PHOENIX -- Arizona is one of a just handful of states that issues special practice permits to medical school graduates who haven't completed a residency. But six months into the program, use of the permits is low.
Supporters of the program say it's one way to address Arizona's dire physician shortage while also providing experience for medical school graduates who apply for a first-year residency program position but don't match with one because of an ongoing shortage of residency slots.
Such graduates are often referred to as "unmatched," meaning they graduated from medical school but were not matched with a medical residency program.
So far, few are making use of the permits, which first became available in November. While 99 permits had been issued as of May 12, only 12 permittees were practicing under a supervising physician, according to data from the Arizona Medical Board. It is unclear if the program will grow in the future.
Senate Bill 1271, signed by Gov. Doug Ducey on May 4, 2021, created a one-year transitional training permit for medical school graduates who have successfully completed Step 1 and 2 of the United States Medical Licensing Examination or equivalent exams but haven't gone through residency, which is required to become a fully licensed physician in Arizona.
Gov. Doug Ducey signed Senate Bill 1271, which created a one-year transitional training permit for medical school graduates who have successfully completed Step 1 and 2 of the United States Medical Licensing Examination or equivalent exams but haven't gone through residency.
A residency is a post-graduate program where doctors spend three to seven years working in a health care facility to continue their training in a specialized field of medicine.
Transitional training permits are only available to doctors who in the prior two years either applied for a residency position and failed to match or were selected for a residency position but failed to complete it for reasons not considered grounds for disciplinary action
This year, only 80% of applicants matched to first-year residency positions in the U.S., leaving almost 8,500 doctors unmatched, according to the National Resident Matching Program, which matches doctors with residency positions. Data from the Program shows the number of residency positions has increased since the 1980s, but not enough to keep up with demand.
Arizona is among five states that have enacted legislation creating special permits allowing doctors who haven't completed residency to practice medicine under the supervision of a licensed physician.
Such permittees are often referred to as assistant physicians or associate physicians. In 2014, Missouri became the first state in the nation to enact such legislation. Since then, Arkansas, Kansas and Utah have enacted similar laws.
Missouri's permit program attracted scrutiny after one high-profile permit holder, Missouri state Rep. Tricia Derges, was indicted on charges accusing her of selling fake stem-cell treatments, illegally prescribing drugs and fraudulently receiving COVID-19 relief funds, Kaiser Health News reported.
Arizona is the only state offering these permits that limits them to medical school graduates who did not match with a residency. But Arizona is more permissive than Utah and Missouri in specifying where permittees may work. Arizona allows permittees to work in a variety of health care facilities, while Missouri and Utah require permittees to provide primary care in medically underserved areas.
The Arizona Medical Board has a list of permittees and their supervising physicians on its website. According to the board's database of physicians, the majority of supervising physicians are in Maricopa County, and most of them specialize in family medicine or internal medicine.
SB 1271's sponsor, Sen. Nancy Barto, R-Phoenix, told The Arizona Republic in an email that she sponsored the bill as a way to help deal with the shortage of physicians in Arizona.
According to a June 2021 report by the Association of American Medical Colleges, an estimated 2019 physician shortage of 19,800 in the U.S. is predicted to grow to between 37,800 and 124,000 by 2034.
The AAMC report says this shortage primarily is driven by an increase in demand for physicians because the U.S. population is growing and getting older, as well as the fact that a large portion of the physician workforce is nearing retirement age. More than two out of five active physicians will be 65 or older within the next decade, according to the report.
The shortage is especially notable in Arizona, which ranks 42nd in the nation for the number of active primary care physicians relative to the population, according to a 2019 report by the University of Arizona Center for Rural Health. The report found that Arizona's primary care physicians are able to meet just 40 percent of the state's primary care needs.
Michael Dill, director of workforce studies at the AAMC, told The Republic the solution to the shortage is to train more physicians. U.S. medical schools have increased the number of students enrolled, he said, but the problem is the shortage of residency positions available to doctors after they graduate.
The vast majority of funding for residency positions comes from the federal government through Medicare. In 1997, the federal government capped the number of Medicare-funded residency positions. Congress added an additional 1,000 slots in December 2020, but Dill told The Republic this is not enough. He said the AAMC estimates an additional 14,000 slots are needed.
Barto said SB 1271 helps to address the physician shortage by allowing unmatched medical school graduates to practice medicine.
"While these graduates are awaiting a residency slot, rather than settling for a job that pays far less they can now put their medical training to good use," Barto said.
Dill said this kind of legislation won't solve the problem of the physician shortage. He said a better solution is to fund more residency slots.
Barto said SB 1271 wasn't intended to fully fix the problem. However, she said Arizona shouldn't ignore viable solutions while waiting for the federal government to add more residency slots, which she said they haven't made a priority in the past and are unlikely to in the future.
Dr. Zobia Aijaz is one of the doctors who has a transitional training permit. Aijaz moved to the U.S. in 2016 after graduating from medical school in Pakistan, but she hasn't been able to match to a residency position, leaving her unable to continue her medical training. She has been working related jobs such as research, but she said what she really wants is to be able to practice medicine, because that is what she has trained to do.
"(It's) a wastage of my skills and my knowledge," Aijaz said.
Aijaz, who lives in Texas, which does not have a transitional training permit for medical school graduates, applied for a permit in Arizona and received one April 5. Aijaz said she wants to move to Arizona to practice medicine under her permit, but she hasn't been able to find a supervising physician. One reason for this is because physicians don't want to have to pay for extra malpractice insurance, she said.
A transitional training permit is valid for one year, and the permittee can get it renewed for an additional year up to two times, provided that each year they apply for renewal they applied for at least three primary care residency positions and once again did not match.
Aijaz said she is worried she won't be able to find a supervising physician before her permit expires.
Permittees are allowed to perform the kinds of health care tasks typically performed by residents. Additionally, permittees each year are required to participate in at least 60 hours of continuing medical education. The supervising physician must make sure health care tasks performed by the permittee are within their scope of experience.
A physician may act as a supervising physician for no more than one permittee at a time. Supervising physicians are required to directly supervise permittees by being physically present while they give care for their first six months of full-time practice.
After that, supervising physicians are required to indirectly supervise by being present in the facility and available to give direct supervision. Supervising physicians must review all medical records related to clinical encounters performed by the permittee as part of a process for evaluating the permittee's performance.
The Arizona Medical Association initially opposed SB 1271, but later changed its position and registered as neutral after the bill was rewritten via amendments. Dr. Ross Goldberg, immediate past president of the Arizona Medical Association, told The Republic this was because they were able to negotiate to get the bill into a form they found more acceptable.
The initial version of the bill would have allowed medical school graduates who haven't completed residency to practice medicine as "associate physicians." It didn't specify that permittees needed to be unmatched, but it did limit them to providing primary care in medically underserved areas, which the final version doesn't.
The first version also didn't include a time limit for how long the permit would last, and its supervision requirements were less strict.
The Arizona Academy of Family Physicians opposed both versions of SB 1271. Its president, Dr. Shanyn Lancaster, told The Republic in an email that the organization felt the bill would put patient safety at risk and lower the quality of medical care.
"Doctors who have recently graduated from medical school still need experienced teachers, in accredited programs, to teach them the safety, effectiveness, professionalism, humanistic, and communication skills to become quality physicians," Lancaster said.
Barto said patient safety isn't an issue because doctors graduate medical school with an average of 6,000 hours of clinical training, which is more than other non-physician health care providers such as physician assistants and nurse practitioners.
Barto pointed to a 2018 report by the right-leaning American Enterprise Institute that found that vulnerable populations such as Medicaid recipients, the uninsured and people living in rural areas are more likely to receive primary care from nurse practitioners than physicians.
"The training permit program is constructed to put patient safety first," Barto said.