Everyone agrees that the United States does not have enough primary-care physicians. There are huge swaths of the nation, especially rural and inner-city areas, that lack any primary-care physicians. The Department of Health and Human Services estimates that the shortage is at least 16,000 doctors.
Various strategies have been pushed to solve the problem, such as creating medical schools that emphasize educating primary-care providers, increasing the number of residencies for medical school graduates, and expanding the number and authority of non-physician providers of primary care to include nurse practitioners, physician assistants, psychologists and pharmacists.
But these are all long-term changes to a problem that is only going to become more dire. A growing aging population will need more primary medical care. The Affordable Care Act, with its laudable emphasis on primary care and prevention, is likely to increase the demand for primary-care doctors as insurance coverage is extended to more Americans. Some primary-care doctors, already overwhelmed by patient demand and paperwork, are becoming less accessible by creating smaller, boutique cash-only practices or are simply retiring.
So what to do? One exceedingly controversial idea has just become law in Missouri.
Missouri will allow medical school graduates to work as “assistant physicians” treating patients in underserved rural areas, even though they have not been trained in a residency program. In the U.S., at least one year of residency after medical school is usually required to practice medicine independently. Most medical school graduates spend at least three years in residency before starting to practice on their own. Under the new law, an assistant physician must have passed the first two sections of the national licensing exam for doctors but not the final one. If they want to become full-fledged physicians, they will still have to pass the last test and do a one-year residency.
These assistant physicians — not to be confused with physicians’ assistants, who are not medical school graduates — must work in person with a collaborating physician for 30 days and could prescribe most medications. They then may treat patients on their own if they practice within a 50-mile radius of that supervising doctor. They also must be approved by the state Board of Healing Arts, which issues medical licenses.
The Missouri State Medical Assn., which represents the state’s 6,500 physicians, helped draft the legislation. It argued the law was needed to address a severe shortage of healthcare professionals in the state. At least one-fifth of Missouri’s residents lack adequate access to a doctor.
There are many national medical groups who oppose the idea. Letting someone practice without a residency in the view of critics is to dangerously weaken professional competency.
So who will these new doctors be? Some will be graduates of medical schools who failed to get into a residency program — a growing problem as more medical schools open but more residencies do not. Even some highly competitive students do not get a residency in their chosen specialty. This year, among students who are more than one year out of medical school, and thus probably in their second try at getting a residency, only 48% succeeded.
Others will have failed or gotten low scores on Step 1 or Step 2 of the U.S. Medical Licensing Examination on the first try, even if they passed or did better on subsequent attempts. Some will have gone to non-U.S. medical schools.
It’s a bit of a leap to say that those who choose the assistant physician route in Missouri all failed at getting a residency. A few medical school grads will choose to be an assistant physician rather than enter residency. That being said, the most competitive U.S.- and non-U.S.-trained students are going to go the residency route.
So the bottom line is that assistant physicians are not likely to be the cream of the U.S. medical school crop. But that crop is not yielding many primary-care providers, given the level of debt new graduates face and the lower salaries primary care pays. And new residency slots are not going to open any time soon.
The real question is, can someone who successfully got through four years of medical school, including a lot of clinical time, who is supervised and certified by another doctor for a month and by the state board but who is probably not near the top of their class, deliver high-quality primary care to people who currently have nothing?
I think we don’t know. But I think it is very likely that most can. And Missouri, and other states like Michigan that are considering following its lead, are right to give assistant physicians a chance. Fairly good primary care is a lot better than no care at all.
Arthur L. Caplan is the director of medical ethics at NYU Langone Medical Center in New York.
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