Can Physician Assistant Licenses Solve Matching Issues?

Faarina Khan, MD, MPH always knew she would have to overcome obstacles to achieve her dream career in medicine. As an American citizen who attended Dow Medical College in Karachi, Pakistan, she knew her International Medical Graduate (IMG) status would work against her as she sought residency training in the United States.


Dr. Farina Khan

But Kahn didn’t expect to fail the National Resident Matching Program (NRMP) four times.

Khan’s situation is far from unique. Earlier this year, about 93% of US physicians and 91% of DOs matched. But according to a report of the NRMP.

Bryan Carmody, MD, associate program director at Eastern Virginia Medical School, analyzes correspondence trends on his medical education blog, “The Sheriff of Sodium.” He said there are approximately 1.33 PGY-1 positions available for every US medical and DO graduate student.

“However, there are not enough residency positions for each applicant when you include new applicants and international medical graduates – so the position-to-applicant ratio drops to 0.85.” He also noted that 2,000 American medical seniors failed to match, as well as more than 5,000 DIMs.

This continuing mismatch has led some states to seek ways to utilize the unparalleled medical expertise of graduates while improving people’s access to care. One solution was the creation of physician assistant licenses. Physician assistants – not to be confused with physician assistants – are medical school graduates who have not yet completed their residency.

In 2014, Missouri became the first state to create a physician assistant license. The first licenses were issued in 2017. The physician assistant license allows its holders to practice medicine in Missouri under a collaborative practice agreement with a physician, who is ultimately responsible for the care provided. .

The scope of practice for physician assistants is similar to that of other mid-level practitioners, such as physician assistants or nurse practitioners, with whom they are sometimes confused. They perform physical examinations, diagnose illnesses, provide simple treatments, and have limited privileges when it comes to prescribing medications. An important distinction is that most other mid-level providers have master’s-level training and can practice in a variety of settings, while physician assistants are limited to outpatient settings.

Arizona, Arkansas, Utah, and Kansas have created licenses similar to Missouri’s, and other states are considering them as well.

Stepping stone to residency

For Khan, the Missouri Physician Assistant license has become a professional lifeline. Her initial failures left her emotionally devastated but more determined than ever to succeed in medicine. After completing a year of internship in Pakistan and working as a medical assistant in Chicago, she enrolled in the Masters in Public Health program at the University of Kansas and became a research assistant there.

She then applied for and obtained a Missouri Physician Assistant license and eventually found her way to Medina Clinic, in Grandview, Missouri where she volunteered for 3 years.

Before the COVID-19 pandemic, she commuted 3 hours each way every Saturday from Witchita, Kansas, to the clinic seeing patients throughout the morning and afternoon. “I didn’t get paid a penny as a physician assistant, but it was worth it. I did it for the experience and for the benefit of the patients,” she says. “This is the only opportunity I have come across that allows you to work at your appropriate level of training and brings you back to direct patient care.”

His peers in Medina included physician assistants who traveled from other states, including New York, Connecticut, Michigan and Texas, for their monthly shifts. “We’re a very resilient group. We keep applying, we keep trying,” she says of her former colleagues. “We spent blood, sweat and tears trying to become someone in medicine, and we don’t want to give up on that dream.”

Medina’s approach seems to be bearing fruit. According to the clinic’s website, 35 physician assistants — just over half of Medina’s total volunteer corps, including 10 this year — have participated in residency programs across the United States since Medina began work with assistant physicians.

In 2021, Khan joined this group. On her fifth try, she was matched with family medicine at the Roseburg Family Medicine Residency in Roseburg, Oregon. “I credit my work as a physician assistant with finally helping me break through,” says Kahn, who is president of the National Association of Physician Assistants/Associates, a nonprofit advocacy group. “It was an almost identical experience to what I do now in residency, except my Missouri experience was not ACGME [Accreditation Council for Graduate Medical Education] accredited.”

Licensing debate

The Missouri license depends on physician assistants practicing on an outpatient basis in underserved areas. The states Healing Arts Council states that applicants must have completed Stage 2 of the United States Medical Licensing Examination (USMLE) within 3 years of graduating from medical school and applying for a physician assistant license.

Kansas has created a special license for University of Kansas medical school graduates who do not fit into a residency program to practice under continuous direct supervision for up to 2 years. A spokesperson for the state’s only medical school declined an interview with Medscape because “our students have never used it.”

Even in Missouri, licensing adoption is relatively low. The Medical Licensing Board estimated that last summer the number of physician assistants in the state was 200 to 300, although the number actually practicing appears to be significantly lower. Openings for Physician Assistants circulate primarily by word of mouth among unrivaled physicians eager to gain clinical experience. Competition is fierce for the few sites willing to hire physician assistants.

Clinical experience license

While the Missouri model has proven popular with other states, the most recent state to tackle the unparalleled physician/increased access to care problem has taken a different approach. In October, Washington State began offering a medical license specifically for IMGs.

Known as a clinical experience license, it does not limit the physician’s scope of practice or geographic location. License holders must pass all three stages of the USMLE and work under the supervision of a fully licensed physician. The clinical experience license is valid for 2 years, with the possibility of renewal for one year, for a total of 4 years of practice in the state.



Micah Matthews

Micah Matthews, MPA, deputy executive director and legislative director of the Washington Medical Commission, the state’s licensing body, said his state specifically wanted to avoid Missouri’s approach of requiring physician assistants to practice primary care in underserved areas.

“The problem with that logic is that you’re telling an inexperienced doctor to practice the widest possible medicine in a remote area without extensive support,” he says. “It sends the message to people in our state that if they live in a rural area, they should just expect less or inferior medical care. It’s not fair.”

In Missouri, collaborative physicians such as Wael Mourad, MD of the Medina Clinic, clinical professor of community and family medicine at the University of Missouri-Kansas City, are taking it upon themselves to help prepare their physician assistants to apply for the residency by offering a program of life reviews and mock interviews. In Washington, this residency-based approach is built in.

“Our intent with this license is to funnel people into residency so they can complete that and become fully licensed physicians,” Matthews said.

To this end, Washington State requires that any potential sponsor have at least three full-time physicians providing direct clinical care.

“Earning three good letters of recommendation is consistently rated as a barrier to entry into residency for IMGs,” says Matthews. “We’ve set it up so that each IMG will receive three strong letters of recommendation from licensed Washington physicians who will know the candidate’s work and be easily accessible to discuss residency applicants.”

Attention international graduates

As to why the new Washington license focuses only on IMGs and not U.S. graduates, Matthews thinks it’s a matter of both fairness and recruiting more experienced clinicians to help increase access. taking care. “The data I’ve seen shows that unmatched U.S. grads have a higher likelihood of matching in sophomore year than an IMG would in any year,” Matthews says. He adds that many IMGs apply to dozens of residency programs without ever matching.

As in Missouri, adoption of the new license category has been slower than expected in Washington State. “We were told there were 50 to 60 IMGs who met all the requirements and another 400 who needed to complete one or more milestones,” says Matthews. “In our first 8 months, we issued 19 clinical experience licenses.”

He thinks the backlog in licensing applications may be because applicants need to identify their sponsors and clarify their duties before applying.

Clearly, the stakes for physician assistant licensing are high, both on an individual and societal level, he says. Carmody sees the potential for positive and negative consequences of licensing.

“If you look at it from the patient’s perspective, it’s probably a win if they’re better able to access care,” he says. “If you look at it from the unparalleled perspective of the doctor, I think it’s a short-term win and a long-term loss if the assistant physician role doesn’t let them pay off their medical school debt or if the residency programs do not seem favorable on experience.”

He said he was also concerned about the inequities of creating a two-tier physician system if the physician assistant license became a permanent option for clinicians.

Kahn does not share this concern. “We’re not trying to circumvent residency. The Physician Assistant license is meant to be a bridge to residency,” she says. “It’s a tool that’s supposed to allow us to help ourselves and the residents of those states until we’re able to give the proper training and licensure and then can serve as appropriate and fully licensed physicians in those states.”

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