Compare and Contrast: MDs v. NDs practicing without residencies

Compare and Contrast: MDs v. NDs practicing without residencies

The Missouri Legislature recently passed a bill which would allow newly minted MDs and DOs to practice medicine without having completed a residency, but only in medically underserved areas.  The idea is to use medical school graduates who didn't match with a residency program to help fill the primary care physician shortage.  

The Governor has until July 15 to sign or veto the bill and there is no word yet on what he will do. For the political record, the Missouri State Medical Association lobbied for the bill, the Missouri Academy of Family Physicians isn't taking a position, and the American Academy of Physician Assistants, along the Missouri Academy of PAs have been vocal in their opposition.  

Which brings me to the subject of "naturopathic doctors."  Why?  Because NDs claim that they are capable of practicing as primary care physicians with the same degree of skill as MD and DO PCPs.  ND licensing bills routinely start out by defining them as PCPs, including the authority to prescribe drugs.  Fortunately, that scope of practice rarely ends up in their practice acts in the few states that license them.  That doesn't keep them from coming back to the legislature each year to ask for more.  

In a handful of states, however, NDs have a full PCP scope of practice, including the authority to prescribe real drugs.  Washington and Oregon are examples of this.  The scope of practice shrinks from there across state lines.  So far, only 18 states license NDs at all.  

But a limited scope of practice still leaves plenty of room for mischief.  One reason is that NDs generally have an unlimited ability to diagnose and treat, even if this does not include all therapies within the MD's armamentarium.  Because naturopathic education and practice is not reality based -- it includes such fantasy treatments as homeopathy, colonic hydrotherapy, and dietary supplements for all manner of diseases and conditions -- patients are subjected to often worthless and sometimes dangerous diagnoses and treatments.  

The clinical education of NDs is woefully inadequate.  It occurs mostly in ND school-based clinics, where they are supervised by an ND faculty.  The range of diseases and conditions they treat is limited and their exposure to patients not in ambulatory out-patient settings, such as nursing homes, hospitals, and rehabilitation centers, is practically nil.  And they can go into practice immediately after they graduate from school, no residency required.

All of this makes the contrast between state licensing requirements for NDs and Missouri's proposed licensing requirement for MDs sans residency very interesting.  

Missouri's plan for allowing MDs without residencies to practice in medical underserved areas is chock full of limitations.  They

  • will be called "assistant physicians" and be considered the same as physician assistants under Centers for Medicare and Medicaid Services regulations.
  • must have passed Steps 1 and 2 of the US Medical Licensing Exams within the previous 2 years.
  • cannot practice outside of medically underserved areas.
  • must disclose their limited status to patients and wear ID badges.
  • are limited in their prescribing of controlled substances.

The most important safeguard for patients is a written collaborative practice arrangement assistant physicians must have with a licensed MD or DO, each of whom can have an arrangement with no more than three assistant physicans.  The collaborating physician is responsible for the assistant's services and they must have agreed-upon protocols or standing orders for the delivery of health care services.  The collaborating physician must be continuously present for the first month of practice and, after that,  maintain geographic proximity except in certain limited circumstances. The assistant physican must submit to his or her collaborating physician

a minimum of ten percent of the charts documenting the assistant physician's delivery of health care services to the collaborating physician for review by the collaborating physician . . . every fourteen days.  

If the assistant physician prescribes controlled substances, the percentage of charts submitted for review jumps to twenty percent.  I wonder how many NDs would be permitted to stay in practice with this type of supervision from a practicing MD or DO?

The contrast between the approaches of MDs and NDs to the limitations of practicing without a residency couldn't be more obvious than in this proposed law.  MDs obviously realize that med school grads are not ready for prime time without a residency and worked with the state legislature to ensure strict limitations.  NDs deny that a residency is necessary and sponsor legislation permitting practice right out of school.  MDs realized that supervision is absolutely necessary.  NDs deny that supervision is required to safely practice.  MDs enforce limitations on assistant physicians with chart review and other restrictions.  NDs don't have anyone reviewing other NDs' charts.  Even without a residency, med students must practice in a variety of clinical settings and put in far more hours of clinical training.  Naturopathic students are mostly limited to school-based ambulatory clinics where they see a narrow range of diseases and have little opportunity to prescribe drugs, yet want full PCP scope of practice.

Whatever you may think of the idea, any patient is far better off with an assistant physician than an ND.  Reality-based medicine beats fantasy-based medicine hands down. 

















Points of Interest 06/29/2014
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