The Recent Exodus of Nevada ACGME* Graduates
By Scott Goodsell, OMS-II; Rhiannon Ryan, OMS-II; and Joseph P. Hardy, M.D. Touro University Nevada
The State of Nevada is currently facing a severe physician shortage. In a 2017 report by the AAMC (American Association of Medical Colleges), Nevada ranked 49th in the Nation for active physicians by degree type per 100,000 population (1), and 47th in the Nation overall for physicians per 100,000 population. Specifically, the AAMC report ranked Nevada 48th in primary care physicians per capita. Because many Nevadans lack access to necessary healthcare, the importance of increasing the supply of physicians has been a focus in recent years.
While this focus has centered on increasing the number of medical students in Nevada, in fact, the number of medical school graduates will increase the physician to population ratios only if those physicians will practice in Nevada after completing their post –graduate specialty training. Historically, less than 40% of public medical school graduates in Nevada remain in Nevada to practice. Nevada does score well, compared to other states, with 77% of state medical school graduates, who complete their residency specialty training in Nevada, remaining in Nevada to practice. However, only a minority of state medical school graduates remain in Nevada for their required post-graduate training.
The University of Nevada, Reno, School of Medicine, received about $ 109 million dollars in State General Revenue Appropriations in the last three years, while graduating 202 medical students, for a cost of over a half a million ($ 539,000) per medical student graduate(4). The historical retention of 38% of UNSOM’s graduates has resulted in about 12% of the total active Nevada physicians (5). In reality, it costs, in publicly allocated money from the Legislature, over $ 1.4 million dollars to educate one Nevada public medical school student who will eventually practice in Nevada. In contrast, non-public medical schools, such as Touro University Nevada College of Osteopathic Medicine, which graduates more than twice the number of physicians annually than the public school, does not cost the Nevada taxpayer anything. The nascent medical school at Roseman University, likewise, would produce medical school graduates without taxpayer funding. Less than 6% of ACGME program positions in Nevada are held by Touro University Nevada graduates. Touro University Nevada physician graduates who complete their ACGME specialty training in Nevada remain to practice at the same 77% rate.
Physicians completing Graduate Medical Education in Nevada have been an important source of actively practicing physicians. Nevada historically retains about 50% of physicians completing ACGME (residency) programs. The recent AAMC report ranks Nevada as 8th in the U.S. in retaining ACGME graduates in the State, of whom about 10% are graduates of the public medical school. University of Nevada health policy analysts have published exit interviews of physicians completing ACGME programs in Nevada to determine, among other information, what percentage are remaining in Nevada to practice. Since 2010, those numbers have ranged, plus or minus, in the 50% level, as noted specifically on the graph below. However, the last two years have noted an aberration. While the retention rate in 2015 was the average of 50%, in 2016 the retention rate of physicians completing Nevada ACGME programs in Nevada dropped to an unprecedented 40%, and in 2017 the retention rate further dropped to 30% (2)(3). The reasons for the progressive reduction in retention of Nevada physicians completing their ACGME training has not been elucidated.
Nevada generally does well in retaining physicians who complete Graduate Medical Education in Nevada. One mode of obtaining more physicians to practice in Nevada is to increase the number of Graduate Medical Education residency training positions in the State. ACGME programs are funded through the Centers for Medicare and Medicaid, and are limited or capped, according to a formula. By developing more hospital-based training positions, more physicians will complete their ACGME training in Nevada, with more physicians remaining in State to practice medicine. This theory seems sound, but threatened by the experience of the last two years of the ACGME programs exit interview results. Utilizing limited public funds wisely to maximize the public’s access to medical care seems increasingly compelling. An investigation of the genesis of the exodus of recent ACGME graduates from Nevada would appear to be an urgent priority.
*The American Medical Association’s Accreditation Council of Graduate Medical Education
2017 State Physician Workforce Data Report (Rep.). (Nov. 2017). Association of American Medical Colleges, Figure 1.2, Table 1.2., Summary table (page 65).
Griswold, T., Packham, J. (2015). Nevada Residency and Fellowship Training Outcomes – 2006 to 2015. Nevada Health Workforce Research Center.
Griswold, T., Packham, J., Marchand, C., Etchegoyhen, L., & Jorgensen, T. (2017). Physician Workforce in Nevada. Nevada Health Workforce Research Center.
Annual Summary of State General Funds appropriated to the University of Nevada, Reno, School of Medicine, Jennifer Ouellette, Program Analyst, Fiscal Analysis Division, Legislative Council Bureau, August 29, 2018 (copies are available from any of the above article authors).
Nevada Board of Medical Examiners (NBME) database of active physicians, September 2018 (available from the NBME for a fee).