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CHICAGO -- Should unmatched medical school graduates be recruited to help out in rural and underserved areas? Members of the American Medical Association's (AMA) House of Delegates appeared divided on this question.

"Our patients who live in underserved areas and rural areas do not deserve a lower standard of care than those who live in more urbanized areas," Sterling Ransone, Jr., MD, president of the American Academy of Family Physicians, said Tuesday during the delegates' annual meeting here. "Also, the complexity of primary care services and chronic care management cannot be adequately performed by those without full education and full training."

Questions About Assistant Physician Programs

Ransone was speaking during a discussion regarding a resolution from delegates in Missouri, where the state has passed a law allowing physicians who didn't match to a residency program to obtain a license called Assistant Physician allowing them to practice as primary care doctors in underserved areas in collaboration with a licensed physician.

The Missouri delegates' resolution called for the AMA to work with the Centers for Medicare & Medicaid Services (CMS) to obtain Medicare reimbursement for the services of these physicians, as is already done by some private insurers and state Medicaid programs. The resolution also called for the AMA to allow these physicians to become a subgroup of the AMA, and to oppose any effort to let them become licensed physicians without completing residency training.

However, an AMA reference committee had recommended that the resolution not be adopted, and Albert Hsu, MD, an ob/gyn delegate from Columbia, Missouri, proposed a substitute resolution calling for the association to study the Assistant Physician program in Missouri, as well as similar programs in other states, and report back with recommendations on whether these programs should limit the maximum number of years that an individual could be in such a program. It was Hsu's resolution on which Ransone was commenting.

Hsu said he suggested the substitute resolution because, although he knew of two physicians who matched to residencies after spending time in the Assistant Physician program, he was concerned that "this could develop a new class of mid-level providers ... I think this question could benefit from further study."

Alisha Reiss, MD, speaking for the Young Physicians Section, opposed Hsu's resolution. "Let's be honest, folks; this is about the integrity of our profession and the protection of our patients," she said. "We [do not] need to study what creating a subclass of undertrained physicians will do for our profession and our patients. We need to make this go away."

But Woody Jenkins, MD, an alternate delegate from Oklahoma who was speaking for himself, liked the idea of a study on how to support unmatched graduates. "We need to find a way to help these individuals and mutually help our workforce shortage," he said. "Missouri has been working on this for awhile, and I can tell you in rural Oklahoma we need help in our underserved areas ... Unmatched physicians have more training than other non-physician practitioners. Doing a study can help identify any unintended consequences" of such programs.

Matt Gold, MD, who was speaking for the Organized Medical Staff Section, also liked the idea of a study -- but not the one Hsu suggested. "This is the wrong study," Gold said. "To tell you the truth, a proper study would be to find out whether MD graduates short of residency are, in fact, superior to mid-level practitioners. I think that would be a very interesting piece of information." In the end, Hsu's substitute resolution was defeated and the delegates agreed with the reference committee recommendation not to pass the original resolution either.

Debt Relief for Cash-Strapped Physicians

Delegates passed a resolution asking the AMA to advocate at the federal level for debt relief or loan forgiveness for independent physician practices facing COVID-related financial jeopardy. The resolution, which was offered by the Texas delegation, noted that during the early days of the COVID-19 pandemic, many physician practices relied on funding from the Economic Injury Disaster Loan, a federal small business loan program, to keep their doors open.

"Small and independently owned practices are at a severe disadvantage when it comes to practice overhead and ability to get business loans," said Ray Callas, MD, speaking for the Texas Medical Association. "These practices are often providing care to some of our most underserved areas ... Focusing financial relief and loan forgiveness for our small and independently owned practices allows them to stay independent, and that's what we want from the House of Medicine."

Ramin Manshadi, MD, a solo-practice cardiologist in the California delegation who was speaking for himself, noted that a federal loan has helped him keep his practice doors open during the pandemic. "And even if my employees were out for 2 weeks, I continued to pay them to help them with their livelihood," he said. However, "larger entities that are able to survive this storm are better than us. For example, one of my employees wanted to raise her hourly wages from $17 to $35, because Kaiser offered that much for her."

More on the Gun Violence Issue

AMA members also continued with their discussion of the gun violence issue. The delegates first voted on a resolution to convene an AMA task force on the topic that would work with other advocacy groups to find ways to end the gun violence crisis; they agreed to refer the resolution to the AMA's board of trustees with a deadline of November 2022 for a decision. But later in the day, Melissa Garretson, MD, speaking for the American Academy of Pediatrics, asked for that decision to be reconsidered.

Garretson addressed the board of trustees' concern that the formation of a task force might impede work the board is already doing on the topic. "I would like to hear from my AMA board chair regarding the official position of why the board feels like a task force would stop their work on this incredibly important issue for our country," she said. "I would also like to provide information regarding additional task forces that this House has established that perhaps did not stop the work of the board" on other issues.

In response, AMA board chair Bobby Mukkamala, MD, addressed the delegates. "I can assure you that I and the rest of your board hear the testimony of this House loud and clear," he said. "We hear that our existing efforts have not been enough, that we need to rethink our approach to this epidemic, that we need to consider new options."

Mukkamala noted that the following day, outgoing AMA president Gerald Harmon, MD, was scheduled to participate in a White House call to explain physicians' experience with gun violence. And he added that the board "will push for stronger action by Congress and the administration."

After Mukkamala's remarks, a tearful Garretson thanked him and said those comments "were what I needed to hear," and she withdrew her motion. At the urging of Bruce Scott, MD, speaker of the House of Delegates, all the delegates stood and applauded.

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