Learning that their state continues to provide far too few doctors, nurses and other medical professionals to serve its fast-growing population, Nevadans sometimes ask Debera Thomas why she doesn’t simply add more classes at the Orvis School of Nursing at the University of Nevada, Reno. If only it were so easy.
Thomas, dean of the Orvis School, and her peers in medical education across the state struggle with knotty issues as they focus on training the hundreds of new doctors and nurses Nevada needs. The need is clear. The number of physicians in Nevada — one primary care doctor for every 1,768 residents by one recent count — ranks near the bottom of U.S. states, explained Marc J. Kahn, M.D., dean of the UNLV School of Medicine. By comparison, Vermont has one primary-care physician for every 886 residents. Specialists — physicians ranging from pediatricians to psychiatrists — are in particularly high demand.
“We are still pretty far behind in many specialties,” said Thomas L. Schwenk, M.D., dean of the School of Medicine and vice president of health sciences at UNR.
The situation is dire, too, in nursing. “Almost every state is experiencing a worsening nursing shortage, and Nevada is one of the hardest-hit,” said June Eastridge, dean of the Nevada State School of Nursing in Henderson.
Nevada is home to 724 registered nurses (RN) per 100,000 population, up from 642 per 100,000 a decade ago. The national average, however, is more than 920 RNs per 100,000, Thomas said. Again, Nevada ranks close to the bottom among the 50 states. The problem isn’t a shortage of potential students.
Touro University Nevada, an institution in Henderson that’s the largest medical school in the state, receives 4,000 to 5,000 applications a year for the 180 available slots in its physician-training program. Shelley Berkley, Touro’s chief executive officer and senior provost, notes that competition is equally strong for the other medical specialties at the school. Several hundred people compete for 40 available seats in the physical therapist program; more than 2,000 apply for 80 openings in the physician assistant curriculum.
The School of Medicine at UNR receives about 1,500 applications each year for the 70 seats available in each new class. About 1,800 applicants sought the 60 seats available in the class that began studies at the UNLV School of Medicine this year, and application numbers have been growing by 15 to 20 percent a year. The Nevada State School of Nursing just received 183 applications for 96 seats; the Orvis School at UNR heard from 150 qualified applicants for 64 seats.
“We are constantly amazed at how much interest there is in medicine,” Schwenk said.
Eastridge, in turn, said potential students seek out nursing careers for the personal satisfaction of caring for others as well the expectation that nursing will provide a recession-proof career with plenty of opportunities for mobility and advancement. Students in medical and nursing schools aren’t wrong about the employment possibilities.
Touro, which opened its Nevada campus in 2004 specifically in response to the state’s need for medical professionals, sees strong demand for its newly minted physicians.
“All of my students have multiple job offers before leaving Touro,” said Berkley. Thomas said 98 percent of the Orvis School’s nursing graduates have a job waiting for them the day they graduate, and all are employed within a year.
Why the Gap?
If demand is so high, and potential students sometimes line up 30 deep for a single opening, why can’t Nevada make up ground faster in the race to meet residents’ needs for medical professionals? Like many issues in healthcare, it’s complicated. For starters, Eastridge said a shortage of qualified faculty members has been an ongoing issue in nursing schools, and the shortage of teachers is only growing worse as college budgets are tightened during the COVID-19 crisis. The pandemic’s financial effects ripple across medical education.
UNLV Medicine, the clinical arm of the medical school, operates 15 clinics that generate revenue that is fed back into the school. Already, it’s feeling the pinch from the 6.5 percent cut in Medicaid payments undertaken by the state government, itself hard-pressed by the pandemic. Those challenges could grow if access to healthcare insurance changes and UNLV Medicine needs to treat more patients who don’t have insurance coverage, explained Kahn.
As significant as those financial issues are, the larger issue faced by medical educators — and the state as a whole — is the lack of enough residency positions for recently graduated doctors and the lack of enough clinical positions for student nurses. Graduates of medical schools need residency programs to complete their studies, and many new graduates have been forced to look elsewhere to complete residencies.
“If you don’t have residency programs, a lot of those students leave the state,” said Schwenk. “And some of them don’t come back.”
About 80 percent of students who complete medical school and their residencies in Nevada end up staying in the state. If they go elsewhere for their residencies, the number who return to Nevada can drop as low as 40 percent. If they don’t come back, the state is unable to count on them to help overcome its shortage of physicians.
“Most physicians practice in the same place they have trained,” Kahn said. “Until we expand residencies, fixing the shortage of physicians in Nevada will be a slow process.”
Schwenk notes that some hospital organizations in the state are stepping up their investment in creation of residency programs. The programs are costly, and hospitals don’t always get full reimbursement from Medicare for the patient care provided by medical residents. On the other hand, residency programs can provide some strategic advantages — not least, as a recruiting tool for Nevada hospitals.
Although Nevada is seeing a flurry of hospital construction in Reno as well as Las Vegas, new and expanded hospitals across the state won’t necessarily help much. Not every hospital is prepared to provide residencies or train medical students, Kahn said.
State lawmakers have paid attention to the issue. The Nevada Legislature made an important commitment, Berkley explained, with its decision in 2016 to provide funds — about $5 million a year — to jump-start residency programs around the state. Many of those grants have helped establish residency programs in medical specialties where physician shortages are particularly troublesome. Similar issues confound the folks who run nursing schools.
Nursing students are required to complete clinical training, essentially, an internship in a hospital or medical setting. But the number of available clinical placements is limited, and numerous nurse training programs are competing for those placements.
“We can’t take in more students if we don’t have the hospital room to place them, which ultimately hinders the progress we can make on graduating more nurses to combat the shortage,” Thomas said.
Budget cuts add to the problem. One faculty member is required to oversee eight nursing students who are completing clinical work in a hospital. Thus, Thomas notes, fewer faculty members mean fewer students can complete their required clinical training. Eastridge said new hospitals may provide some relief to the clinical training bottleneck.
“However,” she adds, “it takes time to create a culture that supports the presence of nursing students. We want our students to learn in an environment that welcomes them and understands their role in patient care. Having this clear definition and understanding prevents misunderstandings, frustration and incivility against students.”
Clinical placements became even more challenging when hospitals trimmed their clinical-training spots with the arrival of COVID-19. “Some skills involved in a practice profession need to be experienced and practiced in-person,” Eastridge said.
Nursing students can complete up to half their clinical hours using medical simulators, but Thomas said those simulators also are in high demand to teach medical students. And simulators aren’t always available at all. Hospital labor and delivery rooms are closed to nursing students during the pandemic, and UNR doesn’t own a birthing simulator. Thomas hopes donors will step forward.
The pandemic’s effects are felt in every corner of medical education. Campuses quickly moved to online classes and lectures with the arrival of the pandemic last spring.
The third- and fourth-year medical students who spend most of their time learning in hospitals were pulled from clinical training in March, so UNR’s School of Medicine provided simulated training, conferences and the like to keep its students engaged.
Even if they weren’t allowed in hospitals during the early days of the pandemic, UNR medical students volunteered in community health settings. Some provided COVID-19 testing, for instance, while others helped contact-tracing efforts. This autumn, schools carefully opened the labs that are important to medical education.
Touro, for instance, continues with virtual delivery of classes and lectures, but it opened the labs of its largely vacant campus for socially distanced hands-on coursework. “Cadavers cannot dissect themselves,” Berkley added.
She said the hybrid teaching model appears to be effective, and it’s keeping students on track for on-time graduation. That’s important to keep students from racking up more debt, and it maintains the flow of medical professionals into a state that badly needs them. On the other hand, Berkley worries that students in virtual classrooms won’t develop the close personal bonds common among traditional cohorts of medical students.
Still, Schwenk observes that disruptions in medical education are nothing new. The Spanish Flu pandemic, two world wars, the Great Depression, and the arrival of HIV all challenged medical educators and their students. “There are many ways to get to the point where medical students are well-trained,” Schwenk said.
Even though COVID-19 dominates the headlines, medical educators are looking beyond the pandemic. Roseman University of Health Sciences, a private non-profit institution established 21 years ago in Henderson, has reinvigorated plans to launch a college of medicine to join its existing programs in dentistry, pharmacy, and nursing.
To spearhead the new college, Roseman University this summer recruited a team led by Dr. Pedro “Joe” Greer, formerly a professor of medicine at Florida International University in Miami. Among Greer’s honors: He’s one of only three people in the world to have received both a MacArthur “Genius” grant as well as the Presidential Medal of Freedom. He describes the strategy of the new college of medicine as strongly community focused, starting with students who have roots in the Las Vegas area.
“We need to reflect our nation’s and region’s diversity in our students, and reflect it in our institution, our leadership, our culture, and our approach,” Greer said.
Among the cornerstones of the new school will be an emphasis on population health, the use of education and other tools to improve the physical well-being of all the people living in a geographic area.
“We know that it is a person’s zip code, not their genetic code, that determines their health outcomes,” Greer said. “Specifically, 70 percent of health outcomes are attributable to non-biological factors.” The new college is projected to accept its first class in the autumn of 2024.
The UNLV School of Medicine, meanwhile, broke ground in late October on the $150 million medical education building that will provide its permanent campus. The building on nine acres in the Las Vegas Medical District is expected to be complete in 2022. Its construction was funded by donors. UNLV expects to learn in February whether it will be granted full accreditation by the Liaison Committee on Medical Education, the accrediting body for medical schools in the United States. Kahn said the establishment of the UNLV School of Medicine is bringing benefits beyond the training of new doctors and improved health care for the community.
“The academic health center will attract biotechnology and research to diversify our economy and improve the quality of life for our citizens,” Kahn said. Schwenk added the effects of a strong system of medical education ripple through the state’s entire economy.
Quality education, he said, results in quality medical care. Quality medical care, in turn, ensures an excellent quality of life and becomes a cornerstone for economic development.
“These are the signs of a thriving, growing, successful community,” Schwenk said.