Teresa Horst, like thousands of other medical school students, felt lost after graduation.

She was one of about 3,000 students – about 10% of medical school graduates – who didn’t get accepted for a residency program to complete training in a specialization.

Medical schools started increasing enrollment 20 years ago to meet an anticipated shortage of physicians. However, the number of available residency programs remained the same, excluding thousands of medical school graduates.

Horst applied for a residency the following year. She was competing against graduates from the current year, the prior year and previous years. Horst and thousands like her had no path forward to practice medicine and pay off student loans.

She typed into an internet search engine, “What do you do if you didn’t match for a residency?”

Horst discovered an opportunity in Missouri to become an assistant physician. Missouri was the first state to pass legislation creating a licensing program where medical school graduates who aren’t matched with a residency and pass board examinations can continue learning under a licensed medical doctor.

“We continue to have many more qualified graduates of accredited medical schools,” said Keith Frederick, an orthopedic surgeon who introduced the bill as a state representative from Rolla in 2014. “I knew the criticism was going to come that we were just giving licenses out to people who couldn’t hack it and that’s why they didn’t match into a residency. And that’s just not true. We also put a stipulation they had to pass their board exams, which are exceedingly difficult.”

The Association of American Medical Colleges (AAMC) projects a shortfall of up to 139,000 physicians in the U.S. by 2033. The organization reported 40% of physicians will be retiring in the next decade. It also projects the over-65 population will increase 45%, creating a shortage of a wide range of specialists.

“Solving these problems requires a significant amount of out-of-the-box thinking,” said Jeffrey Howell, executive vice president of the Missouri State Medical Association. “You have to shake the system up a little bit and this program definitely does that.”

Some medical organizations oppose assistant physicians and are attempting to limit it or prevent expansion. The Missouri Academy of Family Physicians testified in 2019 against a bill expanding the number of assistant physicians. Dr. Michael Munger, board chair of the American Academy of Family Physicians, wrote in a letter to Missouri legislative leaders opposing the bill, saying it “would dangerously erode the level of medical care for all Missourians and further divide the medical field through the continued expansion of assistant physicians.”

Kansas, Utah, Arkansas and West Virginia have added assistant physician licensing and the Arizona legislature is currently reviewing the program.

Earlier this year, Horst was matched with a residency opportunity in Mississippi and begins this summer. She’s the fourth assistant physician to work under Dr. Jennifer Powell, a family medicine practitioner in Osage Beach, Mo. All of her assistant physicians eventually matched into residency programs. Powell said Missouri’s assistant physician program is a partial fix for a broken system.

“The problem is they’re not told about this when they’re applying to medical school,” Powell said. “It’s hard to get into medical school. And then we have physicians with medical degrees but they can’t get fully licensed because they can’t get into a residency program.

“The matching process for residency is very much a competition on personality rather than qualifications. It causes a log of angst for people.”

Stress and anxiety problems in the medical profession led Frederick to consider creating the legislation. Frederick said research found approximately 400 doctors commit suicide each year, a third of residents have depression and 11% have suicidal ideations.

“If sometime during your residency you’re having real difficulties, you should know you could step away for a while to get help,” Frederick said. “You could then come to Missouri, practice in an assistant physician position under the wing of a licensed, experienced doctor. You could work and get things in your life squared away.”

Serving a family medicine practice helped Horst gain valuable experience with a wide range of patients. She said Powell’s guidance helped her decision-making process.

“In medical school, you don’t make a lot of decisions because you’re just observing,” Horst said. “Here, you make decisions and it boosts your confidence. I don’t know what I would have done without this program. I don’t think I would be going to residency this summer if it wasn’t for this program and Dr. Powell.”

Annual AAMC studies revealed 44% of medical schools surveyed believe their graduates will have major or moderate difficulty finding residencies after graduation. The report cites a 25-year congressionally imposed cap on federal support for graduate medical education through Medicare, the largest public funding contributor for residencies. Teaching hospitals, medical schools and physicians are continually lobbying Congress to raise the cap to increase residencies to help meet the health care needs of an aging population.

Until the funding problem is solved, Powell will continue to help assistant physicians in her practice.

“It’s less about me getting help in my practice and more about me helping them,” Powell said. “I take it very seriously. My job is to try to train them as best as I can, almost like an apprenticeship.”

This article was originally posted on Missouri’s assistant physician program, first in U.S., aims to solve residency, doctor shortages