With Missouri lawmaker indicted for medical fraud, questions about her unusual license

Patricia Derges wanted to be a physician, but it didn’t work out.

After graduation from Caribbean Medical University in Curaçao in 2014, she didn’t get placed in a residency — the years-long specialty training program required to become a licensed doctor.

Three years later, she was part of a relatively new category of medical practitioners, called assistant physicians. Unlike physician assistants, who complete a masters degree program, assistant physicians are medical school graduates licensed by the state to treat patients without completing a residency.

As she became a celebrated clinic owner in southwest Missouri and then a successful candidate for the statehouse, Derges brought attention to this rare form of practice that originated in Missouri and is not widely accepted by the medical profession.

Then, on Feb. 1, weeks after being sworn into office, the Nixa Republican was indicted in federal court on wire fraud charges, accused of pocketing nearly $200,000 from patients for a purported stem cell treatment that was actually amniotic fluid without cells. She has pled not guilty.

Stripped of her committee assignments and removed from the House Republican Caucus, Derges faces escalating pressure from party leadership to resign her seat.

Missouri currently has more than 300 licensed assistant physicians, though fewer than a third of them are actually practicing as required under contract with a supervising licensed physician, according to the state’s medical licensing board. Since the license’s creation in 2014, a few states, including neighboring Kansas and Arkansas, have adopted or considered similar programs.

It was billed as a way to address dual shortages in health care: of residency spots and rural doctors.

Every year, roughly 8,000 residency applicants do not secure a spot. Primarily funded by the federal government, the number of residency spots has not kept pace with two decades of rising medical school enrollment, according to the Association of American Medical Colleges.

It’s left medical school graduates with tuition debt and a degree that qualifies them for few other professions.

Meanwhile, an aging population has led to higher demand for doctors. In Missouri, 115 geographic areas, including 80 rural ones, are designated by the federal government as medically underserved, lacking enough primary care providers.

“It is becoming almost impossible to recruit physicians into small towns like this,” said Jennifer Conley, a family physician and owner of the Nevada Medical Clinic in southwest Missouri.

Conley, 50, and her partner deliver babies at the local hospital, the only one between Kansas City and Joplin that offers obstetrics care, she said. As they consider their future retirements, they’re “hoping not to leave this place a maternity desert.”

Missouri State Medical Association executive vice President Jeff Howell said it only makes sense for eager medical school graduates to be part of the solution.

“There are tons of good kids that don’t get a residency, and to make all those kids go trade GameStop [stocks] and drive Ubers, it doesn’t make sense when we have such a shortage of health care providers in rural parts of the state,” said Howell, who supported the assistant physician law when it passed in 2014 but who has opposed recent expansion efforts.

The program has drawn stiff opposition from parts of the medical establishment, including the American Academy of Family Physicians, and doctors who say there is no substitute for the rigors of a residency.

While medical school provides students fewer than 6,000 hours in front of patients, a residency adds anywhere from 10,000 to 22,000 additional training hours, said Misty Todd, a family physician at Bothwell Regional Health Center in Sedalia.

“Medical school teaches you how to take a test and about physiology, but residency is where you learn your skills, where you do procedures and where you learn how to critically think,” she said.

Todd has advocated against measures to expand the assistant physician program in Missouri, raising concerns over the quality of medical care.

In 2018, a study by two Missouri family physicians found that in the first year of the assistant physician program, those who became licensed had scored lower on their medical licensing exams than their counterparts who secured residencies. Most, like Derges, graduated from Caribbean medical schools, and none from Missouri medical schools.

Little else is known about the state’s assistant physicians, 98 of whom are currently practicing. A spokeswoman for the state’s Department of Commerce and Insurance, which includes the medical licensing board, said details of the agreements with their overseeing licensed physicians are private.

There are few limitations in state law to what assistant physicians are authorized to treat.

They must work in primary care in medically underserved areas. After a month directly under a supervising physician, assistant physicians can work on their own, up to 50 miles away. They can get authorization to prescribe medication. The overseeing physician is required to review just 10% of the assistant physician’s charts, and 20% in cases where opiates are prescribed.

Versions of the program in other states are more tightly regulated. In Kansas, only University of Kansas medical school graduates are given special permits to treat patients while re-applying for residencies. The permits come with a two-year cap, do not allow the practitioners to prescribe controlled substances and require the graduates to practice in the same building as a supervising licensed physician.

Initially denied an assistant physician license on technical grounds in 2017, Derges testified in favor of a bill that allowed herself to become eligible. Since then, she’s pushed several times for looser restrictions on licensees, which did not make it to the state House floor. As a new lawmaker this year, her first bill was a measure that would have allowed herself and other assistant physicians to become traditional physicians without residency after five years.

“If we were asked whether or not this was a good option for the citizens and patients of Missouri we would probably say no, it’s not,” said John Paulson, president of the Missouri Academy of Family Physicians.

In addition to the alleged stem cell scheme, Derges is charged with illegally writing prescriptions for oxycodone and Adderall — drugs that federal officials say have “high potential for abuse” — on behalf of other assistant physicians she employed, without examining the patients in person. She falsely claimed a faculty position at the University of Missouri Columbia when applying for a medical license in Florida, the Missouri Independent reported Feb. 10.

Todd sees the accusations against Derges as a warning sign about the program.

“The severity of the claim seems to be out on its own,” she said. “But with her being the talking head I do think it puts them in a very bad light, that their medical knowledge has significant gaps.”

Todd is working with the University of Missouri, where she completed her residency, to add a handful of residency spots at Bothwell Health geared toward practicing in rural communities.

“You have to go through the right channels,” she said.

But those positions, assistant physicians’ proponents say, are a drop in the bucket of a nationwide doctor shortage.

Assistant physician Trevor Cook said some primary care clinics in underserved areas take months before accepting a new patient.

“I like residency and I think it’s a good option, but when it’s something that’s clearly causing all these deficits, you can’t just say, ‘Either we save you, or no one saves you,’” he said.

Cook grew up in Texas, following his father around at his job as a physician assistant. He attended medical school in the Caribbean before applying to residencies in the U.S.

“I’ve lived and breathed and devoted my life to medicine and just like a lot of people we hit a roadblock,” he said of not securing a residency. “It has nothing to do with merit or skill or anything like that. It’s just that the numbers just say there’s not enough places.”

He got other jobs in medical offices, then moved to Missouri to become an assistant physician when the program was created. He’s practiced for two and a half years, remaining with his supervising physician at a clinic in St. Louis.

He sees everything from asthma and basic screenings to broken bones and recently, coronavirus. He’s slowly become more independent in the clinic, but said his supervising physician checks all his charts.

He believes the time he’s spent treating underserved Missourians can be the equal of a residency, and wants to see a pathway to a physician’s license someday.

Conley, the Nevada doctor, disagrees. She called residency “absolutely critical” and said Missouri should have enacted more limitations on assistant physicians.

“I don’t think people should go into this thinking, ‘This will be my new life work, this is where I stop,’” she said.

But she saw some value in the program as a stepping stone. She’s hired five assistant physicians at her clinic at different times over the past several years, hoping to recruit her future replacement and keep family medicine alive in her 8,000-person town.

“Hopefully I help them get into residency and they might want to get back and plant down roots here too,” she said.

She said she supervises them strictly and said they would all be good doctors. Four of the five are now in residency programs, an achievement Conley said was likely impossible without her letters of recommendation. One, who did not get a residency last year, still works for her and is applying again.

None have been from Missouri, but she’s tried to hire practitioners with Midwest roots who would consider returning. One of them, she said, might.

Bigger health systems and hospitals often won’t hire assistant physicians because insurance companies won’t cover their services, she said, and most malpractice insurance plans don’t include them. Some clinics, including one in Kansas City, only take assistant physicians as unpaid volunteers hoping to gain experience.

When the state created assistant physicians, it also started a grant program to open clinics in rural Missouri that would hire them. A state health department spokeswoman said no money appears to ever have been allocated for the program.

Without a significant increase in traditional residency spots, Conley doesn’t see a long-term solution to the doctor shortage in underserved areas.

“I’m busting my hump here trying to get the next generation and not getting it, so it’s probably not working as intended,” she said. “It would have been nice. I wanted it to work.”

This story was originally published February 11, 2021 at 5:00 AM.