Other Medical Careers Part Three: Physician Assistants

Inspired By Actual Events

(House DO, one of our good blogfriends, has taken a hard look at the requirments of medical training and decided to divert to PA school. To him is this article dedicated-PB)

As an intern, I once rotated on a service that had a lot of Physician Assistants. One night on call I was paged by one of them to come up to the floor and help him with some paperwork. Naturally I refused. It was late, I was tired, I wanted to get a few hours of sleep, and I told him so.

“Well,” came the peevish reply, “I’m here and you don’t see me getting any sleep.”

“Well,” I replied politely, “You’re not on call, you’re working a shift, you got here at six PM and while you will go home at six AM, I will be here into the afternoon. Not to mention that I got here yesterday morning and have been here ever since while you will work your three shifts this week and I will probably never see you again. Call me if I can help you with anything important.”

That’s about all you really need to know, philosophically, about Physician Assistants. They’re kind of like doctors and can and do perform many of the same functions but they have limitations. Hell, we all have limitations. Medical school and residency sometimes seems primarily about teaching us what they are. As a PA, your limitations will just be lot closer than those of a physician, kind of like the difference between a dog with the full run of the backyard and one who is brought up short by his chain while chasing a squirrel.

Physician Assistants were invented at Duke University in the mid 1960s to address the shortage of primary care in rural North Carolina. Their inventor, Dr. Eugene Stead, studied the training methods used to produce doctors quickly during World War II and created a training program based partly on these methods. His first students were former United States Navy hospital corpsmen (what the Army calls “medics”) who then, as now received extensive medical training far beyond that of paramedics, their closest civilian counterparts. An important thing to keep in mind is that medicine was not nearly as complicated in World War II (or even as late as the 1960s) as it is today when there were, for example, only sixty or so medications in common use and most of those were of the crapshoot variety. You could probably train a doctor to mid-twentieth century standards in a couple of years if you got right down to it.

True to the original ethos of Dr. Stead, most PA training programs heavily favor those with prior careers in allied health such as nursing or paramedicine but this requirement is not universal and my sources tell me that not every program necessarily looks for this.

There are now 130 Physician Assistant training programs in the United States. Most are Master’s level programs although a few still offer an undergraduate degree. The curriculum in the Master’s level programs is typically two years with the first spent on didactics and the second on clinical training after which you may become certified and begin to practice. There are opportunities for further training but this training is not required, de facto or otherwise, to start working and earning a living which is the principle appeal of PA training versus medical school. While a typical physician will train for a decade before he even starts his career, a PA can start earning an income after two years.

It’s a pretty good income too. The average PA salary is close to the mythical “six figures” and some, particularly those in the more lucrative specialties, can earn even more. It is not hard to get into a lucrative specialty either as the demand for PAs in all fields currently far outstrips the supply. That’s one of the beauties of PA training. It is versatile and a PA can move relatively easily (compared to a physician) between specialties. A PA, for example, who is interested in surgery can work for a surgeon and by “first assisting” in his cases can get a pretty good practical grasp of it. If, on the other hand, he has a hankering for primary care (although even PAs run screaming away from it…they are highly intelligent profesisonals after all) he can work as an essentially unsupervised primary care clinician in most states especially in the rural areas which have a shortage of doctors.
The conventional wisdom is that PAs are the equivalent of physicans and this is certainly the mantra you will hear repeated so often during your medical training that it will become a reflex action, kind of like your catechism, to reassure those around you that except for the two extra years of medical school and all of that residency stuff, it’s all the same. But that’s kind of the issue. You either believe that extensive training is required to produce a doctor or you do not. Because our society is highly over-doctored to begin with and most of medicine is fairly routine, those who do not will correctly point out that not every patient is either complicated or critically ill and that it doesn’t take an advanced degree to diagnose an ear infection or treat routine hypertension. Since it it currently takes a minimum of seven years to produce a primary care physician versus two for a primary care PA, the advantages of PAs are obvious. It is also easy to see how in a narrow medical specialty many of the routine tasks can be performed by PAs. If you first assist a general surgeon who concentrates on a narrow repertoire of abdominal procedures, eventually you will have a very good grasp of what is involved and excellent procedural skills without having been through the bottleneck of medical school and a six year surgical residency.
On the other hand, a lot of medicine isn’t routine, some patients are complicated, and if there’s one thing I’ve noticed about cookbook medicine it’s that most of the patients didn’t read the book and don’t follow the recipes. I’m sort of old school about this. I am perfectly willing to concede that PAs can and should take over many medical duties if they are more cost-effective. At the same time the more I learn about my own specialty the more I appreciate the need for a broad and lengthy period of training before we are released upon a trusting and unsuspecting public. I have been hard at it for six years and I am still humbled on a daily basis by my relative ignorance compared to my attendings. And I don’t think I’m in the minority when it comes to an honest assement of my skills and knowledge as a resident either. There is a lot to know, some of it highly nuanced and much of it requiring pretty good clinical judgement that you cannot learn in a couple of years and especially not without the background in medicine that even those lazy bastards in PM&R can’t help but acquire.

Unfortunately, PAs (and other midlevels) have found themselves at the cutting edge of efforts to dumb down medicine in the name of economic efficiency. If I were a PA I would be deeply offended to be associated with this effort, first because PAs are not dumb in the slightest and increasing their scope of practice will require more, not less, resources. Second, and most importantly, if we buy into the premise that medicine is nothing more than an algorithm that we can read from a card and apply to every patient not only do we not need physicians but PAs themselves are probably over-trained for their jobs and eventually they will be replaced by motivated junior college graduates.
I mean, there’s nothing to it, right?

Advantages: Practice as a licensed clinician after minimal training. Good salary, can exceed physician salaries in some specialties. Variety. Mobility. You can wear a white coat and many of your patients will think you are a doctor. The training is not as rigorous from either an intellectual point of view during didactics or from a “fuck with your head” point of view during clinicals as physician training. Nobody will ever insist you have a “passion” for physician assisting as a prerequisite for the job. No residency required although you can get further training if you want it. Only two years worth of debt before you start making money.
Disadvantages: Very few, actually. The training is not as rigorous as physician training and, despite the propaganda, you may keenly feel your lack of skill and knowledge compared to your boss. On a specialty by specialty basis, you will never make as much as a physician for the same amount of work. And your salary will also decrease under any socialized system currently gathering its strength behind the mountains of Mordor before it is loosed upon us all. But other than that it’s not too shabby.

More here and here.

55 thoughts on “Other Medical Careers Part Three: Physician Assistants

  1. oh i have been waiting for you to speak about my beloved PA’s. Although you have had some bad experiences with PA’s that don’t want to work as i have with residents, i would like to say that PA’s once in a field for 1-2years can provide very good basic care. It is like on the job training. Most do not have the basic science knowledge, bu they do deveop practical knowledge. in my experience with working with both PA’s, NP’s, and residents in the military, private practice, and university practice, a good PA who know’s their role is extremely effective. NP’s, more often than PA’s, get a little full themselves (may be it is because they do not need the physician to actually practice or differences in root philosophies of patient care). residents like the cools stuff, i my case procedures; clinic, not so much.

    in my practice, the PA’s are grunts. they put their noses to the grindstone and work. ask questions about treatment, and then move on. they have been a godsend for our practice with it’s expansion.

    because ortho pays well, we have a lot of PA’s that stay in the field and become extremely good at what we do. i guess repetition is the key to adult education. then again, we aren’t savin’ lives like dem ER doc’s; i be seein’ dem on the TV usin’ da shockers and stuff. 😉

  2. I agree. If I’d had an interest in primary care I would have considered PA. If you want a procedural/surgical field, though, the PA is doomed to being the equivalent of the porn fluffer for the rest of their career. Doing surgery without actually getting to do the surgery … somebody bring me an oven to stick my head in.

  3. “socialized system currently gathering its strength behind the mountains of Mordor”

    I love that metaphor! Very nice blog entry. I’ve known a few excellent PAs, including one in my med school class. I think the major drawbacks are (1) limited career options (e.g., how many PAs do you see teaching, doing research, running programs or departments, writing medical books for the public, etc.?) and (2) status (I know this shouldn’t matter, but some of us can’t imagine ending up in a career as an “assistant”).

  4. Aflak’s metaphor of the physician assistant as medical fluffer is hilarious yet disturbing.

    The rise of the physician assistant and nurse practitioner phenomenon has coincided with medicine becoming more algorithmic and protocolized. Someonetc’s comment about a PA position being “like on-the-job training” is fairly accurate for most PA jobs.

    Even hospitalists (once thought of as glorified uber-residents who offloaded admission and discharge work from subspecialists and outpatient docs) are turning to NPs/PAs to assist with discharge coordination, interdisciplinary management, etc., within the hospital.

    I believe the physician assistant role can be an extremely valuable one; however, the oversight by a physician must always be maintained. It is that extensive training that we go through during medical school and residency that helps us identify the patients who aren’t following the textbook.

  5. Interesting post.

    Just to raise another point of discussion, I think that a problem with PAs and (less so) with advanced practices nurses is patient confusion. Although I always introduce myself as a med student, patients invariably call me “Dr.” I have been on service with PAs and patients call them “Dr” as well.

    I think this is a problem. It’s not just a pride thing. I think patients have a right to know by whom they are being treated.

  6. just out of curiosity and because you have mentioned it a couple of times before causing me laugh out loud; why are PM&R docs lazy bastards?

  7. The biggest disadvantage for PAs: you’re always someone’s scut monkey. At least as a physician you can pursue some degree of autonomy. Several PAs I’ve talked to say it’s hard to find a non-a**hole to work with.

    My feeling is that PAs are best suited to work as specialist extenders, where they see a limited number of types of cases/problems or assist on a limited number of procedures. I think that primary care is the worst spot for them, citing the nuance and complexity of medicine noted by Panda. Of course, since MSIVs are continuing to run screaming from primary care, someone is going to have to help us schmucks already here.

  8. let’s see..PM&R..I suspect the following:

    In spite of a relaxed lifestyle with zero call and weekends, PM&R people are well
    paid to play with a lot of tests and treatments, as most of their patients have nebulous pain generators and access to insurance. This pisses off the more run-ragged members of the profession, understandably.

    I personally would find PM&R strangulating and depressing. By the time someone ends up with PM&R, they are usually chronic painers, hard group to deal with.

    so, Minnie, howzit?

    oh, good days and bad days. This weekend I was……etc etc etc

  9. I have worked with PA’s and NP’s in a variety of practice settings settings. The single biggest problem with these mid-levels is that they can get themselves in over their heads pretty easily. IT takes maturity and fortitude to recognize the limits of one’s training and experience.

    I’ve worked in a socialized Kaiser-type environment where the attitude was most decidedly that PAs were equivalent to MD’s. As one FP put it to me, “They (mid-levels) make mistakes. We make mistakes.” In this organization, PA’s could actually rise to the level of clinical chief of service in primary care. Granted that job is a pain in the arse, and might amount to little other than a glorified nurse manager, but the fact remained that this was a colossal political promotion for these individuals. They also had full and equal status on the medical staff, with all the voting rights included. I think this speaks volumes about the attitude PCP’s had about themselves- and it is not a complimentary one.

    In my current setting, the mid-levels very much are beholden to the physicians, and the team works much better. There is no pretense to being full blown independent practitioners, or peers on political level.

    I must say that that one distinct and enviable advantage of being a PA is that one which is exploited by nurses. They can move laterally with great ease. This helps tremendously with the problem of burnout in medicine. I’ve often wished that after 20 years of practicing the same specialty I could tomorrow decide I’d had enough and say, pick up urology, or gastroenterolgy. The rigors of re-training in other medical or surgical specialties is forbidding. We do not have the luxury of training on the job like mid-levels. It would be very rewarding, and I think to the greater benefit of patients, colleagues and medicine in general if there were a way of making these lateral shifts more easily.

  10. Who wouldn’t want to get paid full salary to learn a specific job set/specialty?

  11. Well, that’s kind of the point. Becoming a PA or NP makes pretty good sense from an economic point of view.

    Now, this is going to come as a shock but for me, the intangibles of medicine are so important that if I couldn’t have been a physician I would have stayed in engineering.

  12. You know I’ve been wondering why the hell my blog has gotten so many comments lately. lol. I guess I should check your site more often. I’m actually quite honored that you read my blog. w00t w00t – big times!!!

    For the record I haven’t made up my mind yet. But man, it’s starting to look so good. Get some good healthcare experience decide from there whether to get the full degree or go into some other area. Enough ranting in your comment section.

    Thanks again for the article! I was about to ask your advice anyway.

  13. you started out this post with how you shot down staff member at the hospital, something you have mentioned before – regarding higher level residents, attendings (and even interns, when you’re still in med school) – would you consider devoting an entire post to the topic – when it is okay and under what cirumstances can you “talk back” without it backfiring and harming your (future?) career? thanks

  14. I did not “shoot down” a staff member. I am a physician and I don’t take orders from or work for PAs.

  15. Well, regarding NPs and PAs, my experience is that we are losing exceptional people to these professions because of the personal price tag problem of the MD/DO thing.

    If I told the whole story of the two incompetent physicians I was charged with moving away from a certain workplace I would set myself up for a lawsuit. But while I was working on that project I had the pleasure of working with one of the nicest people ever…she went to PA school and broke our hearts. And yes, she was very smart too…

    Block nights might get some of those people coming to medical school….

  16. Well, as a PA who later got a doctoral degree in another field, I have had the best (and the worst, at times) of both worlds. I’ve practiced in five specialties over almost 30 years; I have chaired a PA Program and an academic department; I’ve written book chapters and gotten a sabbatical overseas to study another health system. Not bad for two years of studying! I’m not rich but I’ve had an interesting career.

  17. But to give you the down side: we do have to keep up and study just like the rest of you; we have a very, very steep learning curve if we transfer to a new specialty, so must of us never do; we have to re-certify every seven years, even to keep our license in most states; and we frequently have to work with (for, sometimes) physicians who are much younger with much less experience in a given field. It is difficult to find someone you trust enough to work for; when you just work with others, like most physicians do, it is not as much as a problem. Contrary to popular (physician) belief, if the doc tells you to do something that goes sour, you both get sued, even if you argued against it in the first place. On the other hand, litigation against PAs is much less common.

  18. As a nurse, I always hear how MDs prefer to hire NPs vs. PAs because the NPs have better instincts. There has to be a big difference between a nurse who worked in the field for years and years seeing a variety of patients before becoming an NP vs. someone who learned medicine from books and one year of on-the-job training.

  19. You know, I really think that stuff boils down to someone’s personal instinct and ability to sort of ‘match’ a patient to their prior experience. It’s a tentacle thing. Really doesn’t matter what discipline you come from.

    For instance, there was once upon a time a medical assistant, making 14$/hr, who knew her patient was in extremis and the TWO MDs who were around were both just completely clueless, sent him home over her witnessed objections, patient died within hours.

    NP,PA,DO,MD….doesn’t mean too much when you don’t have the tentacles to take the gathering of experience and apply it properly to future purposes, just like our friends in the ant kingdom do day in, and day out….

  20. So gaye, why pursue any degree of formal education? If it’s inborn, why not just jump in as an apprentice whenever you want and get the OJT to build/confirm whether you have the “tentacles”?

  21. NP’s vs PA’s ?????

    A generalization without data — just my 10 years of hiring them as EM director:

    A good NP/PA is gold — treat them well to keep them around.

    A bad PA/NP is a severe liability.

    PA’s seem to approach a clinical scenario with a working differential and medical decision making much better than NP’s, in general. IMO

  22. Moose! I said the degree doesnt’t HELP, or which type you have doesn’t MATTER, if you DON’T have the talent/tentacles for the job. I never said OTJ training should supplant formal training.

    There does exist a problem with formal training, and that is that clueless people,
    whose DNA never allowed for tentacle formation, if and when they make it through training, well, they get unleashed, with a license. And very little hope of leaving the profession because of the debt, the years lost, the power, etc etc etc, so it often will take a travesty to get them out, and guess what, that often isn’t enough, either.

  23. So if the degree doesn’t help, why do it? Because it does help if you do have the tentacles?

  24. Ok, forget tentacles, talent is a better word, although SO overused.

    I forgot to mention I like insects. I save ants, flies, spiders…..once when I was a small child I cried for hours because, after carefully burying a dead ant I rescued from a pool, I had the sudden thought- maybe I didn’t give him enough TIME to revive??!!!!

    But mosquitoes, I love to crush them, see their carnage arrayed over the bloodied surface of a thigh or forearm, for instance…..there are certain limits to compassion, I think we would all agree.

  25. NP vs PAs: I prefer PAs, on the average. So do nearly all specialty physicians I know. In a specialty the most important thing we demand from our midlevels is not having an ego and knowing what requires our attention. NPs tend to have (often unjustifiably) higher opinions of what they know, probably due to leftover nurse/doctor antagonism from being a RN and the fact that most didn’t start out planning on being NPs whereas PAs knew they were getting into assisting physicians from the get-go.

    In primary care I suppose it’s probably different, there seems to be much less oversight going on. But primary care is a mess in general, so whatever.

  26. Just to comment on prefrence of NP or PA. Its actually common to find a PA with years of experience. I have been ED RN 5 years before going to PA school. My school has FMG, PT, RN/RT,chiros,Medics and numerous other backgrounds. Majority will enter the fields most comfortable, hopefully some will become family practice providers.
    I often get asked by nurses why not NP since they can practice solo. My response is ” are you crazy” If i wanted to be independent i would go to Medschool. Also the very limited clinical time in NP school scares me.

  27. Maybe Other medical careers part four could be NP. Or even venture out of medicine and cover pharmacy. It is a stress filled, six-figure income career. Just a thought.

  28. As a boarded physician, and one who has worked in very busy ED’s w/ both PA’s and NP’s, I have some angst about this issue.

    I have worked with many very good “mid-level” providers. I think the overwhelming consensus is most of these folks help physicians do more, make more $, and care for more people.

    Now, the downside. Yes, my years of pre-med, med school, and residency training, and THEN many years of clinical practice, academic submissions, and mentoring ARE different from someone who spent a couple of years getting an “equivalent” degree. When I was a third year medical student I learned how to write a prescription. That did NOT make me a primary care provider.

    As for primary care, it is in this area where I think mid-level providers are the most appropriate. I do not think there should be “PA BRAIN SURGEONS.” Anyone that thinks there should be, please say so. The medical School where I used to be an attending began a very disturbing practice: all of the specialist services (neurosurgery, ENT, trauma, orthopedics, etc.) all hired NP’s to work on their services. Now I am not stupid. I know these people were hired because 1) students don’t do much “scut work” anymore, 2) residents don’t do as much “scut work” anymore PLUS they have “work hour limits.” But when one of my faculty colleagues (a board certified internist) wrecked his knee skiing and called over to the ortho service so he could arrange a visit with a surgeon, he was told he would be evaluated by the “NP” who saw him promptly, ordered a plain film (normal of course), and prescribed motrin (of course).

    three months later when the Medicine Professor still could not walk he finally got in to see a “real” doctor, who promptly diagnosed his ligamentous rupture w/ an MRI and scheduled him for surgery.

    Now, I wonder what would have happened if the Orthopedics Chief were having some chest pain and we sent him to see the third year medical student for a workup . . . ???

    bottom line, do you really want the “PA” doing your Mom’s neurosurgery???

  29. I disagree with Kelly, who is a burnt out RN. As a PA student with over 10 years experience as a RT, I know for a fact that NP students have much fewer hard science classes thank PA students, I mean they don’t even have Gross Anatomy Lab? How can you get away with that?
    A lot of NP training is fluffy nursing theory stuff and they can continue working while most PA students cannot work in school due to the rigorous nature of the program.
    Most PA students have years of pt care under their belt.

  30. PA for over 20 plus years with time in academics,have published papers,worked in various specialties and current solo provider in UC clinic.Never been sued,have a great relationship with supervising doc and enjoy taking care of people under the guidelines of current standards of care. I have been trained in clinical reasoning skills and not algorithims. I value all team members and respect MD’s for their knowledge and in return have the respect of those I work around for my skills and capabilites and not the title behind my name. There is plenty of work for both midlevels and MD’s the way I see it.

  31. Ok As I read all of this nonsense regarding the PA profession, I am reminded that Dr. House is a DO. Did you now sir that the allopath did not respect the osteopaths in its infancy? While some of that has changed, it is still pervasive in the academic medical center. Let us not forget, the majority of the world realizes that your path to the DO is lined with rejection letters from the allopathic schools. Why, even as a senior in clerkship at Yale, one of my professors told me very confidently and secretively, ‘do not trust the DO, they do not know what they are doing.” So while you stand upon your horse desperately trying to raise yourself above the PA remember this, PA’s do not want to be doctors, they want to have balance in their lives; they want to have time with their families; and they want to have a career that helps others. Simply put, your problem with PA’s comes from the a place where you can’t believe that they do what they do after you have spent all those years trying to be somebody; but you didn’t quite make it, because after all, you are only a DO. Even an MD who is a foreign graduate holds higher professional esteem than you do.

    Is all of this fair? It is about as fair as you trying to understand speak about a profession that you are not apart of. Take a look at the curriculum and them talk about what you know not what you think you know. But then maybe residency has done a great service to you because it is clear that your philosophy is …”it is not how much you know BUT how much you make people think you know.”

    (What on Earth are you talking about? Did you even read the article? the fact is that an Emergency Medicine resident, on the day he becomes an attending, has seven or eight years of medical training under his belt, many of it of the eighty-hour-per-week high-pressure variety. I am not the smartest asian bear-mammal to lumber out of the bamboo grove but, uh, seven years is much more than two years. Did I not point out the advantages of being a PA versus a doctor, number one being that the lifestyle is a lot easier? The lifestyle is a lot easier because, and it’s just a dumb bear-mammal free associating here, the training in easier and thus not as rigorous…and thus a PA does not, in fact, know as much as a doctor, all other things being equal. Surely there are dumb physicians but it should be clear that it is easier to be a dumb PA. I have met several who are truly dangerous.
    And I am an MD, not a DO, or wasn’t that clear? It’s Panda Bear, MD…not Panda Bear, DO.
    Good Lord. You are really not going to like what I have to say about Nurse Practitioners. -PB)

  32. Forgive me, but I find all this discourse about the differences between PA’s and MD’s borderline absurd in most cases and frankly irrelevant in all cases. The fact is, PA’s are PA’s, and MD’s are MD’s. They are not the same. The absolute bedrock foundation of the PA profession and training model is that they are subject to supervision by an MD.
    This does not neccesarily mean subservient to, but bottom line is that a PA cannot practice without MD supervision anywhere. That is the the way it is. That is the way it should be.
    PA’s do not compete with MD’s.
    By the way, I am a PA.

  33. “I don’t take orders or work for PA’s”. I find that statement interesting for one particular reason-This mid-level provider is recognizing their limitations, calling the more highly trained physician for help and getting the response you would not expect- basically “I’m not doing it”. In 14 years of experience in a military setting and civilian sector has shown me that the good, competent, personable physicians handle PA’s very well, don’t feel threatened by them and embrace them. It is my full belief that ANY good medical professional has good instincts, knows their limitations, is personable and truly cares about people. Mid-level providers, utilized properly, free-up the physician for the more complex cases and make the practice even more cost effective and profitable. The PA profession was started by distinguished PHYSICIANS at Duke University in the mid 1960’s to fill a void in healtcare delivery. See link for more information http://www.paworld.net/whatisapa.htm#todayspa

    (The PA was being lazy, had gotten used to having cheap resident labor, just as used to it as anybody else in the hospital, and I will be damned if I’m going to lose sleep to help ease the paperwork burden for somebody making four times my salary, operating on a full complement of sleep, and not in any way authorized to demand anything of me whatsoever. As a sequel, the PA complained to the attending, he asked me about it, I said, “I don’t take orders from PAs,” and he agreed that I don’t. You’re reading too much into it. He was snotty, I was polite but firm that my sleep trumped his desire not to fill out forms. -PB)

  34. You are an ER resident, not a neurosurgeon.

    Get over yourself.

    Maybe you’re feeling a little threatened because a midlevel can do your job as adequately as you can?

    (“Adequate” is not a word we want to use in medicine. The fact that you bother to post on my site shows a bit of insecurity on your part, don’t you think? Like I always say, you may feel you know as much as a physician or are just as capable but that is probably a reflection of your lack of knowledge more than your competance. A little bit of knowledge is a dangerous thing.-PB)

  35. I’m a Neurosurgeon and have been practicing for over 25 years. Had it not been for my PA’s, my work would be impossible. They are truly an asset to the healthcare system.

  36. Harumph. Interesting reads, actually just what I was hoping to find out here in what Leary so eloquently defined as the ‘New Deity’.

    GATE kid in elementary school. I didn’t goto high school. Terrible home life. Lived in the streets. Worked store to store (good people in some of those stores started taking good care of me…I ended up a classical piano teacher, no less! Yet through all those years when I thought college was just for other folks, I knew where I belonged. So I started volunteering all across the boards. Alzheimer’s, Peds ICU, Hospice, AIDS Hospice, did my best to shape some slags in a program who were next to endagering some of their patients….the list goes on. Now I’ve been in the ER for about 6 years, and just transferred into surgery. Not much I can do in there except ask alot of questions and clean up the muck, but what a treat for me. I just sent out my PA apps, and now I’ve gotten a third invitation to interview next month, at a school that I have a large degree of respect for. Who knows. I may be coming to one of you on a rotation, any one of you. Know this. I’m smart, not just with the molecules, but I’m smart with people. And now after working paid in my colleges anatomy labs, I’m good with the blade and the bones.

    Doctors rule my world. They answer my questions. They figure out that what’s causing media-steinum chest pain in a young post-childbirth female of 20 years is, alveolar rupture. And while they do what we all sometimes need to do, read those books in order to find the most appropriate answer, I sure did hold more respect in her attempts than I would in my own. I might find the same answer, but she’s the one with the experience to know what to do next. If she can teach that to me, then I’m that much stronger.

    Then again…I also had to go through 5 files where scrips had been incorrectly written,and we had to call the patients and inform them that their Doc made an error. That’s when it’s important to remember that we’re all human, and we all inevitability err. More importantly, we’re there for each other to help pick up the pieces of the broken mug, make things right, and move on as a team.

    At least that’s what I’m talkin’ about.

  37. I stumbled across this blog while googling other things and I was amused by the discussion here. I am an NP in Utah and I independently own and operate a small family clinic by myself. I am an NP. I have attended PA school. I have a total of 14 years of full time college study and 5 degrees, so I have seen it all I tell ya. I have been in practice for 26 years and I can tell ya that there’s room for everyone to do their part for a patient/client. Enough bickering already! To the best of my knowledge I put on my panties one leg at at time this morning so I could get dressed and get to the office to engage in the best medical decision making and problem solving for my scheduled patients today—and it doesn’t matter to them if I am an MD, NP, or PA. What matters is they know I am engaged with them in solving their problem, I listen, I care, and I conscientiously go about my business within the scope of my practice and when it’s more than I can do I know the right folks to refer to. The only thing I really took exception to is the attitude that PA training is harder than NP training. I beg to differ—I’ve experienced them both—each has different rigors and my NP program was all clinically based—very little theory. Buyer beware is a good caveat for any student seeking a degree—no replacement for due diligence and doing your research before you sign on the dotted line my friend.


    (Look, you’re not a “Doctor” even if you have a phoney-baloney, plastic banana, good-time rock-and-roll nursing “doctorate,” and from your website you appear to be misrepresenting yourself mightily to your customers.  So sorry.  You are not going to get the usual ego-stroking here. There is a difference between the training of a doctor and a mid-level.  The difference does matter, and it’s only people with the short end of the stick who say it doesn’t.  As for degrees, I only have two but I guess that just prevents me from listing a whole bunch of initials after my name like many mid-levels do to, let’s just say, compensate.  -Panda Bear, MD, BSCE, ATLS, ACLS, PE, SGT USMC.)

  38. Well, reading all these posts has sure been interesting. I came here looking for an answer, but now I am just more confused than ever. I am getting ready to graduate from UF and I am also getting ready to apply to medical school. Now I am not being sexist, but being a female, I have definitely thought about going to PA school. I have had SO many doctors tell me reason after reason not to go to medical school and that does not seem to be the case with PA school. Now, for some reason, I am still wanting go to medical school. Am I crazy? I want to have a family and I want to have somewhat of a life, but I have always wanted to go medical school. Sometimes I think it is possible to have it all, but I am not too sure if it will be enjoyable. Any advice?

  39. As a PA I mostly agree with your comments. Let me point out just one thing however. PA’s are NOT independent nor are we trying to become independent. I tell ALL of my patients that I am a PA, explain what it is, and dont get upset if someone refuses to see me. Not only that but I am the first to refer if I am over my head.

    NP’s on the other hand are pushing for the rights to become solo practitioners, they are pushing to become doctores of NP with no more schooling than they have now. This concerns me. Midlevels should be proud of their positions and not be trying to reach doctor or solo practitioner ranks.

  40. Funny its mentioned that PAs don’t have much of a basic science background. I have a degree in Microbiology from a major university’s honors program, a minor in biochemistry, have published papers in peer-reviewed science journals, worked as a staff-scientist for the federal government, and actually dropped out of a masters in biotechnology program to attend PA school. PA school is much more rigorous than my previous masters work. I also have 12 years experience as a volunteer EMT and two years volunteering with a free clinic. In PA school, we take many of the same courses the med students do. Recently one of my med-student classmates told me she has a journalism undergrad degree, no work experience and no medical experience to speak of. Its true PAs don’t get the same med-school basic science classes, but I don’t think we’re too shabby either. I would also note that I am the norm among my PA classmates, not the exception.

  41. I am a PA and I am so glad I work with laid back, nice, humble, physicians who treat me pretty much as an integral part of the team.

    Thank God I don’t work with self-absorbed, self-important, and frankly worried physicians like most of the people on this blog.

    It is a fact, many patients prefer the personality of a PA, we are easier to talk to, we don’t wear gay stuffy bow-ties with long lab coats, and drive Jags and drone on and on about the stock market and our yachts in the doctors lounge. Zzzzzzzzzzzz You all make me sick…

    Ps most of the younger docs are pretty cool and treat PAs with respect not like dull boring humorless old physicians you so often see…

    (Dude, are you for real? -PB)

  42. Also, Panda Bear (what a tard name by the way), doesn’t take into account, how much money most PAs owe and we deserve the so-called “mythical figure” he talks about.

    Many PA students owe about 100K in debt for undergrad/PA school, Panda Bear fails to mention this…


    (Panda Bear was my radio call sign as the Mortar Section Leader and then the Platoon Sergeant of a Weapons Platoon in a by-God Rifle Company of the United States Marine Corps. What? You don’t like Panda Bears? -PB)

  43. “2 years of debt” OK Panda Bear fails to mention the 4 years of undergraduate debt and the possible 2 years of tech school debt first (RT, RN, EMT etc..)…plus the very expensive PA school debt on top of all this…

    Panda you don’t even know your facts…”a little bit of knowledge is dangerous.”

    (Oh Good Lord. Physicians have the four years of undergraduate debt too. I didn’t have that much because I wasn’t a dumb ass and went to my inexpensive state university. Whatever the case it still makes financial sense to become a PA because you might not make as much but you start making it earlier with less debt. -PB)

  44. “One night on call I was paged by one of them to come up to the floor and help him with some paperwork. Naturally I refused. It was late, I was tired, I wanted to get a few hours of sleep, and I told him so.” This says it all. Your lucky that you were not in the military during this conversation. I guess that your time in the USMC did’nt teach you anything about team work or leadership. Get off your high horse buddy. Doc’s and PA’s work as a team. We need to be there for each other. Even when the little intern is a little sleepy weepy during a 30 hour shift. Suck it up and drive on Marine!

    (Go fuck yourself. Medicine is not the military, I am no longer on active duty, and was honorably discharged from the Marines in 1991. If your implication is that because I was a Marine back when you were in kindergarten I now have to be a subservient scut monkey for the rest of my life then you are mistaken and I’m not going to live your idiotic military fantasy. Not to mention that you have no idea whatsoever what it is like to be an intern or a resident on Q3 or Q4 call for months at a time and perpetually sleep deprived. “Sleepy weepy” indeed.

    I repeat, I do not work for PAs, don’t take orders from them, and certainly will not do their low-level work for which they were hired and are being paid. I don’t take orders from nurses, respiratory therapists, or anybody else for that matter. It may be a team but you are not in charge of the team, something around which you need to wrap your mind.

    “Drive on.” What the fuck does that mean? -PB)

  45. I have to say that I love this discussion as well as the moderators comments! I am a PA and have to echo some prior posts reminding everyone that we are not trying to be solo practicioners and it is drilled into us that we are meant to facilitate complete and accurate healthcare in this crazy system, and allow the physician to spend more time and energy on the more difficult cases. Any PA, or midlevel who wants to “run the show” is breaching our original purpose. BTW, I have seen a difference in thought with PA/NP We are more focused on gathering the data, formulating a differential and then discussing with the physician if need be and implementing a combined effort treatment plan for difficult cases. The NP’s get caught up in the
    “i’m the boss” mentality and don’t seek help/instruction/more data as needed.

  46. Hi All: Stumbled upon this site while reading cafe pharma. What a riot!

    I have a very diverse background. I was an RRT for 20 years, spent 3 of those in the cath lab, a drug rep for 6 years,( the longest most miserable 6 of my life I might add), and 3 years as an RN. I was accepted to Med school, but declined to go, because ALL of my physician friends urged me not to.

    I was recently accepted to both CRNA school and NP school, and have decided to go to NP school. I live in a very rural area, and the docs I work with can’t wait for me to graduate so I can work with them.

    Couple comments Panda…

    You NEVER take orders from someone “lower” than you? Just the other day I asked the double board cert. ER doc to change a branded script to an unbranded script because the patient had no insurance. He did it. I say hey doc, don’t forget to write the order for that 2 view chest…hey, the guy’s heart rate is 145…how about xopenex instead of albuterol? No doctor has ever pulled their rank on me!

    You cannot pigeon hole people based on their EDUCATION, but character and experience are the deciding factors for any healthcare provider. I know PA’s and NP’s who will blow you away… and I know cardiologists and neurologists who I would not let operate on a gerbil.

    Enough of your arrogance. Your just the type of doctor that gets laughed at behind your back because you are a dick head, and you know it.

  47. I think they should be able to Pursue solo practitioner, not MD. If NP’s can do it why can’t PA’s ?

  48. Panda,

    Thank you for posting this, and for not taking any crap from the insecure haters who only arrived on this page because it’s the first hit they got when they searched for “physician assistant” on sdn (selection bias, anyone?).

    Also, I’d like to point out that Jennifer’s comment, and the comments of several posters who mentioned a difference in attitude between the PA’s and the NP’s, is demonstrated even within the post itself. Many of the PA’s who have commented, despite your (appropriately–it’s a blog) one-sided rant against problems with PAs, have been courteous and eager to insist that their fellow mid-levels hold to their appropriate, and important, role.

    Compare that to, for instance, NP “DoctorKara” who thinks her education “doesn’t matter” because she “puts [her] panties on one leg at a time” and “listens” and “cares” about her patients.


  49. Man, this is really sad to read as an eager (yet clearly naive) PA student who is/was excited to work as a team with physicians. Also, I repeatedly did have to prove my passion for physician-assisting during the application process for PA school. All the programs I applied to a very interested in your reasons for wanting to become a PA and any comment resembling something about not being able to cut medical school will guarantee an automatic rejection. PA schools want you to know exactly what the role of a PA is and that it is not a fast-track MD career. I enjoy working as a part of a team and that is one of the many things that drew me to the PA career and I am very saddened to know how some physicians really feel about us, especially because I have been nothing but impressed with how much my program requires us to know.

  50. Dear NP: “Did you ever have your hands in someone’s guts for 5 hours with a cursing, salty surgeon? Ever hold an anoscope as a lowly student? How about suture on the Aorta? Diagnose (or even suspect) Subacute Bacterial Peritonitis, GB, Eosinophilic Esophagitis, Jet-Ski induced Rhabdo etc…?” Yeah I said Jet-ski Rhabdo.

    NP’s have lobbied over and over to work independently. The illogical though is that this infers greater clinical acumen. They should jump at the chance to have oversight by a physician. Instead they pride themselves on being independent” Despite the A1c levels of their patients soaring. Then they say to a 67 year old female (in an invariably overly loud tone) that she should only come in for antibiotic treatment if she has been sick for 10 (!) days!

    Oh, but how their training as nurses gives them the “gut instinct” to know that a 71 year old, obese, diabetic, hypertensive, tachycardic woman with exertional left arm and neck pain and shortness of breath stairs, “most probably” has musculoskeletal pain – and then they are stupid enough to tell me “don’t get all crazy on the work-up because she has been getting physical therapy”.

    You are worse than the RT who said, “I know you want a head CT of the man with severe hypoNa who is currently intubated, but I am telling you right now – it’s gonna be normal”


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