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.