American Medical Review - Medical schools in Arizona more than doubled their enrollment in the past decade, but most of those young doctors won't establish a practice in an Arizona neighborhood or work at a local hospital.

That's because most students who graduate from Arizona medical schools train out of state, and physicians are more likely to establish careers where they complete their residency training during those pivotal years after medical school.

One key reason that medical-school graduates leave Arizona is that the state does not have enough residency slots at hospitals or community health centers that allow doctors to train and practice their craft after graduating. The shortage has been made worse by a federal limit on Medicare-funded slots, state funding cuts to graduate medical education and some hospitals' reluctance to start or expand training programs.

Medical-school representatives and business leaders say the physician training crunch is an issue that affects health, quality of life and the economy in Arizona, where there is an ongoing physician shortage. With two new medical schools planned, the problem could grow even larger.

"We talk about importing physicians, but we are exporting graduates," said Lori Kemper, dean of the Arizona College of Osteopathic Medicine at Midwestern University of Glendale.

Kemper and other medical-school representatives met Tuesday at the University of Arizona College of Medicine-Phoenix to discuss a newly released report funded by St. Luke's Health Initiatives, a health-policy foundation, about Arizona's medical education challenges.

The report shows that Arizona ranked 20th in the nation in medical-school enrollment but 37th in the number of residency slots. The report suggests the state needs to add 848 to 885 residency slots at a cost of $89 million to $93 million to meet national averages.

If medical-school students train in Arizona, they are much more likely to practice medicine here. The St. Luke's report shows that 75 percent of active physicians who graduated and trained in Arizona stayed, while only 28 percent of Arizona medical-school graduates who completed training out of state returned to Arizona to practice.

Most residency slots are paid by the federal government through agencies such as Medicare and the Department of Veterans Affairs. The Medicare program, which provides about two-thirds of government funding for residency slots in Arizona, has capped funding of most new residency slots since 1997. Since then, Arizona's population has grown more than 25 percent.

In 1997, the Arizona Legislature approved graduate-medical-education funding that allowed hospitals to also collect matching Medicaid funds. The state funding was approved each year until 2010, when the Legislature cut $15million, which meant that Arizona also missed out on nearly $30 million in matching Medicaid funds for those residency slots.

Arizona has not received any Medicaid funds for residency slots over the past two years, although Phoenix Children's Hospital, Maricopa Integrated Health Systems and the University of Arizona are poised to gain some Medicaid funding because they provided their own matching funds.

Unless Arizona takes steps to fund graduate medical education, health leaders warn that the physician shortage could worsen, particularly among primary-care physicians who play a critical role in stressing preventive measures that keep people healthy.

Stuart Flynn, dean of the University of Arizona College of Medicine-Phoenix, said the challenges of funding physician training is a crisis that could jeopardize Arizonans' access to health care, leading to "a generation after us that suffers immensely."

The state's medical-school enrollment surged 117 percent last decade, making Arizona the second-fastest growing state for medical students. The enrollment surge made possible by medical-school expansions put Arizona's 29.5 students per 100,000 people in 2010 nearly on par with the national average of 31.4 students per 100,000.

But the state's physician-training positions have not kept pace. Arizona had 21.7 residency slots per 100,000 population in 2010, compared with a national average of 35.8.

Arizona is poised to see the gulf between medical students and training slots grow wider.

The University of Arizona College of Medicine established a Phoenix campus in 2007 and has gradually increased enrollment. Arizona also has two osteopathic medical schools, Midwestern University in Glendale and A.T. Still School of Osteopathic Medicine in Mesa.

Creighton University will open a campus at St. Joseph's Hospital and Medical Center over the next two years for third- and fourth-year medical students. The Creighton students will complete their first two years of medical school at the Catholic university's main campus in Omaha, Neb., before moving to Arizona to finish. Mayo Clinic also expects to launch a new medical-school branch at its Scottsdale campus in 2014.

The health leaders said the medical-school expansions are a bright spot for metro Phoenix, a region that historically relied on recruiting physicians from out of state to meet the needs of Arizona's growing population.

Some leaders say it makes little fiscal sense for the state to expand medical education without paying for the training slots for the physicians when they graduate.

Others warned that the nation's physician workforce has changed over the past decade. Because all states face a federal Medicare cap on new slots, competition for physicians has grown intense and there is no guarantee that enough doctors would relocate to Arizona to meet the state's needs.

Arizona needs to add nearly 2,400 physicians to meet the U.S. average of 35.8 physicians per 100,000. The demand for new doctors will intensify under the Affordable Care Act, which would extend medical insurance coverage to most of the estimated 1.2 million uninsured Arizonans beginning in 2014.

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