Nevada election officials will recount ballots in five counties after independent presidential candidate Roque De La Fuente requested and paid about $14,000 for the effort.

De La Fuente finished last in the state but this week requested a recount in Nevada, a state Democrat Hillary Clinton won. De La Fuente says he wants to counterbalance a recount Green Party candidate Jill Stein requested in Wisconsin, which President-elect Donald Trump won. Stein also has requested recounts in Trump-won states of Michigan and Pennsylvania.

Nevada Deputy Secretary of State for Elections Wayne Thorley said Wednesday that state law requires the five counties — Carson City, Douglas, Mineral, Nye and Clark — to begin the recount within five days and to complete it within five additional days.

Thorley says if recount results show a discrepancy of at least 1 percent for De La Fuente or Clinton, a full state recount will be launched.

Green Party presidential nominee Jill Stein is pushing back against charges from Wisconsin Republicans that she illegally coordinated with Democrat Hillary Clinton to raise money for recounts in three states.

Stein campaign manager David Cobb said in a statement Wednesday that “The recount effort is non-partisan and Stein is not coordinating with any other campaign.”

Cobb says, “Any allegations to the contrary are fabrications.” He says the Wisconsin Republican Party’s complaint to the Federal Elections Commission “is nothing but a PR stunt to push a false narrative that will ultimately have no impact on the recount in Wisconsin.”

The complaint contends that Clinton is the only person who could benefit from a recount and that she appears to have illegally helped Stein raise nearly $7 million for the recounts in Wisconsin, Pennsylvania and Michigan.

Stein requested the recount on Wednesday. She had already requested recounts in Pennsylvania and Wisconsin.

Republican Donald Trump won all three states. He defeated Democrat Hillary Clinton in Michigan by 10,704 votes out of nearly 4.8 million ballots cast. Stein alleges that irregularities and the potential for hacking into scanning devices call into question the results.

The Michigan recount could start as early as Friday.

Trump’s victory is highly unlikely to be reversed in any of the states. But Stein says the recount will ensure the integrity of the election.

Republicans say the recount will cost taxpayers far more than the $973,000 Stein must pay when filing her recount petition.

Wisconsin’s elections chief is telling local clerks that he knows they’re frustrated with trying to complete a presidential recount in less than two weeks.

Green Party presidential candidate Jill Stein requested the recount. It’s slated to begin Thursday and must be completed by Dec. 13 or Congress could gain control of the state’s electoral votes.

Commission Administrator Mike Haas held a teleconference with clerks Wednesday to walk them through final preparations.

Twice Haas acknowledged they’re unhappy with conducting a recount during the holiday season on behalf of a candidate who got only 30,000 votes in Wisconsin. But he told them he hopes they’ve accepted that the recount must be conducted, by law, and that it will be done professionally.

The Wisconsin Republican Party alleges that Green Party presidential candidate Jill Stein’s recount effort in Wisconsin amounts to illegal coordination with Democrat Hillary Clinton.

The state Republican Party filed a complaint with the Federal Election Commission on Wednesday. The complaint comes the day before the scheduled start of the recount of Wisconsin’s vote, won by Republican Donald Trump by less than 1 percentage point.

The complaint contends that Clinton is the only person who could benefit from a recount and that she appears to have illegally helped Stein raise nearly $7 million for the recounts in Wisconsin, Pennsylvania and Michigan.

Spokeswomen for Stein and Clinton’s campaigns did not immediately respond to requests for comment.

Stein plans to request the recount later Wednesday. She has already requested recounts in Pennsylvania and Wisconsin.

Republican Donald Trump won all three states. He defeated Democrat Hillary Clinton in Michigan by 10,704 votes out of nearly 4.8 million ballots cast. Stein alleges that irregularities and the potential for hacking into scanning devices call into question the results.

The Michigan recount could start as early as Friday.

Trump’s victory is highly unlikely to be reversed in any of the states. But Stein says the recount will ensure the integrity of the election.

Republicans say the recount will cost taxpayers far more than the $973,000 Stein must pay when filing her recount petition.

Green Party presidential nominee Jill Stein will not be appealing a Wisconsin judge’s ruling that the state’s presidential recount can be done without hand counting every ballot.

Stein spokeswoman Margy Levinson said in an email Wednesday that the ruling made Tuesday night in Dane County Circuit Court would not be appealed. Levinson says given the time constraints, they want to focus resources on the recount that begins Thursday.

The majority of Wisconsin counties planned to do a hand recount of ballots cast even though the judge’s ruling means they can choose to feed the ballots into tabulation machines to double check the counts.

Levinson says Stein’s focus will be on verifying the vote on the ground and she encourages counties to voluntarily conduct a hand recount.

Wisconsin election officials are set to hold their last meeting with county clerks before launching a presidential recount.

The recount is set to start Thursday. The Wisconsin Election Commission plans to meet with the clerks via teleconference and an online seminar Wednesday morning. The agenda calls for discussing counting procedures, how to treat absentee ballots, how to review provisional ballots and how to track expenses.

Green Party presidential candidate Jill Stein requested the recount, alleging without evidence that the state’s electronic voting machines may have been hacked. The commission had to grant that request under state law. Stein also wanted all 72 counties to conduct the recount by hand, but the commission refused to order that and a Dane County judge affirmed that decision late Tuesday evening.</s>CARSON CITY — Roque “Rocky” De La Fuente, an independent candidate for president who garnered less than 1 percent of the vote in Nevada, filed late Tuesday for a recount of a sample of the state’s presidential ballots.

De La Fuente identified 93 precincts to be recounted and paid $14,154.98 to the secretary of state’s office ahead of the 5 p.m. deadline to cover the cost.

In the November election, De La Fuente came in dead last in the presidential contest on the Nevada ballot, even trailing “None of these candidates.” He received just 2,552 votes, or 0.23 percent. Democratic contender Hillary Clinton won Nevada with 47.9 percent of the vote, beating Republican President-elect Donald Trump by a little more than 2 percent.

In a statement Tuesday, De La Fuente said he ran in the Democratic presidential primary, then ran in the general election in various states as an independent and as the nominee of both the Reform Party and the American Delta Party in “an effort to champion election reform.”

Under state law, the secretary of state’s office has five days to complete a recount of the precincts requested — two each in Carson City, Douglas, Mineral and Nye counties and the rest in Clark County, the state’s population hub and home to about 2 million people.

If the recount shows a discrepancy equal to or greater than 1 percent for either De La Fuente or Clinton, a full recount of all ballots in the state will be ordered, said Wayne Thorley, elections deputy for the secretary of state’s office.

“If it shows yes there was a discrepancy, we’ll recount the entire state,” Thorley said.

De La Fuente also filed a petition last week requesting a recount in Wisconsin, but later withdrew it after Jill Stein, the Green Party presidential candidate, filed a petition there and telegraphed plans to file also in Michigan and Pennsylvania. On Tuesday, his campaign said it would instead ask for recounts in Nevada and Florida.

Stein missed deadlines and was not on Nevada’s Nov. 8 ballot, and therefore was ineligible to request a recount here.

Republicans have denounced the recounts, with President-elect Donald Trump labeling the effort a “scam” and his senior adviser Kellyanne Conway calling Stein and Democrat Hillary Clinton, whose campaign on Saturday threw its support behind Stein’s moves, “a bunch of crybabies and sore losers.”

In the statement, De La Fuente indicated he was concerned about the integrity of the vote and was not pursuing the recount for partisan reasons.

“I am not a big fan of President-elect Trump, but I also ran against Hillary in the Democratic primary,” De La Fuente said. “In my opinion, a recount should be done to validate the election or expose the need for substantive election reform. It shouldn’t favor one candidate over another.”

The Nevada Green Party supports De La Fuente’s recount effort here, state co-Chairwoman Kim Borghese said.

“He has that right and it basically just ensures that there’s no corruption or fraud going on in the system,” Borghese said. “It’s the fair and right thing to do to make sure there is election integrity”

De La Fuente, who could not be contacted by the Las Vegas Review-Journal late Tuesday, said in the statement that he doesn’t expect to change election results.

“It’s not about flipping a state and changing the results,” he said. “It’s about making sure that every vote counts as it’s cast.”

De La Fuente, a businessman whose website lists auto dealerships, banking and real estate among his enterprises, added that he targeted Nevada because he had standing to seek a recount here, whereas Stein did not.

“Jill wasn’t ballot-qualified in Nevada, whereas I was,” he said. “So, she can carry the burden in Wisconsin and the other states in which she as an interest, and I’ll add two more to the mix.”

Colton Lochhead of the Review-Journal contributed to this report. Contact Sandra Chereb at schereb@reviewjournal.com or 775-461-3821. Follow @SandraChereb on Twitter.</s>LANSING, Mich. – The Latest on presidential recount efforts in Michigan, Pennsylvania, Wisconsin and Nevada (all times local):

Nevada election officials will recount ballots in five counties after independent presidential candidate Roque De La Fuente requested and paid about $14,000 for the effort.

De La Fuente finished last in the state but this week requested a recount in Nevada, a state Democrat Hillary Clinton won. De La Fuente says he wants to counterbalance a recount Green Party candidate Jill Stein requested in Wisconsin, which President-elect Donald Trump won. Stein also has requested recounts in Trump-won states of Michigan and Pennsylvania.

Nevada Deputy Secretary of State for Elections Wayne Thorley said Wednesday that state law requires the five counties — Carson City, Douglas, Mineral, Nye and Clark — to begin the recount within five days and to complete it within five additional days.

Thorley says if recount results show a discrepancy of at least 1 percent for De La Fuente or Clinton, a full state recount will be launched.

Green Party presidential nominee Jill Stein is pushing back against charges from Wisconsin Republicans that she illegally coordinated with Democrat Hillary Clinton to raise money for recounts in three states.

Stein campaign manager David Cobb said in a statement Wednesday that "The recount effort is non-partisan and Stein is not coordinating with any other campaign."

Cobb says, "Any allegations to the contrary are fabrications." He says the Wisconsin Republican Party's complaint to the Federal Elections Commission "is nothing but a PR stunt to push a false narrative that will ultimately have no impact on the recount in Wisconsin."

The complaint contends that Clinton is the only person who could benefit from a recount and that she appears to have illegally helped Stein raise nearly $7 million for the recounts in Wisconsin, Pennsylvania and Michigan.

Stein requested the recount on Wednesday. She had already requested recounts in Pennsylvania and Wisconsin.

Republican Donald Trump won all three states. He defeated Democrat Hillary Clinton in Michigan by 10,704 votes out of nearly 4.8 million ballots cast. Stein alleges that irregularities and the potential for hacking into scanning devices call into question the results.

The Michigan recount could start as early as Friday.

Trump's victory is highly unlikely to be reversed in any of the states. But Stein says the recount will ensure the integrity of the election.

Republicans say the recount will cost taxpayers far more than the $973,000 Stein must pay when filing her recount petition.

Wisconsin's elections chief is telling local clerks that he knows they're frustrated with trying to complete a presidential recount in less than two weeks.

Green Party presidential candidate Jill Stein requested the recount. It's slated to begin Thursday and must be completed by Dec. 13 or Congress could gain control of the state's electoral votes.

Commission Administrator Mike Haas held a teleconference with clerks Wednesday to walk them through final preparations.

Twice Haas acknowledged they're unhappy with conducting a recount during the holiday season on behalf of a candidate who got only 30,000 votes in Wisconsin. But he told them he hopes they've accepted that the recount must be conducted, by law, and that it will be done professionally.

The Wisconsin Republican Party alleges that Green Party presidential candidate Jill Stein's recount effort in Wisconsin amounts to illegal coordination with Democrat Hillary Clinton.

The state Republican Party filed a complaint with the Federal Election Commission on Wednesday. The complaint comes the day before the scheduled start of the recount of Wisconsin's vote, won by Republican Donald Trump by less than 1 percentage point.

The complaint contends that Clinton is the only person who could benefit from a recount and that she appears to have illegally helped Stein raise nearly $7 million for the recounts in Wisconsin, Pennsylvania and Michigan.

Spokeswomen for Stein and Clinton's campaigns did not immediately respond to requests for comment.

Stein plans to request the recount later Wednesday. She has already requested recounts in Pennsylvania and Wisconsin.

Republican Donald Trump won all three states. He defeated Democrat Hillary Clinton in Michigan by 10,704 votes out of nearly 4.8 million ballots cast. Stein alleges that irregularities and the potential for hacking into scanning devices call into question the results.

The Michigan recount could start as early as Friday.

Trump's victory is highly unlikely to be reversed in any of the states. But Stein says the recount will ensure the integrity of the election.

Republicans say the recount will cost taxpayers far more than the $973,000 Stein must pay when filing her recount petition.

Green Party presidential nominee Jill Stein will not be appealing a Wisconsin judge's ruling that the state's presidential recount can be done without hand counting every ballot.

Stein spokeswoman Margy Levinson said in an email Wednesday that the ruling made Tuesday night in Dane County Circuit Court would not be appealed. Levinson says given the time constraints, they want to focus resources on the recount that begins Thursday.

The majority of Wisconsin counties planned to do a hand recount of ballots cast even though the judge's ruling means they can choose to feed the ballots into tabulation machines to double check the counts.

Levinson says Stein's focus will be on verifying the vote on the ground and she encourages counties to voluntarily conduct a hand recount.

Wisconsin election officials are set to hold their last meeting with county clerks before launching a presidential recount.

The recount is set to start Thursday. The Wisconsin Election Commission plans to meet with the clerks via teleconference and an online seminar Wednesday morning. The agenda calls for discussing counting procedures, how to treat absentee ballots, how to review provisional ballots and how to track expenses.

Green Party presidential candidate Jill Stein requested the recount, alleging without evidence that the state's electronic voting machines may have been hacked. The commission had to grant that request under state law. Stein also wanted all 72 counties to conduct the recount by hand, but the commission refused to order that and a Dane County judge affirmed that decision late Tuesday evening.</s>Roque “Rocky” De La Fuente, an independent candidate for president who garnered less than 1 percent of the vote in Nevada, filed late Tuesday for a recount of a sample of the state’s presidential ballots.

Roque "Rocky" De La Fuente, an independent candidate for president, filed for a recount of a sample of Nevada’s presidential ballots on Tuesday, Nov. 29, 2016. (Matt Volz/AP)

CARSON CITY — Roque “Rocky” De La Fuente, an independent candidate for president who garnered less than 1 percent of the vote in Nevada, filed late Tuesday for a recount of a sample of the state’s presidential ballots.

De La Fuente identified 93 precincts to be recounted and paid $14,154.98 to the secretary of state’s office ahead of the 5 p.m. deadline to cover the cost.

In the November election, De La Fuente came in dead last in the presidential contest on the Nevada ballot, even trailing “None of these candidates.” He received just 2,552 votes, or 0.23 percent. Democratic contender Hillary Clinton won Nevada with 47.9 percent of the vote, beating Republican President-elect Donald Trump by a little more than 2 percent.

In a statement Tuesday, De La Fuente said he ran in the Democratic presidential primary, then ran in the general election in various states as an independent and as the nominee of both the Reform Party and the American Delta Party in “an effort to champion election reform.”

Under state law, the secretary of state’s office has five days to complete a recount of the precincts requested — two each in Carson City, Douglas, Mineral and Nye counties and the rest in Clark County, the state’s population hub and home to about 2 million people.

If the recount shows a discrepancy equal to or greater than 1 percent for either De La Fuente or Clinton, a full recount of all ballots in the state will be ordered, said Wayne Thorley, elections deputy for the secretary of state’s office.

“If it shows yes there was a discrepancy, we’ll recount the entire state,” Thorley said.

De La Fuente also filed a petition last week requesting a recount in Wisconsin but later withdrew it after Jill Stein, the Green Party presidential candidate, filed a petition there and telegraphed plans to file also in Michigan and Pennsylvania. On Tuesday, his campaign said it would instead ask for recounts in Nevada and Florida.

Stein fell short of signatures needed to qualify for Nevada’s Nov. 8 ballot after the verifiation proces by the secretary of state’s office. A federal judge upheld the secretary of state’s determination. Because she was not on the ballot, Stein was ineligible to request a recount here.

Republicans have denounced the recounts, with President-elect Donald Trump labeling the effort a “scam” and his senior adviser Kellyanne Conway calling Stein and Democrat Hillary Clinton, whose campaign on Saturday threw its support behind Stein’s moves, “a bunch of crybabies and sore losers.”

In the statement, De La Fuente indicated he was concerned about the integrity of the vote and was not pursuing the recount for partisan reasons.

“I am not a big fan of President-elect Trump, but I also ran against Hillary in the Democratic primary,” De La Fuente said. “In my opinion, a recount should be done to validate the election or expose the need for substantive election reform. It shouldn’t favor one candidate over another.”

Clinton won Nevada, while Trump won Florida, Michigan, Pennsylvania and Wisconsin.

The Nevada Green Party supports De La Fuente’s recount effort here, state co-Chairwoman Kim Borghese said.

“He has that right and it basically just ensures that there’s no corruption or fraud going on in the system,” Borghese said. “It’s the fair and right thing to do to make sure there is election integrity.”

De La Fuente, who could not be reached by the Las Vegas Review-Journal late Tuesday, said in the statement that he doesn’t expect to change election results.

“It’s not about flipping a state and changing the results,” he said. “It’s about making sure that every vote counts as it’s cast.”

De La Fuente, a businessman whose website lists auto dealerships, banking and real estate among his enterprises, added that he targeted Nevada because he had standing to seek a recount here, whereas Stein did not.

“Jill wasn’t ballot-qualified in Nevada, whereas I was,” he said. “So, she can carry the burden in Wisconsin and the other states in which she as an interest, and I’ll add two more to the mix.”

Colton Lochhead of the Review-Journal contributed to this report. Contact Sandra Chereb at schereb@reviewjournal.com or 775-461-3821. Follow @SandraChereb on Twitter.</s>CARSON CITY — Roque “Rocky” De La Fuente, an independent candidate for president who garnered less than 1 percent of the vote in Nevada, filed late Tuesday for a recount of a sample of the state’s presidential ballots.

De La Fuente identified 93 precincts to be recounted and paid $14,154.98 to the Secretary of State’s Office ahead of the 5 p.m. deadline to pay for the process.

In the November election, De La Fuente came in dead last in the presidential contest on the Nevada ballot, even trailing “None of these candidates.” He received just 2,552 votes, or 0.23 percent. Democratic contender Hillary Clinton won Nevada by 2 percentage points over Republican president-elect Donald Trump.

In a press release Tuesday, De La Fuente said he ran in the Democratic presidential primary, then ran in the general election in various states as an independent and as the nominee of both the Reform Party and the American Delta Party in “an effort to champion election reform.”

Under state law, the secretary of state’s office has five days to complete a recount of the 93 precincts requested — two each in Carson City, Douglas, Mineral and Nye counties and the rest in Clark County, the state’s population hub and home to 2 million people.

Contact Sandra Chereb at schereb@reviewjournal.com or 775-461-3821. Follow @SandraChereb on Twitter.</s>Independent candidate Roque “Rocky" De La Fuente has requested a recount of the results of the presidential election in Nevada, his campaign confirmed today.

De La Fuente said in a statement Tuesday that he is asking for recounts in Florida and Nevada “to create a nationwide awareness of the vulnerability of our election system” and to ensure that “your vote counts for the candidate for whom it is cast.” Green Party presidential candidate Jill Stein has made similar recount requests in recent days, moving to challenge election results in Wisconsin, Michigan and Pennsylvania.

Democrat Hillary Clinton won 47.9 percent of the vote in Nevada to Republican President-elect Donald Trump’s 45.5 percent. De La Fuente, a San Diego businessman and little-known candidate, received the fewest number of votes on election night, 2,552 ballots or 0.23 percent of the vote, even fewer than Nevada’s unique “none of these candidates” option.

The recount was first reported by Nevada political journalist Jon Ralston.

De La Fuente said he chose to focus on Nevada because the state’s February caucuses were conducted “in a way that should have raised eyebrows." He described his recount efforts in the two states as a “spot check” on the election results.

“Both states have ‘earned’ the right to be audited, the limited recounts won’t be prohibitively expensive, and neither candidate will be unfairly favored,” De La Fuente said.

To ask for a recount, a candidate or voter must submit a letter to the Nevada Secretary of State’s Office stating which office or ballot measure he or she is requesting be recounted, along with the precincts that they request to be included in the recount. They must also submit a deposit to cover the costs of the recount.

Requests for a recount are due within three working days of the official canvass of the votes, which occurred this year on Nov. 22. A recount must begin five days after the demand is filed and be completed within five days after it has begun.

The Nevada Secretary of State’s Office did not immediately return an email or phone call Tuesday night seeking additional information.</s>CARSON CITY — A recount of ballots in select precincts from five Nevada counties sought by a last-place presidential contender will not automatically trigger a statewide recount, even if the stipulated 1 percent discrepancy is found, a state election official said Wednesday.

Roque “Rocky” De La Fuente, who came in dead last in Nevada with 2,552 votes in the Nov. 8 general election, filed for a recount Tuesday just minutes before the 5 p.m. deadline to do so. He paid a fee of $14,154.98 to finance the effort to recount ballots in 93 precincts, or 5 percent of the total.

Under state law, if a discrepancy of 1 percent or more is found in either the votes received by the person requesting the recount or the person who won — Democrat Hillary Clinton in this case — a new counting of all ballots cast in that race can be ordered. But it is not mandatory or automatic.

“State law gives the secretary of state some discretion on when a person who requests a recount is entitled to a full statewide recount,” elections deputy Wayne Thorley said. “The secretary of state will need to review the results of the sample recount of 93 precincts before making any decisions on a full statewide recount.”

The precincts chosen by De La Fuente include two each in Carson City and Douglas, Mineral and Nye counties, with the rest in Southern Nevada’s Clark County.

A review of returns by the Review-Journal shows that De La Fuente received a combined 202 votes in those precincts. Should the recount of those sample precincts result in a difference of just three votes to his total, all of Nevada’s presidential ballots could be subject to a new tallying — an effort that could take about five days and cost an estimated $50,000.

But the final determination would be made by Republican Secretary of State Barbara Cegavske, who would consider whether the effort could change the election’s outcome and is thereby warranted.

Clinton won Nevada with more than 539,000 votes, or 47.9 percent. Republican President-elect Donald Trump received 512,000 votes, or 45.5 percent.

De La Fuente’s total amounted to 0.23 percent of votes cast, and even trailed “None of these candidates” by more than 26,000 votes.

In a phone interview Wednesday, he said he expects the vote totals to change, though he doesn’t expect to win the election.

In selecting precincts for the recount, De La Fuente said, “I picked all the districts where I suspect election fraud and election manipulation.”

“I’m very, very concerned,” he added, alleging votes were stolen from him in Nevada and other states.

De La Fuente’s Nevada recount comes amid similar efforts filed by Green Party candidate Jill Stein in Wisconsin, Michigan and Pennsylvania.

Republicans have scoffed at the recounts, and Trump has called the effort a “scam.”

De La Fuente ran and lost in the Democratic primary, then ran in the general election in various states as an independent or the nominee of the Reform Party and American Delta Party.

The secretary of state’s office formally notified election officials in the Nevada counties of the recount demand. Those counties now have five days to begin their new tallying, which will involve retabulating cartridges from the electronic voting machines and scanning absentee ballots.

They then have five days to complete the task and report the results to the secretary of state.

Contact Sandra Chereb at schereb@reviewjournal.com or 775-461-3821. Follow @SandraChereb on Twitter.</s>In November, the University of Nevada, Las Vegas (UNLV) School of Medicine began accepting applications and interviewing students who will start their medical school education in summer 2017.

That sounds like good news – and it is – because of Nevada’s severe shortage of physicians. However, it’s only one step by Nevada healthcare professionals to help the state catch up. According to a biennial report from University of Nevada School of Medicine in May, there are 5,726 physicians licensed to practice or in residency in Nevada.

That sounds like a lot, but 69.8 percent are in Clark County, and 22.4 percent in Washoe County, leaving less than 8 percent practicing in the rural counties. In addition, doctors 60 years or older account for 27 percent of Nevada physicians.

“We have a tremendous shortage [of physicians] and in nearly all specialties,” said Dr. Thomas Schwenk, dean, University of Nevada, Reno (UNR) School of Medicine. The problem is compounded by the fact that, “until recently we’ve had a limited system of public medicine education leading to residency education and into practicing physicians,” he said.

Dr. Schwenk, along with the dean of UNLV’s forthcoming School of Medicine, Dr. Barbara Atkinson and the deans of Touro and Roseman Universities are working to repair Nevada’s dismal numbers. Nevada ranks 48th in U.S. states for the number of physicians per capita, 50th for the number of primary care physicians, 51st for registered nurses, 47th for psychiatrists and 41st for psychologists. The number of pediatric doctors is 9.6 per 10,000 children in Nevada while the rest of the country is at 15 per 10,000.

The good news is that, anywhere from 50 to 80 percent of physicians remain where they’ve performed their residency, and Nevada ranks eighth in the U.S. for physicians remaining after residency training.

Keeping Up with the Demand

That good news remains good news as long as there are enough residencies to train and keep the doctors going through them. Unfortunately, at the moment, Nevada doesn’t have enough residencies and the state isn’t unique in that. There doesn’t seem to be enough residency or fellowship programs across the country.

“There’s no question there’s demand all over the country [for residency programs],” said Mark Penn, dean, College of Medicine, Roseman University of Health Sciences. “There’s lots of individuals that want to become physicians but we don’t have enough spots for all of them.” Which means if the state can create residency programs, there is the possibility of attracting students from other states, who just might stay.

The Legislature and the Governor, with the deans of new and existing medical schools, are now recruiting doctors, creating residencies and looking to put together medical fellowships in order to train specialists. After four years of medical school and three to five years of residency, fellowship training for specialities is another three to seven years.

“We have to support that scope by training so we have enough cardiologists, enough pulmonologists, enough cancer doctors and that’s done with fellowship training,” said Dr. Anthony Slonim, CEO, Renown Health. A fellowship program takes years to build, which is one reason Renown has partnered with Stanford University. The organization hopes to entice some of their specialists to Nevada while building programs.

Deans of Nevada medical schools are working together, combining strengths rather than competing. There are enough hopeful medical students to go around, and more applicants for residency slots than there are slots. In early 2016, there were 138 first year residency positions and the state’s medical schools included UNR and Touro.

“So at that moment in time, Nevada is a net exporter of medical students who have to go somewhere else to train,” said Dr. John Dougherty, dean, Touro University Nevada.

In September 2013, the University of Nevada Board of Regents decided to expand medical education in Nevada. In January 2014, it decided on a new medical school at UNLV. Dr. Atkinson was recruited as dean and began the numerous steps involved in creating a school of medicine.

“I spent the first six months meeting with people in the community, talking to the people at University of Nevada, Reno School of Medicine and people in Las Vegas, really planning the curriculum and what the future should look like,” said Atkinson. “My goal was to make sure the school was what the community needed: to provide physicians to the state.”

In January the Liaison Committee on Medical Education (LCME), the accrediting body for the U.S. and Canada, reviewed the accreditation materials. In July, they performed a site visit. In October, the school was approved to accept the first class.

For the 60 openings, 800 applicants requested notification and the pool of qualified students is 2,000 to 3,000 strong.

Meanwhile, Roseman is in the second phase of the accreditation process. Documentation was submitted to LCME in June, 93 elements taken into account, and 92 approved.

Accreditation was denied over questions of adequate funding. “It’s not uncommon to have some bumps in the road,” explained Penn. When fully accredited, Roseman expects to have 60 students in the school’s first class.

Those 800 aspiring medical students eyeing Nevada’s schools come from across the country. But while Atkinson said there’s no mandate to accept only Nevada residents, qualified Nevadans and students with ties to the state are first choice.

“We want to be sure to choose people who are going to want to stay,” said Atkinson. “The issue is obviously to pick them from people who are already here, who have family here and who are most likely to stay here.”

To that end, the curriculum is tied to the Las Vegas community, “so they’ll really understand our community and the diversity of our community,” added Atkinson.

Once the students are in the state, the next step is to build residency programs, because 80 percent of graduates who do both medical school and residency in the same place tend to stay.

“Our problem in Nevada is we don’t have many of the residency programs that students like to take,” said Atkinson. That means a number of students automatically leave the state, which is why medical schools, local hospitals and medical practices are working together to build residencies in all the specialties.

Partnerships are the backbone of residencies. Medical students must do rotations in both hospitals and outpatient practices. That means, across the state, residency partnerships are forming for the good of the community.

“We have an explosion of interest, with Mountain View Hospital developing a system and Valley Health committed to do the same,” said Schwenk.

That’s something like 200 to 250 new residency slots. UNLV is also set to continue UNR’s strong partnership with the University of Southern California. The system is also adding new partnerships with Renown Health and expanding others with the VA Sierra Nevada Health Care System. There’s even talk of adding rural residencies in places like Elko. Rural providers are especially in demand.

“The growth we’re experiencing right now [in medical education] means the graduate education side is critically important,” said Dougherty. With Mountain View, Valley Health and Dignity looking to start residencies between 2017 and 2019, the number of residency slots should rise from 135 to closer to 300. “It’s massive change, and it’s wonderful. Technically, now Nevada is going to be a net importer of students into training programs.”

Residency programs can provide better healthcare now for Nevada residents. Medical students spend their first two years in lectures, listening to people talk about medicine, said Dougherty. They spend the next two years as active learners, in hospitals and medical practices.

“When you have a residency training program with the students, the students get a better education,” said Dougherty. “Residents are active learners and will challenge and engage the medical students. The two are synergistic and the impact they have on the attending physician is positive. Because you never want to be shown up by a 24-year-old kid, as a physician, you work a little harder to keep up on stuff,” Dougherty said.

Southwest Medical Associates is a provider of clinical education in Southern Nevada, partnering with University of Nevada Schools of Medicine and Touro.

“Basically we’re doing what I call collaboration,” said Dr. Linda Johnson, senior medical director, provider of clinical education, Southwest Medical. Whether a student is training to be a practical nurse, a physician’s assistant or a doctor, he or she has to do clinical rotations.

“We don’t have specific programs where they’re doing their training only with us because we’re collaborating with other institutions in the community to provide the site,” said Johnson.

Southwest Medical’s program recently brought in six students to spend the majority of their clinical year training in the facilities, before going to work for the practice by graduation. Southwest will also be the clinical site for Universal Health Systems (UHS) approved Family Practice and Internal Medicine residency, producing 60 new family practice doctors and 120 internal medicine interns and residents.

In Northern Nevada, Renown Health’s residency program with UNR School of Medicine offers internal medicine and family practice and, because of the shortage of physicians in Nevada, they’re also the clinical training program for the new physician assistant program at UNR.

Because training new physicians is a 10-year process, and recruiting them from other states won’t fill all Nevada’s needs, medical professionals are looking for creative solutions to implement in the short term. That includes training practical nurses and physician assistants.

“We’re thinking creatively about options with which to enhance physician supply beyond training, recruiting and advising physicians,” said Slonim. “We have to think about providers who can reach into the community.” Physician assistants and advanced practice nurses can do that, which enhances the role physicians play in the community by providing services to people.”

These solutions don’t answer all of Nevada’s healthcare challenges. There may be a large pool of medical school applicants to draw from (the four states Nevada schools of medicine draw most from are Texas, Florida, California and Utah), but the pipeline to medical schools isn’t strong.

“One challenge for us in state is that we don’t have a robust college environment,” said Dougherty. “Most states have a network of colleges and universities, either private or public.” Nevada has fewer than 10, and they’re located primarily in the metro areas.

Working to fill that pipeline, Roseman University of Health Sciences gives presentations in junior highs, high schools and community colleges, to motivate students to explore the health professions, said Penn.

It may sound like a strange challenge, but Nevada also doesn’t have enough patients. There’s a lack of critical mass when it comes to patients in specific disciplines, said Schwenk. When creating residencies and fellowships, the number of patients needing specialized care must be considered. There’s a reason why major metropolitan areas and coastal cities with large populations traditionally offer more training in more specialized disciplines.

“It’s hard in Reno, for example, to do a neurosurgery residency, because there’s not the breadth and volume, but we’re thinking orthopedic surgery in Reno,” said Schwenk. While Reno might be able to sustain a cardiology fellowship, a sub-specialty might require partnering with an institution like Stanford.

“The main issue with many sub-specialty programs is they require a strong research component,” said Schwenk. “We would have to invest heavily in research, so what’s required is money and investment with hospitals and other healthcare facilities.”

In October, the Graduate Medical Education Task Force recommended distribution of $10 million approved in the executive budget during the 2015 legislative session. The funds will be awarded to both University of Nevada Schools of Medicine, Touro University and to Valley Health Hospital System and Mountain View Hospital in Southern Nevada, both of which are forming new residency program s. The lion’s share, however, was directed toward expanding primary care residencies in the state.

“We need to fill the specialities,” said Atkinson. “I’m hoping that by the next legislative session we will have been so successful that we’ll be getting additional funds for both primary care and specialties.”

There’s a need to fund residencies like dermatology and ophthalmology, and there’s also a need for fellowships in areas like pediatrics. To create some of these, UNLV is working with University Medical Center (UMC), Sunrise Hospital and the VA, where current UNR School of Medicine residencies are.

“We’re working with them to expand,” said Atkinson. Or to begin. 7:Dignity Health hospitals, for example, have never had residencies, but are working to create them.

Growing physicians isn’t a short-term goal. In 2014, the decision was made to create the UNLV School of Medicine. Financial support began in 2015. Accreditation was obtained in October for the first class, which starts summer 2017, and graduates 2021. Residencies last at least three years, and four or five for many specialties, meaning specialists will be working in their fields in Nevada – provided they stay – in 2025.

“From the year the legislature approved support for UNLV [School of Medicine], that’s 10 years before we have a new doctor,” said Schwenk. “That’s discouraging for some people, but it just means it’s taking us a while to catch up.”

“The most exciting thing is just being able to see the difference it’s going to make in the care of patients and in seeing the young medical students blossom in this exciting curriculum,” said Atkinson.

The new medical schools and residency programs will provide a shot in the arm for Nevada’s economy. According to Penn, a recent study showed the economic impact of medical schools within a state can be upwards of $1 billion.

“That’s everything. It’s the new people you bring on, the impact into the community, with all kinds of other services that grow and come out of that,” said Penn. Looking at that research, he believes Roseman’s College of Medicine will probably have an impact between $500 million and $1 billion. “UNLV talks about over $1 billion. The numbers are pretty huge. I think together the two new schools coming on could have a collective impact of anywhere from $1.5 to $2 billion,” he added.

Technology plays a part in the new medical education too. Electronic medical records, telemedicine to care for rural patients and robotic surgery are all innovations in the medical field, but today’s medical students will go into practice never having not known about them.

“We have to continue to evolve and meet the needs of the practicing world because we’re trying to prepare our students for that world,” said Penn.

It’s a collective effort that’s underway to do just that. Penn said, “That’s one thing when we as deans [of the medical schools], get together and discuss. How do we do it? Some things you have to do separately because you have to, but there is a ‘greater good’ phenomenon you have to consider. How do we work together to make this a better place for all of us?” added Penn
Reform candidate Rocky de la Fuente files for a sample recount in parts of Nevada.