Efforts to expand use of assistant physicians face opposition
Created to address clinical staffing shortages in underserved areas, the assistant physician role is also designed to employ medical school graduates who have not matched into a residency program.
However, providers and medical organizations have not widely embraced assistant physicians as an effective solution. In the eight years since the position was created, only five states have licensed it, including Missouri, which created the position.
Assistant physicians graduate from medical school and have many of the same responsibilities as other clinical staff such as the similarly named physician assistants. But they do not have to complete a residency or undergo extensive hours of clinical rotations before diagnosing and treating patients. Assistant physicians are required to work in medically underserved areas, cannot practice independently and are not reimbursed by Medicare along with some commercial insurers.
Organizations such as the American Medical Association and American Academy of Family Physicians have opposed the designation, saying they are concerned about safety issues and that the quality of care provided by assistant physicians—particularly in medical care deserts—may not be not on par with doctors who have completed their residencies.
Discussion on the future of assistant physicians recently resurfaced in the medical community as advocates create model legislation for other states and seek to alter existing rules.
In June, the AMA House of Delegates rejected a proposal from its Missouri delegation to support assistant physician programs, and said it opposes any effort for graduating physicians to become independent, licensed physicians. It also opposes expanding the scope of their practice to other services or by geography without completing formal residency training.
ADDRESSING A PROBLEM
In 2014, Missouri created a licensed position called assistant physicians, sometimes referred to as associate physicians.
By tapping into a population of graduates that did not match into residency programs and having them work as licensed physicians in areas short of health professionals throughout Missouri, the state was able to “take an available resource and apply it to a real need,” said Keith Frederick, a former member of the Missouri House of Representatives.
For years the limited availability of residency or postdoctoral training slots and application process complexities, paired with a greater number of graduates, has made the path to licensure more difficult, said Frederick, who helped pass the state bill to license assistant physicans. The assisant physician role becomes an opportunity for individuals to provide services and make a living to repay medical school loans, he said.
“If you have that amount of debt, and you can’t continue training, it’s kind of like having a mortgage but no house and no job,” Frederick said.
Assistant physicians work under a collaborative practice agreement with a licensed supervising physician and typically have the same duties as nurse practitioners or physician assistants, prescribing medications, performing patient exams and assisting in surgery.
To become an assistant physician in Missouri, an individual must be a U.S. citizen or legal resident who is proficient in English, has graduated from a recognized medical school, has passed steps one and two of the U.S. Medical Licensing Examination and has not matched into or completed a residency program.
Once they receive their license, assistant physicians are required to receive a month of clinical training before practicing in a health provider shortage area, with oversight from a supervising physician.
Utah, Arkansas, Arizona and Kansas have followed Missouri’s example and established similar licensing programs.
After graduating from medical school, Trevor Cook got a job as a medical scribe and dove into the residency application process, which he described as a “capitalistic hellscape.” Cook said he spent thousands of dollars sending out test score transcripts and applied to hundreds of programs but was not accepted.
Cook came across job listings for assistant physicians in Missouri. Following 120 hours of training with a collaborating physician, Cook obtained his assistant physician license in 2018 and began working in urgent care.
“I perceive it as becoming a professional in the business, and the only way to really learn is to do it,” Cook said.
For the last four years Cook said he has had the same responsibilities as a doctor, running tests, treating and diagnosing conditions, updating emergency medical records and referring patients to specialists. Cook said he sometimes works with his supervising physician, who is required to review at least 10% of his notes and be within 50 miles while Cook is practicing medicine.
A major sticking point for healthcare leaders is concern that assistant physicians do not have the same level of training and qualifications as those who have completed a residency program.
“We are very much in favor of our trainees following the traditional accepted path to full licensure,” said Alison Whelan, chief academic officer at the Association of American Medical Colleges. “It dictates by specialty the type of learning and clinical experience that the resident must have to be an effective independent practitioner.”
Just because a student has a medical degree does not mean they are ready to provide safe and effective independent care, especially without receiving training, supervision and feedback specific to their practice area, Whelan said. Residency programs can span more than four years and include 16,000 hours of direct clinical care experience.
The AMA has opposed the concept of the assistant physician since Missouri introduced it, fearing it might weaken the organization’s case for increasing graduate medical education funding and creating more residency slots.
This year, more than 42,000 students applied for around 39,000 residency positions, and almost 37,000 positions were filled, leaving several thousand applicants unmatched, according to data from the National Resident Matching Program.
The main reason residency slots go unfilled is because students tend to try to match into specialties such as family or emergency medicine that are not a good fit for them, said Dr. Sterling Ransone, president of the American Academy of Family Physicians. When residency slots fill up in specialties, students untrained in other areas are in limbo, unable to apply to an area with open slots, Ransone said.
Ransone said he advocates for the correct allocation of funds to schools, hospitals and residency programs that allow for graduate students to gain more exposure to underserved communities and a variety of specialities.
Recently, the AMA urged support for two federal bills. One, the Resident Physician Shortage Reduction Act, would expand Medicare funding for 14,000 additional residency positions. The other, the Physician Shortage Graduate Medical Education Cap Flex Act, would provide teaching hospitals with an extra five years to set their funding cap if they form residency training programs in primary care or other specialties facing shortages.
In July, the Health and Human Services Department announced $155 million in awards to 72 teaching health centers that operate primary care medical and dental residency programs in underserved and rural communities.
Amid all the abbreviations, titles and job descriptions in healthcare, some are concerned the assistant physician role adds to the confusion for patients, particularly with the existence of physician assistants. Physician assistants take a different road to licensure, though they have many of the same responsibilities as assistant physicians.
To become a physician assistant, medical students must earn a master’s degree through an accredited physician assistant program—which includes more than 2,000 hours of clinical rotations—and pass the Physician Assistant National Certifying Examination. Physician assistants have to complete 100 hours of continuing medical education credits every two years to maintain their certification.
In 2020, Missouri issued 169 assistant physician licenses, compared with 114 in 2021 and 17 in 2022, according to the Missouri Board of Registration for the Healing Arts. The state issued 200 physician assistant licenses in 2020, 282 in 2021, and 139 this year.
CONCERNS FOR UNDERSERVED AREAS
Assistant physicians are required to work in areas that lack medical providers, which has led to worries about health equity.
“There’s some concern that they’re going to create a kind of second-class physician that is for people who are already socially and economically disadvantaged,” said Patricia Pittman, director of the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University. “Essentially, rich people see physicians and less rich people see those who were not able to become physicians, which is a bit problematic from an equity perspective.”
Treating individuals in communities that lack access to care is often more complex due to the myriad social issues underlying their condition and requires more clinical experience rather than less, said Doug Olsen, president of the board of directors at the Association of Clinicians for the Underserved.
Rather than only allowing assistant physicians to work in healthcare deserts, their position should be expanded as part of a workforce for the entire state of Missouri, Olsen said.
“If they’re good enough for the underserved, they should be good enough for the served,” he said. “If they’re good enough for the uninsured, they should be good enough for the insured.”
Olsen said there is an absence of consistent evidence and patient-reported outcome measures that prove assistant physicians deliver high quality care and should be practicing with an expanded scope, despite eight years of the position’s use.
Better solutions exist for staffing and care access in medically disadvantaged areas, such as obtaining long-term funding and creating partnerships between stakeholders and teaching health centers to provide more training opportunities and bring in more clinicians, said Amanda Pears Kelly, executive director for the Association of Clinicians for the Underserved.
“What we’re trying to do with healthcare transformation is create situations where we can actually lift up these communities so that they’re no longer underserved,” Pears Kelly said.