Nevada needs many more doctors.

What's working and what isn't to increase their numbers, that's this week on Nevada Week.

♪♪ Support for Nevada Week is provided by Senator William H. Hernstadt.

-Welcome to Nevada Week.

I am Amber Renee Dixon.

And if you're new to Nevada, you may have trouble finding a doctor.

Nevada ranks 45th in the country for the number of active physicians in the state, and 48th for primary care physicians.

There are several reasons why this physician shortage exists, and here to explore solutions to it are Dr. Marc Kahn, Dean of the Kirk Kerkorian School of Medicine at UNLV; Dr. Wolfgang Gilliar, Dean of the College of Osteopathic Medicine at Touro University Nevada; Maggie Arias-Petrel, Secretary-Treasurer of the Nevada State Board of Medical Examiners; and Dr. Pedro "Joe" Greer, Founding Dean of the Roseman College of Medicine.

Thank you all for making yourself available for an important discussion.

I want to start with you, Dr. Joe, or should I say Dr. Greer?

-How about Joe?

-Okay.

Joe, all right.

I looked at my birth certificate.

There was no doctor.

[laughter] -Congratulations.

Your university is now a medical school.

(Dr. Pedro "Joe" Greer) A medical school with pioneering curriculum and trying to prepare the very best doctors that we possibly can.

I got, I got these two guys here that have set the bar so high that I got to try and catch up with them.

-So preliminary accreditation, you got that in February.

What does that now allow you to do?

-That allows me then to go up in front of what's called the AAMC, the American Association of Medical Colleges, and their Council of Dean.

Once they approve us, which they did a week later, then we could start admitting students.

We have a very short window.

Our window is we're going to start our first class July 21.

Having said that, within a week, we already had 700 applications.

-Wow!

-And of that, we've already had a little over 300 going to what's called a secondary aspect of the application where they actually have to pay a fee.

And so we're very excited.

We have, of that, at least 15% are actually students from Nevada.

-Very cool.

So this means that Nevada now has four medical schools?

-Yes.

-Yours, UNLV's, UNR's, and Touro's.

Dr. Gilliar, is four enough?

(Dr. Wolfgang Gilliar) I would think at this moment, it is absolutely enough; but we may realize down the road that we need more.

Actually, we are so fortunate, I think, in Nevada, to have four medical schools.

And this is really the beginning of formulating the need, or to supply the need for physicians.

Touro, for instance, was founded 20 years ago, knowing that there was a lack of physicians.

So there was a mission to bring physicians and grow them.

And so when you say, is it enough, I would think we can show that there is enough, because right now, more than than 1/3 or so of our students have to go outside of the state because we don't have the residencies here.

-And that's the big issue here, right, Dr. Kahn?

Is that where you would start in solving this giant issue of the physician shortage?

(Dr. Marc J. Kahn) So when you look at numbers from our state, if a student graduates medical school in the state of Nevada, they have about a 40% likelihood of practicing in state.

If they complete a residency in state, they have about a 60% likelihood.

But if they do both medical school and residency, now we're up to 80%.

So increasing our number of residency positions is critical to getting more doctors in the state.

The number of residency programs funded by the federal government was frozen in 1997.

We were a very different state then, and, as such, we only have about 403 federally funded positions.

We need a lot more, and we've been, I think, successfully talking to lawmakers, the governor, et cetera, to provide state funding for residency programs.

And that's at least a partial solution.

-To give some context, how many residency positions does California have that are funded by the federal government?

-Over 9,000, and New York has over 18,000.

-Okay.

Now-- -And in these cities, you sometimes have four to seven medical schools.

So if you go to New York City-- -I'm from New York, where we had 16 medical schools.

-Well, so, and then, did I see it right?

Did you disagree with Dr. Gilliar when he said that four is enough?

Did I see you say-- -Well, no, I don't disagree with him at all.

The reason four is enough is because we don't have enough hospital beds to train all the doctors.

So your limit-- that's your rate-limiting step.

He is 100% correct.

Is four enough?

The entire country has a shortage of physicians.

We just suffer more of it, but it's the entire country.

I mean, the wait to get a primary care doctor anywhere in this country is three to six weeks.

That's why everybody's going to the emergency room and urgent cares.

-And in our state, you know, we talk about a primary care shortage, which we certainly have, but, in fact, in our state, we don't reach the 50th percentile in physicians per capita in any specialty.

So we're short on surgeons, we're short on hepatologists, we're short on hematologists, we're short on rheumatologists, physical medicine and rehab; we're short across the board.

-It's 100%.

And you need these things across the board.

When you have metabolic disorders--and I'm talking as a liver specialist--that increases your risk for what we call fatty liver and the NASH, nonalcoholic steatohepatitis and then cirrhosis.

That has become the number one reason for transplants.

This has to go back to a healthy lifestyle.

This has to go back to affordable living.

This has to go back to all these different things that we need to take care of.

And then we, as medical schools, pick up certain slacks.

For example, I know that with UNLV, Touro, and we also, we take care of the most vulnerable populations.

We take care of the homeless, the uninsured, and the underinsured.

And why do we do that?

Because somebody has to, number one, and number two, these situations are wonderful learning experiences for our students.

Remember, a medical student generally comes from an affluent family, so for them to try to understand how a family of four is surviving on less than what they pay in tuition is not an easy concept for a 23, 24 year old that's been in universities their whole life.

But we have that responsibility to take.

So you now have three medical schools in Las Vegas that people are paying to go to so they can take care of the most vulnerable.

-Dr. Kahn, you have said on this show multiple times, this is a two-pronged approach, growing from within but also bringing doctors in from out of state.

When you moved here in-- was it 2020?

-Correct.

-Your primary complaint was with the Board that Maggie sits on.

-So I don't-- I want to give my friend an opportunity to talk, and I think she's got some exciting things to bring forward.

So this is the Allopathic Board.

Dr. Gilliar can talk about the Osteopathic Board.

But it was challenging.

Some of that may have been related to the pandemic, but it took me nearly a year to get a license with academic credentials and Board certification in three specialties, et cetera.

I know my colleague, Dr. Greer, can comment on that as well.

So we do need some fixes, and I'm enthusiastic that I think fixes are in the works.

-Maggie, let's talk about the results of this past year.

-Absolutely.

(Maggie Arias-Petrel) So what I could tell Dr. Kahn is that we heard you, and we have actually taken, at least from my time on the Board, many steps to make that happen with the help of technology and also retraining staff and everything like that.

We are here to support our growth.

So the numbers are actually very good.

From just from '23 to '24, we went up to 19% in processing the applications and granted license from 75 days, right, approximately to 39 days.

And also the licenses have gone up by 24%.

So that, in itself, is, is good news for our state.

Is it taking care of all the needs?

Absolutely not.

We need more providers.

We definitely need what I call the frontline medical providers, your primary care providers, your internal medicine, your pediatricians, OB/GYN.

So I've been, you know, lucky enough to go and see at the national level what other states are doing.

How can we bring best practices here?

You are so right.

There are other states that are so lucky to have so many medical schools and programs, and so they don't see the pain that we go through in just trying to recruit doctors.

I've been in healthcare for 30 years in Las Vegas in the administrative side, and when I moved to Las Vegas-- -She started when she was seven.

-So when I moved to Las Vegas, my job was actually to recruit doctors to come to Las Vegas.

And that in itself was, you know, we had to work magic to bring people and doctors and ties to come here.

-But at the same time, when we spoke ahead of this, you told me that doctors at one time looked at Nevada as a place to come to perhaps escape some trouble in their past.

-Well, yes.

And I've seen that with the Board-- not you.

[laughter] -That's why I left Miami.

[laughter] -But, you know, it does happen.

I, you know, we do have those to where we don't just deny licenses, we like to have the doctors come and answer some of the questions that were the, Yes, I did this or I did that.

And so, you know, we like to be fair and interview those doctors.

And yeah, I mean, they have, pretty much have been jumping from state to state and with all kinds of crazy stuff.

-And that's still happening?

-It does.

-The other problem arises when you employ doctors, because if you employ a doctor and they're not licensed, you're paying a doctor's salary without that doctor bringing anything in to the bottom line.

So, I mean, you just can't go and say, Go get your license, and then I can employ you.

You're recruiting.

-Yes.

-So that's the other rate-limiting stuff.

-And we are educating the doctors, because oftentimes they would be honest and say, Look, I didn't fill out the application.

It was my secretary, my assistant.

So we always tell them, Doctor, this is a document where you need to review it.

You need to sign it.

Because if, if you were supposed to say yes and they answer no, that delays the process.

So we want to be-- it takes a little bit of education, but I think we're getting good at that.

-Dr. Gilliar, I've seen you make all sorts of facial expressions during this.

Where do you want to start?

-Part of that is that all of this is really true.

And this is why we are here, because the complexity of so-called healthcare, but having physicians, enough physicians, is not one solution.

And I'm a general systems thinker.

I'm an open systems thinker.

What I mean by that is we need to look at various options of bringing the brain and brain power together to solve the problem.

We have an Osteopathic Board here, licensure board, which is working.

In one month, you have your license if you are aligned well.

And they are really, they're to be done in one month.

So why this should be excluded or go somewhere else?

I don't know.

Some people are trying to do that, but it's okay.

That's on the plate, on the platter.

But having-- for instance, we just graduated, or about to hit our match, almost 100%.

One student didn't make it for whatever reason.

But out of those, we have 55 students who are staying here.

-Tell us about your Match Day.

-Match Day is, to me, the culmination of a person's dream when you go from the dream to reality and when you not only know where you're going, but who you will be.

-May I add that each of us get a medical student.

That's four years of education, undergraduate medical education, then the graduate medical education residency can be from three to seven years or longer.

So when we're bringing them in, it's a minimum seven years before they can practice.

-Right.

-And maybe 11 years.

So that's why the other part of bringing people in becomes so important.

-Okay.

Let's go back to what Match Day entails.

-Match Day is the day when the students literally receive an envelope where they are being told at one certain time when you open up, of which institution you go to and in which specialty you have matched, where you will be going for the next 4, 5, 6, 7 years.

-To do your residency?

-And to do the residency, exactly.

-Known as graduate medical education?

-That's correct.

-How many students graduated?

-Okay, we have 169 who participated in that match.

And out of those, 168 found a spot, total are going.

-How many in Nevada?

-How many of those?

55 will be staying here.

-And we had 60 students in our match, and 43% are staying in state.

Again, there's a shortage in training positions.

Ours was fun, because ours was magical, because ours had a Harry Potter theme.

-Yes, and you played the trumpet.

-Trombone, but yes.

-Trombone, sorry.

-Not very well, but it's okay.

-I raised the champagne glass.

-He's from New Orleans.

[indistinct] -But I raised a champagne glass.

How is that?

-Wonderful.

Well, and we have video of those Match Days to show.

It's really, really neat.

Let's talk about last legislative session, because there was $8.5 million set aside for graduate medical education in Nevada.

What happened to that money?

-You know, I don't know.

There was a committee formed that included the deans of the medical schools.

That committee did not meet.

-Never?

-So we need to change the way that we're doing things.

And there is current legislation to make changes in the process and to put the money into a different part of the state, and we're enthusiastic about that, because all the three deans would be on that panel.

-This is what they told me up there, that, No, no, because one of the things that we do, we're educators.

They're scholars.

I'm not a scholar.

I'm an educator.

I'm an administrator.

But one of the things that is most important is we increase the quality.

Because it's not just an issue of having a physician.

You want the best physician.

I mean, my goal is to take the old saying you had here in Vegas, that "What happens in Vegas stays in Vegas."

I want us to be so creative that what happens in Vegas, I want the world to know.

I want them to know what you can do in a state where you're not anchored by the traditions of the East and the West Coast, where you can actually bring in new ideas and education to prepare the kind of doctor we need, because we as a profession have a problem.

There was a recent article in the Wall Street Journal about why Americans don't like doctors.

We had the biggest drop from before the pandemic, after the pandemic of any professional group.

We went from the 80s to 53% of approval.

-Distrust.

-So we need to-- -Can I add something?

-Then I want to jump in.

I have something.

-What I would like to propose is exactly the direction you're saying.

Years ago, one of my patients said, Dr. Gilliar, when I arrived here in the '70s, we had to say, we go out into the airport, all of that stuff.

But we also said at that time, We don't have culture.

We don't have sports.

Look what we have now.

We have the Smith Center.

We have all the sports teams.

We are the best or the largest entertainment capital, if you want.

Why don't we do exactly what you said, invest into Nevada as the leader of productive, innovative, visionary healthcare because of the problems we have.

And I'm going to ask all of us to say, stop and forget the past and say, we have to go the airport, all that stuff.

But I'm going to say the state and us have to find $100 million, not 8.5 million or 10.

We need $100 million for 10 years to really look at the healthcare, to not go and go from pockets of very good ones.

We have very good ones, and I love it here in Las Vegas, but we need to really come together and say, This is our mission, almost like a startup.

And I really think then we can drive it.

-And let's not forget.

Let's not forget, a plug for UNLV, that we have one of the world's best hospitality schools.

We're a hospitality community, so let's take advantage of those concepts, and let's make healthcare consumer friendly.

Let's borrow knowledge that our folks in the hotel industry know about.

And let's not make only the quality good, but let's make the experience top notch as well.

-And this is going to become important in positions being paid in the future, because customer satisfaction is going to be one of the criteria; whereas, the profession of medicine is the only business in this country where the client is not the most important.

-Dr. Gilliar, you're asking for $100 million over the next 10 years for graduate medical education?

-For a group coming together and say, How can we formulate the best healthcare development for the state, not just graduate medical education.

-So then let's go back to the 2023 legislative session.

That group is established by the legislature.

Two years later, it still hasn't even met.

-And that's only part of it, because if you're doing what Dr. Wolfgang is saying, guess what?

You could have all these mental health therapists.

That's the number one public health problem here.

Instead of just forming psychiatrists, where you could have a psychiatrist managing a team of therapists that can get out there.

We have to be really progressive in how we think and approach this problem.

The idea that it's just us physicians that are going to resolve this problem is really nice thinking in 1952, but we're a team.

-I think we need to include community and also make, make a roundtable of everybody, not just the deans, but include everybody, community.

-I think that panel was supposed to include a ton of different people.

-It was, and I'm lucky being at a university like UNLV, where we're, you know, we have the formulation of an academic health center.

So we have five health science schools: Nursing medicine, dental medicine, integrative health, and public health, and then we have behavioral health.

And we're working together as a group of people to try to solve these problems.

But Dr. Greer is spot on.

This is not just a physician problem.

This is a teamwork problem, and Dr. Greer and I are about the same age, although he looks a lot younger than me.

-I'm a lot older.

-But anyway.

But we, you know, when we trained, the doctor-- we talked about doctors, we didn't talk about teams.

But now we know how essential teamwork is in providing quality health care.

We need to teach our students that.

-You need your nurses, you need your, your PAs, your nurse practitioners.

I mean, they're all part of the-- -Your community health workers.

-Yes.

-Maggie, one of the critiques of the numbers that you were talking about for increased medical licenses, as well, how many of them are actually moving to Nevada, relocating here?

And some are not.

They're actually doing telehealth.

But you told me a different perspective on how to look at that in regards to mental health.

-Yes.

I could tell you that more in an administrative side in trying to provide health care for our patients.

So we have actually granted licenses to doctors that do this telemedicine for mental health, especially, in trying to reach areas that are remote and, you know, where definitely they don't have the, this, this kind of medicine.

And the technology is amazing.

I mean, they have now this kind of like a 3D situation where the patient has experience, especially for mental health.

So the technology is there, and we've been, you know, open-minded to all of those things.

While we work here, in having our own providers, we have to rely on those other aids, if you would, to have that available for our patients.

-I want to get into-- -I want to add something else.

During the pandemic, we tried telemedicine.

The problem was there were so many folks, especially people of color, Hispanics, had no doctor.

If you don't have a doctor, telemedicine doesn't work.

You need somebody at the other end of the, you know.

-Wow.

And that's a great point.

-Need a primary care doctor.

-Okay.

Let's talk about this legislative session.

What about Senate Bill 124, which would be-- it's a reintroduction of a bill, and it would allow students who have graduated, who have gotten a medical degree in a foreign country.

Can someone help me?

I lost my particular work.

-So, I mean, I think-- -But what is it?

It's for a foreign medical student to get a limited license.

-Which, first and foremost, a foreign medical graduate has the same pathway to get a license in this country as anybody else.

So why do I want to give a limited license to somebody that is not qualified?

The idea is getting qualified people here.

I mean, we went through this in Florida, too, where we would see a large influx of Spanish-speaking physicians leaving their countries for whatever reason, coming to the United States, and they tried to pass a bill saying, Well, they can keep up with their CMEs, continuing medical education, through literature in Spanish.

Well, literature in Spanish here lags behind the literature in English, lags behind the literature in German, lags behind the literature in French.

So even though they could understand that you want them to have the most current literature-- you want the best qualified.

-Dr. Gilliar?

-I think I was initially against it.

-Last year, or last session?

-Last session and this session.

-And this session.

-I spoke out simply because I figured it didn't have enough teeth.

Now there is some provisions in there that I say it is one pathway we can support, because I don't think it's going to be a major pathway.

If there's a way that proves to us it works, I have no problem with that.

-You do support it, or do not?

-I do support it.

-And you, the Nevada State Board of Medical Examiners?

-We do, and I tell you why.

So we opposed last session, obviously, but at the national level, we saw that the Federation of National Boards, they had a big presentation in Washington, D.C., where they educate everyone what the disparities were in terms of licensing, the percentages of licenses to other countries, but, yet, nothing that will help with, especially with, you know, minorities in itself.

So and they they have a language, and they also have mentorship through the university.

So that's why it's important to have the universities very involved.

In my opinion, you know, they kind of serve as the bridging the gap of whatever those doctors don't have.

So it's sort of like a pathway, in a way.

You know, I've had a meeting with Senator Doñate, who was working and sponsoring, and I, you know, suggest that even some language that needs to be there, because it could not be like a mandate.

It shouldn't be a mandate, and it has to be taken case by case, because not every country has the same education as we do here in the States.

There is some universities outside United States that follow the American curriculum.

So that could be where, okay, those are, you know, they could, they could pass the test and they could potentially be good to practice here.

But then you have those schools that, you know, is four years and the training is not there.

-Dr. Kahn?

-I think, you know, as-- I think the devil is going to be in the details.

There are certainly very highly qualified, exceptional foreign-trained physicians.

I think, though, we have an obligation to our communities and our patients to make sure that the care is up to date and appropriate.

And as Dr. Greer alluded to, there are pathways.

And you talked about residency programs overseas.

The group that oversees and accredits residency programs, the ACGME, the Accreditation Council for Graduate Medical Education, has an international branch, ACGME-I.

So it's not hard to fathom that folks coming from overseas should come from a program that's been certified by ACGME-I.

And then, finally, the American Board of Internal Medicine, that Dr. Greer and I know well and others, have pathways for internationally trained people to take the same boards that Dr. Greer and I took, and I think people-- -He has the last word, because we have run out of time.

-We have run out of time.

-But we'll have you back next year.

We'll do this all again and see what kind of progress has been made.

How about that?

-That's true.

And now that you have an SEC coach at the helm of the football team at UNLV.

I've been an SEC guy myself.

-This is not very relevant.

-And you got the ACC too.

-Thank you all for joining us.

And thank you for watching.

I'll see you next week on Nevada Week.

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