Monday, Feb. 2, 2004 | 11:05 a.m.
The proliferation of medical malpractice lawsuits in Nevada is not deterring medical students from coming to the state, but is affecting their training, students and officials say.
The students and University of Nevada School of Medicine officials are contradicting an American Medical Association study released in December that said medical students and residents are fleeing from states with medical malpractice problems such as Nevada. The study said more than one-third of medical students and residents are avoiding high-risk specialties and residency programs in malpractice-plagued states.
Dr. Cheryl Hug-English, associate dean of admissions for the medical school, said it has not seen any effect on the quality of applicants it receives as a result of the medical malpractice crisis -- though in Nevada and nationwide fewer students have been applying to medical schools.
"We did not see as dramatic a decrease as reported nationally," Hug-English said. "We saw a dip in our numbers, (but) certainly nothing that impacted the quality of the students we were accepting at all."
The medical school admits 52 students each year.
Students have not left the school as a result of medical malpractice concerns, Hug-English said.
She said it's difficult to say whether medical malpractice has affected students' specialty choices.
"Students certainly change their mind from the beginning of medical school to the end and that has been true since before the medical malpractice issue," she said.
She said students' personality types and academic strengths are more often used to determine a speciality than income or malpractice concerns.
Dr. Stan Kirson, assistant dean for graduate medical education at the medical school, said the number of resident applications has exceeded the 200 openings even after the malpractice crisis erupted.
Nevada medical students and residents at the University of Nevada School of Medicine and Touro University's College of Osteopathic Medicine in Las Vegas say they are aware of the malpractice situation and their training is being affected, but they aren't deterred from fulfilling their dreams.
Touro is based in California, but sends some of its medical students and residents to Las Vegas for training. The university is scheduled to open a Las Vegas campus in the fall.
The AMA classified 19 states including Nevada as being in a medical malpractice liability crisis. States deemed to be in a crisis have limited access to physicians, high malpractice insurance premiums for physicians and a large number of medical malpractice lawsuits.
Nearly 4,000 medical students and residents were surveyed in August in 45 states and Washington, D.C.
The findings include:
State-specific data was not available from the AMA.
"It's an indication of where we are headed in the world," said David Rosman, a fourth-year Massachusetts medical student and AMA board trustee.
He said it would be an overstatement to say medical liability is the only factor in future physicians' decisions, but it's a greater factor than it was in the past.
Rosman is interviewing for residency positions in radiology, a high-risk specialty.
"The liability situation plays a relatively significant role in what state I'm going to end up in," he said.
Rosman isn't considering Nevada because he wants to stay close to home, but he is looking at other states considered to be in a malpractice crisis.
"As we're seeing malpractice premiums skyrocketing, we're headed for a meltdown," he said. "My hope is that we're able to solve it before there's a problem with access to care."
Dr. Richard Baynosa, a third-year resident at the University of Nevada School of Medicine, said malpractice premiums and the threat of lawsuits will not stop him from becoming a surgery physician.
"You always try to stay aware (of medical issues), but the focus is on training, learning as much as you can and treating your patients the best you can," Baynosa said.
"In this stage of residency, medicine is in constant flux: medical malpractice, Medicare reimbursement, information technology," he said. "The road is still long and there are many more changes ahead."
Baynosa said Nevada was more appealing than his home-state, California, three years ago when he was looking for a residency program. He said he chose Las Vegas because it is such a rapidly growing city and managed-care insurers have less influence on the health care industry than in some other markets.
Baynosa said he will likely practice in Nevada once he finishes his residency training. But it will be another eight to 10 years before he will have his own practice.
Larry Matheis, executive director of the Nevada State Medical Association, said the school of medicine is less affected because of its size and focus.
"They've been able to hold on, but it's partially because they've got a relatively small residency program and a big focus on primary care," he said. "I don't think the school is having more trouble recruiting students now than a few years ago."
He said it used to be that medical students worried only about tests and hospital rotations. Now an increasing number are worried about malpractice and its implications.
"If they start out with these reservations and concerns, there's the chance they'll be less content," Matheis said. "It's the longest training period for any of our professions (and) it's very expensive. The last thing they should be doing is second-guessing the profession and that's what they're doing."
Dr. Joseph McNerney, associate dean for clinical education at Touro University's College of Osteopathic Medicine in Vallejo, Calif., said the medical malpractice crisis does affect training for medical students and residents, but has not stopped them from enrolling.
"It affects medical students in several ways," McNerney said. "The number of available clinical teachers is impaired in Nevada because of the liability crisis. (Medical liability is) changing their ability to even have residency programs."
About 60 percent of residents open their practices in the same area they received their residency training, which is why the crisis must be addressed in Nevada, McNerney said.
Matthew Black, a fourth-year medical student at Touro, said he has concerns about medical malpractice premiums, but it has not altered his career path because the crisis should improve before he starts practicing in four years.
Black is studying in Las Vegas and plans to specialize in emergency medicine, which is one of the specialties facing higher malpractice premiums.
Black said he had trouble obtaining an obstetrics/gynecology rotation and wasn't able to perform as many procedures because of malpractice concerns.
"(Hospitals) were a little less likely to let us do things like innovations and other procedures," he said.
Jim Richter, a fourth-year medical student at the University of Nevada School of Medicine, said malpractice concerns altered his training, but not necessarily for the worst.
"I'm not sure it negatively impacted my education, but it changed it," Richter said. "I didn't just learn about surgery. I learned about the business of medicine."
He said surgeons talked about how malpractice was affecting them, which is something he wouldn't have learned in a classroom.
Also, he conducted his obstetrics/gynecology rotation in July 2002, which shocked him.
"A lot of women were using UMC at the last minute for deliveries not because they didn't have insurance, but because there were no obstetricians to go to," he said. "Nobody was taking new patients. That was a a very sobering rotation. I saw how malpractice was affecting everyday people."
Malpractice premiums won't have much of an effect on Richter's career because he wants to pursue pathology, which has lower premiums than other specialities.
Local hospitals say there hasn't been much change in what medical students and residents are allowed to do because they have to be supervised at all times.
Valley Hospital, owned by Pennsylvania-based Universal Health Services, said it has added some policies. For example, medical students and their attending physician must fill out a request form seeking approval for a student to assist with certain medical functions, hospital spokeswoman Gretchen Papez said.
If the physician is not supervising, the students are not allowed to perform the functions, Papez said.
Valley did not have a medical student program during the peak of the malpractice crisis and still does not have a resident program.
University Medical Center, owned by Clark County and the main training hospital locally, had to reorganize a few physicians' shifts to make sure residents are properly supervised, hospital spokeswoman Cheryl Persinger said.
She said it's up to the physician as to how much the student or resident can participate in a patient's care.
Dr. Babak Ghadishah, a third-year internal medicine resident at Touro, said Las Vegas still has a lot of opportunities for students and residents even if medical liability is an issue.
Ghadishah said he is undecided about whether he will return to Los Angeles or stay in Nevada when his residency concludes.
"Malpractice insurance did cross my mind," he said. "Eventually you can make more money here, but if you're going to pay twice or three times the amount in malpractice insurance it's going to end up the same.
"(Malpractice insurance) is not as high for internal medicine and general practitioners, but they have to take that into consideration," he added.
Jeff Juanlu, a fourth-year medical student at Touro, said he isn't too worried about the medical malpractice crisis because he has four years of residency training before he can practice and he plans to specialize in internal medicine.
Once he starts practicing, the malpractice crisis could affect him indirectly because there will be a limited number of specialists to refer to his patients, Juanlu said.
An initiative on the November 2004 ballot will attempt to further reform medical malpractice. In the meantime, medical students and residents say that caring for their patients and being the best they can in their fields are more important than worrying about the malpractice issue.
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