Are Assistant Physicians a Good Idea?

The Missouri Assistant Physician Program was initiated in 2014. The Missouri State Medical Association helped write and pass the bill through the Missouri legislature. Much of the motivation was to provide graduate MDs as mid-level practitioners, both to help out unmatched graduates and to counter the argument that rural Missouri needs more APRNs. New physician graduates who cannot obtain a residency position may become APs, working only under the direct supervision of practicing physicians. The program was limited to three years, with the “up or out” idea that the AP would then obtain a residency position. The Board of Medical Licensure created regulations. There have been APs in practice in Missouri since 2017. Currently, there are probably between 200 and 300.

Recently, there has been controversy. One AP in a rural area has been indicted by the Federal government for fraud. The extent to which this individual was supervised appears unclear. House Bill 550 was introduced in the legislature this session (by the same individual) and would have created an alternative pathway to licensure for assistant physicians. In a nutshell, an assistant physician could have applied for full licensure as a physician after they completed five years in a collaborative practice arrangement with a physician. MSMA opposed this bill.

A later amendment added and then removed from several bills at the end of session would have limited the number of years that an assistant physician could have practiced in Missouri. Different versions of the amendment would have also required assistant physicians to be graduates of either a Missouri medical school or a medical school in the U.S. or Canada. Because it was a controversial topic requiring further discussion, the amendment was stripped from bills.

A resolution at the recent MSMA Annual Convention called for limiting the program to three years for any participant, which was the original intent. The resolution called for MSMA to strongly opposing a pathway to full licensure. This resolution is very much in line with the original legislation as supported by MSMA, and with current MSMA policy.

What is the justification for the AP program? Partly, it’s to provide help to rural medical practices. Rural health is used to justify other mid-level practitioners, so using graduate physicians would be a reasonable step. But in point of fact, the problem of unmatched physician graduates is serious, and getting worse. The AP program does provide a way for unmatched graduates to work within the medical system. It may also help with our growing physician shortage. Let us explore that in a bit more detail.

The national physician shortage was predicted 30 years ago and generally acknowledged about 15 years ago. It was grudgingly accepted by the academic medical establishment about five years ago. In response, the number of medical school graduates has increased by about 4,300, both DO and MD, since 2017. It’s a slow process, because it’s both time-consuming and expensive to increase medical school output.

Consider all of this from the point of view of young physicians. Following admission to medical school, participation in the NRIMP is the second major event in their professional lives. Obtaining residency training is as important as gaining admission to medical school.

Have the number of residencies also increased? Actually, yes. Congress enacted a cap on residency positions about 25 years ago, in order to limit Medicare funding for residencies. Despite this, the number of first year positions has steadily increased. But the total number of applicants has also gone up. There is a mismatch between applicants and available jobs. According to the National Intern and Resident Matching Program (NIRMP), 43,000 applicants matched into 33,000 first-year positions in 2021.¹ Only about 78% of applicants found positions. This is not a recent situation. The number of applicants outstripped the number of places around 1980. And yet, we have a physician shortage in the U.S. Isn’t public policy fascinating?

Consider all of this from the point of view of young physicians. Following admission to medical school, participation in the NRIMP is the second major event in their professional lives. Obtaining residency training is as important as gaining admission to medical school. Without it, no state will license the new physician. Most graduates of U.S. schools will obtain residencies, but a growing number will not.

The NIRMP results from 2021 show that 1,400 MD graduates of American medical schools and 800 DO graduates remained unmatched. Now, this is not a final number. There are some DO positions outside the match in legacy osteopathic programs. And some percentage of all these unmatched individuals will somehow find their way into training programs. But on the face of it, close to 2,000 graduates of U.S. schools will not get the training they need to become licensed physicians. That’s six to eight percent of all U.S. graduates. The odds are much worse for international graduates. There were 5,300 applicants in the match who were U.S. citizen and graduates of international schools. Of these, 2,100, or 40%, were unmatched. International graduates who are not U.S. citizens fare no better, about 45% remaining unmatched. But at least these physicians have home countries to which they may return. And which may actually need them. Unmatched U.S. graduates simply come home, and try to find something to do with their lives.

OK, back to the Assistant Physician program. When it was adopted in 2014, it was very unpopular outside Missouri. The American Medical Association (AMA) passed a resolution opposing AP programs. An alphabet soup of the medical educational establishment registered opposition. This included the Association of American Medical Colleges (AAMC), the Accreditation Council of Graduate Medical Education (ACGME), and the Accreditation Council of Continuing Medical Education (ACCME). And others. All of these represent people with financial interests in the current system, and will of course oppose any changes. Several other states considered adopting similar programs, but none have been opened yet. It seems unlikely that this program will be imitated in many other states, partly because of a lack of enthusiasm, partly because of the entrenched opposition.

Has the program worked as advertised? We’re not sure. Figures for the program are very hard to obtain. Certainly, some recent grads have gone into the program, worked for licensed physicians, and moved on to resident training positions. We just don’t know how many.

The program has the potential to become a pathway to practice without residency training. That would require new legislation; probably not this year, but possibly in the future. To a non-medical legislator, it might seem very reasonable to treat five or ten years of preceptorship as equivalent to residency training.

So, is the Assistant Physician program a Good Thing, or not? Does it help young physicians move on to residency training? The data just isn’t out there. As a first step, MSMA should work with the Board of Healing Arts to find out. But more broadly, it seems unlikely to effectively address either the physician shortage or the problem of unmatched young physicians. Why not? For one thing, it is clearly not going to be adopted nationwide, or even regionally. For another, it represents a return to the apprenticeship system of training physicians. In short, it doesn’t address the core problem of too few residency positions.

According to the Accreditation Council of Graduate Medical Education, there are 865 sponsors of residency programs, and 560 sponsors of more than a single program.² That’s out of 6,000 hospitals nationally.³ In Missouri, 14 institutions sponsor residencies,³ out of maybe 180 hospitals.⁴ That’s comparing apples and oranges, of course. Many sponsoring institutions send residents to several hospitals. But it emphasizes the problem. More hospitals need to be in the teaching business. We don’t need individual physicians trying to train their apprentices. We need institutions mobilizing groups of physicians to train residents.

Let me put it less tactfully. Do you want new physicians in your town? Does your local hospital have residency training? No? Well, good luck to you! If you, personally, are not involved in residency training, nor is your hospital, then you’re part of the problem. We cannot get more physicians unless we train them. That’s the responsibility of our entire profession. We need to do better for Missouri.