Tuesday, September 23, 2014

Never a shortage of bad ideas....

Everyone seems to know that there is a shortage of primary care physicians.  In the next 6 years, there is a predicted shortage of over 20,000 primary care docs.  There are lots of reasons for this- primary care doctors make less money, have more paperwork, have to see more patients...I could go on and on.  Of course, in the United States the prestige of a job is directly proportional to the paycheck received, so...you do the math.  The fact remains that only about 30% of medical school graduates go on to a primary care residency, and even fewer than that actually end up doing primary care, as many people who do an internal medicine residency eventually specialize.

Now, I obviously love doing primary care. I love seeing patients for years and having an ongoing relationship.  But I will admit that I seem to be part of a dying breed, and I would love to see that change.  However, true change will take a whole lot of adjustment in the US medical system.  Since that's hard to do, Missouri has decided to take another tack.

Missouri has passed a law that creates a new entity- an "assistant physician."  No, not a "physician assistant"- PA's have been around for decades.  A PA is a health care provider who has completed a masters degree and is certified by the Board of Medicine.  They work under the direct supervision of a physician.  An "assistant physician" is something else entirely.

First, a quick review of the US medical education system:
1. high school
2. 4 years of college
3. 4 years of medical school
4.  1 year of internship
5. 2-4 years of residency
6. 1-? years of fellowship

Primary care doctors stop after step 5.  For example, after high school I did 4 years of college at the University of Rochester, 4 years of med school at the University of Rochester,  1 year of internship at St. Vincent's, 2 years of residency at St. Vincent's, and then I stayed on for an extra year as the Chief Resident.  Specialists go on to step 6.  A cardiologist has a 3 year fellowship.  An endocrinologist has a 2 year fellowship.

Medical students apply to residency during their fourth year of med school.  It's a very competitive process, because there are only about 29,000 first-year residency spots available for about 40,000 applicants. Now, there are only about 16,000 graduates from US med schools a year, but there are also graduates of international medical school competing for spots, along with those who did not match in a previous year and are trying again.  In 2014, internal medicine filled 99.1% of its spots through the match, and family medicine filled 95%.  The most competitive spots, in specialties like orthopedics, radiation oncology, plastic surgery, etc pretty much fill completely.  The remaining spots go quickly in a process called SOAP.  1,075 positions were filled during SOAP, which leaves about 10,000 medical school graduates without a residency spot.  The vast majority of these are graduates of international schools, but about 500 US students were left without a residency.

Missouri has decided that these unmatched medical school graduates are perfect to fill the primary care void in rural areas.  They've decided that if a graduate passes Step 1 and Step 2 of the USMLE, they can work with an established doctor for 30 days and then basically go out on their own.  Forget about the fact that they don't have to pass Step 3 of the USMLE and obtain an actual license.  They have to be within 50 miles of a designated preceptor and have 10% of their charts reviewed by said preceptor.

This idea is so bad that it really, really blows my mind.  First off, these new graduates are one of two groups: either they are a bottom-of-the-barrel student who truly could not get into any program or they really wanted a competitive specialty and couldn't get it.  Both are poor candidates for primary care.  One group probably can't hack the difficulty of it, and the other has no interest in primary care at all.  Add to this the fact that US medical schools are not set up to graduate doctors who are ready for practice. That's what residency is for.  Med school teaches you the science and the basics.  The true training comes from residency.

Primary care is difficult.  I'm biased, of course, but I think it is one of the hardest specialties.  For many sub-specialists and surgical specialties, the diagnosis is already made by the time the patient reaches the door.  Look at the most competitive specialties that I listed above.  Not as much in the way of cognitive work in those specialties.  Of course, they have amazing other skills, but historically, cognitive work in medicine is incredibly undervalued.  After all, how do you put a price tag on a physician's thought process and diagnostic acumen?  It's difficult.  Anyway, what I'm saying is that in primary care a patient doesn't walk up to you and announce, "Hey, I'm experiencing an occipital lobe infarct!"  They come in and say, "I'm kind of dizzy and not myself."  And you are left to figure it out.

The last place in the world that a new grad with no residency training should be is in a rural area taking care of patients who have not had adequate primary care in ages.  Those patients are likely to be sick, sick, sick.  They need and deserve real health care, not some new grad who has no training and doesn't really want to be there in the first place.  Missouri seems to be operating under the delusion that some care is better than no care at all.  They forget that poor care can do actual harm to a patient, and someone who doesn't know what he's doing can be a true danger to others with a prescription pad in his hand.

I also want to know what sucker physicians are going to agree to be preceptors for these assistant physicians.  The liability implications of this make my head spin.  No way would I agree to be responsible for the actions of some wet-behind-the-ears new grad who is 50 miles away from me.  No way.

Look, there are always going to be difficulties in getting physicians to practice in rural, remote areas.  That's why the areas are rural and remote.  No one else wants to live there, either.  But this is the wrong way to go about solving this problem.


  1. Wow. That's terrifying.

    For the new grads that don't match their first year, what do they do in that year before they try again?

  2. Well, if they are an international medical grad, they'll most likely stay in their home country, where many of them are fully qualified doctors and can practice. US medical grads who don't match usually try to do research or something to improve their chances in the next Match. I'm sure a small percentage don't reapply and go on to do something else entirely.

  3. Every year I have to have earwax removed by a fully qualified ENT, with years of training as you describe. He bills a lot and I assume well paid. Why is he necessary? For earwax removal, it would seem a lower paid person would do as well perhaps a two year RN. Thoughts?

  4. One of my pet peeves in pulp literature is the character who is a super-high-powered specialist at a major university -- I've seen ENT's, cardiologists, research scientists -- who decides that they have been too selfish with their life, and they are going to practice Real Medicine and go become a rural family practitioner. Which they do, and they save lots of lives and have authentic experiences and realize what being a doctor is all about. I am a rural family practitioner, and my job is hard and requires a lot of knowledge and work. In addition, I have the same hassles with insurance companies and various regulatory agencies as any big-league specialist. I also have a lot less nursing and administrative support, so I do way more of the paperwork on my own. I love my job, but it is tough, and it makes me crazy that people often think it's something anyone with a little bit of medical training can do.

    1. Ah, the Doc Hollywood fantasy scenario, right?