It takes courage to speak up when everyone seems to have an opinion that's different from yours. It's easier, in the short term, to follow the crowd, especially if doing so can be rationalized. However, we lecture patients about making good choices, we advise our children to do the same, and as leaders in our communities and professional organizations, so should we.
Sherry L. Robbins, M.D.
Therefore, when Tennessee lawmakers considered legislation earlier this year that was dubbed the "Doctor of Medical Science (DMS) Act,"(www.capitol.tn.gov) our state academy leaders had to make a difficult decision. As we met with proponents of the legislation, we were told that the bill would address the access-to-medical-care issues of Tennessee's underserved. The bill called for establishing a license for a new type of provider that was, ultimately, to be called an "Essential Access Practitioner" (EAP).
The license would be open to physician assistants with a master's degree and three years of clinical experience after they completed a DMS program, which would be administered through a medical school and consist of 50 credit hours. The didactic portion of the DMS program offered in our state consisted of an online curriculum and web-based group discussion of cases, which was supposedly based on an internal medicine board review course. The clinical training component would simply consist of these PAs continuing to practice under the supervision of their primary care physician of record, with a few cases to be logged per week.
These new "doctors" (later, EAPs) would then take a yet-to-be-devised board exam and be allowed to practice primary care in Tennessee in what was touted as a team-based system, although they would be permitted to be the only practitioner in a location as long as they maintained an undefined association with either a hospital or physician group that practiced primary care. There were no stipulations of supervision, but they would be allowed to seek consultation with subspecialists for cases that they alone determined needed such expertise.
The good news was that this new class of providers would fall under the Tennessee Board of Medical Examiners (BME), and it was expected that the BME would close loopholes as it worked out the details. Supporters claimed that being the first state to roll out this program would be a feather in Tennessee's cap, although similar legislation already had been shot down in Washington.
Repeatedly, we were told that the legislation was a "done deal." As the Tennessee AFP (TNAFP) Legislative Committee discussed options, it became clear that none of us was comfortable with sitting by and allowing this legislation to alter the course of the practice of primary care. We knew that the primary care services offered through this legislation would not approximate the concept of truly physician-led, team-based care that the AAFP has put forward. It would be a disservice to the patients of Tennessee and, quite possibly, would make it even less likely that underserved areas would get physicians in the future. It also would be difficult for our patients (and students trying to decide on careers in medicine) to determine the difference between these doctors of medical science and actual medical doctors.
Our legislative committee agreed that this situation was worth fighting, even if ours was a lone voice. We sent a letter signed by the committee members to the Tennessee Senate Health and Welfare Committee just before its vote. Unfortunately, the bill passed out of that committee with only one opposing vote -- from Sen. Joey Hensley, M.D., a TNAFP member. We sent copies of our letter to the House Health Committee and a blast email to our members and then scrambled to arrange a day on Capitol Hill in Nashville.
Our letter found its way into the hands of a fourth-year internal medicine-pediatric resident, Amber Thacker, M.D., who happens to have a background in policy and advocacy and membership in Physicians for Patient Protection, a national organization devoted to quality care concerns. Thacker had scored an opportunity to testify before the House Health Committee the same day that TNAFP members were on the Hill to lobby against the bill. Other TNAFP members responded to our call for action and voiced their concerns to legislators by phone and email.
Additionally, we learned that the Tennessee Osteopathic Medical Association and American Osteopathic Association had sent a joint letter of concern to legislators. The AAFP also sent a letter(3 page PDF) that reached our representatives just before the committee meeting. It was obvious that many physicians and organizations had concerns; it just took some networking to bring our voices together in a concerted effort.
Thacker's testimony highlighting problems with the bill prompted a lively discussion in the House Health Committee. Representatives from both political parties levied tough questions at Sen. Richard Briggs, M.D. -- the Senate sponsor of the bill -- in a rare show of nonpartisan solidarity, and the so-called done deal began to crumble.
Finally, the committee's discussion was rolled to the next week, and those of us present scrambled to meet with legislators. Evidently, many of them had been told that there was no physician opposition. Therefore, most had planned to vote for it despite having reservations.
We were amazed when the osteopathic school that had pushed for the legislation quickly withdrew its support, promising to no longer seek licensure for its DMS graduates in any state. The bill was taken off notice in the House Health Committee.
However, while doing her usual careful monitoring of bills of concern, TNAFP Executive Director Cathy Dyer noticed that the Senate bill was back on the agenda for the full Senate a few days later, so we again got the word out to our colleagues. Soon, the Senate was bombarded with phone calls urging an end to the bill. It was rolled to the Senate Calendar Committee but not withdrawn. However, all those who had previously characterized the legislation as a done deal were now declaring it dead. Eventually, the legislative session ended without further action.
Interestingly, our state medical association has claimed that organizations that opposed the bill were misinformed. The association even released a video recently, outlining what it termed were myths about the bill -- a surprising development, given the organization's supposedly neutral position on the issue.
We TNAFP leaders, however, continue to affirm our stance as the correct one and disagree with many elements of the video. We carefully did our homework and simply came to a different conclusion, which we view as valid and the only right conclusion for our patients, our peers and the integrity of family medicine/primary care.
I am glad that we found the courage, even when we thought we were alone, to speak out against the so-called done deal and its massive support system. Whether our victory this legislative session proves conclusive or not, I trust that we will continue to muster such courage when it's needed.
I learned from this experience that the TNAFP should work to build stronger relationships with our legislators on an ongoing basis so they can better understand family physicians' perspectives and view us as a trusted source of information on health care issues.
I also am reminded that when you do what you know to be right, you can have peace with yourself and can stand up to those who second-guess you. I know that I would have had more trouble sleeping had we remained silent, allowing this legislation to pass unchallenged. May we all have the courage to stand for what is right and the good fortune to find that we are not standing alone.
Sherry L. Robbins, M.D., is president of the Tennessee AFP.