In November, the University of Nevada, Las Vegas (UNLV) School of Medicine began accepting applications and interviewing students who will start their medical school education in summer 2017.
That sounds like good news – and it is – because of Nevada’s severe shortage of physicians. However, it’s only one step by Nevada healthcare professionals to help the state catch up. According to a biennial report from University of Nevada School of Medicine in May, there are 5,726 physicians licensed to practice or in residency in Nevada.
That sounds like a lot, but 69.8 percent are in Clark County, and 22.4 percent in Washoe County, leaving less than 8 percent practicing in the rural counties. In addition, doctors 60 years or older account for 27 percent of Nevada physicians.
“We have a tremendous shortage [of physicians] and in nearly all specialties,” said Dr. Thomas Schwenk, dean, University of Nevada, Reno (UNR) School of Medicine. The problem is compounded by the fact that, “until recently we’ve had a limited system of public medicine education leading to residency education and into practicing physicians,” he said.
Dr. Schwenk, along with the dean of UNLV’s forthcoming School of Medicine, Dr. Barbara Atkinson and the deans of Touro and Roseman Universities are working to repair Nevada’s dismal numbers. Nevada ranks 48th in U.S. states for the number of physicians per capita, 50th for the number of primary care physicians, 51st for registered nurses, 47th for psychiatrists and 41st for psychologists. The number of pediatric doctors is 9.6 per 10,000 children in Nevada while the rest of the country is at 15 per 10,000.
The good news is that, anywhere from 50 to 80 percent of physicians remain where they’ve performed their residency, and Nevada ranks eighth in the U.S. for physicians remaining after residency training.
Keeping Up with the Demand
That good news remains good news as long as there are enough residencies to train and keep the doctors going through them. Unfortunately, at the moment, Nevada doesn’t have enough residencies and the state isn’t unique in that. There doesn’t seem to be enough residency or fellowship programs across the country.
“There’s no question there’s demand all over the country [for residency programs],” said Mark Penn, dean, College of Medicine, Roseman University of Health Sciences. “There’s lots of individuals that want to become physicians but we don’t have enough spots for all of them.” Which means if the state can create residency programs, there is the possibility of attracting students from other states, who just might stay.
The Legislature and the Governor, with the deans of new and existing medical schools, are now recruiting doctors, creating residencies and looking to put together medical fellowships in order to train specialists. After four years of medical school and three to five years of residency, fellowship training for specialities is another three to seven years.
“We have to support that scope by training so we have enough cardiologists, enough pulmonologists, enough cancer doctors and that’s done with fellowship training,” said Dr. Anthony Slonim, CEO, Renown Health. A fellowship program takes years to build, which is one reason Renown has partnered with Stanford University. The organization hopes to entice some of their specialists to Nevada while building programs.
Deans of Nevada medical schools are working together, combining strengths rather than competing. There are enough hopeful medical students to go around, and more applicants for residency slots than there are slots. In early 2016, there were 138 first year residency positions and the state’s medical schools included UNR and Touro.
“So at that moment in time, Nevada is a net exporter of medical students who have to go somewhere else to train,” said Dr. John Dougherty, dean, Touro University Nevada.
The Making of a Medical School
In September 2013, the University of Nevada Board of Regents decided to expand medical education in Nevada. In January 2014, it decided on a new medical school at UNLV. Dr. Atkinson was recruited as dean and began the numerous steps involved in creating a school of medicine.
“I spent the first six months meeting with people in the community, talking to the people at University of Nevada, Reno School of Medicine and people in Las Vegas, really planning the curriculum and what the future should look like,” said Atkinson. “My goal was to make sure the school was what the community needed: to provide physicians to the state.”
In January the Liaison Committee on Medical Education (LCME), the accrediting body for the U.S. and Canada, reviewed the accreditation materials. In July, they performed a site visit. In October, the school was approved to accept the first class.
For the 60 openings, 800 applicants requested notification and the pool of qualified students is 2,000 to 3,000 strong.
Meanwhile, Roseman is in the second phase of the accreditation process. Documentation was submitted to LCME in June, 93 elements taken into account, and 92 approved.
Accreditation was denied over questions of adequate funding. “It’s not uncommon to have some bumps in the road,” explained Penn. When fully accredited, Roseman expects to have 60 students in the school’s first class.
The Making of a Physician
Those 800 aspiring medical students eyeing Nevada’s schools come from across the country. But while Atkinson said there’s no mandate to accept only Nevada residents, qualified Nevadans and students with ties to the state are first choice.
“We want to be sure to choose people who are going to want to stay,” said Atkinson. “The issue is obviously to pick them from people who are already here, who have family here and who are most likely to stay here.”
To that end, the curriculum is tied to the Las Vegas community, “so they’ll really understand our community and the diversity of our community,” added Atkinson.
Once the students are in the state, the next step is to build residency programs, because 80 percent of graduates who do both medical school and residency in the same place tend to stay.
“Our problem in Nevada is we don’t have many of the residency programs that students like to take,” said Atkinson. That means a number of students automatically leave the state, which is why medical schools, local hospitals and medical practices are working together to build residencies in all the specialties.
The Making of Residencies
Partnerships are the backbone of residencies. Medical students must do rotations in both hospitals and outpatient practices. That means, across the state, residency partnerships are forming for the good of the community.
“We have an explosion of interest, with Mountain View Hospital developing a system and Valley Health committed to do the same,” said Schwenk.
That’s something like 200 to 250 new residency slots. UNLV is also set to continue UNR’s strong partnership with the University of Southern California. The system is also adding new partnerships with Renown Health and expanding others with the VA Sierra Nevada Health Care System. There’s even talk of adding rural residencies in places like Elko. Rural providers are especially in demand.
“The growth we’re experiencing right now [in medical education] means the graduate education side is critically important,” said Dougherty. With Mountain View, Valley Health and Dignity looking to start residencies between 2017 and 2019, the number of residency slots should rise from 135 to closer to 300. “It’s massive change, and it’s wonderful. Technically, now Nevada is going to be a net importer of students into training programs.”
Residency programs can provide better healthcare now for Nevada residents. Medical students spend their first two years in lectures, listening to people talk about medicine, said Dougherty. They spend the next two years as active learners, in hospitals and medical practices.
“When you have a residency training program with the students, the students get a better education,” said Dougherty. “Residents are active learners and will challenge and engage the medical students. The two are synergistic and the impact they have on the attending physician is positive. Because you never want to be shown up by a 24-year-old kid, as a physician, you work a little harder to keep up on stuff,” Dougherty said.
Southwest Medical Associates is a provider of clinical education in Southern Nevada, partnering with University of Nevada Schools of Medicine and Touro.
“Basically we’re doing what I call collaboration,” said Dr. Linda Johnson, senior medical director, provider of clinical education, Southwest Medical. Whether a student is training to be a practical nurse, a physician’s assistant or a doctor, he or she has to do clinical rotations.
“We don’t have specific programs where they’re doing their training only with us because we’re collaborating with other institutions in the community to provide the site,” said Johnson.
Southwest Medical’s program recently brought in six students to spend the majority of their clinical year training in the facilities, before going to work for the practice by graduation. Southwest will also be the clinical site for Universal Health Systems (UHS) approved Family Practice and Internal Medicine residency, producing 60 new family practice doctors and 120 internal medicine interns and residents.
In Northern Nevada, Renown Health’s residency program with UNR School of Medicine offers internal medicine and family practice and, because of the shortage of physicians in Nevada, they’re also the clinical training program for the new physician assistant program at UNR.
Because training new physicians is a 10-year process, and recruiting them from other states won’t fill all Nevada’s needs, medical professionals are looking for creative solutions to implement in the short term. That includes training practical nurses and physician assistants.
“We’re thinking creatively about options with which to enhance physician supply beyond training, recruiting and advising physicians,” said Slonim. “We have to think about providers who can reach into the community.” Physician assistants and advanced practice nurses can do that, which enhances the role physicians play in the community by providing services to people.”
These solutions don’t answer all of Nevada’s healthcare challenges. There may be a large pool of medical school applicants to draw from (the four states Nevada schools of medicine draw most from are Texas, Florida, California and Utah), but the pipeline to medical schools isn’t strong.
“One challenge for us in state is that we don’t have a robust college environment,” said Dougherty. “Most states have a network of colleges and universities, either private or public.” Nevada has fewer than 10, and they’re located primarily in the metro areas.
Working to fill that pipeline, Roseman University of Health Sciences gives presentations in junior highs, high schools and community colleges, to motivate students to explore the health professions, said Penn.
Patient Care Requires Patients
It may sound like a strange challenge, but Nevada also doesn’t have enough patients. There’s a lack of critical mass when it comes to patients in specific disciplines, said Schwenk. When creating residencies and fellowships, the number of patients needing specialized care must be considered. There’s a reason why major metropolitan areas and coastal cities with large populations traditionally offer more training in more specialized disciplines.
“It’s hard in Reno, for example, to do a neurosurgery residency, because there’s not the breadth and volume, but we’re thinking orthopedic surgery in Reno,” said Schwenk. While Reno might be able to sustain a cardiology fellowship, a sub-specialty might require partnering with an institution like Stanford.
“The main issue with many sub-specialty programs is they require a strong research component,” said Schwenk. “We would have to invest heavily in research, so what’s required is money and investment with hospitals and other healthcare facilities.”
In October, the Graduate Medical Education Task Force recommended distribution of $10 million approved in the executive budget during the 2015 legislative session. The funds will be awarded to both University of Nevada Schools of Medicine, Touro University and to Valley Health Hospital System and Mountain View Hospital in Southern Nevada, both of which are forming new residency program s. The lion’s share, however, was directed toward expanding primary care residencies in the state.
“We need to fill the specialities,” said Atkinson. “I’m hoping that by the next legislative session we will have been so successful that we’ll be getting additional funds for both primary care and specialties.”
There’s a need to fund residencies like dermatology and ophthalmology, and there’s also a need for fellowships in areas like pediatrics. To create some of these, UNLV is working with University Medical Center (UMC), Sunrise Hospital and the VA, where current UNR School of Medicine residencies are.
“We’re working with them to expand,” said Atkinson. Or to begin. 7:Dignity Health hospitals, for example, have never had residencies, but are working to create them.
Short-Term Solutions
Growing physicians isn’t a short-term goal. In 2014, the decision was made to create the UNLV School of Medicine. Financial support began in 2015. Accreditation was obtained in October for the first class, which starts summer 2017, and graduates 2021. Residencies last at least three years, and four or five for many specialties, meaning specialists will be working in their fields in Nevada – provided they stay – in 2025.
“From the year the legislature approved support for UNLV [School of Medicine], that’s 10 years before we have a new doctor,” said Schwenk. “That’s discouraging for some people, but it just means it’s taking us a while to catch up.”
Looking Ahead
“The most exciting thing is just being able to see the difference it’s going to make in the care of patients and in seeing the young medical students blossom in this exciting curriculum,” said Atkinson.
The new medical schools and residency programs will provide a shot in the arm for Nevada’s economy. According to Penn, a recent study showed the economic impact of medical schools within a state can be upwards of $1 billion.
“That’s everything. It’s the new people you bring on, the impact into the community, with all kinds of other services that grow and come out of that,” said Penn. Looking at that research, he believes Roseman’s College of Medicine will probably have an impact between $500 million and $1 billion. “UNLV talks about over $1 billion. The numbers are pretty huge. I think together the two new schools coming on could have a collective impact of anywhere from $1.5 to $2 billion,” he added.
Technology plays a part in the new medical education too. Electronic medical records, telemedicine to care for rural patients and robotic surgery are all innovations in the medical field, but today’s medical students will go into practice never having not known about them.
“We have to continue to evolve and meet the needs of the practicing world because we’re trying to prepare our students for that world,” said Penn.
It’s a collective effort that’s underway to do just that. Penn said, “That’s one thing when we as deans [of the medical schools], get together and discuss. How do we do it? Some things you have to do separately because you have to, but there is a ‘greater good’ phenomenon you have to consider. How do we work together to make this a better place for all of us?” added Penn
