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of Family Practitioners, TMA, THA, Texas Osteopathic Medical Association, directors of family practice programs, and three members of the public. Because of the expertise of the committee, incipient programs will be able to develop more tenable training plans and have access to assistance for developing programs. The Coordinating Board will rely on the recommendations of the committee but will make all decisions itself and be responsible for final screening and awarding of contracts. Lyndon Olson Jr., state representative, P.O. Box 2910, Austin. Medical education I read with interest the article on rural medical education \(Obs., wholeheartedly concur with your observations. As one with an interest in health economics and as a member of the Brackenridge Hospital Board, I would like to share with you additional information on the impact of HB 282. The bill is apparently an attempt to head off state reliance on federal aid for primary-care residency programs which will require “indentured servitude” in underserved areas of doctors benefiting from those programs. The Olson bill is based on the recommendations of the Joint Advisory Committee on Government Operations, the so-called “Little Hoover Commission,” which did its work over the last legislative interim. The committee recommended that the state create 300 new family practice residency programs, but that the state’s funding be limited to one-half the cost of each residency position. The report of the committee estimated the cost of a residency slot at $30,000 per year; $90,000 to train one doctor over the three-year program. The other half of the cost was to be picked up by the communities in which the programs were located. The cost of the education program, however, is only part of the cost of training doctors as has been graphically demonstrated at Brackenridge Hospital. In 1972, the city of Austin contracted with the Central Texas Medical Foundalocal doctors, to run a medical education program at Brackenridge Hospital. The initial contract was for $259,283. By 1976 the contract totaled $1,245,106, a 380 percent increase. The Olson bill provides for the residency programs to be run by similar physician-run corporations. 24 The Texas Observer In order to have a residency program approved for accreditation by the AMA, a hospital must meet strict requirements. It must be accredited by the Joint Commission on the Accreditation of Hospitals, it must provide the residents with diverse “clinical material” \(i.e., paequipped laboratories, radiology departments and other support services necessary for modern, high-quality, high-technology medical care. Needless to say, few hospitals outside of major urban centers meet these requirements. In addition to the start-up costs, there are ongoing expenses incurred by teaching hospitals such as charges for lab tests, radiology, in-patient care, etc., which are ordered by the doctors or doctors-in-training. If these services are ordered for patients who can pay, or who have third-party coverage, they are a source of revenue for the hospital. If the patients cannot pay, the hospital must take the loss and pass it on to the entity which operates it. For Brackenridge Hospital, that entity is the general revenue fund of the city of Austin. It has been estimated that costs in teaching are from 30 to 50 percent higher than in nonteaching hospitals, due to the inexperience of the doctors-in-training and to the way in which care is delivered in the teaching setting. At Brackenridge, although the number of surgeries and deliveries has declined since 1972, utilization of laboratory services has increased 50 percent and use of radiology services by 47 percent. As no one knows what type of hospitals will be used for residency training, I will assume that residents will be placed in public hospitals with emergency rooms. This assumption is based upon AMA recommendations that residents have access to “service or ward beds” as opposed to private patients for teaching purposes, access to outpatientdepartment patients \(usually poor peoPublic hospitals with emergency rooms cannot refuse to admit patients. Residents provide a handy way of letting the local doctors who don’t like to do “charity” work in the emergency room off the hook. At Brackenridge, the number of doctors volunteering at the emergency room has declined, due in major part to the provision of emergency room doctors through CTMF. Since the arrival of CTMF, the number of no-pay patients treated at the hospital has increased 78 percent; similar experiences have been had by other public hospitals with teaching programs in the state. The local taxpayers must subsidize the deficit, which for Brackenridge is around $7 million per year, not including the $1.2 million for the medical-education program. Communities which “benefit” from the Olson bill will likely share a similar fate. Medical education does offer advantages to a community. It helps to keep doctors up-to-date in medical care, and it does encourage doctors to remain nearby. There is some evidence, however, that the primary-care marketplace in Austin will be near overflow in the next few years, a situation which will militate against retention of primary-care doctors in the Austin area. Medical education, especially residency training, is an extremely expensive undertaking, and as you note in the article, may not be what is needed to improve health-care delivery in Texas. It is widely accepted that 80 to 90 percent of a doctor’s office practice could be handled by a welltrained nurse or physician’s assistant, yet the state is about to commit to increased production of the most expensive provider of primary care a doctor trained to residency level. Sophie Carroll Weiss, 2112 Highgrove Terrace, Austin. Reconsider SJR 43 While I am usually impressed with the Observer’s work, I must object to your recent endorsement of SJR 43 in your article on Sen. Walter Mengden \(Obs., eliminate influence peddling, SJR 43 is worded so broadly that it would seriously injure the operations of some state agencies for which influence peddling is no problem. SJR 43 proposes to amend the constitution so that “no state agency except an institution of higher education may accept a gift or grant of funds or other thing of value from a private source.” Within the context of article XVI, section 6, that amendment would not only prohibit drug companies from giving money to the MHMR agency, but would also prevent state agencies from accepting funds from foundations. Specifically, agencies such as the Commission for Arts and Humanities and the Historical Commission would no longer be able to operate programs funded by foundations. Even the Admiral Nimitz Museum and other state-supported non-university-connected museums would be prevented from accepting gifts of relics, art collections, or any “other thing of value” if SJR 43 were incorporated into the constitution. In light of this, I urge you to reconsider your support for SJR 43. Carol L. McDonald, 2510 Enfield Rd., #7, Austin. Postmaster: If undeliverable, send Form 3579 to The Texas Observer, 600 W. 7th, Austin, Tex. 78701