Medical Groups Clash Over New Class of Rural Health Provider

The newly created position of assistant physician is meant to help rural residents find qualified medical care. (Photo courtesy Alex Proimos/Creative Commons)
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July 31, 2014 - 6:30am

About one-fifth of the U.S. population lacks adequate access to doctors. Rural counties in Nebraska and other Midwestern states often don’t have enough. A controversial new kind of health occupation was created in Missouri to address the shortage.


Richard Oswald is a 64-year-old farmer who grows corn and soybeans in Atchison County, Mo., in the northwest corner of the state.

When Oswald was younger, most small towns in the area had their own doctor, even ones who made house calls. But those days are long gone.

“The last time I tried to get an appointment with the local doctor, I was told it would be about three weeks out,” Oswald said. 

Atchison County is classified as a medically underserved area by the government, and the lack of doctors has forced Oswald to leave the state in search of one.

“That’s why I did what I did and went across the Missouri river to a town called Auburn, Neb.,” Oswald said.

It’s a familiar story to many residents of farm country. Hundreds of rural counties across the Midwest are considered medically underserved. But in cities all over the region, there are medical school graduates without a home.

Assistant physicians

One possible solution to the problem faced by places like Atchison County was proposed on the opposite side of the state by St. Louis plastic surgeon Edmond Cabbabe. He says he realized that many recent medical school graduates were having trouble finding residencies.

“They’re sitting there idle,” Cabbabe said. “They cannot earn any living. They cannot gain any experience, and there was no solution available to them.”

Of more than 17,000 medical school graduates in the United States this year, about 600 didn’t match for a residency. Cababbe’s plan would allow these graduates to work in medically underserved areas in Missouri as primary care doctors.

While most medical school graduates go on to spend at least three years getting additional training as resident physicians, these recent graduates would be licensed as so-called assistant physicians. Ten percent of their work would be reviewed by a fully-licensed doctor.

“So they are not going to be doing the practice on their own,” Cabbabe said. “They’re going to be supervised a little bit. They’re going to have to be trained a little bit before they can get into the system.”

The plan won the support of the Missouri State Medical Association, and a bill to create assistant physician licensing was sponsored by state Rep. Keith Frederick, a Republican who is an orthopedic surgeon.

Frederick explains that like many other states, Missouri already has a program that offers tuition reimbursement to doctors who agree to work in underserved areas, but it has had limited success.

“There’s still a great need, particularly in our rural areas, where we just haven’t been as successful as we would like,” Frederick said.

This plan, however, won the support of the Missouri State Medical Association.

If members of the public are likely to be baffled by the name similarity between "assistant physician" and "physician assistant," a recognized occupation, they're not alone. 

The first such plan in the country, it has pitted health providers against one another amid concerns about the plan’s effect on the health of patients and the dilution of professional standards.

National attention

Since its approval by the Missouri state Legislature, the plan has attracted the attention of national groups. They are concerned not just with its statewide implications but its possible spread to other states.

In mid-June, the American Medical Association House of Delegates passed a resolution rejecting the assistant physician concept.

“We should not replace a hardship with a danger,” one delegate said. 

The American Academy of Physician Assistants also weighed in and encouraged Missouri Gov. Jay Nixon to veto the bill.

The American Academy of Physician Assistants’ Ann Davis says the group's main concern is the potential lowering of medical standards because of people’s rural location.

“Groups that have some of the biggest problems with access to care now are being offered a professional that otherwise would not be licensed in Missouri or anyplace else,” she said.

Dr. Cabbabe dismisses those concerns. He notes that, with four years of medical school, which includes two years of clinical rotation, assistant physicians would have more than enough training for the work.

Crucial need

Back in Atchison County, concerns over quality and job title don't matter as much to Richard Oswald as the glaring lack of health providers.

Remembering a handful of health scares when his children were growing up, he supports the assistant physician plan, if only as a way to fill a crucial need.

“I think anything to bring better health care and more availability here is undoubtedly going to save lives,” he says.

While that remains to be seen, rural residents all over the country will be watching Missouri’s new doctors.

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