ACGME Chief Sees 'Huge' Risk of Error in Proposed Assistant Physician Licensure

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."

16 comments on "ACGME Chief Sees 'Huge' Risk of Error in Proposed Assistant Physician Licensure"
Tim Fontaine (12/3/2015 at 5:17 PM)

It is so obvious that the CEO is fear-mongering by stating that one of his concerns would be that Assistant Physicians/MD may make drug interaction mistakes...REALLY? What the general public does not know is that all doctors either use medication interaction apps on their laptop or phones, or consult a hard text reference source in order to not make these mistakes. Trained pharmacists are the only professionals I have ever spoken with that know most of the drug interactions per rote memory. Moreover, most hospitals/clinics are on or will be going to EMR/EHR [INVALID]ems - they have built-in drug interaction settings which automatically alert you if a dangerous interaction could occur. The CEO is creating a paper tiger. If you look at what the CEO and the ACGME has to lose when MO starts licensing APs and other states start following suite, then you will see why he states what he does. Thanks, Tim F.,MD,MPH,CT(ASCP)
dana (12/9/2014 at 7:09 PM)

I live in USA from 10 years,I'm an US citizen,,,I have passed all USMLE steps but couldn't get a residency spot. I don't have a job ,I'm a saty at home mom.I was a reputable physician in Europe but I cannot use my knowledge to help American people,Very sad!!!!!
Andrews C Ninan, MD, MS, FRCS (12/7/2014 at 2:12 PM)

There is yet another side of this equation. There are legal citizens in this country, people who have been qualified and worked abroad (U.K. and India) after doing their residency abroad in specialities (for over 20 years in both countries) but not had the chance to be included into any residency programs in this country due to being "overqualified". These people, like myself, are wasting their time when their knowledge could be utilised without any fear of not having had any supervised training in this country.
CJI (8/8/2014 at 1:04 PM)

How would the capabilities of these assistant physicians be different than that of general medical officers in the US military who are without specialty training, yet providing preventative and primary care to service men and women?
Lammy (7/16/2014 at 10:24 AM)

Finally people are starting to realize that there is an agenda being propagated by the NRMP, ERAS, AMA, and ACGME, which the CEO of the ACGME himself, has admitted too. That agenda being, to keep certain cohorts of medical school graduates (i.e. USFMG) from obtaining residencies. He should be ashamed of himself as he boldly makes admission to his agenda. These doctors have spent just as much time, effort, and energy as anyone else in studying medicine to help people. And not all graduates of Caribbean medical schools are the result of lack of admission into a US medical school. I never even tried to gain admission into a US medical school. My studies in medicine took me to the UK and eventually to the Caribbean. Incidentally, what difference does it make? Medicine is medicine is medicine irrespective of where you trained. Apparently so, because the US government financed my education. If my training is good enough to obtain US student loans for the training, then who is the CEO of ACGME to turn around and develop an agenda to block me, or anyone else indebted to the US government from completing a medical residency in the US? And to use the US citizen taxpaying dollar to do it? It's not like it's HIS MONEY. Talk about the MAN holding you down (LOL)!!! And for all the NP's and PA's getting on here boasting their 100 years of experience, etc...yeah right. It is unbelievable how as a group you can get on here and try to raise alarm to the opportunity for a PHYSICIAN to assume the duties and responsibilities for which they were trained. Your argument is as logical as a brown paper bag. It is very unprofessional to lament regarding the possibility of a PHYSICIAN entering the workforce and making a contribution to improving healthcare quality and access. Now...Step Aside!!!
Dave (7/14/2014 at 8:04 PM)

Not to stir the pot between MLPs and physicians, but some of the comments made seem based more on emotion and concern for territorial encroachment than for the improvement of access to healthcare for our patients. It may be surprising to some, but there might also be some physicians out there (recent medical school graduates) who would prefer this route versus completing a full residency program. They would do so knowing that they would be under the supervision of a board-certified physician, just as an NP or PA. Regarding the level of education required to practice in such an environment, it would seem to me that, statistically, a graduating medical student already has many more hours training in the pathophysiology of disease and it's management by the end of four years of medical school versus that required of an NP or PA (correct me if I'm wrong). The difference being that the expectation is they will continue on their education far beyond this during residency, continuing to rack up more hours. Experience beats nothing, but if an NP or PA can serve in the role described in the article, it is astounding to think that anyone would see this as potentially hazardous to patient care, unless they too want to apply this to how NPs and PAs practice medicine. This aside, maybe what we should be focusing on is how this could be beneficial to an already growing problem of access to care. PAs and NPs do a wonderful job of recognizing basic primacy care issues and making appropriate referrals when necessary. Increasing the pool of providers capable of performing the aforementioned task at a reduced cost to the system would decompress this issue some, as well as allowing medical students seeking an alternative career to a full residency to contribute to the cause. Beyond this, with an increasing number of medical student spots without an increased appropriation of residency positions, a bottleneck has been created. How do you think we can manage to afford these individuals who have incurred a ton of debt to utilize their degree in a compassionate way without having to find another job? I proposed this to mid-level provider recently, who promptly informed me that they would have to go back to school to become an NP or PA - wait, what? Seriously? This is an inherent issue with some of the commenter arguments made, and truly shows how much more motivated the counterarguments are by concern for this becoming more systemic and encroaching on their job market than it is for patient care and concern for those seeking out healthcare careers (all, of which, are tasking in their own right). What I would rather see is this concept becoming more systemic, allowing for alternative careers to graduating medical students as well as contributing to the problem facing the US regarding access to patient care. The military already does this with general medical officers and it has been successful. Most general medical officers are assigned to primary care billets after an internship and practice in the manner touched on by the article, often in austere environments, and do so hand in hand with their PA colleagues. For what it's worth, it seems to have worked well enough. If anything, maybe this is what the system has been waiting for - recognition of the amount of time and effort it takes to become a graduate medical student and the knowledge that comes along with it. If all they are asking for is an alternative career option, likely with similar pay, hours, compensation, and expectations in how one practices, this needs more attention and to come to fruition nationally.
Jojy Cheriyan MD (7/14/2014 at 7:09 PM)

This will put an end to the corruption and bribery filled residency training [INVALID]ion process, and more competent medical graduates will get opportunities to practice the skills and knowledge they earned. Tens of thousands of US citizens with foreign medical degrees and passed all the licensing exams (including Step3) are subjected to bullying, black mailing and abuse by the expensive ERAS and NRMP gambling games.A binge and purge exam score, age discrimination, racism, medical graduation year etc are used to torture and abuse medical graduates.Tens of thousands of skilled US citizens who worked day and night and invested money in foreign countries see there dreams shattered when they return to their Mother Land. A corrupted caucus in ACGME has been behind to block the entry of competent young graduates into the work force.Thousands of residency slots have been cut in last 10 years. They want to keep the Medical Care cost high for their vested and selfish interests. If this decision was made earlier lives of many Veterans and millions of people could have been saved.Many states including New York has allowed nurses to practice Primary Care independently without any supervision. This is a good step and many people will get access and care easily and at lower cost.
paul (7/14/2014 at 12:44 PM)

What happened to medicine's prime dictum: "First of all do no harm". The fundamental issue here is patient safety, which seems to be buried in veiled slights to other health professions and politics by some respondents. First of all, just because the CEO of the ACGME is the CEO, doesn't make his concerns, or those of organized medicine, any less valid. Second, let us remember we are potentially opening the door to individuals who received their medical training many years ago. I wonder how patients are going to feel when they learn they are potentially getting their care from individuals who may be out of medical practice for 10 years or more and who may have not practice or even had an interest in primary care prior to this initiative. Third, as a practicing PA and medical educator for 40+ years in an academic medical center, I and many others who have had the pleasure of working with students of medical, understand that medical students are not prepared to provide patient care upon graduation from medical school[INVALID]-let alone primary care which entails knowledge accross the spectrum of medical specialties. Let's face it, Missouri had several opportunities to look at other safer, more cost effective alternatives, like expanded use of Physician Assistant/MD-DO teams. Yet Missouri legislators and organized medicine (both allopathetic and homeopathic) in the state continue to oppose legislation that would allow PAs to exercise the full range of the skills which we are educated to bring to bear in providing cost effective, accessible, quality patient care. And as a Mizzou graduate, I'd like to know why Missouri, with all of its rural health needs, still does not have a PA program in the State university system, as exists in the surrounding states of Iowa and Nebraska, which moved on this matter a long time ago? As one of the first PA graduates in the US, and a past president of our national membership and educational organization the AAPA and PAEA, respectively, I never dismiss new ideas and models without thoughtful consideration[INVALID]-but the idea of assistant physicians is ill advised and will put some of Missouri's most vulnerable and high need patients at unnecessary risk. And still no one speaks of the checks and balances, other than a short apprenticeship, that will be built into the system (if any) to protect patients served by assistant physicians. For all these reasons and others not yet discussed, such how actuaries will figure this initiative into malpractice calculations, I, and those who understand that our first responsibility is to our patients, cannot support this ill advised initiative.
Albert R. Davis, MD (7/14/2014 at 11:35 AM)

In response to Dr. Nasca's comments: First, he has no objectivity on the matter. He's president of the organization that is responsible for resident education in the U.S. Of course he's opposed to practicing without a residency. Second, I agree with him, roughly, that residency education is better than no residency education. But a doctor with less training is better than no doctor, and he fails to acknowledge that important point. Third, the shortage of residencies is not Dr. Nasca's fault, but rather than offering solutions to the problem such as reducing or removing federal involvement in residency training, he continues to support the cash-cow monopoly that feeds his family and resorts to weak rationalizations in support of continuing the status quo. He asks if "we want to be in a circumstance where we are back in the 1950s?" Would that be the same 1950's when the U.S. health care system was the clear leader in the world? Allowing non-residency trained graduates might be a surprising step in that direction. Dr. Nasca discusses eliminating disparities in care, but that issue is much less simple than he seems to recognize. It goes back to the long discussed argument about equality - does "equality" in America mean equality in opportunity, or equality in outcomes. He apparently supports equality in outcome, but that can only occur when all care is provided at the level of the lowest common denominator. Welcome to the VA... Equality of opportunity is the issue, and it is organizations such as the ACGME/federal government monopoly which are responsible for failing to provide that equal opportunity to all qualified candidates. If they will not/cannot do so, then those candidates should be able to pursue other opportunities to excel. America's legal system will fairly quickly weed out those who can't make the grade. Unfortunately, there will be harm along the way, but that harm will be offset by better care overall. If Dr. Nasca has his way, the harm will be greater, and there will be no offset. Missouri's choice is a suboptimal one, made from among many suboptimal alternatives. Dr. Nasca's alternative is among the most suboptimal of them all.
pat (7/14/2014 at 11:08 AM)

So wait, its OK for NP's to essentially complete the majority of their course work online (which they do at the institution where I worked) and essentially practice independently in many states, but it's not OK for a med student with literally thousands of more hours of study and classroom time in addition to 3rd and 4th year rotations to do something similar? Looks like the midlevels are concerned about someone encroaching "their" territory. I would rather send my family or child to a assistant physician who had 4 years of rigorous med school training plus what they are now proposing any day. I hope it succeeds and expands.
KarenCPNP (7/14/2014 at 10:57 AM)

Good day, As a 'mid-level' Pediatric provider, I too practice under a collaborative agreement with my doc, I also can prescribe the same 3 classes of narcs, plus everything else. I've been a PNP for 18 years, with 18 years as an RN before that. It's a scary propostion to think of someone without residency suddenly being responsible for whatever walks in the door. I realize alot of interviewing, examining and developing a treatment plan is done while in medical school, but, let's face it, there is always something that's wrong, something that could be done this way or that way, etc. Those are the skills that I believe are honed in residency. I worked for 9 years in a Children's hospital, affiliated with a prestigious university. I interacted with medical residents every day. I can't imagine how they could go from med school to practicing, without that 3 years of residency. Additionally, for 3 years I worked for the Dept of Surgery, at the same hospital, and saw first hand the 1st year surgical residents who could potentially complete their entire first year before coming to our Pediatric Hospital. Suddenly, they are thrown to the wolves in terms of dx and rx-ing kids, which we all know are not little adults. These Residents, all very good and intelligent young people, were blown away and made many med errors, most caught by the floor nurses b/c they were still in their adult prescribing mode. Also, strange orders that, if they were ordered for an adult, would be o.k., but on a kid, not so much. I also went through the same growing pains. Heck, I still do. The 2 docs, PA and I are always asking each other, 'hey, what do you think...", or 'come look at this rash and tell me what you think'. During the winter, I am the lone provider on Saturday's for sick visits only. So far, nothing has come up I couldn't handle, but like the "AP's" I too have phone back up. But I have also been doing this a long time, and know what I don't know! I did my time in an urban area with extreme poverty for 2 yrs before I totally burnt out. This is a very difficult population to deal with. I'm sure rural areas would have the same issues, i.e. poor education, limited resources, and lack of knowledge of their own s/s, even after you have instructed them more times then you can count. We were lucky, we are very close to the hospital, so when someone crash and burns in the office, 911 is there in less than 5 minutes. Of course it doesn't happen often, but when it does, it's nice to have another provider with you. Imagine being way out in the sticks, 45 min or more from a volunteer ambulance/ER and this happens. Somebody will not be having a good day. I just think this is not quite the way to go to increase medical care to rural areas. Too much is learned in residency to not attend one. If the Feds won't pay, then definitely the States need to get involved in caring for their own constituents, to fund additional residency slots.
pgy2 (7/14/2014 at 10:24 AM)

I just finished my first year of residency in a semi rural region at a clinic that sees only medicare, medical, and uninsured, much like those in Missouri would have to. I have to disagree with the other commwnters, letting graduates who have not really worked in the real world manage these patients would be an absolute disaster. I think the training the past year has been invaluable and I still have three to go. The new interns are very intelligent but many of them cannot handle these kinds of complicated patients, not to mention they would not know how to manage patients who are drug seeking. Tons of essentially just medical interns practicing in rural clinics where they may only vaguely remember what sick hospital patients look like who are free to practice anything they want... That is a terrifying possibility and yes it would create two tiers of medical care, with people who couldn't pass or get decent boards nor match with programs... I hate to make a generalization but they are probably not going to be as likely as other residents to take an evidence based approach to practice and more of a trial and error. Also, I'm a DO, and I know many colleagues who didn't match or who barely got out of medical school who just didn't study very hard or have the discipline for self learning that is crucial to staying a good physician over the decades that you practice. Call me crazy but I agree, this is a horrible horrible idea. There's a study showing 50% of residents remain near the population they were trained in, so Missouri creating more residencies is a very viable solution.
Dr. Patel (7/14/2014 at 10:16 AM)

I see no problem with this. PA's do what 2 years and essentially practice medicine. I didn't do a primary care residency (another 4 year one though), and am currently in General Practice. Does this mean I have to go back to residency in FP/IM, get boarded, fill all MOC requirements (which are over-priced and unreasonable), before I can practice medicine?
SP (7/14/2014 at 1:41 AM)

I don't think there's going to be a problem. Don't let Dr. Nasca and his negativity get you down if you're going to apply for this license. You're a doctor. You went to medical school and know how things work on a cellular level. Don't be a chicken. Stay sharp, check meds and allergies before prescribing, monitor for adverse reactions, do vaccines based on ages and immune status, and use good judgement. Send patients to specialists when not 100% sure. And don't forget there's an ER. Hey who knows, maybe the rural physicians will end up providing better care. Time will tell. I passed my USMLE Step 3 on the first try... Above the average. I'm an American... I didn't match to any residency program. There are first and second year U.S. resident physicians FAILING step 3. That's pathetic. Maybe it's time to start letting the real doctors do their residencies.
Brett Snodgrass (7/13/2014 at 8:47 AM)

Dear Sir, Medical school is not only observation. Medical school should not only be that. Furthermore, those who medical board specialty certification, namely the UMKC Pathology Chair did not exhibit knowledge of the difference between a sign and symptom. The UMKC GME Office. What is more, the DIO lied to the ACGME. In medical school I performed laceration repair, wrote notes with treatment plans. The ACGME is not as high of quality compared to medical school as the good doctor thinks. If his department had reviewed the surgical lumpectomy reports from November, 2010 to June 2011, they would have realized that there was no "ischemic time," or "time to formalin-fixation," as was claimed in the letter from the ACGME-accredited DIO. This letter was sent in reply to Amy Beane after reading my complaint and was filled with false information, aka lying probably with the aim to avoid a site visit. If the ACGME reviewed the lumpectomy reports from those eight months it would be readily apparent that the reports do not contain the critical information claimed by the DIO of UMKC. Patient safety advocates may realize that women are likely not receiving accurate testing and many may be sent to an early grave. They are likely given more toxic chemotherapy for a cancer that may be respond to less toxic hormonal therapy. This is patient harm that went on for months. Furthermore, I brought this poor care to the Pathology Chair in January 2011. She told me that they would discuss it at their faculty meeting that month. By May 2011, women's breast tumors, lumpectomy specimens, were still sitting in the pathology department becoming necrotic. I brought this up to the DIO of UMKC who replied, sounds like they are working on it. Not providing important medical evaluation by appropriate pathology exmination to women with breast cancer for a period of at least* 8 months is not "working on it." It is criminal, possibly repeated murder by negligence. How can there not be risks when a Pathology Chair and Program Director does not know the difference between a sign and a symptom? All the ACGME had to do was read the report from 04 18 2011 written by the ACGME-accredit program director and ask, "lack of energy," is that an objective assessment as is required by our organized. Would a competent pathologist think "lack of energy," is a sign or a symptom. Would a competent pathologist document any supplementary information. Furthermore, on a "quality measure," according to the Letter to Amy Beane, getting the lumpectomy specimens within formalin rapidly is very important. They claimed that they usually do it in thirty minutes. I saw breast specimens sitting on the counter for hours and I reported this, along with other factual information which I cannot prove, to the ACGME. However, if you review the reports that supposedly contain the "often" documented, "ischemic time" you will realize that the DIO, and the Pathology Chair at UMKC are lying and not Dr. Snodgrass. In my humble opinion Sir, potentially sending many women to an early grave through months of negligent care is not good. Nothing about the ACGME Program Director who does not exhibit knowledge of the difference between a sign and symptom suggests that all ACGME programs are high quality. Nor is ACGME accredited training in all programs of a superior nature to USA medical schools. An ACGME-accredited Pathology Chair and Program Director, who did not know a sign from a symptom is probably not more competent than a physician who did not complete an ACGME-accredited training program but saw thousands of patients over years. Furthermore, there are those that do not complete ACGME programs due to the incompetent documentation of someone who did. Other signs of competency include publications in prestigious medical journals, acceptance to world congresses, and completion of elite fellowships. In addition, a company in Missouri has paid many thousand dollars to sue the medical board on my behalf. The ACGME monopoly should not be mandatory for those who completed training in the USA, and have an outpatient job under the supervision of another doctor. How can things not go wrong? Sir, quality, is not measured by the ACGME in all programs. How can quality not improve when a Chair does not know a sign from a symptom and the DIO lies to the ACGME about the content of pathology reports. The Pathology Chair has never written a history and physical in the USA, and the medical board thinks she is more clinically competent than myself. Unfathomable. Furthermore, she never completed the USMLE Step 2 CS. The IOM needs to recognize the conflict of interest that Dr. Nasca may have in his overall honorable organization. Sir there is no difference between the VAScandal and the care I saw at UMKC. The ACGME monopoly is not equivalent to quality as they frequently claim. I completed a prestigious dermatology clinical research fellowship and I learned more about patient interaction, professionalism in social media, and how science relates to the practice of medicine, than the pathology chair did during any year of pathology residency. Not all residency programs are the same. In fact, pathologists probably lose their clinical skills before they are determined clinically competent by a medical board. We need more outcome-based assessments of medical training such as the USMLE. Nodding the head when the DIO lies to the ACGME about tumor care, and not reviewing the reports is horrendous. It was only recently did I learn about this from the medical who tried to reprimand me for accurately reporting the unfathomable and unethical conduct in the UMKC Pathology Department. In my humble opinion, women that are getting more toxic treatment for their breast cancer is not something a medical board, or the ACGME should blow off. Kind regards, -Brett Snodgrass, MD Alpha Omega Alpha
Spook (7/12/2014 at 11:52 PM)

This is a great idea, this guy does not know what he is talking about. The whole point of this is to provide care to area WHERE PROVIDERS DO NOT WANT TO LIVE/WORK. which means, NO M.D., D.O., N.P., or P.A. wants to work there, hence the need. So why the big stink if you are a PA or NP complaining about it? If you don't like it, MOVE TO RURAL MISSOURI AN PROVIDE CARE. obviously, you are not, which is why this bill got signed. and I am a foreign grad myself, ECFMG Certified (passed step 1 and step 2), didn't match into residency. my wife is in her last year of residency and can tell you straight up that she isnt "that much" more better off than me in terms of clinical knowledge. these Assistant Physicians are still practicing UNDER the license/guidance of a LICENSED PHYSICIAN.


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