Sunday, July 27, 2014

MDs in Missouri say, "Show me."

Here's a fascinating story in Governing about Missouri's approach to alleviating a physician shortage in rural areas.  (Thanks to the folks at Commonwealth Magazine for the tip in one of their daily newsletters.)  The lede:

A new Missouri law allows recent medical school graduates to practice primary care in underserved areas without completing a residency in a teaching hospital.

The Missouri State Medical Association, the law’s chief backer, is calling it an unprecedented effort to help deal with doctor shortages in rural and other underserved areas, but opponents raise questions about whether circumventing the traditional path to the exam room will do more harm than good. 

The article goes on to explain:

Missouri’s law, signed by Gov. Jay Nixon earlier this month, carves out a new classification called “assistant physician.” The law allows medical school graduates who have completed their licensing exams but haven't finished a residency to practice immediately in underserved areas. These graduates have to join a primary care practice of a “collaborating physician” who agrees to accept responsibility for an assistant physician. An assistant physician, who can legally be called a doctor, has to practice continually with his or her collaborating physician for one month before being able to serve independently.

My buddy Rosemary Gibson, a board member at the Accreditation Council for Graduate Medical Education, doesn't like the idea.  She is:

warning other states not to follow Missouri's lead because rural residents are sicker, older and poorer, on average, than the country as a whole. She said the Missouri law goes well beyond the scope-of-practice laws that have popped up in state legislatures. 

“On the surface, it looks like a quick fix, but I think it really behooves [policymakers] to do their homework, to understand what it means to have a graduate of a medical school be called doctor, to have prescriptive authority for powerful drugs like narcotics, to accurately dose and treat people,” she said. “Primary care is not simple. If you have a lot of older people living in rural areas, they have a lot of co-morbidities [such as diabetes combined with heart disease].”

I've run the story by other experts in medical education.  Another buddy, Dave Mayer, said:

I don't like the new law either. But it made me think and ask myself the following question: What is worse...Putting a new medical school graduate on an acute care hospital floor July 1st and asking them to take care of many hospitalized patients into the evening with little in-house supervision or asking a new medical school graduate on July 1st to take care of a few non-acute, non-hospitalized patients in a clinic where there is another fully trained/completed residency MD on site during the time they are working? Both have serious flaws but the second non-acute scenario sounds less scary to me. 
Of course, it can be a false choice to compare one scenario to the other, but the point is well made.  What's your take?


@idealanesthetic said...

From Twitter:

a) leaving a new doc with little/no supervision in any scenario is bad; b) this is an odd end-around to head off NP primary care; c) calling them "doctor" creates confusion, wondering if pts or other providers will be aware that person is an "assistant"; d) & just curious, how will billing work?

Barry Carol said...

This approach makes me very uncomfortable. I think we might be better served if the medical profession explored some of Dr. Ezekiel Emanuel’s ideas about how to shorten the time it takes to complete medical school and, later, residency and fellowship training. To attract more primary care doctors to rural areas, maybe we could look into loan forgiveness programs in exchange for a certain number of years of service and/or just pay them more.

christinerbeeson said...

An interesting approach. It is humorous that people find it frightening and offensive, as the idea of residency training is relatively recent in the history of medical training- indeed, just two generations ago our medical mentors were completing just one single year of training for intensive specialties like surgery! Everyone else was just practicing straight out of school. This doesn't seem frightening to me at all. A break from the norm, perhaps, but history has a funny way of repeating itself in new and "progressive" ways!

Vamsi Aribindi said...

I firmly believe medical training needs to be made longer- not the opposite. Especially rural primary care, where doctors deal with some of the sickest patients with no backup. There are no cardiologists to manage heart failure by seeing the patient every month, no nephrologists to help watch the kidneys, no endocrinologists to help with the diabetes.

All there is is the family physician. NPs and PAs make a lot of sense for urban environments- where anything problematic can be bumped up to see a specialist. Not so much when there's no one else around.

That said, if a brand new PA school graduates can see patients under a similar arrangement, it doesn't really make sense that new graduates of medical school couldn't.

Barry Carol said...

It seems that rural primary care doctors and their patients should be able to access specialists through video communications technology if none are available locally to provide support in managing chronic conditions.

Neil Mehta said...

If meded folks knew that the students were going to be independent practitioners instead of residents at the end of med school the curriculum would look quite different.

Wonder what these schools will do to adapt to this?

Jesse said...

I believe the Missouri law is a bad idea for the people who will be their patients.

First and foremost, a newly graduated doctor who has not completed a residency simply does not have the organization of knowledge to use what they have learned in medical school in a practical way. To make matters worse, many of them tend to think they do, adding overconfidence to their lack of experience.

First year residents in hospitals are in fact pretty closely supervised by more senior residents, and have an entire program built around them to educate them to become physicians who can practice effectively. The newly minted doctors in Missouri will have no such program. The "supervising physician" is supposed to review 10% of their records. What about the other 90%?

This law is just putting warm bodies into offices, seemingly filling a need but it is dangerous. The untrained doctor will miss serious diagnoses, and will test for things that a seasoned doctor of just a few years would recognize is not necessary to test for, thus resulting in more overuse, as well as incidental findings that will lead to further testing that was never needed and ultimately risk for the patient. The benefit to patients will be small at best but offer false security because "now they've seen a doctor." This is at best checking a box that they've dealt with the problem, but in no way an effective solution and could cause more harm then benefit,

Some will say, "Oh, that's just another doctor being protective of his turf". Not true. I am concerned about the safety of those who will put their trust in these new graduates.

On top of this all, the way I was presented this law, it is meant for the several hundred medical school graduates who fail to match for a residency. In general, those are not the students who were at the top of their class, to say the least.

Barry Carol said...

As a patient, I would prefer to see a seasoned NP for primary care than a doctor just out of medical school with no residency training.

Rural Missourian said...

Hilarious. I'm sure you'd be willing to show how un-frightening this all is by agreeing to have a surgeon with only one year of training operate on you or your loved one. If anything went wrong, his/her collaborator would only be 50 miles away. Should be fine!

There's been a few advancements in medicine over the past two generations. You should read up on some of them next time your fire up the ol' computer on your dial up.

Anonymous said...

Every state should follow suit. Many Americans do not have a primary care physician. I live in a rural area and I needed to see a doctor for a problem a few months ago. The minimum wait to see a M.D. or D.O. was 3 weeks. I ended up seeing a Physician Assistant at a minor emergency center who seemed fresh out of a 2 year P.A. program. I would have much rather seen a 4 year medical school graduate who had passed 2 written licensing exams and an personal clinical exam (USMLE steps 1, 2 and 2CK) which are required under the Missouri law.

There are currently 5,000+ U.S. citizen and permanent resident medical school graduates currently in the United States that have passed all medical school exams but cannot get a specialized medical residency to get any state license. Congress could end the doctor shortage immediately by allocating an additional 500 million per year to add additional specialty training but refuses to do so because the medical lobby (doctors themselves) do not want increased competition and a possible decrease in salaries.

Anonymous said...

No doctor or someone who has 8 years of education. 2 of which were spent with patients? Someone who can refill meds, up your Beta Blocker? Give you clonidine when HTN spikes. Someone that can check out a kids ear infection....