Nevada has one of the worst physician shortages in the country. Yet most of our medical school graduates leave the state to train and practice elsewhere. What’s the cure for this condition?
Dr. Karleen Adams looks forward to weekends — not because she’s off, but because she’s on. Her day at Valley Hospital starts at 5 a.m. and quickly ramps up into an intense and well-orchestrated whirlwind of activity. She examines patients, scrutinizes charts and lab results, consults with nurses about patients’ medication, attends lectures on diseases and hospital policy, discusses cases with attending physicians and stands by in surgeries to hold a laparoscopic camera or help close a wound.
Phew. If there’s a lull, she’ll answer some emails, get in some studying or grab a quick nap. A graduate of Touro University in Henderson, Adams is in her second month of a family medicine residency at Valley Hospital, a three-year training program at the end of which Adams will be a fully fledged medical professional ready to practice as a physician.
“You work incredibly hard,” she says of the 12-hour days that consume two of her weekends a month, “but it’s so rewarding. And it’s just an amazing place to be. If you work a 12-hour day without feeling like you’ve been there all day, it’s because you like being there. At the end of every day, I’m like, ‘Wow, what a cool job.’”
Sounds like the job is growing on her — and you might say Vegas is growing on her, too.
“I’m a Northwest girl,” says Adams, who grew up in Spokane, Wash. “I miss the greenery, the lakes and streams, but I’m starting to grow more attached to the whole Vegas area — because of the things to do, and how you become connected with the other residents here.” In fact, she’s thinking about staying on to work after her residency, as part of a United Health Services program. The program will pay her a stipend now in exchange for practicing in Nevada for two years after she wraps up her hospital training.
The fact that Dr. Adams is starting to like Vegas is important. It’s vital for doctors to like Nevada. Indeed, there’s another purpose to hospital residencies and fellowships beyond training tomorrow’s physicians, a purpose that’s a kind of social engineering for the greater good: Keeping that newly minted medical talent in our own community.
According to surveys, 60 percent of Nevada medical school students end up leaving the state after graduation to eventually practice medicine. That’s quite a brain drain. But that percentage improves when medical school grads stick around for training. Consider another statistic: About 58 percent of actively licensed physicians who completed their graduate medical education — residencies — in Nevada continue practicing in the state. That’s a bit better. Now consider this: Eighty percent of physicians who complete both their undergraduate studies and graduate medical education in Nevada remain to work in the state. It’s a rare (and positive) distinction that puts us at No. 4 in the nation for retaining our med graduates as physicians — a ranking that managed to hold steady even during the economic downturn.
“It’s an important statistic,” says John Packham, director of health policy research at the University of Nevada School of Medicine. “My mantra is, ‘Build these programs and they will stay.’”
The doctor is ... out?
And we need those doctors to stay — badly. Nevada has one of the worst physician shortages in the country. According to Packham’s most recent study, Nevada ranks 46th in the nation for the number of primary care physicians per capita — there are 173 of them for every 100,000 of us, according to some of the latest figures. And we rank dead last or close to last in the U.S. for general surgeons, orthopedic surgeons and psychiatrists. Fewer doctors doesn’t mean it’s just harder for you to get an appointment — or that you may spend a bit more time flipping through a month-old Time Magazine in the waiting room. The physician shortage also drives people to the emergency room for routine issues — expensive care that can drive up health care costs.
And a physician shortage isn’t exactly good for the local economy. “If there are certain specialties we don’t have, patients take their business out of state,” says Packham. “We know there’s a significant outmigration of patients who go elsewhere for care.” Packham tells an anecdote about an acquaintance who took his daughter to a doctor friend in San Diego to take care of a minor finger fracture because he wasn’t sure how long he’d be waiting in a Vegas hospital.
Sure, we can encourage the doctors we currently have to stay in the state, and try to import talent from beyond our borders. But the most common-sense approach on the table is to keep the talent we’re growing. Every year, Nevada produces about 200 combined medical school graduates from the University of Nevada School of Medicine and the private nonprofit Touro University Nevada, which opened in 2004.
“That’s not an unreasonable number of graduates,” says Dr. Thomas Schwenk, dean of the University of Nevada School of Medicine. “We rank comparatively well to other states for medical graduates. But it’s in sharp contrast to how low we rank in medical residencies and physicians per capita.” We rank 45th in the nation in primary care residents per capita.
In other words, there’s a bottleneck: We’re producing a healthy number of medical graduates, but not as many opportunities for post-graduate training in the form of residencies and fellowships — again, the glue that keeps those brand-new doctors in town for years to come. In any given year, there are anywhere from 100 to 130 residency slots available in Nevada, which are open to medical grads around the world. The University of Nevada School of Medicine has 12 residency programs, including internal medicine, family medicine, general surgery, plastic surgery, pediatrics and OB/GYN. Those programs have more than 100 slots open for a multi-year residency in any given year, most of which take place at University Medical Center. Meanwhile, Valley Hospital, which partners with Touro University to train its graduates, has seven residency programs. In any given year, about 30 slots are open in those. There’s the bottleneck: About 200 med grads a year statewide, with 130 or so residency slots open to applicants from around the world. Plenty of med grads, not enough residencies.
That disparity feeds into an annual glut of medical graduates who don’t match into a residency program at all. According to the Association of American Medical Colleges, this year, more than 34,000 medical students applied to more than 29,000 residency slots — leaving many eager young doctors without a program to complete their final training required to practice as doctors in the U.S.
Money infusion, stat!
why don’t we just make more residency slots? We don’t control the purse strings. Largely through Medicare, the federal government is in charge of paying for graduate medical education, kicking in about $9 billion a year to fund more than 100,000 residencies nationwide. State governments, grants and other money fill the gaps. The problem? The Balanced Budget Act of 1997 essentially froze the number of federally funded residencies, leaving states to scramble and scrape for ways to create new post-grad medical training programs to meet rising demand.
“Whether there are 10 or 100 spots, once they’re filled, that’s it. I blame Bill Clinton,” jokes Dr. Jerome Hruska. He just completed his residency in internal medicine at Valley Hospital, and is about to start a fellowship there in pulmonary critical care. He witnesses firsthand the physician shortage, noting he often sees patients in the emergency room for routine issues. “At certain times, you’re taking ER calls, and you’re kind of like, ‘Where’s the help?’ It can get a little frustrating.”
Hruska originally wanted to pursue a residency in orthopedics after medical school, but such a residency didn’t exist in the state at the time. It brings up another issue. The residency shortage is not just a question of depth. With its relatively slim portfolio of slots, Nevada lacks residencies in specialties and subspecialties that Nevadans need.
“The lack of numbers of residencies and fellowships is an issue,” says Packham. “But we also lack breadth. We have a pediatric residency you can get here, but we don’t have pediatric oncology or pediatric endocrinology. We lose that person we might have had as an undergraduate. We need more specialized training.”
He adds: “But I caution people that if I were the czar, I’d say we need to expand our primary care offerings as well. Yes, we’ll need specialists, but those 300,000 or 400,000 (Nevadans) who will be newly insured through the Affordable Care Act will need primary care doctors.”
“Last year, we graduated the first class of oncology fellows, and 75 percent of them stayed on to practice in Nevada,” says Dr. Miriam Bar-on, associate dean for graduate medical education at the University of Nevada School of Medicine. “That’s very good, but if we have students who want to go into anesthesiology, radiology, orthopedics or pathology, they absolutely have to leave the state. We can’t address these because we don’t have the programs.”
There are emerging alternatives to relying on the feds to bankroll residencies, but it’s not like you can create a program with a fat check and a handshake with a hospital. Establishing residency and fellowship programs is a complex endeavor. In fact, some hospitals are hesitant to embark on building them, and little wonder: It’s like bolting on an entire new department.
“Money is the first step,” says Dr. Bar-on. “We need resources, and the Accreditation Council for Graduate Medical Education is very specific about faculty-to-resident resources. For example, if you want to have an orthopedic residency, the requirement says there has to be a specific resident-to-faculty ratio, and orthopedic faculty don’t come cheap.”
“It’s an investment,” says Dr. David Park, Touro’s chief academic officer for the residency program at Valley Hospital. “It’s a money investment and a personnel investment. The hospital needs to create a new department of graduate medical education, hire a program director, hire a director of medical education, have coordinators for each program, and obviously these people work with medical staff. We’re talking a seven-figure investment. Once the residency gets going, Medicare will pay that back, but it takes time.”
Don’t need no (undergrad) education
You might think those involved in the campaign to improve Nevada’s graduate medical education opportunities would favor another medical school. Not the case. At least at the moment, they see another medical school as only throwing the ratio of med school grads to residency slots even more out of whack.
“The confusing thing is that often the media and our legislators think that undergraduate medical education and graduate medical education are the same,” says Dr. Mitchell Forman, Touro’s dean of the College of Osteopathic Medicine. “They’re very different. We believe we don’t need more undergraduate medical education.” His response to Roseman University of Health Science’s April announcement of its intention to launch a medical school in Henderson is blunt: “That could not have happened at a worse time. All these entities will be competing for limited numbers of clinical clerkships and residencies. What we need is more graduate medical education. We have to have facilities willing to open up to these programs. We need to help them in doing that, and we need to look at alternate mechanisms of funding.”
UNSOM’s Packham agrees. “My feeling on that is that we don’t really need another medical school as much as we need to expand those residency programs,” he says. “We can graduate all the M.D.s we want, but all that means is a much more competitive race for those static number of residency slots.” Congress recently tossed Nevada an extra handful of residencies, but it’s a drop in the proverbial IV bag. “If you ask me whether we need a new medical school or more graduate medical education, I say double graduate medical education.”
Packham wrote an April editorial for the Reno Gazette Journal, blasting the idea of a new medical school in Las Vegas. He writes, “Calls for a new medical school divert precious energy and attention from Nevada’s most pressing health workforce need: expanding our state’s primary care workforce. ... In particular, Nevada needs to aggressively expand residency programs and graduate medical education opportunities for physicians in primary care fields such as internal medicine, pediatrics and family medicine, and most of this expansion must take place in Las Vegas. The evidence is clear that if you build these programs, a significant majority of physicians completing their training in Nevada will remain in the state to begin their medical careers.”
Leaving the waiting room
So what’s the solution? No easy ones but hard work, innovation and enterprise. Officials at Nevada medical schools aren’t waiting around for the feds to loosen the purse springs. Instead, they’re scraping up money from nontraditional sources and forging relationships with private institutions.
Dr. Forman of Touro University is proud of the partnership Touro has struck with Valley Hospital. He hopes to create more of those partnerships, though he says it doesn’t help that our private hospitals are mere nodes of larger corporate healthcare juggernauts with distant headquarters out of state.
Also in that vein, Dr. Park of Touro says he’s close to landing some landmark private funding to create even more residencies in the Las Vegas Valley.
“Instead of being handcuffed to the 1997 Balanced Budget Act, we’re pursuing innovative new ways where local organizations may help fund new graduate medical education,” says Dr. Park. He declines to name the organization he’s hooked up with, but he says, “It’s moving forward and making great progress.” His target date for the launch of the program is July 2014.
Meanwhile, over at the University of Nevada School of Medicine, Dr. Schwenk is overseeing the creation of a long-sought fellowship program to train child and adolescent psychiatrists, which he also hopes to launch in July 2014. “This is a very creative, non-federal government-based approach to developing training in a critical shortage area,” he says. Rather than hit up Congress for money, his team raised $2.5 million for a two-year fellowship program from state agencies such the Department of Child and Family Services and the Department of Juvenile Justice.
Cinching the money also required wearing new hats: Child and adolescent psychiatrist Dr. Lisa Durette led the fundraising campaign.
“I’ve been essentially panhandling for the last couple years,” she jokes. “Fundraising was a totally new venture for me, so I was kind of a fish out of water. But on the other hand, I don’t know who could be a better advocate, telling these agencies, ‘Here’s what we do as child psychiatrists, here’s what we can offer to a community that needs us.’ This is one of the most underserved specialties in town. Kids need this, and we need fellows.”
What also might ease the doctor shortage is a new state law that went into effect July 1, allowing nurse practitioners to practice limited forms of medicine without the supervision of a doctor. Previously, nurse practitioners had to be contractually tied to an overseeing physician. The new law allows N.P.s to practice independently, offering a menu of basic care that includes standard turn-your-head-and-cough fare such as X-rays, mammograms, diabetes care, blood testing and general consultation. The idea is to free up these skilled nurses to absorb the rising demand for health care amid our chronic doctor shortage — again, one that’s only going to become more apparent when the Affordable Care Act goes into effect in 2014, giving roughly 30 million more Americans health insurance. But Packham says we need “heavy lifting” — more graduate medical education — to meet the coming demand.
None of this is to say that medical students leaving the state is all that bad — as long as those new doctors come back. “I actually like medical school students to get out and see a different perspective rather than staying here the entire time,” says Dr. Jennifer Baynosa, chief of UMC’s residency program. This summer, she’s overseeing 29 residents at the county’s public hospital. “We don’t want to inbreed. It’s valuable to get a good education elsewhere and bring it back to Nevada, and the medical school side is very active in trying to recruit those graduates back. They talk to those stellar students before they go away on their residencies, talk about what their plans are, and encourage them to come back.”
And it doesn’t hurt if they’ve already got a soft spot for Southern Nevada. As Dr. Adams continues her family medicine residency at Valley, her post-residency plans and visions change with each new experience.
“I kind of always imagined myself being a small town doctor, having some property off the grid and providing services for services in return,” says Adams. “But my vision has changed so much. At first I wanted to be anesthesiologist, then a dermatologist, and now I’m in family practice. I just want to complete this residency, learn as much as possible, and be the best damn doctor I can be.”