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  • Writer's pictureRebekah Bernard

Board Certification: A Double Standard for Physicians?

There is an increasing double standard in the practice of medicine and the practice of advanced nursing, and one of these is the difference in ‘board certification.’ Nurse practitioners take just one board examination in the course of their career, which is 3 hours long and 200 questions. Nurse practitioners never have to take another exam – they just have to submit their work hours, which can even be volunteer hours. In contrast, physician board exams are most more rigorous, lasting 9-10 hours or more, and must be repeated every 7-10 years. In 2015 the American Board of Medical Specialties added another layer to the process, requiring that physicians participate in a continuous “Maintenance of Certification” (or MOC) process to maintain board certification.

Many physicians balked at the increased burden and cost of this MOC process, and grassroots organizations even sprung up to provide alternate pathways to make it easier for physicians to practice medicine. Today we are talking with Dr. Paul Mathew, a neurologist and a board member of the National Board of Physicians and Surgeons.

Listen to the podcast here:

Watch the YouTube video here: Get the book 'Patients at Risk:" Join PPP: Certify with the National Board of Physicians and Surgeons:

Previous article from Dr. Bernard on board certification:


Rebekah Bernard MD 0:07

Welcome to 'Patients at Risk,' a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host, Dr. Rebekah Bernard and I am joined by a special guest co-host tonight. Dr. Amy Townsend. She's a fellow board member with me with the group Physicians for Patient Protection. Amy, thanks for being with us.

Amy Townsend MD 1:10

Thank you for having me back, Rebekah.

Rebekah Bernard MD 1:12

There's an increasing double standard in the practice of medicine and the practice of advanced nursing and one of the differences is this concept of board certification. Nurse Practitioners take just one exam to be considered board certified. It's about three hours long, it's 200 questions, and they never have to take another exam the whole rest of their career, all they have to do is submit work hours, which can even be volunteer hours. In contrast, physician boards are much more rigorous, lasting at least nine to 10 hours if not more, they must be repeated every seven to

10 years. And in 2015 the American Board of Medical Specialties added another layer to the process requiring that physicians participate in continuous maintenance of certification or MOC process to maintain board certification. And so some grassroots organizations have sprung up to try to provide alternate pathways to make it easier for physicians to practice medicine. So today we're talking with Dr. Paul Mathew. He is a neurologist and he's a board member with the National Board of Physicians and Surgeons. Thank you so much for joining us. Dr. Mathew.

The National Board of Physicians and Surgeons NBPAS

Paul Mathew MD 2:22

Absolutely. Thank you for having me.

Rebekah Bernard MD 2:24

Paul, can we start out just by having you tell us a little bit about your background and how you got interested in medical advocacy?

Paul Mathew MD 2:30

Yeah, absolutely. I think like many of us, I was attending a national meeting, in my case, the American Academy of Neurology. I knew nothing about what MOC was. And I had to learn what the steps were and the modules and the uploading and downloading is a very confusing process. And me and just about everybody in the room are asking, What is this all about? Why are we being asked to do this? Why are we paying to do this? Why are we being forced to buy modules? What about these surveys where you can cherry-pick colleagues and patients who will then give you high ratings and pass? So it all seemed like busywork. And nobody really seemed to have good answers to these questions. I personally started a petition when we had 1200 signatures of neurologists, asking just to remove the modules, keep the exams, keep the money, just remove the modules. That petition later triggered the letter from the American Academy of Neurology and the American Psychiatric Association, both of them actually supporting the point of removing modules. And the ABPN, which is the American Board of psychiatry and neurology said no, we have no power to remove the modules, we have no power to make any changes, even though at the same time the ABIM had suspended their modules and their process because it's such an uproar. So that's kind of what got it started for me. Eventually, when I realized that there was too much money involved and people really had no motivation to change that I reached out to Paul Tierstein who's a cardiologist in California. Scripps Clinic, he's the one that started the National Board of Physicians and Surgeons. I joined as the neurology representative as a board member and then eventually got elevated to director of Legislative Affairs.

Rebekah Bernard MD 4:04

Thanks for that. We're going to dig into the NBPAS more why it even had to come into existence. But let me start with Amy. Amy, when do you remember first learning about this new change to board certification for physicians?

Amy Townsend MD 4:19

Yes, I did my initial board certification. Everyone expects to kind of go through that process newly starting out. I was surprised I think I mean, it was wasn't really anything that some of my predecessors had really talked about it as to how time-consuming and how expensive it was to actually do recertification. So I did my initial certification and then did one-time recertification and I also added some additional qualifications and took the test for hospital medicine. So I was boarded in both family medicine and then have additional hospital medicine certification. When it came back around to having to continue to do all that like Like you said, all of that busy work. It just wasn't worth it to me, you know, I did not see any value in the process was really, really expensive. And then I actually read a couple of the papers about Dr. Wes Fisher, who had brought the lawsuit against that certification process. And it really, I mean, some of the information that was there about all of the kind of money grab and how much money some of the leadership of the boards were making, just really left a bad taste in my mouth. So when I decided to go into private practice, actually left hospital medicine, I did not really need I mean, the hospital that I was in did not require me to participate in MOC. So I said, You know what, I really just don't see the value in this anymore. And I decided not to continue that mock process. And then found out about the National Board of physicians and surgeons in that process and actually have that certification now instead.

Rebekah Bernard MD 5:57

Paul, I'm still happy that you guys decided to create this alternate pathway. I had a similar story to Amy, I was ready to recertify. I originally certified in 2002. I was doing my recertification in 2009. And then here, it was 2015, it was time to go again. I went to the computer, I started putting in my information, I signed up to take the test. And then all of a sudden it said please, you know, insert your credit card to be charged $3,500, something like that for these modules that you're going to have to do over the next couple of years. And I was like, 'Huh,' so I said, Well, let me just start the process. And basically, it was like until you put that full payment in. And they even had the offer that you could finance it through them. I mean, it was crazy. And I said, 'Wait a minute. This, to me, is just a financial racket.' And I also was going into direct primary care. So I decided I'm not going to do this anymore. But many physicians are not able to do that because most insurance companies for credentialing and hospitals require the standard board certification. So Paul, what is the NBPAS doing to try to get more acceptance of this alternate pathway. Are you making much progress on that?

Paul Mathew MD 7:12

Well, first, I do want to comment on the expense, which I don't think people really realize the gravity.

There was a JAMA article that did an analysis and for an internist to participate in a 10-year MOC cycle, you're already $16,000 when you look at cost of test prep material, the actual MOC fees time off from work, and not seeing patients lost revenue is $16,000. For hematologist-oncologist to participate in the 10-year cycle, you're ready $40,000 in terms of again, lost revenue, and all these other figures.

And then when you look at the revenue generated the ABMs boards in the financial year, 2013 generated $263 million dollars, and they had $239 million in expenses. So you're ready surplus $24 million, I would be happy to take that rainy day fund to the bank any day of the month. And in addition, a lot of this surplus money did end up in overseas accounts, which really makes you wonder, you know, where's this money going? And eventually, what is it being used for?

Rebekah Bernard MD 8:22

It's so interesting that you say that because what you mentioned is not just the direct cost of the testing, but all these additional fees. And I think this may be one of the reasons why we're having a hard time making changes because there are a lot of other organizations who profit off of this process. For example, our own academies, our own specialty societies, our state societies, they all offer different test preps, they offer courses they offer, you know, CMEs that can be applied to it. And they all make money off of this as well.

Paul Mathew MD 8:51

Yeah, to your point, actually, for a long time, many of the societies were selling the modules that were required in order to get that credit for MOCs. One other thing I'll tell you, so a lot of people say, oh, physicians have plenty of money they can pay for these fees. What people don't realize is more and more of the organizations that we work for the hospital systems are actually footing the bill for MOC. So just to give you a figure that there's a hospital, which will remain unnamed. And let's say that there are 1200 physicians working for that hospital, and a $2,000 a pop, that's $2.4 million over 10 years or $240,000 per year that that hospital is shelling out just to pay for MRC fees. That's not even including loss of revenue from not seeing patients. And also let's not forget when you're losing revenue from not seeing patients that have also reduced patient access to health care, both in terms of physicians who are taking time off to do these MLC modules, but also physicians who just think to themselves, listen, I'm towards the end of my career. Continuing to jump through these hoops is not worth my time. I am preferring early retirement because it's one less thing to deal with. So when people say, 'oh, doctors have plenty of money,' no, believe it or not, a lot of that money is coming from the hospital General Fund, which is not being spent on, you guessed it, the opioid crisis, as well as COVID-19 funding.

Rebekah Bernard MD 10:11

Right. And also the idea that physicians have plenty of money and blah, blah, blah. That's not necessarily the case, either. I mean, look at your, you know, our primary care colleagues, many of us, actually, it's kind of interesting, because I was seeing the prices that are being paid now, for nurses that are working for COVID-19 units. And the pay per hour is actually as much or more than some physician colleagues that I know are getting paid to work in their jobs. Yes, of course, I'm not to say not saying physicians don't make a good living. But there's no reason that people need to profit off of our labor, we're not making that much that everyone can just skim a little bit off the top. So So what are you guys doing to try to get more acceptance, especially if hospitals are shelling out that much money? It seems like it'd be in their interest to make a switch.

Paul Mathew MD 10:57

That's correct. But actually, one other point I did want to highlight is that you were talking about how we're separating into physicians who have lifetime certification before 1994. And those that don't, and what some subtle nuance that people don't realize is grandfathered physicians or people that have lifetime certificates as a group are 80% Caucasian, and 70%. Male.

So not only is MOC compliance discriminatory based on age, but also based on race and gender, because, in fact, there's an elite status that's being granted to older white male physicians.

Rebekah Bernard MD 11:31

That is definitely a nuance that I was not aware of, and very interesting. So my big concern with NBPAS and I am a proud member, and I have been since I believe 2016 when I certified and then I let my ABMS lapse. But here in the state of Florida, only the A BMS is recognized and therefore I'm not allowed to call myself a Board Certified family physician in any kind of writing or advertisement. And it's really interesting because nurse practitioners, you know, everywhere I'm a board-certified and, you know, 12 different things. And meanwhile, I can't even call myself board-certified, even though I've originally done it and recertified because the board of medicine does not recognize this pathway. So what is being done to try to promote and make changes so that we can get recognized and have this alternate pathway actually be meaningful to more of us,

Paul Mathew MD 12:25

We actually have been trying to avoid the language 'alternate.' Because we are a legitimate enterprise, we are in the recertification business. And you know, that's reflected in a lot of the position statements that we've issued for some of the bills that we've supported. That recertification should be acceptable by the AMA, the ABMs, and the NBPAS. And the reason for that is what unites the three organizations and initial certification examination. So one thing we all stand behind is that the knowledge that's acquired and the clinical experiences that are gained during residency are highly variable between all the programs all over the country. So it makes complete sense for all residents who and fellows that complete an ACGME or non ACGME residency or fellowship to sit a standardized examination that they can complete. And we can certify that they have a uniform body of knowledge upon graduation. Now, that is one of the requirements for NBPAS is that you complete a residency -that you complete an initial certification examination. And we also require 50 CME hours in your specialty. So a lot of people do say, well, that's not a very high standard. I will remind everybody that when you complete CME for your state licensure, there's really no verification, but you're actually just attesting that you've completed it. Nobody, a lot of the time even checks that and more importantly, nobody actually checks that its relevance and meets your specialty, or subspecialty, which you're certifying to get back to your question. So the steps that the NBPAS is taking, number one, we are encouraging people to become diplomats, even if your hospital doesn't accept that becoming a diplomat is a very important first step. Because again, we are nonprofit, all the board members are volunteers. So really all the money that's generated by NBPAS is just paying for the administrative office staff that's actually going through the certificates and issuing the certificates and the rest of the money is actually really supporting lobbying and ensuring that policy and bills are passed that ensure that it's a level playing field between the ABMS and the NBPAS.

Rebekah Bernard MD 14:21

So Paul, what you're saying is that you guys will not be buying a luxury condominium? Or what are the other things that the ABMs bought? There was an amazing Newsweek expose - there were several of them where they just went through the insane expenses and different things that the ABMs board was spending their money on.

Kurt Eichenwald Newsweek Article "A Certified Medical Controversy"

Paul Mathew MD 14:42

Yeah, I mean, there was a luxury condominium in Philly, a chauffeur-driven limousine. You know, the other thing that they had were these very lavish meetings where family members were all encouraged to attend and, you know, the bills that they ran up at some of these resorts was unbelievable, you know, the the the most expensive event that the NBPAS hosts is a zoom meeting twice a year. So you know, we are not ballers in that sense.

Rebekah Bernard MD 15:06

It sounds like the board of PPP. We're right there with ya.

Paul Mathew MD 15:09

Yeah, it's more or less for the love of the game. I can say, you know, my only disclaimer is every once in a while I do get travel expenses covered if I am giving a lecture on the subject, and occasionally some speaking on right, but no salary to speak of, definitely not six figures. And if you log in the 1000s of hours, I've been logging in for NBPAS since 2014. It would be a fool's errand to think I'm going to come up ahead of the game in any way financially.

Rebekah Bernard MD 15:34

So it sounds like the first thing that you want our listeners to know is that even if there's not really a compelling reason for you to do so right now, it makes sense for you to go ahead and become a diplomat of the NBPAS now because they're going to be able to use those dues. It's not much I think it's like, isn't it like $169 for two years, I just renewed mine. It's not a tremendous amount of money, and ideas, the more of us that do it, the more power the organization has to, therefore, lobby and try to get this accepted.

And again, just to clarify, this is in no way replacing an original board certification. We still want all physicians to complete their residency to pass their board examinations to make sure that they know how to practice medicine. This is just about eliminating the burdensome recertification process.

I will say when that all came about physicians were really upset about it. And there were all sorts of meetings and letters written and what really upset me was that the ABMs completely ignored the outcry from physicians. In fact, they had it in some of these different articles that they wrote about it. Well, this is what the doctor said, they don't like this. They don't like that they're concerned. But ultimately, they just said, but we're still going to do it anyway. And so that's where I got frustrated because I feel like this happens to doctors all the time. And we're just kind of railroaded into doing what whoever in power tells us to do even when we're all saying no, we don't want to do this. And it's because then they hold our ability to have hospital privileges and credentials away from us if we don't comply. Same with Meaningful Use and all these things. And I think physicians are just getting pretty tired of it. But it is hard to stand up. So I thank you for doing that.

Paul Mathew MD 17:16

Yeah, so you actually hit the nail on the head, unnecessary administrative burdens, are the driver of physician burnout, as much as people like to think otherwise. That is the case.

You know, one other note that you hit upon, which I'd like to expand on is one size that does not fit all. You hear it over and over again in different specialties. I'm an adult anesthesiologist, why am I going to review pediatric intubation techniques and be tested on that? After all, I practice adult anesthesiology? My favorite example is I'm a neurologist at no point in my career, have I taken a biopsy then looked at it under a slide and then identified it, but that is tested on some of this material, which is absolutely frivolous. The other thing I will say is, you know, NPBAS has already succeeded. Because the ABMs boards, many of them have actually gone from a 10 year high stakes exam to an article reading and then taking quizzes. Some people would argue that's actually more onerous, instead of one painful exam every 10 years, you now have multiple open-book quizzes. Now my issue with that, once again, one size does not fit all, what am I really going to gain from reading an article on a zebra neuromuscular disorder that I as a headache specialist will never ever see in clinic? And more importantly, why am I paying attacks to read an article that I may have read anyway? And is really answering a couple of questions proving that I understand the material any more than I would have just from reading the journal articles myself, I would say no.

Rebekah Bernard MD 18:43

Yeah, I agree. Now, Amy, and since have you actually dropped ABMs or not yet?

Amy Townsend MD 18:49

So my certification, I think, ends this year. So I have not, I haven't done the stuff to renew it. So I'm assuming that it will just drop off, which is fine with me. One of the other things that I was gonna ask, though, Paul is I know in the state of Texas back in is either 2017 or 2018, we actually passed with the help of the TMA, we passed legislation that actually prohibits hospitals from discriminating between physicians that are participating in mock versus those who are not participating in MOC but the law, unfortunately, had a couple of little carve-outs, you know, one of the carve-outs was if you have a hospital, that the medical Executive Committee and the medical staff decides that they want to require more participation, then they let that pass, I think in some of the medical schools and things like that they can also require participation and mock. But you know, I think it was at least a concerted effort to try to push back on some of those requirements, and it was headed by the Texas Medical Association.

Paul Mathew MD 19:48

They make your point regarding that law. It is in fact a law. And the big issue is that a hospital can only require MOC if the medical staff is not an executive committee, not the credentialing committee. If the General physicians have voted in favor of requiring MOC, the big problem we've had is we have actually approached the Attorney General in Texas about this issue saying this hospital is not following the law. And unfortunately, they've turned around to us and said, You have no standing in Texas to raise that issue. However, if there are brave physicians who are willing to say, Hey, listen, my hospitals breaking the law, we would be more than happy to serve along as co-plaintiffs. In that case, unfortunately, there's a shortage of physicians that are willing to kind of stick their neck out.

Rebekah Bernard MD 20:33

We'll put the call out right now, if anybody is listening, that might be interested in pursuing that you can definitely get a hold of one of us so that we can get you to the right people. I do know that you're in Florida, just in a hospital just north of us, a physician colleague of mine was successful in getting the staff bylaws to change to accept and NBPAS. And it's because he's a person that's very well respected. He's been on staff on the medical Executive Committee, and I asked him, 'How did you do it?' And he said, 'honestly, I just showed up, I showed up to things. I was on committees, and people got to know me, they trusted me. And when I came to them, and I explained to them all about this, they were like, Okay, let's do it.' So I'm sure not every hospital is like that. But clearly what we need are physicians that are willing to advocate for this as an option. And if you can't get anywhere working on that way, then maybe there are other venues as far as, you know, legal strategies that could be taken. But it probably just starts with just asking, and I don't know me, did you ever have any experiences live with that when you were on hospital staff, or it never really came up?

Amy Townsend MD 21:35

So you know, I was actually vice president of medical affairs for a Regional Hospital system, and very often times set on on the credentialing committee. And I did not know at the time a lot about this topic. I mean, this was several years ago, but I do remember them mentioning during one of those meetings that we couldn't discriminate or differentiate between allowing physicians to be credentials based on mock, but there were comments that we need to find other ways around that. So you know, it's still even though in Texas, there's theoretically supposed to be that that protection, I witnessed that firsthand.

Paul Mathew MD 22:12

Yeah, so what I will say is that early on the campaign or the push was kind of an anti-MOC, which we realized really was not a good way to go. Hospitals and other institutions, including insurance companies, like to brag that their doctors are board-certified and continuing in certification. So we've actually shifted our approach.

As I mentioned earlier, we're not anti MOC, but we are pro-competition and pro recertification in terms of the AOA, the ABMs or the NBPAS for recertification.

And I'll share with you guys a very quick, very inspirational story with you. So if you look here, there's a lapel pin that says NBPAs, I was wearing this. And so I wear this at all the meetings that I attended, somebody saw it and said, Wait, you're part of that? And I said, Yeah, I'm home and they're like, whoa, wait a minute, you're that guy. So lo and behold, I told him, it's actually pretty simple. You just on, there's actually templated letters as well as petitions. So this guy actually took the football and ran with it went back to his hospital, at a bunch of signatures from physicians. And again, it was just requesting that Mbps be one of the offerings that physicians can select for recertification. Lo and behold, took this petition took the letter brought up before the credentialing committee, those a vote, and now this hospital system of, I think seven hospitals in Georgia, accept NBPAS. So people might be very pleasantly surprised that it really doesn't take much effort. And I know physicians for patient protection. I mean, that's the underlying theme, instead of complaining, just an ounce of advocacy, if everybody did a little bit would really move mountains.

Rebekah Bernard MD 23:48

And what you've just explained is how one person can make such a difference. And of course, it starts with you because you were that one person that happened to show up wearing your pin. And then this other person says, I want to do that. And then look how it just snowballs and You're so right. physicians, we often sit back we do enjoy talking about all the problems and challenges that we have. But it's a lot harder to actually take action. So thank you for that story. I think it's it is really inspirational. And hopefully, everyone listening out there will want to, you know, just do something to advocate for our profession, whatever you're passionate about. And I'll just mention that, you know, of course, I'm direct primary care, I don't have insurance. They don't accept any insurance. I don't have any hospital privileges. But I will say that changing to nbpas for my recertification has not had any negative repercussions on me whatsoever. It did not affect my malpractice rates. In fact, I was concerned about that. But my malpractice carrier said no, really as long as your practice is in good standing, your license, then it's not an issue. And it hasn't affected really anything other than the fact that I just can't advertise that I'm board-certified. But fortunately, my practice is full and my patients know you know who I am. I just - I would love to see that change just because it kind of drives me a little bit crazy that I can't just label myself what I am, which was originally board certified.

Paul Mathew MD 25:08

It's interesting you bring that up Rebekah because we are actually approaching multiple state boards of medicine with that request, saying that we are primary source verification, both with NCQA and with other states. So we're trying to push for that.

The other thing that I would strongly encourage both of you, and anybody who's a diplomat of NBPAS, is after your MD or your DO, write DNBPAS. People will see it, they will recognize it, and they'll say, Oh, I heard about that. And that's an opportunity to start the conversation.

And you know, dominoes may fall, and you may notice, oh, wow, regionally, more and more hospitals are accepting. And all it really takes is one hospital for the dominoes to be set off.

Amy Townsend MD 25:45

And that was going to be my question is what do we need to do to change that, that ability for us to say that we're, you know, actually board certified? And it sounds like that you guys have a path forward for doing that. And so I would be very interested in seeing how I can help do that. And in my state,

Paul Mathew MD 26:00

absolutely. So it's just a matter of petitioning the board of medicine, a lot of time with the state legislature. So I mean, it's pretty straightforward and reasonable to do. And I think all these things are going to come to fruition soon enough. It's been a long road. But I think with a lot of the excessive spending that we see in the healthcare system, there are going to be more and more politicians looking to trim the fat. And one great thing is what are all politicians concerned about? When you propose a bill? How much is this going to cost my consent? Right? And how much will this will cost $0.

Rebekah Bernard MD 26:33

And in fact, it may actually save money,

Paul Mathew MD 26:35

Your pitch to any politician: it costs $0, increases patient access to healthcare, decreases the cost of health care. I mean, if that's not a trifecta, I really don't know what is.

Rebekah Bernard MD 26:46

It's fantastic. And you know, this is also an example where our academic colleagues have really taken the lead and sometimes us lowly doctors, in the quote, in the trenches, we sometimes feel like, maybe academic doctors are not necessarily understanding what we're going through. But actually, in this case, Dr. Teirstein, the Scripps Clinic, and I think a lot of these other really big name, academic associations really took the lead on this, which I have to say I just appreciate so much because it does add that level of credibility people trust that these academic institutions are not going to put out subpar doctors.

Dr Paul Teirstein, founder of NBPAS

Paul Mathew MD 27:21

Yeah, there's on the board. There's a couple of us from Harvard, Dartmouth, Columbia. So a lot of bigger names that really does add credence to what we're doing. We'll also say, you know, fortunately, or unfortunately, depending on if you like the glass half empty or half full, the AMA has issued several position statements saying that recertification or certification should have nothing to do with practicing medicine. Unfortunately, after those position statements have been issued, really no actionable items have come from it. So I'm continuing to work with the delegations from Pennsylvania and hopefully, Maryland and Massachusetts. So their delegates at the AMA House of Delegates can really push instead of an anti mo See, which I think will never set sail, but rather a pro-competition stance.

Rebekah Bernard MD 28:06

Yeah, I love that. And definitely let me know when you're ready to approach the board of medicine here in Florida because I would love to be part of that process. And it sounds like you've got a Texan here, too, that would jump on that. Yeah. You know, as we wrap up the end of our talk, I wanted to shift gears just for a minute, because we have a neurologist here with us. And I noticed when I was reviewing your CV, that actually you're one of the medical editors for the journal practical neurology. So you know a lot about medical journals. And I was just wondering, did you may have seen that Jama neurology article that called for an increase in advanced practice clinicians in neurology, and I was wondering, what was your take on that? PPP - we issued a letter a response to the journal, which they declined to publish citing lack of space. But I would love to hear your take on that.

Paul Mathew MD 28:55

Yeah, no, in this regard, I think there's a little bit of a divide in PPP there. There's some kind of I hate to say extremists that are saying that NPs should be disbanded and the profession should be gone. You know, I think that'll never happen. And I think the olive branch, the way to really deal with this would be physician-led teams. That's the official stance of the American Academy of Neurology. You know, how much they actually act on that it's hard to really say, I have actually sent some messages regarding that particular article, as well as some of the other videos that have been put out saying equating a nurse practitioner who has some training in neurology with a full-fledged neurologist. So I think it's really problematic. But at the same token, I think the big the bigger issue, as both of you know, is these independent practice bills, which are really, really concerning.

Rebekah Bernard MD 29:43

Well, I think that was the issue with the journal article. PPP advocates for physician-led care, we do not want to see NPs or PAs go away - they are essential parts of the team. And studies show over and over again that when physicians and nurse practitioners and physician assistants work together, patients get great care. The problem was that the article was saying, well, there's a shortage of neurologists. So let's train more nonneurologists, practitioners to take on that role when everybody in medicine knows that neurology is one of the most challenging specialties. It requires an incredible fund of knowledge. And I mean, it's to me, like, I just don't understand how you could say, well, either you could go to medical school residency and a long fellowship. Or you can take someone who did 500 hours and train them to do the same thing. And really, the article was calling for more independent practice saying that they need to be used to the level of their, the extent of their license, or, you know, the mantra that they say, and I think that was the problem that we had with the article,

Paul Mathew MD 30:44

right. So I mean, this is a topic for a whole nother session. But you know, as if I'm not busy enough, with MSC, one thing I'm really pushing for that both of you probably know about is PGL. So PGL, it stands for postgraduate licensure, this is something that I think everybody needs to get on board with for so many reasons. So just to let the audience know, a PGL, or postgraduate license is someone who has completed medical school passed all their Steps, but does not match into a residency program. So they would be able to be they would be granted a PGL license under which they could work under a position that is fully licensed and has completed residency and fellowship, this would be a one-year position. And then you know, they would then get clinical experience to apply for the match. Again, there are some PGLs, who would unfortunately just not match again. And so my thought is there could be a graduated scale. So every year that you continue to PGL, there's an incremental raise in your salary. And there are some people that will fill that role fantastically. And year after year, they'll just be an essential part of the practice and a contributing member of the team. I think PGLs will do a lot of things. Number one, they'll help address the physician shortage. Number two, it'll give these medical graduates a place to gain clinical experience and potential for some of them a final destination. And finally, with an influx of PGL licensed physicians, you may actually see a dramatic drop in independent practice bills and practices of nurse practitioners and Pa. So I think in this once again, kind of like with mo see the only losers were the ABMs and the AMA in terms of their mo c product. In this case, really the only losers would be these Mills that are generating at times 100% online doctorate degrees for NPs and MBAs.

Rebekah Bernard MD 32:29

Yeah, that's the I know that PPP has supported we've called it associate physician, but post-graduate licensing sounds a little better to me, because there is confusion. What does that even mean? I like that term, we definitely have been supportive of that. We know that 4000 United States citizens, every year graduate from medical school and fail to match, and 2000 of those graduated from United States medical schools, there's just not enough slots. And so of course, the long-term solution, we need the residency slots, but in the meantime, absolutely. There needs to be a path for these graduates to be able to work as at least as you know, apprentice physicians or something. So until they're able to get that final training.

Paul Mathew MD 33:14

Yeah, I mean, I would avoid assistant and associate because that just gets very confusing with PA, as both, you know, physician assistants are fighting to be called Physician Associates. So let them keep that terminology. A physician is a physician, so they're an MD PGL or a DO- PGL. So there's no confusion about who we are what we do. I think this is also a huge opportunity for medical schools. Let's say you are at the University of West Virginia, and there are some rural areas that you that really desperately need care, you set up a satellite there, you have some seasoned experienced physicians, and then you open up a bunch of PGL posts for people to work. You know, a lot of those people, as I said, may never match. Some of them might think to themselves, you know, I really like this clinic. I like working here. There's a graduated pay schedule. I'm content with working here full time or part-time I raise a family and do other things. So I think the opportunities here in terms of medical school collaboration, doing what's best for these medical school graduates as well as serving underserved populations where there's a food shortage.

Amy Townsend MD 34:14

I think that the nomenclature, I love that that nomenclature, I think that there's a lot of physician groups that are advocating for the same thing, but it's all under different terminology. You know, I think that we really need to make a concerted effort to use the same terminology when we're talking about these physicians and I really liked that acronym or that those abbreviations i think that that really describes exactly what they are.

Paul Mathew MD 34:36

Yeah. And to your point, it's very transparent. It'll say right on the label on your business card, MD-PGL. But patients will see the MD part. So they'll know Okay, this is a physician. This is not someone that completed somebody's formal training.

Rebekah Bernard MD 34:51

Well, I want to thank Dr. Paul Mathew, so much for coming on and for your tireless advocacy on behalf of physicians and patients. Thank you so, so much. Thank you Dr. Amy Townsend for joining me. And if you'd like to learn more about this topic, we'd encourage you to get our book. It's called patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's, and at Barnes and, please like and subscribe to our podcast and our YouTube channel. It's called patients at risk. And of course, if you're a physician, we would love for you to join our group. It's called physicians for patient protection, our website physicians for patient And of course, join the NBPA s, as well.

Paul Mathew MD 35:31

I just have one closing comment. So again, even if you're an ABMS, or certification has not expired, do consider being dual boarded and becoming board certified by NBPAS. I have been for the past six years now, do consider adding the DNBPAS after your MD or your DO. And again, you might be quite surprised how quickly you can get your hospital local institutions to accept them VPS. And you'll be doing a huge disservice not only to yourselves but to all of your colleagues.

Rebekah Bernard MD 35:59

I'm going to put those initials after my name immediately. So thanks for that and it's Thanks so much for listening and we'll see you on the next podcast.

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