Christus Spohn's Battle to Save Lives and Residency Programs

This discussion was recorded on January 9, 2024. This transcript has been edited for clarity.

Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Today, we'll be discussing a story that made national headlines in October 2023: the proposed closure of the Christus Spohn emergency medicine residency program affiliated with Texas A&M University that was planned for 2026, and the recent grassroots and administrative actions that were taken to avert this closure.

Joining me today is Dr Alainya V. Tomanec, program director of the emergency medicine residency at Christus Spohn, along with Dr John D. (JD) Cambron, associate program director of emergency medicine residency at Christus Spohn. I want to welcome both of you to our broadcast.

Alainya V. Tomanec, MD: Thanks for having us.

John D. Cambron, DO: Yes. Thank you for having us.

Navigating Challenges Amid the Residency Closure Threat

Glatter: Dr Tomanec, I want to begin with you. Can you set the stage for the main reasons you believe that hospital leadership planned to close the emergency medicine residency in 2026?

Tomanec: The main reason that they gave us when we asked that same question ourselves was that Christus is a very large corporation. They're continually reviewing their funding allocation and determined that the funding allocation was more strategically used for a focus on primary care due to the need for primary care expansion in the community. The resources were limited, and that was the best plan at that time when they were evaluating how to allocate that funding. It was seen that the phase out was the best way to provide reutilization of that funding but also to continue and finish out training of the residents that were already here.

Glatter: This news hit at a very difficult time, obviously, during interview season in early October. JD, I'll let you kind of talk about that a little bit. I'm curious how you rebounded from that.

Cambron: Yes. We had a single interview day, and we were very excited about our number of applicants to that point. The timing was somewhat unfortunate, given we had to halt our current interview season a day or 2 before we were scheduled to have our next interview day. That really, throughout the process, helped us talk to our community leaders about putting the pedal to the metal about why we needed to get this decision reversed acutely and that it couldn't be a slow-drag process because we needed to resume our interview process immediately if we were going to have a chance to successfully match our upcoming class.

I have to thank and really applaud our community supporters and leaders for recognizing how significant that was and accelerating this timeline of reversal because we have jumped right back into interview season. I really feel like we did not miss a step. Our residents and our faculty group are unified beyond belief. Because of that, we've had a large amount of participation in our interview days, and we've been interviewing very well I believe. We've had good interview numbers, good applicant numbers, and we're looking forward to March.

Glatter: Dr Tomanec, I'm curious, in terms of the residents themselves, do most of the residents who train at Spohn stay in the area?

Tomanec: In fact, a majority of our faculty are actually previous graduates of this program. I'm a graduate of this program. I graduated in 2014. Many of our residents stay on not only as faculty, but work in the community, work in the region, and then also work in the rural facilities in our hospitals and some with our freestanding emergency rooms (ERs) here in town. It's a little bit hard to track because, you know, in emergency medicine there are many different employment models. Over 50% of our graduates have stayed and worked in the Coastal Bend, so it was very important to us to bring that to light and show the community that we do keep people that we train here, we're serving the community, and we're here for them. That's why we exist.

That was part of the reason why we were able to gather such support from everybody in the political advocacy world, our physician groups around town, and just the community members, too, because they see that we do stay. Many of our local physician leaders and medical directors at most of the hospitals in town and the ERs are graduates of the program. That was important to them as well to keep that here because they want to have doctors to continue to staff their ERs as well.

Physician Shortages and the Residency Training Dilemma

Glatter: Right. That's very critical, especially because you're a Level II trauma center. Your volume size, I believe, is 135,000, and you're providing an incredibly important service to the community.

It leads me to the next topic about the attrition of emergency physicians vs the oversupply that's all been the subject of a workforce study in 2021 by the American College of Emergency Physicians (ACEP) that — assuming roughly a 3% attrition — looked at there being roughly 7800 physicians in oversupply. Another study by Cameron Gettel, MD, MHS, looked at this issue, which — assuming a 5% rate of attrition — resulted in a surplus of only several thousand physicians instead of 7800.

Ultimately, this also ties in with the lack of graduate medical education (GME) funding in terms of residency positions and how this antiquated system from 1996 really is a barrier to acquiring spots that are needed for training. There's this delicate balance: How many physicians do we train? Certainly, for the rural communities, this is very integral. I'd love to know your position about your area, your local Coastal Bend community, and how this is affected by these workforce projections.

Tomanec: Historically, it's difficult to recruit to the Coastal Bend. Our local medical society, Nueces County Medical Society, just very timely did a survey of the physicians in the region and found that 75% of them are trying to recruit unsuccessfully for a variety of specialty practices. Over 40% of our physician workforce have plans to potentially retire in the next 5 years.

That directly goes against what some of these workforce projections show. The timing of those studies — being around COVID and bringing to light the working environments of physicians, the lack of collaboration among administration and physicians, and the mismatch of medical student graduates and training spots — was very unfortunate and impacted the decisions of medical students who were the least informed about actual workforce needs.

The truth is that none of these studies ever applied to the Coastal Bend region. We are underserved from a physician standpoint, primary care all the way up to most of the subspecialties, and we will continue to be underserved and have high recruiting and physician needs here. None of those studies ever applied.

I do think that it's really important to bring to light that the need is far greater than what has been publicized. That's not just within emergency medicine but will also be in our field because of our earlier attrition.

Glatter: Your program was not the only program threatened. There's been over 20 programs that have closed in the past year, I believe. This includes a neurology residency throughout the country and other subspecialties. This is a real issue. Looking at the match results in 2020, there were 19 unfilled emergency medicine spots, 219 in 2022, and then 555 in 2023. That trend upward obviously concerned everyone.

I think the data are a little bit skewed in my opinion in terms of what we're seeing. This mismatch might be an overcorrection, possibly, for what the circumstances are in terms of the needs. Physician hiring compared with new advanced practice provider (APP) hiring is declining in rural communities. The question is how we can balance and train appropriate numbers of emergency physicians alongside APPs in rural communities.

Cambron: That's a complicated one to address. I agree that much of that starts with the antiquated federal GME funding system that has been in place since 1996. Our spots have been capped since then, yet our medical schools continue to expand, grow, open. We're matriculating many more medical students, yet our PGY1 spots remain nearly the same.

We're kind of running into a bottleneck where I believe that an overhaul of either the federal GME funding spots or more medical school placements and funding in these rural areas is necessary. People tend to stay where they train, right? If you train an individual in a rural community, they're much more likely to stay in that area. I think that the focus in the future needs to be on training individuals in these rural underserved communities. It's just hard to do without adequate funding of course.

Addressing GME Funding Challenges and Corporate Influence on Training

Glatter: The question is, how do we uncouple the GME process that ties federal funding to these spots? Legislatively, it is going to be a challenge, but I think it's a work in progress. The problem is that private equity certainly has swooped in. Corporate ownership of residencies has been growing, as you know, and is a problem. It threatens the traditional training of emergency medicine, and the conflict of interest when these other entities exist is something that certainly is on everyone's mind.

Tomanec: A couple of things about the rural expansion and the APP collaboration. I'm a very strong supporter of a collaborative model that's physician led. We work very closely in our region with our nurse practitioners and physician assistants and have a great model that is physician-led.

The important thing to mention is that we need to train board-certified physicians so we can staff all of our ERs with board-certified positions everywhere, not just in our major cities but in our rural hospitals, so that we can have that physician-led collaboration that's the same level and standard of care no matter what ER you present to. The only way to do that is to train emergency physicians who will stay and work in the rural ERs. Like JD said, the place and the way to do that is to train them where they might stay.

That's, again, part of the reason why we were so convicted to fight for this program because of the location and the need. Many of us are from the region and have seen the need and the change of the increase of board-certified physicians in not only our city emergency rooms, which wasn't the case before this program started, but also has expanded now to the rural facilities around the region as well as around the Coastal Bend.

The GME funding is a very complicated issue. The infusion of private equity money was an inevitable one. It had to happen because there was no other money to be had. We need to train residents. Hospital systems and institutions realize the value of having residents training in their hospitals from a clinical service standpoint, which is why they're willing to foot the bill. What we have to be careful of is quality. We want quality and we want board-certified physicians to be trained, graduate, and work everywhere and have an equal distribution.

We also need oversight from our governing bodies within GME to make sure that these programs are providing high-quality education. If the funding sources are going to switch and we're opening new programs, we have to make sure that the high-quality education is monitored as well.

One thing that concerns me is that if we do shift and aren't able to overhaul governmental funding for graduate medical education, and it does shift to private equity, how are we going to ensure that that's an equal distribution of physician needs within the physician world?

How are we going to say, you can only open three emergency medicine programs because that's a fairly profitable emergency residency program for your hospital to have. We also need primary care. We also need this specialty. Maybe that's not as financially rewarding to the hospital to open that residency program. We're going to further increase our mismatch of physician shortages if that's one of the ways that we go. We'll have to address that as well if we can't overcome the governmental funding issue.

Glatter: When your program was founded, it was 2007, I believe there were three emergency medicine residencies in the state of Texas. Now, there are 18 or 19. Certainly, the hospital looked at that thinking that there's an oversupply, and that maybe this is time to cut back.

That decision from a financial standpoint has such repercussions in the care of the community, where people can't get an appointment maybe for a month or 2, and they have an acute issue. Obviously, they're going to come to the emergency department where they can get care that they need.

Cambron: This goes back to the crux of some of the inaccuracies of the original oversupply study and how you can't just generalize it to all regions of the country. Although our program opened when there were only three total programs in the state of Texas, and now that there are 18, we're still an extremely underserved community from an emergency medicine residency training standpoint.

If you're practicing in our community and you're a board-certified emergency physician, it's overwhelmingly likely that you trained at our program and that you didn't come from those other programs within the state or elsewhere. If you're working here in this general area, it's usually because you trained here. If you remove the program from this area, you're going to have a huge undersupply of emergency medicine–trained physicians.

Fostering Unity and Community Support

Glatter: Until 2029, there's a guarantee that you will have 12 residents per class to train? Is that set in the agreement? Are there any other aspects of the agreement you could discuss?

Tomanec: The agreement is between the Nueces County Hospital District and Christus Spohn. There's a preexisting partnership that exists there that is related to the serving of the patient population that's under the Nueces County Hospital District. This is an expansion of that partnership. The funding is over a 6-year time period of a designated particular amount of funding per year that is staggered funding. The matching of the residences is really up to the program. That funding is contingent upon matching a full class and would be reduced if we didn't match a full class.

Glatter: Based on the press that you received nationally, I think you'll have quite a number of people interested in moving to the Coastal Bend community. What are other aspects that you do to draw in residents to your program?

Tomanec: The biggest benefit of our program is the people and the group of people that we work with (our faculty, our residents, and the community here), which is why it's such an amazing case study to have the people that make us stay here are the people that kept us here.

One of the benefits of being in a smaller setting is that it was truly humbling and invigorating at the same time, to have everybody that you've interacted with step up in your support and allowed us as a group of physicians to advocate and say, look, these are the things that we think are important. This is what other people think are important, is important about having us here, and be able as a physician group, as a unified group, to take that to our hospital administration and say, look, we asked you to reconsider. We are presenting you with these things and then actually listen and now be working with us to see what we were pointing out that maybe wasn't as transparently obvious as benefit that we offer, has been really the most important thing.

A lesson that everybody should try and take from this is that we, as physicians, have to do a better job about demonstrating our value beyond the financial benefit. We are very motivated people. If we work together and advocate for what is important, rather than being overwhelmingly burdened by all of the aspects of healthcare that none of us like and that is more difficult for us to change, maybe we can continue to make small steps and make our practice environments more pleasant. That will make those other things a little bit easier to tolerate.

That is what keeps people coming to Corpus Christi. We advocate for one another. It's an educational environment. We are always looking to improve ourselves and share education with other people in the hospital, not only other physicians but also nurses and staff, and train up the people that we work with, which is how it continues to build people to train and then come back and work.

Glatter: It speaks to the value of grassroots organizing. Online, I found many people posting on Change.org, and was able to view many responses from the community — close to 4000 — who spoke out quite vocally about the value of your training program.

It shows the collective power of physicians and community members getting together and talking logically and logistically about the value of investing in emergency medicine and beyond that, in primary care, as we've discussed.

Cambron: Our group has a very cohesive and unified vision, and we all really do get along with each other very well. I was unaware of the community support from our physicians in the community until we went through this process.

We attended a Nueces County Medical Society meeting where we interacted with specialists and primary care physicians of all different specialties who were unbelievably supportive and told stories of the community in the rural community and the change that has occurred since 2007 to today within all of their specialties, whether that be pediatrics, trauma, psychiatry, cardiology, and the impact that having the truly emergency-trained physicians in their communities has had and how appreciative they are. Without that, and those stories infiltrating the nonmedical community, I really don't know whether this would have gained the traction and the legs it needed to be reversed.

Final Thoughts

Glatter: Do you have any additional thoughts that either of you would like to add?

Tomanec: It really helped to increase the lines of communication and have them have more of a partnership with us, like, how can you help us and how can we help you? Maybe that's something that we overlook in GME because we're very focused on education, but we also need to learn and teach our residents that, yes, there still is business of healthcare. To not ever broach that subject is probably a disservice to them.

There's a very renewed support from the administration here at Spohn, and we are using that to help our applicants feel comfortable with us and interviewing here. One thing I want to make sure is communicated is the stability of the program and that our applicants are coming to a safe program that's sustainable, and that we're going to be able to train them fully and have the same amount of resources, if not more, than we did prior to this happening.

Cambron: I think it's also important for your GME staff and your core faculty to make sure they do what they can to have a seat at the table. For various hospital committees (your critical care committees, your cardiology committees, your med exec staffs), you really should have a seat at the table, speaking from an emergency medicine residency, but all residencies, so that you can communicate clearly with all staff, you can be in the know going forward, and your voice can be heard. That aspect of hospital management administration is awakened in us now. We definitely want to make sure our core faculty and staff are present on those committees going forward because we think it'll help the hospital function better.

Glatter: Lately, I would say in the past decade, many emergency positions are now occupied positions in administration: chief medical officer, even CEO of healthcare systems. The type of training we do allows us to be in a position enabling the understanding of the healthcare system because of the breadth of whom we treat.

Tomanec: I agree that we're probably the best suited to understand all the aspects: the quality, the value, the value of throughput, the consultant interactions, and the value of the community relationships for referrals into the ERs. As an ER physician, you really are one of the best suited to sit in those management positions and have insight to appropriately enact change.

We really do have to make sure that we continue to thank all of our supporters. Our county judge and county commissioners were pivotal, in addition to Texas Medical Association (TMA), Texas College of Emergency Physicians (TCEM), and our local medical societies.

I just had a meeting this morning. It was a healthcare advocacy task force that's comprised of members from the hospital district board, myself and Dr John Herrick, one of my other associate program directors, county commissioners, and some community advocates just to continue focusing on different healthcare issues that arise. This is maybe something that other communities need if they don't have it. It's turned out to be a very effective outlet.

Glatter: Absolutely. There was an important op-ed written in your local newspaper by Dr Reuben Pedraza, president of the Nueces County Medical Society, and Dr Rick Snyder II, president of the Texas Medical Association, that truly encompassed and embraced all of the principles we've discussed. I think such outreach and communication with the community is so vital.

Also, I'd like to mention that Texas ACEP and ACEP in general advocated on your behalf. I know you appreciated the support in that capacity. I agree that was quite helpful.

Cambron: It sure was. Not only through written form, but they were present in person at county commissioner meetings advocating for us at the stand. They were fantastic.

Glatter: That's great to hear. That's why we invest in our organizations. That's the power collectively of people and also of the ability to manage crises that arise like this.

Tomanec: It really was an invigoration of knowledge and how we all need to be more active in our political organizations. It's really easy to say somebody else is doing it, but the support that they offered was invaluable and really inspired us to pay it forward. We all have to do it. It can't just be the 15 of us here. Everybody has to try and realize the benefit and offer something to make bigger things happen. We're very excited to try and champion that.

It really does help to demonstrate the value of building relationships and providing good patient care, because in the end, the patients are the ones that are going to support us as well.

Cambron: I want to say again, I cannot thank our supporters enough for having our back and getting us through this, and we cannot wait to pay it back.

Glatter: Thank you again and I really appreciate your time. Best of luck.

Robert D. Glatter, MD, is an assistant professor of emergency medicine at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is a medical advisor for Medscape and hosts the Hot Topics in EM series.

Alainya V. Tomanec, MD, is program director, chairperson, and associate medical director of the CHRISTUS Spohn-Shoreline Hospital Emergency Department in Corpus Christi, Texas.

John D. Cambron, DO, is an assistant professor of emergency medicine at Texas A&M University School of Medicine and associate program director at Christus Spohn Shoreline Emergency Department in Corpus Christi, Texas.

Medscape Emergency Medicine © 2024  WebMD, LLC

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

Cite this: Robert D. Glatter, Alainya V. Tomanec, John D. Cambron. Christus Spohn's Battle to Save Lives and Residency Programs - Medscape - Feb 09, 2024.