Tennessee Becomes the Latest State to Remove Barriers to Assistant Physicians

Jeffrey A. Singer

Tennessee Governor Bill Lee (R) signed HB 1311 into law on May 17, creating the new health care practitioner category called “graduate physicians.” Tennessee now joins Missouri, Arizona, Arkansas, Utah, Kansas, Louisiana, and Idaho in removing barriers that prevent medical school graduates who have not landed a residency position from providing primary care services to patients and honing their knowledge and experience while licensed primary care physicians supervise them.

With a large, medically underserved rural population, Missouri was the first state to launch a new licensure category in 2017: assistant physician (AP). APs are essentially apprentice physicians, a common way to train physicians before the modern era of residency programs. Under this reform, medical school graduates who cannot land a residency position can still care for patients in primary care clinics while enhancing their knowledge and skills.

As Spencer Pratt and I point out in our recent Cato briefing paper, most states require medical school graduates to complete at least one year of postgraduate residency training before granting them a license to care for patients as non‐​specialist general practitioners (GPs). Yet the number of medical school graduates exceeds the number of residency positions. According to the American Medical Association, in 2021, roughly seven percent of Doctor of Medicine (M.D.) and roughly ten percent of Doctor of Osteopathic Medicine (D.O.) graduates failed to match with a residency program. Many are stuck in limbo. They cannot apply the knowledge and skills acquired with their doctorate degrees to care for patients. They can also not hone and develop those skills in a residency program.

A 2021 survey found that one in three physicians and advanced practice registered nurses intend to reduce work hours, and one in five physicians plan to retire. A recent Association of American Medical Colleges study forecasts a shortage of as many as 48,000 primary care physicians by 2034. Researchers project California, Texas, and Florida to have the worst shortages

Some states enacting legislation like Missouri’s call this new category of physicians “associate physicians.” Others call them “bridge physicians.” Tennessee’s new law labels them “graduate physicians.”

Missouri allows APs to renew their licenses indefinitely annually. Some states cap the number of years that APs may work, after which they can only keep caring for patients if they complete a year or more of residency.

Such caps are a drawback because, as our briefing paper explains, the assistant physician model could create an alternative pathway to obtaining a license to practice as a GP. GPs are still a significant component of the primary care provider workforce in the United States.

Unfortunately, Tennessee’s new law sets the cap at two years, after which graduate physicians can no longer treat patients. Nevertheless, Tennessee lawmakers have taken a step in the right direction toward mitigating the worsening shortage of primary health care clinicians.

I will moderate a Cato online event on this subject on May 22, with a panel consisting of the Missouri physician‐​legislator who spearheaded the country’s first assistant physician law, a practicing assistant physician in rural Missouri, and a senior research fellow from Heritage Foundation who has studied this reform proposal in depth. You can register for the event here.