Innovative Assistant Physician Program Enhances Patient Care: The Nevada Medical Clinic Experience

Nevada Medical Clinic (“the clinic”) has recently recruited an ‘assistant physician’ (AP) position for our busy Missouri practice. The innovative legislation for this license passed in 2014 but regrettably licenses were not available until 2017.

Our clinic became aware of this unique healthcare practitioner and began investigating it in early 2017. It has been increasingly difficult to recruit physicians to our charming but isolated small town. There are many other locales in this nation that have similar needs and attributes. We are a privately-owned clinic with six physicians and three nurse practitioners. We find it challenging to compete with higher guaranteed salaries from large corporations and hospital systems. Many new graduates, most carrying huge educational debt, are skeptical that they can succeed in private practice. Consequently, few are willing to consider private practice especially in rural locations. Our clinic concluded that we could utilize an assistant physician; we hoped it would also be an opportunity for permanent recruitment.

We listed the position on the website www.residentswap.org. There were no other similar positions listed. We were inundated with responses from potential candidates and quickly requested our posting be removed. We later learned that numerous medical school graduates move to Missouri and apply for an assistant physician license. To date we are not aware of other practices using assistant physicians. We were delayed in our implementation date by logistical challenges. Our liability carriers and insurance providers were not aware of this new limited-practice license and needed time to adapt policies and premiums for it. The first physician assistant license was issued July 31, 2017. We quickly obtained the National Provider Identifier and began the insurance credentialing process. Missouri Medicaid representatives had not heard of APs and needed to review copies of the legislation. Some of the Medicaid carriers are not credentialing APs individually so we are billing charges “incident-to” the collaborating physician’s services. Our local hospital is still adapting the by-laws to include APs job description and privileges before granting credentials. We based the AP’s salary offer on those representative of a first-year resident’s income in the Midwest.

From left, Amanda Turner, MD, who is the primary collaborating physician for Dr. Mukherjee, Jennifer Conley MD, who is the author of the article, and Elizabeth Mukherjee, MD.

Missouri is one of only a few states to offer a position of this nature. Arkansas passed similar legislation in 2015.¹ Kansas limits AP opportunities only to graduates of the University of Kansas School of Medicine.² The number of unmatched residency applicants in 2017 was greater than 8,000.³ This disturbingly large number has been growing. Unfortunately, there are limited ways for these highly trained women and men to use their medical degrees without a residency. The American Association of Medical Colleges reported in October 2016 that the average 2015 medical school graduate had more than $180,000 in debt. This debt was incurred and these loans made with the understanding that successful medical school graduates will be able to progress through post-graduate residencies and then have excellent employment prospects. The reality of such a large disparity between medical school graduates and available residencies is that the competition for post-graduate training has become ultra-intense. Of note, 1,000 US allopathic medical school graduates did not successfully match last year.³

The assistant physician license has met with some criticism that it might encourage graduate physicians to circumvent further training. Allegedly this might lead to a sub-class of physician providing inferior care. The current standards have strict eligibility requirements including US residency, English language proficiency, medical school graduation within the past three years and successful completion of the first two steps of the US Medical Licensing Exam within the past two years.⁴ The law’s intent, and our expectation, is that the AP will use the unique supervised medical work experience positively for enhanced application to the following year’s residency match program and completion of residency/fellowship training.

The AP must collaborate closely with the supervising physician and not provide care independently. APs are considered learners. The experiences of each AP depend to a great extent upon the supervision and teaching skills of participating collaborating physicians. The AP is a unique physician extender and should enhance both the quality and quantity of care fully trained physicians can provide.

Ideally the number of available residency positions will increase to meet the demand from medical school graduates and to supply communities across the nation desperately trying to recruit new physicians. There has been an effort to advance legislation of this nature through the federal government as resident salaries are historically covered by Centers for Medicare and Medicaid Services. Medical school enrollments have increased. In the past two years Missouri has seen an increase at University of Missouri-Columbia from 96 to 128 by utilizing a satellite campus in Springfield and also at Kansas City University of Medicine and Biosciences which opened a new campus in Joplin for an estimated 150 more students annually. Residency positions have not kept pace. Employing APs may give unmatched individuals the opportunity to learn and begin supervised medical practice until they can complete their training.

Our assistant physician is Elizabeth Mukherjee, MD, and is a 2017 graduate of Ross University School of Medicine in Dominica, West Indies. She earned a Bachelor of Science in Molecular Biosciences and a graduate certificate in Autism Spectrum Disorders from the University of Kansas. She is a graduate of Blue Valley Northwest High School in Overland Park, Kansas. She was born in Kolkata, India. She later moved to Reading, England at age six and Overland Park at age 10. She volunteered in Moshi, Tanzania, for two months and Ngeruka, Rwanda, for one year as a health volunteer. She is interested in family medicine with obstetrics. Elizabeth has been able to participate and further those interests at Nevada Medical Clinic.

Within the first month the physicians and staff have developed rapport, familiarity, and respect towards our AP. We hope that Dr. Mukherjee will be matched into a residency program and come back to join us as a partner after her graduation. We are considering hiring another AP next year and might expand the number and responsibilities. We will be monitoring the financial impact of this AP employee and determine the feasibility of continuing the program.

From our perspective the AP is a win/win for the non-matched physician, our fully trained physicians and staff and most importantly the health and well-being of our patients.

Biography

Jennifer Conley, MD, MSMA member since 2003, is a family practice physician in Nevada, Missouri.

Contact: jconley@nevadamedicalclinic.com