Assistant Physicians Coming to Missouri

Lucy VanPelt The Doctor is INMissouri is planning to allow medical school graduates who have not completed residency to treat patients in underserved parts of the state. Bills that would allow medical school graduates to provide medical care have passed the General Assembly and are awaiting Governor Jay Nixon’s signature. The newly-minted physicians would receive “assistant physician” licenses and would be able to treat patients in collaboration with a licensed physician – much in the way a physician assistant does. However, the new graduates will be able to call themselves “doctor” while physician assistants will not.
Now the American Academy of Physician Assistants is up in arms because the arrangement would “jeopardize (physician assistant) practice” and because these insufficiently trained Assistant Physicians might be confused with Physician Assistants. The new doctors will have more schooling than the physician assistants, but will only be required to work with a collaborating physician for one month before they can practice alone.
One other important thing to note in the legislation: The collaborating physician maintains full responsibility for all actions of the assistant physician. In other words, if the assistant physician commits malpractice, the supervising physician takes the fall for it.

Creative licensing such as this will be a boon to states since each of these extra providers will have to pay significant licensing fees to the states each year.
When the assistant physicians can’t fill the void in access to care, next up will be medical students who independently treat patients in remote campsites and who receive a “Assistant Physician Aide” designation.
When still more providers are needed, Missouri can then license college students who have completed 12 hours of Basic Life Support and who have any scouting merit badges, calling them “Pre Assistant Physician Aides.”

Anyone should be able to provide medical care. Parents already do it to their children. Just like people who choose to purchase a Kia rather than a Mercedes, people who want to pay five cents for Lucy’s psychiatric treatment versus far more for a formal Dr. Phil evaluation should be allowed to do so.
Two things can’t be overlooked:

  1. The credentials and training of the person providing the care must be fully disclosed to the recipients of the care
  2. Those providing the care must be subject to the same regulations, responsibilities and penalties of any other provider performing the same actions. Providers shouldn’t be able to escape liability for negligent actions by blaming someone else or by alleging that they are behaving reasonably given their amount of training. If you want to do brain surgery, you’re held to the standards of a brain surgeon, not a pre assistant physician aide.

We need to carefully consider the evolving paradigm of medical care in this country. The Affordable Care Act ostensibly provided Americans with medical insuance. Now that the bill comes due, how should Americans be receiving care? See tomorrow’s post on my other blog at DrWhitecoat.com for more discussion of this topic.

UPDATE JUNE 25, 2014

Additional article on the topic here

32 Responses to “Assistant Physicians Coming to Missouri”

  1. Kyle says:

    Of note, the AMA also weighed in against this concept of “Assistant Physicians” just a couple weeks ago at the June meeting.

  2. Marni says:

    That’s great. The underserved areas, where medical needs are most likely to be acute and the patients the most sick from long-standing lack of care, are going to get these untrained quasi-physicians. Great. Let’s keep in mind that these quasi-physicians will consist of two types of people: 1) Those that wanted a competitive specialty and didn’t match and have no interest in primary care, or 2) Those that were unable to match in primary care due to poor performance.

    Neither is a good option.

    How about we finally get around to increasing the amount of residency positions available in this country!!

    • Mr Smith says:

      Stop letting the AMA lobby the federal government to restrict the number of medical school and residency spots so that they can artificially inflate the demand and pay for their services. The only reason an anethesiologist earns $400,000 a year is scarcity. No where else in the world do they make that much.

      • John Castle says:

        When I look at the 4000 cables and tubes surrounding the anesthesiologist in the OR while he/she multitasks and reads the latest NRA magazine while peripherally watching his monitors, I think he deserves MORE than the $400K. I have trouble tying my shoes strings and maintaining an upright position at the same time. The anesthesiologist is worth it — especially when it’s me on the table! :)

      • Joey says:

        Except many anesthesiologists take a nap in the physician lounge while a CRNA does all the work in the O.R.

    • Kevin says:

      I have to agree. The main strategy of the AMA to maintain high income (esp for specialists, which are the bulk of AMA members) is to maintain scarcity. This is basic economics, not some evil genius. That is the real reason behind trying to prevent expansion of mid-level practitioners and alternative med. It was the main reason for attacking osteopaths before the were assimilated. One year post-grad training to practice gen med in virtually any state for decades. This isn’t new.

    • Frangel says:

      Excuse me! But is disrespectful to call somebody Quasi-Physician, when in fact, they hold a MD degree that sometimes cost more than 250 000 and 8 years of University Studies. And Second the reasons your declares as causes of not matching are not real. SOMETIMES of better said Most of the time the reasons for not matching is just Had BORN IN a FOREIGN country!!!

      • SGA says:

        I agree. Once you’ve finished your degree, you are a doctor. You can maintain that you are n Assistant Physician but no one can say that you are a Doctor. Much like you were born in a family, you carry your family’s name. Compared to Physician Assistant’s, of course these Med Greaduates still has a higher level of learning. PA is a Master’s Degree at the most, while AP (assistant Physician ) is a Doctor’s Degree and they did have many hours of hospital and clinical experience. Come one what the fuss, this is a no brainer! Let’s move on!

  3. PatM says:

    This begs at least one question:

    How many medical school graduates who do not complete any GME are there floating around?

    Or to narrow that further, how many are floating around that do not have statutory bars to practice – i.e., a criminal conviction?

    • WhiteCoat says:

      Probably not many grads who do not complete GME. I don’t know exact numbers, but all Medical Practice Acts that I am aware of require some amount of post grad training in order to practice independently.
      Limiting issue may be lack of available residency spots. See Marni’s comment above.

      • Lee Weiss says:

        There are a SIGNIFICANT number of US citizen International Medical Graduates who have not been able to gain residency training. From Mexican Medical schools alone over the last 10 years in excess of 7500. Many have done an extra or “fifth” pathway year. Many have passed all 3 steps of the USMLE. Most are fluent in Spanish. I have no doubt that many could assume the Assistant Physician role – especially in needy areas where Spanish is the first language. BTW – in the last “match” more than 1300 US citizens that are US med school grads – failed to match and failed to scramble. We need to create alternative training programs – using the robust Community Hospital system that eventually trains and brings these needed grads into the organized house of medicine. This is not MD vs Do vs NP vs PA. That is simply a specious arguement.

  4. John Castle PA-C says:

    My opinion is that these medical grads and the PA will be starting off on about the same level, so as a PA I can’t complain about this arrangement. The old GP of my youth is about the same thing. Where the PA concept is a better idea is because the PA will be looking for a site to hang his hat and stay a few years and raise a family. The assistant physician (AP?) will only stick around until he makes his match and then he’s outta there. So the AP will meet the technical needs of the community, but he won’t be a community provider since he’s no more than a temp.

    • WhiteCoat says:

      The “transient” versus “community member” is a good point. Would be interesting to see any stats on how long PAs stay in their first job after graduation. Average for EPs is about 2.5 years.

    • Mandy says:

      “The old GP of my youth is about the same thing.”

      In other countries, a GP (General Practitioner) is a highly respected medico with a lot of responsibility. They are certainly real doctors, and then some. The only things they refer up to specialists are those they themselves can’t handle. But they do most primary care, including pap smears, normal diabetes care, normal prenatal care, uncomplicated deliveries, common dermatology and allergy and mental health issues… They are FAR better trained than the average American Nurse Practitioner, Assistant Physician or Physician’s Assistant.

      They are board-certified medical doctors and not at all “pretend doctors”.

  5. Lee Weiss says:

    There are thousands of American International Medical School graduates. Many of these grads speak spanish fluently. A significant number of these graduates have done a “Fifth Pathway”. A majority of these grauduates are languishing deeply in debt. The vast majority have tried unsuccessfully for years to get post grauduate training and licensure. Given the opportunity – I believe the majority of these graduates would accept service obligations in physician shortage areas to get training and licensure. Wake Up America. now American Medical School graduates cannot routinely get post graduate training. This is lunancy.

  6. Mark Plaster says:

    What a flash from the past. I graduated from Un of Missouri-Columbia School of Medicine in May of 1979 and took the FLEX exam in June to obtain a full and unrestricted license to practice medicine. I was one of the few interns who showed up with real medical license and was able to moon light right away. It really wasn’t so bad. I knew what I didn’t know. We need to focus on the positive solutions to doctor shortages. This is just a stop gap. As for liability, these APs will, like any physician, be held to the standard of someone “similarly trained”.

    • WhiteCoat says:

      You know what you didn’t know, but many others don’t.

      This may be a stop gap, but it may also turn into a permanent solution. Would be a sneaky way for government to provide a “doctor” to patients when the doctor has little training. Would you want a medical school graduate with no medical training treating your parents?

      As for liability, the “similarly trained” standard isn’t a standard. Interns can be held to the standard of attending physicians. One such case is Clark v. University Hospital UMDNJ.

      Here are some other cases cited in the opinion along with the policy issues surrounding the decision.

      “There are also several federal court decisions where, without discussion, the courts held residents, or other medical-care-givers  with even less training, to the same standard as physicians.   E.g., Powers v. United States, 589 F.Supp. 1084, 1091, 1099 (D.Conn.1984) (first-year resident held to same standard as doctor);  Steeves v. United States, 294 F.Supp. 446, 453, 454-55 (D.S.C.1968) (one-month intern held to same standard as doctor).   At least one state court opinion similarly held residents to the same standard.   Green v. State of Louisiana, 309 So.2d 706, 708, 712 (La.Ct.App.1975) (unlicensed foreign doctor employed under temporary permit held to same standard as doctor), cert. denied, 313 So.2d 601 (La.1975);  Lindsey v. Michigan Mut. Liab. Co., 156 So.2d 313, 315, 316 (La.Ct.App.1963) (intern held to same standard as doctor).”

      “There is no support in New Jersey for defendants’ argument.   Indeed, reducing the standard of care for licensed doctors in their residencies because of the limited nature of their training would set a problematic precedent.   For example, should we reduce the standard for doctors who are inexperienced in a particular procedure that they negligently performed?   Or should we also reduce the standard of care for doctors who graduated in the lower third of their medical school?   Defendants held themselves out as doctors and should be held to the standard of care they claimed to profess.”

      The liability can be problematic for several reasons. First, the new doctor may be held to the standard of an attending physician. Second, the liability is statutorily transferred to the supervising physician which creates an issue of whether malpractice insurance will cover any negligent acts. Also opens up the supervising physician to claims of negligent supervision, which likely wouldn’t be covered by traditional malpractice insurance.

      I agree we need positive solutions to doctor shortages, but also think that patients need to have some manner of being informed of bona fides of the caregivers to whom they entrust their lives.

      • John Castle says:

        PAs are held to the same standard as a doc when they screw up.

      • Gree says:

        “A medical school graduate with no training”?

        Excuse me but foreign medical graduates underwent years of training and residency and they’re more trained to serve underprivileged and underserved communities. Please stop criticizing them for being given the opportunity to practice in the medical field again. America has so many underserved communities with no healthcare, are you willing to serve there for a fraction of a salary? More opportunities like this should be given to fmgs so America can take advantage if their skills. Leave the menial jobs to lazy citizens who have no education.

      • John Castle says:

        An interesting spin, but I ask you if the poor and underserved deserve a lower quality of medical care than the rich and the middle class? Why should FMGs allowed to practice with one class of society and not with all levels of our society? No, my friend, we have our standards, and after being the “victim” of medical care in one Latin America nation, I’m not willing to loose those physicians on the US until they can meet our standards. That said, those FMGs that are able to meet our standards are usually the cream of the crop of their country, and I’m proud to work with and for them. Blessings.

  7. Doug Boyett says:

    interesting idea. i was reading something recently about European doctors, it seems a lot of countries have the students go right from high school to med school and then residency which puts younger doctors with presumably longer shelf life (lifetime years of medical practice) into the world. seems like a better method. Being FP trained myself and young enough to recall what i knew and didn’t know when i graduated med school I agree with the writer above who stated that GPs aren’t just docs with basic training. takes a training and practice but i recall most of med school being book /lab studies with some patient care scattered across medicine, surgery, peds, obstetrics, etc

  8. Sam says:

    I would like to invite all PA’s and NP’s to take the USMLE Step 3 examination. Let’s do a cohort study to see who is qualified to practice independently. People want to knock new medical graduates? Then put your money where your mouth is and take the test. There would need to be special accommodations, though, because you aren’t even qualified to take it. You need to graduate medical school first.

    • John Castle says:

      Wow, Sam! What’s that about? I’m a PA but I don’t believe in independent practice. That’s an NP thing, not a PA preference. In fact, PAs refuse independent practice, though as a retired military PA I haven’t had all that much supervision during my career. Not sure what is causing your angst. I’m on the same page as the docs on this forum that are worried about underqualified DOCs practicing in MO. Please clarify how the mid-level provider subject came up with such emotion. Thanks.

      • Sam says:

        Why was the AAPA mentioned?

        The article like it was written by someone who feels threatened by having real doctors as assistant physicians despite the fact that there is a need.

    • Ray says:

      This a great opportunity for those Medical students who hasn’t matched and are unemployed along with the debt of more than $150,000 in student loans. The medical school grads has been completed 4 years of training and passing the step 1, step 2 CK and CS as opposed of PA’s that only take one examination for their professional license. They deserve be taking in consideration and approve this new law that will help them have a solution to paying the student loans and unemployed statuses along with provide medical services in underserved areas.

  9. Sadi says:

    It’s a great step towards overcoming Physician shortage in USA. I am just not sure why everybody will accept a graduate registerd Nurse or a nurse practicioner but not a medical graduate who is trained to be a GP after all. Medical residency training for three years is a good thing but 6- 12 month of GP training is a very wise decision. There are thousands of medical graduates who can’t get residency positions at least in excess of 7000 or more who are forced to do odd jobs because even if they want to enter the system in any other way like Physician assistant or Nurse practitioners they can’t. they would have to start over because they would get absolute no credit for their education or medical background from such programs.They are overqualified to work as a medical assistant , medical techs, ultrasonographers etc and I am only talking about those medical graduates who have passed all United States medical licensing exams and are eligible by law to practice in certain states after one year of medical residency trainings etc. Only because every year they are replaced by physicians who are brought in on J 1 waivers.
    The system can not do anything to solve this problem. No one care about wasting skill sets that can be used to provide primary care and same more lives. People are happy to get treatment from PA’s and NP’s but not from doctors. Why such a panic and fuss , they are not providing care independently they will be supervised by other board certified physicians. ( which is a cheapest alternative instead of providing more residency training positions)

    Physcian assistant programs and Nurse practitioners programs want all medical graduates to repeat all undergrad courses, these course should only be 3-5 years old and its mot possibel for a medical grad, by the time he is out from med school his courses are 4-5 years old. These program requires 2 year of undergrad courses and top scores in GRE and then 28-30 month didactic and clinical rotations to be able to practice in USA, if there were some advance standing in such programs for medical graduates like waiving prerequistes or giving credits for similar didactic courses already taken in medical scholls would enable these medical graduates to do only hands on clinical rotations for 15 months and enter the workforce quickly as compared to lose skills in 5 year of completing a PA program training. To bridge the loopholes in the system to bring these medical graduates back to workforce this bill is awesome. Hope all other states will follow.

    I hope such initiatives be taken by all other states as well and I am pretty confident that it will turn out to be just fine.

    • John Castle says:

      A number of years ago to increase practicing PAs in Florida, a bill was passed to allow FMGs to take a test written in Florida to allow them to practice as PAs. They couldn’t pass it. There’s a definite difference in medical education between most nations and the US. And there’s a definite difference in the practice of medicine. A few months ago in Ecuador I was having chest pain that turned out to be a rib dislocation off of my sternum. It was an acute pain. They would only give me Toradol which didn’t even touch the pain. They refused to give me any opiates. I went to another clinic that wasn’t an ER and also no analgesia to give me pain relief. I suffered for a week while there. In summary, I say we need to keep out standards as they are to maintain the world’s finest medical system. Compassion is understood when the FMG can’t find work in his chosen profession, but there should be more compassion shown in the long-term for the American patient.

      • Frangel says:

        Yes John, you are right!There’s a definite difference in medical education between most nations and the US! REST of THE WORLD teach how to practice real clinical medicine and don’t prescribe OPIOD when in fact you don’t need it. C’mon John, you are just generalizing, most foreign medical graduates fail USA exam because English barrier and differences in test, the same way I will see most of medical practitioners of USA failing a medical board in French, Spanish or HINDI in INDIA. USA education system is not as good as people make it looks like and medical school is not the exception. Remember that economy “control prestige” Sometimes when prof something is good just because in fact is convenient for somebody to pay to research if its good. The rest of the world also practice medicine some countries (INDIA, CHINA etc)even before Native American population were discovered by Europeans. Sorry about your experience in ECUADOR but that happened to me who I’m MD multiple times here in USA. So!

  10. Frangel says:

    It’s this a kind of joke or what!!! I still don’t understand how it’s possible a country who allows Nurses and PA to prescribe, have any doubt to let general practitioners do! Also when they sell medical degrees for 250 000, that is disgusting. I am a foreign medical graduate awaiting for residency, to be more exact a Proud CUBAN MD and by the way a pretty good one(laugh. Seriously USA have more than thousands of MD recruited in their one country who can serve well to the nation workings as Med Assistant/ phlebotomy and in some cases even as a Home Health Aides. I can tell more Some of these Physician were recluted by the own government using a program for VISA called Cuban Medical Professional Parole, and my question is for what “because no program consider your experience” And its funny but a MD of 29 years old who also hold a certificate of added qualifications in ICU, its not and old graduate just because graduation year is 2010, but in the reality we used to get filtered, even if we were practicing even in more experiencing and challenging situations that the actual USA practice. SO finalizing we are responsible for our own medical shortage, I wish pretty soon USA states take similar alternatives to solve the problem, and also please take of the MASK to have the perfect and competitive Health System and Ultra-Super medicine, because in fact that is FALSE, the world is more than USA ok!

  11. Frangel says:

    And to finish if you are complaining of your own Medical School Graduate Curriculum, sorry but is your own fault because is very difficult to believe that after 4 years of undergraduate training and 4 of medical school the general practitioner you make needs further training to practice medicine. Sorry but if its like this this is not a career its a money laundry for the University. Sorry my sincerity, but in my country a general practitioner have more babies delivery and medical practice on his belt, than a pilot flying 24/7 for a year with American Airlines. I’m the only that is seeing semantic concepts MD means MEDICAL DOCTOR, or what the hell they are designed for to fry chips in the Mall. Residency is just postgraduate training, to have additional skills in a certain area, no to accomplish the deficiency of a medical school curriculum that allow to practice medicine. A lawyer practices LAW, an architect practice the career. NOBODY needs additional studies to perform the duties he suppose to be trained for…!!!!

  12. Andrew says:

    I agree that an assistant physician is not prepared to practice independently without direct supervision of a practicing physician. However, why do we permit NPs and PAs to practice right out of their schooling, and in most cases, they get paid more than a resident physician. I think the assistant physician program has opportunity to decrease the debts of both the assistant physician as well as the overseeing physician if the business aspects of everything is drawn up correctly. I would take a 4 year med school graduate who has two years of clinical experience over a 2-3 year PA or NP with less clinical experience any day.

    • John Castle says:

      The difference? The PA by law has a physician supervisor. That PA is NOT a loose cannon unless the supervisor is incompetent. The assistant physician (AP?) has no supervisor. In principle I would agree with you if there was no supervisor involved. But the supervised PA has a resource and evaluator. Who is going to evaluate the AP who is being placed due to their being no other medical authority in that area?

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