Texas is the latest state to consider licensing assistant physicians / associate physicians to treat patients within the state. These are not to be confused with physician assistants. The former titles are medical school graduates who have not matched to a residency program. The Texas House Bill is 2556.
Background: A medical school graduate with a doctor of medicine (MD) degree or a doctor of osteopathy (DO) degree are not allowed to practice medicine until they have completed a residency program. Residency is similar to on-the-job training, where medical graduates are supervised while working in a hospital or clinical setting. Residency is brutal, with residents often working 80 hours a week and frequently being on call when not working. Indeed, a Harvard Business Review article asked if 80 hours a week is enough to train a doctor, since the Accreditation Council for Graduate Medical Education now limits residents’ workload to no more than 80 hours week. The following is what I wrote on Match Day, March 17, 2023:
Residency is advanced on-the-job training in a physician specialty that lasts from three to seven years depending on the area of practice. Here is the problem: there is a shortage of residencies in the United States. In many years up to 10,000 medical gradates get the bad news they failed to match to a residency. Some will try again next year, while many will never match and give up, embarking on a different career while saddled with student loans that rival a mortgage.
The title assistant physician is relatively new. Missouri was the first state to pass legislation in 2014, allowing medical school graduates who had not matched to a residency to work under a licensed physician. The first year after the law was implemented (2017) 99 assistant physicians obtained a license, of which only 25 were able to reach a collaborative agreement to practice under a licensed physician.
Numerous other states have passed or at least debated some type of assistant physician legislation, including Arizona, Arkansas, Georgia, Kansas, New Hampshire, Oklahoma, Utah, Virginia and Washington. The Canadian province of British Columbia is also weighing the idea. Some state programs are time limited, requiring assistant physicians to match to a residence or cease practicing medicine. The experience in Missouri shows that some assistant physicians have used the program to ultimately match to a residency. The Kansas program is only for University of Kansas graduates, none of which have used it.
State programs to license medial school graduates who have not been accepted to a residency program raises questions about the role of assistant physicians. There are currently too few residency slots for all who apply. Tens of thousands of medical school graduates – including a few U.S. medical school graduates, but mostly those trained abroad – will never match to a residency program. Should state assistant/associate physician programs be only about better preparing a few (marginal) medical school graduates to compete for residency slots? Or can assistant/associate physicians serve a need in underserved areas? Residency is competitive, with those thought the most qualified first in line for graduate medical training. Indeed, the experience in Missouri found that the few assistant physician positions that exist are also highly competitive with more applicants than physicians willing to collaborate. A further question is how to integrate assistant physicians with physician assistants and nurse practitioners, the latter two also hoping to expand their scope of practice. For the purposes of Medicare/Medicaid reimbursement, assistant/associate physicians have the same scope of practice as physician assistants and nurse practitioners.
The United States is facing a shortage of physicians, with many areas underserved by primary care providers. Up to 10,000 medical school graduates a year are denied a residency slot, many of which will never be able to practice medicine. Many of those graduates can serve a need and benefit from alternative supervision arrangements. States will have to experiment and work out the details of who qualifies and in what capacity.