Texas.
Training here was the first choice for Lloyd, 31, who wants to practice medicine in his hometown and in a specialty in high demand.
Not all Texas medical school graduates have the opportunity to remain in the state.
In recent years, residencies have become increasingly competitive in Texas, where a spate of new medical schools soon could produce more graduates than there are residency slots.
That mismatch could lead future doctors educated here to leave Texas — and not return — at the same time it faces a growing physician shortage.
Dr. Woodson Scott Jones, vice dean for graduate medical education at UT Health San Antonio’s Long School of Medicine, estimates medical graduates could surpass the number of residency slots by 2021 if no action is taken.
One hindrance is the high cost of residencies.
Each year, a portion of students who graduate from Texas medical schools will leave for competitive residency opportunities elsewhere in the United States, regardless of how many spots are available here.
On Friday, when graduating
medical students across the country found out their residency assignments, some UT Health San Antonio graduates were matched with prestigious sites across the country, including at the Minnesota-based Mayo Clinic and the Cleveland Clinic in Ohio.
But if too many leave, that would help feed the growing doctor shortage in Texas, which is particularly dire in primary care, psychiatry and general surgery, Jones said.
Because physicians tend to put down roots where they complete their medical training — Texas retains about 80 percent of the doctors who train here — the state essentially would be exporting future physicians, he said.
Growing medical schools but not residencies is “foolish,” Jones said. “It’s a very poor investment on the part of the state.”
Expanding graduate medical education is a nationwide concern, but it’s felt acutely in Texas. In the past decade, the state has heralded new medical schools in Austin, the Rio Grande Valley and San Antonio, where the University of the Incarnate Word recently opened a school of osteopathic medicine.
“You have a lot of qualified medical students who’ve gone through all of this time, who have accrued all of this debt, have all this knowledge and don’t have the ability to apply it because there’s not enough political will to actually create the residency spots needed,” said Lloyd, the newly minted graduate. “It really doesn’t make sense to have a lot of medical students without adequate spots for them to actually seek training.”
Additional schools have been approved at Sam Houston State University, the University of Houston and the University of North Texas Health Science Center, which last year pledged to create 500 new residencies.
Although UIW won’t graduate its first class until 2021, Thomas Mohr, the school’s associate dean for graduate medical education, said it has three active residency programs with San Antonio Community-Based Family Medicine, Laredo Internal Medicine and Laredo Family Medicine and will be unveiling a psychiatry residency this summer.
The programs, designed to target underserved populations, are being funded by a combination of money from the state, hospitals and philanthropy, he said.
As a private school, UIW is not required by the state to develop residencies, but “we feel it is an ethical imperative and a moral obligation,” he said.
Subsidizing
The largest residency program in the Alamo City is run by UT Health San Antonio, which currently has around 830 residents and fellows completing their medical training here.
The majority, 66 percent, train at University Hospital, while a quarter are assigned to the veterans health care system. The remainder train with the military or are scattered at other hospitals and practices throughout the city.
On Friday, UT Health matched with 178 residents through the National Resident Matching Program, 12 more than last year. The cost of eight of the additional slots will be covered by University, while four are being funded by the Texas Higher Education Coordinating Board, according to UT Health San Antonio.
A major source of money for medical residencies is a combination of federal and state dollars.
The Centers for Medicare and Medicaid Services funds graduate medical programs through reimbursements, but the number of residents it covers at teaching hospitals has been capped since 1997, the Association of American Medical Colleges says.
In Texas, the coordinating board also provides funding for first-year residencies and for the creation of new residency programs.
But the financial burden of training residents still can fall heavily on hospitals, said Dr. Robert Hromas, dean of the Long School in San Antonio.
Each of the school’s residents costs about $100,000 to train per year, a sum that includes a modest salary and administrative expenses. Because federal and state money doesn’t fully cover its residents, Hromas said, University allocates more than $20 million each year to fill the gap.
“If University Hospital hadn’t subsidized their residency program, San Antonio would be in trouble as far as getting physicians to practice here,” Hromas said.
‘Catch-up mode’
For specialities where physicians are in short supply, like psychiatry, residency programs can serve as a vital recruitment pool for hospitals.
Carol Carver, chief operating officer for Clarity Child Guidance Center, said the majority of doctors with its affiliated physicians group trained at the child psychiatric hospital through UT Health San Antonio’s residency program.
Baylor College of Medicine, which runs a small and relatively new pediatrics residency program at the Children’s Hospital of San Antonio, matched with 13 residents on Friday for its fifth class from a pool of 1,049 applicants. Five of the new residents are from Texas.
Dr. Mark Gilger, who recently became the residency director at the Children’s Hospital, said its program was started with the need for more graduate medical training in mind. After the hospital graduated its first class of 10 doctors last year, all but one went into practice in San Antonio, he said.
“In order to address it locally, you’ve got to train them locally,” Gilger said of the physician shortage.
UT Health San Antonio leaders are hopeful that the Legislature will allocate more money this session to medical residencies. Legislators appropriated $53 million in 2015 to the coordinating board’s Graduate Medical Education Expansion program and $97.1 million in 2017, the coordinating board says.
“We have seen in this sort of catch-up mode, the Legislature’s kind of catching us up where we need to be,” Jones said.