Recruit doctors through graduate medical education and retain them through higher wages

Doug Geinzer CEO of High Performance Providers

•“Any great city has medical schools, and there’s a blossoming academic medical infrastructure here in Las Vegas.” That’s Doug Geinzer’s belief, based on his 10 years as CEO of High Performance Providers — a venture Geinzer founded that connects self-insured patients with providers through direct contracting — and as former executive director of Las Vegas HEALS, a nonprofit promoting health education, advocacy, and leadership in Southern Nevada.

Geinzer says graduate medical education (GME) is critical in diversifying a community’s medical offerings, as it attracts “more specialists and subspecialists to teach those areas.” Moreover, he sees medical schools as sites of training and learning for both students and faculty — “the students teaching the teacher and vice versa. When you have a bunch of students going, ‘But, why?’ it forces the senior political leadership to answer with factual information that they know will be fact-checked by the young kids.”

While GME serves as a recruitment tool for medical professionals, Geinzer sees retention as an issue linked to provider reimbursement. “We tackled recruitment with the expansion of GME,” he says. “(Nationally) 57 percent of doctors will stay where they do the residency.” Thus, he believes, keeping medical students and residents in

Southern Nevada requires a focus on retention, which is linked to compensation. “What a lot of people don’t realize is that compensation is directly tied to provider reimbursement, how much they’re getting paid to do the work they do, and that comes down to the commercial carriers,” he says.

Direct contracting — which allows “employers to buy (medical services) directly from providers” — is one method that Geinzer sees as benefiting employers, patients, and physicians. Direct contracting “allows the employer, who’s writing the check, to write a smaller check, so the employer is saving a lot of money. In the world of surgery, they save on average, 40 to 50 percent,” he says. This, he explains, would make healthcare more affordable. “We all have these high deductible health plans because the employer cost-shifted to us, the workers, and they all have this max out-of-pocket so that we can’t afford the care that we need,” he says.

According to Geinzer, direct contracting benefits employers, who save money on plans; it benefits employees, who save on the actual cost of the service, because, when patients go through a direct contract, there’s no copay; and it benefits providers, who get paid at a higher reimbursement level.

All of this, in turn, would increase physicians’ wages, incentivizing them to stay practicing in their communities. — NB

Encourage

The PET scan was the aberration.”

With a comprehensive view of the patient’s health, Wint says, a better approach would have been to wait six months and re-scan her brain to see if any signs of frontotemporal dementia persisted. As for the primary care doctor, he could have followed up with the cardiologist or radiologist who made the diagnosis and probed further to find out how they arrived at what should have been a surprising conclusion about his patient.

26 DAYS

Average wait time to see a doctor in the U.S.

Dylan Wint Director of Cleveland Clinic’s Lou Ruvo Center for Brain Health

As an MD-PhD with specialties in neurology and psychology, Dylan Wint is good at digesting the abstractions of the patient-practitioner relations he’s observed over 20 years in his field. The top thing he sees as lacking across the medical profession is what he calls a “longitudinal approach” to patient care.

Here’s an example: A Las Vegas woman goes to see a cardiologist at a comprehensive medical practice out of town. While there, she falls and gets hit in the head by an automatic door. She tells her cardiologist about this during the exam, and he notices that she seems confused and woozy. So, he orders a PET scan of her brain. A radiologist reads the PET scan and diagnoses frontotemporal dementia. The woman returns to Las Vegas and sees her primary care doctor about the diagnosis. He refers her to the Lou Ruvo Center, where Wint gives her a thorough neurological exam, determining she does not have dementia; she had a concussion. Between the fall and the correct diagnosis, months pass, during which the woman and her care team are assessing everything through the lens of an illness that isn’t actually there.

“The cardiologist was doing the right thing to check her brain, because she did have an event,” Wint says. “But I know this patient. There’s nothing else that would lead to a diagnosis of dementia.

“That (used to be) the role of the traditional primary care or family doctor,” Wint says. “They didn’t just know you, they knew your family, lived in your neighborhood, know your history, the area. With the fracturing of healthcare we’ve lost that longitudinal view, the primary care physician who isn’t just sending patients out for consultations.”

One problem with regaining this traditional approach is it would require shifting how practitioners are rewarded. Rather than reimbursing them for the number of times they see a patient, or the time spent with them, pay would have to account for the quality of the care itself.

“There are small incentives for doing the extra things like talking to other providers and explaining test results,” Wint says. “Those should be core features of the system: coordination of care among providers, careful explanation to the patient of what’s going on.”

To get the larger picture, he suggests that the follow-up surveys patients get after every office visit ask further-reaching questions, rather than focusing on a single contact with an individual provider; for example, “How did this visit fit into your overall treatment plan?” and “How are you progressing?”

Zooming out even further, Wint says, the problem is that we don’t do healthcare in the U.S.; we do illness care. “Everything is centered around what happens when your health fails.”

“Health is a concept that starts at birth and fuses everything we do until the day we die,” he says. “To set up a system that willfully ignores that is setting up a system that’s bound to fail patients.” — HK

8%

Amount by which that wait time has increased in the last five years

1/3 – Number of seniors who visit at least five different doctors each year

34% Increase in number of specialists Medicare recipients saw 2000-2019

9% American adults who report poor communication with their healthcare provider

49%

Big Idea

Make primary care more affordable

David Weismiller Professor of Medicine in the Department of Family and Community Medicine at UNLV

•Family physician David Weismiller has focused much of his career on education. In addition to being a professor at UNLV’s Kirk Kerkorian School of Medicine, he teaches continuing ed courses for physicians with the American Association of Family Physicians, the Emirates Family Medicine Society Scientific Congress, and other organizations. Through this work, he raises awareness of the cost and access barriers preventing effective patient care.

These ideas, Weismiller says, “aren’t very sexy. I mean, who wants to talk about this stuff?” Still, he believes the most pressing issues facing healthcare in Nevada — and the U.S. in general — are its high prices and the difficulty finding primary care physicians.

Typically, Weismiller explains, the more a community spends on health care, the more the life expectancy of its members goes up. This is true in most of the world’s developed nations, but not the United States. Among comparable countries, the U.S. has the highest cost of health care and very little to show for it. The reasons are complex. Insurance in America is, by and large, linked with employment. Employers rarely invest in coverage for longer-term or chronic issues, because they won’t see the benefits of such investment during their employees’ tenure. This, in turn, leads to outsized costs for acute treatment down the road, and to highly preventable deaths.

At the same time, Weismiller explains, those without jobs or benefits simply can’t afford to see a primary care doctor. The leading causes of preventable disease and death in the U.S. include tobacco, excessive weight, and excessive alcohol use — all of which are best treated by a primary care physician. For instance, Nevada Medicaid covers a medication that reduces the risk of diabetes by 17 percent, but it won’t pay for you to see a registered dietitian to facilitate lifestyle modifications, which would halve the likelihood of getting diabetes. This creates a cascading effect of costs and inefficiencies, whereby the burden of primary care falls on emergency room doctors and nurses, who are not trained to address these concerns. “They’re not talking to you about this in the emergency department,” Weismiller says. “‘Yes, you should quit smoking. But right now, we’ve got to deal with your heart attack.’”

Accessing primary care physicians is especially pressing for Nevada. We are, essentially, a rural state — aside from Washoe and Clark, no county has a population greater than 61,000. Investing more in well-distributed healthcare would go a long way toward addressing preventable illnesses and deaths throughout the state, Weismiller says.

He has hope, despite healthcare problems being highly politicized in America. For him, as a doctor and as an educator, it begins with addressing the No. 1 complaint people have about doctors: “We don’t listen.” Weismiller begins his second-year lectures specifically telling students how to listen to patients.

This is essential, he contends, not just to more effectively treat patients, but also to build back trust with the public at large. “From there, we’re able to deal with all the other issues in a reasonable way.” — CG

50% 2

Reduction in diabetes disease risk with non-covered dietitian

Number of urban Nevada counties

17% 15

Reduction in diabetes disease risk with Medicaid-covered prescription drugs

Number of rural Nevada counties

1. 95 MILLION

Nevadans

To meet national populationto-provider averages, Nevada would need an extra:

4,290 Registered nurses

5,719 Certified nursing assistants

Big Idea

A health workforce Marshall Plan

John Packham

55% 1 is a little over 20 years, Nevada has been plagued by health workforce shortages,” Packham says.

The pandemic exerted unprecedented stress on healthcare systems across Nevada, leading 55 percent of front-line healthcare workers to report burnout and fatigue in 2021. Inevitably, this has negatively affected healthcare workforce numbers in recent years: According to the most recent data, almost 2 million Nevadans live in a primary care physician (PCP) shortage area, equivalent to more than 57 percent of the state’s population. Similarly, even before COVID, Clark County recorded one PCP for every 1,760 people in 2019; in Pershing County, one for every 6,725.

John Packham, the associate dean for the Office of Statewide Initiatives at UNR, considers this shortage to be among the most pressing problems facing the state’s healthcare system today. “For as long as I've been looking at these issues, which

His solution is a health workforce Marshall Plan, reminiscent of the one implemented to rebuild Europe after World War II, to keep practitioners in-state. Just as the U.S. provided economic assistance to European nations, which created their own plans for reconstruction, the state of Nevada should invest more money in existing local academic programs, Packham argues. The idea would be to “educate and train our own” nurses and healthcare practitioners instead of drawing them from elsewhere in the country. This, he stresses, will be especially important for local nurses, as Nevada is continuing to face a critical shortage of them. As of 2021, the state needs an extra 5,719 certified nursing assistants and 4,290 registered nurses to meet national population-to-provider averages.

Packham acknowledges that keeping healthcare professionals in Nevada will require both a decrease in cost for medical education and competitive pay increases as graduates enter the workforce as teachers or providers. Yet he is adamant that his Marshall Plan for Nevada’s healthcare workforce is achievable, provided that consistent effort is made.

“(It) will require dollars, it will require changes in public policy,” he says. “But I'm optimistic that if you build those programs, make them affordable for Nevada residents and students, they will stay. And that's what we need.” — AD but he didn’t care because he was raised reading it.” Some Indigenous People tested his knowledge, too. Anderson recalls one tribe in Arizona inviting him to see if he could read a panel of petroglyphs. He told them it was a map to a battle site. They confirmed it and led him down a path to where the battle occurred.

How should we decipher and interpret petroglyphs? What was the creator trying to say? Humans can’t help but interpret apparent messages left by other humans, but modern people can easily misinterpret the symbols of ancient peoples. For instance, we might jump to the conclusion that the image of a man holding an atlatl above his head with a deer or bighorn sheep nearby is describing a hunting episode or conveying the news that it is a good hunting ground. But we would be imputing our 21st-century experience to something that could bear no relation to the culture of the Ancestral Puebloans. “If they emphasized what they were eating in their rock art, walls would be covered with bunny rabbits,” says Whitley. (They’re not.)

Martineau would likely agree. He pointed out that hunting was so common that it was not worth celebrating except for the unusual hunt or animal. More telling is the fact that sheep were almost never depicted dead on their backs. Rather, he argued, sheep and deer symbols were used to express action or direction. To what? Water, of course.

In the desert Southwest, water has almost always been the most precious commodity. Droughts were especially widespread in western North America in the 11th, 12th, and 13th centuries and lasting for as many as 70 years, precisely the times when many rock writings were created. The search for water was responsible for continuing migrations within and out of the Great Basin for at least two millennia and probably much longer. Anderson interprets one panel on Atlatl Rock at the Valley of Fire as shamans sending their prayers for rain heavenward. David Whitley inferred from comments by the Numic-speaking peoples (Shoshone and Paiute tribes) that petroglyphs of Great Basin bighorn sheep depicted the spirit helpers of rain shamans. Immediately after a rain, sheep knew where desert plants would be sprouting. It was then possible to predict rain by bighorn movements, confirms James DeForge, executive director of the Bighorn Institute in Palm Desert, California.

Whitley contends that other animals were portrayed as spirit helpers as well — birds, amphibians, insects, fish, and reptiles. Rattlesnakes were the helpers of rattlesnake shamans, who could cure snakebite and handle snakes. Lizards crawling through cracks in the rocks and frogs jumping into the water represented the shaman’s ability to travel seamlessly between natural and supernatural worlds. Anthropomorphic figures are usually of shamans with elongated bodies and heads sometimes topped with headdresses.

Abstract designs are more difficult to interpret, Whitley says, and in many cases depict any of several entoptic images (geometric light images in our optical and neural systems) perceived during shamanic hallucinations. These include grids; dots, circles and flecks; concentric circles and spirals, parallel lines; zigzags and diamondchains; meanders; and nested curves. Zigzags likely represent the tracks left by a sidewinder, while diamond-chains resemble the pattern on the back of diamondback rattlesnake. Concentric circles and spirals represent whirlwinds that could concentrate supernatural powers and carry the shaman into the spirit world. Humans (shamans) were commonly portrayed with heads of concentric circles or spirals instead of facial features.

As for why rock-art creators did their work to begin with, Anderson believed the primary function was to preserve, to hand down a library of storied rocks. Daniel Bulletts says, “It depicts a story that that person saw, something that he was hunting, something he came across. Each year that person came back to the same spot and added to that story. And other people that visit can read who did what and where certain things are and if this was good area to either harvest or hunt. It was not the domain of just shamans, as some say. That is more of a modern-day interpretation.”

Kevin Rafferty feels rock-writing creators were probably trying to depict relationships between man and the spirit world. Whitley is more explicit in that regard: “The rock-art motifs were more like pagan idols in the sense they had power. I’ve had informants tell me that if a rock-art panel is destroyed, it will release horrible sickness all over the world. But then they become important for a variety of other things. For one, they become images that serve in development of individual and group identity. People would be taught to respect, to consider sacred these sorts of things. Rock-art sites were recognized as places of supernatural power. They are potentially useful for curing yourself and getting better luck, so people would go to rock-art sites to pray and meditate.”

Professor Peter Welsh and art conservator-editor Liz Welsh of the University of Kansas, authors of Rock-Art of the Southwest, argue that rock writing may have been meant to convey all these things — and more. “I feel that Indigenous People have more at stake in the interpretation of sites, linked as the sites are to evidence of ancient occupation and, therefore, to ongoing rights,” Peter Welsh says. “Archaeologists are asking different questions of the sites, so folks tend to talk past each other. Yet, I have also experienced very encouraging collaborations.”

Writing The Future

COLLABORATIONS WITH PARTIES beyond Indigenous communities and the scientific world will be required to preserve the rock writing Martineau dedicated his life to documenting. Some two-thirds of Nevada, 48 million acres, is public land, most of it managed by the BLM. Van der Voort outlines her agency’s current initiatives to protect rock-writing sites and educate the general public to engender respect for them.

Each of the six BLM districts in the state has one or more field offices, and each of those is assigned a staff archaeologist, she says. Site-monitoring, inspections, and patrols alert the BLM to vandalism. The Archaeological Resources Protection Act, applicable to sites more than 100 years old, is the main instrument for protection. If a new site is discovered, the BLM will sometimes withhold the locality from the public or, if it meets any of four criteria, nominate it for inclusion on the National Register of Historic Places. In the case of rock writing, the most relevant criteria are that it 1) represents distinctive characteristics of a type, period, or method of construction, or 2) is likely to yield information important in history or prehistory.

“Education is the key,” Van der Voort says, citing the example of Project Archaeology, a Northern Nevada program meant to foster understanding of past and present cultures. The Nevada Site Stewardship Program run by the Nevada State Historic Preservation Office trains volunteers to monitor archaeological sites on a quarterly basis and report any vandalism. John Asselin, public affairs specialist of BLM’s Southern Nevada District Office, is part of the team working toward the opening of a permanent Visitor Contact Station at the Sloan Canyon National Conservation Area early this year to replace the one destroyed by vandals at the beginning of the pandemic. Five bands of the Paiute Tribe and five other tribes are assisting in the interpretive plan for the station. Asselin says the BLM is also cooperating with tribes at Gold Butte National Monument to educate people on why the cultural sites there are important.

At Basin and Range National Monument in Lincoln County, archaeologist Robert Hickerson says 30 site stewards monitor 30 rock-writing sites dating up to 4,000 years ago, including several at White River Narrows. Alicia Styles, monument manager, adds that there is a Friends group there, along with two field rangers and a supervisory manager, to oversee sites. “We have installed interpretive kiosks to talk about the value of the resources and how to protect them,” she says. “We have a 3-D model website on prehistoric rock art that allows visitors to virtually explore and appreciate our cultural resources.” Last year, their partner, the Desert Research Institute, gave a presentation at local schools, bringing in a drone to talk about current research and technologies, “which always sparks the interest of middle school and high school students especially,” Styles laughs.