The CEO of the Accreditation Council for Graduate Medical Education calls Missouri's move to license assistant physicians "precedent-setting and very concerning on a number of fronts."
Thomas Nasca, MD |
Missouri doctors are pushing for a new physician workforce to help solve the state's dire physician shortage.
And to put it mildly, Thomas Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education doesn't like the idea one bit. Nasca runs the organization that oversees accreditation of 9,300 U.S. residency programs in the U.S. and another 1,000 international programs that assure a steady supply of doctors.
Endorsed by the Missouri State Medical Association, the bill was signed into law Thursday by Gov. Jay Nixon. It sets up rules by which medical school graduates who haven't yet passed their final credentialing exam can treat patients in primary care settings.
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The new law requires these doctors to be supervised on site by a "collaborative" physician for 30 days, after which the assistant physician could treat patients without that collaborator's presence in settings 50 mile away. These young assistant physicians will be able to prescribe Schedule III, IV, and IV drugs.
Beyond that 30-day period, the collaborative physician is required to perform chart reviews on 10% of the assistant physician's cases every two weeks, but little else.
Here, edited for clarity, is what Nasca has to say about the assistant physician role:
HLM: The proponents of this legislation say it's a plausible and creative solution for a doctor shortage in a region that is one of the 10 most medically underserved states in the country. It would put to work some of the 7,000 to 8,000 medical school graduates who otherwise would be cooling their heels waiting to get into a residency slot. What's the truth?
Nasca: The vast majority of these 7,000 to 8,000 graduates who didn't get a residency slot are graduates of osteopathic or allopathic medical schools outside the United States. There are very few graduates of domestic schools who do not get residency positions. About 40% are U.S. citizens who went to medical school outside the U.S. because they couldn't get into medical school in the U.S.
So I'm very concerned about what's going on in Missouri. What's proposed is precedent-setting, and very concerning, on a number of fronts.
The question for the public is, do we want to be in a circumstance where we are back in the 1950s? With physicians caring for patients without accredited U.S. graduate medical education? That's the fundamental question.
I believe that the American public does not want physicians who have not been formally trained to practice medicine. Even with a limited license. The American public does not deserve second class care.
HLM: But we value foreign medical school education do we not?
Nasca: The assumption that medical school education is the same outside the United States as inside the United States has not been proven.
HLM: Why don't we have more U.S. residency slots?
Nasca: They're supported by and large by federal funding of residency positions, the number of which has been capped at 1998 levels. The number of slots has gone up slightly because hospitals will fund those internally, but it hasn’t gone up dramatically.
The response from the state of Missouri, if it has an inadequate number of formally trained physicians, should be to create more graduate medical education programs.
Missouri is just looking for a way out. A better example is Utah, which has the same shortage problem. But Utah has decided to fund residency programs independent of federal money. And they're now producing more doctors to serve their state.
I'm not minimizing the challenge of getting medical care to rural populations. But I think the state has responsibility to do things correctly.
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HLM: These assistant physicians would be supervised by a collaborative physician on site for 30 days. After that, the assistant physician could practice within 50 miles of his or her collaborating physician. What's wrong with that?
Nasca: Think about that, they're 50 miles away. Who's supervising what they're doing? That level of supervision would not be permitted for any resident even up to seven years into a residency training program. Yet we would allow individuals with no training to have that degree of distant supervision? That's not just no oversight, it's inadequate in the extreme.
HLM: Will patients be harmed if this is implemented? What could go wrong?
Nasca: What couldn't go wrong?
These graduates' [who would be eligible for the assistant physician license] experience in general medicine is measured in months. During this time they never had authority or responsibility to care for patients on their own, and yet in Missouri, we would turn them loose in a place where there is no one available to them to tell them what's the right thing to do.
These are physicians with rudimentary experience. But in Missouri, they'd be turned loose to manage patients with complex diabetes, congestive heart failure, arrhythmias, [and] malignancies? This is nuts.
The risk of an error is huge. Even seemingly simple things can produce dramatically adverse outcomes in patients. Drug interactions would be a primary example. They presumably would be practicing general medicine in pediatrics.
And to care for children and adults with chronic illness? Each of those is a unique specialty, and to expect someone to do that with no training at all, I think, [presents] safety issues to the public.
And there's another important issue. We in medicine and in society are trying to eradicate disparities in care. But this will serve to systematize disparities. These people will be practicing in these communities for generations. In reality, what we will have done is create a system that provides poorer quality care than we do for other areas.
HLM: Has any other state tried to do anything like this?
Nasca: No, and here's the irony: We've been asked by other countries to introduce our system of education and oversight because they aspire to have the quality and high levels of care that we have. We have other parts of the world saying, "We don't want this anymore." And here we have Missouri introducing this in United States.
That's irony in the extreme.
HLM: NYU Langone medical ethicist Art Caplan thinks the idea is OK for rural areas with few physicians.
Nasca: I have to quibble with Dr. Caplan. He's talking about this as a stopgap measure. But these people are going to be practicing for 40 years. The reality is, they're not going to get into a residency program. Because the next year, and the year after that, there are another 7,000 medical school graduates trying to get into residency programs.
The odds of getting into a residency slot after failing the first time goes down dramatically, and after two or three years, it's almost a given that you will not get in.
And the insinuation that primary care can be done by anybody is flawed.
HLM: Have you told the MSMA your view?
Nasca: No one has asked for my opinion. But I think the AMA has done that in spades.