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Doctor Shortage 'Fix' Is a Disaster Waiting to Happen

Cheryl Clark, for HealthLeaders Media, July 10, 2014

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.

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23 comments on "Doc Shortage 'Fix' Is a Disaster Waiting to Happen"

Anne Walsh, MMSc, PA-C, DFAAPA (7/27/2014 at 5:40 PM)
To Eugene, who knows "for a fact that they can diagnose way better than a PA or a NP" - you apparently don't read enough healthcare research (or even just browse any of the dozens of daily-weekly-monthly [INVALID]s from a variety of professional medical organizations) to know that your anecdotal statement has no basis in fact, MOST ESPECIALLY in primary care and in chronic disease mgt. PAs and NPs, state licensed and nationally certified, have long provided high quality medical care that is at minimum equivalent to, and often, superior to, that of physicians, usually at lower cost; this statement is backed by extensive research over the 50+ years of our professions' existence. There is a reason your "assistant physicians" can't pass their boards (Step 3) or get into a residency program (many spots in primary care go unfilled each year, and still, programs would leave them unfilled and lose federal money rather than accept these marginal applicants???). Shame on you for supporting any legislation that perpetuates healthcare disparities, only serving to KEEP the medically disadvantaged, disadvantaged! The solution to Missouri's problem is simple: adopt the same practice laws for PAs and NPs found in other states, where we are able to actually do the job for which we are trained. The PA profession was created BY PHYSICIANS in the late 1960's specifically to address the primary care physician shortage by teaming us up WITH a physician. We actually do a great job when allowed to do so; the vast majority of my patients (in 15 years of practice) prefer to see me for their visits, rather than my excellent supervising MDs, even when I insist they schedule with the MD because of complicated issues. Why? My superb medical training and clinical experience (which by the way tells me there is a whole lot more to quality medical care than "diagnosis"). In fact, the "diagnosis" can often be made by the patient herself searching the internet; oh, that medicine, particularly primary care, were as simple as "diagnosis." I am a Family Medicine PA and a medical school faculty member in California, a state that well-knows how to effectively use PAs and NPs in their abundant healthcare shortage areas. I was born, raised, and college-educated in Missouri, and my entire family still lives there - some in rural areas. This new law makes me embarrassed for and ashamed of my home state, and scared to see what the healthcare future holds for disadvantaged Missourians...God help them all.

Dale (7/20/2014 at 2:46 AM)
Truly a bonkers idea, that might work with adequate oversight, which probably won't be provided by near-by presumably overworked primary care docs. Perhaps the medical school primary care faculty could provide some oversight; there are 3 possibles; can't see Washington U stooping to that. The PA comments are spot on. They are usually smart (good GPA) people (and that does matter; why do you think med schools use it as a screen?)However, they can make more money working with urban specialists. NP's vary, since the entrance criteria are lower, but they do very well in specialty areas. Broad spectrum primary care is difficult even for doctors; and the concept that these "assistant physicians" won't have complex cases, which they must identify, walk into their offices is fallacious. I do agree that some care is better than no care (so long as one isn't seeking the next Oxycontin script), so the concept might have legs with a much better review and support system. Since my 2012 FM board score was 800, and I'm very near retirement, I wonder if MO can pay for a network of reviewers/on-call docs to support these people. I suspect some entrepreneur is salivating over the opportunity. Unfortunately, if it works, more appealing states will co-opt it. But, hey, email me with an offer; I've got a few good years left, and the program could be made to work with adequate support.

Eugene C. Santillano, MD (7/18/2014 at 1:43 PM)
1) perhaps emergency extension of GME funding to approve additional preliminary primary care internships that provides 12 months of experience, guidance, and eligibility to sit for Step III of the ACGME required USMLE to ensure these practicing physicians have minimum requirements for unrestricted medical license. 2) make these primary care internships equally acceptable for continuation into Any primary care residency (FP/IM/Peds) AND not count against the GME eligibility for future residency training dollars 3) this is basically rekindling the Generalist category of practice, which predates the AAFP Board Specialization It is not safe to send a new Medical Student into an unsupervised practice. I am sure that this proposal will be acceptable for the AAPS Board Certification Pathway, and I am confident that most medical school graduates are at least as trained and probably better prepared than your usual PA or NP graduate, but I think it is best to require some training beyond medical school before you send an under trained medical professional to take care of patients on their own.