Graduate Physician Act
by Megan Pereira
Tennessee House Bill 810 (2020), referred to as the “Graduate Physicians Act,” is a bill that establishes a process for licensure of graduate physicians (medical students who have successfully completed an M.D. program and have passed Step 1 and Step 2 of the United States Medical Licensure Exam but are not moving on to a residency program). This licensure would permit the graduate physician to practice under the supervision of a licensed physician in a capacity equivalent to that of a physician assistant.
The Graduate Physicians Act is being brought to the House as one potential way to aid in the primary care shortage. In the United States today there is a shortage of health-care providers, particularly in the field of primary care and in rural areas, that can create a barrier to accessing healthcare (Davis-Huffman, 2017, p. 35). This issue, referred to as health professional shortage areas (HPSAs), can be designated for an entire geographic area or for a particular population (such as the homeless, Medicaid eligible, or migrant farmworkers) (Health Resources and Services Administration, 2019). Individuals in HPSAs receive lower quality healthcare and ultimately have a greater risk of negative health outcomes (Nies & McEwen, 2015).
Many propositions have been made to solve this primary care provider shortage and there is apparent tension among various fields (physicians, physician assistants, and nurse practitioners) as to the correct solution. Physicians may see the solution as increased funding for residency programs to increase residency spots or increased pay for primary care providers to incentivize medical students to join this specialty. Nurse practitioners and physician assistants may see the solution as increased scope of practice to provide autonomy and eliminate the need to practice under the supervision of a physician.
However, it is unlikely that one proposed solution will solve the problem, but rather multiple changes to the healthcare system made with the good of patients in mind.
The Graduate Physician Act is one such change, providing another option for patients to access high quality care. Individuals who would qualify as “graduate physicians” will have successfully completed a medical school curriculum and have passed the first two medical licensure exams.
Additionally, by the end of medical school they will have completed an average of 6,000 clinical hours. For comparison, the average clinical hours required in a nurse practitioner program ranges from 500-1,500 and the average required in a PA program is 2,000 hours (Primary Care Coalition, n.d.).
While nurse practitioners and PAs are licensed to work under the supervision of a physician at that point, there is no provision for a graduating medical student if they do not move on to a residency program of which there are far fewer spots than there are applicants each year. With this extensive training and proven competency as indicated by passing licensure exams, graduate physicians could increase the availability of high quality primary care if the graduate physicians act passes.
Importance as a Student Nurse and Future RN
While on the surface this may not appear to be an issue that would be of concern to nurses, supporting the graduate physicians act is one way that I believe I, as a future nurse, can advocate for my patients before they become my patients. The graduate physicians act is one way to help decrease the shortage of primary care providers, thereby increasing access to healthcare. As nurses, we are taught to think not only about our patient at the bedside, but also about public health and prevention. Studies have shown that increasing the supply of primary care providers is associated with lower mortality rates, so this is an issue that nurses should be concerned with because it could have significant impacts on overall population health (Basu et al., 2019).
Additionally, the potential effects of this bill could trickle down even to the bedside. Hospitals across the country are overflowing with patients and the result for many nurses is increased nurse-to-patient ratios when providing care. A meta-analysis of available research shows that higher nurse-patient ratios are consistently associated with poorer nursing outcomes (Shin, Park, & Bae, 2018). These outcomes included higher levels of reported burnout, greater job dissatisfaction, and increased intent to leave the job. Increased access to and quality of primary care have been shown to decrease the number of inpatient hospitalizations among the elderly (Huang, Meyer, & Jin, 2019) and increase hospital bed availability which would decrease patient load and help with nurse-patient ratio problems (Kim, Park, Yoon, & Kim, 2019).
Therefore, the graduate physician act has the potential to improve nursing outcomes for the bedside nurse.
Implications for citizens
The primary care shortage affects millions in the state of Tennessee. Currently in Tennessee, there are 32 counties that qualify as medically underserved and 20 counties classified as geographical health professional shortage areas, meaning that for the entire population in that county access to health professionals is at a shortage (Tennessee Department of Health, 2019). 16 of those geographic health professional shortage areas are classified as “high needs” (Health Resources and Services Administration, 2019). In total, an estimated 2,494,850 people are residents of these health professional shortage areas in Tennessee (Kaiser Family Foundation, 2019). All of these people are at an increased likelihood of negative health outcomes. While the graduate physicians act certainly will not solve this problem, it can be a step in the right direction to begin to reduce these disparities.
Clinical Experience in Advocacy
This assignment has been a helpful opportunity to grow in both my desire and my ability to advocate for patients. Advocacy is an essential part of nursing and it should not stop at the bedside. Nurses must also learn to advocate on a policy level and use their voice to bring about systemic change. For me, this assignment was a step in that direction. It forced me to do what I otherwise would not have done. I learned how to track the movement of a bill through the state House of Representatives, how to locate my Senator and Representative, and how to research policy issues so that I can be a well-informed advocate. In the research process, it has also helped expand my view of the impact policy changes can have on a society. As I thought through the significance of this bill for me as a future nurse and for citizens in my area, I realized that advocating at a systems level can have long-lasting and far-reaching positive effects. All of these things helped shift my thoughts from what was honestly an ambivalence toward policy to a greater desire to be an advocate and a greater confidence in the potential changes that can occur.
The Graduate Physicians Act provides one solution to the large problem of primary care provider shortages in Tennessee and will be a step in the right direction to reducing that shortage.
While the Tennessee Nurse Association is opposing this bill, claiming that “there is no need for this, if APRNs [advanced practice registered nurses] were allowed to practice to full scope of practice, they could address primary care shortages in the state,” I do not believe that to be the most appropriate response (Tennessee Nurses Association, 2020).
Instead of warring over who should be the clinicians to solve this shortage, it seems ultimately in the best interest of the patients to open the door for the most competent clinicians, whatever their degree, to be more accessible to those in shortage areas.
Basu, S., Berkowitz, S. A., Phillips, R. L., Bitton, A., Landon, B. E., & Phillips, R. S. (2019). Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015. JAMA Internal Medicine, 179(4), 506. doi: 10.1001/jamainternmed.2018.7624
Davis-Huffman, P. M. (2017). Health Care Environment and Policy. In Murray, E. Nursing Leadership and Management for Patient Safety and Quality Care. (pp. 27-44). Philadelphia, PA: F.A. Davis Company.
Health Resources and Services Administration. (2019). HPSA: Find. Retrieved from https://data.hrsa.gov/tools/shortage-area/hpsa-find
Health Resources and Services Administration. (2019, September 20). Types of Designations. Retrieved from https://bhw.hrsa.gov/shortage-designation/types
Huang, Y., Meyer, P., & Jin, L. (2019). Spatial access to health care and elderly ambulatory care sensitive hospitalizations. Public Health, 169, 76–83. doi: 10.1016/j.puhe.2019.01.005
Kim, A. M., Park, J. H., Yoon, T. H., & Kim, Y. (2019). Hospitalizations for ambulatory care sensitive conditions as an indicator of access to primary care and excess of bed supply. BMC Health Services Research, 19(1). doi: 10.1186/s12913-019-4098-x
Nies, M. A. & McEwen, M. (2015). Community/Public Health Nursing. St. Louis, MO: Elsevier.
Shin, S., Park, J.-H., & Bae, S.-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273–282. doi: 10.1016/j.outlook.2017.12.002
Tennessee Department of Health. (2019). Federal Shortage Areas. Retrieved from https://www.tn.gov/health/health-program-areas/rural-health/federal-shortage-areas.html
Tennessee Nurses Association. (2020). Legislative Priorities. Retrieved from https://www.tnaonline.org/government-affairs/legislativepriorities/