New Assistant Physician Licensure Program Raises Concerns

Ricki Lewis, PhD

October 23, 2018

To fill gaps in underserved areas, some states are creating new categories of physician licensure, such as Missouri's assistant physician program. An analysis of the program though raises questions about the providers' qualifications and the quality of care they provide.

In 2017, the first year assistant physicians (APs) could practice, APs were considerably less likely to have passed Steps 1 and 2 of the US Medical Licensing Examination (USMLE) on the first attempt than all graduates of US medical schools from 2012 through 2016, according to findings published online today in JAMA.

The low pass rates are reason for concern, write Grant S. Hoekzema, MD, and James J. Stevermer, MD, MSPH, both from the University of Missouri and Mercy Hospital in St Louis. "Failure of the Step 2 examination has been associated with increased disciplinary action and worse clinical outcomes," they write.

Currently Missouri is the only state with an AP program. For licensure these providers must be US citizens or legal residents, have graduated from a recognized medical school, speak English, passed Steps 1 and 2 of the USMLE, and not completed a residency.

To practice, however, an AP must have a collaborative practice agreement with a sponsoring physician, similar to what is required for nurse practitioners and physician assistants. The licensee must work with the collaborating physician for 30 days, and after that, practice within 50 miles of the sponsor (recently changed to 100 miles in light of the ease of telecommunication). The collaborating physician must review 10% of the AP's charts.

Comparing test scores was an objective way to highlight the concerns of several people in the graduate medical education community, given the requirements and competency assessments of APs, Hoekzema said in an interview with Medscape Medical News.

The authors compared results on Steps 1 and 2 of the exam for AP applicants for licensure in 2017. Overall, 99 APs were licensed, with USMLE scores available for 92. Of those, 64 (70%) passed Step 1 on the first try compared with 94% (96,747) of the 4-year total of US medical school graduates (P = .07).

For Step 2 clinical knowledge, 39 APs (42%) passed on the first attempt compared with 96% of all graduates (P < .001), and for Step 2 clinical skills, 46 (50%) passed compared with 96% of all graduates (P < .001).

Of the 99 APs, 92 (92.9%) graduated from medical schools outside the United States, and of those, 76 (82.6%) graduated from medical schools in the Caribbean. Seven (7.1%) APs graduated from medical schools in the United States, six from allopathic schools, and none from Missouri schools.

Just 25 of the licensed APs were practicing under a collaborative agreement, all of them international graduates, the researchers found.

Hoekzema attributes the low percentage of APs with a collaborative agreement to the fact that "the legislation was new and so potential collaborators were wary of signing on an AP or not even aware of the legislation. A cursory review of the current pool here near the end of 2018, 1 year later, doesn't show a significant uptick in that percentage, which highlights that the applicant pool is much larger than the demand."

Moreover, not all APs are practicing in underserved areas where they were intended to work. Only 20 of the 25 (80.0%) APs were employed in a federally designated health professional shortage area. For example, Todd Shaffer, MD, MBA, a professor of Community and Family Medicine at the University of Missouri, Kansas City, mentioned a clinic in Kansas City that's actually in Grandview, a suburb that crosses a rural county line, where three APs have enabled the supervising physician to keep a clinic open longer.

The larger concern, though, is the rigor of training and assessment. Shaffer compares the month of supervision required for APs to the 3-plus years of supervision a resident receives from an attending physician.

An AP "is a student who hasn't done well on boards or hasn't matched and is providing care that has minimal to no supervision. Some people might say some care is better than no care. But some care can actually be more dangerous," Shaffer said.

"AP licensees are not reviewed and evaluated to any degree that is even close to their counterparts who enter residency training after medical school," said Hoekzema.

APs won't impact rural healthcare, Shaffer said. "What's the evidence it works? None whatsoever...The solution is more people training in primary care and making clinics in rural areas places where people want to practice medicine."

APs are intended to provide primary care. However, the Association of Medical Doctor Assistant Physicians website describes this "new breed of provider" as qualified to prescribe drugs and treat patients in family practice, general practice, internal medicine, pediatrics, and obstetrics/gynecology.

What exactly an AP does, according to Missouri Statute 334.037, is vague: "administer or dispense drugs and provide treatment as long as the delivery of such healthcare services is within the scope of practice of the assistant physician and is consistent with that assistant physician's skill, training, and competence and the skill and training of the collaborating physician."

Rushed Legislation?

The idea began with good intentions but critics suggest it may not have come out as intended.

"Our state has lost a significant number of rural physicians. Representative Keith Frederick of Rolla, Missouri, the orthopedic surgeon who sponsored the bill, had heard about medical students graduating and not getting residencies. He saw two things: We need more doctors in rural areas, and students were not matching into residency programs," Shaffer said.

Trevor Cook, MD, an AP at a clinic in downtown St Louis, runs the Assistant Physicians website and agrees. "America is short on doctors. The Association of American Medical Colleges states that by 2025 there will be a shortfall of between 14,900 and 35,600 primary care physicians. This number is most devastating for medically underserved areas, which are disproportionately affected by the doctor deficit." Yet at the same time, he added, residency programs have been overwhelmed with applicants. "APs were made to fill a need."

The AP pool includes students who couldn't pass the exam or "may have been too selective and wanted orthopedics, for example, with no backup choice. Sometimes good people are in that group," Shaffer explained. The bill as envisioned would funnel graduates of medical schools in Missouri as APs into primary care, but the final version included any recognized medical school anywhere.

Then the bill was slipped past the Missouri Academy of Family Physicians, Shaffer and Hoekzema maintain.

"The legislation was passed in 2014 as part of an omnibus bill, with little to no input from the medical community. The sponsor had the support of the Missouri State Medical Association. As a member of the Missouri Academy of Family Physicians, I wasn't aware of the legislation until it passed. As a residency program director in a primary care discipline, I was asked to weigh-in on the rule-making process by the Missouri Board of Healing Arts chair, which provides licensure. The process found areas of concern, and so the first licenses weren't granted until January 2017," Hoekzema explained.

In May 2017, Frederick described the bill's intent to the Associated Press. "We've been trying for years to address maldistribution of physicians. We have all sorts of incentive programs and all sorts of ways to try to get them to go out to Podunk, but a lot of them just don't want to go to Podunk."

Hoekzema and Stevermer note that similar bills have passed in Utah, Kansas, and Arkansas. But "most of the country has not heard of this and even states that have limited versions of similar license categories have not informed the medical community," Hoekzema told Medscape Medical News.

Limitations of the study include limited data on applicants or licensees, practice settings, or employers, and coverage of only 1 year.

The authors and commentators have reported no relevant financial relationships.

JAMA. 2018;320:1706-1707. Abstract

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