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SHOW ME THE MORONS
Mary G. Barry, MD
M
Louisville Medicine Editor
[email protected]
issouri, the Show-Me state, has
just shown the country how low
it can go on the IQ scale, or on
any common-sense measure of valuing
patient care. In early July, Gov. Jay Nixon
signed into law Senate Bill 716, allowing
medical school graduates fresh out the door
– without any residency training whatsoever – to hang out their shingles in private
practice. The intent is “to improve access to
health care,” as if the quality of that care does
not matter. As the law is written, this applies
to work in rural and medically underserved
areas only. These “Assistant Physicians” are
required to have close supervision by a licensed physician for only one month, defined as a physician who practices within 50
miles, as well as an ongoing chart review of
10 percent of patients seen, every two weeks.
There is no time limit in this law, so that in
a year, the “experienced” doctor reviewing
the brand new one could have only his own
year of teach-yourself medicine to rely on.
Teach-yourself medicine is good for
looking things up, supposing the texts you
use are authoritative, current, and correct.
Teach-yourself medicine in daily primary
care – when you have never once independently diagnosed and treated anything
– anything! – means disaster. You will make
major mistakes. You will be overwhelmed
and probably hysterical by the end of the
first day, when you have just been presented with 20 people with laundry lists of
symptoms, some of whom have dangerous
problems, like rheumatic heart disease with
cor pulmonale, which you have never even
heard of. You will not know what half their
medicines are. You will not know why they
are really there. You will not know what is
wrong with them, or how bad it is, or what
you and they should do about it. After you
fail to ask the right questions (and while
you are getting panicky about how long
this seems to take) you will miss telltale
physical signs. You will send home the lady
with early bowel obstruction. You will put
the asthmatic on water pills, and the man
with heart failure on inhalers. You will fail
to note the CVA tenderness, forget to do a
pregnancy test, and think the breast mass
is a cyst. You will not stop to palpate the
tender temporal artery, since you doubtless
have never heard of vasculitis.
They will bring you a sick child, yet you
only had two months of pediatrics, so you
will ask the parents what they think it is,
and pray. Half your mind will still be on the
child when you see the drug abuser who is
delighted that he has a newbie to tell about
his pain, and you will use your newly issued
powers to give him Vicodin. You will let
your medical assistant take the vital signs
with a machine, and thus your farmer with
new-onset atrial fibrillation, who smiled at
you even though he has been short of breath
lately, will have an aphasic stroke out in the
field the very next day. (You did diagnose
him with COPD, since you have heard of
that before.) When his daughter calls to tell
you he can’t talk or move his leg, you will
still have no idea why that happened, or that
it was preventable, and you will have nightmares (as will your malpractice insurer) for
months. And by the way – who in his right
mind will underwrite you?
Then you get to do it all over again the
next day, all by yourself. You don’t know how
to get any test authorized, even though you
Googled what test was needed (presuming
you are somewhere in the neighborhood of
the correct diagnosis). If that test is normal,
then what? You have no clue. Somewhere
in the back of your mind you remember
that you are supposed to be doing preventive care, but who needs what, and when,
and anyway you don’t have time. And then
you get to take weekend call, and cannot
get through dinner, much less sleep, and
your spouse looks at you in the morning
and thinks, “We were out of our minds to
do this.”
Amazingly, the Missouri State Medical
Association supported this measure. Said
Jeffrey Howell, “Missouri has an opportunity to be a trailblazer on this type of licensure
and solving the health care access problem.
This is a brand new idea and something we
can really take advantage of.” Howell et al
were unswayed by the fierce opposition of
the AMA, both the national and Missouri Academy of Family Physicians, and the
ACGME (Accreditation Council for Graduate Medical Education). Additionally, the
national and state Academy of Physician
Assistants lobbied strenuously against this,
since the “Assistant Physician” name – it(continued on page 34)
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