I was at a recent Grand Rounds presentation where the speaker was discussing the surge of physician retirements. She presented 2016 data which showed that the average retirement age of a physician had decreased to 57. She also presented results of a recent survey which claimed that 60% of physicians still in practice would retire if they could. This data is alarming.
There are many reasons given to explain why physicians are leaving the profession and most are related to decreases in pay, increases in overhead costs such as buying an electronic health record system, increases in administrative work-load to meet requirements of several governmental agencies and new laws, and the constant battles to meet documentation needs in order to be paid by third-party payers. Whatever the reasons, it is clear that we are heading into a perfect storm where there will just not be enough physicians to take care of all the people.
In November 2015, the Association of American Medical Colleges (AAMC) reported that there will be a projected shortfall of between 46,000 and 90,000 physicians by 2025. To meet this shortfall, new medical schools have opened and many of the existing schools have increased their class size. Increasing the number of medical students is a good first step but it is not enough. The number of residency slots for medical school graduates will also need to be increased.
Currently, the number of residency slots is capped based on Medicare and Medicaid funding. The number of residency slots should be increased to help with the “doctor shortage” since all medical school graduates still need residency training before they can get a license to practice. There should be enough residency slots available so that each medical school graduate will be able to do residency training.
There are other education programs which are designed to train people to help with patient care. Physicians Assistants, Nurse Practitioners, certified Nurse First Assistants, and Nurse Anesthetists are other professional health care providers but most of them need to practice under a supervising physician; in most places, they are not allowed to practice independently. Even with these non-physican health care providers, there is still a projected need for an increased number of physicians.
In an effort to train more independent providers, there is now a new degree being offered to physician assistants which is meant to provide sufficient knowledge and training to allow these graduates to function as independent primary care providers.
This new pathway will result in a degree called the “Doctor of Medical Science” (DMS); this training is designed for someone—not a physician—to practice clinical medicine with all of the privileges afforded to a medical doctor in the discipline of primary care. Lincoln Memorial University (LMU) recently announced the start of this new program. In a recent press release they stated, “Lincoln Memorial University is pleased to announce a new type of medical training with its launch of the brand new Doctor of Medical Science (DMS) degree. The only one of its kind, this program bridges the gaps between physician and physician assistant (PA) training for the development of a new type of doctoral trained provider to aid Appalacia and other health care shortage areas.”
The DMS will be for Physician Assistants who have at least three years experience in clinical practice. The curriculum will be a two year program and will consist of 50 credits. The first year will have online didactics delivered by clinical and PhD specialists on staff at LMU-DeBusk College of Osteopathic Medicine and other teaching hospitals. The second year will be more online didactics specific to a clinical specialty.
LMU has already received approval for this program from the Southern Association of Colleges and Schools Commission on Colleges.
Although the original Doctor of Medical Science degree was meant for those who wanted to do research in the clinical sciences, this degree from LMU is clearly meant to be a professional degree which would allow for direct patient care on the level of a primary care provider. In fact, the Tennessee legislature is considering a bill to allow for those with a DMS to practice independently (Tennessee Senate Bill 850).
A physician who specializes in a primary care discipline has to go through medical school for four years, pass the appropriate licensing exams and then successfully fulfill the requirements of a residency which will be another three, or more, years in an accredited training program. The training of a Doctor of Medical Science envisioned by LMU, in my opinion, is not “equivalent” to the training of a medical doctor accredited by the Board of his specialty.
It is known that PAs do not have the same training as medical students in the basic sciences and it is unlikely that the added didactics envisioned by LMU will fill these gaps. Online training has not been shown to be equivalent to the laboratories, face to face lectures, and clinics that medical students must attend and master.
I doubt that the required three years of clinical experience of those PAs who will matriculate into the LMU program will be equivalent to a three year residency that MD’s must go through. Graduate medical education requires graded advancement under the direction of medical doctors, doctors of osteopathy, and PhD’s who are tasked to assure that the trainee can practice “safely and independently” at the conclusion of the training. There is no assurance that the experience of the PAs going through the MSD program will allow for them to practice safely and independently.
If graduates of the MSD program are to be licensed by the State, they will probably have to pass a certification exam just like physicians do. Who will write this exam for the MSDs? Will the exam be written, oral, or both? Will the exam provide for the same test of knowledge, education, experience, training, and skills that the Board certification exam given to candidates for Board certification in a primary care specialty does?
Becoming a physician requires tremendous commitment. Years of schooling and post graduate training and then life-long continuing education and peer review are requirements of the profession. We are at the bedside or in the operating room on a daily basis. We take care of patients day and night, on weekends and holidays. Illness can occur at any time and we are there. We don’t “do” health care; we practice medicine and learn to do it better every day. We are a “learned” profession that brings value to our society. We should not be looking for ways to dilute this value.
Until we can affirm that the knowledge, education, training, experience, and skill sets acquired by the Doctor of Medical Science is equivalent to that of a medical doctor, we should not let these “advanced” PAs practice medicine independent of the supervision of a medical doctor. When a patient is really sick and his life is on the line, we depend on medical doctors to provide the medical care. Our society expects, and should receive, nothing less.
Dr. Weiman’s website is www.medicalmalpracticeandthelaw.com
Dr. Weiman is the author of two books; Medical Malpractice and Fundamental Issues in Health Care Law.