A controversial new law in Missouri will allow medical school graduates who haven't yet passed their final credentialing exam to treat patients in underserved primary care settings. The law has encountered strong opposition from organized medicine.

Signed last week by Governor Jay Nixon, the law creates the new position of "assistant physician." These doctors would be supervised on site by a collaborative physician for 30 days. After that, they could treat patients without direct supervision in settings 50 miles away and will be able to prescribe Schedule III, IV, and V drugs.

The assistant physician can provide only primary care services and only in medically underserved rural or urban areas of the state or in any pilot project areas, the law states. An assistant physician is defined as any medical school graduate who has passed the prescribed medical examinations and who has not entered into postgraduate residency training prescribed by rule of the State Board of Registration for the Healing Arts.

The Missouri State Medical Association (MSMA) helped draft the legislation and said it is necessary because a physician shortage especially in underserved areas has limited access to care. Missouri last year was listed by the federal government as 1 of the 10 most medically underserved states in the nation.

"This is a decent solution," Jeffrey Howell, the MSMA's general counsel and government relations director, told Medscape Medical News. "Patients in these areas aren't getting any care now. Our attitude is that some care is better than no care. We hope this law will be a trailblazer for other states."

Howell said the assistant physicians have graduated medical school and passed the first 2 sections of the licensing exam. They must be approved by the Missouri Board of Healing Arts and must find a physician willing to collaborate with them. It will likely take the board a year to promulgate regulations for assistant physicians.

"Flawed Assumption"

Opposition from organized medicine was swift. Thomas Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education, said the possibility of harm is striking.

"These are physicians with only rudimentary experience," he told Medscape Medical News. "In Missouri, without direct supervision, they'd be able to manage patients with complex diabetes, congestive heart failure, arrhythmias, and malignancies. This doesn't make sense.

"Physicians in the United States are not trained to enter practice upon graduation from medical school," Dr. Nasca said. "They don't have the skill sets required for independent practice. It's a flawed assumption to suggest that novices are prepared to provide clinical care on their own in a rural area where any medical condition could present itself. This isn't an emotional response. It's a data driven response to a very bad idea."

Despite recognizing the need to serve challenged areas, he doesn't see this as the appropriate remedy. "I don't underestimate the challenges we face in delivering care to rural populations and the urban poor. But to provide inadequate care is no solution. There is a dramatic difference between a medical school graduate and a doctor trained in a residency program. Why go back to the 1940s when doctors just out of medical school provided care without supervision? The idea that primary care is somehow simple is ludicrous," Dr. Nasca said.

The American Medical Association's (AMA) House of Delegates last month resolved to "oppose special licensing pathways for physicians who are not currently enrolled in an Accredited Council for Graduate Medical Education or American Osteopathic Association training program, and have not completed at least 1 year of accredited post-graduate U.S. medical education."

"It is essential that the next generation of physicians is sufficiently trained," AMA Board chair-elect Stephen Permut, MD, said in a statement. "The AMA favors increasing the number of residency slots to train physicians in needed specialties and regions to improve access to health care. …Increased funding for graduate medical education will help us accomplish that."

The American Academy of Physician Assistants (AAPA), which represents 95,000 physician assistants in the US, also has strong objections. "Patients in rural and underserved areas, who are already at a geographic and often economic disadvantage, deserve the same quality of care as those who live in prosperous areas of the state. …It is unfortunate that the Missouri General Assembly — and the physician organizations that supported the provision — did not take into account the negative ramifications that may occur when proposing that physicians not yet fully trained provide medical care to the state's most vulnerable patients," AAPA president John McGinnity, MS, PA-C, and CEO Jennifer L. Dorn wrote in a letter to Gov. Nixon.

Instead, Missouri should increase state funding for medical residency slots, provide incentives for the existing workforce to practice in rural and underserved areas, and decrease barriers for other healthcare professionals to practice at the top of their education and training, the AAPA said.

The MSMA's Howell strongly disagrees with critics of the law. "The opposition puzzles me," he said."The physician shortage in Missouri is so bad that communities with 2,000 to 5,000 people barely have access to a doctor one day a week. And they share that doctor with 2 or 3 communities. The new rules are no different than those for older doctors who didn't have to go through a residency program. They just graduated from medical school and began treating patients.

"It says a lot about the medical establishment that they think people who graduate medical school are incapable of caring for patients while they're being supervised in a collaborative relationship," Howell said. "We have 6 medical schools in Missouri. Even if 5 or 6 doctors didn't get a residency match, that's 25-30 providers who can help."