It’s said everything is bigger in Texas, which makes the fact that it’s third on the list of states producing the largest quantity of physicians in the country (born, trained, licensed, or graduated) unsurprising.
It also makes Nick Zenarosa, MD, the chairman and director of the department of emergency medicine at Baylor Medical Center at Garland, a member of a large club. The Illinois native with a med school degree from the University of Illinois-Chicago initially arrived in Dallas in 1991 for his residency in internal medicine at Parkland Memorial Hospital. Although he next moved to Charlotte, North Carolina for a second residency in emergency medicine, Dallas held his heart. He returned to his adopted home in 2004 when the Baylor position opened up.
"I came back as soon as I could," he says. "Dallas is a very easy city to live in." He and his wife bought a small ranch in the northeast suburb of Sachse and settled in to the good life, Texas style.
Administrators like Kent Tucker, the vice president of ancillary services at Huguley Memorial Medical Center in Fort Worth, love to color in that picture:
• The city offers outstanding entertainment opportunities, ranging from major professional and college sports to cultural events at the Myerson Symphony Hall in Dallas and Bass Hall in Fort Worth.
• Myriad recreation facilities, such as golf courses, tennis clubs, biking trails, and youth leagues in a number of sports keep residents active.
• A number of good public and private schools are located throughout the area.
• DFW Airport is conveniently located in the middle of the metroplex, allowing easy access to most destinations within the United States as well as international locations.
• Housing options, from acreage in the country to gated golf course communities, are all affordable.
Yet the physicians say these traits, while attractive, aren’t unique in the recruiting game. What has them giddy about this 384-square-mile city are the Texas-sized opportunities available for their medical careers. For example, Zenarosa stepped into what the American College of Emergency Physicians labeled a very poor emergency medicine situation, not from a quality standpoint, but because the huge shortage in this specialty meant limited access.
"The only reason we actually got one C in our report card was because we were the first state to really pass a form of court reform for litigation," he notes. "We had scared away quite a few malpractice insurers in Texas, so a lot of doctors left in the early 2000s."
However, the Texas legislature passed Prop 12 and House Bill 4 in June 2003, installing a $250,000 cap for doctors and $500,000 cap for hospitals on non-economic damages in medical malpractice cases. Since then, carriers have stampeded back into the Lone Star state with physicians right on their heels. Still, the roundup hasn’t sated the population’s appetite. At the time the legislation passed, Texas had 25 percent fewer doctors for its population than any other state.
Area economist Ray Perryman estimates that medical liability reform will boost the state’s annual gross product by $17.3 billion in five years while personal income will increase by $10.9 billion. Zenarosa is just tickled with the fact it means he has a shot at filling his ranks. "Previously we tried to hire a guy who had been in one lawsuit 10 years ago but couldn’t because we couldn’t find malpractice insurance for him. Now, that’s all changed," he says.
Change is the constant in Dallas in 2006 and growth is the operative word. The population rose by 31 percent between 1990 and 2000 and is expected to add another 24 percent by 2010. And as the population swells, so do the hospital systems, where, once again, large is the name of the game. There’s Parkland, perhaps best known as the hospitalwhere President John F. Kennedy was pronounced dead. (The area once occupied by the trauma room is now a waiting area for the X-ray department; a plaque marks the site.) Baylor University Medical Center consists of 19 hospitals, with a heart hospital to open in 2007. The University of Texas-Southwestern Medical Center boasts a faculty including four active Nobel laureates. All three are ranked among the nation’s best by U.S. News and World Report. Texas Health Resources, one of largest faith-based, nonprofit U.S. health-care systems, counts 13 hospitals and 2,600 beds. It was named among nation’s "100 Most Wired" companies for 2006. Altogether, there are 60 hospitals, 13,000 beds, and 5,800 physicians in the Dallas-Fort Worth metro area, according to the latest market report from Wetfeet.com recruiting firm in San Francisco.
"You can saturate a market like Chicago, New York, and Los Angeles. But we’re more like an Atlanta - there’s not really a developed downtown, so the city is sprawling out and they’re building these big new hospitals 20 to 30 miles outside," says Marc Bowles, the executive vice president of the Delta Companies in Irving, Texas. "You’ve got a lot of physicians basically planting their stakes further out in communities projected to grow over 10 years."
Kurt Mosley, the vice president of business development for the MHA Group, also in Irving, says he "likes the even balance of profit and non-profit hospitals in the area."
Zenarosa embraces the competition because "it usually raises the bar and the standard of care" in his experience. "In order to compete, you have to provide a service other hospitals don’t have," he says. In his emergency medicine department, that means investing in new concepts with regards to Baylor’s higher risk patients. For example, Zenarosa is doing point-of-care testing as opposed to laboratory testing, so he receives answers in minutes rather than hours. Doctors there are also doing more bedside ultrasounds.
Meanwhile, at Medical City - a 598-bed tertiary care center on Dallas’ north side that includes Medical City Children’s Hospital and Dallas Craniofacial Center - the claim to fame is organ transplants. The heart transplant center alone received recognition from the Department of Health and Human Services as one of the country’s premier programs. Totaled, Medical City has performed 310 stem cell transplants, 229 heart transplants, 22 kidney transplants, and 119 prostate seed implants, according to its Web site. Surgeons here conduct robotic-assisted microsurgery, beating heart surgeries, and minimally invasive heart surgeries at their disposal.
Methodist Dallas Medical Center advertises services like 24-hour hysterectomies, a Weight Management Institute designated as a surgery center of excellence by the American Society of Bariatric Surgery, as well as a mock grocery store. This innovative tool helps rehab patients navigate the shelves and aisles of real supermarkets once they’re discharged from their stroke, head injury, or joint replacement surgeries.
At Parkland, it’s not enough to rack up accolades on service. Its president and CEO, Ron J. Anderson, MD, has been dubbed 15th on the list of 50 Most Powerful Physician Executives in Healthcare for 2006 by Modern Healthcare. Thomas Royer, the president and CEO of Christus Health in Irving, ranked seventh on that same list.
The employment situation for physicians can get tricky in Texas. According to Bowles, it’s illegal for a 501(c)(3) hospital to hire doctors, but they get around this technicality by forming a separate corporation that feeds into the hospital corridors. Nevertheless, a majority of physicians choose to work independently in single-specialty groups.
The graduating residents who learn in these environments are treated like Hiesman trophy winners, Mosley says, so his numbers show only 25 to 30 percent remain in the Dallas area. "A lot of people count on their residents staying, and low and behold, they’re gone in the July exodus and then these hospitals need help," he says.
Candidates for these openings usually have some tie to the area, including a spouse who hails from the state. The next largest segment is the international medical graduate level - Pakistani in particular - as the international airport makes the city an excellent gateway to home, wherever that is on the globe. California and Florida natives report in large numbers, too. But by and large, medical practices rarely pull from the East Coast or Midwest without tapping into some family connection.
Those who do fly in for a visit find a wide, open range of opportunities. Mosley says he’s in dire need of ob/gyn, primary care, internal medicine, family practice, and pediatrics physicians. Bowles’ clients are asking for orthopaedists, cardiologists, radiologists, geriatricians, and dermatologists with increasing frequency. "We don’t ever hear of people having too many physicians," he says.
Mosley agrees, and he speaks from experience - after breaking his foot in the fall of 2005, his primary care physician said a specialist should set it. The soonest he could get an appointment was 3.5 weeks away. "And I had an angle because we know these doctors!" he adds. Dermatology is even more booked up, thanks to the sun damage to the over 40-crowd who grew up without sunscreen; Bowles books his appointments in this specialty seven to eight weeks out. "One of the physicians that a lot of the people in our office see stopped taking insurance," he relates. "He didn’t have time to deal with the paperwork. Patients pay in full up front and file on their own behalf, and this dermatologist is still stacked up."
One internal medicine physician reports that 60 percent of his business stems from asthma patients, and Type II diabetes has reached almost epidemic proportions. "Folks here are overweight," Mosley says matter-of-factly. "When I first came here, I would go out to dinner with people and it was like watching the dietary intake of an adult puma. You eat steak in Texas!"
Pediatricians bilingual in Spanish can write their own ticket, as experts predict the Hispanic population in Dallas will grow 40 percent in the next five years, compared with 10 to 18 percent over the last two decades. "And a lot of them are here legally and have a nice insurance package," Mosley says. But Spanish isn’t the only language showing up in the classrooms across the city - educators now work with a lot of Caribbean dialects as well. Mosley likes to point out that Dallas also shows up on the "most ethnically diverse communities in America" lists.
Big cities and the medical systems that serve them automatically come with a few imbalances and growing pains. Dallas is certainly no exception. But leaders in the medical profession are rolling out innovative solutions every month. For instance, new surgery centers are drawing surgeons and paying patients from the community-based hospitals, leaving administrators like Zenarosa with a call schedule riddled with holes and a higher-than-average uninsured load. "We may not have neurosurgeon coverage on a weekend. We may not have plastic surgery coverage other times," he explains.
So cutting-edge hospitals have now begun paying doctors to be on call - and the move means specialists are offering to fill the schedules, since uninsured patients don’t cause as large a financial hit under those circumstances.
Physicians’ overbooked schedules also force large numbers of people, even those with good insurance coverage, through the E.R. doors, creating a strain on those departments. Mosley once took a friend suffering from a migraine to the nearby emergency room only to wait eight hours for treatment. As a result of such stories, some specialists have turned to open access scheduling, which leaves chunks of time available each day to see immediate needs patients.
Managed care never truly gained a foothold in Dallas, with Kaiser Permanente failing to make a profit. Mosley, in true Texas form, relays a story a physician once told him to explain the situation: "He was addressing an audience and asked everyone who had a dog to raise their hands. Next, he asked if their dogs liked bones. Everyone again said yes. But the physician came back with, ’Your dogs don’t like bones. They like steak and settle for bones.’ The public here in Texas wanted the steak and was willing to pay for it.
"Patients with heart palpitations wanted to go right to a cardiologist, so they sort of revolted and said they wouldn’t go into a capitated system, and employers started dropping the insurance plans that dictated those models," Mosley says.
The few HMOS still kicking, however, offer reimbursements lower than Medicare, particularly for practices based closer to the downtown areas. Dallas’ large corporations that wield economies of scale have some negotiating power when striking deals with medical groups.
Yet another challenge: salaries. Physicians across the board earn in the upper three-fourths of salaries across the nation, but that’s still less than groups in the Midwest and West are dangling. Mosley blames it on Dallas’ relatively young population (median age is 32.1 years), which isn’t into the three Bs: baby boomers, Botox, and bariatrics. Where someone practices also affects her income. According to Bowles, a family practitioner could expect to earn between $130,000 and $140,000 practicing in the city proper, while her counterpart two hours outside the city makes $220,000 for the same workload.
Yet income rarely becomes a sticking point, recruiters say. The fact that Texas has no state income tax means more dollars end up in doctors’ wallets. And Wetfeet’s statistics show that Dallas scores an incredible 93.06 on the ACCRA Cost of Living Index with the U.S. average at 100. "I understand from talking to physicians that they can’t keep up with the cost of living in most major metropolitan areas, but here you can stay ahead of it," Bowles assures.
Living the good life
That’s just the beginning of the perks. Unfortunately, the myths about some parts of the state punish Dallas. No, it’s not humid, Mosley assures - that’s Houston and San Antonio. "Trace their latitudes and you’re as far south as Cabo San Lucas. Track ours and you hit San Diego," he points out.
Residents passionately contend that the image of cowboy hats, spurs, and horses is just a surface look. Mosley admits he wondered how he would fit in after hailing from Newport Beach, California. "But with the exception of a little twang, they are the same people that are in California," he says.
Certainly the employer base is strong, with the city - nicknamed in some circles as the Silicon Prairie - responsible for 47 percent of all tech-related revenue in Texas. That industry alone amounts to 230,000 jobs, with another 20,000 in communications manufacturing, ranking it third in the country for information and communications jobs. Tourism accounts for more than 100,000 jobs in the area, with conventions alone hauling in $4 billion for the local economy coffers. Residents have 300 banks to choose from. When the dust settles, pundits say the city will lead the nation in employment growth through 2010.
So when Bowles wants to describe the city, he uses adjectives like young and energetic. It’s especially conducive to singles, thanks to the diverse corporate scene. Residents can buy tickets to root for the Dallas Cowboys (football), the Dallas Mavericks (basketball), the Texas Rangers (baseball), the Dallas Stars (hockey) or the Dallas Sidekicks (soccer) - not to mention the competitive college sports scene. "I was amazed at how many jogging clubs there are here, and on the weekends, children’s sports activities are just tremendous," Mosley says. Little League is huge among residents, high school football is king, and softball is the ’in’ sport for adults.
A plethora of arts organizations reflect the city’s ethnic diversity. Performance groups range from classical music, theater, and dance, to Latino dance and music, to African music and cinema. The arts community’s crown jewel will no doubt be the Dallas Center for the Performing Arts, a four-venue, $275 million complex which began construction in the Dallas Arts District last November. The complex, scheduled for completion in 2009, will include an opera house, a theater, outdoor artists’ square, a performance hall, and a performance park.
Families can send their students to one of the six public four-year colleges and universities or 17 private colleges located in the metroplex. In the k-12 arena, 215 of the 236 total public and private schools rank as exemplary based on results of the Texas Assessment of Academic Skills Test. These schools typically turn in a 90-percent passing rate on the exam, a 94 percent overall attendance rate, and a dropout rate of less than 1 percent, reports Wetfeet.
"Austin, with its political roots, is considered the liberal town, although in any other state it wouldn’t be considered a liberal community," says Bowles. "San Antonio, with its retired military population is very slow. Houston is still very much tied into the energy loop, so the ability for folks to climb the corporate ladder and exceed earning expectations there are more limited," he adds. "The diversity of the economy here means, for the most part, Dallas is leading the way in Texas."
Housing ranks as the most affordable category of all. Of course, the Plano suburb is reaching saturation, but Frisco, McKinney, Duncanville, Southlake, and Addison on the north side are booming. Much of the housing in these areas features multimillion-dollar gated communities. Younger physicians, particularly those without family concerns, are beginning to take advantage of a downtown revitalization, moving into hip lofts and condominiums in the Uptown area along McKinney Avenue. Even the ritzy W Hotel is moving into downtown digs, offering both high-rise residential and hotel facilities.
"Most people come to Dallas on a conference or training and they think we’re all about shopping and eating. But it really does offer the opportunity to build a family, start a career, and be able to get home in time to see your kids. It’s a good quality of life," Bowles sums up. g
Julie Sturgeon is a free-lance writer based in Indiana and a regular contributor to UO.