Practice without residency

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tony729

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If you have graduated with an M.D. from one of the big 5 medical schools and are unable to match/get residency, does that mean you cant practice? Even if you plan on starting a private practice?
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tony729 said:
If you have graduated with an M.D. from one of the big 5 medical schools and are unable to match/get residency, does that mean you cant practice? Even if you plan on starting a private practice?
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Big "5"? Now there's "5" that are "big"?

Listen, we gotta stop this nonsense.

There are only 3 schools who have a long track record of getting graduates into residency. They are: St. George's, Ross, and AUC. And, as far as graduates go, AUC even brings up the rear (with 226 grads in 2014 into U.S. residency on their Match lists, as opposed to Ross and SGU which both had more than 450).

Saba is under the Dutch government. And, they provide a good education. I'll grant you that. But, there is nothing "big" about them.

And there is no other "big" Caribbean school that meets the criteria of (1) solid and long-standing track record of getting grads into choice residencies, and (2) licensure in all 50 states [which is not the only criteria people should consider, although it's important].

Thank you.

-Skip
 
tony729 said:
If you have graduated with an M.D. from one of the big 5 medical schools and are unable to match/get residency, does that mean you cant practice? Even if you plan on starting a private practice?
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Your best case scenario is to get a 1-2 year unaccredited AGCME internship in Puerto Rico, which will allow you to get a general practitioner license in most US states... The problem is most IMG know that route now; therefore, it's becoming harder to get.
 
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There maybe one State that would accept an 1 year post graduate internship/residency but the vast majority of Boards of Medicine of each state require at least 2 consecutive years in same specialty if IMG. Even from ANY Caribbean school. In Florida the requirement is 2 consecutive years with a signed contract for a third year residency.
 
DocBlin said:
There maybe one State that would accept an 1 year post graduate internship/residency but the vast majority of Boards of Medicine of each state require at least 2 consecutive years in same specialty if IMG. Even from ANY Caribbean school. In Florida the requirement is 2 consecutive years with a signed contract for a third year residency.
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Not sure that is correct for FL... I know a couple of physicians with 2 year internship who are fully licensed in FL as general practitioners...
 
W19; I speak from personal experience. My son (who NOW licensed in FL, NY, NJ) during his FL license application process over a year ago, was requested to produce proof of satisfactorily finishing 2 years in his FM residency and a signed contract for the third year. This was accomplished by his PD writing two separate letters to the Florida Board stating each request. Maybe this is something new. But either way there are NO 1 year IMGs obtaining a license to practice easily...
 
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W19 said:
Your best case scenario is to get a 1-2 year unaccredited AGCME internship in Puerto Rico, which will allow you to get a general practitioner license in most US states... The problem is most IMG know that route now; therefore, it's becoming harder to get.
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I wouldn't rely on or recommend this. You might be able to get a license, but actually practicing in a group is going to be a different story. Most practices require you to (eventually) be board certified in some specialty. You also might/probably will need this to get and keep hospital admitting privileges. You can't usually do this for a long period of time without board certification.

So, unless you want to open a medical marijuana clinic and write prescriptions for people with a bogus condition, just plan on doing and completing a residency, and then becoming board certified.

-Skip
 
Skip Intro said:
I wouldn't rely on or recommend this. You might be able to get a license, but actually practicing in a group is going to be a different story. Most practices require you to (eventually) be board certified in some specialty. You also might/probably will need this to get and keep hospital admitting privileges. You can't usually do this for a long period of time without board certification.

So, unless you want to open a medical marijuana clinic and write prescriptions for people with a bogus condition, just plan on doing and completing a residency, and then becoming board certified.

-Skip
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These people usually end up working for the prison system and county health departments.
 
Not to mention, most if not all insurance companies won't pay you unless you are board certified in your specialty (by finishing residency and passing the board exam). Having a state license is not enough.
 
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Del Caribe said:
Not to mention, most if not all insurance companies won't pay you unless you are board certified in your specialty (by finishing residency and passing the board exam). Having a state license is not enough.
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I worked with a couple of these physicians at a county department of health and I thought they were good... Of course, they were not making what a typical physician makes, but 100k/year working monday-friday with all holidays off and no calls is not that bad...
 
tony729 said:
If you have graduated with an M.D. from one of the big 5 medical schools and are unable to match/get residency, does that mean you cant practice? Even if you plan on starting a private practice?
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If you plan on opening a (legal) private practice you will still need a license to practice independently in your desired state, for which you must have at least a 1-year internship. So, yeah, if you plan on opening a private practice you will need to match somewhere.

Beyond the legal requirements, it is highly unlikely that you will feel comfortable practicing medicine on real patients right out of medical school. Those skills are learned in residency.
 
W19 said:
I worked with a couple of these physicians at a county department of health and I thought they were good... Of course, they were not making what a typical physician makes, but 100k/year working monday-friday with all holidays off and no calls is not that bad...
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Good luck paying off those loans and making a reasonable living.

-Skip
 
Unless you have board certification, many of your scripts will be require a prior authorization. Also, you won't get reimbursed from insurance companies.

You could set up a cash only GP, urgent care type clinic though.
 
...provided you had a couple million dollars to invest, yes you could set up a cash only urgent care facility.
 
Could I do this before applying to residency? in a gap year per say?
 
I thought that's only for allopathic schools?
Correct me if i'm wrong
 
Actually here is the latest info:

http://pr.mo.gov/boards/healingarts/DRAFT Assistant Physician rules.pdf

Assistant Physician Licensure
In 2014, a new classification of licensure for physicians was created with the passage of Senate Bills 716 and 754. This legislation established licensure for assistant physicians. An assistant physician, as defined by Missouri law, is an individual who is a resident and citizen of the United States or is a legal resident alien who has not completed an approved postgraduate residency, has successfully completed Step 2 of the United States Medical Licensing Examination or the equivalent and is proficient in the English language.

The Missouri State Board of Registration for the Healing Arts has posted the DRAFT Assistant Physician rules online. The Board solicited comments on these draft rules and will be reviewing those comments at their September 27, 2015 conference call.

The rule promulgation process is lengthy as represented on the Rulemaking Flow Sheet. We have highlighted the flow sheet to represent where we are in the process. At this time, we are unable to estimate the effective date of the rule, however, we will continue to update the website as information becomes available. For full text of the bills, please click the links below:

http://www.senate.mo.gov/14info/BTS_Web/Bill.aspx?SessionType=R&BillID=28296866
http://www.senate.mo.gov/14info/BTS_Web/Bill.aspx?SessionType=R&BillID=28627659
 
FutureDO2016 said:
Actually here is the latest info:

http://pr.mo.gov/boards/healingarts/DRAFT Assistant Physician rules.pdf

Assistant Physician Licensure
In 2014, a new classification of licensure for physicians was created with the passage of Senate Bills 716 and 754. This legislation established licensure for assistant physicians. An assistant physician, as defined by Missouri law, is an individual who is a resident and citizen of the United States or is a legal resident alien who has not completed an approved postgraduate residency, has successfully completed Step 2 of the United States Medical Licensing Examination or the equivalent and is proficient in the English language.

The Missouri State Board of Registration for the Healing Arts has posted the DRAFT Assistant Physician rules online. The Board solicited comments on these draft rules and will be reviewing those comments at their September 27, 2015 conference call.

The rule promulgation process is lengthy as represented on the Rulemaking Flow Sheet. We have highlighted the flow sheet to represent where we are in the process. At this time, we are unable to estimate the effective date of the rule, however, we will continue to update the website as information becomes available. For full text of the bills, please click the links below:

http://www.senate.mo.gov/14info/BTS_Web/Bill.aspx?SessionType=R&BillID=28296866
http://www.senate.mo.gov/14info/BTS_Web/Bill.aspx?SessionType=R&BillID=28627659
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Even as an IMG who could potentially benefit from this, I don't like the implications of this bill. Given that the primary purpose of residency is the guided experience of "doctoring" from those already in practice , this seems like the next inevitable step in the "watering down" of a physician's experiential education. We're going to keep deluding ourselves' that fewer and fewer hours of guided clinical experience are necessary for safe practice. Eventually, we're going to whittle those hours down to the point that we're putting patients at risk. While we should strive for efficiency in medical education, we should err on the side of patient safety, and I'm not yet convinced that this rule is doing so, especially while there is so much uncertainty regarding the current resident work-hour restrictions.
 
bedevilled ben said:
Even as an IMG who could potentially benefit from this, I don't like the implications of this bill. Given that the primary purpose of residency is the guided experience of "doctoring" from those already in practice , this seems like the next inevitable step in the "watering down" of a physician's experiential education. We're going to keep deluding ourselves' that fewer and fewer hours of guided clinical experience are necessary for safe practice. Eventually, we're going to whittle those hours down to the point that we're putting patients at risk. While we should strive for efficiency in medical education, we should err on the side of patient safety, and I'm not yet convinced that this rule is doing so, especially while there is so much uncertainty regarding the current resident work-hour restrictions.
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Don't you think these physicians as a whole would be more qualified than NP?
 
W19 said:
Don't you think these physicians as a whole would be more qualified than NP?
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Not necessarily. I don't know the specifics of the typical NP curriculum but I doubt the practical clinical knowledge between a fresh NP, a fresh PA, and a fresh MD is really all that vast. I say that having spent hundreds of hours on training floors with NP, PA, and med students over the last 2 years. What differentiates physicians from NP's and PA's is the integration of deeper basic science knowledge with the residency experience, which forces rapid assimilation, integration, application, and exposure to clinical medicine. The average residency is something like 15,000 to 20,000 work-hours of exposure to medicine crammed into a couple of years. That amounts to 7 to 10 years of clinical practice for your average NP or PA.

To me, losing that residency experience seems like it devalues much of the purpose of becoming a physician. If those assistant physicians go on to pursue a residency after a year of practice under a licensed physician, it's not that big of a deal. Historically, however, failing to match in the year immediately after graduation has a significant negative impact on your future chances of matching. While some residency programs might look favorably on that extra year of practice, in general the only physicians going to this AP program will be those with poor scores that were unable to match in the first place. It seems likely to me that this program will become a sinkhole for physicians that don't have other options for securing residencies.

I have no direct experience, admittedly, as I'm still a half-year away from (hopefully) starting residency, but every physician I've spoken with has told me that your residency is where you really "learn" medicine, and everything else is just preparation. Losing that seems to devalue the profession as a whole.
 
@bedevilled ben If these physicians won't be more qualified than a new minted NP; I guess med school curriculum has some serious issues then... NP spend only a year doing 'basic science' while these MD/DO spend 2 years... NP needs only 700 hours of clinical preceptorship while MD/DO spend a lot more than 700 hours of clinical rotations... Therefore, if NP can practice independently in 20 states with online classes and 700 hours of clinical preceptorship, I think it makes sense to give these MD/DO a chance to practice in a limited capacity after spending at least a year working under the supervision of a licensed MD/DO...

'While some residency programs might look favorably on that extra year of practice, in general the only physicians going to this AP program will be those with poor scores that were unable to match in the first place. It seems likely to me that this program will become a sinkhole for physicians that don't have other options for securing residencies.'

I had the experience of working as a RN before going on to med school. I have a few friends who I went to school with that are NP and I believe and 'low ranked' student from medical school who has problem to match is 'better' than most NP in term medical knowledge.... In fact, a watered down step3 was given to NP students from one of the best NP programs in the country (Columbia University), only 50% passed it... So for me it makes sense to let some of these MD/DO practice where there is shortage of 'providers'.

I also worked with a couple of these MD with no residency in county clinic in FL, which was designated 'area of critical needs' and the more complicated cases were given to them instead of some NP who were working at the clinic...

I understand it's not a perfect situation, but if we are truly concerned about shortage in rural areas, I think this a good way to start tackling that because we all know most NP won't go to these areas even if they use that as way to gain practice parity with physician...
 
W19 said:
@bedevilled ben If these physicians won't be more qualified than a new minted NP; I guess med school curriculum has some serious issues then...
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I'm not contesting that medical school provides better "medical knowledge" in terms of basic science concepts. You'll note that I specifically said practical clinical knowledge in my previous post.

I'm not familiar with the study that you're referencing regarding NP's taking Step 3 exams so I can't comment on it.

I don't think the answer to a physician shortage in rural areas is to crank out half-trained doctors. That does a disservice to the profession and to patients alike.
 
bedevilled ben said:
I'm not contesting that medical school provides better "medical knowledge" in terms of basic science concepts. You'll note that I specifically said practical clinical knowledge in my previous post.

I'm not familiar with the study that you're referencing regarding NP's taking Step 3 exams so I can't comment on it.

I don't think the answer to a physician shortage in rural areas is to crank out half-trained doctors. That does a disservice to the profession and to patients alike.
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What do you mean by 'practical' knowledge? I put the # hours needed to be an NP... Practical knowledge can be done by spending tim working with patients... I said in my post that NP need 700 hours to be able to practice independently... As a 4th year med student, don't you already spend more than 1000 hours 'rotating'? Besides, these AP (assistant physicians) will spend at least a year working under a MD/DO...

What disservice it does to the profession and patients when people are already 'practicing medicine' with half of the training or even less than that of physicians?
 
bedevilled ben said:
I'm not contesting that medical school provides better "medical knowledge" in terms of basic science concepts. You'll note that I specifically said practical clinical knowledge in my previous post.

I'm not familiar with the study that you're referencing regarding NP's taking Step 3 exams so I can't comment on it.

I don't think the answer to a physician shortage in rural areas is to crank out half-trained doctors. That does a disservice to the profession and to patients alike.
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In all fairness, physicians should be able to practice as midlevels without a residency if we've got 4,000-6,000 clinical hours during MS3 and 4 yet NPs can come out of a BS to NP program with only 700 hours of clinical and can practice independently.
 
Mad Jack said:
In all fairness, physicians should be able to practice as midlevels without a residency if we've got 4,000-6,000 clinical hours during MS3 and 4 yet NPs can come out of a BS to NP program with only 700 hours of clinical and can practice independently.
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That was my point...These people won't have the full status of physicians; they will be AP... So why AMA align themselves with ANA/AAPA and want to deny these people the ability to practice medicine when they are more qualified than NP?
 
W19 said:
That was my point...These people won't have the full status of physicians; they will be AP... So why AMA align themselves with ANA/AAPA and want to deny these people the ability to practice medicine when they are more qualified than NP?
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Probably because they don't want to "dilute the brand." If we bring ourselves down to the level of midlevels by allowing improperly trained physicians to work as midlevels, then it will lead to market confusion, people thinking that they are being seen by competent physicians that are not, etc etc.
 
Mad Jack said:
Probably because they don't want to "dilute the brand." If we bring ourselves down to the level of midlevels by allowing improperly trained physicians to work as midlevels, then it will lead to market confusion, people thinking that they are being seen by competent physicians that are not, etc etc.
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I guess that's probably the motive. However, I would contend that many who are being treated by NP/PA don't even realize that...besides these people will be AP--another type of 'provider'. They are not physicians. I guess the best way to solve that confusion is let these people sit for the PA board and allow them to practice as PA. Some states used to do that for FMG until AAPA lobbied against it...
 
W19 said:
I guess that's probably the motive. However, I would contend that many who are being treated by NP/PA don't even realize that...besides these people will be AP--another type of 'provider'. They are not physicians. I guess the best way to solve that confusion is let these people sit for the PA board and allow them to practice as PA. Some states used to do that for FMG until AAPA lobbied against it...
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Yeah, there's a lot of competing interests at play. I think the best way to go forward would be to replace midlevels almost entirely with all these excess unmatched FMGs and IMGs, but that's just me 😉 Of course, the reason the AMA/LCME etc doesn't want that is because then there'd be a ****load of extra physicians without residency in the country, who would no doubt apply for residency year after year rather than be content with their midlevel position, thus saturating the match beyond all viability.
 
Mad Jack said:
Yeah, there's a lot of competing interests at play. I think the best way to go forward would be to replace midlevels almost entirely with all these excess unmatched FMGs and IMGs, but that's just me 😉 Of course, the reason the AMA/LCME etc doesn't want that is because then there'd be a ****load of extra physicians without residency in the country, who would no doubt apply for residency year after year rather than be content with their midlevel position, thus saturating the match beyond all viability.
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The Missouri AP program is clearly aim to attract FMG/IMG since 98%+ of US students find a spot in the match or at least scramble... A lot of FMG/IMG would like to have program like that all over the country as back up...
 
W19 said:
The Missouri AP program is clearly aim to attract FMG/IMG since 98%+ of US students find a spot in the match or at least scramble... A lot of FMG/IMG would like to have program like that all over the country as back up...
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Yeah, and that's why they don't want it implemented elsewhere. Because those FMGs in Missouri, you know what they're doing? Applying to the match every year, claiming they've got clinical experience etc etc that will make them great residents. Multiply that across the country and you could have a massive problem, where we've got 80,000 midlevel physicians that are applying to the match each year, crowding out new US grads.
 
It will be interesting to see how this plays out. One question is how Assistant Physicians will bill insurances. The law states that AP's are considered PA's as far as Medicare is concerned. Not clear that they can do this, unless Medicare agrees. I can't just open the Pastafarian School of Medicine and say "All graduates of PSoM are hereby considered graduates of Harvard Medical School". Well, I can say that, but it doesn't make it true. If physicians were actually upset about this, you could probably at least tie it up in court for years.

My other concern is around malpractice. The law clearly states that the supervising physician is completely responsible for the AP. Will insurers cover AP malpractice? I'm sure the same question was asked for PA's and NP's, so I expect it is yes. But again I think they have a seat at the table, and need to agree.

I think this is a terrible idea. Perhaps it might be reasonable for an IMG who has practiced elsewhere doing primary care. But a fresh grad, providing primary care after only a month or so of direct supervision, will be a mess. Is is better than "no care", if no one else is willing to work? That's an open question.
 
Mad Jack said:
Yeah, and that's why they don't want it implemented elsewhere. Because those FMGs in Missouri, you know what they're doing? Applying to the match every year, claiming they've got clinical experience etc etc that will make them great residents. Multiply that across the country and you could have a massive problem, where we've got 80,000 midlevel physicians that are applying to the match each year, crowding out new US grads.
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Good point! But I am not sure that people making 120k+ working 40-50 hrs/wk would want to become a resident working for minimum wage, but I could be wrong... Interestingly, I have a friend (a carib grad) who was able to use some loopholes in the system to get a GP license... and I asked him the other day if he applies to the match this year and he thought I was joking... The guy is making 180k/year working in rural America... Why would he want to become a resident?
 
W19 said:
Good point! But I am not sure that people making 120k+ working 40-50 hrs/wk would want to become a resident working for minimum wage, but I could be wrong... Interestingly, I have a friend (a carib grad) who was able to use some loopholes in the system to get a GP license... and I asked him the other day if he applies to the match this year and he thought I was joking... The guy is making 180k/year working in rural America... Why would he want to become a resident?
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100k versus 180k is a big difference.
 
W19 said:
@aProgDirector I think they have to work for 1 year under a physician--not 1 month!
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From the law:

7. The collaborating physician shall determine and document the completion of at least a one-month period of time during which the assistant physician shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present. Such limitation shall not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100 133 as of April 30, 2008.
 
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W19 said:
Good point! But I am not sure that people making 120k+ working 40-50 hrs/wk would want to become a resident working for minimum wage, but I could be wrong... Interestingly, I have a friend (a carib grad) who was able to use some loopholes in the system to get a GP license... and I asked him the other day if he applies to the match this year and he thought I was joking... The guy is making 180k/year working in rural America... Why would he want to become a resident?
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I don't blame your friend one bit for not desiring a return to residency from the position they are in now. Good for him / her finding a pathway to become a GP!
 
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DocBlin said:
W19; I speak from personal experience. My son (who NOW licensed in FL, NY, NJ) during his FL license application process over a year ago, was requested to produce proof of satisfactorily finishing 2 years in his FM residency and a signed contract for the third year. This was accomplished by his PD writing two separate letters to the Florida Board stating each request. Maybe this is something new. But either way there are NO 1 year IMGs obtaining a license to practice easily...
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It's actually 2-year for IMG in FL... and 1-year for AMG.

http://flboardofmedicine.gov/licensing/medical-doctor-unrestricted/
 
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