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Table.  First Attempt Pass Rates for Assistant Physicians on the US Medical Licensing Examination vs All US and International Medical Graduates
First Attempt Pass Rates for Assistant Physicians on the US Medical Licensing Examination vs All US and International Medical Graduates
1.
Missouri Department of Health and Senior Services. Biennial report, 2016-2017. https://health.mo.gov/living/families/ruralhealth/pdf/biennial2017.pdf. Accessed February 16, 2018.
2.
Missouri Division of Professional Registration. Assistant physicians. https://pr.mo.gov/assistantphysicians.asp. Accessed February 16, 2018.
3.
US Department of Health and Human Services. HRSA data warehouse: find shortage areas by address. https://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.aspx. Accessed February 16, 2018.
4.
Norcini  JJ, Boulet  JR, Opalek  A, Dauphinee  WD.  The relationship between licensing examination performance and the outcomes of care by international medical school graduates.  Acad Med. 2014;89(8):1157-1162. doi:10.1097/ACM.0000000000000310PubMedGoogle ScholarCrossref
5.
Cuddy  MM, Young  A, Gelman  A,  et al.  Exploring the relationships between USMLE performance and disciplinary action in practice: a validity study of score inferences from a licensure examination.  Acad Med. 2017;92(12):1780-1785. doi:10.1097/ACM.0000000000001747PubMedGoogle ScholarCrossref
6.
Missouri Senate. Senate Bill No. 718 during 99th General Assembly. http://www.senate.mo.gov/18info/BTS_Web/Bill.aspx?SessionType=R&BillID=69472996. Accessed July 3, 2018.
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Research Letter
October 23/30, 2018

Characterization of Licensees During the First Year of Missouri's Assistant Physician Licensure Program

Author Affiliations
  • 1Department of Family Medicine, Mercy Hospital St Louis, St Louis, Missouri
  • 2Department of Family and Community Medicine, University of Missouri Health, Columbia
JAMA. 2018;320(16):1706-1707. doi:10.1001/jama.2018.11191

To address a shortage of primary care physicians in rural areas, the Missouri legislature created a new category of physician licensure called the assistant physician.1,2 The assistant physician licensee must be a citizen or legal resident of the United States, have graduated from a recognized medical school, have English-language proficiency, have passed Steps 1 and 2 of the US Medical Licensing Examination (USMLE) (or equivalent), and have not completed a residency.

Assistant physicians are limited to providing primary care services in underserved areas.2 Assistant physicians can only practice under collaborative practice agreements with fully licensed physicians and with a scope of practice and responsibilities consistent with advanced practice nurses and physician assistants.

The licensee is responsible for securing a collaborative practice agreement, which requires a 30-day period treating patients with the collaborating physician. Subsequently, assistant physicians can practice within 50 miles and with review of 10% of all charts. The collaborating physician must be immediately available for consultation electronically or in person.

There is no time limit on practice as an assistant physician or in obtaining a collaborative agreement once licensed. Arkansas, Kansas, and Utah have enacted similar but more restrictive legislation, and other states have considered doing the same. We describe the cohort of licensees from the first year of this novel license in Missouri.

Methods

We requested data on all assistant physician licensees from January 1, 2017, through December 31, 2017, from the Missouri Board of Healing Arts (the Board) via access from sunshine laws. We received deidentified, aggregate data on medical school, USMLE examination performance, and, when applicable, the locations of collaborative practices.

We cross-referenced practice locations against health professional shortage areas by zip code using the geocoding function on healthlandscape.org.3 We compared USMLE pass rates of assistant physicians for all 4 Step examinations with both the US and international medical graduate cohorts taking the USMLE during 2012 through 2016, which is the period when the assistant physicians would have taken the examinations.

We tested 2 sample proportions with a 2-sided P < .05 for significance and used R statistical software version 3.5 (R Foundation for Statistical Computing). The Mercy Hospital St Louis institutional review board determined this study was exempt.

Results

During 2017, the Board licensed 99 assistant physicians, 25 (25.3%) of whom had a collaborative agreement. Of the 99 licensed assistant physicians, 92 were international medical school graduates (92.9%), of whom 76 (82.6%) were from schools in the Caribbean region. Seven assistant physicians were US medical school graduates (7.1%); of these 7, six were from allopathic schools and none were from schools in Missouri.

All 25 licensees practicing under a collaborative agreement were international graduates. Of these 25, twenty (80.0%) were working in a federally designated health professional shortage area.

The USMLE performance for the assistant physician licensees was provided for 92 of the 99 assistant physicians (92.9%). Assistant physicians had significantly lower USMLE pass rates on all 4 Step examinations compared with the matching cohort of US medical graduates and for 3 Step examinations (except for Step 1) compared with international medical graduates (Table).

Discussion

Concerns about assistant physician licensure were raised based on the first year of experience in Missouri. Pass rates for all USMLE Step examinations were significantly lower than those of US medical school graduates; this was also true when comparing with international medical school graduates, with the exception of Step 1. Failure of the Step 2 examination has been associated with increased disciplinary action and worse clinical outcomes.4,5

Only 25% of the licensees had secured collaborative agreements during the first year and thus were the only ones able to practice. Despite requirements that the collaborative practice be located in underserved areas, 20% were not in primary care health professional shortage areas.

Limitations of this study include lack of data on applicants or licensees, practice settings, or employers. In addition, data were available only for 1 year.

Future research should study the quality and safety of the care that assistant physicians provide and their clinical roles and career path, as well as patient perceptions. The Missouri legislature recently broadened the licensure beginning in 2019; however, it is unclear what effect these changes will have.6

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: July 13, 2018.

Corresponding Author: Grant S. Hoekzema, MD, Department of Family Medicine, Mercy Hospital St Louis, 12680 Olive Blvd, Ste 300, St Louis, MO 63141 (grant.hoekzema@mercy.net).

Author Contributions: Dr Hoekzema had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hoekzema.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Both authors.

Statistical analysis: Hoekzema.

Administrative, technical, or material support: Both authors.

Supervision: Hoekzema.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We acknowledge the legal department of the Missouri Board of Healing Arts for their assistance in the collection and management of the data and Jimin Ding, PhD (Department of Mathematics and Statistics, Division of Biostatistics, School of Medicine, Washington University in St Louis), for her analysis and interpretation of the data. She was compensated for her services as contracted by the graduate medical education department at Mercy Hospital St Louis.

References
1.
Missouri Department of Health and Senior Services. Biennial report, 2016-2017. https://health.mo.gov/living/families/ruralhealth/pdf/biennial2017.pdf. Accessed February 16, 2018.
2.
Missouri Division of Professional Registration. Assistant physicians. https://pr.mo.gov/assistantphysicians.asp. Accessed February 16, 2018.
3.
US Department of Health and Human Services. HRSA data warehouse: find shortage areas by address. https://datawarehouse.hrsa.gov/tools/analyzers/geo/ShortageArea.aspx. Accessed February 16, 2018.
4.
Norcini  JJ, Boulet  JR, Opalek  A, Dauphinee  WD.  The relationship between licensing examination performance and the outcomes of care by international medical school graduates.  Acad Med. 2014;89(8):1157-1162. doi:10.1097/ACM.0000000000000310PubMedGoogle ScholarCrossref
5.
Cuddy  MM, Young  A, Gelman  A,  et al.  Exploring the relationships between USMLE performance and disciplinary action in practice: a validity study of score inferences from a licensure examination.  Acad Med. 2017;92(12):1780-1785. doi:10.1097/ACM.0000000000001747PubMedGoogle ScholarCrossref
6.
Missouri Senate. Senate Bill No. 718 during 99th General Assembly. http://www.senate.mo.gov/18info/BTS_Web/Bill.aspx?SessionType=R&BillID=69472996. Accessed July 3, 2018.
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