“Is it possible today to practice medicine in the U.S. after one year of residency or a stand-alone internship?” The answer to this popular question on Student Doctor Network is yes—in 37 states for DOs and 33 states for MDs who graduated from U.S. medical schools, according to the Federation of State Medical Boards (FSMB). But physicians who choose this once-common path for general practitioners face a number of hurdles.
In all specialties recognized by the AOA or the American Board of Medical Specialties, becoming board certified requires completing a residency. Increasingly, only board-certified or board-eligible physicians can obtain hospital privileges or employment in hospital-owned groups or become credentialed to serve on insurance panels as preferred providers.
With the majority of medical graduates today becoming employed physicians—many of whom work for hospitals or health systems—certification has become ever more essential, says Paul E. LaCasse, DO, MPH, the president and CEO of Botsford Health. This is especially true given the growing trend of hospitals and health systems consolidating, he notes. Large health systems are imposing rigorous credentialing requirements on the hospitals, clinics and practice groups they are acquiring.
“Physicians will find it more difficult to enter into employment relationships without doing a residency,” says Dr. LaCasse, who chairs the AOA Bureau of Hospitals’ executive committee.
Given such restrictions, the number of new physicians opting not to complete a residency is believed to be “very, very small,” says Humayun J. Chaudhry, DO, the FSMB’s president and CEO, noting that hard numbers are not available.
Yet some physicians do enter practice after one year of training. They may be in a transitional stage of their careers if they’ve been unable to land a residency position in their desired specialty. They may be moonlighting to acquire additional income and experience while in their second year of residency. They may be in the U.S. military, which allows one-year-trained physicians to serve as general medical officers and flight surgeons. Or they may have chosen to open an unconventional cash-based practice.
Because of the shortage of primary physicians in this country, some osteopathic physicians believe that the three-year training requirement for family physicians, pediatricians and general internists is unnecessarily long. As new medical schools open and class sizes expand, many of the profession’s leaders are concerned about the shrinking proportion of graduate medical education slots. Encouraging internship-trained DOs to practice might help avert a shortfall of GME positions, some members of the profession point out.
Breaking the mold
Using it as a bridge between internship and residency, Ryan Stevenson, DO, began practicing after one year of GME so he could gain experience and income while waiting for the next year’s match. Failing to match into dermatology, one of the most competitive specialties, he sought employment after finishing his rotating internship in Michigan.
“Most of the physicians I know who wanted but didn’t get derm decided to do research or some teaching before trying again the following year. I was the only one I know of who started practicing,” Dr. Stevenson says. Searching for employment opportunities online, he found that even though he was not board eligible, his job prospects were better than he expected.
For a short time, Dr. Stevenson worked for an organization that advises health insurers about their members. He made house calls over a large swath of Michigan, earning what he describes as a decent flat fee per patient to take a history, perform a physical exam and provide a recommendation to the patient’s physician. But weary of the travel, he soon took contract work to practice at a medical clinic.
“There weren’t any restrictions on what I could do in the clinic. But from time to time, there were issues with insurance reimbursement because I wasn’t board certified,” says Dr. Stevenson, who is now serving an AOA-approved family medicine residency in Bay City, Mich.
“The best thing about the experience is that I learned how much I enjoy general practice.” Although he still hopes to transfer to a dermatology program, he views family medicine as a desirable backup plan.
Other osteopathic physicians, in contrast, have made a conscious choice to forgo or not complete residency training because they don’t intend to practice conventional medicine.
A number of the profession’s leaders know or have heard of DOs who’ve started cash-based osteopathic manipulative medicine practices right after their internship year. “I occasionally hear anecdotally about physicians who say, ‘I just want to have a cash business and do OMT, so I don’t need specialty certification.’ But I’m seeing this much, much less often today than ever before,” Dr. Chaudhry says.
Less recognized within the profession are internship-trained DOs who call themselves general practitioners and provide a variety of medical services, including OMT, without accepting insurance. These DOs often embrace various aspects of alternative medicine and oppose osteopathic medicine’s movement away from traditional osteopathy.
One such physician, Dustin Sulak, DO, has made a name for himself in Maine as a medical marijuana expert. He left the AOA-approved Maine-Dartmouth family medicine residency in Augusta, Maine, after his internship year to launch an integrative medicine practice.
“Leaving residency after internship is one of the best career decisions I’ve ever made—second only to choosing to become a DO over an MD,” Dr. Sulak says. “I actually started out subletting an office from an acupuncturist two days per week, offering OMT and hypnotherapy. The medical cannabis movement kind of swept me up for the ride.”
Although he has maintained what he describes as a strong relationship with Maine-Dartmouth and takes some of the program’s residents on rotation in his clinic, Dr. Sulak realized while in training that a full family medicine residency didn’t suit his professional interests or his desired work-life balance.
“Most primary care residency programs are heavily allopathic, regardless of their affiliation, and postgraduate years two and three basically consist of specialty training in allopathic medicine,” he insists. “Furthermore, the hardship of residency promotes unhealthy lifestyles and often damages the mental and physical health of young doctors.
“I wanted a healing-oriented practice with an OMT emphasis. I didn’t want to work for an insurance company. I wanted to direct my own education. I did not want to spend another two years in training that felt like indentured servitude, learning the type of disease-management medicine that is at the root of our country’s health care crisis. One year of that training was just the right amount for me personally.”
Need for traditional GPs
Osteopathic physicians who want to practice after one year of training should not have to set up cash-based OMM or other narrowly focused practices, contends Edward J. Canfield, DO, a family physician in Sebewaing, Mich. Obstacles set up by insurers and hospitals are unnecessarily preventing competent, qualified generalist physicians from entering practice sooner, he says.
Dr. Canfield argues that restrictions against licensed but not specialty-certified physicians have exacerbated the primary care physician shortage while allowing nurse practitioners and physician assistants to expand their scope of practice. Nurse practitioners have secured independent practice rights in 17 states, he says, stressing that physicians with four years of medical school and one year of GME are much better qualified for independent practice than NPs are.
In an opinion piece for The DO last July, Dr. Canfield argued for bringing back traditional general practitioners who can serve as independent primary care physicians after completing a rotating internship. Besides reducing the physician shortage, this would enhance the appeal of primary care by allowing physicians to begin earning a decent living sooner.
“In my plan, these GPs would go into underserved areas and work for two to four years to pay down their student loans,” says Dr. Canfield, the Michigan Osteopathic Association’s immediate past president. “If they decide to go into a residency program at a later date, they can. But they will have paid down the massive student loan debt that is going to haunt them for the rest of their medical career.”
Because a five-year physician has far more clinical and classroom experience than an NP or a PA, Dr. Canfield says that his proposal would improve patient health and safety in geographic areas where mid-level clinicians have growing autonomy.
A family physician in Meadville, Pa., Kenneth A. Unice, DO, agrees that competent generalist physicians should be able to practice without restrictions after completing a rotating internship—as used to be the norm.
Most osteopathic family physicians who graduated before the 1990s entered practice right after internship, notes Dr. Unice, who finished his rotating internship in 1979 and then began practicing. The requirement that family physicians complete three years of GME is excessive, he says.
“If you take diligent, qualified DOs who have done an internship and have them serve society two years earlier,” maintains Dr. Unice, “those two years of practice will make them better physicians than an extra two years of residency would.”
The decreasing ratio of residency positions to graduates is also important to the debate, points out Anna Lamb, DO, the president of the New York Society of Osteopathic Physicians and Surgeons. “If graduates do a traditional internship, there may or may not be a residency program for them to go into,” she says.
But Dr. Lamb doesn’t advocate making it easier for one-year-trained DOs to practice without limitations. “The thing that makes us special now as physicians is our level of training,” she says. “There is a higher expectation of us. We should not be trained on the job, like mid-levels.”
Raising the bar
The growing complexity of medical practice over the past 20 years has made residency training all the more important, says Dr. Chaudhry, a former president of the American College of Osteopathic Internists. With the federal government and private health insurers demanding more and more documentation from physicians, the knowledge threshold for doctors has become even higher, he says.
Indeed, many physicians nowadays earn multiple advanced degrees and certifications to enhance their skills, confidence and competitiveness.
“There may be an occasional individual today who decides after a year of residency to go hang up a shingle, but I think they are few and far between,” says AOA Trustee William S. Mayo, DO, who serves on the Mississippi State Board of Medical Licensure. “Besides concerns about reimbursement and hospital staff privileges, I don’t think most physicians would feel comfortable enough with their knowledge base to enter practice before finishing residency.”
Individuals who go into medicine typically have very high standards for themselves, notes Dr. Mayo, an ophthalmologist. “They are caring and want to help people, but they are driven to excel,” he says. “It’s hard to imagine someone in the middle of the medical education process saying, ‘I no longer care about excelling. I want to take shortcuts.’ ”
Joseph R.D. deKay, DO, who serves on the Maine Board of Osteopathic Licensure, concurs that entering practice after a year of GME is rare and unadvisable these days.
“Doing just an internship and nothing beyond is a dying trend,” Dr. deKay says. “Physicians cannot obtain stature in the medical profession without more than one year of postgraduate training in today’s world.”
To promote quality care and consistency, why don’t all states adopt a three-year minimum for GME, as the FSMB recommended in a 1998 position statement?
The one-year GME requirement dates back to the time when both MDs and DOs did a rotating internship. “Licensing boards originally insisted on that one year of training, so that no matter what you went into, you had the foundational aspects of the general practice of medicine,” Dr. Chaudhry explains.
The allopathic medical profession dispensed with a required rotating internship more than 30 years ago. The osteopathic medical profession, in contrast, required a traditional rotating internship until 2008. Although the one-year training requirement is really the relic of a bygone era, the vast majority of U.S. states have retained it, Dr. Chaudhry says.
Though the FSMB still recommends three years of GME for licensure, it has no authority to mandate it. “As state boards review their statutes—as they do periodically and sometimes by law if there is a sunset provision—we remind them of the FSMB’s recommendation,” Dr. Chaudhry says.
Yet the FSMB is reconsidering its three-year training suggestion. As part of that process, the federation is looking at data from its credentialing and verification service to see exactly how frequently individuals with only one year of GME seek a license. The FSMB also plans to survey state licensing boards on their perception of the three-year training recommendation.
“As we study this issue, we will take into account innovations occurring in both undergraduate and graduate medical education,” Dr. Chaudhry says.
For example, as a way to train osteopathic physicians more effectively and, potentially, more quickly, the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education recently recommended a pathway for producing primary care physicians that moves away from a rigid time frame for completing training toward a competency-based continuum.
Minimum lacks momentum
Although osteopathic medical educators are weighing how to leverage the profession’s strength in primary care and train practice-ready physicians faster, most of the profession’s leaders do not advocate that graduates today enter practice after one year of GME.
“The fund of knowledge necessary to be a primary care physician is at least more than one year of training,” says Richard Terry, DO, the chief academic officer for the Lake Erie Consortium for Osteopathic Medical Training (known as LECOMT). “Certainly after one year of internship, the average physician would not be prepared to go into practice.
“It’s not only an issue of getting hospital privileges or being credentialed by insurance companies. It’s also a question of clinical competence. Do interns really learn enough to practice outpatient medicine after just one year?
“With the current complexity of medicine and the medical climate today, it’s just not practical.”
But physicians are lifelong learners, points out Dr. Canfield. “We have the capacity to learn and relearn,” he says. “We’ve gotten in the habit of overtraining ourselves because family physicians want to be seen as specialists.”
To be a good generalist physician, says Dr. Canfield, “you need to know when you don’t know, so you can move those patients to someone who can take care of them.”
New physicians should aim higher, counters Dr. deKay, a family physician in Hiram, Maine. Speaking as someone who has practiced independently for more than 30 years, he offers this advice to graduates: “I would counsel any young physician coming along to do more than just get a license. Get the residency training and peer guidance that comes with teaching hospital affiliation.
“Clinical competency is never a done deal. But a foundation that puts one on a level of mutual respect from the onset of practice makes for a much safer start than just doing the minimum you can get away with.
“The idea of being a general practitioner after a single year of internship is a historical fact but not one with a future for U.S. physicians, in my opinion. Far too many safety measures are now in place to allow this notion to thrive.”