Research published in the Oct. 23/30 issue of JAMA explores a new category of medical licensure called "assistant physician" that was authorized by the Missouri legislature in 2014 and fully implemented on Jan. 1, 2017.
The article(jamanetwork.com) titled "Characterization of Licensees During the First Year of Missouri's Assistant Physician Licensure Program" was authored by Grant Hoekzema, M.D., of Creve Coeur, Mo., and James Stevermer, M.D., of Fulton, Mo., both family physicians.
As the authors point out, Missouri's requirements aren't all that tough. An assistant physician must
- be a citizen or legal resident of the United States,
- have graduated from a recognized medical school,
- be proficient in English,
- have passed steps one and two of the U.S. Medical Licensing Examination (USMLE), and
- have not completed a residency.
Applicants who are awarded the license must obtain a collaborative practice agreement with a fully licensed physician that includes a 30-day period of treating patients together. After that, the assistant physician may practice within 50 miles of the collaborating physician, who must review 10 percent of patient charts and be immediately available for face-to-face or electronic consultation.
"Assistant physicians are limited to providing primary care services in underserved areas," wrote the authors.
The new category of medical licensure — more restricted forms of which are available in Arkansas, Kansas, and Utah — is touted by state legislators as an answer to the primary care physician shortage in rural and underserved communities.
FP Gets Involved
Hoekzema, the study co-author, chairs the Department of Family Medicine at Mercy Hospital in St. Louis and served as residency program director there for 17 years. He's also, among other positions, past president of the Association of Family Medicine Residency Directors and a current member of the Accreditation Council for Graduate Medical Education's Review Committee for Family Medicine.
Hoekzema told AAFP News that he only learned about the Missouri legislation after it had passed. At that time, "The chair-elect of the Missouri Board of (Registration for the) Healing Arts asked primary care residency directors to comment on the rules that would govern the initial implementation of the new license category," he said.
"I decided that after the legislation went into effect, as a novel category of license to practice, it needed to be studied. I felt that instead of assuming my perceptions would be correct, and to best address both critics and proponents of the legislation, we needed to have objective information about those physicians willing to seek the new license," said Hoekzema.
Apparently the Missouri legislature "assumed the law would attract highly qualified medical school graduates who did not match in a residency program but who wanted to build their résumé with some more clinical experience, and then go back into the Match," he said.
"But many of us in the primary care graduate medical education community knew that folks who don't match in residency are often not the most qualified of medical school graduates, and this was the group of people we felt would likely see the assistant physician licensure category as a way to practice medicine where no one else would let them," said Hoekzema.
Those concerns were borne out by 2017 data collected by the authors, who noted that USMLE Step examination pass rates for all assistant physicians "were significantly lower" than those of U.S. medical school graduates on all four Step exams (the two portions of the Step 2 exam were considered separately) and lower than those of international medical school graduates (IMGS) on three of the Step exams (Step 1 was the exception).
"Failure of the Step 2 examination has been associated with increased disciplinary action and worse clinical outcomes," the authors wrote.
During 2017, the Missouri Board of Registration for the Healing Arts licensed 99 assistant physicians. Of those,
- 25 had secured a collaborative agreement with a licensed physician;
- 92 were IMGs, 76 of whom graduated from schools in the Caribbean;
- seven were U.S. medical school graduates, six of whom were from allopathic schools;
- none was from a Missouri medical school.
Of the 25 assistant physicians with a collaborative agreement, all were IMGs, and 20 were working in health professional shortage areas.
Regarding USMLE performance first-attempt pass rates,
- on Step 1, assistant physicians had a 70 percent pass rate compared with 94 percent for all U.S. medical graduates and 78 percent for all IMGs;
- on Step 2 clinical knowledge, the pass rate was 42 percent for assistant physicians versus 96 percent for U.S. graduates and 81 percent for IMGs;
- on Step 2 clinical skills, the pass rate was 50 percent for assistant physicians versus 96 percent for U.S. graduates and 79 percent for IMGs; and
- on Step 3, the pass rate was 66 percent for assistant physicians versus 96 percent for U.S. graduates and 86 percent for IMGs.
The authors noted that Step 3 is not required for licensure in Missouri.
Hoekzema took the opportunity to talk further with AAFP News about the research; his comments are reflected in the following Q&A.
Q. What would you consider your most significant finding?
A. Our data clearly point to assistant physicians as a group being less capable of passing standard licensing exams at the same level as their peers. Our other findings point to the difficulty in enforcing legislation without any rigorous oversight.
Q. Can you expand on that last comment?
A. Since the original legislation required assistant physicians to practice in underserved areas — particularly hoping for those areas to be in rural Missouri — it was important to study if the legislation was fulfilling its intent. However, we found that most assistant physicians were practicing in urban areas, and 20 percent were not in underserved areas — if they were practicing at all.
This implies that the legislation did not improve the rural workforce in any substantial way in its first year. It is obviously too early to draw any conclusions about the long term.
Q. Do you have any personal experience with the assistant physician issue in Missouri?
A. Our residency program does not employ any assistant physicians, but we have been approached by several asking if we would consider hiring them. I have also had several assistant physicians email me about their reasons for obtaining an assistant physician license and asking me why I opposed this career option. I have written an article(issuu.com) for the Missouri AFP, presented to the Mercy Health Foundation Board of Directors and written a letter to the editor(www.stltoday.com) of the St. Louis Post-Dispatch — all making clear my concerns about the legislation.
Q. Why is this an important topic to track?
A. This license category represents a huge paradigm shift that has the potential to drastically change the graduate medical education landscape and the physician/mid-level/advance practice nurse workforce debate. To offer a career path for medical school graduates from anywhere in the world to come and practice in the United States without residency training is an unprecedented move.
Q. Are there patient safety concerns?
A. Yes, and the safety concerns certainly should be at the forefront. Scope of practice and oversight and supervision have been concerns of physicians when it comes to physician assistants and nurse practitioners since those forms of licensure came into being, and assistant physicians now fall into that same camp.
The evidence about the safety and quality of care of complex patients or those with undifferentiated complaints by those with different levels of training than a licensed physician is limited. And now we have added a new group to that mix.
Q. Where should the research go next?
A. We need a national solution to the maldistribution of physicians in residency training; we have plenty of medical school graduates but not enough places to train them to be board-certified family physicians.
For those medical school graduates who do not match, we need a more comprehensive way to determine if they are safe and competent to practice in a supervised setting that has appropriate limits. Passing legislation that creates pathways to practice before these issues are worked out is putting the cart before the horse.
Q. Any last thoughts?
A. The Missouri legislation was sponsored by an orthopedic surgeon — someone who has never practiced primary care. I would posit a question to all those who feel that medical school graduates without residency training can provide primary care: Would you allow that same person to perform surgery with minimal or no supervision? Would you be OK if only 10 percent of their surgical cases were reviewed? Would it be OK if those folks delivered babies or managed complex psychiatric patients or an emergency room with minimal supervision and no residency training?
If the answer is no, then why is it OK for them to do primary care, which can be very basic, but also can become very complex — all in the course of a single visit?
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