Protecting patients

AOA convenes coalition to address assistant physician legislation

Five states have introduced or adopted bills licensing medical school graduates to deliver medical care without completing residency training.

In response to the proliferation of states considering assistant physician legislation, the AOA recently convened a group of influential health care stakeholders to discuss potential implications for quality care and patient safety.

The Assistant Physician Summit, held at the National Osteopathic Advocacy Center in Washington, DC, engaged representatives from 19 health care organizations, including the American Medical Association, American Academy of Family Physicians and the Federation of State Medical Boards.

In 2014, Missouri lawmakers enacted legislation creating a new type of health care provider, the assistant physician. The law licenses DO or MD medical school graduates to provide primary care services to patients in rural and underserved areas without completing postgraduate residency training and with limited physician supervision.

As licensure rules are being developed in Missouri, similar bills have been adopted in Kansas and Arkansas, and proposed in Washington and Virginia. The AOA is working with other health care entities to oppose this type of legislation and educate policymakers on patient safety risks.

“With the osteopathic profession’s strong emphasis on providing primary care in rural and underserved areas, the AOA is well positioned to lead advocacy efforts around this critical issue on behalf of physicians and patients,” says Nick Schilligo, the AOA’s associate vice president of state government affairs.

The training gap

According to Rosemary Gibson, senior advisor at The Hastings Center and award-winning author of “Wall of Silence,” the new provider designation poses a significant health threat for patients who may be unaware they are not seeing a fully trained and licensed physician.

Rosemary Gibson

“The biggest danger is that these providers don’t know what they don’t know,” says Gibson. “Residency training is essential to help physicians build the knowledge and experience necessary to provide comprehensive, high-quality care.”

The lack of close-proximity physician supervision required for practicing assistant physicians is of particular concern, Gibson notes. The Missouri law requires a DO or MD to continually supervise an assistant physician for one month, after which they can practice within a 50-mile radius of the supervising physician.

“There’s an enormous knowledge gap between someone who is eligible to become an assistant physician and a fully trained and licensed DO or MD,” says Gibson.

Brandon Isaacs, DO, wholeheartedly agrees. Serving as assistant dean for postdoctoral education at the Pacific Northwest University College of Osteopathic Medicine, he works to develop graduate medical education positions in a remote six-state region currently offering less than 2% of the nation’s residency slots. “We have no need for untrained, unlicensed providers who can’t practice independently or in a hospital setting,” he says.

‘Better options’

Although proponents of the legislation maintain that licensing assistant physicians will help states address physician workforce shortages in medically underserved regions, Dr. Isaacs says alternate funding for more residencies and elimination of GME position caps present better options for increasing access to care. Other proposed measures encouraging medical school graduates to pursue primary care include physician loan repayment or forgiveness programs and Medicaid payment parity for primary care services.

Brandon Isaacs, DO

“By allowing students who don’t match into their desired specialties to become assistant physicians until they can try again next year, we’re just kicking the can down the road, and then throwing more cans in the road for next year,” Dr. Isaacs says. He encourages students seeking to match into highly competitive programs to have a backup plan that includes considering the many primary care residency slots that go unfilled each year.

Next steps

Following the summit, participating health care organizations are preparing a unified strategy report that will provide a common platform for educating lawmakers and proposing alternative solutions.

“This summit represents a significant step forward,” says Dr. Isaacs. “We now have a collective voice at the table and tools we can use to educate lawmakers about the implications of the legislation.”

40 comments

  1. Physicians should be able to practice after medical school without residency. They did in the past. This is why I don’t support the AOA. We are proliferating PAs and NPs with substantially less training, and in 21 states they can work without supervision. But the AOA is concerned about the cash cow that is CME and residency administration fees. Our leadership has been replaced by politicians. All a bunch of sell outs.

      1. My thoughts exactly! How little does the medical student know in comparison to a PA or NP? Let’s give prescriptive “authority” to third year medical students.

    1. Agreed. PA has 1000 clinical hours and NP’s have 400-500 Clinical hours while a MD without residency has 2 years of Intense clinical exposure. MD’S without residency also pass their boards steps 1 and 2. It is really rediculous that a NP and PA are given a license to practice and not an MD without residency.

  2. This is bound to create more confusion as to who is and isn’t a doctor. It only dilutes the doctor’s role. As it is we have nurse practitioners out in practice on their own everywhere. They are supposed to have some physician oversight, even if off sight, but that is not the case. As the CMO of an insurer, I can never find one to call me back when I have concerns about the care of one of our plan members.

    We need to be lobbying for more funded GME positions or at least PGY-1 slots for licensure – as most state require at lease 1 PGY year of training if not more. This is NOT a stop gap.

    If we cannot get the feds to support us, then we need to get more creative – with private, foundation, community and/or corporate funding. As a last resort, perhaps the trainee will have to pay for their complete training, as unpalletable as that may be.

    It is immoral and unethical to graduate students and then not allow them the right to practice as physicians when PAs and NPs/APRNs with far less training are allowed to do almost anything these days.

    Either we believe that GME is a necessary safety standard or we do not. If we believe it is, then we have an obligation to find a way to make that process happen.

    1. So agree, Debra. Full licensing should not take place without at least one year of residency training, and passing all 3 parts of USMLE.

      Eliminate caps for GME to increase the number of primary care slots available. I know several great students who did not match this year.

      To think that someone would be competent to treat patients fresh out of medical school is insane.

      I also don’t agree with the poor oversight MLPs have in some areas. They have much less training yet in some states they don’t have to have an on-site physician.

      I totally disagree with the poster who claimed the AOA (and AMA for that matter, since I’m an MD) make us do residency for financial reasons. Do you want someone operating on you that has not completed a residency training program?

      1. Well said Janem1276! Successful completion of a residency program is a must. And even after it, it takes about 5 years of practice to feel competent in the field. Plus continue medical education is needed to attempt to remain up to date as medicine keeps evolving.

      2. These positions aren’t made for surgeons. These positions are made to expand the primary care that the State of Missouri lacks.
        I agree that should be no caps, or at least give those who did not match a year to complete their license criteria. After that, these people can at least have opportunity to work in other industries. Without a license, these grads are nothing. Many can’t get jobs and the competition is even higher than during match. US-IMG’s make up a large number of primary care doctors, and very good ones too.
        The Match and USMLE make millions with 42,000 applicants for 28000 spots. Exams are expensive, applications are expensive and there isn’t even a bit of promise that there will be a chance to get a placement and at LEAST get a license with a limitation. Either we take this assistant physician action or start expanding the intern year spots to complete the licensing and education and be done with it, and stop getting so greedy with accepting applications from abroad. US citizens and permanent resident should have a priority, because they are the ones who have to stick with the debt, not those coming from outside to apply for these spots. Many amazing doctors come from other countries, but we have to have our priorities straight.

  3. They ARE doctors since they graduated from medical school.

    One thing to consider here are the medical school graduates with unfortunate board failures that residencies won’t take because they’re too afraid of losing their accreditation. How is it fair that an otherwise good student who will make for a competent physician – again, they ultimately passed their boards and graduated medical school – should be left flapping in tge wind with $250-400k worth of debt and no residency just because their academic record wasn’t absolutely perfect?

    I’m for the Assistant Physician positiom but I do think it should be monitored by a supervising physician on a daily basis. I recognize that this blurs the line between doctor, PA and licensed doctor, but at the end of the day patients get care and that’s what really matters.

    1. “at the end of the day patients get care” — good, bad, or indifferent.
      I would not support a “solution” that furthers the trend toward medical care as a commodity. There are already too many substitute physicians claiming to practice medicine and diluting the role of doctor to that of “provider”.

      1. I agree. I am more than a “provider.” As a board certified FP Doctor, I’ve trained more, studied more, and seen, diagnosed, and treated many more patients than a PA or an NP.

  4. Regardless of outcome, the name “assistant physician” needs to be changed.
    It sounds like ‘physician assistant’ and someone graduating from medical school is a physician. By naming “assistant physician” it sounds like they are a PA.

    And the graduating physician has more school and more clinics experience (2 years) versus an NP and PA combined! And they can practice pretty free. This is more concerning to me.

    1. Someone graduating from medical school is not yet a physician. That doesn’t take place till licensing exam is passed and the graduate is licensed as a physician.

  5. I think it’s really sad that the AOA opposes a solution to a problem that it enables. DOs were the ONLY rural docs with an intern year only of GME for decades. Thousands of those docs are providing quality care right now and many of them are higher ups in the AOA!

  6. Aren’t PAs (physician assistants) who, apparently used to be referred to as “physician’s assistant” (note the apostrophe followed by letter s) – lobbying to now be called assistant physicians? If so – then that “really” blurs the lines between an assistant physician who competed medical school but not residency and an assistant physician who completed PA school (and no residency).

    isnt it the case that greater than 94-95 of US DOs match ? If that’s the case then the bottleneck doesn’t appear to be GME – especially when we import almost a third of primary care residents from abroad. I just think the con of creating a new type of “assistant physician” jeopardizes scope of practice more than creating a solution to any physician shortage problem.

  7. Perhaps those who support the idea of “assistant physician” should ask themselves if they would entrust the care of the person they love most to that person or someone with advanced training and experience. The answer to this problem is not quantity.

  8. I am about to complete residency and have been moonlighting in an ED over the past few months. As I have begin to “spread my wings,” I have become more and more aware of what I don’t know. Consequently, I fully agree with the article’s states that new medical school graduates “don’t know what they don’t know.” Believing that medical school grads with little or no residency training are ready to provide essentially unsupervised patient care is an invitation to disaster. Without doubt, I have come to be frighteningly cognizant of my knowledge gaps as I draw closer to completing residency. Although I am beginning to feel confident that I can safely manage patients on my own, I cannot imagine placing that trust or responsibility with someone who has very little real world patient exposure. As someone has said, you don’t learn to practice medicine in medical school, but only on the rigors of residency. While there may be urgent needs to create more “providers” in needy areas, giving free rein to very inexperienced medical school grads is not doing any favors for the patients that may fall under their care. To use a cliche, it is a recipe for disaster.

  9. How in the world is the AOA advocating to hold back PHYSICIANS (they are graduated doctors not assistants) when they do nothing to stop increased NP independence who have far less time in training, standardization of programs, or quality of end physician supervision in training or in practice? If four years of medical school and hundreds of thousands of dollars is not enough to train competent physicians than they need to seriously reconsider the product (education) they are putting out because apparently NPs and PAs can do MORE for less and in less time.

  10. I still independent midlevel practice is ridiculous. It appears the only way the AOA and AMA are defending scope of practice is to tout healthcare is better with teams with physicians at the helm. I think a better approach would be advocating to consumers/ patients – ultimately when given a choice patients would rather see physicians – but midlevels cost less to employ.

  11. Any physician who has actually completed a residency knows the absolute value of residency. If one has never completed residency, one might feel competent without knowing why they are not. Residency in-service exams are a very good example of the amount of knowledge gained over the course of residency.
    There are reasons why rules and regulations changed over time. Going backwards is not the answer—in all aspects of medicine.
    Comparing resident-trained physician care to NP and PA care is not equivalent. Wanting doctors to go down to the education level of a paramedical professional is unacceptable. This is not the appropriate answer.
    If anyone has truly completed residency in any specialty and thinks they are not more competent to take care of patients afterwards, I would be surprised.
    Putting “doctor” in front of a name does not make that person competent to provide full scope of care.
    I like the ideas of payment parity and tax-free loan repayment as ways of encouraging more people to finish a primary care residency and care for an underserved population. I hope more people consider it.

  12. I do not support the AOA. They have expanded enrollment and schools without providing the matching number of residency slots. The schools have invested heavily in enrolling PAs and NPs for healthcare education. The schools have invested heavily in enrolling pharmacists for healthcare education. In my school, it appeared my tuition was going more towards the pharmacy students. The AOA contributed to this problem of independent PAs and NPs. Now, they want to stop physicians from working, while they created that problem as well with the lack of residency positions. Yes, the residency training and fellowship training I did was very valuable, and I am board certified in my area, but I think any medical school graduated who has earned a medical license can provide basic primary care. The AOA is saying these physicians are inferior to PAs and NPs. What a joke. The AOA needs to disappear. I was never sure who interests they truly served. The younger physicians many catered to them to get an inside track to ortho, derm, and other specialities they had little chance matching into at the non-AOA residencies.

  13. My first question would be, so when do you know what you don’t know? If you think residency takes care of that, you are a fool for a doctor and need to go back into training. Having been “out” for 28 years and in practice, there is rarely a day goes by that I don’t have to go to the books or online to look up something. My practice is over 95% diabetes, and the next resident I get that wants to put everyone on sulfonylurea drugs, I may have to euthanize. If you think residency is the be all, end all, you have lost the whole reason to do it in the first place. It is little more than a good starting place…….and 20 years of residency would not equal 20 years of practice.
    I agree with several other folks as well. This type of controversy just makes it that much easier for NP/PA to expand. When the AMA/AOA bailed on their constituents and became more interested in proper political stance than well reasoned, scientifically based positions, physicians’ respect dwindled. This type of thing does not help physicians at all.

  14. Assistant Physician creates a second class of physicians. I am sure they will not be compensated at the same rate as boarded physicians. We could be creating a Registrar/Consultant system like in the UK. What happens to them if they don’t match in a residency after their first year out? You will then have many more applicants for the same number of limited residency slots.. I see this as a cost saving maneuver by the insurers. This problem could easily be resolved by the residency programs themselves. They could add more slots and divide the salary pie by a larger number, essentially lowering residency salaries, or, they could create several additional “Unfunded slots” where residents would be responsible for the majority of their living expenses. I teach at a COM and by the number of late model BMW’s, Mercedes, and lexus’s, in the student parking lot, many graduates appear to have the means to sustain themselves during residency. I believe this approach is much more desirable than creating second class citizens.

  15. There is no way I would trust my care or the care of my loved ones to someone who is fresh out of medical school, wasn’t able to match, and only spent one month under the supervision of a trained physician. I am a PGY-2 resident and only now am I even beginning to think that I can take care of patients on my own. It is ridiculous to claim that 4 years of medical school alone is superior to the training than PAs/NPs get. The training is vastly different; PAs/NPs are learning how to actually work in the real world. Medical students spend most of medical school learning “book smarts” and are not trained on how to apply this knowledge to real world situations. Although a PA/NP may not know as much about the physiology or pathogenesis of CHF as a graduate medical student, I’ll bet they know a lot more about how to stabilize a decompensated heart failure patient who comes into the ED.

    1. Thank you for actually standing up for us PAs & NPs. We are well aware of our differences in training, and no PA would tell you otherwise. Because of this, PAs subscribe to the philosophy of team-based care with physician leading the team, so we are not trying to displace physicians at all–if anything we are trying to help improve access in underserved populations, too. As for the subject of this article, I do think it will be very confusing to most patients who can barely understand the various levels of doctor training and other med personnel in general, and how much can 1 month of direct supervision prepare you? Maybe if physicians were compensated more to be in family practice or as an internist in the first place we wouldn’t have such trouble with access.

  16. “It is ridiculous to claim that 4 years of medical school alone is superior to the training than PAs/NPs get. ”

    PA Programs are 2 years: 1 year didactics + 1 year clinical rotations. Med school is 4 years: 2 years didactics + 2 years clinical rotations. I’m confused by the post…

  17. I thought Physicians get licensed after completing their internship? That sounds like 5 years of training versus 2 for a PA.

  18. Gee, I wonder why I wasn’t invited to this Summit since I sponsored the bill in the Missouri legislature that established Assistant Physicians. Like most states, we don’t have enough primary care doctors. Medical schools continue to expand enrollment but residency slots have not kept pace. When a physician does not match and owes 200-250K and the AMA, ACGME and the AOA contend that such a doctor is not as qualified as the NP or PA whose education was much shorter, involved much less sacrifice and was much less costly I see hypocrisy. Why have the leaders of these organizations remained silent over the last three decades as state after state sanctioned independent practice rights for NP’s as they faced increasing shortages of physicians. Why has the AOA entered into agreements with ACGME that will result in the loss of scores of DO residency slots and lead to more doctors who don’t match. What is a doctor who does not secure a residency supposed to do in the AOA’s opinion? The assertion that the NP or PA is more qualified to practice than a newly graduated physician has no basis in fact. The selection process to enter medical school is much more rigorous than the selection process to be accepted to an NP program. Medical school is not only much longer than an NP course of study but the intensity is greater. Does anyone believe if newly graduated NP’s and newly graduated physicians took the same standardized medical boards that the NP’s would score higher? The AOA, AMA and ACGME are also three organizations that have remained silent in the face of decades medical students and residents suffering from high rates of depression and suicide described last year in the JAMA Psychiatry article. ” Medical Student Depression and Suicide: National Response Needed”. Worry about matching is a risk factor for depression and suicide. I suggest that it is our obligation as physicians to seek out every single physician who becomes licensed as an Assistant Physician to provide him or her with a collaborative practice opportunity and allow her to use the knowledge and skills she has, earn a living, take care of patients and advance his education with our help. With appropriate educational opportunities,including the use of telemedicine, and documentation of mastery of the material I believe we should consider allowing a year of credit toward a primary care residency for one or two years of such collaborative practice. These new doctors can earn while they learn (their services can be billed for just like a NP or PA) and more residency slots will have effectively been created without the money that is traditionally needed (but not available) for residency expansion. The AOA should be facilitating such innovation instead of using membership dues to hold meetings to stonewall it. Here in Missouri, I sponsored the Assistant Physician bill, I also introduced HB 1658, the “Show Me Compassionate Medical Education Act” , to address med student well being, and I sponsored legislation that became law last year to facilitate Direct Primary Care in Missouri. We’re doing a lot more to make Missouri a great place to practice. If you know of any med students/physicians who don’t match tell them that we welcome them and their talents in Missouri.

    1. Thank you for all that you have done. Thank you for using logic for once to address the rural physician and residency slot shortages simultaneously. Please stay the course. Very few people seem to care about the well being of medical students and rural patients. I hope more and more states take note of your actions and follow suit.

    2. Dr. Frederick,
      Thank you for your post. It filled in many gaps in my understanding of the problem. If you scroll up and read my earlier comments, I think you would agree with my thoughts, I believe the answer lies in more training opportunities rather than fewer. I believe more residency slots could be created and your concept of distant internet supervision could be incorporated into this model since money for post grad medical education is limited. I am deeply concerned that the assistant physician category would end up similar to recent law school grads taking paralegal jobs because they cannot find employment. Government seems to prefer solving difficult issues by granting greater practice privileges through legislation rather than education. I always favor education. I have a real stake in this as my son is finishing his second year in osteopathic medical school. Remember, the ACGME threw D.O.s out of their programs when 500 of MD grads didn’t match.
      The AOA for decades has counted on a large number of new grads attending allopathic residencies. They got caught with their knickers down and did the politically expedient solution by merging residencies. I fear the vast majority o non-matching students will be D.O.’s. Thank you for your concern and dedication to this issue

      1. Hello Dr. Seifert,
        You’re right– I think we agree on a lot regarding this issue. Creating more residency slots is the best answer. However, that has been known for a long time now and nothing has been done to address that problem. Instead of cutting the pie into more pieces and forcing residents to take $20,000 per year, why not bill the insurance companies and Medicare and Medicaid for their services the same way that services from NP’s and PA’s are billed. If a licensed physician takes on an Assistant Physician and collaborates with him or her both would gain. The Assistant Physician could make at least as much as a resident’s salary, and would be learning and getting credit towards an eventual residency. The collaborator could act as the employer and make some income to compensate her for serving as a primary care instructor. In days gone by we did that for free, but in today’s diminishing reimbursement climate physicians have an opportunity for additional income when supervising midlevels, so providing some income for the collaborator as an incentive to teach the AP makes sense. This could be augmented with web based learning and telemedicine clinical encounters or innovative educational sessions such as the ECHO program in New Mexico and now in Missouri. If done well, it might be possible to allow one year of collaboration to count as the first year of residency, which could expand the available slots by one-third quickly. While we are waiting for additional funding for residency slots, let’s allow these newly graduated doctors to earn and learn instead of just marking time while the interest on their loans is accumulating and their skills are getting stale. I feel our loyalty is to these new doctors who are being betrayed by the system with few options, soaring debt, and alarming rates of depression and suicide. If we are going to spend time teaching medicine to midlevels, we should take care of the members of our own profession first since they have more skin in the game by virtue of the time, effort and expense that they have invested compared to the others.
        Thank you for engaging in this discussion. This is what is needed to begin to bring solutions to a problem that is only getting worse each year. Instead of having a summit to stamp out the spread of Assistant Physicians (which I believe they will not be able to do) our national organizations should be looking to innovate and use technology to develop new models for postdoctoral training that increase the number of residency graduates we can produce, while maintaining a quality educational experience. You know, it actually might be a better residency experience if carefully structured and implemented by people who care- like you. For anyone who wants to discuss this by phone, I would be happy to do so. My cell is (573) 201-8914, and I am on CST.

    3. Sir – very well said. I have watched this play out on both sides. I believe that a resident in collaboration with a physician can provide medical care safely to our population. Having served in the military, and having seen the care provided by medics who work under a PA or physician – I know it can be safely done. All those who oppose this, must not understand the after effects of not being accepted into a residency. I believe that a medical school graduate who is ECFMG licensed and have completed Step 1-3 will be able to provide the same if not better care than a PA/NP, recently graduated. Those who argue against allowing the assistant physician to do that work, should also hold the belief that a PA/NP is unable to provide safe and compassionate care. They are dead wrong!! My prayers go out to all the Med school graduates unable to attend a residency because the system has failed them, and no one has said a single word about it until you!! Thanks for all you do to encourage these graduates, and all you do o a daily basis to provide health care to the folks of MO. By the way, for the physician assistants who have an issues with this, “lest we forget” – sir, you have my full support!!

  19. Please avoid the use of the oxymoron “newly graduated physician” as it implies that new graduates are actual licensed physicians, and seeks to ignore an important distinction between “doctor” and “physician”.

  20. It is totally insane to allow NP’s and PA’s to practice under the supervision of a physician and claim that a med school graduate is not competent of doing the same. Likewise, the mere fact that NP’s are allowed to practice solo is foolish! However, it is a reality. There is nothing or no one who can convince me that a NP has more medical knowledge than a med school graduate. If NP’s can practice medicine solo, I say med school graduates (i.e. physicians) who don’t match should be allowed to do the same after one year of supervised training with a clinician. It is ludicrous to me that we have to even have this debate. Do you really think that a med school graduate who doesn’t match or doesn’t pass the steps on the first time is not capable of being a great physician??? What a foolish way of thinking!!

    1. The AOA has long opposed independent practice for nonphysician clinicians. Instead, we support physician-led, team-based care. We believe that direct involvement of a fully trained and licensed physician is instrumental in ensuring that patients receive the highest quality of care available. Patients in rural and underserved areas deserve the same quality of care as those who live in prosperous areas.

      While we support the concept of addressing workforce shortages, lowering the bar for who can provide care deteriorates licensure eligibility standards that we believe are essential to protecting the public.

      In support of these principles, we will continue to oppose inappropriate scope-of-practice expansions. An example of this is our recent advocacy in opposition to a scope-of-practice expansion proposal within the VA System.

      There are alternatives available that would allow greater access to health care for patients without placing their health in jeopardy by removing the direct involvement of a fully trained and licensed physician from their immediate care. They include expanded funding for community-based primary care residency training and financial incentives that encourage physicians to practice primary care in the areas of greatest need. The AOA supports and advocates for both of these options.

  21. First of all, let us all hope that the residency caps get expanded or eliminated. Right now the US is facing an expanding, aging population, and a shortage of doctors. Letting over 8,000 doctors go without a residency each year makes no sense in the face of this.
    Might some of these graduates lack competency? Sure. However, I highly doubt it is the majority. Even a good number of those on the cusp may merely need some extra experience under a practiced supervisor. Why not simply increase the time spent under supervision if competency is the issue? Maybe a year to get them close to a 1st year post grad level.
    We aren’t even considering former residents who had to stop due to unforeseen issues like finances, family, medical illness, etc. Many of these doctors are more than qualified but may be in a limbo between the time they can get back into a residency and the time they are ready for employment. It seems better to have them treating patients and getting experience in the inbetween.
    I can understand the AOA wanting to make sure patients are taken care of, but until the residency gap issues are solved, maybe we should focus on utilizing and improving the doctors we have waiting in the wings.

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