Medical Mission?

Are Texas medical schools missing a social conscience? Many fare poorly in a new national study that ranks medical schools based on their contributions to meeting the nation’s health care needs. Two in particular — University of Texas Southwestern Medical Center in Dallas and Texas A&M Health Science Center in College Station — rank near the bottom of the Annals of Internal Medicine report’s “social mission” scale, based on an analysis of graduates who practice primary care, work in medically underserved communities or are themselves minorities.

Some Texas schools are none too pleased with their social mission rankings, which they say were calculated so narrowly that the contributions of major state research centers were excluded. UT-Southwestern's medical school dean, Dr. Greg Fitz, acknowledged the importance of producing doctors that fit the needs of the community. But he said “social mission” should include preparing well-trained doctors and teachers for the future and developing new cures and treatments through research and discovery. “At UT-Southwestern, we take this more comprehensive approach to social mission seriously,” he said, “and are proud of our achievements in all of these areas.”

Advocates for expanding Texas’ primary care workforce counter that the study clearly affirms what they’ve been saying all along: The state’s medical schools aren’t doing enough to produce health care providers Texas needs. “It begs the question of what role and responsibility taxpayer-supported medical schools have to train and recruit the physicians Texas needs,” said Tom Banning, executive director of the Texas Academy of Family Physicians.

The researchers, financed by the nonprofit Josiah Macy, Jr. Foundation, reviewed the current professions, locations and ethnicities of roughly 60,000 practicing physicians who graduated from 141 U.S. medical schools between 1999 and 2001 and have completed their residencies and internships.

Despite Texas’ growing primary care shortage, only one state medical school — the North Texas College of Osteopathic Medicine — broke the list of the top 20 schools producing primary care physicians. UT-Southwestern ranked 123 out of 141. UT-Houston and Baylor University ranked only slightly better.

No Texas medical schools broke the top 90 universities producing doctors who work in so-called “health professional shortage areas,” or medically underserved communities — despite the fact that much of the state qualifies. UT-Southwestern had the third lowest rating; Texas A&M ranked 134 out of 141.

State medical schools ranked equally low in percentages of minority students. Minorities made up just 9.3 percent of UT-Southwestern’s student population, the 17th-lowest ranking. Texas A&M and Texas Tech weren’t far behind, with 10.6 percent and 11.6 percent, respectively — though the state population is about 45 percent minority. 

Based on these thresholds, no Texas medical schools made the study’s top 20 “social mission” list — but two were on the study’s worst 20 list. UT-Southwestern ranked second worst, after Vanderbilt University. Texas A&M ranked 17th from the bottom. 

UT-Southwestern's Fitz criticized the study for using data on students who graduated a decade ago. He said that from 2001 to 2009, the proportion of UT-Southwestern grads entering primary care fields rose from 27 percent to 42 percent. (The study’s authors said they used 1999 to 2001 graduates to ensure the students had made their way through residencies and internships, which can take years to complete.) Fitz also said that in the last three years, UT-Southwestern has tripled the number of African-American and Hispanic students admitted to its program. “While our increase in the number of underrepresented minority students is a very positive step, we are not satisfied and will continue to push for an even more diverse student population,” Fitz said.

Because of the study’s “narrow perspective,” schools like UT-Southwestern that put a premium on research grants were penalized, Fitz said. Some of the top-performing schools in the annual U.S. News and World Report ranking “fell into the bottom 20 ranking in this social mission study,” Fitz said. (UT-Southwestern ranks no. 20 on the U.S. News scale.)

Dr. Edward Sherwood, interim dean of medicine at Texas A&M Health Science Center, said his university takes issue with some of the findings of the study, including its calculation of minority students and graduates working in underserved communities. (Students on two A&M campuses work in clinics for uninsured Texans, Sherwood said, but those examples weren't included in the study.) But he said A&M’s medical school was founded with “social mission” at its core — and that the study still serves an important purpose. 

“We don’t want to nitpick about differences in the numbers,” Sherwood said. “The overarching purpose of the authors was to call attention to the social mission, which we agree to, and to say there is more we can and should be doing. It got our attention, and we will redouble our efforts in these arenas.”

The researchers acknowledge that universities that get a lot of grant money from the National Institutes of Health — which both UT-Southwestern and Texas A&M do — tended to fare poorly on the social mission score, largely because they are oriented more to research than practice.

But the study indicates being a large research institution may not be an excuse for poor performance on the social mission scale. The University of Minnesota; the University of Washington; the University of California, San Diego, and the University of Colorado all are in the top quarter of medical schools receiving NIH funding — and of medical schools that produce primary care physicians. The University of Washington and the University of Minnesota rank 30 and 34 on the study’s social mission scale, respectively.

The big question the study raises, Banning said, is whether the state should give the same level of financial backing to all Texas medical schools, when some contribute far more to the state’s primary care workforce: “What we need to ask is, should the state be supporting those schools that receive significant outside funding the same as the schools producing doctors who are going to go in and care for Texas patients?”