Spring 2011
The strengths of graduate medical education programs

synapse: University of Nevada, Reno School of Medicine

internal medicine residents in Reno

Flora Lwin, M.D.'08, Amy Sanguinetti, M.D.'08, Omar Canaday, M.D., and Joseph Vaisman, M.D. are all internal medicine residents in Reno. Photo by John Byrne

The University of Nevada School of Medicine has stayed true to its founding principle of educating primary care doctors for Nevada, while gradually adding the graduate medical education specialty training sought by physicians nationwide.

By Anne McMillin, APR

Beginning with obstetrics and gynecology in 1981, and continuing to the present with fellowships planned for specialties ranging from pediatric emergency medicine to minimally invasive surgery, the community-based programs at the School of Medicine are meeting the needs of today's physicians, while still producing primary care doctors for Nevada.

"There has been a shift nationwide toward producing more primary care doctors, which we have always done, so now our goal is to establish more training programs," said Miriam Bar-on, M.D., associate dean for graduate medical education.

"We are developing specialties to meet the needs of Nevadans and to diversify our training portfolio to give graduates what they want," she said.

"Growing primary care residencies while expanding to develop specialties will help alleviate the doctor shortage in Nevada."

Primary care residency growth is dependent on the reallocation of program caps—the number of slots the Center for Medicare and Medicaid Services will allocate to a hospital for reimbursement of resident salaries. In 2004 the medical school benefited from a prior reallocation when University Medical Center in Las Vegas gained 25 slots, allowing the implementation of the emergency medicine residency program.

"We stand to gain slots in the current reallocation for primary care and general surgery because two-thirds of the approximately 2,000 slots to be reallocated are going to the states with the greatest need, including Nevada," Bar-on said. "Our primary care residency expansion will be successful if we can get some of those reallocated slots."

Here we look at several graduate medical education programs through the eyes of residency and fellowship program directors to examine program strengths and visions for the future.

Pediatrics (Las Vegas)

Over the past 12 years the pediatric residency program in Las Vegas has evolved and grown from its solid foundation in clinical training toward a more academic approach to medicine, according to Jack Lazerson, M.D., program director.

"We are building on the strong clinical training residents receive at Sunrise Hospital and University Medical Center provided by both our full-time academic and part-time clinical volunteer faculty," he said.

Lazerson's plan is to incorporate more clinical and research experiences into the training program to produce more academic practicing pediatricians. A key program goal is for residents to learn to recognize that patients who present with unusual conditions afford an opportunity for a research-based approach that may lead to realizing clinical advances.

"We want residents to ask: what can I learn from this patient and what is the patient trying to teach me?" said Lazerson.

Quality improvement through enhanced protocols for patient safety and supervision of residents are also being pursued. Changes to the residency curriculum, in keeping with standards put forth by the Accreditation Council on Graduate Medical Education, are instilling a more self-directed approach to residents' training with fewer lectures and more online and modular learning opportunities. Residents are required to act as teachers to medical students and produce more scholarly and research activities. Research has grown such that 30 percent of the school's current pediatric residents have published or presented at national meetings and conferences.

Family medicine (Reno)

David Fiore, M.D., program director described several strengths of the family medicine residency program in Reno.

"As a community-based, medical school-administered program, we have the best of academic faculty in the first year of residency with a rich infusion of community experiences in the final two years," he said. Fiore believes that less than 20 percent of medical schools nationwide operate their residency programs under this model, which is an attraction for many applicants.

Stable faculty with little turnover, who bring past experience in many different practice environments and varying educational backgrounds, also add to the richness of the family medicine resident experience in Reno.

"We are also an essentially unopposed program, with psychiatry and internal medicine residents complementing us," Fiore said. "These two residency programs are able to take some of the influx of patients and leave us more opportunities for hospital and private practice experience with patients."

Looking forward, Fiore wants to continue to build by strengthening his program's ties within the community and promoting the already excellent relationships with area hospitals. He sees the national increases in primary care funding from health care reform as a benefit to Nevada.

"The effect is to increase the attractiveness of primary care and especially family medicine, which will make it more competitive and allow us to recruit even more quality applicants," he said.

General surgery (Las Vegas)

John Fildes, M.D., general surgery residency program director, sees the program's strength in its numbers: surgery has a high faculty-to-resident ratio and is a small program in a busy hospital with high operative volume.

"Our residents are taught surgery early on, as the opportunities arise right away at UMC," Fildes said.

Residents' clinical time is balanced by weekly classroom sessions learning from lectures or simulation training in a didactic environment to complement the clinical experiences.

"We also offer research opportunities for our residents for up to a year in one of our three basic science laboratories," Fildes added. Those labs include plastic surgery research focusing on ischemia and reperfusion, trauma and burns research with emphasis on resuscitation and hypothermia, and pediatrics surgery research on biliary atresia.

Fildes said the program will continue in its strength of producing well-trained surgeons for Nevada, while simultaneously expanding and elevating the surgical assets of the community.

Acute care surgery (Las Vegas)

Fildes also oversees the acute care surgery fellowship, a new specialty which encompasses the disciplines of surgical critical care, emergency general surgery, trauma and burns. It is the hospital-based practice of surgery for time-sensitive injuries and illnesses, the first approved program of its kind in the U.S.

"Rotations that prepare the fellow for emergency general surgery are required including pediatric surgery, orthopedics, neurosurgery, thoracic surgery, vascular surgery, hepatobiliary surgery, and colon and rectal surgery," Fildes said.

"Our faculty have practiced this model for more than 10 years."

The mix of patients presenting at UMC offers broad experience for surgical residents and fellows.

As time progresses, Fildes expects the fellowship to continue to graduate the best-trained individuals to become leaders in this new specialty.

Child psychiatry (Reno)

Erika Ryst, M.D., program director for the child psychiatry fellowship based in Reno, sees the program's range of experienced, nurturing and supportive faculty and its ability to attract quality applicants as its strong points.

"We offer training experiences in varied settings thanks to the groundwork laid by Dr. Henry Watanabe, one of our emeritus faculty members," Ryst said.

One of those settings is the Washoe County School District, which has welcomed School of Medicine child psychiatry fellows.

"Our program has flourished and grown with the school district and we are working with them to get federal grants to expand mental health services within the schools," she said.

Other training settings include juvenile probation services and the Renown Health pediatrics department.
Ryst said the scope of experiences offered by Nevada is "not for the faint of heart."

"I did my training on the East Coast and only read about some of the conditions that I didn't see in patients until I came here," she said. The result of such a range of experience is that fellows exit the program quite confident in their abilities.

A supportive faculty is also a benefit of the program because there is a large amount of material to learn and child psychiatry is different from other training programs, Ryst said.

"We offer quite a bit of direct supervision in the first year as fellows learn to deal with the child in the context of the family or the system in which that child exists," she said.

"Fellows are usually grateful for that early oversight."

The child psychiatry fellowship has been successful in recruiting quality applicants since its establishment in 2006. Many of those applicants are recruited from the University of Nevada School of Medicine.

"We put a lot of energy into identifying students early in medical school who might have an interest in child psychiatry. By doing so, we know what we are getting and have seen them stick with that interest over time," Ryst said.

Ryst points out that every child psychiatry fellow trained by the School of Medicine has remained in Nevada to help improve the status of child mental health services in the state.

Internal medicine (Reno)

A well-balanced residency experience that allows physicians to pursue additional training in fellowships, research endeavors or clinical patient care is the strength of the internal medicine residency program in Reno.

"Our residents do well because they get hands-on work and practical training," said Jennifer Hagen, M.D., internal medicine residency program director.

"We hear from both residents and applicants to the program that this is a wonderful learning atmosphere which is collegial, has a strong focus on education, a good faculty-to-resident ratio and plenty of time with attending physicians," she said.

Diversity, whether in the form of physician residents from different cultures or in their chosen path to earn a medical degree, also enriches the residency experience, according to Hagen.

She added that residents historically make a strong showing of scholarly work and are often selected to present at American College of Physicians meetings.

"The opportunity to teach students is emphasized as part of their residency and gives them formal training in teaching and evaluation skills," Hagen said.

Faculty who are passionate about education and supportive department leadership also add to the overall resident experience.

Psychiatry (Reno)

Mark Broadhead, M.D., residency program director for psychiatry in Reno, sees his department's core faculty leading a small program as a major benefit for residents.

"They have greater access to faculty for mentoring and can feel more supported. It is a family feeling where residents can know and emulate their professors."

Broadhead said faculty strongly believe in a full and complete understanding of psychotherapy and creating changes to the mind and brain through specific techniques and talk therapy.

"We take this philosophy seriously and it attracts applicants," he said.

Having a child psychiatry fellowship, which also draws strongly upon psychotherapy techniques, alongside the psychiatry residency, appeals to applicants who are interested in this type of program and who want to stay in one location for several years.

"We strive to produce knowledgeable and competent psychiatrists who are also well-balanced human beings," Broadhead said. "To make them better psychiatrists, we want them to have life balance and a breadth of life experiences."

The diversity of training sites within the residency exposes residents to different ways psychiatry is practiced thereby better equipping them to enter practice.

"We train at large and small nonprofits, the Veterans Administration and public and specialty mental health systems so our residents know how different mental health systems operate which broadens their exposure to this field and shows them that treatment differs between systems because the patients are different," Broadhead said.

Broadhead said the program will continue to play to its strengths, build its reputation and reach out more toward its community partners to give them opportunities to become more involved.

Emergency medicine (Las Vegas)

Just one percent of those applying for the School of Medicine's emergency medicine residency this year will be successful. Approximately 850 applications have been received for just eight positions, and these numbers reflect the strength of the program, according to Michael Epter, D.O., residency director.

"The strength of this program is the residents themselves. They are dynamic and have pushed this program forward since it began in 2006," Epter said. "Having a piece of ownership in the program spurs residents to work harder and they are able to look back with pride and loyalty on the program."

A consistently strong group of "fire-starters" in the young program's history laid the groundwork and foundation for those who have followed, Epter said.

"Our residents have always been proactive, and have a strong work ethic and palpable loyalty to the program," he said.

Another indicator of the program's success is that it received the highest accreditation cycle of five years on its first site visit last year.

Epter believes that the enthusiasm of the residents is matched by the young faculty directing the program.

"Our faculty represents the nucleus of people who love to take on a new task and see it grow and mature," he said, adding that this characteristic is a perfect complement to the hard-charging residents.

The strong support of departmental chair Dale Carrison, D.O., and residency coordinator Jennifer Michalski also help make the program a success.

Finally, Epter points to the unique population of patients, most of whom are seen at UMC, as being very attractive to residents for their learning opportunities.

"We see quite a variation in patient pathology and have the only Level One trauma center and burn center in Nevada, essentially making us the only game in town and allowing for great training and education for our residents," he said.

Family medicine (Las Vegas)

The family medicine department in Las Vegas has some unique fellowships that make the residency program attractive to potential applicants, according to Aron Rogers, D.O., residency director.

"We offer something more in post-residency training with our sports medicine, urgent care and obstetrics fellowships," he said.

Combining these fellowships with nationally-known and proactive faculty leadership who are working to increase the residency program's complement and extend its reach to rural communities by securing more grant funding also add to the program's appeal, he added.

Rogers said the variety of the teaching experiences in the residency's first year, with rotations in all specialties including obstetrics and gynecology, emergency medicine, surgery and pediatrics, gives residents a solid core of experience and makes them very well prepared for the final two years.

"We also see a wide mix of patients, from the insured to the indigent, at our clinic and at University Medical Center, which gives residents a wide range of pathology to experience," he said.

Finally, residents and fellows are heavily involved in community service projects, much of it on their own time, across Las Vegas.

"We gave anti-tobacco presentations to 570 fifth graders in 19 classes along with high school sports physicals to more than 1,400 student-athletes and nearly 800 flu shots at clinics and health fairs during the last academic year," he said.

Sports medicine (Las Vegas and Reno)

The School of Medicine's sports medicine fellowships, which are partnered with the athletic departments at the University of Nevada, Las Vegas and the University of Nevada, Reno, provide a wonderful opportunity to be intimately involved with collegiate athletics and the wide range of clinical opportunities that arise from those settings, according the Michael Milligan, M.D., fellowship director in Las Vegas.

"It is pretty exciting with the two fellowships that both are primary care sports medicine physicians leading the health care of teams at UNR and UNLV. We have the expectation that athletic health care is becoming more comprehensive in nature and our fellows are taking that attitude," Milligan said.

He said sports medicine fellows have extensive training in the acute conditions that arise on the field of play, such as concussions, lacerations and orthopedic situations, as well as the long-term medical aspects of the athlete which range from screenings to nutrition.

"Our fellows come to understand the unique aspects of the athlete," Milligan said.

The future of graduate medical education

With the base of these and other programs, School of Medicine faculty are working to broaden and deepen graduate medical education in Nevada.

The national focus on primary care could allow the School of Medicine to grow from approximately 275 residents and fellows to 300 or even 350 in a relatively short time.

The future for graduate medical education includes developing fellowships in internal medicine subspecialties such as gastroenterology and cardiology in Las Vegas as well as endocrinology in Reno.

Furthermore, the objective is to create additional core residency programs to attract University of Nevada School of Medicine students who currently leave the state to obtain their residency training.

The ultimate goal is to produce and retain physicians in Nevada to help improve the physician shortage and provide care for the people of Nevada.