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The power of two
Story by Heidi Kyser
After years of bad blood and north-south infighting, we may finally have a cure for Nevada’s med school crisis
People outside health care might not realize we have a public medical school in Las Vegas. Well, sort of one. That is, we have third- and fourth-year students from the Reno-based University of Nevada School of Medicine (UNSOM), who come here to do their clinical rotations. Often, they don’t stick around in Las Vegas after med school, either. They move on to cities with big hospitals that offer lots of residencies and fellowships in sought-after specialties. The unproductive north-south divide in the medical school — future doctors do their academics in Reno, their clinical work in Las Vegas — reflects the state’s political divide: The decision-makers are in the north, but most of the voters are in the south. And it’s been the source of just as much tension, bad blood and hard feelings.
Now, two Nevada newcomers, respective deans of the established and an emerging medical school, are attempting to bridge the river of bad blood flowing between Reno and Las Vegas over public funding of medical education. They may just have a shot at success too, given the stakes: vast, much-needed improvements to their institutions and billions of dollars in potential economic impact to their communities.
“The bottom line for me is about public medical education coming together to collaborate around growth. We want to stay together and expand together,” says Thomas Schwenk, dean of the UNSOM, who’s been trying to patch up north-south wounds since he arrived in 2011.
“Tom and I have been meeting regularly to talk about issues and how we’ll do things. We want to make this twice as good for the state, not drain one city for the benefit of the other,” says Barbara Atkinson, who was coaxed out of retirement from the University of Kansas Medical Center in May to lead the creation of UNLV’s new medical school as its first dean.
Schwenk and Atkinson may simply be singing the same publicity tune. Or, they could find themselves in a situation where rivals frequently do: banding together to slay a common enemy — in this case, the dearth of public funds for new projects. For the current fiscal year, the state allocated $30 million for UNSOM, which has a $160 million operating budget. The government’s contribution has decreased over the last five years. Nevada has a doctor shortage — we ranked 45th in the country for number of physicians per capita in a 2010 report by the Association of American Medical Colleges. To get more doctors, we need at least one bigger, better medical school than UNSOM, which graduates 60 students per year, as well as more fellowships and residencies at hospitals. But on the state’s financial diet, expanding public medical education has been next to impossible.
The lack is most apparent in Southern Nevada, with the bulk of the state’s population. A 2011 Brookings Mountain West study found that greater Las Vegas is the largest U.S. city without an M.D.-granting medical school. Of the top 100 U.S. metropolitan areas, we have the smallest share of health services despite being the 30th largest city.
“We’re only doing 64 percent of the medical business expected for a population center of our size,” Brookings Director Robert Lang says. Besides losing the direct spending on health care, he adds, the city misses out on the potential influx of government research grants and patent royalties, as well as the indirect economic boost from office jobs and demand for lodging, groceries and other amenities.
On Aug. 22, a statewide steering committee that includes Atkinson and Schwenk, along with the presidents and provosts of UNLV and UNR, will make its recommendations on public medical education to the Nevada System of Higher Education Board of Regents. Once the regents approve the recommendations, they’ll pass them along to Gov. Brian Sandoval in the hope he’ll accommodate them in his next budget and the Legislature will adopt them in its 2015 session.
Getting to a general consensus on the recommendations was already a major accomplishment, but the hardest part is yet to come: convincing the public and elected officials that Nevada needs two medical schools — and that it should fund them.
“I’d say that’s still a work in progress,” Schwenk says. “It’s complex anywhere, and 10 times more complicated here, because of the history involved.”
The present past
UNSOM was established 45 years ago. For the most part, its students do their academic training in Reno and their clinical training in Las Vegas. In the ’90s, Lang says, there was some discussion about moving UNSOM south, but it didn’t go anywhere. If it had, he believes, it would be like the University of Oregon’s medical school: much higher-performing, because of its location in the larger metro region of Portland, rather than the school’s hometown of Eugene.
“And it would still benefit UNR,” Lang says, “but they didn’t want to do that.”
Atkinson experienced a similar situation at the University of Kansas Medical Center, which she led from 2002 to 2012. In the 1960s, she says, the university, based in Lawrence, expanded to a full-time medical school in Kansas City, where the population was large enough to train doctors. Wichita is actually the biggest city in Kansas, though. There was a branch campus there with its own building, but, like UNSOM in Las Vegas, it was only for the third- and fourth-year students — and some 50 of the 175 total students enrolled. During Atkinson’s tenure, she expanded the Wichita campus to a full, four-year school, in addition to starting a campus focused on primary care in the more rural town of Salina. The University of Kansas medical school now graduates a total of 211 students per year.
Money is one reason why cities hoard medical schools; they tend to be good economic engines. A study published last year by market research consultancy Tripp Umbach found that a new medical school in Las Vegas could generate an annual impact of $1.2 billion by the time it matures in 2030 (the current medical school generates an impact of approximately $316 million). Atkinson thinks that projection sounds about right, considering Kansas’ medical school went from $700 million when she arrived to $1.2 billion when she left.
“There are some politics around a medical school — where it’s going to go and who gets the goodies,” Lang says.
One unintended consequence of keeping UNSOM based in Reno has been a preponderance of private hospitals in the Las Vegas market. With no school to anchor an academic medical center, the local hospital system has developed in an insular, competitive fashion. Lang believes that both universities in the Nevada system having equal access to public investment in medical education would create a “Switzerland effect” — the medical schools would provide a strong, neutral public factor to offset the dominance of the private market. This would attract more high-level specialists and raise the quality of care across the board.
“We have good physicians, just not enough of them,” he says. “Right now, if you call for certain things, you’ll get an appointment to be seen in October. Do you sit on it and wait, or hop in your car and drive to L.A., where they can see you next week? That’s money spent in L.A. that could be spent here.”
The current Affordable Care Act-induced upheaval notwithstanding, medicine is generally a stable industry. Exporting clients rather than importing them, insiders say, moves the city (and, consequently, the state) one step away from its goal of economic diversity. But we won’t get the physicians we need to keep patients in town without a medical school. So, how do we get a medical school … or two?
The new, new way
After arriving in Nevada three years ago, Schwenk spent some time getting the lay of the land. Then, he hatched the plan he was originally hired to hatch: UNSOM would expand both its Reno and Las Vegas campuses, filling in each one’s gaps — more clinical training up north; more academics, including a classroom complex, down south. With the help of public and private investment, the two campuses of UNSOM would grow simultaneously until, some time down the road, they could be spun off into two separate, full-fledged medical schools.
Sounds great, right? Not to those who’d been baptized in the river of bad blood. For instance, Lindy Schumacher recalled how, in her former position as director of giving for the Lincy Institute, she’d been convinced to donate money to UNSOM for a Las Vegas medical school that never materialized. As Schwenk’s plan began to make the rounds, she publicly expressed her reluctance to be fooled a second time.
[HEAR MORE: What’s so important about medical residencies? Learn the answer on "KNPR’s State of Nevada."]
Meanwhile, UNLV’s Lincy Institute had commissioned Tripp Umbach to do a comprehensive med school feasibility study. CEO Paul Umbach himself presented the findings at a community forum in November 2013. The study generated a spirited public debate and some behind-the-scenes wrangling, all of which resulted in med school plan No. 2: a separate UNLV medical school, but launched off the platform of UNSOM’s accreditation. A memorandum of understanding between the Nevada System of Higher Education, UNLV, UNR and UNSOM followed. System chancellor Dan Klaich got the job of shepherding the flock to a new medical school in Southern Nevada, one way or another.
The way turned out to be plan No. 3: two completely separate medical schools, each with its own accreditation. Reno would get the existing UNSOM, and Las Vegas would start the new UNLV Medical School from scratch. The details of the plan are currently being hammered out — in double-time. In January, Klaich hired Tripp Umbach to refine its analysis according to the new plan. In March, he started holding meetings of the statewide steering committee. By June, the group had a tentative budget, project timeline, governing structure and updated memorandum of understanding. Next up: a website and other public communications.
The process entails much hard work by Atkinson and Schwenk, who are tasked with fulfilling two distinct visions harmoniously. The new UNLV Medical School dean must lay the foundation for an urban academic health center. When she’s not meeting with potential community partners, from philanthropists to hospital managers to private medical school deans, she’s working on UNLV’s application to the Liaison Committee on Medical Education, the U.S.-sanctioned authority for accrediting medical schools. Once Atkinson turns in the $25,000 application, she will have 18 months to complete a self-study, outlining her plan for admissions, curriculum, support services and facilities. She’ll have to hire faculty, pass the committee’s site visit and earn approval to begin admitting students, hopefully by the fall of 2016 so they can start classes the following year.
Oh, and she’ll need somewhere to put them. She’s talking to the Veterans Administration about using the education facility at its new North Las Vegas campus in the interim, but the permanent solution is an estimated $75 million building at UNLV.
For his part, Schwenk is charged with ramping up the clinical practice program in Reno. He’s working on an agreement with Renown Health, northern Nevada’s largest hospital operator, to offer third- and fourth-year teaching and fellowships in pediatrics and neurology. Others, hopefully, will follow. But, in order to grow class size, UNSOM will have to keep some of its clinical teaching capacity in Las Vegas for the long term. At a recent meeting in Las Vegas, a special committee began the process to add cardiology and gastroenterology programs at UMC; next on the agenda are pulmonary critical care and orthopedic surgery. Schwenk isn’t relying solely on the public hospital in Las Vegas, either. Recently, Renown Health made a $5 million commitment to UNSOM for new graduate programs in family medicine, internal medicine, general surgery and other areas.
“We hope there will be as many as 150 to 160 new residencies there,” Schwenk says. “That’s slightly more than are currently at UMC. Over time, UMC may become the primary clinical teaching hospital for UNLV, and Mountain View for UNSOM.”
The development of graduate medical education provides an example of how Atkinson and Schwenk could collaborate. Although UNSOM is the only current sponsor of fellowships and residencies in the state, hospitals can transfer programs between schools, and Schwenk says it’s common in other states for multiple schools to study under the same clinical roof. If UNLV and UNSOM work together, the process for distributing residencies among their students will go more smoothly.
The big ask
Klaich says the process overall has been marked by civility and cooperation so far. “We all agree that there is a greater capacity for medical education in the state, that we have a critical need for more doctors, that increasing the pipeline is one important way to meet that public health need. … One thing I’ve insisted on is taking the regionalism and the fighting out of this, so that we’re serving the real, critical public health needs of Nevadans. I do think a lot of the contention has been taken out of it, but this process has a long way to go. It won’t be easy or cheap.”
The total projected cost is still being figured. It will, no doubt, be a big ask for the governor and the legislature. But Klaich says the public should feel good about UNLV and UNR coming together to meet the state’s health care needs. It doesn’t make sense, he argues, to have mirror images of the same school in two cities. But if a collaboration can meet each region’s particular demands through different missions and specialties, it will be a wise use of state dollars. That, Klaich says, is what he’s trying to do.
“It’s been easy in the past for the state to ignore this issue because there’s been so much political conflict,” Schwenk says. “If the two schools can go forward together, it will be hard for the state to avoid acknowledging that it has a problem, we have the solution, and it’s time to implement it.”
Correction: This story has been corrected to reflect that Renown Health recently committed $5 million to UNSOM for new graduate programs.
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