Why More Assistant Physicians Should Be Utilized in Primary Care

Last month, I wrote about “What is an Assistant Physician?,” and also introduced you to Amber Milward, MD AP. It’s been three weeks since she started with us here at Direct Primary Care Clinics, LLC in Osage Beach, Missouri. So, what do I think?  I think I need to explain why Assistant Physicians should be utilized in Primary Care.

Dr. Milward’s knowledge is far superior to that of any nurse practitioner student that has previously rotated through my office. This is no surprise, since Dr. Milward matriculated from an accredited medical school. The healthcare industry is beginning to take notice of Assistant Physicians’ strength of education. According to the Primary Care Coalition Issue Brief: Collaboration Between Physicians and Nurses Work, the number of clinical hours (hands-on training seeing actual patients) for MDs is four times that of those getting a Doctorate of Nursing Practice (DNP).

So when it comes down to it, who would you prefer to be treated by if you’re sick – Someone with 500-1500 combined clinical hours, or someone with 6,000? Of course, there is another big difference in that certified physicians (like myself) have also completed at least three years of residency in primary care – including another 9,000-plus hours of intense, grueling training.

Of course, specialty residency training delivers a superior level of overall knowledge and expertise. I am not saying there is anything wrong with Nurse Practitioners, merely pointing out the vast difference in training and education. I have yet to work with or meet a Nurse Practitioner or PA (Physician Assistant) who does not acknowledge the extent of my education and training, as well as appreciating what they can learn from me. I believe they would each likewise feel there is something to learn from those MDs who have completed medical school, but have not completed residency training.

Imagine a practice consisting of a Family/Internal Medicine/Pediatrics physician, supported by an Assistant Physician (MD), a Nurse Practitioner (APRN or FNP) and a Physician Assistant (PA). Patients would have confidence that the care they receive from such a collaborating practice would be complete and thorough, as the definition of a collaborating practice is under the umbrella of supervision of the residency-completed overseeing physician.

To my fellow residency-completed primary care physicians: I suggest that you consider hiring an Assistant Physician as a mid-level provider in your practice. It would be a bit more like the “good ol’ days,” when physicians were trained as apprentices. The extent of their knowledge base is fantastic, and they are closer to medical school than you; they’ve more recently dissected the human cadaver. They have more recently practiced over and over the one-handed tie. And they are eager to work and to learn everything you can teach them about what you know best: how to deliver excellent individualized primary medical care. Feel free to contact me if you have any questions!

What is an Assistant Physician?

In 2014, then-Missouri Governor Jay Nixon signed the bill that created a new “mid-level” medical provider position, making Missouri the first state to license Assistant Physicians. But what is an Assistant Physician?

An Assistant Physician (NOT to be confused with a Physician Assistant!) is a graduate of a medical school, who therefore has a Doctorate in Medicine (MD), but has yet to complete a residency program. This medical school experience contains intense learning and skill development, covering ALL areas of medicine. For physicians, the residency that follows hones those skills into a particular specialty, such as Internal Medicine or General Surgery.

So why didn’t these medical school graduates get into residency? Is it really that difficult to get into a residency program?

Most folks don’t care if their physicians have an MD or a DO behind their name, which is good.  They are still “doctors.” There are differences in the methodology of the two schools, but overall competency is pretty much equivalent between the graduates who matriculate from medical schools or osteopathic schools.  Take a look at the chart below and note the 2016 percentages of MD and DO graduates in the U.S., as well as International Medical Graduates, who are degreed from non-U.S. medical schools.

Figure 1

Figure 1:Society of Teachers of Family Medicine

This gives you some idea of what the competition looks like, but not as clearly as this second graph I found:


When I graduated from my US medical school in 1999, it was so easy to get my first choice– notice the difference between number of available slots in Family Medicine residencies (blue line) and the number filled (red line). Nearly 600 residencies went unfilled in 1999, versus just over 100 empty spots this year. No wonder my second choice wanted to convince me to be their first choice – I was a U.S. medical school grad! Easy-peasy!!!

But take another look at that same graph – what happened around 2013? The number of residency positions in Family Medicine had decreased over the years, because they weren’t filling. Then in 2013 they started filling again. The number of available positions gradually increased, but the rate of filling those positions remains the same. In short, it has become a fierce competition to get into residency.

I know, I know – I’m throwing a lot of boring statistics at you. But the bottom line is this: getting into residency has become extremely competitive. Unfortunately, this leaves many competent doctors left behind in a cartoonish dust cloud. So they re-apply the next year. And the next. After a couple years out of medical school – with the medical school debt they can’t possibly pay back on a non-physician salary – it becomes harder and harder to get into residency.

Okay, this is all very well and good, but I have been speaking in a vague and abstract manner.  Let me put a face and a soul to this problem:

Meet Amber Milward M.D., AP. She received her Bachelors in Science from the American University of Antigua, St. Johns, then went on to earn an M.D. from their accredited medical school in 2013. While attending medical school, she also earned her online Masters in Healthcare Administration from Walden University in Minnesota, with the goal of gaining a competitive edge when applying to residency programs. Upon graduating in 2013, she applied for residency positions in multiple primary care specialties. And then again in 2014. And again in 2015. She was told by every residency program director that they “ranked” her as a potential candidate, but she had not matched – meaning, she had yet to get a foot in the door of a residency program.

Since then, she has done volunteer work to keep her skills up, and studies to stay up-to-date. But stuck in the limbo-land of Medical School/Residency purgatory, she could not get a paid position that allowed her to use the knowledge and skills she has obtained. Until Missouri’s Assistant physician program became reality. This program gives her –and the many other qualified medical professionals just like her– an opportunity to use their earned medical degrees to benefit patients in need of care.

Dr. Milward, Assistant Physician, will begin a collaborative practice agreement with me in April. Dr. Milward is originally from Arkansas and is no stranger to the Ozarks. She can learn a lot from our members and this experience will give her a lot of additional training.  I hope you will all welcome her and help her learn even more about Family Medicine. As I will attest, the ONLY excellent way to learn the practical side of family medicine is from listening to you – our patients.

New Year Resolutions

Have you contemplated your New Year’s Resolutions for 2018 yet? Most folks want to get healthier, quit smoking or drinking soda, or want to start exercising and lose weight. And you’ve probably been told that all those goals should be pursued under the direction of – you guessed it – your physician. But do you know why?

There are so many options out there. Want to quit smoking?  “Use vaping as a substitute,” you may have heard. But studies are showing that vaping is no better (and maybe a little worse) for you than cigarettes. Patches help, but if you smoke with a patch on you can flood your system with nicotine, which doesn’t help with the smoking cessation attempts, and can even impact your blood pressure or heart health! You can take prescription medication, which – at best – has up to a 60% success rate. You still need a prescription for these medications, and smoking cessation programs are most successful under the direction of your physician.

What about weight loss? I remember an old Garfield cartoon where Garfield was thinking, “Diet is just  DIE with a T.” Tens of billions of dollars are spent annually on over-the-counter supplements, and there are fad diets galore. But are they healthy for you? There’s a lot of misinformation out there, and people can actually become malnourished while on some diet plans. So, what are you to do? It’s always best to pursue any major health changes under the direction of your physician.

Fitness centers abound, so there’s little excuse for not exercising. And these facilities have fitness experts who can help guide you along the path of what exercise you should apply.  But there are situations where excessive exercise can be quite detrimental for people with certain conditions. And therefore (you know this is coming), you should always consult your physician before starting an exercise regimen.

I already told you about the 21 Days That Changed My Medical Career. The 21-Day Challenge weight management program through nutraMetrix worked for me, big-time, as well as for my staff.  It will work for you, too, with some guidance from me as your physician. We will target the problems you have, and use either some parts of the 21-Day Challenge, use all parts of the 21-Day Challenge, or we might even use NONE of those strategies and choose to explore other options.

If appetite is a problem, we can use ear acupuncture for cravings and appetite. Are proper food choices challenging for your condition? Our Wellness Coach, Rebekah, can help guide you to the particular foods ideal for YOUR body. What exercise programs are safe for you and your medical conditions? You have your personal physician (Me!) to consult for that.

We are also poised to do ear acupuncture for smoking cessation. This tried-and-true method has far better success rates than any pharmaceutical product of which I am aware. Sure, you can seek ear acupuncture for smoking cessation from other sources. But you are NOT guaranteed a personal physician who graduated from an accredited U.S. medical school, who studied physiology and biochemistry from university professors, and who learned anatomy on a human cadaver. T DPC Clinics you have the dual benefit of a formally-trained physician who ALSO now brings the techniques of Traditional Chinese Medicine to bear on you and your Western health problems.

And just in time for you to make good that New Year’s Resolution, here’s what we’re doing in 2018: If you want to utilize acupuncture (for any purpose), you can add on a Wellness Package to your membership. The “Wellness + Acupuncture” package is $35/month for one person, and $60/month for two or more people on the same membership. This subscription gets you a complete package, with 24/7 availability to BOTH your personal physician and your personal wellness coach! It also includes the cost of acupuncture; otherwise, the Wellness Package is $30/month for one, $50/month for two or more of same membership.

That’s right – for only $35 a month, you can meet your health resolutions head-on and finally have success in 2018. Here’s to a healthy New You!


Taking a stab at it

I’ve finally completed the Acupuncture Course for Physicians through The Academy of Pain Research in San Francisco! With my extensive hours of practice (especially body acupuncture), I am ready to apply all my knowledge for my members! We’ve already had some wonderful successes with it, from healing skin wounds, to treating wrist pain following a fracture, to helping with sleep, to helping with weight loss. Can I help you with your problem? I’ll take a stab at it!

Here’s what I’ve learned through the practice period: it takes commitment. There is no magic bullet, no super pill, no “single-acupuncture-treatment-and-I’m-healed.”  The more chronic and complex the problem(s), the longer it will take. But the commitment pays off, big time.

Here is the concept: we have energy pathways throughout our body that communicate with the brain. The brain is truly the engineer driving the complex train system. When there is pain, that means the energy has congested – has an obstruction over the tracks, so to speak. Until the obstruction is removed, the brain will continue to perceive the pain – even to the point that it becomes a habit. The brain is designed to learn, but not “un-learn.” It’s as if the brain gives up on that area, even after the obstruction is removed. Let’s say repetitive movements with one hand or one arm cause the muscles to cramp up. The brain perceives the blockage in the system caused by the repetitive strain on the musculature. If it goes on long enough, even when the muscles are no longer cramping up, the brain will believe there is still pain.

So, how long does it take to create a habit? Behavioral experts say it can be as little as 21 days for something simple, but more like 66 days for something more complex. This is why with longer-standing problems (the longer the obstruction has been on the tracks, so to speak) there is a higher likelihood that pain will continue to be perceived after the obstruction is removed. So is it any wonder – if acupuncture is “re-training” the brain – that in order to achieve true results it may require a couple months of treatment?

I’ve also learned that once a month is likely not often enough, and certainly once a week isn’t sufficient, at least not during the initial phase. The frequency should be at least twice-weekly treatment for 3-4 weeks, followed by a break and then another 3-4 weeks for chronic issues. I have not yet had anyone go for the 9-10 weeks that would encompass 66 days. But I have some dedicated souls who are working towards it.

The Bottom Line? Rome wasn’t built in a day.

Our body is designed to heal itself.  But in order to do so, it must have all the right tools. While duct tape and popsicle sticks came in handy for MacGyver, the body cannot effectively run on junk, much less heal itself. It needs good nutrition, sound sleep, and plenty of water – the three things in which I observe most patients to be deficient. If we are trying to heal using acupuncture, but are missing essential ingredients, all the acupuncture in the world will not be enough to get over the hurdle. This is why I recommend members add the Wellness Package to their membership. It helps get the body prepped and ready to address the needs of opening the energy system, in order to create the best environment for healing.

So – I’m ready to take a stab at it.  Are you?

Wellness Package

What is Wellness Coaching?

“Wellness” is how you create health through specific practices. A wellness coach takes a holistic approach to your well-being by assessing the Seven Aspects of Wellness. These Seven Aspects include the following: physical, emotional, environmental, intellectual, spiritual, financial and social. Through a detailed analysis of these aspects, the coach and client work TOGETHER to formulate a plan for lasting lifestyle change.

A Wellness Coach is there to help you identify and make the lifestyle changes needed to achieve your personal and health-related goals. They are trained in specific strategies, techniques and methodologies and can provide tools to help in the process of lifestyle transformation.

What should I expect in a coaching session?

During the first session, you will go through a specific detailed questionnaire. This is for me, your coach, to learn about you as an individual. You will be explaining your wellness vision and where you see yourself from one week to five years from now. Once the “what” and “why” is established, you and I will address the “how”. This is done by establishing the potential obstacles to the desired behavior change, and where the strategies to overcome these obstacles are developed. Strengths are also identified and implemented to encourage lasting change.

My job as your coach is to encourage you to achieve your goals, which are made simple and short-lived to achieve the larger, more long-lasting goals. You set realistic and well-defined goals as I hold you accountable to your goals. Through this process, you become more accountable to yourself, and your self-confidence and self-esteem grows with each success. Before you know it, you are making changes that you never thought possible!

In our sessions together, I may utilize some of the following techniques to help in your wellness journey: Auriculotherapy (reflexology on the ear) can help with several things, such as weight loss, smoking cessation, pain management and a great way to relax; Essential Oils, which are also utilized in Auriculotherapy; Education on the uses of Essential Oils for emotional health and everyday use; Stress Management techniques such as breath work, meditation, progressive relaxation and guided imagery may be utilized for stress related issues; Flower Essence may be used as an energy medicine to balance emotional and spiritual imbalances; Energy Work is used to balance any aspect of wellness needing to be addressed; Food as Medicine, using nutrition as a major source of our Qi (Energy), to promote the health of our bodies and give the brain good fuel. Coaching tools such as the Wheel of Balance and the Values Sorter survey are used during coaching sessions to help you identify the areas of change and develop strategies for change that are lasting.

Wellness Package for Members:

For only $30/month per individual or $50/month for a 2+ person membership, you can have unlimited access to your Wellness Coach, including group classes on various topics. You will receive guidance on Food as Medicine, supplements for good health, and your guidance and care will be supervised by your private, personal physician.


Call (573)933-0870 TODAY to add your Wellness Package and get started living your life to its fullest potential!

The 21 Days That Changed My Medical Career

For a few months now, I’ve been personally using and recommending nutraMetrix supplements, especially the Isotonix product line, due to its superior absorption in the body. When I took time out of my schedule for a day-long teleconference on nutraMetrix products – offered only to health professionals – I learned about the TLS Weight Loss program and the 21 Day Challenge. But before I felt comfortable recommending this program to patients, I wanted to experience it myself. So I discussed this with my staff. Would they join me? Indeed, they would.

Between the three of us, 3 dress sizes (2 of them mine!) and 36 pounds were lost, and some visible body toning was achieved – all in only 21 days. We experienced it together, sharing zits and joint aches during the detox week while the toxins from the so-called “food” we had previously eaten were literally seeping out of our pores. We amazed each other with innovative ways to eat 3+ cups of vegetables in one meal. We kept our Culligan Man busy bringing us bottles for our water cooler. We begged the sales reps to NOT bring any cookies, breads, muffins or Starbucks when they visited our office. We learned about portions, how to fill up on GOOD, genuine food, and the importance of planning and preparing ahead for success. We learned to love water, even though it meant visiting the bathroom much more often. We discussed our cravings, but when the 21 days were over, none of us plunged head-first into any of those things. We’d seen such good success that we didn’t WANT to go back to eating junk.

All of this was very good to learn. But I experienced something that, as a physician, has changed how I approach health and the science of medicine.

For about 15 years, I have been on pharmaceutical blood pressure medication. A few years ago I had to increase the dose. I was then faced with either a) adding another medication to control my blood pressure, or b) switching to a super-strong, highly effective (and expensive) blood pressure medication, though initially at a lower dose. However, I recently had to increase that powerful medication to the highest dose, assuming it was a natural progression due to aging. But here’s what has happened:

Within six weeks of starting on the nutraMetrix OPC formula (powerful, highly-absorbable anti-oxidants), I had cut my high-power blood pressure pharmaceutical in half, but maintained my blood pressure in the 120’s-130’s. Then I started the 21 Day Challenge.  Within a week I was lightheaded while standing and had to stop the high-powered blood pressure medication altogether and switch back to the less potent medication. Today is Day 28, and I’m still avoiding processed foods as much as possible, and only drinking one cup of caffeinated drink a day– my Linghzi mushroom coffee! And as of this morning my blood pressure was 112/65.

This experiment of eating right and avoiding the so-called “foods” that I’d been gorging myself on has been largely responsible for my blood pressure improvements.  My goal is to be on the lowest dose possible and (hopefully) eventually stop pharmaceuticals altogether.  I am aware this will require a multi-faceted approach. But this experience has opened my eyes to the fact that food is medicine, and that THIS is the direction I need to take my medical practice.

As I incorporate Eastern Medicine’s use of acupuncture and its various methodologies, it is important to stress the role of the Qi (energy) entering the body from the food we eat. While the nutritional aspect of medicine was very weak in my medical school training (and non-existent in my residency training), I now need to further educate myself. But I also happen to know someone well, a person whom I respect and who IS trained in Food as Medicine (as well as Wellness Coaching, auriculotherapy, use of supplements and essential oils). So the thought came to me, “Why not bring her on as a member of our medical team to offer Wellness Packages with our memberships?” As I’ve experienced first-hand, patients can benefit from learning how to use the foods they eat, as well as having unlimited access to a Wellness Coach. For a small additional cost per month, our members can now have unlimited access to those services, including classes and group meetings. As our staff learned, making these changes with others is GREAT support and helps keep us accountable.

So, it is with great pride I introduce Ms. Rebekah Anglin as our latest full-time employee at Direct Primary Care Clinics. As part of the Wellness Package that members may add to their memberships at a very low monthly cost, Rebekah will be available some evenings and odd hours, based on the needs of our members and her clients. Call Ann Orr at our offices (417-664-5054) for more information.

By the way, we HIGHLY recommend the 21 Day Challenge through nutraMetrix. But now, you can talk to Ms. Rebekah about the program… in-person, right at our office.