The Role of Residency Training For Physicians

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Session 84

The Premed Years
In today’s episode, Ryan and Allison talk about an article recently released in The St. Louis Post-Dispatch about some legislation being passed in Missouri where graduating medical students may be allowed to skip internship or residency and straightly go into practicing medicine.

Ryan and Allison express their views about the article as well as walk us through the path to becoming physicians, their training, and insights.

Here are the highlights of the conversation with Ryan and Allison:

The traditional path to going into clinical practice::

  • Four years of training (Three for some)
    • First two years of medical school are classroom-based
    • Third and fourth year – devoted to time caring for patients in the wards
  • Matching to find out where you’re going for your residency training
    • Internship (Which is actually your first year of residency)
    • 2-6 additional years of residency training
  • Two routes:
    • Become an attending physician
    • Do a fellowship (which allows you to sub-specialize) then become an attending physician

You need at least an internship to be able to get a full medical license where you can practice on your own.

The impetus behind Missouri’s bill:

  • Missouri clamors for more doctors. 500 students didn’t match so there lies a shortage of residency spots for students graduating from medical school.
  • Missouri seeks to employ these graduating students who have not completed residency training since they are technically doctors.
  • The ruling creates a new classification in their state licensure called the “Assistant Physician.”

The Missouri legislature has already approved this measure (as of June 23, 2014)

What is an assistant physician?

Someone who is licensed by the State and Board of Healing Arts and is allowed to practice primary care and prescribe medications in rural and underserved areas of the state. A practicing physician will be supervising the assisting physician for only one single month.

What medical school does not teach you:

  • How to be a doctor
  • How to practice medicine

Medical school only teaches you education, the foundation and the framework for medicine.

What you get from residency training:

  • More responsibilities year after year
  • Graduated supervision (as you progress, you develop more abilities to stand on your own feet and be able to lead)
  • At the end of residency, you are pretty much an attending physician
  • Confidence of having the backup of residents, fellows, and attending physicians supporting you
  • Mentorship
  • Learning different styles

The red flag of practicing medicine in a rural and underserved areas of the state:

A disservice to the patients because you are practicing medicine to sick patients without supervision

The importance of pattern recognition:

You will learn through repetition.

The 10,000-hour philosophy:

  • Based on Malcolm Gladwell’s book, The Outliers that follows the 10,000-hour rule to become great at your field (That’s equivalent to 4,160 hours a year a resident gets)
  • Residency is a minimum of 3 years which gives about 12,000 hours
  • Without residency training, you will have to work 5 years to reach that same level of hours in training

More insights from Ryan and Allison:

  • Why can’t a PA or NP fill this role?
  • Why is the supervision just for a month?
  • Other states only require one year of internship before going out in practice
  • Not every state will let you practice medicine with just one year of internship.
  • Physician shortage is a fact. Something’s gotta give. But it always has to be of the benefit of the patients.

Final words:

Work some type of “team” into the solution otherwise there would be a lack of support network and lack of ability for the physician to keep learning.

Links and Other Resources:

Article about Assistant Physicians

Malcolm Gladwell‘s Outliers: The Story of Success

Are you a nontraditional student? Go check out

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Dr. Ryan Gray: The Premed Years, session number 84.

Intro: Hey, this is Z-Dog MD; rapper, physician, legendary turntable health revolutionary, and part-time gardener. And you’re listening to the Medical School HQ Podcast, hosted by the irredeemably awesome, Ryan Gray.

Dr. Ryan Gray: Hello and welcome back. I’m your host, Dr. Ryan Gray, and I believe that competition amongst your premed and medical student peers is detrimental to becoming a great physician. In this podcast we show you how collaboration, hard work and honesty are critical to becoming a superior physician in today’s healthcare environment.

Thank you again for joining us. I think I thank you guys every week for continuing to come back, but I still feel it’s very special that you guys come and spend half an hour or an hour with us every week- hopefully every week, and listen to what Allison and I- or Allison and my guests have to say. So thank you again for coming back.

We do want to let you know go to, we’ve got something special there for you all about the MCAT.

I have the lovely Miss Allison, Dr. Gray.

Dr. Allison Gray: Hello.

Dr. Ryan Gray: Back in the studio, AKA our basement office.

Dr. Allison Gray: Yes I do live here.

Dr. Ryan Gray: You do live here, yeah. Welcome back to our studio.

Dr. Allison Gray: Hey thanks.

Dr. Ryan Gray: So today we’re going to talk about something that was in the news, and it’s not necessarily something premed related or medical student related, but I think it’s something that has some overarching repercussions in the whole healthcare field if this is something that catches on. And so it will be interesting, we’ll give you our thoughts on what we read in this article about some legislation that’s being passed in Missouri, and we’ll talk about our path to becoming physicians, and our training, and what we think about this. But before we get there, I want to talk about one thing first.

Premed Life Magazine. If you haven’t checked out Premed Life Magazine yet, go check them out, They are a bimonthly magazine for premed students, and they’ve got a bunch of great editorial articles, and different- a bunch of different stuff in their issues, so go check them out. They are our partner magazine and we’re their partner podcast. So we’re glad that they support us and we support them.

So Allison let’s talk about this article. I originally saw it, I forget where, but it’s an article in the Saint Louis Post Dispatch; the world renowned Saint Louis Post Dispatch.

Dr. Allison Gray: No offense, I’ve never heard of it.

Dr. Ryan Gray: Yeah neither have I. But it talks about some legislation that Missouri is passing that allows- that may allow medical students, graduating medical students, so newly minted doctors, MDs or DOs, to go straight into practicing medicine without an internship or without a residency. So talk- can you talk for a minute about historically how the steps that a physician goes through to actually practice medicine?

Dr. Allison Gray: Sure.

Dr. Ryan Gray: And why this is different.

Historical Physician Path

Dr. Allison Gray: Absolutely. So classically a medical student will have four years of training- I think it’s probably been four years for a long, long time. I mean back in the day it was probably much more-

Dr. Ryan Gray: There were some three year programs and then four year, and now we’re going back to three years.

Dr. Allison Gray: Well and really- right, or five years. But really back in the day it was more of an apprenticeship and so it might have taken any period of time, who knows. But in the last bunch of years, it’s been three or four years, and for the most part four years still. And so the first two years of medical school as a lot of you know are- if you’re still in that traditional setup are classroom-based where you’ll do your anatomy, your physiology, your biochemistry. And then your second two years, your third and fourth year, are devoted to time on the wards where you really learn what it’s like to care for patients on the wards. And this might be in the hospital, in the ER setting, in the clinic. And when you’re done, when you graduate, you match- well actually before you graduate you match and then you find out where you’re going to be doing your training. Now there are some physicians out there who don’t actually go and do an internship or residency. They might actually just go directly and start working in consulting jobs; there are other-

Dr. Ryan Gray: Business school.

Residency and Intern Year

Dr. Allison Gray: Right, there are other opportunities, things that physicians do once they have an MD or a DO. But again speaking classically, in this day in age after you graduate medical school and you match, you move to wherever you’re going to be doing your internship and July 1, or technically actually, a few days before July 1 you start your internship. Internship is the first year of residency, so it’s kind of- it’s quite confusing probably for people who are not in the healthcare field because you say you’re an intern, well what does that mean? And an intern means you’re in your first year of residency training. And after that intern year, you have somewhere between two and six additional years of residency training. So a residency- a full residency training can be anywhere from three to seven years. Seven years is like neurosurgery, plastics, I think it might be six, most of them are more in the three, four, five range. And once you’re done with that, then there are two routes you can go. One is that you go directly to then becoming an attending physician which is what I am now, where you are practicing. You’re out on your own or in a group practice, a solo practice, an academic setting, whatever it may be, you’re the attending. Or the alternate route is that before becoming an attending you do a fellowship, and that fellowship is a way for you to sub-specialize or specialize further in a field that sort of you are propelled from your residency. So for example you might do your residency in internal medicine and then do a cardiology fellowship. And then after that fellowship, again you can then go on to become an attending. So that sort of encompasses the classic- the path that most physicians nowadays will take if they are going into clinical practice.

Dr. Ryan Gray: Yeah, and there are some barriers that residency breaks down on the way to becoming an attending, and that is the boards. So to be able to get a full medical license, in every state- and this is why Missouri is different and they’re working this out, in every state you need at least an internship to be able to get a full medical license where you can practice on your own.

Dr. Allison Gray: Right and part of that, right, is that the first two step- step one and step two, and by the way step two is two parts, those are all based on education that you develop, that you learn in medical school. Step three, which is that last crucial step is all based on training that you had during your internship. So how do you get your license without that internship, without that training, that gives you what you need to know to succeed on step three?

Dr. Ryan Gray: Yeah, or the COMLEX. Let’s not forget the DO schools.

Dr. Allison Gray: Correct, absolutely. I apologize for all you out there who are DOs, I just- because I’m an MD that’s just how I- that’s my go-to but absolutely.

New Missouri Legislation

Dr. Ryan Gray: So that’s kind of a back history of a traditional path, and let’s talk a little bit about what they’re actually proposing. So I have this article pulled up and the Missouri legislature has approved this measure already-

Dr. Allison Gray: This is hot off the press, too.

Dr. Ryan Gray: Yeah this came out June 23, 2014 so just a week ago as we’re recording this. And so the legislature already passed this ruling that would create a new classification in their state licensure. So typically like for Massachusetts where we are, where we did our residency training and my internship training, and now where we both practice, they have two distinct licenses for physicians. They have a trainee license that you have when you’re in residency.

Dr. Allison Gray: A limited license.

Dr. Ryan Gray: A limited license as it’s called, yeah. And then when you are out practicing it’s a full medical license. Once you pass that step three, or COMLEX three, then you are eligible for that full medical license and that’s what you need to be able to practice on your own. And so Missouri is saying, “You know what? We need more doctors.” And the impetus it looks like behind this is the fact that- what was big in the news last March was that a little bit more than 500 people, 500 US students didn’t match in the match. And so everybody is up in arms about, ‘Well there’s not enough residency spots for all of these students graduating from medical school and we need doctors, so how do we fix that?’ And the Missouri legislature said, ‘Well why can’t we employ these graduating students who technically are doctors, they have an MD, they have a DO, but traditionally aren’t allowed to work yet because they haven’t gone through an internship.’ And so they’re looking at adding this- what they’re- I don’t know why they came up with this name, the Assistant Physician Classification to their medical license. And so I don’t know how confusing that’s going to get when you have PA versus an AP if they’re going to keep that name, hopefully not. And so-

Dr. Allison Gray: Right or an AP MD, or AP DO-

Dr. Ryan Gray: Oh that’s true, I didn’t even think about adding that extra because they do have that.

Dr. Allison Gray: Right.

Dr. Ryan Gray: I’m an MD AP.

Dr. Allison Gray: Yeah, what does- oh my God. People have enough trouble understanding MD, DO, and all the other things.

Dr. Ryan Gray: NP, PA.

Dr. Allison Gray: Oh yeah.

Dr. Ryan Gray: And nurses that are now doctors.

Dr. Allison Gray: It’s- you know it’s a very- look in this day in age and with the shortage of physicians and also importantly- and this article points this out too, we’re expecting a lot more patients to be seeking medical care because with the Affordable Care Act, there are going to be more people who have insurance coverage. And especially in some of these more rural states that you know, for years have not- people have not had access to healthcare, partly because they don’t have insurance. So I think I applaud the state for trying to come up with a new idea-

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: Our big question is, is it going to work?

How Would it Work?

Dr. Ryan Gray: Yeah, and so let’s dig in a little bit more about what they’re thinking. So they are- they define an Assistant Physician as somebody who’s licensed by the state, Board of Healing Arts is what they call it, it’s kind of strange. And these Assistant Physicians would be allowed to practice primary care and prescribe medications in rural and underserved areas of the state. So that was I think one of the first big red flags that went off in my mind, is- well actually before we get there, the biggest red flag- and we can talk about our experiences Allison. When you graduated medical school, were you ready to work on your own?

Dr. Allison Gray: Of course not.

Dr. Ryan Gray: What does- why not? Does medical school not teach you how to be a doctor?

Medical School Directly into Practice

Dr. Allison Gray: Well because that’s the key thing, it doesn’t. Medical school does not, newsflash for everyone, it really doesn’t and you’ll find this on your own path to becoming a physician I would imagine. I think if you polled most physicians they would agree with this statement. Medical school doesn’t teach you to be a physician, it doesn’t teach you practicing medicine. It teaches you the foundation, the education, the framework for medicine, and certainly it gives you kind of a- glimpse is not fair, it’s more than that. You do have a[Inaudible 00:13:02],you do have experiences which teach you the beginnings of what it’s like to practice medicine. But absolutely, I mean that training, that residency training, is so critical in my mind.

Dr. Ryan Gray: Yeah, oh without a doubt.

Dr. Allison Gray: I can’t imagine having gone from graduating medical school and then skipping right to practicing, even with some sort of supervision. I mean it’s just such a disconnect in my mind.

Dr. Ryan Gray: So go back and think about your residency training. And the way I thought about this was it’s a mindset thing for me. As a medical student I understand my role as a medical student. I know that I will typically have residencies backing me up- residents backing me up, and attendings backing them up. And then you get into residency and each year of residency you’re given more and more responsibility so that at the end of your residency, you are pretty much working as an attending and you have a much longer leash to practice medicine.

Importance of a Support System

Dr. Allison Gray: Yes, and one of the key terms that sticks in my mind from my own training is this concept of graduated supervision. That you- as you progress through, just as you said Ryan, you develop more and more of your own ability to stand on your own two feet and be able to lead. It’s a sort of- it also teaches you with every step along that path to become a leader more and more. And so yes, by the time I was in my last year of residency, I was operating as- well not operating because I don’t operate, but I was working as an attending in some ways but in the sense of my knowledge base, and my- just my confidence level. So I just think back to my first day of my internship, and I was petrified, I mean I was- you know I think a lot of us, your first day out, it’s a very big shift psychologically and in practice to go from signing your name as MS4 (medical student four), to then signing your name, stamping it with MD as in you’re the person writing the orders, it’s you are the person responsible. Now of course you have, like you said, residents, fellows, attendings supervising you, supporting you. To not have that back-up, I agree with you, back-up is a huge part of that kind of buffer initially that makes you feel like, ‘Okay, I can do this. I have a lot of people supporting me and it’s okay if I make some mistakes because I have that back-up.’

Dr. Ryan Gray: Yeah. And it’s not only the confidence knowing that somebody may catch your mistake, and you have all those extra people behind you, it’s that they are there.

Dr. Allison Gray: Yes.

Dr. Ryan Gray: They are there for you to bounce ideas off of, for you to go to them with your thoughts and say, “Hey, we got this new patient in, here is what I’m thinking, I’m thinking about adding this medication, removing this one, what do you think?”

Dr. Allison Gray: Absolutely.

Dr. Ryan Gray: And this- I’ll go back to this red flag of practicing medicine in rural and underserved areas of the state. Now underserved could be the middle of a city, so that’s a little bit different. But a rural area will, in my mind, that is like that old movie Doc Hollywood. There’s a single physician within a couple hundred mile radius and you are that person.

Dr. Allison Gray: Right.

Dr. Ryan Gray: No back-up, probably not a lot of specialty care for you to refer people out to, probably patients that are maybe a little bit sicker than a ‘typical patient’ because it is a rural area and they lack that good quality access to healthcare, so they probably have very uncontrolled diabetes, they may have very uncontrolled hypertension, high cholesterol, sleep apnea, whatever it may be. And so as a newly minted doctor you’re going out to a rural area without much supervision- and we can talk about the supervision that they’re talking about, and you’re practicing medicine with sick patients. And to me, that’s a disservice to the patient.

Learning by Repetition

Dr. Allison Gray: I think so too. Part of how we learn as physicians is by being around other physicians. And so if you’re going to go out there, not only without really any framework to understand the practice of actually how to be a physician, and then you also are not surrounded by anybody to bounce ideas off of and to learn from, and just to learn from their experience, it just seems like a very scary thing. And you know also Ryan, one of the other big thing that sticks out in my mind that is so crucial about residency training, is repetition. I remember someone telling me, I think I was walking down the halls of MGH with one of my co-residents and we were talking with one of our senior residents about, “Oh my goodness, we have so many admissions and we’re just- we’re slammed,” and we were just really I think kind of struggling because we were exhausted and we had all these admissions to do. And he said, “Look,” he said, “the way that you learn to do this is volume. You learn by repetition.” And he was absolutely right. You know by seeing hundreds and hundreds of stroke patients, by seeing so many people come through the door with a certain set of symptoms, a certain pattern, it’s pattern recognition that you learn and repetition is what drives the knowledge into your head, into your core, so that you just don’t forget it, so that it becomes just- not automatic but it just becomes you know crystal clear in your head and then you just learn and develop and build on that. So again to not have that repetition, or to have that repetition occur for the first time as you’re going out there on your own with you and maybe one other physician 200 miles away from you, it’s- I think it’s going to be really scary for these new folks.

10,000 Hour Rule

Dr. Ryan Gray: Yeah. There’s a book written by Malcolm Gladwell called ‘Outliers.’ And it talks about this 10,000 hour rule. And Malcolm Gladwell who’s a world renowned writer talks about how if you want to become great, like the person in any specific field, then you need to practice that craft for 10,000 hours. And I just did some quick math-

Dr. Allison Gray: I was just going to ask you what’s the math on that?

Dr. Ryan Gray: Yeah I did some quick math. If a typical resident will work eighty hours a week, unfortunately, if we do that eight hour max. So we’ll do eighty hours a week, there’s 26 weeks- actually there’s- why did I think that?

Dr. Allison Gray: I don’t know, 52.

Dr. Ryan Gray: Yeah I was thinking pay periods. So there’s 52 weeks, actually that totally changes all my math. So there’s eighty hours in a week times 52 weeks a year, that’s 4,000 hours. 4,160 specifically hours a year that a resident gets.

Dr. Allison Gray: And how interesting then that residencies are a minimum of three years which gives you about 12,000 hours.

Dr. Ryan Gray: 12,000 hours.

Dr. Allison Gray: There you go Malcom Gladwell, he was just looking at how residency works.

Dr. Ryan Gray: And so let’s extend that to a newly graduated physician who goes out and works let’s say forty hours.

Dr. Allison Gray: And you know we should use that amount of time, because remember we are talking primary care. And so it’s not fair to say well some residents get seven years of training- if you’re going to be practicing in primary care, that’s a three year residency. Because if you’re doing family practice or if you’re doing internal medicine and then going into primary care that’s three years.

Dr. Ryan Gray: Yeah. And so three years, roughly 12,000, it’s probably right around the 10,000 hours when you work in vacation time and days off and other stuff. A physician coming out of a three year residency will have about 10,000 of experience and therefore kind of fits this ‘Outliers’ Malcolm Gladwell philosophy of being able to master that subject. A physician just graduating medical school, starting practice without a residency training will have to work five years to reach that same level of hours and training, that 10,000 hour rule.

Dr. Allison Gray: Oy.

Dr. Ryan Gray: So when you think about it that way it’s like, well those five years to get to that point, what is- I don’t want to say the carnage, but what does that trail of patients look like? And I’m obviously going to the extremes here but that’s just-

Dr. Allison Gray: No but I agree with you. I think- all these things keep coming up in my mind, other things, the key things that residency teaches you and provides for you that you just don’t get elsewhere. I mean mentorship, learning different styles. We’ll talk in a minute about the supervision that we keep alluding to that they’re going to be talking- that they’re suggesting with this model.

Dr. Ryan Gray: We’ll talk about it.

Dr. Allison Gray: Okay we’ll talk about it now. Their plan is to have a practicing physician be supervising this Assistant Physician for a month. One month.

Dr. Ryan Gray: A single month.

Dr. Allison Gray: A single month. And I think they have to be on site all the time. And wow, one month. So I can tell you as a practicing attending physician now, I’ve been in practice now out on my own- not on my own, I work in a group practice, but I’ve been out as an attending for a year. And there are still things constantly that I’m learning, and new ways of doing things, and tweaking things. But I think it took me a bunch of months to really feel like, ‘Okay, spread my wing, you know I can do this.’ And at the very beginning when I was first out in practice as an attending, I was going to my mentor who hired me all the time to ask him questions. And that’s having had a full residency training in my field. You can’t- maybe there are some physicians out there who just go and kind of do their thing, and see what works and what doesn’t. But I think if you have the best interest of the patient at heart and you’re trying to learn and see what works, and give the best possible care you can, then you’re going to be constantly questioning and asking and figuring out, ‘How do I do this?’ And there’s a shift that happens too from going from inpatient care in the hospital to outpatient care in practice. So to go from medical school- the halls and walls of medical school to then out in the middle of a rural area, that’s such a huge shift too. How in with one month are you going to have enough mentorship and skill building and training to have any clue what you’re going to do for those- what, four years and eleven months that you need to build up those 10,000? It’s when you break this down with this math, it just gets more scary to me. Both for these Assistant Physicians who are yet to be named, and for the patients. I don’t know, Missouri.

Dr. Ryan Gray: Calling out Missouri.

Dr. Allison Gray: Sorry, Missouri. Missouri produces great thing, I mean- you know? But that’s- yeah.

Healthcare Extenders

Dr. Ryan Gray: So let’s talk about what are known as healthcare extenders. Physician Assistants, not to be confused with Assistant Physicians- and that was confusing too. If you’re an Assistant Physician, typically you’re assisting a physician. So if you’re a physician assisting another physician, but there’s no other physician on site, how are you an Assistant Physician? You should be just an assistant- a physician.

Dr. Allison Gray: It’s almost like a different word-

Dr. Ryan Gray: It’s a tongue twister.

Dr. Allison Gray: Yeah, it’s almost like a different word for apprentice or something. But I mean to be- and what’s the person that advises the apprentice? Like the master or something, right?

Dr. Ryan Gray: Something like that.

Dr. Allison Gray: These people are like going to be basically an apprentice without a master after a month.

PAs and NPs Serving this Role

Dr. Ryan Gray: Yup. So let’s talk about PAs and NPs. And why can’t a PA fill this role? Or an NP fill this role? This is kind of what they are made for almost. Just the difference would be that they’re lacking that clinical oversight that typically their license allows them to work under.

Dr. Allison Gray: So you’re suggesting that basically a PA or NP serve this role but without any supervision kind of?

Dr. Ryan Gray: So it would be you would need some remote supervision. So I remember a time when I went and saw a dermatologist, and it was a PA that I saw. And the MD who this PA worked under- because as a PA you have to work under a physician’s license. The MD ran a totally different clinic in a totally different part of the state. And talking to this PA about it, because I was an MD at the time, and asking him the logistics of it he said, “Yeah he cosigns all my notes and he’ll come down to this practice once a week and do X, Y, and Z with me.” So that was the oversight that had been worked out and apparently that was kosher with the laws of that state. So why- I’m wondering why can’t that be instituted here as well.

Dr. Allison Gray: Yeah, absolutely. I mean I think in some ways that’s a safer bet. PAs have- we looked this up recently just to clarify, but they have two years, did we say, of school?

Dr. Ryan Gray: It’s roughly about 27, 28 hours depending on the school. It’s typically about a year of classroom stuff.

Dr. Allison Gray: And then a year of clinical training.

Dr. Ryan Gray: And then a year plus of clinical training.

Dr. Allison Gray: So right, so if you compare that to medical school, it’s four years of medical school versus really-

Dr. Ryan Gray: It’s half.

Dr. Allison Gray: Yeah. So- but really-

Dr. Ryan Gray: They’re training for a different role.

Dr. Allison Gray: Right, they’re training for a different role and I think the key thing that you just mentioned is they’re getting ongoing supervision. So my question is why are they so quick to be saying to these Assistant Physicians, “Okay here’s your mentor, here’s your supervision, okay bye.” Why is it only a month? If PAs and NPs get ongoing supervision; okay I get it because maybe that Assistant Physician has MD or DO at the end of their names, so maybe they’re saying, “Well okay fine they don’t need it.” But really, that’s what we’re saying, yes they do.

Dr. Ryan Gray: And actually I think NPs can practice typically on their own.

Dr. Allison Gray: Yeah I think, well-

Dr. Ryan Gray: They’re different than PAs.

Dr. Allison Gray: But I think they still- I know from NPs that I work with, they still have to practice under a physician’s license.

Dr. Ryan Gray: Okay, every state might be a little bit different.

Dr. Allison Gray: Yeah, it’s very true. States- like Massachusetts is a pretty strict state so that may vary. And also I mean if- you know like we’ve talked about before, some states only require you to have one year- we haven’t even talked about that yet, one year of internship before going out in practice. And maybe- actually, Ryan since I just segued into that, you know you’ve had a different experience than me because you did a year of internship and then went directly into practice.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: But you also have- you’ve been taking care of kind of a different population.

Dr. Ryan Gray: Yeah, I take care of a healthy population.

Dr. Allison Gray: Right, so what do you think about that? I mean-

Dr. Ryan Gray: So I’ve had one year of ‘residency training’ with my internship, and then I was pulled to be a flight surgeon, a practicing attending ‘physician’ taking care of patients on my own. And-

Dr. Allison Gray: No quotes about it.

Dr. Ryan Gray: No quotes.

Dr. Allison Gray: Yes. You have been.

Dr. Ryan Gray: Yeah. My patient population is healthy relatively. I take care of pilots and where I was stationed before I took care of their families, so maybe not a healthy population with their family. So it was a little bit different. But again I’m surrounded by other physicians.

Dr. Allison Gray: And you also had some supervision I remember in your first year.

Dr. Ryan Gray: Yeah, for a while.

Dr. Allison Gray: Yeah, in your first assignment, yeah.

Dr. Ryan Gray: They review all your records, and blah, blah, blah, blah, blah. But anyway-

Dr. Allison Gray: Yeah.

Dr. Ryan Gray: And again everybody is going to be different. But for that role I felt comfortable having just had the one year of internship for the type of people that I’m seeing and treating.

Dr. Allison Gray: Right.

Differing State Laws

Dr. Ryan Gray: And what Allison just mentioned, not every state will let you practice medicine with just one year of internship. So the state we currently live in, Massachusetts, you have to have a full residency behind you, at least three years of training post medical school to actually get a full license and practice in the state.

Dr. Allison Gray: Right so the fact that you practice in the state because you’re in the military, so it’s a different situation.

Dr. Ryan Gray: Correct.

Dr. Allison Gray: But yeah, so like I can’t imagine that the same role could go into practice in Massachusetts because how could they design that when they don’t even allow physicians to practice? How would that work, right?

Dr. Ryan Gray: Yeah, that would be interesting.

Dr. Allison Gray: That’s what makes all of this hard too, that we’re one United States but every state is different. Could it be more complicated? I just think about like countries like Germany where you know, stroke care is so much more sort of straight-lined, streamlined- streamlined, because everything is centralized, there are a whole bunch of hospitals but they’re all the same system, it’s one country, it’s not like it differs- I mean maybe it differs by province or something like that. But it’s just- it’s- I don’t know, we have a lot of challenges in the United States. And again, I think Missouri is thinking outside the box. People are going to have to come up with some new ideas because we do have a physician shortage, it’s only going to get worse. We’re going to have less- or I guess not less and less people matching, but more and more people who need residency spots that don’t get them because we’re not creating more residency spots. And meanwhile we’re going to have a lot more people who are seeking medical care because they have insurance. So something’s got to give, I just don’t feel that this solution is really in the benefit of the patient or the healthcare provider because it doesn’t- it doesn’t sort of make a safe situation for anybody. And where is that learning going to happen honestly? Is it going to happen when that person makes a mistake after mistake and then the state realizes, ‘Oops, everybody’s getting sued, this is not working.’

Dr. Ryan Gray: You’re going to get a flood of malpractice lawyers to the state of Missouri.

Dr. Allison Gray: That’s not good.

Dr. Ryan Gray: Alright, any final thoughts on this Allison?

Dr. Allison Gray: No, I mean I think- just you know the role of NPs and PAs, I think it’s great that there’s that team, and I guess that’s my final thought Ryan. One of the things about medicine that does make medicine great, it makes medicine work well, is still this team concept that we always talk about; and I think that that’s also what we’ve talked about on both sides of the coin is missing in this new model they’re talking about, and maybe that’s what they have to realize and that’s what- not that I’m some all-knowing person here but that’s my thought on it. That they need to work some type of team into that solution. If that’s what they’re going to go with, if they’re going to go with an Assistant Physician, they need a team around that person to help that person, to help their patients, because to really go it alone after you get your diploma and you get a month of supervision and then you kind of- good luck to you, that team is lacking and I think that’s that support network and that ability for the physician also to keep learning is going to be missing. So maybe they can build on it, but not pass it the way it is. I think the government- the governor has to now approve it or veto it, that’s the next step in all this. So maybe we should write him an email.

Dr. Ryan Gray: Tell him to listen to this podcast.

Dr. Allison Gray: Those are my final thoughts.

Final Thoughts

Dr. Ryan Gray: What are your thoughts on this? If you’re listening to this, and you have any strong thoughts either for or against or disagree or agree with what we’re saying, go to, that’s our dedicated show notes page specifically for this episode where you can leave a comment and tell us what you think. I’d be interested to see what people think about this; if they’re excited to finish school and get out and actually practice because that’s what we all kind of go into school wanting to, or if they’re scared, or what. It would be interesting. If there’s any lawyers listening to this, what do you guys think of it? That’d be interesting.

Alright Allison how can people email us?

Dr. Allison Gray: They can email us directly by emailing at- so or See I know our emails very well, I just don’t know our Twitter handles. Wait I do, you can also find us on Twitter at @MedicalSchoolHQ for Ryan, or @Allison_MSHQ. See I did.

Dr. Ryan Gray: She’ll never read your tweet.

Dr. Allison Gray: I’m sorry, this is such an old joke, I really just need to get on the Twitter.

Dr. Ryan Gray: On the Twitter, did you just say ‘the’ Twitter? Wow, sorry folks. Anyway, that’s awesome. Alright so very interesting topic, brought up a lot of mixed feelings when I read it so I hope we were able to kind of express our thoughts and get some dialogue going. I think what Allison talked about is correct. Missouri is thinking outside the box and that needs to happen. I think as you progress through your premed career, as you progress through your medical student career and as a resident and later on as a physician, don’t accept the status quo for what it is. Always be thinking outside the box of how to make things better. Always, constant process improvement, constant anything improvement should be at the forefront of your mind. Don’t accept just because that’s the way we’ve always done it, is the reason why we do it. So I think that’s an important thing to think and maybe a good take home message here is it’s okay to think outside the box like Missouri is doing, but they just did it wrong.

Dr. Allison Gray: Change is coming, so yeah.

Dr. Ryan Gray: Yeah, change is okay. Alright I hope you got a lot of great information out of this today and as always I hope you join us next time here at the Medical School Headquarters. And don’t forget to go to and download that free report today.