Over a fifth of Missourians, especially those who live in rural areas, don't have adequate access to doctors, according to the Department of Health and Human Services.
Now the state Legislature has approved a plan to address the problem by creating a new kind of health occupation.
The first such plan in the country, it has pitted health providers against one another amid concerns about its effect on the health of patients and the dilution of professional standards.
Richard Oswald is a 64-year-old farmer who grows corn and soybeans in Atchison County, Mo., in the northwest corner of the state. At the end of a recent workday, he explains that, once again, his corn is coming up early this year.
“The old axiom is ‘knee high by the Fourth of July’ and that’s not true anymore,” Oswald says. “It’s head high by the Fourth of July these days.”
The growing season is not the only thing that has changed in Atchison County.
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,” he says.
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, Nebraska,” Oswald says.
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 says. “They cannot earn any living. They cannot gain any experience, and there was no solution available to them.”
Of more than 17 thousand 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 med 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 says. “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 Rolla Republican who is an orthopedic surgeon.
Frederick explains that Missouri already has a program that offers tuition reimbursement to doctors who agree to work in underserved areas.
“But there’s still a great need, particularly in our rural areas, where we just haven’t been as successful as we would like,” he says.
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.
“I’m just sort of confused,” says Paul Winter, president of the Missouri Academy of Physician Assistants.
About 900 physician assistants work in Missouri, and their group opposes the assistant physician plan.
It's not just the similar names, says Winter.
Last year Representative Frederick championed a plan that loosened restrictions on physician assistants to make it easier for them to practice in rural areas. That plan was passed into law and hopes were high that physician assistants would help fill the rural healthcare gap.
Winter believes a lot can be done with physician assistants under the new laws, and he was surprised that Frederick has proposed what seems to be the creation of a competing position.
“If we’re not fully utilizing PAs to their maximum ability in the state of Missouri, then I have to question — Why are we inventing a new profession?” he asks.
Despite the concerns of Winter’s group, the bill to allow assistant physicians was approved by the state Legislature on the final day of the session.
Since then, the plan has attracted the attention of national groups, 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, encouraging Missouri Governor Jay Nixon to veto the bill.
The academy’s 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 says.
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.
“For the role they are playing, they are much more qualified than an actual physician assistant or a nurse practitioner,” he says.
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.
Gov. Nixon has until July 14 to sign or veto the bill creating assistant physicians. Without action from him, it automatically becomes law.