Assistant Physicians: COVID-19 Draws Notice to New Type of Physician

Marcia Frellick

July 02, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The expansion of the physician workforce to fight COVID-19 is shining a spotlight on a group of physicians whose scope of practice has been controversial: assistant physicians (APs).

Not to be confused with physician assistants (PAs), APs are doctors who graduated medical school and passed Step 1 and Step 2 of the US Medical Licensing Examination (USMLE) but did not match into a residency program. They can practice primary care under some degree of supervision in certain states.

Some states are graduating medical students and nurses early to help fight COVID-19. Trevor Cook, MD, the founder of the Association of Medical Doctor Assistant Physicians (AMDAP), told Medscape Medical News that APs should be put to work as well. In Missouri and some other states they already are, he explained.

Under an agreement with a physician, who must be located no more than 50 miles away, Cook is seeing a slew of patients in Missouri with COVID-19 symptoms and taking on non-COVID-19 patients as emergency departments fill.

Faarina Khan, MD, is an AP at The Medina Clinic in Grandview, Missouri. She has been coordinating the COVID-19 response for AMDAP. Khan told Medscape Medical News that hospitals in states including Illinois, Indiana, New Jersey, Pennsylvania, Washington, and Wyoming are offering temporary emergency licenses to APs during the crisis so they may serve "in an official medical capacity."

The extent of the APs' duties are determined by the group requesting help, she explained.

"We are an often underrecognized and overlooked resource," Khan said. "Whether it's at the state governors' level and/or the national level, solid moves need to be made to mobilize us and allow us to serve our country in its greatest time of need."

Khan hopes that other states will allow AP licenses after they evaluate how APs assist during the COVID-19 pandemic. "Showing what we can do in a situation such as the current one, may be what is needed to facilitate launching the program in other states and may allow licensing of their own APs," she said.

Clif Knight, MD, vice president of education for the American Academy of Family Physicians (AAFP), cautions that proper supervision of APs by a fully licensed physician is essential, even during this crisis. "Folks should not be placed in situations where they are making clinical decisions that they're not prepared to make," he told Medscape Medical News.

Knight stressed that the use of APs during the pandemic should be temporary and "should not be misconstrued as some sort of educational experience on a path to licensure."

The Origin of APs

Cook's role as national champion of APs began long before the COVID crisis started, back when his path to becoming a physician took an unexpected turn. After graduating from a medical school in the Caribbean that was more affordable than US schools, completing clerkships in Chicago, graduating, and passing his exams, he got the crushing news that he did not match into a residency program.

"Imagine you go through 8 years of medical school, you pass every single exam that the US throws at you. There was an extreme amount of stress for the better part of a decade, and then at the end of that, there's just not enough room at the inn," he told Medscape Medical News.

After working as a medical scribe, teacher, and electronic health records consultant, he found an option closer to his dream recently legalized in Missouri: becoming an AP.

Cook — who now lists "MD, AP" after his name — founded AMDAP in 2017 "to fill a need."  He says assistant physicians, or associate physicians as they are called in some states, offer a way to provide care for more patients and make use of medical training currently going to waste when a doctor has graduated but doesn't match into a residency slot.

Not matching into residency is a failure of a system to supply enough spots to keep up with medical student and patient demand, Cook argues, not the failure of medical school graduates to meet a proficiency bar. "It's bringing people who need doctors to doctors who need patients," he said, adding that the AP role can also be either a path to residency or a career choice unto itself.

Although embraced by Cook and others, the role sparked controversy when Missouri first legalized it in 2014 and again last year when legislation was introduced to expand the role. Depending on whom you ask, APs either represent an important way to increase the healthcare workforce in rural or underserved areas — especially during a pandemic — or they are downright dangerous for patients.

It's bringing people who need doctors to doctors who need patients. Dr Trevor Cook

In Missouri, APs can practice in primary care in underserved areas and must work under a contract set by a collaborating physician. They are directly supervised for 30 days (120 hours), and then APs may practice in collaboration with a physician, who must be located within 50 miles. APs can prescribe drugs from schedules 3-5 and from schedule 2, if that authority is granted in the collaborating agreement.

Other States Following Missouri's Lead

Advocates of APs, including the Missouri State Medical Association (MSMA), say that the role is crucial to address the unmet needs of patients, especially in rural areas. Short of more residency spots opening up, delivering care with physicians who have graduated from medical school but have not matched into residency is the next best option, advocates say.

According to Association of American Medical Colleges (AAMC) data, more than half of physicians (54.2%) practice in the state where they serve their residency. Jeff Howell, JD, general counsel and director of government relations for the MSMA, said Missouri doesn't have nearly enough residency slots, with only six schools.

"We're not in a position here in our state to fund more slots out of the general revenue, so we had to come up with some way to increase healthcare professionals in rural areas," he told Medscape Medical News.

In Missouri, the Health Resources and Services Administration projects that a shortage of 530 physicians in 2013 will more than double to 1220 by 2025. In the short term, COVID-19 is already stretching current state resources. As of early July, Missouri had almost 22,000 COVID-19 cases and more than 1000 deaths. Currently, Missouri's Division of Professional Registration lists 318 APs.

In its defense of APs, the MSMA points to the growing nationwide shortage of physicians and the slow growth of residency spots. In a just-released report, the AAMC predicts the United States will see a shortage of up to nearly 140,000 physicians by 2032. Using unmatched medical graduates to fill that gap may help. This year, 1897 applicants did not match at a residency and entered the Supplemental Offer and Acceptance Program, according to the National Resident Matching Program.

With an eye toward helping to address those shortages, other states, including Virginia and New Hampshire, have introduced legislation to allow APs. Legislation has also been signed in other states, including Utah (2017), Arkansas (2015), and Kansas (2016). Howell explained that the idea is to get individuals with practical training out into the community until they can try again to match into residency. Ideally, they would then return to practice in underserved areas as fully licensed physicians.

AP Role Is "Dangerous" and an "Insult to Patients," Say Critics

On the other side of the debate are various organizations within medicine who suggest that the AP role is dangerous. They advocate for more state-funded residency spots, rather than the creation of a stopgap like APs.

A bill introduced in the Missouri legislature last year, House Bill 710, was intended to expand the role of APs and provide a path for them to become fully licensed physicians, without residency. That bill did not pass and drew a rebuke from the AAFP.

In a letter dated May 6 last year, Michael L. Munger, MD, AAFP board chair, wrote, "Acceptable training in an accredited residency program following medical school graduation cannot be bypassed and allowing for the certification of individuals without this training is dangerous for patients and quality health care."

Howell said the MSMA agrees that becoming an AP should not be a step toward full licensure without residency. "That was never the intent," he said. He explained that it is up to the physician supervising the AP to understand what that individual can and can't do, and the state relies heavily on the supervisors for that.

In addition to expanding clinician reach, the AP role is intended to keep the graduates' skills sharp while they await a second shot at the match, Howell said. "If a medical student doesn't match and they're going to have to wait a year to try to match again in a residency program, we'd rather have them being an assistant physician than waiting tables or driving an Uber — keep their skills sharp while they're trying to get into a residency program."

Gary L. LeRoy, MD, president of the AAFP, told Medscape Medical News that laws permitting APs are an affront to the complexities of primary care and an insult to patients.

"How disrespectful is that to individuals who live in those areas, that they feel they're not deserving of a fully board-certified specialist in primary care to take care of their very complicated healthcare needs. There's nothing primary or simple about that," he said. "That 'This is better than nothing' makes no intellectual sense to me at all."

Residency programs add between 12,000 and 16,000 hours of direct practical training, he noted. "Medicine is not something you can cookbook your way through."

Medicine is not something you can cookbook your way through. Dr Gary LeRoy

LeRoy pointed to a study in JAMA that showed the Missouri Board licensed 99 APs during 2017; 25 of them (25.3%) had a collaborative agreement. Of the 99 APs, 92 were international medical school graduates and 76 were from schools in the Caribbean. Just seven APs were US medical school graduates.

The study found that APs were significantly less likely to have passed Steps 1 and 2 of the USMLE on the first attempt than all graduates of US medical schools from 2012 through 2016. In addition, the researchers wrote that "despite requirements that the collaborative practice be located in underserved areas, 20% were not in primary care health professional shortage areas."

Careful Consideration Recommended

The American Medical Association (AMA) acknowledges that the rationale behind reaching out to unmatched medical graduates is a reasonable one. In a statement provided to Medscape Medical News, the AMA explained that the organization "appreciates the intent of utilizing physicians who don't match into a residency as a way to bridge critical gaps in the health care workforce, particularly those due to limited residency positions."

However, the AMA stopped short of endorsing the role. Instead, they suggested other approaches, such as "increasing the number of state-funded residency positions — including those positions in medically underserved areas, or pursuing ways to make existing residency programs more accessible or attractive to medical school graduates."

The AAFP's LeRoy suggested that a better strategy is investing in residency training programs housed within teaching health centers that are affiliated with hospitals but located in communities. A significant number of physicians trained there end up practicing in those communities, he noted.

Even among those who currently work with APs, caution is recommended when considering their role. Wael Mourad, MD, chief health officer of the Health Partnership Clinic headquartered in Olathe, Kansas, volunteers on weekends at The Medina Clinic in Grandview, Missouri, where he collaborates with 6-10 APs. Although the system fills a need at The Medina Clinic, "beyond that I would be very careful," he told Medscape Medical News.

Mourad said he would not recommend APs for larger clinics that must meet financial, quality, and productivity goals. At The Medina Clinic, he said, strict protocols have been put into place, similar to protocols for nurse practitioners who work in retail store health clinics.

The restrictions are much heavier than they would be for a fully licensed physician, he said. APs cannot do unsupervised procedures and have clear and easy referral pathways. Mourad also reviews their work and communicates next steps.

All of the APs he oversees intend to pursue residency again, Mourad said, and he doesn't recommend the AP role be a career choice. He helps the APs with application and interview tips. "Without question, this is not the same as residency," Mourad emphasized.

Howell of the MSMA said the numbers show that something has to change both for patients who can't access care and for unmatched medical school graduates, and that APs are just one solution.

"You have teaching hospitals who want to protect their turf, medical schools who want to protect their turf, and organized medicine wants to protect their turf," Howell said. "Sometimes you've got to think differently to solve problems."

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, The Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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