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UTHSCSA
DEAN’S MESSAGE
UT SCHOOL OF MEDICINE SAN ANTONIO:
TEXAS AND THE RESIDENCY SHORTAGE
By Francisco González-Scarano, MD
Insufficient Graduate Medical Education (GME) slots or intern- health care needs of the country, the Josiah Macy Jr. Foundation
ship and residency positions, is a major bottleneck in medical edu- asked the Institute of Medicine to conduct an independent review
cation and one of the more significant factors in our current and of GME and persuaded 12 other organizations to contribute to this
worsening physician shortage. Hundreds of physician graduates effort. The report was released in July 2014.
each year do not match into chosen specialties because of insuffi-
cient positions; some are unable to match at all. Texas has taken Key findings of the report were that there is:
many steps in the right direction, and is cited as a positive example • a mismatch between the health needs of the population and spe-
to other states, but more must be done on the national level.
cialty make-up of the physician workforce
The residency shortage was more acute in the 2016 match, which • persistent geographic maldistribution of physicians
had nearly 35,000 applicants for 27,000 first-year slots, including • insufficient diversity in the physician population
more than 12,700 international medical school graduates (IMGs.) • a gap between new physicians’ knowledge and skills and the com-
Of the 5,323 U.S. citizen IMGs—most of them graduates of
Caribbean medical schools—2,869 did not match to any position. petencies required for current medical practice
• a lack of fiscal transparency regarding Medicare/Medicaid fi-
I wrote about GME in November 2014, and specifically about
the release of the Institute of Medicine’s report and recommenda- nancing
tions for improving the nation’s GME funding system. I will repeat
that history of GME funding and the recommendations, which are These points, along with the funding cap, have led to the current
important in setting the stage of the current shortage. situation and the states taking a more active role each year in fund-
ing of GME.
The GME funding system now operative was spawned during of
the creation of the Medicare and Medicaid programs in 1965. As a Texas and GME Disparity
component of the Social Security Act, federal money has provided Medical residents tend to stay in the state where they complete
billions of dollars to fund GME, including residency and fellowship
programs for both osteopathic and allopathic medical education. their training. Fortunately, Texas has a strong retention rate, but
In fact, federal dollars contribute approximately $15 billion to sup- there is still a great disparity in funding or number of positions rel-
port residency training, with 90 percent—$10 billion and $4 billion ative to our population in comparison with other states. This is an
respectively—coming from Medicare and Medicaid. The Veterans important issue—residents/population figures represent the pipeline
Administration is another though much smaller source. This fund- of physician health care providers—and thus can be seen as an in-
ing for Graduate Medical Education is a trivial figure, about 0.5 dicator of future adequate numbers for the state.
percent of the country’s total health care bill of roughly $3 trillion.
One need only look at the state populations compared to the
In 1997, the “Balanced Budget Act” capped residency slots at the number of residents per capita (Figure 1.). The three largest states
FY 1996 levels, perhaps due to a perception that there was an excess —California, Texas and Florida – rank 31st, 22nd and 41st, respec-
number of physicians. This had the effect of also freezing geographic tively for number of GME residents per 100,000 people. Texas,
distribution (the Northeast has the largest concentration of training with 27 million people, ranks second in population and has 29
slots). In 1999, the cap for rural hospitals was increased by 130 per- medical residents per 100,000 people. New York, with 20 million
cent of their 1996 levels. The Affordable Care Act of 2012 created people, has 83 residents per 100,000, ranking it second in residents
a five-year, $230 million program to increase primary care GME, per capita.
and attempted to move some GME slots from hospitals with excess
capacity to those in need of more physicians in the area (more rural Texas ranks third in number of total residents, with 8,012, but
hospitals). that number is misleading when compared to Pennsylvania, which
has less than half our population (13M) and nearly the same num-
Because of concerns about the responsiveness of the system to the ber of residency slots, bringing their medical residents per 100,000
to 63, more than twice that of Texas. In the chart we include Cali-
36 San Antonio Medicine • June 2016
