Nashville Hospitals, Colleges Partner to Address Physician Shortage
Combating a nationwide physician shortage is no small feat, but it's one Nashville hospitals and medical colleges are tackling hands-on through a growing number of Graduate Medical Education programs and partnerships.
"It's really about workforce development and making sure we have physicians to take care of patients," said Cathryn Rolfe, JD, vice president and COO of Graduate Medical Education for HCA Healthcare. "For the average person, the physician shortage may not be as evident as the need for nurses, but it's what prompted HCA Healthcare to strongly invest in graduate medical education."
A report from the Association of American Medical Colleges projects the U.S. will face a shortage of between 54,100 and 139,000 physicians by 2033, due to a surge in both older patients requiring more care and retiring providers. However, a daunting roadblock to GME programs nationwide is a federally mandated cap on GME slots available to residents.
"People think physician shortage is about the number of students accepted to medical school or the number of medical schools, but it's about residency programs," Rolfe said. "How the country went from too many to not enough can be a bit confusing. When Medicare was established under the Social Security Act of 1965, funding of residency positions through Graduate Medical Education was included. As persons over 65 were going to have expanded access to healthcare, Congress realized it must have enough physicians to meet this increase in demand. Hospitals who'd been training residents for decades were now getting federal funding and residency slots increased, which tended to be in academic medical centers.
"Programs and training spots for residents grew basically unrestricted for over 30 years and sufficient numbers of physicians were being trained. The 1997 Balanced Budget Act changed all of that when it capped the number of new residency slots Medicare would fund so new program creation stalled. The only new Medicare-funded residency programs being built were in hospital's that never had a residency program and were not capped. Even with CMS funding, hospitals starting GME had to make sufficient capital investments to open new programs thus supply started to lag behind demand."
Navigating the Cap
For most hospitals, Medicare caps the number of residents it will fund per hospital based on how many residents it funded in 1996. It also gives hospitals starting their first new GME programs five years to establish and grow programs before caps are set. Once set, hospitals' resident caps are generally permanent. However, stats show 70 percent of hospitals train more residents than Medicare funds -- indicating they can train more physicians now than when these caps were set.
"It's not that there are fewer places, but places that do facilitate GME have limitations on growth based on financial restrictions from CMS," said Tristin Casteel, director of Medical Education at Ascension Saint Thomas. "We can add more trainees, but it's 100 percent at our expense with no offset from CMS. That makes it challenging to grow training programs, but we realize it's necessary to support not just Tennesseans but citizens around the country. The investment is worth it, even without reimbursement."
Residencies by the Numbers
Nationally, Ascension welcomes 2,700 residents and fellows in 154 accredited programs and 66 specialties and sub-specialties. In Nashville, Ascension trains 108 residents and three fellows in nine programs including primary care and advanced general dentistry, a program that started in 2018. Their new cardiac fellowship, to launch in 2022, will accept three fellows annually, and leaders are looking for ways to create more opportunities at Ascension Saint Thomas Rutherford.
"We've been trying to be strategic about how to utilize the cap we have," Casteel said. "We're looking at the need for physicians in the communities we serve to determine what type of investment we make and focusing on a strategic approach to building relationships with residents early during the course of training."
As an academic medical center, Vanderbilt provides training to more than 1,100 trainees annually in 100 programs. "We're in the unique position of providing clinical, research and educational missions on one campus," said Kyla Terhune, MD, MBA, associate dean for Graduate Medical Education and vice president for Educational Affairs. "There is always a balance of missions, and each of those missions feed one another. There certainly is an advantage of continuing to invest in training programs, because we can't have a future clinical mission without producing competent physicians from our training programs. Part of it is thinking about current patient needs and growth needs and how training programs can help support other arms in our mission."
Rolfe said the gap between applicants and available positions keeps growing, and HCA is addressing workforce shortage by building residency programs in locations that make sense for HCA. Nationally, the system offers 5,000 GME spots in 61 of their 185 hospitals, with plans to expand to 7,000 residents in 345 programs at 74 hospitals by 2025.
In July, TriStar Health welcomed their first GME class with 10 residents in internal medicine and eight in psychiatry at Centennial Medical Center and a class of eight residents in family medicine at TriStar Southern Hills. Rolfe said locally, they plan to grow to 400 residency spots in Nashville in the next five years - a promising goal considering the organization's growing number of agreements with local colleges.
In 2018, HCA announced a partnership with Meharry Medical College, offering GME opportunities at TriStar Southern Hills Medical Center. Meharry has eight other fully accredited Accreditation Council for Graduate Medical Education (ACGME) residency programs within the School of Medicine and the School of Dentistry. Students also gain inpatient and outpatient experience at Nashville General Hospital at Meharry and the Department of Veteran Administration Tennessee Valley Healthcare System, Alvin C. York Campus in Murfreesboro.
In 2020, HCA also announced a partnership with the new College of Medicine at Belmont University. According to a school-issued release, plans for the new Thomas F. Frist Jr. College of Medicine at Belmont University are taking shape after the university announced a name, location and founding dean for the school, with plans to break ground on the Wedgewood Avenue site by the end of 2021.
TriStar Health will provide residents with clinical experience and elective rotations during their third and fourth years of medical school. Belmont is now pursuing accreditation from the Liaison Committee on Medical Education, which grants colleges the ability to offer medical degrees. Approval would make the Thomas F. Frist Jr. College of Medicine the fifth accredited medical college in Tennessee.
"It's exciting to be a part of a medical school, and there's a lot of energy and enthusiasm here," said Reuben A. Bueno, Jr., MD, associate dean for clinical education and professor of surgery at the Thomas F. Frist, Jr. College of Medicine. "The goals of the medical school will be in alignment with goals, missions and vision of Belmont University, and we're developing relationships so that students and faculty can serve the local community."
Serving Rural Communities
Addressing rural healthcare is another challenge for Tennessee's GME programs, but it's one lawmakers are taking seriously. Approved May 2021, Senate Bill 298 provides an increase of $5.5 million to fund residencies in Tennessee's rural communities by establishing opportunities in family practice, general pediatrics, internal medicine and psychiatry. Residencies will be open to all graduates of University of Tennessee schools, Meharry Medical College and Vanderbilt University. Since 60 to 70 percent of doctors stay in the communities where they train, lawmakers hope to offset Tennessee's current workforce projection, which shows a shortage of 1,050 physicians by 2025.
Through its partnership with the University of Tennessee Health Science Center, Ascension also has made it a priority to address needs in rural areas. "We know that when residents train in urban environments, there is a high likelihood that they'll stay there. If we infuse training programs in rural areas, we believe that same methodology will translate," Casteel said. "Residents see the impact they have and the need that exists, and we want to recruit them to stay."
The Rural Pathways Program offered through East Tennessee State University's Quillen College of Medicine also focuses on producing graduates who will practice in underserved and rural communities. "The state is looking to try to improve on disparity that exists for rural residents," said Geoffrey Smallwood, MD, chief academic officer at Ascension Saint Thomas. "If steps already in place are coupled with Medicaid expansion, that's a big lever and would give all Tennesseans the best chance to have a safe, meaningful level of healthcare."
Terhune said residents tend to be devoted to and return to communities where they're from, and Vanderbilt relies on that fact to encourage careers in rural areas. "One strategy is looking at those who've grown up in rural communities and encouraging them to contribute to those areas again," Terhune said. "Part of training a diverse group of trainees with diverse interests is recognizing and encouraging those who want to work in rural areas."
Focus on Diversity
Training residents from increasingly diverse backgrounds is critical for all Nashville GME programs.
"We work to recruit a diverse group of residents and fellows every year," Terhune said. "Our trainees are future physicians, so we're making sure we have a pipeline to ensure physicians are able to reflect, understand and serve our population for years to come."
Rolfe agreed, noting the definition of "diversity" can vary by program and hospital. "The ACGME has been concerned about demographic diversity in residency and fellowship programs by specialty for some time and recognizes that the definition of 'minority' may change by specialty and geography," Rolfe said, noting that hospitals in El Paso or Miami might be underrepresented by Caucasian residents, and that males are predicted to represent only one-third of OB-GYN residents by the year 2028. "You recruit the best students you can to care for the patient populations you serve and mitigate healthcare disparities. Your patient population is best served by people who understand their circumstances of health."
Casteel said today's awareness of and need for diversity in both resident selection and training is reflected in Ascension's ABIDE program, dedicated to equality and inclusion. "This allows residents to have meaningful conversations about creating tangible steps to address patient needs," she said. "If we can create opportunities in Ascension to integrate GME work around diversity, the larger conversations will be invaluable." The evolution and challenges of GME programs in 2021 are undoubtedly unique, but today's residents are stepping up to lead and learn as they transform into the physician leaders of tomorrow.