(Editor's note: This is the first in a two-part series exploring issues surrounding the training of physicians in Rhode Island and its impact on local health care.)
Sen. Pamela J. Lauria is on the front lines of a health care crisis.
Lauria has worked as a primary care nurse practitioner at Coastal Medical Physicians Inc. for 27 years, helping patients manage chronic illness and screening for diseases before they become debilitating.
But this type of care is getting harder to find for Rhode Islanders and many others nationwide because of a shortage of doctors specializing in family medicine, internal medicine and pediatrics.
It’s gotten so bad that “primary care providers can’t even find a primary care provider,” she said.
Now Lauria, D-Barrington, has taken on a new role: co-chairing a special legislative commission exploring if it makes sense to establish a new medical school at the University of Rhode Island to solve this shortage of doctors locally, a medical school that could offer an
affordable education to Rhode Island residents – particularly disadvantaged residents – who would be more likely to stay here to practice medicine after graduation.
That’s the idea anyway.
But others see problems in primary care that they say a new public medical school wouldn’t address.
Those problems include lower earnings for those who enter primary care compared with other specialties, lower insurance reimbursement rates in Rhode Island driving some doctors out of state, and the proliferation of guidelines, record keeping and paperwork for primary care practices that frustrate providers and lower the number of patients that each doctor can take on.
“Everyone is searching for a single silver bullet,” said Dr. Jeffrey Borkan, assistant dean for the primary care-population medicine program at Brown University. But he warned that a new school might not be the cure, saying that “everything from money to status to training environments” is impeding the growth of the primary care workforce.
Right now, Brown University’s Warren Alpert Medical School operates alone in Rhode Island, churning out about 80 to 130 or so graduates annually from its building in Providence’s Jewelry District.
[caption id="attachment_476434" align="aligncenter" width="1024"]
MOVING ON An analysis of Warren Alpert Medical School graduation data from 2011 to 2020,
cross-referenced with R.I. Department of Health records, shows that a small
percentage of Alpert graduates are licensed to practice in Rhode Island. / SOURCES: WARREN Alpert Medical School residency match lists
2024 R.I. Department of Health medical license data[/caption]
An analysis of available data indicates that only a small percentage of those graduates remain in Rhode Island. Of the 1,112 students who graduated from Alpert Medical School between 2011 and 2020, only 85 – or 7.6% – are licensed and practicing in Rhode Island in 2024 across a variety of disciplines, according to figures compiled from Brown and R.I. Department of Health databases.
Just how many primary care doctors are needed to solve the shortage? That depends on who you ask.
While one projection from 2013 determined 99 more would be needed by 2030 to address the growing and aging population, Dr. Michael Fine, a family physician and former RIDOH director, says the forecast doesn’t take into account that as many as 200,000 to 400,000 state residents don’t have a primary care doctor now, which would require 133 to 266 more doctors, according to his estimates.
And then there is the retirement of primary care doctors, which has seemingly picked up pace since the COVID-19 pandemic, observers say.
Proponents of creating a public medical school at URI say it will provide more affordable medical training that will attract a more diverse group of students who are more likely to stay in Rhode Island and will better match the diversity of the state’s population.
At the legislative commission’s first meeting in late August, URI President Marc B. Parlange – who is also serving as the panel’s co-chair – made it clear that the idea has the backing of the leadership at URI.
A college of medicine at the university would “provide a unique opportunity to recruit Rhode Island students who are interested in both primary care and giving back to their communities,” Parlange said.
[caption id="attachment_476432" align="aligncenter" width="1024"]
STANDING ALONE: For decades, Brown University’s Warren Alpert Medical School has been the only medical school in Rhode Island. Now state officials are considering the pros and cons of opening a college of medicine at the University of Rhode Island.
PBN PHOTO/WILLIAM HAMILTON[/caption]
PLENTY OF QUESTIONS
It’s not like a medical school will appear at URI soon.
The 21-member commission of lawmakers, public health officials and URI leaders appointed by Senate President Dominick J. Ruggerio has been tasked with looking at various ways to address the crisis in primary care, focusing on the education and retention of physicians.
The members are expected to meet through most of 2025 and have been given a deadline to submit their findings and recommendations to the Senate by Jan. 2, 2026.
A large portion of the focus will be on the potential of a public medical school and tackling questions such as startup and operating costs, location, size, residency positions and competition.
Parlange and other URI administrators say that adding a college of medicine to the university’s lineup of advanced programs in nursing, pharmacy and health sciences makes sense.
“We’re already training a health care workforce of the future with our existing, extensive and well-established programs,” Parlange said at the commission meeting in August.
But for many, solving the shortage of doctors entering primary care goes beyond opening another medical school.
It has a lot to do with money.
For medical students, crippling debt is commonplace – averaging more than $200,000 for medical school students who graduated in 2023 nationwide, according to the Association of American Medical Colleges.
“It’s like owning a house without owning a house,” said Kelly McGarry, a professor of medicine and program director of general internal medicine and primary care at the Alpert Medical School.
“Unless we change the financial dynamics for those that wish to commit to full-time or even partial primary care practice, we will continue to not attract enough people to fill the need,” she said.
And the debt is coupled with few financial incentives for entering primary care. In 2021 and 2022, the average starting salary for physicians entering family medicine was about $250,000, according to AMN Healthcare, a health care staffing company. For pediatrics, salary offers averaged $232,000.
However, for specialties such as radiology, urology and oncology, salaries reached more than $400,000 on average. And with six figures of debt, salary differences can dictate a doctor’s career path, observers say.
In the Ocean State, young physicians might be feeling the financial pressures even more.
Rhode Island has lower reimbursements from Medicaid and private, employer-sponsored health plans for services compared with Connecticut and Massachusetts, according to a March study from the Rhode Island Foundation.
Indeed, the financial website WalletHub ranked Rhode Island as the second-worst state for doctors earlier this year, calculated through numerous metrics, including average annual wages for physicians and malpractice award payout amounts per capita.
The incentive for doctors to move to neighboring states is a cause for concern, according to a December report from the R.I. Office of the Health Insurance Commissioner.
“We have more people leaving primary care than coming in,” said Debra Hurwitz, executive director at the Care Transformation Collaborative of RI, a nonprofit that advocates for primary care. “We don’t have a defined pipeline of individuals coming in.”
Most everyone agrees that large numbers of physicians won’t choose primary care as a career path unless the financial barriers are addressed. But not everyone agrees on how to lower the barriers.
Some say funding should support loan repayment and, preferably, scholarship programs.
With a new school, Rhode Islanders can “find ways of reducing tuition for people who are going to do primary care, and in exchange for that, obligate them to practice in the state,” said Fine, who is a member of the special legislative commission.
“If you come from Central Falls, and your dad works as a landscaper and your mom works as an office cleaner, you’re not going to take on $300,000 worth of debt in the hope that after you’ve acquired the debt, you might get that debt slowly paid down,” he said. “It’s too intimidating.”
In the last General Assembly session, Lauria sponsored a measure to create scholarships for five medical students, five nurse practitioners and five physician assistants in exchange for a commitment to work in Rhode Island.
The legislation did not pass. Instead, money was provided to expand the Wavemaker program, a loan repayment program for those in science, technology, engineering, mathematics and health care fields.
Lauria says a URI medical school could come with more robust scholarship programs.
A public medical school with reduced tuition is key for Christopher F. Koller, a former state health insurance commissioner who is also on the commission examining the medical school issue.
“From a societal standpoint, we’re better off making the schools cheaper than just supporting the cost structure,” he said.
Another benefit: those who attend public medical schools are more likely than those from private schools to enter primary care, according to Koller.
As it stands, Rhode Islanders do not “have the ability to go to medical school at an in-state tuition rate,” Lauria said. This can lead Rhode Islanders to take on more college debt when attending medical school.
[caption id="attachment_476435" align="aligncenter" width="1024"]
DIVING IN: Dr. Michael Fine, former director of the R.I. Department of Health, attends the first meeting of the legislative commission investigating whether the state should establish a medical school at the University of Rhode Island. He is a member of the commission. At right is fellow commission member Stacy Paterno, executive vice president of the Rhode Island Medical Society.
PBN PHOTO/MICHAEL SALERNO[/caption]
IN TRAINING
The process of becoming a physician is not only expensive; it’s lengthy, too.
Students spend four years earning an undergraduate degree before applying to a medical school. After another four years to obtain a medical degree, graduates are matched to a residency program for additional training that can last between three to seven years, depending on the specialty.
There are about 850 resident slots at Rhode Island clinics and hospitals, most affiliated with the Alpert school, according to health care officials. And they’re filled by medical students from around the country.
Some health care professionals raise questions about the potential ripple effects of opening a second medical school.
Borkan, for one, says there are not enough training sites around Rhode Island as it is now, and adding another medical school would “just create havoc.”
There are a limited number of current physicians willing to teach and train medical students and residents, according to Borkan.
Another medical school would only place another burden on primary care physicians, who are already facing record levels of burnout since the COVID-19 pandemic, he says. Additionally, when physicians take time to train students, it takes away time that could be used treating patients. With fewer patients, providers take a financial hit for little to no compensation.
“I think that having a state medical school is an error in a state like Rhode Island,” Borkan said.
State officials say they’ve taken steps to ease those problems.
Last spring, Lauria sponsored a bill to create a training site program to provide some financial backing to physicians who train students. As a result, the General Assembly allocated $2.7 million in the fiscal 2025 budget for the program, which will fund 30 primary care training sites across the state.
This will allow providers to be compensated when reducing their medical office hours to teach students. Supporters hope this new program will help increase the number of spaces to train new primary care providers.
“We need to be able to pay primary care practices in the community to participate actively in educating the next generation of primary care providers,” Hurwitz said.
TAKING UP RESIDENCE
Many say residency programs are especially important in growing a physician workforce since one of the strongest predictors of where doctors end up practicing is where they complete residency.
“If we want to increase primary care supply in Rhode Island, it’s actually more important to pay attention to where people train than where they learn,” Koller said.
But the trend is weaker in Rhode Island, according to AAMC data.
In a survey of residents who completed training in Rhode Island between 2012 and 2022, only 42.9% were still practicing in the Ocean State in 2023. On average, 57.1% stay in the state where they finished their residency.
Retention rates are even bleaker for primary care residents.
A 2024 study, co-authored by Borkan, found that only 14% of those who graduated from Rhode Island primary care residencies in 2023 intended to practice primary care in Rhode Island. The study surveyed all of the state’s residency programs, finding that a majority of those who stay in Rhode Island come from Brown’s Family Medicine program – the only family medicine residency program in the state.
“When you train a family physician, you get a primary care doctor,” he said. “When you train an internist or a pediatrician, 10% or 20% of the time you get a primary care doctor, but the rest of the time you get a subspecialist,” he said.
A significant number of internal medicine residents end up subspecializing, drawn by financial pressure and a lack of exposure to primary care in medical school.
“There’s a lot of pressure in the programs to go into a subspecialty, and that decision often has to be made in the first and second year” of residency, Borkan said.
And the organization of residency slots provides additional barriers to entering primary care.
Medicare funds most residency slots, but teaching hospitals can decide what they use these funds to teach. Of Rhode Island’s 850 residency slots, only around 100 are in primary care, officials say.
Most residency slots are in Lifespan Corp.-affiliated hospitals, which largely focus on specialty care, according to Koller and Fine.
To make a significant impact on primary care, Borkan said Brown and Lifespan should change “hundreds of their residency training slots to primary care.”
Fine agrees that more primary care residency slots are needed, adding that the General Assembly could help reform residency programs.
“We haven’t required that hospitals take the money they get for graduate medical education and devote it to primary care,” he said. “I would require that any academic hospital devote 50% of its training slots to training primary care doctors.”
Some states have funded additional residencies to address shortages. However, hospitals have little incentive to devote these slots to primary care.
“Lifespan has every incentive to train cardiologists [and] thoracic surgeons because they generate more money for Lifespan,” Koller said.
Lifespan Corp. declined to answer questions on the issues surrounding a state medical school while Care New England Health System said in a statement that it looked forward to reviewing the commission’s recommendations.
STAYING PUT?
Many see a new medical school as an opportunity to keep Rhode Islanders in their home state, as well as a chance for underserved and marginalized people to get access to an education in medicine.
Fine notes that, according to AAMC data, 102 Rhode Islanders applied to medical school in 2023 and 53 were accepted, a higher acceptance rate than the 30% national average. But only one was Black, one Latino and five listed multiple ethnicities. Of the 53 accepted to medical school, 38 went to out-of-state institutions.
There already has been “quite a bit of interest and quite a bit of enthusiasm” on campus about the potential for a new medical school, Parlange said in an interview with PBN.
Around 6,500 URI students major in the biomedical or health sciences, and many end up in medical school, he says, noting that an in-state public medical school could increase physician retention. “Students who are from Rhode Island tend to stay in Rhode Island,” he said, citing URI graduation data.
In contrast, according to an analysis of licensure data, less than 8% of those who graduated from the Alpert school between 2011 and 2020 are licensed physicians in Rhode Island.
Additionally, Rhode Island has the second-worst retention of medical students in the U.S. behind New Hampshire, another state only home to an Ivy League medical school, according to a 2021 AAMC report. Less than 50% of those who complete medical school or residency in Rhode Island stay here, compared with the national median of 69.7%.
Many questions still remain, including the economic impact of a medical school, the demand among Rhode Island students, and startup and operating costs, all of which will be weighed against the potential risks of not investing in primary care.
Lauria says the commission is looking to diagnose the crisis over the next year and prescribe a course of treatment.
“Obviously, it’s a big undertaking, but it’s really exciting work,” she said.
Ryan Doherty is a PBN Contributing Writer.
This is a classic example of a supply shortage, triggered by government introduced barriers to entry. The solution is BOTH a second medical school, and less government red tape; in other words, return to free market healthcare. The answer is staring everyone in the face, yet our elected officials won’t publicly admit this.