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?
What I found so interesting is the a dramatic departure from "this has always been the way that it's been done.” I find the new Missouri law extremely progressive and an effective response to a growing crisis in rural America. At the same time, I can certainly see the threat that this law brings to traditional academic medicine. (Just to clarify, under the Missouri law, an assistant physician is recognized as a medical doctor and that is different from a Physician's Assistant.)
In the blog, Rose Mary Gibson of the Hastings Center recognizes the vulnerability of the underserved due to their poor health status and the importance of well trained physicians caring for such patients. However, the model that we have adopted in our region to care for the patients in our region is the use of Advanced Practice Professionals in addition to primary care physicians. In a perfect world, we would love to have the most highly trained providers on staff and we are fortunate to have many who are just that.....extremely well trained. Quite honestly, our Advanced Practice Professionals have done a great job with our most vulnerable patients; and our nurse practitioners in the Center for Clinical Resources are a perfect example.
As our physicians are well aware, it has become very difficult to recruit for primary care physicians due to the shortage nationwide and that trend will continue. At WMHS, we have not had a Maryland-trained physician come directly from their residency or fellowship in quite sometime. We have had many discussions, but to no avail.
In Paul's blog, Dr. Dave Mayer's perspective is interesting in that he doesn't see a difference between going out and caring for patients in underserved areas under the direction of a MD or DO versus entering a residency and caring for patients in the hospital under the auspices of a physician preceptor. If those in academic medicine feel threatened by the Missouri law, they should recognize the crisis that exists and is only worsening by doing so much more in developing new physicians to embrace a rural environment for their practice setting post training. Why not make it a requirement for a percentage of those admitted to medical school that they practice in a rural setting for at least three years after completion of their residency?