New legislation in Missouri will create a new class of medical license, the "assistant physician." Critics say it will establish a reprehensible dual standard of care, one for the rural and underserved and another for everyone else.
Update: The bill was signed into law on July 10.
From Missouri's Ozark Mountains to its northern plains, a healthcare drama is quietly underway. And it is sure to be the House of Medicine's ruin.
Or its salvation.
ACGME Chief Sees 'Huge' Risk of Error in Proposed Assistant Physician Licensure
It depends who's talking, but I think it's going to be a national disaster because of the dangerous precedent it sets.
Legislation sitting on Missouri Gov. Jay Nixon's desk will, if he signs it by July 14, empower Missouri's medical board to create a new category of doctor's license, "the assistant physician."
This new type of certificate would be handed out to medical school graduates who didn't get into a residency program and who passed Step 1 and 2 exams, but not the most important one, Step 3.
With minimal prior exposure to patients, these young doctors would be licensed to practice just like regular doctors, as long as they only treated patients in the most physician-starved poor and rural areas throughout the state.
This licensing lunacy would allow unqualified clinicians to misdiagnose, misprescribe, and bungle treatments inevitably leading to patient harms too numerous to detail.
The bill's antagonists, and there are many including the American Medical Association's House of Delegates, fear the "Show Me" state will have a reprehensible dual standard of medical care, one for the rural poor and one for everyone else.
'This Is Nuts'
"The magnitude of the potential for harm is so striking, it's hard to put into terms," says Thomas Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education. In the third and fourth year of medical school, students have only four months of experience evaluating patients, yet "the scope and diversity of diagnoses is measured in the thousands.
"These are physicians with rudimentary experience. But you'll then turn them loose to manage patients with complex diabetes, congestive heart failure, arrhythmias? Malignancies? This is nuts."
But the bill's proponents, including the Missouri State Medical Association (MSMA), which represents some 10,000 practicing Missouri physicians and helped draft the legislation, say Bravo! Allowing these new physicians to treat patients who otherwise have miserable access to care is a brilliant solution to a dire physician shortage.
After all, Missouri last year received a federal designation as one of the 10 most medically underserved states in the nation. Acknowledging that many more doctors are needed to treat thousands of newly insured, Jeffrey Howell, the MSMA's government relations director and general counsel, insists the pending bill does not set up a different standard of care.
Only Worried About Competition
"The people who are objecting to this are only worried about competition. They can talk about standards of care, or what happens if someone gets hurt all they want, but all this really just boils down to competition," Howell contends.
"You can help people in rural areas by thinking outside the box, and come up with solutions, or you can continue to allow those people to not get care. We prefer Option A."
Besides, he says, "there are 7,000 to 8,000 medical students (international and U.S.) who don't get a residency match every year and have to wait. They do research or wait tables or do whatever they can. We thought it better that they actually saw patients and kept their skills sharp until they could try for a residency the next year."
That's not acceptable to the AMA, which in June resolved to "oppose special licensing pathways for physicians who are not currently enrolled in an Accredited Council for Graduate Medical Education or American Osteopathic Association training program, and have not completed at least one year of accredited post-graduate U.S. medical education."
Rather, the AMA said, the graduate medical education system should find funds to increase the residency slots so more doctors will have a chance to practice. A residency program is crucial, the AMA believes.
Solution to the Doctor Shortage
But Howell says the physician shortage in Missouri is so bad, communities with 2,000 to 5,000 people barely have access to a doctor one day a week. "And they share that doctor with two or three similar communities."
Besides, says Howell, the new rules would be no different than those for older doctors. "A lot of those guys didn't have to go through a residency program. They just graduated from medical school and went back to the farming communities they grew up in, hung out their shingles, and treated people."
If signed, the law would require the Missouri Board of Healing Arts to write specific rules, and do background checks for all applicants. The new licensees would have to be proficient in English. And essential to the deal is that each licensee must have a signed agreement with a "physician collaborator," with whom they would directly work for 30 days before practicing in another setting, and never no more than 50 miles away. That collaborator would review 10% of the licensee's patient charts.
Howell says the idea is that these assistant physicians would only practice basic primary care, "which means treat the flu, give vaccinations, and prescribe simple antibiotics. Their scope of practice will be very similar to what you see for a nurseor physician assistant." But they would be able to prescribe drugs in Schedule III, IV, or V.
And though they would be called "doctor," they'd have to tell patients they are assistant physicians.
The American Academy of Physician Assistants, which represents some 90,000 physician assistants in the U.S. (not to be confused with the new "assistant physician" license the legislation would create), also has strong objections.
One reason is the name of the new license, which sounds too much like theirs. "As a patient, if I saw someone called an assistant physician, I'd be very confused," says Ann Davis, AAPA spokeswoman. They won't understand.
Much more worrisome, Davis says, is "that someone who is not fully qualified in anything will now be able to provide care for patients in Missouri. Physician license requirements are developed for a reason. And medical school is designed to prepare you for a residency. To jump over that set of requirements and allow folks who are not fully required to provide care is completely untested."
The AAPA believes the concept does indeed set up a dual standard of care. "It says, here's this group of people who are not qualified for licensure, but we'll offer up to them these people who are disadvantaged. That's a very troublesome concept."
Sophie's Choice?
What an ethical dilemma. Which is worse? New doctors who aren't as well trained treating the rural, underserved poor? Or rural, underserved poor not getting care at all?
I sent the question to Art Caplan, medical ethicist at NYU Langone. He quickly replied:
"I favor this despite the risks of being treated by less well-trained docs. Most of primary care at this point can be delivered by well trained nurses and PAs. (I'm) not sure how many med school types did not match, but allowing them to do basic care seems reasonable."
Caplan argues that a dual standard of care in the U.S. is nothing new.
"…nothing versus something for many rural and poor persons. This idea helps bridge that gap," and is "a clever idea that must be pursued… until more doctors are willing to serve in poor, rural, and inner city areas."
I disagree with Caplan. The idea makes me nervous. The Show Me state should at the very least show us—perhaps with a small and tightly supervised pilot—that this idea really can improve care without creating misdiagnosis and malpractice disaster, which would be a huge embarrassment for Missouri and potentially worse for patients.
But I don't think it can.