Efforts to expand use of physician assistants face opposition
Created to address clinical staffing shortages in underserved areas, the Physician Assistant role is also designed to employ medical graduates who have not enrolled in a residency program.
However, providers and medical organizations have not widely adopted physician assistants as an effective solution. In the eight years since the position was created, only five states have authorized it, including Missouri, which created the position.
Physician assistants are graduates of medical school and perform many of the same responsibilities as other clinical staff, such as physician assistants of the same name. But they don’t have to complete a residency or endure long hours of clinical rotations before diagnosing and treating patients. Physician assistants are required to work in medically underserved areas, cannot practice independently, and are not reimbursed by Medicare as well as some commercial insurers.
Organizations such as the American Medical Association and the American Academy of Family Physicians opposed the designation, saying they were concerned about safety issues and that the quality of care provided by physician assistants, particularly in medical care deserts, might not be on par with doctors. who have completed their residency.
The discussion about the future of physician assistants has recently resurfaced in the medical community as advocates create model legislation for other states and seek to change existing rules.
In June, WADA’s House of Delegates rejected a proposal from its Missouri Delegation to Support Physician Assistant Programs and said it opposes any effort to have graduate physicians become independent, licensed physicians. He also opposes expanding the scope of their practice to other departments or by geography without formal residency training.
SOLVE A PROBLEM
In 2014, Missouri created an accredited position called assistant physicians, sometimes referred to as associate physicians.
By tapping into a population of graduates who did not fit into residency programs and having them work as licensed physicians in areas short of medical professionals across Missouri, the state was able to “take an available resource and l ‘apply to a real need,’ said Keith Frederick, a former member of the Missouri House of Representatives.
For years, the limited availability of residency or postgraduate training slots and the complexities of the application process, coupled with more graduates, have made the path to licensure more difficult, said Frederick, who helped pass the state bill to license physician assistants. The physician assistant role becomes an opportunity for individuals to provide services and earn a living to repay medical school loans, he said.
“If you have that amount of debt and you can’t keep training, it’s kind of like having a mortgage but no house and no job,” Frederick said.
Physician assistants work under a practice agreement in conjunction with a licensed supervising physician and generally perform the same duties as nurse practitioners or physician assistants, prescribing medications, performing patient examinations, and assisting with surgery.
To become a physician assistant in Missouri, a person must be a U.S. citizen or legal resident who is fluent in English, graduated from a recognized medical school, passed steps one and two of the U.S. Medical Licensing Examination and has not matched or completed a residency program.
Once licensed, physician assistants must undergo one month of clinical training before practicing in an area with a shortage of health care providers, under the supervision of a supervising physician.
Utah, Arkansas, Arizona, and Kansas followed Missouri’s lead and established similar licensing programs.
After graduating from medical school, Trevor Cook got a job as a medical scribe and immersed himself in the residency application process, which he described as a “capitalist hellscape”. Cook said he spent thousands of dollars sending in transcripts and applied to hundreds of programs, but was not accepted.
Cook came across job postings for physician assistants in Missouri. After 120 hours of training with a collaborating physician, Cook earned his physician assistant license in 2018 and began working in emergency care.
“I see it as becoming a professional in the business, and the only way to really learn is to do it,” Cook said.
For the past four years, Cook said he had the same responsibilities as a doctor, performing tests, treating and diagnosing conditions, updating emergency medical records and referring patients to specialists. Cook said he sometimes worked with his supervising physician, who had to review at least 10% of his notes and be within 50 miles while Cook practiced medicine.
A major sticking point for healthcare leaders is the concern that physician assistants do not have the same level of training and qualifications as those who have completed a residency program.
“We are very supportive of our trainees following the traditionally accepted path to full licensure,” said Alison Whelan, director of studies at the Association of American Medical Colleges. “It dictates by specialty the type of learning and clinical experience the resident must have to be an effective independent practitioner.”
Just because a student has a medical degree does not mean they are prepared to provide safe and effective independent care, especially without receiving training, supervision and feedback specific to their area of practice, said Whelan. Residency programs can span more than four years and include 16,000 hours of direct clinical care experience.
The AMA has opposed the physician assistant concept since Missouri introduced it, fearing it would weaken the organization’s case for increasing funding for graduate medical education and creating more residency slots. .
This year, more than 42,000 students applied for about 39,000 residency positions and nearly 37,000 positions were filled, leaving several thousand applicants unmatched, according to data from the National Resident Matching Program.
The main reason residency spots aren’t filled is that students tend to try to fit into specialties such as family or emergency medicine that aren’t the right fit for them, Dr. Sterling Ransone said, president of the American Academy of Family Physicians. When residency slots fill up in majors, students untrained in other fields are in limbo, unable to apply to a field with open slots, Ransone said.
Ransone said he advocates for proper allocation of funds to schools, hospitals and residency programs that allow graduate students more exposure to underserved communities and a variety of specialties.
Recently, the AMA requested support for two federal bills. One, the Resident Physician Shortage Reduction Act, would extend Medicare funding to an additional 14,000 residency positions. The other, the Physician Shortage Graduate Medical Education Cap Flex Act, would give teaching hospitals an additional five years to set their funding cap if they form residency training programs in primary care or other specialties facing shortages. .
In July, the Department of Health and Human Services announced $155 million in grants to 72 teaching health centers that operate primary care medical and dental residency programs in underserved and rural communities.
Among all the healthcare abbreviations, titles and job descriptions, some fear that the physician assistant role is adding confusion for patients, especially with the existence of physician assistants. Physician assistants take a different route to becoming licensed, although they have many of the same responsibilities as physician assistants.
To become a physician assistant, medical students must earn a master’s degree through an accredited physician assistant program—which includes more than 2,000 hours of clinical practice—and pass the national assistant certification exam. to the doctor. Physician assistants must complete 100 hours of continuing medical education credits every two years to maintain their certification.
In 2020, Missouri issued 169 physician assistant licenses, up from 114 in 2021 and 17 in 2022, according to the Missouri Board of Registration for the Healing Arts. The state issued 200 physician assistant licenses in 2020, 282 in 2021 and 139 this year.
CONCERNS FOR UNDERSERVED AREAS
Physician assistants are required to work in areas that lack medical providers, which has raised concerns about health equity.
“There are concerns that they are creating a kind of second-class doctor for people who are already socially and economically disadvantaged,” said Patricia Pittman, director of the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University. “Essentially the wealthy see doctors and the less wealthy see those who couldn’t become doctors, which is a bit problematic from an equity perspective.”
Treating people in communities who lack access to care is often more complex due to the myriad social issues underlying their condition and requires more clinical experience than less, said Doug Olsen, president of the Board of Directors of the Association of Clinicians for the Underserved.
Rather than only allowing physician assistants to work in health care deserts, their position should be expanded as part of a statewide workforce in Missouri, Olsen said.
“If they’re good enough for the underserved, they should be good enough for the served,” he said. “If they’re good enough for the uninsured, they should be good enough for the insured.”
Olsen said there is no consistent evidence and patient-reported outcome measures that prove physician assistants provide high-quality care and should practice with an expanded scope, despite eight years of using the job.
Better solutions exist for staffing and access to care in medically deprived areas, such as obtaining long-term funding and creating partnerships between stakeholders and teaching health centers to offer more training opportunities and bringing in more clinicians, said Amanda Pears Kelly, executive director of the Clinicians Association for the Underserved.
“What we’re trying to do with healthcare transformation is create situations where we can actually uplift these communities so they’re no longer underserved,” Pears Kelly said.