THE EVOLUTION OF PROGRAM IMPLEMENTATION AND FINANCING

The 1989 law mandated that third-year family practice clerkships be instituted starting with the 1990-1991 school year in each of the eight medical schools. As of late 1994:

1. All eight schools report compliance with the family practice clerkship requirement and all schools increased the number of primary care faculty; and

2. All schools report increasing student exposure to community-based primary care earlier in the curriculum, including offering preceptorship experiences in family practice for students after their first year. Each school relies on community physicians to supervise medical students in preceptorships and required or elective clerkships.

About 1,100 students annually spend one month in a rural clerkship. No additional funding was provided to the schools to implement this measure. Each school is directed to expend specific amounts from their state appropriations or institutional funds for these clerkships. For 1996-97, the legislature mandated a total of $7.3 million be spent on these clerkships across eight medical schools.

However, it is not clear whether the clerkship requirement is a significant influence on a student’s decision to go into family medicine. A 1993 report by the Office of the State Auditor of the family practice clerkship indicated it is too early to determine the effectiveness of the clerkship in increasing the number of family practice physicians.

The Family Practice Preceptorship Program (FPPP) was created by the legislature in 1983 to provide state funding to medical students at each of the eight Texas schools for an elective four-week opportunity to work at a primary care physician practice site. (Family practice preceptorships occurred prior to 1984 without state support.) The program is administered by THECB in conjunction with the Texas Academy of Family Physicians which assists in the recruitment of preceptors.

In 1994, 681 participating preceptors provided 265 pre-clinical experiences to students (usually between their first and second years) and 163 clinical experiences (usually during the fourth year of medical school, as a selective rotation). In 1985, 93 pre-clinical and 280 clinical students participated in the early stage of state funding. Pre-clinical students receive a $500 stipend; $600 is available for clinical students. Total state funding for the program has remained similar to or slightly higher than original appropriation levels.

Statewide support for internal medicine preceptorships was enacted into law for the first time in 1995. Prior to 1995, such programs were privately funded by the Texas Society of Internal Medicine (TSIM) and the Ledbetter Foundation. In 1992, TSIM began to self-fund a preceptorship program for pre-clinical medical students. Preference was given to students choosing to practice with general internists who practice in rural or medically underserved areas. With increases in private funding, the program has expanded from five participating students from one school in 1992 to over 40 students from three schools in 1995.

In 1977, the legislature first made state financial support available for postgraduate training in family medicine. House Bill 282 gives the Texas Family Practice Residency Program, administered by THECB, authority to allocate state funds to family practice residencies on a contract basis. The program initially in 1977/78 appropriated about $852,000 to twelve operating residencies to support 267 positions and to nine new programs for planning activity. By 1994/95, the state provided about $8 million to 23 programs sponsored by Texas medical schools supporting over 460 positions. Currently, there are 25 state-funded programs that support 698 positions. (Another six family practice residency programs and 100 positions do not currently receive state support.)

THECB requires all programs to have substantial sources of support from other entities, such as patient revenue, hospital and local funds, or medical schools; THECB funds are limited to no more than 35 percent of a program's total funding. THECB also is required by the 1977 law to provide for prior budget review and audits of all funded programs and to collect information from programs concerning the area distribution of family physicians and the improvement of medical care in underserved communities.

During the 1980s, the proportion of Texas medical school graduates choosing to go into family medicine started to decline (as elsewhere in the U.S.); the match rate for some family practice residencies was as low as 3 percent. In the late 1980s, a task force's recommendations that medical students receive greater exposure to family medicine and to practice in rural and underserved areas were incorporated into the Omnibus Health Care Rescue Act of 1989 (see above).

The rural rotation program, required by the 1989 law and begun in 1990, started with two family practice residents the first year, eight the second, and interest in this type of residency continues to increase. In 1996, 55 residents were expected to participate. Currently, family practice residents may select a supervisor from over 100 volunteer rural family physicians statewide. Upon completion of the rotation, residents receive $1,500 in state funds.

The impact of the rural rotation requirements has been beneficial -- both because rural practice was incorporated into the core curriculum for medical students and it was elevated to the level of an optional rotation in residency programs. Consequently, there are increased opportunities to expose more physicians in training to rural practice.

Currently, at least 20 percent of medical school graduates go into a rural county to practice. A retention study that was recently conducted found that as many as 66 percent of the graduates of state residency programs between 1972 and 1983 remained in the area where they completed their residencies. In general, nearly 90 percent of the over 2,000 family physicians trained in state-funded residencies have remained in the state to practice. Of those, 40 percent work in towns of 50,000 or less. Furthermore, family practice residencies in 1994 reported providing over $60 million in direct patient care service, $25 million of which was uncompensated care.

Yet, particular regions of the state remain in special need of family physicians. A 1989 report recommended that Texas' medical schools develop or expand family practice residencies along the Texas/Mexico border "as their top priority". Resulting in part from the 1995 appropriations bill, the state's medical schools and community hospitals are in various stages of expanding or creating seven family practice residency programs in medically underserved areas of the state.

Several states are increasingly mandating their publicly funded medical schools to establish required or elective community-based clerkships, rural rotations and other clinical training arrangements for generalist-minded medical students and residents. In 1995-1996, there remained at least 36 medical schools that did not require family medicine clerkships in the critical third year.