Creation of "associate physician" in VA

[unicorn416]

https://legiscan.com/VA/bill/HB900/2016

Thoughts? Seems to be a way to avoid expanding GME funding. (And more confusion over physician assistants, "physician associates", etc.) Any other states that have this?

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[Mad Jack]

https://legiscan.com/VA/bill/HB900/2016

Thoughts? Seems to be a way to avoid expanding GME funding. (And more confusion over physician assistants, "physician associates", etc.) Any other states that have this?

This happened in Missouri about a year and a half ago: http://www.medscape.com/viewarticle/828255

I don't have much of a problem with it- I'd rather have a physician without a residency working under me than an NP any day.

 

[oncology2020]

Yes I would take this over expanding NPs role any day

 

[Mad Jack]

I will say, by the way, that the big risk we're running is brand dilution, so it's not a perfect solution. NPs might look at this and say, "if their big advantage is training, and they aren't even required to do that training to practice, what makes them so much better than us, exactly?"

They'd be wrong, of course, but that's an argument that they'll be making.

 

[ForHumors]

Don't forget that the doctors who will end up doing this generally will be those who didn't match- not exactly putting our best foot forward as a profession when physician associates are inevitably compared to NPs and PAs.

 

[Psai]

Thought we had a doctor shortage or something

 

[Law2Doc]

Really bad idea-- when they screw up it will be John Smith, MD who screws up and be a bad reflection on doctors. It dilutes the brand -- people will not get that this person with MD on their white coat us different than the guy with a full residency. Also you don't really learn how to do anything beyond foundation in med school-- that's just prep and the real learning to be a doctor happens in residency. So It's like serving someone raw dough and calling it associate bread.

The problem is one of politician lack of understanding; people emerge from law school ready to work as a lawyer so politicians logically assume people emerge from medical school ready to work as a doctor, but in fact it isn't set up that way-- you aren't even half baked at that point -- you emerge ready to START studying and training to be a doctor. You have no valuable skills at that point, just foundation. So you WILL make lots of mistakes, and it WILL reflect badly on every other guy with MD on his white coat. It's much better for physicians reputation and "brand" if we don't allow uncooked products (bearing our degree) out of the kitchen.

 

[ridethecliche]

This is dumb.

 

[Stagg737]

This happened in Missouri about a year and a half ago: http://www.medscape.com/viewarticle/828255

I don't have much of a problem with it- I'd rather have a physician without a residency working under me than an NP any day.

We just had the AACOFP head for Missouri speak to us and since the bill was passed, no med students have applied to any of the "AP" positions other than IMG's and FMG's who want to pad their resumes to get into residencies here. It's a nice idea, but its utility has been pretty minimal so far.

 

[Law2Doc]

We just had the AACOFP head for Missouri speak to us and since the bill was passed, no med students have applied to any of the "AP" positions other than IMG's and FMG's who want to pad their resumes to get into residencies here. It's a nice idea, but its utility has been pretty minimal so far.

Might be an issue of geographic desirability though -- a state that's driving distance to more popular coastal cities might get more traction. And of course it will only be popular with FMG -- that's who these programs are for --right now the number of US grads who can't SOAP into something is tiny and most have access to research years, delaying graduation or other better strategies to land a residency.

 

[Brorthopedic]

What's up with the recent need to saturate the healthcare field with different types of medical certificates? This is just getting ridiculous. It's like every person interested in medicine wants to be called a doctor, but either doesn't want to spend the years becoming one or just can't get into medical school.

 

[Law2Doc]

What's up with the recent need to saturate the healthcare field with different types of medical certificates? This is just getting ridiculous. It's like every person interested in medicine wants to be called a doctor, but either doesn't want to spend the years becoming one or just can't get into medical school.

Simple, health care costs are too high, so the government is more than happy to get behind anyone who can provide them with a way to provide "some" healthcare at a fraction of the cost. If voters accept any level of skill and education as long as they wear a white coat and have "doctor" somewhere in their title, a politician is more than happy to offer up this cheaper option. Part of the reason doctors are so expensive is schooling and training aren't cheap, and take years. An NP with a three month "residency" or some "associate" doctor with no residency are much much cheaper options, and if the public "thinks" they are getting healthcare from these, it solves the healthcare cost issue.

 

[Mad Jack]

What's up with the recent need to saturate the healthcare field with different types of medical certificates? This is just getting ridiculous. It's like every person interested in medicine wants to be called a doctor, but either doesn't want to spend the years becoming one or just can't get into medical school.

These would be actual physicians, just ones without residencies.

 

[Brahnold]

Does this mean that FMGs can completely bypass residency requirements? In other words, is the United States now completely open to the world's physicians, so long as those physicians are willing to stay in Virginia and Missouri (for now)?

I mean, yeah, that would be a total disaster for our future.

 

[chipwhitley]

Does this mean that FMGs can completely bypass residency requirements? In other words, is the United States now completely open to the world's physicians, so long as those physicians are willing to stay in Virginia and Missouri (for now)?

I mean, yeah, that would be a total disaster for our future.

If the FMG has completed residency in their own country and been practicing as an attending... it probably won't be bad at all. Many residency programs hire these FMGs because they know they don't have to teach them and can just use them for cheap labor anyway.

 

[Brahnold]

If the FMG has completed residency in their own country and been practicing as an attending... it probably won't be bad at all. Many residency programs hire these FMGs because they know they don't have to teach them and can just use them for cheap labor anyway.

How is that not bad? That's exactly why it is bad. The only thing keeping FMG physicians from doing to the physician job market what H1B workers have done to the IT job market is the need for FMGs to complete residency, and the very finite number of those residencies. If we remove the residency requirement to practice medicine here, all of a sudden there is absolutely no limit to the number of physicians from overseas who can come to work here.

There are a lot, lot more physicians outside the United States than there are physicians inside the United States. They almost invariably all make a lot less money in their home country than American physicians do in America. If a significant number of those foreign physicians are allowed to come and work here, the new prevailing wages for American physicians will equilibrate at some unhappy median between current American physician salaries and current average worldwide physician salaries. American med school debt, however, will not join salaries in going down to a lower level. If you do not see this as a bad thing, then you are a much more selfless person than I am.

But anyway, I'm still not 100% certain that these new laws in MO and VA mean that foreign doctors can practice medicine without residency. Can someone definitively say yay or nay on this? And if it does mean that, anyone familiar with the situation in MO and what effects their law has had on the physician job market there and the FMG participation therein?

 

[Psai]

If the FMG has completed residency in their own country and been practicing as an attending... it probably won't be bad at all. Many residency programs hire these FMGs because they know they don't have to teach them and can just use them for cheap labor anyway.

There's a big difference between having a resident as cheap labor vs a fully trained physician as cheap labor

 

[AnatomyGrey12]

How is that not bad? That's exactly why it is bad. The only thing keeping FMG physicians from doing to the physician job market what H1B workers have done to the IT job market is the need for FMGs to complete residency, and the very finite number of those residencies. If we remove the residency requirement to practice medicine here, all of a sudden there is absolutely no limit to the number of physicians from overseas who can come to work here.

There are a lot, lot more physicians outside the United States than there are physicians inside the United States. They almost invariably all make a lot less money in their home country than American physicians do in America. If a significant number of those foreign physicians are allowed to come and work here, the new prevailing wages for American physicians will equilibrate at some unhappy median between current American physician salaries and current average worldwide physician salaries. American med school debt, however, will not join salaries in going down to a lower level. If you do not see this as a bad thing, then you are a much more selfless person than I am.

But anyway, I'm still not 100% certain that these new laws in MO and VA mean that foreign doctors can practice medicine without residency. Can someone definitively say yay or nay on this? And if it does mean that, anyone familiar with the situation in MO and what effects their law has had on the physician job market there and the FMG participation therein?

Just a pre-med here but the other day my neighbor told me that it doesn't mean they can practice without residency. It means that they are able to be hired more in like a PA type role. That would make some sense to me, assuming their pay would be similar to that of a PA.

 

[chipwhitley]

How is that not bad? That's exactly why it is bad. The only thing keeping FMG physicians from doing to the physician job market what H1B workers have done to the IT job market is the need for FMGs to complete residency, and the very finite number of those residencies. If we remove the residency requirement to practice medicine here, all of a sudden there is absolutely no limit to the number of physicians from overseas who can come to work here.

There are a lot, lot more physicians outside the United States than there are physicians inside the United States. They almost invariably all make a lot less money in their home country than American physicians do in America. If a significant number of those foreign physicians are allowed to come and work here, the new prevailing wages for American physicians will equilibrate at some unhappy median between current American physician salaries and current average worldwide physician salaries. American med school debt, however, will not join salaries in going down to a lower level. If you do not see this as a bad thing, then you are a much more selfless person than I am.

But anyway, I'm still not 100% certain that these new laws in MO and VA mean that foreign doctors can practice medicine without residency. Can someone definitively say yay or nay on this? And if it does mean that, anyone familiar with the situation in MO and what effects their law has had on the physician job market there and the FMG participation therein?

You're right that the salaries would go down. However, if foreign physicians could flood the market here in the US, that would almost certainly drive med school tuition down as well, because no one would or could afford to pay what we pay now. Would suck for the people already out of school and paying loans back though.

 

[W19]

I will say, by the way, that the big risk we're running is brand dilution, so it's not a perfect solution. NPs might look at this and say, "if their big advantage is training, and they aren't even required to do that training to practice, what makes them so much better than us, exactly?"

They'd be wrong, of course, but that's an argument that they'll be making.

But they will be ALWAYS under supervision of a licensed doc... NP are running wild right now.

 

[IlDestriero]

This happened in Missouri about a year and a half ago: http://www.medscape.com/viewarticle/828255

I don't have much of a problem with it- I'd rather have a physician without a residency working under me than an NP any day.

I couldn't disagree more. Physicians that can't get a residency can't get one for a reason, or several reasons. I don't want anything to do with that. I'll stick to my NPs and CRNAs.

 

[W19]

It would have been better to have these people do at least one year unpaid internship since many IMG would not mind... If these laws can squash NP, I am all for them...

 

[Mansamusa]

But they will be ALWAYS under supervision of a licensed doc... NP are running wild right now.

What's to stop an associate MD from being used as a regular MD by the owner of a practice (seeing their own patients, etc while the supervising MD goes off to do their own thing)? Patients won't know the difference between the two MDs

 

[W19]

I couldn't disagree more. Physicians that can't get a residency can't get one for a reason, or several reasons. I don't want anything to do with that. I'll stick to my NPs and CRNAs.

These laws are aiming to attract IMG/FMG since most US students get into residency....

 

[W19]

What's to stop an associate MD from being used as a regular MD by the owner of a practice (seeing their own patients, etc while the supervising MD goes off to do their own thing)? Patients won't know the difference between the two MDs

Most patients don't know the difference between NP/MD/DO/PA anyway... Anyone with a white coat is a doc... Have you worked in healthcare settings? I have seen PA correcting patients all the time and these same patients still call them doc...

 

[Mansamusa]

Have there been any studies looking into the feasibility of creating a shortened IM and general surgery residency track for students commited to doing a fellowship? If you shorten each program by a year, can't we shift that money to open FM residencies, preferentially in rural areas?

 

[W19]

The best way to solve this issue is to return to the GP era... Do exactly what PR does... Have unpaid internship for FMG/IMG, then give them a GP license and mandate insurance companies to reimburse them... There is no PA/NP in PR... You are either a doc or a nurse... nothing in between.

 

[W19]

Have there been any studies looking into the feasibility of creating a shortened IM and general surgery residency track for students commited to doing a fellowship? If you shorten each program by a year, can't we shift that money to open FM residencies, preferentially in rural areas?

That might work.... The mainland can copy to a system that has worked in Puerto Rico.... There is no PA/NP and everyone has access to PRIMARY CARE because GP essentially replace NP/PA...

 

[Stagg737]

What's to stop an associate MD from being used as a regular MD by the owner of a practice (seeing their own patients, etc while the supervising MD goes off to do their own thing)? Patients won't know the difference between the two MDs

Liability. It's essentially using the MD as a PA temporarily with the expectation that they will eventually go into residency and become fully boarded. However, while the supervising physician is the one liable for any mistakes the assistant physician would make, so allowing an "AP" to take care of patients without supervision would be begging for malpractice suits and would technically be illegal.

Have there been any studies looking into the feasibility of creating a shortened IM and general surgery residency track for students committed to doing a fellowship? If you shorten each program by a year, can't we shift that money to open FM residencies, preferentially in rural areas?

The problem isn't that there aren't enough rural FM residency positions, it's that graduates don't want to take them. FM alone had 156 positions go unfilled last year according to the Charting the Outcomes data. Don't buy into the 'physician shortage' talk that bureaucrats like to talk about. There's not a physician shortage, just an imbalance in the distribution.

That might work.... The mainland can copy to a system that has worked in Puerto Rico.... There is no PA/NP and everyone has access to PRIMARY CARE because GP essentially replace NP/PA...

So a student would go through 4 years of med school, rack up the same amount of debt as their classmates, then do a 1 year residency to become a GP so they can be paid half or less of what they would earn if they just did a 3-4 year residency? Does that really sound like it would work to you?

 

[W19]

So a student would go through 4 years of med school, rack up the same amount of debt as their classmates, then do a 1 year residency to become a GP so they can be paid half or less of what they would earn if they just did a 3-4 year residency? Does that really sound like it would work to you?

You know almost all US students get into some sort of residency if that person is not a *****... This program is for FMG from foreign countries that have no student loan. A lot of them will be glad to do 1-year unpaid internship to be able to work as GP... As i said, I have a friend who was trained in PR and he said the system works fine there as far as access to primary care. They have a lot of FMG from latin america that are practicing as GP there...

Of course nothing is going to be perfect, but I don't like NP using a ploy that they want to fill in the void in primary care and asking for same scope of practice as doc when 70% of them go into specialties...

 

[Mansamusa]

The problem isn't that there aren't enough rural FM residency positions, it's that graduates don't want to take them. FM alone had 156 positions go unfilled last year according to the Charting the Outcomes data. Don't buy into the 'physician shortage' talk that bureaucrats like to talk about. There's not a physician shortage, just an imbalance in the distribution.

I do still think it would be better to try to coerce unmatched physicians into areas we need them than to let them practice as PA equivalents in areas they aren't needed. Give anyone who doesn't match the option to do FM or not have a career (or let them continue to try to match into something else). We should be attempting something productive rather than sitting back and letting non-physicians run the field.

(Also, are there reasons those spots go unfilled other than their location? Why would an FMG with debt be so stubborn as to refuse a chance to have a career just because it would involve 3 yrs in a less desirable location?)

 

[Law2Doc]

These would be actual physicians, just ones without residencies.

They will have MDs but not medical licenses, so no not physicians.

 

[Law2Doc]

But they will be ALWAYS under supervision of a licensed doc...

Actually that's not what some of these new laws state -- there's actually only a very short window where they report regularly to a supervisor.

 

[Law2Doc]

Have there been any studies looking into the feasibility of creating a shortened IM and general surgery residency track for students commited to doing a fellowship? If you shorten each program by a year, can't we shift that money to open FM residencies, preferentially in rural areas?

The problem isn't needing more residencies, per se, it's that people don't go or stay in these rural areas post- graduation. So your proposal doesn't really fix the problem imho.

 

[Psai]

You're right that the salaries would go down. However, if foreign physicians could flood the market here in the US, that would almost certainly drive med school tuition down as well, because no one would or could afford to pay what we pay now. Would suck for the people already out of school and paying loans back though.

Right because law degrees are much cheaper now with lower salaries

 

[Mansamusa]

The problem isn't needing more residencies, per se, it's that people don't go or stay in these rural areas post- graduation. So your proposal doesn't really fix the problem imho.

I know- I think the best way to increase rural physicians is to have strong affirmative action programs for rural students. But having residencies up and running will ensure that there is a supply of physicians there until then. It's like in South Africa where the 3rd year after graduating all students have to do a community service clinical year in small town South Africa (obviously this system has problems as well). Students don't stay in the small towns when they are done, but it means these underserved areas always have physicians available.

 

[ACSurgeon]

The best way to solve this issue is to return to the GP era... Do exactly what PR does... Have unpaid internship for FMG/IMG, then give them a GP license and mandate insurance companies to reimburse them... There is no PA/NP in PR... You are either a doc or a nurse... nothing in between.

I've seen some scary FMGs who complete residency in the U.S. and still have no buiseness being a doctor. Obviously the examples I'm referring to trained at programs that no US grad would chose to train at. Giving FMGs an even easier route to practicing medicine seems like a disasterous idea. Yea, everyone can see a "doctor", but most won't actually receive primary care. Primary care is difficult to do well.

I'll take a PA who if nothing else trained in a system where ethics and accountability are emphasized any day over a shortcut route to making someone a GP.

 

[mvenus929]

A lot of them will be glad to do 1-year unpaid internship to be able to work as GP... As i said, I have a friend who was trained in PR and he said the system works fine there as far as access to primary care. They have a lot of FMG from latin america that are practicing as GP there...

As someone training in a field that is primary care--a year is not good enough to provide good primary care. After my intern year, I was so much more aware of how much I didn't know. I am only now, halfway through my residency, feeling relatively comfortable with at least trying to figure out what is going on with a patient, but I still see something at least once a week, either in clinic or inpatient, that I hadn't seen before.

 

[chipwhitley]

They will have MDs but not medical licenses, so no not physicians.

You need an active medical license to actually practice medicine. You don't need a medical license to refer to yourself as a physician. Obtaining an MD degree is enough for that. Note that residents generally are referred to as "physicians" or more specifically "resident physicians".

 

[W19]

@lazymed I guess we disagree... I'd rather have these FMG who pass step1,2,3 with 1-year internship practicing medicine instead of someone who complete a 2-year online NP degree with 500 hrs preceptorship...

 

[W19]

As someone training in a field that is primary care--a year is not good enough to provide good primary care. After my intern year, I was so much more aware of how much I didn't know. I am only now, halfway through my residency, feeling relatively comfortable with at least trying to figure out what is going on with a patient, but I still see something at least once a week, either in clinic or inpatient, that I hadn't seen before.

That will also happen when you become an attending; might not be once a week though, but it will happen... There are a lot GP that are practicing medicine in the US.

 

[unicorn416]

Actually that's not what some of these new laws state -- there's actually only a very short window where they report regularly to a supervisor.

For any attendings (and also fellows and residents) - would you be willing to supervise an associate physician knowing they're fresh out of med school? Or would liability be an issue?

 

[ridethecliche]

Simple, health care costs are too high, so the government is more than happy to get behind anyone who can provide them with a way to provide "some" healthcare at a fraction of the cost. If voters accept any level of skill and education as long as they wear a white coat and have "doctor" somewhere in their title, a politician is more than happy to offer up this cheaper option. Part of the reason doctors are so expensive is schooling and training aren't cheap, and take years. An NP with a three month "residency" or some "associate" doctor with no residency are much much cheaper options, and if the public "thinks" they are getting healthcare from these, it solves the healthcare cost issue.

Right. That's about the moment when physicians groups, the AMA, etc should start putting out ads saying "Think you're seeing a real doctor? Think again..."

 

[Stagg737]

You know almost all US students get into some sort of residency if that person is not a *****... This program is for FMG from foreign countries that have no student loan. A lot of them will be glad to do 1-year unpaid internship to be able to work as GP... As i said, I have a friend who was trained in PR and he said the system works fine there as far as access to primary care. They have a lot of FMG from latin america that are practicing as GP there...

Except they're not...in MO the programs were created to try and help students who didn't match gain hands on experience so they could match as well as address some of the shortages in rural areas.

(Also, are there reasons those spots go unfilled other than their location? Why would an FMG with debt be so stubborn as to refuse a chance to have a career just because it would involve 3 yrs in a less desirable location?)

Yes, but location is the root of those causes. Other than just living in an undesirable area, it's likely that the training isn't going to be as good as in other locations. Partially because funding will be lower, partially because you'll see less patients and get less exposure, and other issues such as potentially having to travel and not having access to resources you'd have at other locations. I'm sure there are plenty of other reasons, but an attending or resident would be a better resource for answering that question than I would.

 

[Brahnold]

I see this as horrible news. To put it simply, the FMG camel now has its nose under the tent. Today it's "associate" physicians in rural MO and VA, tomorrow it will be unrestricted rights for any foreign physician to come practice independently in the United States, driving down wages and destroying our career prospects. I see no reason to expect that the insidious creep we've witnessed with midlevels won't be replicated with FMGs.

 

[Law2Doc]

For any attendings (and also fellows and residents) - would you be willing to supervise an associate physician knowing they're fresh out of med school? Or would liability be an issue?

I sure wouldn't, but I can tell you why some would. We all know a few people out there who aren't good doctors and see their degree as a ticket to make money. The pain killer doc just sentenced to murder is an example. Liability is always an issue, but if you can "supervise" enough people on paper, without doing any actual day to day work, with each giving you a percentage of their take for doing nothing, you can get very rich, very fast and hopefully get out of the picture before the $&@& hits the fan. It's Tony Soprano medicine. The problem is this isn't going to be true supervision or good care, it's going to be about running for luck. You will basically be doing a less structured or financially supported version of the CVS minute clinic model -- putting people out there with dubious training and hoping they know to send anything serious to a "real" doctor and if not, that they only goof up in some minor way. The only difference is when the people on the front line are wearing MD on their white coat, everyone will think they are a real doctor.

The underserved deserve better, and the physician brand can't afford this kind of taint.

 

[VA Hopeful Dr]

That will also happen when you become an attending; might not be once a week though, but it will happen... There are a lot GP that are practicing medicine in the US.

The first part is true, but the frequency is substantially lower. Plus, in residency you learn about lots of things you won't always see in your training but when you do see them you will recognize and be able to treat.

The 2nd part I don't really buy, although I guess that depends on your definition of "a lot" and "practicing medicine". If you're happy doing disability evals all day or working in a weight loss clinic, then go nuts.

 

[deleted503015]

Have there been any studies looking into the feasibility of creating a shortened IM and general surgery residency track for students commited to doing a fellowship? If you shorten each program by a year, can't we shift that money to open FM residencies, preferentially in rural areas?

Is that not what the "fast track" residencies are in IM and Peds?

 

[NickNaylor]

As someone training in a field that is primary care--a year is not good enough to provide good primary care. After my intern year, I was so much more aware of how much I didn't know. I am only now, halfway through my residency, feeling relatively comfortable with at least trying to figure out what is going on with a patient, but I still see something at least once a week, either in clinic or inpatient, that I hadn't seen before.

It's interesting that you say that - most of the senior residents that I've worked with on medicine rotations feel the third year is a complete waste of time and think they are more than adequately trained after PGY-2. Would you agree or do you think you still have much to gain from your final year?

 

[Law2Doc]

It's interesting that you say that - most of the senior residents that I've worked with on medicine rotations feel the third year is a complete waste of time and think they are more than adequately trained after PGY-2. Would you agree or do you think you still have much to gain from your final year?

Meh. Everyone I know late in a residency starts to realize there is so much to know and if not for financial issues and the need to get out and earn already, wouldn't mind a bit more training. You learn more later in residency because you start to appreciate what's looming ahead and your low comfort level. Show me someone who feels like they know everything they need by the end of PGY2, and I'll show you a very bad doctor.

At some point you have to cut things off, push someone it of the nest to start the next level of their career (which is a different kind of learning and pressure) but those dates are pretty much minimums as is, and really very few people who care about competence would argue there's nothing to be gained in later residency.

This was part of the controversy with duty hours -- you need to log enough time working, doing cases, seeing patients, doing procedures to get good at it. The learning curve is steep and the more you learn the more you realize you don't know it could use more training at.