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November 30, 2015

Doc Migration: Many CT-minted physicians leave state

PHOTO | Pablo Robles UConn Health associate deans Dr. David Henderson and Dr. Jacqueline Nissen say physicians leaving Connecticut could become more of a problem as older doctors retire.

The medical schools at UConn Health and Yale will graduate upwards of 200 doctors this spring, but if previous experience is any indicator, well over half of them won't actually practice in Connecticut long term.

Measured several different ways, Connecticut remains in the bottom 12 states for retaining the doctors it trains, according to a recently released report from the Association of American Medical Colleges (AAMC).

No one dismisses the low ranking, but the extent to which it matters — and the factors that cause it — are the subject of some debate, medical school administrators say.

Several possible factors driving the low retention rate include: Yale's high proportion of out-of-state students; a lack of a state medical school debt forgiveness program, which exist in various forms in 38 other states; relatively high malpractice insurance costs; and the tendency of Connecticut medical-school graduates, who administrators say are competitive candidates, to gravitate toward major physician-residency programs in big cities outside of Connecticut.

For its population, however, Connecticut has no shortage of doctors or residencies overall, though administrators say certain specialties are rarer than others.

“You could make the argument that we actually have an adequate number of physicians. They're just skewed as far as discipline is concerned and with regards to geography,” said Dr. David Henderson, UConn's associate dean of medical student affairs.

If Connecticut is losing its doctors it begs the question: Why does the state have a high number of physicians?

One reason is that Connecticut has a large number of foreign medical school graduates practicing here, according to the AAMC data. For its population, Connecticut also has a high number of residencies, who are more likely to stay in the state than people who simply graduate from medical school here.

But an adequate doctor supply isn't guaranteed long term, especially when nearly a third of Connecticut physicians are 60 or older. AAMC projects a national shortage of as many as 90,000 doctors in 2025, as an aging population's demand for services outpaces supply.

Quinnipiac University's fledgling medical school, which will graduate its first class in 2017, could impact Connecticut retention rates in the future, though in what direction is unknown.

Henderson's colleague, Dr. Jacqueline Nissen, UConn's associate dean for graduate medical education and faculty affairs, said there are plenty of hunches about why retention is low. One of hers is that there simply may not be enough jobs for all of the doctors Connecticut graduates.

But she also thinks the state should fund a formal study on the matter, particularly as a potential wave of doctor retirements approaches.

“We've got to replace those people and we've got to have a plan,” she said.

Breaking down the numbers

AAMC's data reflect actively practicing doctors who graduated from UConn and Yale schools of medicine.

UConn and Yale graduates who don't go on to do their residencies or fellowships in Connecticut have the lowest chance (19 percent) of practicing in Connecticut.

That's a combined average, and it places Connecticut 41st in the country. On its own, UConn Medical School has a higher retention rate of 32 percent, which ranks 38th in the country among public medical schools.

Those who do residencies in Connecticut are more likely to stay here than those who just go to an in-state medical school.

About 38 percent of out-of-state med school grads who do their residencies at Connecticut hospitals, stay in the Nutmeg State. That retention rate ranks Connecticut 45th in the country.

And doctors who complete both medical school and their residencies in Connecticut have the best odds of sticking around — nearly 52 percent.

Dr. Bruce Koeppen, dean of Quinnipiac's Frank H. Netter School of Medicine, said it makes sense that residency location correlates strongly with retention.

“The reason for that is during their residency period they meet the local doctors, and they often get job offers,” Koeppen said.

Though more than half of states have some form of debt-forgiveness program for medical students, Connecticut does not.

Many states, including Massachusetts, Rhode Island, Vermont and Maine, partner with the National Health Service Corps, which offers loan forgiveness to primary care physicians who agree to practice in underserved geographies for a certain amount of time. The federal government requires states to match funds at least one-to-one.

The programs are no magic-retention bullet, according to data on states that offer them. Rhode Island and Vermont both rank below Connecticut in retaining doctors who complete medical school and residencies in the same state, according to AAMC.

But it's something. And it could help address the challenge of convincing new doctors to go into primary care, which generally pays worse than specialties.

“If you're graduating from medical school with $200,000 in debt, you might say 'maybe being a dermatologist is a better choice for me,' ” Koeppen said.

Koeppen, who previously worked at UConn for nearly three decades, has advocated for the creation of a state loan-forgiveness program, as has the Connecticut State Medical Society (CSMS).

Ken Ferrucci, CSMS' senior vice president of government affairs, said the society last lobbied for such a program several years ago, but the effort was unsuccessful.

“I think it's one of several factors [in low retention],” Ferrucci said.

He thinks a loan-forgiveness program could help fill-in some of the subspecialty shortages that exist in the state.

“We know from surveys we've done that wait times for specialty services and certain other services are just incredibly long. Try to find a child psychiatrist,” Ferrucci said.

Medical schools have begun to take matters into their own hands, though efforts have been modest.

Nissen and other UConn administrators, for example, are putting together plans to offer several programs aimed at increasing retention rates and the number of primary care doctors in the state.

One, which could launch by 2017, is a fast-track program that would allow certain students to graduate in three years instead of four, potentially saving them tens of thousands of dollars in loans. The tradeoff is that students in the program must do their residencies at UConn.

They're also working on a low-interest loan program for medical students who promise to practice primary care for up to three years. UConn hopes to make the 1-percent interest loans available to four students starting next year, Henderson said.

At Quinnipiac, the school has a primary care fellowship program that provides free tuition to one student in each class who pledges to go into primary care for 48 months in the six years following residency.

“If they do, all the money they didn't pay was a gift,” Koeppen said. “If they change their mind, then all of the money that was waived gets converted to a loan they have to give back to us.”

Yale did not respond to requests for comment for this story.

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