Missouri’s solution to primary care physician shortage prompts backlash

A Missouri law creating a new licensure for medical school graduates who are unable to secure residencies is sparking backlash from medical organizations.

Under the law, medical school graduates who have passed the first two steps of their exams may be licensed as “Assistant Physicians,” and will be able to provide primary care services in rural areas of the state.

Jeffrey Howell, director of government affairs and general counsel for the Missouri State Medical Association says it’s a necessary solution to address underserved populations.

“When they don’t get residency slots, they do research, wait tables or deliver pizza,” says Howell. “We thought, ‘why can’t these people, who have four years of undergrad, graduated medical school and passed the first two steps of their licensing exam, why can’t they provide primary care services in rural area?’”

The primary care shortage has hit rural areas of the state hard. Of Missouri’s 101 rural counties, 98 are designated Primary Medical Health Professional Shortage Areas, according to a 2013 report from the Missouri Foundation for Health.

A lack of physician retention in the state has exacerbated the problem. A 2014 report from the Missouri Hospital Association found that although the state produces 2.7% of the country’s medical school graduates, it’s the second-leading exporter of doctors to other states.

Medical organizations criticize licensure

The new licensure has prompted criticism from several medical organizations, arguing that these graduates are not prepared for the task at hand.

“This is a bad solution to a difficult problem,” says Thomas Nasca, MD, MACP, chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). “The medical school curriculum is not designed to produce an independent practitioner. It’s designed to produce an individual who then goes on to specialty training.”

But Howell says the assistant physicians scope of practice will be narrow. “They won’t be doing anything terribly complicated,” says Howell. “They will basically be treating colds and flus, stitching people up, giving vaccinations. It’s simple primary care stuff that we’re concerned with.”

While primary care physicians may treat many simple health issues, Nasca says they must also have the knowledge to recognize more complicated problems and provide the necessary recommendations.

“Patients don’t come to primary care physicians sorted into simple problems and complicated problems,” says Nasca. “The idea that primary care is simple and this idea that primary care can be done by people who are not well trained is a flawed concept. It is wrong. The primary care physician, in my opinion, has the most difficult job in the healthcare delivery system. That’s because they must not make errors of omission. They must not make errors of failure to recognize. It is a very challenging task."

Next: Law contains safeguards

Law contains safeguards

The Missouri Board of Registration for the Healing Arts will determine the rules of the new licensure, which Howell estimates will be a year-long process. But he says the law includes several safeguards to protect the standard of care provided.

Assistant Physicians will have to enter into a collaborative agreement with a licensed physician who practices less than 50 miles away and who will be required to review 10% of the assistant physician’s patient charts.

At the 2014 American Medical Association annual meeting, the House of Delegates adopted a policy opposing special licensing pathways for physicians who are not currently enrolled in an ACGME or American Osteopathic Association training program.

AAPA raises concerns

The AMA isn’t the only organization opposed to the new licensure. The American Academy of Physician Assistants (AAPA) has also voiced its concern.

“One might ask, why would we create a new class of healthcare providers, when there’s a great resource already in the state?” says Ann Davis, MS, PA-C, the AAPA’s vice president of constituent organization outreach and advocacy. “It might be surprising to hear that PAs [physician assistants] leave the state of Missouri to practice in other states because they have few barriers to practicing at the top of their education and training.”

Davis says even the title “Assistant Physician” will lead to patient confusion. “There’s just no way that it could not be confusing,” she says. “We are absolutely committed to patients knowing who is taking care of them.”

Nasca says the larger issue that must be addressed is graduate medical education (GME) funding, which the federal government has frozen since 1998. He says the rate of medical school graduates has far exceeded the number of available residency slots.

The AMA adopted a policy at it’s annual meeting supporting any state legislation to increase GME funding, and Nasca says he’s seen several states begin to take that step, including Utah, Florida, Illinois, Wisconsin and Texas. But he says it’s crisis that must be solved on a national scale. “This is a major problem that the country needs to address,” says Nasca. “The tip of the iceberg is Missouri.”