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Saturday, September 29th 2012

How Many Medical Schools Does Texas Need?

The state of Texas is very close to opening two new free standing medical schools. One in the Rio Grande Valley and one in Austin. While still hurdles to jump through for these two new schools they look to be part of Texas’ relatively rapid expansion in undergraduate medical education capacity. In the past two decades Texas has seen both new schools and an aggressive expansion of the capacity of its current schools. But such is of questionable necessity. Below is data from 2006 U.S. Census Bureau estimates of state populations and 2006 AAMC medical school enrollment numbers for public medical schools.

State 2006 Public Medical School Enrollment 2006 Estimated Population Public Medical School Seats Per 10000 Population
Alabama 971 4599030 2.11
Arkansas 605 2810872 2.15
Arizona 492 6166318 0.79
California 2899 35457549 0.79
Colorado 611 4753377 1.28
Connecticut 346 3504809 0.98
Florida 1283 18089888 0.71
Georgia 749 9363941 0.8
Hawaii 255 1285498 1.98
Iowa 630 2982085 2.11
Illinois 1722 12831970 1.34
Indiana 1164 6313520 1.84
Kansas 703 2764075 2.54
Kentucky 1026 4206074 2.44
Louisiana 1122 4287768 2.61
Massachusetts 450 6437193 0.7
Maryland 650 5615727 1.15
Michigan 2363 10095643 2.34
Minnesota 924 5167101 1.79
Missouri 767 5842713 1.31
Mississippi 427 2910540 1.47
North Carolina 1024 8856505 1.15
North Dakota 246 635867 3.87
Nebraska 491 1768331 2.78
New Jersey 1402 8724560 1.6
New Mexico 329 1954599 1.68
Nevada 218 2495529 0.87
New York 2480 19306183 1.28
Ohio 3908 11478006 3.4
Oklahoma 617 3579212 1.72
Oregon 516 3700758 1.39
Pennsylvania 1236 12440621 0.99
South Carolina 931 4321429 2.15
South Dakota 207 781919 2.64
Tennessee 861 6038803 1.42
Texas 5243 23507783 2.23
Utah 429 2550063 1.68
Virginia 1803 7642884 2.35
Vermont 426 1945482 2.2
Washington 805 9047320 0.89
Wisconsin 664 5556506 1.19
West Virginia 663 1818470 3.64

Texas public medical school numbers include Baylor College of Medicine which recieves some public funding in return for giving preference to Texas residents.
Washington’s population includes Alaska, Idaho, Montana and Wyoming. Residents of those states receive preferential admission to the University of Washington School of Medicine.
Vermont’s population includes Maine. Residents of that state receive preferential admission to the University of Vermont.

While Texas does not top the list in per capita public medical school seats it isn’t far behind.

    States With Most Per Capita Medical School Seats
    1. North Dakota
    2. West Virginia
    3. Ohio
    4. Nebraska
    5. South Dakota
    6. Louisiana
    7. Kentucky
    8. Virginia
    9. Michigan
    10. Texas

It is slightly disingenuous to compare a state like Texas with smaller states on the list above including Nebraska, South Dakota, North Dakota and West Virginia. There are considerable relatively flat infrastructure costs to running an institution like a medical school. If those states with small populations are going to make a commitment to public undergraduate medical education it is nothing to say they’re going to enroll 200 students instead of 30, and so of course their per capita rates will be higher. In light of that Texas’ per capita numbers are even more favorable.

Texas has the most public medical school students in the country and, perhaps more importantly, the most public medical school campuses in the country. While I don’t have the data, with so many freestanding health science campuses and so many medical students it would not surprise me if Texas already spent more on public undergraduate medical education than any state in the union. And while Texas population continues to grow so has the number of medical students enrolling in the state with every medical school increasing its class size since 2006 and a new medical campus opening in El Paso since the data above.

In 2011 the growth in medical school enrollment in Texas had more than kept up with Texas’ impressive population growth and left the state with 2.36 medical school seats per 10000 population. The new slots in the Rio Grande Valley and Austin promise to continue that trend and boost Texas’ per capita numbers higher. I would argue that while we need to prepare our undergraduate medical education capacity to keep pace with our growing population, that the number of current graduates, even for the foreseeable future, is completely adequate for the health care needs of Texas.

The more substantial problem may be in training these medical students after they graduate. The 2010 medical school graduating class in Texas had 1404 medical students competing for 1390 first year resident positions. Nearly half of Texas medical school graduates, their education subsidized considerably with Texas tax payer dollars, leave the state for residency and are unlikely to return. Texas’ contribution to graduate medical education is abysmal as compared to many other states. From the Houston Chronicle article linked to above,

[T]he state’s coffers are a relatively small part of funding — $79 million was allotted last session. The lion’s share comes from Medicare, which is, if anything, in potentially worse shape than Texas.

Unlike many states the medicaid program provides no direct graduate medical education funding in Texas.

There are many arguable benefits of medical campuses. They bring a likely economic benefit to the local economy and they promote prestige and contribute to the local academic community. They also likely help promote community health. But their primary mission, indisputably, is education and undergraduate medical education is not something we need more of in Texas. The press for these medical schools represents local politics and activity within the university system they are poised to be a part of; egos from Austin and the Rio Grande Valley looking at these campuses as a matter of benefit for their local communities.

[T]o hear [state Senator Kirk Watson] speak these days, nothing is more important — and, perhaps, more career-defining — than establishing a medical school at the University of Texas, as well as a new teaching hospital, comprehensive cancer-care center and other elements of what supporters call “Watson’s 10 in 10” — 10 health care goals to achieve in 10 years.

“We have so many good people ready to do it that success is immensely possible, and to not do it and not get started on the path would be extraordinarily regrettable,” Watson said last fall. “This is big. It’s going to be hard. But it needs to be done.”

Some of the costs of these academic healthcare endeavors will be borne by these communities – Travis county’s health district is asking voters in November for a property tax increase – but plenty of money will come from state general revenue afforded to the university systems. That is money from tax payers across the state who are likely to see no to nominal benefit from these new schools.

New medical schools in Texas are unlikely to improve our statewide physician shortage and may even do little to correct disparities in the communities they’re joining. We’re already graduating enough medical students and in a strong position to continue to do so for our growing population without new medical campuses. The schools will bring new graduate medical education funding, in the form of new Medicare dollars but such will not keep pace with the new medical school graduates they promise. The costs of these new medical schools would be much better put towards improving graduate medical education in the state. That is something that would truly improve Texas’ doctor shortage and potentially the public’s health.