From Excessive Knowledge, Good Lord Deliver Us

(Writing this blog can be difficult. While I am interested in many subjects, developing coherent ideas and putting them down in a logical and entertaining manner does not always come easy. In other words, most of my articles do not just fall effortlessly from my brain. On the other hand, there are some subjects about which I am so interested and have such well-developed ideas that I almost want to avoid writing about them because it feels too much like “phoning it in.” Some run home to their mommies at the first sign of trouble. When I have trouble coming up with anything new I, too, metaphorically run home to the comforting bosom of my mother, revisiting subjects like futile care and the abuse of residents. Precisely because these things are easy to write about and I take great pleasure in doing it, sometimes I feel like a fraud, one who is just repeating himself with only slight variation, and throwing to you, my loyal readers, easy-to-obtain red meat instead of coming up with something original.

With this in mind, please accept the following article as more red meat. I hadn’t planned on writing it but I received so many private emails about what was really just a throwaway line in my last article that I felt compelled to fire up the old easy-writing machine to shoot ducks in a barrel and pluck the low-hanging fruit. You get my drift. I’m not proud of it but there it is. -PB)

Cry Me a Friggin’ River, Why Dontcha’?

It seems that I can’t mention mid-level providers, even in an offhand way as I did in my previous article where I compared Physician Assistants to brand-new interns, without the usual scolding from assorted mid-levels who are quick to rehash the usual half-truths and agitprop about their profession vis-a-vis physicians. It is not enough, apparently, for me to be generally highly complementary to mid-levels in many of my articles but I must instead roll over and submissively urinate, crying Uncle and admitting that the only difference between a physician and mid-level is some inconsequential and medically irrelevant minutia that we had forced on us in medical school and residency but from whose wasteful tyranny the mid-levels have been spared.

This is not the case however and the credence one gives to the theory that Less is Better depends on how much knowledge, the currency of medicine, one has in their possession. Since it is, barring some warping of space-time, impossible to cram the same amount of teaching into a typical two-year-and-change Physician Assistant or Nurse Practitioner curriculum as is crammed into a four-year medical degree, a graduating medical student on his first day of intern year starts out with an advantage in medical knowledge and it’s not an inconsequential one either despite the usual protestation from mid-levels that their shortened curriculum is just as rigorous as the medical school curriculum (but it’s not ’cause they don’t learn any of the useless stuff…see?). Is this extra knowledge important? Of course it is. I am not exactly medical training’s biggest fan but there is not a single thing I learned in medical school, from the structure of cardiac ion channels to neurolation in the embryo that does not, in some way, make me a better physician strictly by virtue of being a more knowledgeable one. It’s easy to stand on the low ground and insist that all of this knowledge is useless but, and maybe I’m missing something, we have not yet arrived at a time where we admire and seek to emulate those physicians who make an effort to limit their knowledge, judiciously deciding that they can do without this or that, and adopting the attitude of one of my fellow students in a now-distant pre-med anatomy class who, exasperated by the depth of the subject matter, said, “This would be a much better class if their weren’t so many word.”

It also should be noted that upon graduation, a mid-level’s mandatory education is at an end while an intern’s is just beginning. Strictly speaking, medical school is a minimum of seven years for all physicians as residency training, although not legally necessary, is a de facto requirement to practice medicine. I will have had eight years of medical training before I feel barely comfortable to practice on my own which is typical. Residency training lasts anywhere from three to seven years (and even more if we count fellowships) which is something that many mid-levels forget or ignore when they assert the equivalence of their training. Additionally, training is not the same thing as punching the clock. In other words, a mid-level can graduate from his program, secure a position, say as an extender for a busy cardiology group, and after a little on-the-job training get into his groove as a paid professional, keeping up with his continuing education requirements of course, but essentially having arrived at a point in his career where he can decide to sit around watching American Idol after he punches out. This is not the case with residency training. Every rotation is training and every day is an exploration of the dark continent of our ignorance, a vast territory whose boundaries no man can see and in which no sooner is one hill crested than we are presented with the prospect of still more hills in the distance. So it goes for eight years and it is the background acquired in medical school and residency, the useless minutia, that provides the foundation for understanding and the ability to synthesize original thinking on medical problems and not to just regurgitate contextless facts.

Now, as to the assertion that because most of medicine is fairly routine a mid-level can handle 90 percent or some arbitrarily high percentage of a physician’s job, the first thing you have to realize is that for those of us in the generalist specialties, even Emergency Medicine, it should surprise no one that fifty percent of what we see is absolute bullshit (if I may be allowed to create statistics from whole cloth, I mean). Far from requiring the skill of an expensive mid-level, most of these presentations could be easily sorted and sent home by a reasonably competent school nurse who has learned even less of that bothersome and useless knowledge. We don’t even need a well-trained registered nurse either because although their focus is patient care and not diagnosis and treatment, registered nurses particularly Emergency Department and ICU nurses, are extremely sharp cookies and they are probably over-trained to assess and send home many of the patients we see.

In other words, in their zeal to devalue medical knowledge, mid-levels are, perhaps unwittingly, bringing into the question not only the justification for having physicians but also for spending money training so many mid-levels to the extent they are trained today. Far better to just allow reasonably motivated high school graduates to take a year or two of basic coursework at their local junior college, give them a white coat and a stethoscope, and let ’em at all of those routine patients. Why not? My undergraduate degree is in Civil Engineering, for example, and any sharp witted, smooth-talking village idiot could make a good case that this contributes nothing to my ability to diagnose and treat disease. The same fellow could also make the case that eight years of medical school and residency training is not necessary to recognize the flu, treat garden-variety diabetes, or write a couple of prescriptions for blood pressure medications. Hell, as long everything goes smoothly and all we expects is low-level primary care then everything is going to be fine. Unfortunately, as we push the boundaries of medicine and reap a bumper crop of increasingly elderly and multiply comorbid patients, most of whom expect to survive their visit to the doctor, the trend nowadays is towards more complex patients, albeit mixed in with some undetermined proportion of sublimely ridiculous chief complaints or cookie-cutter cases that can be handled by our intrepid Junior college graduate.

Mid-levels are quick to note however that the trend even in their professions is towards more, not less education. Obviously some of that useless minutia is of value.

Let me relate a parable. As many of you know I was once an engineer and after graduating with my engineering degree found myself in an engineering firm where I was in charge of a stable of young design-draftsmen, the “mid-level” providers of the engineering world. Most of these design-draftsmen had Associate degrees in Engineering Technology from reputable junior colleges where their curriculum was heavy on drafting with a smattering of low-level engineering design courses. Good guys, for the most part, and I picked their brains for tips on computer-aided design and drafting as many of them had been using AutoCAD for years and were fairly good at it. (Junior engineers nowadays are expected to do a lot of their own drafting, probably because it is easier to do it yourself than prepare a sketch for a draftsman to translate into a finished drawing). The useful thing about well-trained design-draftstmen is that you can send them, for example, the design drawing for a piece of process equipment (a roll cage, conveyor, etc.) and they have the knowledge to produce detail drawings and parts lists without having to bug you all day about it. Same with detail drawings for structural or foundation work. Very few structural engineers, for example, produce detailed drawings of structural steel connections but instead pass the design drawings to a “mid-level” steel detailer who produces cut lists and all of the drawings need to fabricate and assemble the structure. The details are based on the engineers specifications and if, for example, I were to specify a shear-only connection to resist a certain load the detailer would produce the drawings from which the actual pieces could be fabricated. It’s not rocket science and, as a structural engineer, I am quite capable of designing and drawing my own connections but didn’t, habitually, except for the difficult ones that did not fit the cookie-cutter examples in the two major steel design manuals (that would be the AISC ASD and LRFD manuals for those of you who are interested and still following along).

Naturally, when I finished my five years as an “Engineer in Training” (interestingly enough also called an “intern” in the Civil Engineering world) and passed the licensing exam to become a Registered Professional Engineer I was completely responsible for all aspects of the design, drafting, and detailing of everything that passed through my hands including the detail drawing produced by the detailer, himself usually an independent contractor. Did I check every single connection on a large structure, burning the proverbial midnight oil for weeks at a time with a red pen in hand? Of course not. My detailer had been in the business since before I was born and knew a thing or two about steel fabrication. But that was his thing, you see. My thing was design and management and I don’t recall ever taking a detailer or a design-draftsman aside and asking their help for a particularly thorny foundation design problem. That was my thing.

One day, one of the more crusty design-draftsmen let on to me that he didn’t think it was fair that engineers made more money, especially as he believed he could do ninety percent of what an engineer did.

“Well,” I replied, “seeing as ninety percent of my job involves standing around drinking coffee making sure that you’re doing your job I don’t doubt it.”

But you see, the devil is in that left-over ten percent (or fifteen or twenty or whatever percentage makes you comfortable with your career choice). Most of every career is routine, repetitive, and can be handled on autopilot. The difference between medicine and other careers is that one never knows what patient is suddenly going to become one of the ten percent. Consequently we want to avoid the autopilot as much as possible. Emergency Medicine in particular is all about not just treating the ten percent but accurately determining who is part of this dangerous minority and until such a time as we can determine which of the ninety percent only need the school nurse and which need an attending physician, prudence dictates that we have the physician standing by even if many of his cases turn out to be nothing…keeping in mind of course that your definition of “nothing” depends on your training. Many of what I once thought were incredibly complicated patients are now just another boring case of sepsis or meningitis.

In reality the practice of medicine is a team effort, not unlike a symphony orchestra where everyone has a part and an instrument they are expected to play. If any individual from the conductor to the third flute doesn’t do his job well the entire ensemble is going to sound like a high school marching band. While it is true that a good symphony can produce ethereal musical magic from the great composers, they also spend a lot of their time sawing out The Nutcracker to keep the proles interested.
On another note, many of the critical emails I receive about the difference between mid-level providers and residents start out with some variation of, “I have been a PA for twenty years,” and then proceed to expound on the uselessness of an intern. Well, God bless you. I’m willing to allow that a new Emergency Medicine intern on his first day in the department can probably have circles run around him by a Physician Assistant who has been practicing for twenty years. But we’re comparing apples to oranges here. There is a steep learning curve for a resident and I would not presume to say I am even near to cresting it. That’s why we call it it “training.” On the other hand, a typical Emergency Medicine attending with twenty years of experience can run circles around a twenty-year mid-level and their little dog too. They didn’t get that way by stopping their ears against useless medical knowledge.

64 thoughts on “From Excessive Knowledge, Good Lord Deliver Us

  1. There are certainly aspects of overtraining. As you mentioned, you studied engineering. There is no real reason why doctors need a bachelor’s in an unrelated field to study medicine. We should adopt the style of England and make medical school a six-year undergraduate program.


    (I know what you’re saying but in most cases, the undergraduate degree is a rigorous one (mine certainly was) and requiring it cannot help but increase the general quality of American medical school applicants.  What’s an extra two years?  It’s not like the premed is really in the “doctor pipeline yet” and while maybe there would be more applicants to medical school if the total years of training weren’t so daunting, there is no shortage of applicants and matriculants to load into the front end.  Again, the idea to shorten the process is an economic one which I can respect but it is probably a false economy, sacrificing quality to expediency which is unfortunately popular with politicians and those demanding the idea of free medical care with no real concept of quality.  But good medicine?  Nope.  Inevitable? Of course.  I repeat that people want the idea of free medical care more than they are really, for the most part, concerned with quality.  You could indeed put an incompetent junior college graduate in a white coat and most patients wouldn’t know the difference because most mistakes in medicine (with the exception of the surgical specialties) take a little while to manifest…and while they do the public sleeps soundly knowing that they are warm and loved in the comforting embrace of the Mammary State.  -PB)

  2. Amen! If you want to be a Doctor – go to school and be a doctor. We all have our place on the team as the Great Panda has noted.

    Don’t complain because you aren’t the quarterback if you haven’t trained to be the quarterback.

    If I may offer another comparison… My father is a pilot – 90% of the time he sits in the plane and watches the autopilot – I can do that (i’m not a pilot at all) but 10% of the time he controls that huge jet and helps it land or take off and in very very rare cases he controls it in dangerous situations where the weather or plane are not cooperating. Thank God for all of us that he is at the controls and not someone with less training.

    I love my midlevel’s and I LOVE my ED nurses – an experienced nurse can save your ASS if they choose and they can help you look good while they do it. I started as a nursing assistant in the nursing home (change diaper, shower, dress, feed, repeat…) However, I went to school for all those years and am finishing residency because I want to know what to do in those rare situations when I am required and because I like to be the one contributing to the decision making. Thanks again Panda for a great post even if you feel like you are shooting ducks in the proverbial barrel! 🙂

  3. Truth. Nothing bothers me more than when I see med students disrespecting their education. Yeah, it’s a long hard slog through the rice paddies, but you’ll use it in residency and you’ll use it to be a better attending. If you don’t understand why you are ordering something on a pathophysiologic level you shouldn’t be doing it.

    Whether or not our society (which lives to tear down anybody perceived to be “uppity thinkin they’re better than us with all that book larnin”) recognises this is an open question. For most fields besides surgery I think you could put a long white coat over a McDonald’s uniform and get few objections.


    (That’s all I’m saying.  That there is a difference and the difference is important.  The fact that it is not perceived to be is more a matter of economics than good medical practice.  A residency-trained primary care physician, for example, would be better but since they are scarce and relatively expensive, a mid-level is a cheaper and more available alternative.  Nothing wrong with this, of course, but in the case of primary care this is more the result of the “gatekeeper” model of primary care – treating minor complaints but referring “difficult” cases to specialists – than any special powers of midlevels.  Primary care has all but surrendered its once broad scope of practice in the United States for various reasons many of which are elucidated by our good blog-friend the Happy Hospitalist (who you can find on my blogroll).  Contrast this with the UK where General Practioners have a much broader scope and are not so quick to “punt.”

    Still, a residency-trained American internist, the foot-soldier of primary care, is a very knowledgable fellow with a vast fund of knowledge who, if reimbursment schemes were different, might be the kind of doctor who never called a consult except in the most difficult of cases or for a procedure which he reluctantly deemed to be necessary but did not feel confident to perform himself.  American medicine would be a lot cheaper if this was the case too.-PB)

  4. @ HalfMD

    True, medical schools in the UK are six years compared to our eight, but post medical school training is longer in the UK. For instance, to become a GP you would need to spend two years as an FHO, then three years as Specialty Registrar. So five years of post-medical school training to become a GP compared to three years here.

  5. Not to mention the obvious fact that intellectually, the average medical student is much, much smarter than the average PA / NP (of course there are rare exceptions). A hard fact for many to swallow but I doubt the average midlevel provider really understands the level of competition required just to get into medical school these days. Even most accepted medical students don’t fully understand until they are finally thrust into school and realize the caliber of people they are competing and working with. Even amongst medical students and physicians it is painfully obvious that there is a great intellectual and work ethic divide between the students at the top of the class and those routinely at the bottom. Yet every student at the bottom of the class could easily get into any PA school he/she chooses. Honestly, has anyone ever hear of a “genius” PA? The competition is like night and day.

    Physicians are selected to be the best of the best. Pound for pound, year for year, the physician is going to have much more rigorous training and an inherently better decision making capability. I know whom I would much rather place my trust in if I had a family member with a difficult condition.


    (This is not the “Random MSII” our regular visitor but some other person.  I’m sure there was no harm meant but I just want to clarify things.  -PB)

  6. Great points Panda. When a patient comes to their primary care doc to get their simple diabetes or htn managed and gets charged $100 or more, what they always forget is that the doctor did not train only on how to manage DM or HTN, but also 1000’s of other diagnostic evaluation trees and managements.

    When you go for your DM, you are paying for the whole package.

    If all you want is your DM, then you get what you pay for.

    You also said:
    “Many of what I once thought were incredibly complicated patients are now just another boring case of sepsis or meningitis.”

    I struggle (but not really) with this every day when deciding when to bill a critical care. To me it is like flipping a switch.

    I could manage severe sepsis with multiorgan failure with my eyes closed, listening to Guns and Roses on my iPod.

    It is so engrained in my mind that it is “simple” medicine to me. But I know it constitutes critical care.

    Often times, docs sell themselves short and underbill because it just “seem’s to easy” to bill critical care.

    And sepsis takes up but an itty biity tiny part of my vast medical knowledge on just about everything.

  7. As an RN, PhD, NP-type, I think that your view of the “proper” place for mid-levels is absolutely “spot on.” I have less knowledge of PA education, but NP education does not come anywhere near the length, intensity and focus of MD education. I shudder to hear NPs say that they are trained in an equivalent manner to physicians. It is simply not true. I think that NPs and MDs can work in a complementary manner-but come on folks, particularly uppity mid-levels, don’t discount the potential problems that a lack of deep knowledge could lead to, even on a seemingly routine patient matter.

  8. I’m an RN in NP school and I despise the NP’s around me who act like they are equal with MD’s. I watched my brother (an MD) through his years of medical school and I know I am learning a small % of what he learned. I am putting in but a small % of time that he did. We have a place and I think there is room enough for both of us, but not on the exact same podium level.

  9. “…shoot ducks in a barrel and pluck the low-hanging fruit” ??

    You have testicularly endowed ducks?

  10. Um, that was NOT me up there. Now you have people faking they are your regular commenters? LAME.

  11. In response to a prior comment, I have a ‘genius NP’. She spent fifteen years doing ICU, surgical, and emergency nursing. She knows what she knows, but more importantly, her experience enables her to recognize she’s run across something she knows nothing about.

    A significant part of the body of medical learning is a codification of the lessons received as a result of the errors of the past. The mid-level part of the profession is still in the early days of widespread public use, and hasn’t had time for that evolutionary process to fully play out and to be incorporated into their training. It also, by and large, hasn’t had the opportunity to incorporate the ‘learning experience’ that comes from being second-guessed by the practitioners of the tort law profession.

    Be definition, teaching someone how to recognize what they don’t know involves imparting some degree of knowledge of the subject to them. Picture for example trying to explain to that draftsman why the vertical support in the middle of the beam has to stay there even though it doesn’t look ‘cool’. I have a feeling that once the curriculum has been expanded to cover the ‘how to know what you don’t know’ field and the ‘how to stay out of court’ field, it’ll be roughly the same length as physician training and a significant amount of the highly touted ‘cost savings’ will disappear.

  12. Interesting. I am an ICU nurse who is becoming increasingly bored with my profession. The natural progression always seems to become an NP or a CRNA, but for some reason I find myself with no desire to do either of these things, and I think you have just described why.

    The concept of being a “mid-level” anything just seems so self-limiting.

  13. @ Ben.P

    Please don’t forget that post-graduate trainee physician’s hours in Britain are drastically limited (something on the order of 57 hours a week) in comparison to the US, in accordance with European working time directives. So, you are comparing apples to oranges.

  14. Panda, your eloquence is always a pleasure. I know this will sound weird to a lot of folks, but I truly think it is a combination of your engineering training and your ER training.

    In both arenas you have to be able to take complex problems and break them down into terms that are understandable to folks without your knowledge base.

    You do a very good job with that task in your blog.

    Please, continue throwing the red-meat low-hanging-fruit out there. It is desperately needed by our society.

    Regarding your comment about GP’s in the UK being less apt to punt stuff to a specialist, I think I have a bit of insight here (not that it will be news to anyone reading this blog I suspect).

    I think to a large extent it boils down to our litigous society.

    Prior to attnending medical school and my family medicine residency, I was a practicing veterinarian. I practiced for about 4 years before making the change and acquiring more student loan debt.

    During that time, I probably felt the need to refer maybe 5 or 10 patients total to specialists.

    As a family medicine physician, I probably refer that many in a typical week or two.

    It is not because I am any less qualified to treat them. If I were practicing in Borneo or some other place where I had little fear of lawsuits, I wouldn’t refer most of these folks.

    For most of these patients, I don’t really feel a strong medical need to make the referal.

    The fact of the matter though is that if I don’t refer them, or at least recommend such referal, I am totally setting myself up for a stupid lawsuit.

    What sort of scares me is that in those times when I have been required to supervise nurse practitioners (as an employed physician) I have seen many many instances where these midlevels seemed to have the exact opposite approach.

    Many times I have observed them simply blundering ahead in blissful ignorance taking on the treatment of a patient who really and truly should have been referred to a specialist, not for legal reasons, but for actual medical reasons.

    These are patients, that I as a physician would probably be inclined to consider making a referal on, even if I were practicing in Borneo.

    The midlevels however just don’t have the education to recognize what thin ice they are treading upon, so they just plod along, skipping through a minefield.

    They say the lord takes care of drunks and idiots. I think he does.

    Now all that said, I have also worked with some excellent midlevels who in fact did recognize their limits and stayed well within them. They all seemed quite comfortable with the idea that in fact they are not the equivalent of a residency trained physician.

    I think to a large extent it is a matter of maturity. These ones had it. They were okay with what they were and had no need to engage in some sort of occupational sibling rivalry.

  15. every time i see a post against mid-levels, there is always a comparison between the new grads. (2 years PA school vs 4 years of medicals school) the fact is their roles are different. physicians are groomed to be the leaders of a team and mid-levels the workers. although residency is a pain and a majority of the things seem useless, most of the experience is to train you to be a physician in your field. when i educate, i inform my residents, “i am not training you to be a resident.” my personal role is get them to thing more in the role of treating physician rather than worker.

    a new grad on either side is inexperienced. s/he lacks the data points for rapidly assessing and treating patients. you see, as much as we talk about the intellectual (book learning) side of medicine, clinical medicine is basically pattern recognition. the more patterns you see the better you are at recognizing them. that is why experience mid-levels function well. do they recognize the subtleties of different disease patterns or are they up to date on the newest innovations, probably not, but they are there to help as part of the team.

    thanks for the post panda … well said (i particularly like the engineering part. it was close to my heart)

  16. sorry buddy (“Random MSII”), i didn’t know you existed. quite the ego you have there, but you shouldn’t flatter yourself. No one is reading this blog for your comments. Besides doesn’t random imply the likelihood of a different person/number each time?

    As an add on, having also been a former engineer, I find it quite amusing how insecure so many health care professionals can be. It reminds me of debates I sometimes get into with English or Sociology majors who are so insecure they try to argue that their majors just as difficult (in terms of work-load) as engineering majors.

    Why is it so hard to swallow? As a computer science guy I knew that the average person in my department wasn’t as smart as the average EE guy, who wasn’t as smart as the average physics major. Why should that bother me? When I worked many projects at NASA, I never found myself thinking “I could do these guys’ jobs if I wanted to.” I was great at what I did but I knew my place. They were 10 times smarter than me and knew I couldn’t do what they did even if I wanted to.

    On average, rocket scientists (IMO) are much smarter than physicians. Physicians are much smarter than PA/NPs who are probably much smarter than the average hospital tech or wheelchair pusher-guy. Get over it.

  17. While the physician is a conductor, I think it is absolutely insane to give one of the orchestra members an instrument, and then not let him use it. Such is the case of pharmacy. Four years of pharmacy school to obtain a Doctor of Pharmacy degree (sounds similar to something I read earlier), years of therapeutics, guidelines and more guidelines, journal club after journal club, residencies, Board Certification, and there are still some states where I don’t have a right to prescribe. Heck, in New York they’re still trying to decide if I would be capable of giving an IM injection.

  18. I think that what most midlevels who reply with vitrol to doctor’s blogs that talk about them is that they are mistaking a criticism of their chosen profession for a personal attack. Any resonably competeant PA and NP probably could have been a doctor. But they didnt choose that path, and they arent.

  19. While the physician is a conductor, I think it is absolutely insane to give one of the orchestra members an instrument, and then not let him use it. Such is the case of pharmacy. Four years of pharmacy school to obtain a Doctor of Pharmacy degree (sounds similar to something I read earlier), years of therapeutics, guidelines and more guidelines, journal club after journal club, residencies, Board Certification, and there are still some states where I don’t have a right to prescribe. Heck, in New York they’re still trying to decide if I would be capable of giving an IM injection.

    You knew the limitations of pharmacy beforehand, now you are crying because its not all its cracked up to be. Why should you get script rights? You dont know how to diagnose anything.

    We all know what this is really about. You want the prestige and money taht comes with being a real medical doctor and are now trying to change the rules of the game to accomplish that.

    Go to medical school or NP school if you want to write scripts. Otherwise, shut the fuck up and get back in your hole and dispense my meds.

  20. Chris (PharmD) – I should preface this by saying that I have nothing but the utmost respect for the career choice made by pharmacists. I have many friends and colleages in pharmacy school, and also know a few practicing PharmDs (in particular, I worked with a PharmD in the ICU of a large community hospital last summer who’s depth and breadth of knowledge was simply amazing). However, I find it difficult to sympathize with PharmDs who feel entitled to prescribing rights. While I’m fairly certain that a PharmD could run circles around most (not all) MDs when it comes to pharmacology principles, drug mechanisms, dosing, kinetics, dynamics, etc., pharmacy school does not adequately prepare you with the physical diagnosis skills and pathophysiology knowledge base necessary to prescribe medications and then manage those patients. If this were the case, what would we need doctors for?
    Pharmacists, on the whole, have done an incredible job of lobbying for more and more power when it comes to medical decision-making. But, I can’t help but thinking, as it was oh-so-eloquently stated before – if you want to do the work of a doctor, then BE a doctor – go to MEDICAL school. If you want to be a pharmacist, go to PHARMACY school.

    I’m sure I have much lambasting to look forward to (please, proceed to scold me with regards to my “ignorance” on the subject of Pharmacy School education in the United States), but I doubt it will sway my conclusions very much.

  21. Wrong. Chris PharmD.

    As a pharmacist who has gone into medicine I can tell you that it is more like claiming that since you know how to read sheet music you should be able to play flute when you normally play the violin.

    Just because you can read sheet music doesn’t mean you can play instruments you don’t know how to play.

    Until you are going to learn how to diagnose disease and learn about stages of disease (aka medical school and residency) you should not be prescribing.

    This is why I left pharmacy. You knew what you were getting into when you got into pharmacy, but now since you are unhappy you are going to change the profession instead of changing personally.

    Let me repeat! We, as pharmacists, are NOT trained to prescribe. We are trained to dispense and know the subtlties of drug interactions. This does not translate into treating disease with drugs.

  22. The educational system in Europe is quite different from the US one, so it is not easy to make direct comparisons between the two. In Germany, you leave school at 16 if you are not going on eventually to college. If you are planning for college, you go on to what is called a ‘gymnasium’. You get what is equivalent to the last two years of American high school and the first two years of college, and graduate with a ‘baccalaureate’ at about age 20. If you are going on to be an MD, you then will have to be accepted into a combined university/Medical school program (6-7 years). So, by the end of medical school, you have a person who is approx. 26-27 years old, the same as here in the US, just the route is somewhat different.

  23. My apologies for offending the “other” random msii… as there have been the occasional troll here pretending to be Panda or other commenters in the comment section, I initially took you for one of that ilk. Far be it from me to assume that your aim was other than to contribute meaningfully to the conversation. Perhaps because I disagreed somewhat with your comment and the tone differed greatly from anything I would post I jumped to conclusions and for that I apologize. Well come to Panda’s soapbox.


    (I’m working on getting “unmoderated” posting rights so some of our regulars can contribute more.  People do read the comments, by the way, so I encourage everybody to comment.  It’s not like it cost me anything to have comments.  I’ve still only used about two percent of my disk space and my monthly data transfer quota has a long, long way to go before I exceed it. -PB)

  24. To those that think I am crying, well, I actually do have prescribing rights where I live….some states have given pharmacists prescriptive authority. And for those ignorant in pharmacist prescriptive authority that do not believe a pharmacist can obtain prescribing rights, Google “Clinical Pharmacist Practitioner.”
    I agree with those that say I do not have very good training in diagnosing….but I have had years of training in management of chronic disease states and I believe I am highly qualified to prescribe for such conditions.
    So, are you all saying that pharmacist run Coumadin Clinics should not exist?!?!?! Why do the new 2008 JCAHO guidelines require anti-coagulation to be done by “hospital protocol” which is code for “by a pharmacist?” Because pharmacists have proven that they can manage anti-coagulation. The same goes for a number of disease states.
    I do NOT believe that all pharmacists should have prescribing rights, but I believe that those with advanced training and have proven their abilities through Board Certification should.

    ((Bolded part of the comment by me) I don’t know, man.  I know you know what to prescribe, the indications, and the dosages, but there’s more to managing chronic diseases than medications.  Is the pharmacist-practitioner going to be the patient’s primary care doctor providing all routine medical care including prescriptions or is he going to defer most other responsibilities to the incredible shrinking Primary Care Physician?  In other words, do you have the skill and knowledge to be a de facto primary care physician or are you just going to be a medication consultant, someone to whom is sent a patient with medication requirements that you elucidate? 

    I guess I don’t understand what niche you want to fill.   -PB)

  25. You may have just saved me from a lifetime of regret. At 47 I am gearing up to make another attempt at getting my butt into medical school. When I started this endeavor several years ago, all I heard from friends, family and acquaintances was “Gosh, why don’t ya just go to P.A. school? It’s only two years, ya know?” How does one politely explain that one does not want an Associates Degree in medicine? Sheesh!

    So I’m now older and a bit more worn and I was considering going the N.P. route. Path of least resistance and all But not after reading your comments. To quote my med school application: “I want all the toys. No, not the Porsche and the trophy wife, but the most extensive education available so as to make the best possible medical decisions for my patients.”

    (I want to state, for the record that, except that I am a doctor, the medical profession would so not be worth it for me and I have and had no desire to be anything other than a physician.  The idea of becoming a PA as some kind of consolation prize never occurred to me so I understand completely your philosophy.

    But dude, 47?  You’ll be 48 or 49 when you matriculate, 53 when you graduate, and pushing 60 when you get done with residency.  I’m not going to blow smoke up your ass and give you the usual rah-rah, “follow your dreams,” “You can do it!” speech.  I’m sure you can. But residency is harder when you are older.  A lot harder.  Maybe you’ve settled down a bit and are not as stressed out but I’m talking about physically and mentally harder.

    Not to mention that it’s hard to go from being a legitimate adult, particularly if you have a professional career, to being treated like an idiot which is the default postion in third and fourth year of medicial school and residency training.  I reiterate, and I have talked to my wife about this, knowing ten years ago what we know now, I would never have applied to medical school.  Sure, I’ve only got a year left of residency and I might feel differently four years from now but it has not been an easy seven years.  In particular, we look around at the financial wasteland in which we are stuck and wonder how it came down to this.

    My big dream?  Saving the world? No.  Being the bestest doctor I can be? No. (Well, you know what I mean).  Living a reasonable lifestyle?  No.  Cars? No.  Nice House? No.

    It’s paying back all of this fucking debt and digging ourselves out of the hole, a process that will take many years.  -PB)

  26. At my hospital, we have an incredible clinical pharmacist (pharmacy board certified in a specialty) in my home department, who even has his own clinic. He does a super job, no question about it. But, he clearly recognizes that he is not a physician and does not diagnose and treat outside his area of sub-specialization.

    Instead, he punts to lowly residents like me to do a work-up.

    Pharmacists, even clinical pharmacists that are pharmacy board certified are simply not physicians. Nothing wrong with that, it is simply the way it is.


    (You know, I don’t really think of pharmacists as “mid-levels.”  They’re pharmacists.  That’s their job.  To be experts on dosage, indications, side-effects, and contraindications of medications.  I don’t see how this necessarily translates into the need to diagnosis medical problems and prescribe medications.  

    Physician assistants and Nurse Practitioners are able to prescribe, on the other hand, because their training is in diagnosis and treatment.  That’s their job.

    Additionally, I don’t know why pharmacists would actively seek the kind of responsibility required to diagnose and treat (by prescribing medications) diseases.  Imagine what this would do to their liability, not to mention that the question of whether the patient’s doctor is also to be held liable for joint errors in prescribing and treating.

    I think that pharmacists who want to swing more weight should get their additional training and then work in the role of consultants in the hospital.  But retail pharmacists doubling as practioners? Somebody has to explain this to me (really) because I don’t understand it.

    On the other hand, if a Nurse can get a Masters degree and all of sudden, as an NP, be allowed to practice independently, I don’t see why some similar avenue shouldn’t be open to a pharamacist.

    My real point is, why would a perfectly decent pharmacist want to be a mid-level provider?-PB)

  27. Are you afraid the retail gravy train is coming to end. Do you think that the only way to secure your profession is by obtaining a job that is already filled? There are enough people doing what you want to do in the healthcare system. There is no need so why are you trying to create one pharmacist?

  28. Thanks for the interesting post. PA’s are not doctors and they should realize that. If they want to be doctors they can go to medical school. Period.

    The same goes for Pharmacist. This same conflict between Pharmacist and Doctors is also very much alive in Nigeria where i reside. My answer to the pharmacist is go get your MD.

  29. My father is a PA who graduated almost 40 years ago from a well-recognized program in Boston. He then spent over 25 years working in the federal prison system where doctors were increasingly phased out. By the time he retired from the BOP, doctors were only called in as referrals, day to day care was handled entirely by PAs and EMTs. Combine this with the fact that he is perhaps the most naturally astute diagnosticians I’ve known, and he could run circles around most doctors I’ve ever met. However, he’s quick to point out that he’s not a doctor. If he’d wanted to be one, he’d have gone to medical school. He made the choice (and it most certainly was his choice. He could have gotten in to just about any medical school) for his quality of family life.

    He often compares doctors to car engineers, and a good PA to a good mechanic. He knows what goes wrong and the right way to fix it, but he doesn’t know all the minutiae of how and why it went wrong in the first place. I’ll sometimes call him for clarification for something we’re going over in class and he’ll remind me that he never learned the particular thing I’m learning. He knows how to manage an acute Addisonian crisis, but he never learned the biochemistry behind the disorder itself. Part of that is the great advances we’ve made in molecular biology since he was in school, but a greater part of it is that there just isn’t room for it in the PA training. And there doesn’t need to be. A PA is a PA. A doctor is a doctor. They can and should be complimentary members of a healthcare team, but they are not the same.

  30. As a physician in Boston, we have many PAs and NPs working in the area. I work mostly with PAs now but have worked with a few NPs. In my experience, I find that the PAs on our team do not pretend to be MDs. They are PAs and in that role are satisfied in all that they do. They are not pretending to be MDs, nor do they think of themselves as med school rejects. I asked on of them who was a respiratory therapist for 8 years prior to going to PA school why we went instead of med school. He said, he wanted to do what he wanted to in medicine, and have a life outside as well. It was hard to argue that point after my many years of residency and fellowship.
    NP’s that I have worked with however seem more inclined to push the “independent” factor and are a bit more confrontational.

  31. As a physician in Boston, we have many PAs and NPs working in the area. I work mostly with PAs now but have worked with a few NPs. In my experience, I find that the PAs on our team do not pretend to be MDs. They are PAs and in that role are satisfied in all that they do. They are not pretending to be MDs, nor do they think of themselves as med school rejects. I asked on of them who was a respiratory therapist for 8 years prior to going to PA school why we went instead of med school. He said, he wanted to do what he wanted to in medicine, and have a life outside as well. It was hard to argue that point after my many years of residency and fellowship.
    NP’s that I have worked with however seem more inclined to push the “independent” factor and are a bit more confrontational.
    Pharmacists shouldn’t even be in this conversation. They are specialist in medication, and despite all of their wishing and try, are not qualified to do more than manage medications at the most.

  32. I never stated retail pharmacists should act as practitioners. I lobby for something like what was passed in North Carolina, the Clinical Pharmacist Practitioner Act. The pharmacist is given prescribing writes after certain conditions are met to show competency. The pharmacist has a written protocol/agreement with a referring physician for what he/she can prescribe.
    One avenue this could be utilized is at a heart failure clinic, where the pharmacist could up-titrate the beta-blockers and ACEIs, add spironolactone or furosemide, etc. Another way it could be used is having a pharmacist renal dose meds for a nephrology clinic…or insulin adjustments at a diabetes clinic. These are all things that pharmacists are now trained to do in pharmacy school.
    The clinical pharmacist practitioner is NOT a primary care provider. No one could say “Oh, I’m sick. Let me go see the pharmacist and have him prescribe me some drugs.” They would be referred to the pharmacist by an MD or DO for specialized care, such as Coumadin monitoring and adjustment. The diagnosis has already been made by the time the patient sees the CPP.
    If you have ever written for “Vancomycin per pharmacy” then you have done exactly what I advocate for.

  33. “My big dream?…It’s paying back all of this fucking debt and digging ourselves out of the hole, a process that will take many years. -PB)”

    Aaaaaaaaa-MEN. I’m younger than you, PB, but I can totally relate.

    My big fear? That in the next couple of years our entire healthcare system is replaced by some single-payer Medicaid-for-all disaster and I can look forward to a low-paying and soul-sucking government position awaiting me at the end of my training. With a personal debt load that would make many third-world nations shrink in embarrassment. A never-ending spiral of loan repayments and lack of entrepreneurial opportunities would then ensue, and I’d die poorer than I was born.

    The thought alone makes me diaphoretic.

    (What gives me chest pain is the thought of Mrs. Clinton or Mr. Obama, the children of privilege who have never really worked at anything besides government for their entire lives, demonizing doctors and trying to negate my life’s hard work to give the illusion of free medical care to the TPGA-axis. -PB)

  34. Panda, now I’m not really with Clinton or Obama on the socialization of medical care deal. But to be fair “children of privilege who have never really worked at anything besides government for their entire lives” simply does not describe the life history of Obama and I think also does not really apply so much to Clinton either though to a lesser extent than Obama. Being an independent I’m not particularly sold on any candidate yet (though I do have opinions of each) but I just dislike seeing broad sweeping statements like that made when the life histories (at least as recounted on the sometimes doubtable Wikipedia) simply do not fall in line with the statement at all.

    (Mr. Obama went to Harvard Law School and did his undergraduate studies at Columbia University, paid for no doubt by his Harvard Educated father.  Nothing wrong with this, of course, but let’s not pretend Mr. Obama was a poor sharecropper.  Mrs. Clinton has been riding the rails of government for most of her life, as long as she can probably remember, is (or was) feted wherever she goes, and has probably not had to drive herself anywhere since the 1970s.  Again, nothing wrong with this and nothing in their background disqualifies them to be President but there it is.  It’s ironic that both Mrs. Clinton and Mr. Obama would identify me as a member of the privileged class when the only real privilege I had was excellent parents…something that at one time wasn’t even considered a privilege but the rule.  Hence my distaste not for the wealthy and powerful but only the wealthy and powerful who confuse the “common touch” with giving away other people’s money when it is actually (something that Ronald Reagan and both President Bush’s understand) having a decent regard for your plumber.   Nothing more comical than watching John Kerry try to eat Barbeque with the proles.  He’s no Davey Crockett.  Better for him to have said, “You know, I like French food and wine, and I don’t care what you fuckers think about it.” -PB)

  35. Chris said: “No one could say “Oh, I’m sick. Let me go see the pharmacist and have him prescribe me some drugs.” ”

    That actually happens in the UK.

  36. The midlevel is cheaper. 1/3 the training will do that. And it’s becoming all about the money in medicine. So if you get it right 90 percent of the time, and the other 10 percent that gets screwed down the road is tough to pin on anyone, that’s good enough for those who have budgets to worry about.

    Real doctors cost real money. Real money is in short supply.

    So it is what it is.

  37. “Chris said: “No one could say “Oh, I’m sick. Let me go see the pharmacist and have him prescribe me some drugs.” ”

    That actually happens in the UK.”

    And in some countries you don’t need a doctor or a pharmacist. Just walk into a pharmacy and ask for just about anything.

  38. Panda, I had a response that might have gotten lost in your spam filter. No biggie but if you happen to come across it, that would great.

  39. Chris said: “The diagnosis has already been made by the time the patient sees the CPP.”

    So basically you don’t want prescription rights, just the ability to adjust dosages within defined ranges? Nurses even do that when orders are written for it…I’m with Panda, I don’t get it.


    (Yeah, I mean, we have standard orders for adjusting Heparin and coumadin as well as for ventilator sedation that are executed by the pharmacy and the nurses.  I’ve got no problem with that.  But let’s say your patient has a high INR from their coumadin and starts having subtle early neurological signs of an intracranial bleed.  Does a pharmacist know enough about taking a history and performing a physical exam to detect this kind of thing and, more importantly, do they want this responsibility? -PB)

  40. Well, I guess my comment got lost but the gist was this:

    If Obama’s father paid for his education, then Michelle Obama’s recent stump speeches have been full of lies. According to her, they only paid off all student loans 3 years ago, and only because of his book; In her words “[they] got lucky.”

    Hillary may have been first lady of Arkansas beginning n the 70s, but the year Bill was elected was also the year that her lawfirm made her a full partner and, woefully inadequate as my knowledge of the career paths of lawyers is, I strongly doubt that lawfirms make people full partners based on the political associations of their spouses. She earned more money than Bill from the time of his election as governor until he was elected President.

    My previous comment had more, but I’m not really looking to start a debate on the subject. But I still say your ideas about the candidates backgrounds are a bits skewed by your political affiliations and strong preference for members of the military. Nothing wrong with having preferences of course, but I still say your attitudes toward the personal backgrounds of the Dem candidates is colored by you personal political affiliations and not entirely based on the actual history. Not to say that you’re held to a higher standard than the rest of America, but I think that based on your even-handed treatment of other issues, I would have expected more, but only because I respect YOUR respect for discourse and discussion.

    (I repeat, Mr. Obama and Mrs. Clinton don’t actually work per se. They are in “public service” and have spent their adult lives as professional activists and politicians. Mr. Obama was not underprivileged, neither was Mrs. Clinton. Again, there is nothing wrong with this but at a fundamental level, neither of them understand (or have forgotten) the organizing principle that guides most of us, that is, to work to support ourselves and our families as comfortably and securely as possible. For Mr. Obama, Mrs. Clinton, and most politicians of either party to greater or lesser extents, your money, the fruit of your hard work, is currency, the redistribution of which secures their prosperity which is dependent on continuation in either the limelight, public office, of both. If Mrs. Clinton but breathed the merest hint that perhaps, just perhaps, rich doctors like you and me earned what we make and maybe, oh just maybe, it is wrong to tax us into oblivion to pay for entiltlements for people who didn’t work as hard, the undetermined percentage of freeloaders mixed with the Holy Underserved, she wouldn’t have a chance of holding onto her senate seat much less winning the presidential election.

    The knowledge about what motivates elected officials, the need to be re-elected to preserve their access to the perqs and privileges of their office, is so fundamental that to not know it is to make elected leaders into cult figures instead of representatives. Your sacrifice to become a doctor, the long hours you will spend as de facto indentured servant, the things you will have to put up with, my many summers working as a landscaper in the hot Louisiana sun to pay for college, my years as a Marine sweating and bleeding for Mrs. Obama’s rights, the crappy jobs I have worked, and every other normal thing that normal people do who do not lead privileged lives are completely foreign and irrelevant to Mr. Obama and Mrs. Clinton. We are just stepping stones to power, people who will provide the tax money with which they may bribe their constituents.

    Once again, the common touch is for the privileged to have a decent regard for their plumber. That’s all. -PB)

  41. Well, I guess we differ in our definition of prescribing rights. My definition of prescribing rights is “the legal ability to write a prescription.” I don’t link diagnosing with prescribing in my definition.

    Panda: Most of what I mention can be done in a hospital if approved by the P&T Committee. However, it can only be done on an outpatient basis in a handful of states. Only a few states give a clinical pharmacist the right to print prescription pads, see patients, write them a prescription, and have them go to the drug store to have it filled. I believe that pharmacists with proven abilities, under MD supervision, should have this right. I know few PAs or NPs that are more knowledgable in appropriate pharmacotherapy that a clinical pharmacist, but yet we give that right to them.
    Panda: what niche would we fill? Possibly the diabetes clinic for follow-up visits for insulin adjustments? At a Coumadin Clinic….giving the RPh the authority to write the Rx instead of calling the MD, letting them know what to write for, and then having the MD write it. Maybe the RPh could be in an Internal Med office and see COPDers or asthmatics and adjust or change inhalers? These are all conditions that pharmacy schools are training their students to manage….but very few states actually give the pharmacist the right to manage them. You give me the diagnosis, comorbidities, lab work, and I will give you the most appropriate pharmcological intervention for that patient. Absolutely, I am trained to do that… is a required skill in order ot pass the pharmacotherapy board certification exam. Many pharmacists do it every day, but instead of being able to make the change or adjustment, they must leave a note on a chart for the MD.
    As far as the patient with the high INR, I would walk down the hall to the MDs office and inform him so he could do a neuro work-up if needed. And any protocol would require an “emergency clause” of what to do in an emergancy situation. And, as an ACLS provider, I would be well prepared to appropriately react to an emergency situation.
    What advantage would this provide physicians? Instead of taking their time to see a patient who needs their ramipril increased from 5mg daily to 10 daily, he could punt it to the clinical pharmacist. Instead, the MD could be seeing a more acute case, and bill for a higher level of service. And, I have heard that MDs are having a tough time finding appointment slots for their patients.
    And, as I said before, I only recommend this be done by pharmacists with advanced training and education, such as those that have passed a Board Certification exam. As far as responsibility goes….well, that’s why I carry malpractice insurance.
    And dang if they don’t even teach ya how to do a diabetic foot exam in pharmacy school. Yee-haw!

  42. I would like to tell a little story, if I may. I’m a breast cancer survivor, and I started taking tamoxifen last fall to reduce my risk of recurrence. Soon after I started taking it, I started having chest pain and asthma-type symptoms. I called my onc’s NP and she told me to talk to my internist about it because she “did not believe” it was related to the tamoxifen. A couple days later when I saw my internist, she called the oncologist and they agreed that I should get a CT scan to make sure I did not have a PE. (I didn’t.) The next time I saw the onc, the NP said (in front of the onc) that when I had called in she told me to go to the emergency room. When I said she had NOT told me to go to the emergency room, she said “it’s in my notes!”

    My point is that a NP is not really equipped to deal with many situations. At least this one wasn’t.


  43. Panda, you said: …people want the idea of free medical care more than they are really, for the most part, concerned with quality

    That has to be because they don’t know the difference. Sheer ignorance. And too many believe that if treatment appears to go awry, they can just sue! Have any of those who want socialized medicine considered that when the government takes over medical care there will be few medical lawsuits? The government protects itself, for the most part, from such financial liability. I don’t remember hearing much about VA docs being sued.

    Well, Panda, this post of yours is as usual excellent, and thought provoking on so many points. I wish for you and your family great happiness and prosperity!

  44. Panda,
    I would concentrate on good outcomes for your patients and their families more than the importance of the letters after your name or the prestige you feel you have earned. Your patients don’t for the most part care where you went to school or how expansive your training is, they want you to take care of them in a professional and compassionate manner. I think you will be more fulfilled as a physician if you focused on your patients more and left the ego in the beamer before you come into the office. Just my thoughts, best of luck.


    (Whoa. Jim.  I drive an eight-year-old Toyota Echo which I will probably keep for another few years.  I currently make about 12 bucks an hour as an Emergency Medicine resident physician and have one year left of what will have been an eight year ordeal to both earn and justify those letters after my name.  As for patients not caring how expansive my training has been, speak for yourself.  They may not be able to articulate it but I have a reasonable suspicion that they’d rather have a residency-trained Emergency Physician resuscitating their drowned child or a residency-trained surgeon taking out their gallbladder and they’d be appalled, yes appalled, to learn that some mid-level guy passing himself off as a doctor actually only has two years of formal training in medicine. -PB) 

  45. So as someone that has lurked around this blog for sometime, but has never commented, I feel that this is one entry I must finally express my opinions on, and there are several points I’d like to make. I do apologize up front however for any opinions I may be expressing that have previously been made by others and/or debated, but I have not read every post on this site.

    First, I feel that as a physician Panda, and even as one who may work with PAs and NPs, you are most certainly (as you clearly state repeatedly throughout your many entries) not a PA or NP, but instead an emergency medicine resident physician, thus I feel that you are not qualified to assertively promote the level or quality of education that PAs or NPs recieve, even with rudimentary knowledge you may have from those that you’ve spoken with or websites you’ve looked at. Conversely I would never put forth exactly what it is that is learned during medical school, because a medical student I am not. Now just as you (in regard to PA school) I have a general idea of what takes place in medical school, but that does not make me qualified to speak on behalf of anyone. So where am I going with this rambling you may be asking.

    Well I’m going several places, so let’s start here. At least several times I’ve seen mention of who’s smarter? Physicians or PAs? That is just a ridiculous comparison to try to make! Certainly you cannot try to compare intellect amongst individuals based on their occupation. I guarantee there are some MENSA level garbage men out there that would blow physicians out of the water when having an “intellectual” conversation. What differs between physicians and PAs is the amount of education and the style of education. Again, not being a medical student, I don’t know all the nuts and bolts of medical school, but I do know this: in general, PA students recieve more education in regard to medicine their first year, than medical students do during their first two years. I’ve been privy to this situation many times when third and fourth year med students can’t even tell their attending what the diagnostic criteria are for DM (but then the PA student shines when he/she did know). Now it’s certainly not a matter of a PA student looking better here, because that’s not what it’s about. I’m simply pointing out that the style of education is different, whereas med students learn much more pathophysiology of disease during their didactic time, PA students do not and instead learn more diagnostic and therapeutic information during that time. Then when a third or fourth year med student enters the clinical setting along with a second year PA student, they are essentially treated the same! They share the same responsibility, are pimped the same and are taught to perform the same procedures. Where the two paths truly diverge is in the residency phase (and let’s not even start on the whole PA residency bit). Residency is where a physician truly learns his trade (on the job mind you) and becomes competent at treating a physician. The resident floats around and learns different areas of medicine, in addition to having more didactic type lessons, and we’ve proven this to be a very effective system. The PA on the other hand also learns his trade on the job, but is much more limited in his exposure and generally focuses on the specialty he has chosen. But coming out of their respective programs, both are very obviously inexperienced and lacking much clinical skill and knowledge! So back to my original statement about who’s smarter, I don’t think that is a valid comparison to make. To provide further argument for such a statement, in my PA class of 47, 7 were actually accepted to very reputable, mainland (AKA not Carribean, since that can sometimes be a point of snobbiness in the eyes of some) medical schools, and instead chose to attend PA school for their own reasons. In addition there were quite a few others that took MCATs and scored very competitively, had 3.7-4.0 GPAs, etc., and decided not to pursue medical school, again for their own reasons. Then there are the few that had their previous careers and are now pushing 50 and decided to pursue a change, and decided PA school would suit their lives better than medical school at this point (like you have somewhat pointed out yourself Panda). So please don’t anyone try to lump all mid-levels as flunkies that couldn’t hack medical school, that just is not the case.

    Now let’s discuss the NP for a brief moment. Again as my title above implies, I am not an NP and cannot truly speak to their behalf. I am somewhat familiar with their education however and can throw a couple points out. NPs are trained to the nursing model, whereas PAs are trained in a medical model, more closely reflecting medical school curriculum. NPs often time go to school at night, for a year or little more to earn their masters degree so they may hang their shingle (versus the PA student who often attends classes 12-15 hours a day for a year, then has at least a year of clinical mirroring a typical medical student, then may return for 3-6 months of more didactic education). The NP just is not trained in the same fashion as physicians or PAs, and while responsibility may often be at a similar level as PAs, often times the skill sets for NPs are just not there. NPs are often trained more to react to a sign or symptom, then to think about the presentation and treat the underlying cause (like PAs are trained to do). So again another comparison that cannot be considered equal, NPs and PAs. NPs are often very good at what they do, just so long as they stay within what it is that they do (the same goes for physicians and PAs).

    Now let’s throw this out there. There are some dumbass doctors out there. There are some dumbass PAs out there. There are some dumbass NPs out there. No matter where you go in life there are going to be ignorant people that just don’t have a clue. Just because a physician can get through medical school and residency, it does not necessarily mean he’s a good doctor, so let’s not automatically assume that all doctors are (as often seems to be the case in this blog from commenters and the blog writer alike). But again the same can be said for PAs and NPs.

    So let’s talk about the “mid-level guy passing himself off as a doctor.” Surely there is always going to be the guy out there that wishes he’s more than he actually is, and that goes for anyone, anywhere. Just the other day in my state a firefighter was arrested for impersonating his fire chief. So of course there was occasionally be a PA that will misrepresent himself (intentionally or not). HOWEVER, there are physicians that do the same thing. For example, the (anectdotal) surgeon that decided he wanted to do plastics and just began doing breast augmentations and claimed that he was board certified. Then the patient dies on the table and it turns out he was not board certified and was never even trained as a plastic surgeon. We all know that happens. So I’m not saying that the misrepresenting PA is ok, it is absolutely not and he should lose his certification and license, but I’m saying there is always that asshole out there that wants to be something he’s not.

    According to Zainab Usman up above, a PA should realize he’s not a doctor. Well PAs do recognize that. We chose our path for whatever reason we may have happen to of chosen it. Whether certain aspects of the PA career were appealing, or whether certain aspects of the MD path was unappealing, it doesn’t matter. 9 out of 10 PAs are happy with their careers and would not change and I think that really says something about our field. Our goal is to practice medicine with a supervising physician, keyword is WITH. Our goal is not to take over the world of medicine and give physicians the boot, because that is not what we are trained for.

    I feel like I’m forgetting to make a couple of points, but this post has been long enough, so thank you for your time. And Panda, I certainly meant no disrespect to you or your viewpoints, I’m just expressing my own. 🙂

    (Thank you for taking the time to comment.

    1. PA students do not receive more medical education during their first year as medical students receive during their entire first two years. This is a ridiculous theory and more of the same philosophy of “Less is better.” Pathophysiology (and other subjects) which you agree is not really taught to PA students is not useless information and cutting it out of your curriculum makes you less, not more, educated. As for knowing the diagnostic criteria for Diabetes in your first year where medical students might not, well, big deal. We may not have even gotten around to focusing on diabetes until second year because, as important as it is, we have hundreds of other things in line and it will have to wait its turn.

    Again, this is more of the theory that your training is the same…but it isn’t….’cause it’s better….even though you only learn practical stuff and not the useless stuff that would make your brain hurt.

    2. You are buying the agitprop from your profession. You will have two years of formal medical education. A medical student will have four, every one of which is more rigorous than any of yours. While I have never been to PA school, I would bet on this. It’s not as if we lollygag through medical school taking an indifferent course or two mixed in with a lot of fluff while the PA student is a lean, mean, relentless education machine voraciously devouring knowledge. Dude, it ain’t like that at all. There is no discrete point where a medical student overtakes a PA student in medical knowledge because knowledge is more like an expanding sphere than a straight line but a brand-new intern knows much, much more about medicine and has had more clinical experience than a new PA by a factor of at least two but in reality, given the lower level of PA instruction, much more.

    3. Remember also that a brand new intern is only halfway through his education while a PA, with his two years, is done with his (for the most part). If all that was expected out of me at the start of intern year was a PA level of knowledge as well as a PA’s level of responsibility I would have had a low-stress intern year indeed. It is, therefore, easy for a newly-minted PA to feel a little smug because less is expected of him. Everybody feels themselves to be an expert, you understand, whether they are or not, because they are never called to prove the depth of their knowledge. In your case, this is an example of not knowing enough to know what you don’t know but I assure you that you would be a walking time-bomb of ignorance if you were put into an intern role after PA school.

    The rare new PA who performs at an intern level is a prodigy, a hero of the PA world and a veritable Hector of medical prowess. An intern who performs at an intern level had damn better learn to move his lazy ass and is always struggling under the scorn of the whole medical establishment. In other words, as an intern I could do your job standing on my head and feel myself to be on a wonderful vacation.

    4. PA students may be treated the same on rounds during a medical students third and fourth year (but my experience is that they are not) but a medical student has twice as much experience on the wards. See? Two is greater than one. Not a difficult concept. -PB)

  46. PS- Panda you and the average PA student are actually in the same boat, trying to pay off those damn loans!! Yours may be a bit higher, but the average PA cost of $150,000 is nothing to sneeze at! Damn Sallie Mae!!

    (You see, your knowledge of economics might be as limited as your knowledge of medicine because they left out all of the useless stuff about the time value of money. While PAs make less than most doctors, they start making it after only two years of training. I am in year seven and will not begin making a serious dent in my loans until next year. I will make a lot more than you in a year’s time, and have the contract to prove it, but for the time being you have a six-year advantage over me in repayment.

    How you acquired $150,000 in loans is unfathomable. The tuition at Duke, the very soul of the PA profession, is $27,000 per year for two years which equals $54,000 total. I got $18,000 per year above the cost of attendance in loans for living expenses which for you would be $36,000 for a total of $90,000, tops. Is this more of the same, “Our student loans are as big as yours…but they are actually half…we just cut out the unimportant stuff.” -PB)

  47. Rather than waste your time and my time with some long-winded argument about the uselessness of much of the content of our medical education (yes, I am a medical student), let me ask you this one question:

    Which form of THF is involved in the conversion of dUMP to dTMP: 5,10-methylene-THF, methyl-THF, or 10-methyl-THF?

    Don’t have a clue, do you?

    I suggest you surrender your medical license tomorrow. You have no business being in the profession.

    You catch my point?

    (Whoa, buddy. I didn’t say I remember everything I learned. But everything I learned was important at the time in the context of, let’s say, learning about physiology or pathology. Do you catch my point? -PB)

  48. I never stated retail pharmacists should act as practitioners. I lobby for something like what was passed in North Carolina, the Clinical Pharmacist Practitioner Act. The pharmacist is given prescribing writes after certain conditions are met to show competency. The pharmacist has a written protocol/agreement with a referring physician for what he/she can prescribe.
    One avenue this could be utilized is at a heart failure clinic, where the pharmacist could up-titrate the beta-blockers and ACEIs, add spironolactone or furosemide, etc. Another way it could be used is having a pharmacist renal dose meds for a nephrology clinic…or insulin adjustments at a diabetes clinic. These are all things that pharmacists are now trained to do in pharmacy school.
    The clinical pharmacist practitioner is NOT a primary care provider. No one could say “Oh, I’m sick. Let me go see the pharmacist and have him prescribe me some drugs.” They would be referred to the pharmacist by an MD or DO for specialized care, such as Coumadin monitoring and adjustment. The diagnosis has already been made by the time the patient sees the CPP.
    If you have ever written for “Vancomycin per pharmacy” then you have done exactly what I advocate for.
    ChrisPharmD, are you a stroke-victim or something?

    First and foremost, I have NEVER prescribed any medication “per pharmacy”, and any doctor who does such a thing is thinking with his ass and not his head. Certainly, I have consulted the hospital pharmacy and I value their knowledge of drugs and pay close attention to their recommendations, but when it comes to delivering therapy (whether procedural or with drugs), it is my responsibility. Not the pharmacist’s. In fact, when a doctor writes ANY prescription–whether recommended by pharmacist or even a physician specialist, he assumes full responsibility for any outcomes from it. If I consult hematology and they recommend that I prescribe XYZ, then I damn-well better be comfortable with the use of that drug. I cannot say, “Per ‘the hematologist’s’ recommendation” in order to save my ass if anything goes wrong. If my signature is on the script, then it’s MY treatment.

    Now, as a pharmacist, you should know perfectly well that titrating medications–such as Coumadin, for the purpose of maintaining INR within a therapeutic range–is not always as simple as getting a lab test and adjusting the meds….like an insulin sliding-scale. There is a patient in whom those medications are going–i.e. a patient who needs to be evaluated (by a physician…or at every least, SOME sort of practitioner..even a mid-level) for the effects of said drug. As a pharmacist, you are patently untrained to do that.

    And furthermore, the concept cherry-picking diseases you pharmacists will “manage” is beyond absurd. I have no doubt that you would fail to see why. You haven’t been to medical school. Diseases rarely fail to affect some other aspect of a patient’s health. I highly doubt that you are trained in pharmacy school to recognize and handle the co-morbidities of the diseases you seek to manage.

  49. Sorry. I know I’m nine months late, and it’s a long response, but your post has me moderately livid.

    It is very clear to me that you do not have a solid grasp on what a PA education actually entails, or what the requirements are to be accepted into any such program. The University I am attending also has a medical school, so I spend quite a bit of time around the med students. I can promise you that the PA student’s coursework is considerably more intense, if only because it is more compact. They cram as much as they can into that one year of didactic work. (My classmates and I joke that we should have just gone to Med school.) I won’t claim to have learned more than a med student’s two years in my one year, but I’ll boldly bet that we cover about 3/4 of the same material in half the time. Yes, overall it’s less, but that’s why PAs are mid-level providers and not independent practitioners. Oh, and we DO have a pathophysiology course.

    (You make it sound like medical students are just casually strolling through their classes, doing a little studying here and there but nothing like what those red-hot gunners in PA school are doing. This is ridiculous. The didactic portion of medical school is two fairly intensive years of material which is more in-depth than what PAs learn. You may think you studied hard but I betcha’ you don’t know the meaning of “studying hard” until you talk to a couple of medical students getting ready for their exams. “Two years” is twice as much as “one year” in any number system yet invented and your belief that your program somehow crammed more into your year than they actually did is unfounded and based on nothing but your subjective inability to master the material presented to you. Have you been to medical school? Do you think you could pass out board exams (all three of them, not to mention our specialty certification exams)?

    Additionally, the clinical portion of medical school is twice as long as the comparable portion of PA school and is also more intensive with much more pressure being put on medical students upon whom are placed higher expectations. “Two” is larger than “One.” Giving you the benefit of the doubt we can say that upon graduation, a newly-minted doctor has twice the medical education, both didactic and practical, as a PA. Then there’s that residency thing. Remember, a PA after graduating from PA school is fully qualified to practice his trade. A doctor needs an additional three to ten years to practice his.

    Jeez, Buddy. I’ve got nothing against PAs or midlevels but let’s not get ridiculous. -PB)
    Like 2nd Year PA above, I wish to reiterate that neither I nor any of my classmates are in PA school because we were not competitive enough for med school. My undergraduate major was Physiology and Developmental Biology, which wasn’t exactly a cake walk. Many of my friends from undergrad went to med and dent school. We all have the grades and the smarts and significant amounts of hands-on patient care work experience; I worked in health care for 8 years before going to PA school. I knew what I was doing when I made this decision. I chose the route of PA for personal reasons and life circumstances, and I do not appreciate the assumption of laziness and stupidity.

    The trend in PA education is for the profession to become a master’s-level degree. There are only a few programs that still offer a certificate, so you can expect that the newer PA graduates will have masters degrees, so please stop calling it an associate’s degree, because it isn’t.

    I’m not sure if you’re aware of this, but there are strict CME and recertification guidelines for PAs. In addition to a recertification exam every six years, PAs must complete at least 100 CME credits every 2 years, and at least half of those must be Category 1. That makes it pretty impossible for a PA to be totally ignorant in regards to current diagnostics, research, and treatment. We have requirements like this because we KNOW our training is not as comprehensive. That is why we are taught evidence-based medicine, and why continual research is stressed heavily.

    To be honest, I wish there were a residency for PAs. I’d do it gladly to help me develop and solidify my skills. There are a few residency programs for surgery and emergency medicine, but none for general practitioners, which is what I aim to become. If I had my way, a residency would be required for all PAs. As it is, I think my best substitute is to spend my first couple years at a teaching hospital or clinic.

    I don’t think I’m superwoman. I know I’m not. I know that physicians know more when they escape from med school and residency than I will when I get out of PA school, and I respect you for it. That’s why PAs work WITH physicians. I’ll be able to treat and do a whole lot of things, but not everything, and I’m okay with that. I know you disapprove of it, but that is the nature of the profession at its core – to extend primary care to rural and underserved populations where there is a shortage of physicians. Call me a monkey in a white coat if you like, but I know that I can provide a valuable professional service, and I’m not ashamed of that.

    I guess my main gripe is with your and your colleague’s attitude toward mid-level providers as being incompetent losers. Whether or not you like it, I will be practicing medicine soon. You can sit there and give me evil glares and hate me, or you can help me. My only desire is to provide the best possible care for my patients, and because my training is inferior I will sometimes need advice or to refer. That’s how it goes. Bitterness will not help anyone here, including the patient.

  50. I want to apologize.

    Having read some of your older posts regarding PAs and other midlevels, I realize that my heated response was mostly directed toward some of your other commenters’ ignorant and inflammatory remarks, and not the sentiments that you expressed in the original post.

    While I’ll confess that you have some valid points, I still don’t entirely agree with the conclusions you reached or especially the comparisons you made. Of course, we entered medicine with different perspectives and different goals. I don’t expect us to agree, but I understand and respect your opinions of this aspect of a midlevel’s training.

    I’m not plugging my ears and running from “useless” knowledge. I know it’s not useless. To be honest, I originally wanted to go to med school because I wanted to know everything, so I really do know where you’re coming from on this issue. Unfortunately, even though I was a perfect med school candidate with all the right classes, great grades, and work and volunteer experience, at the time I was considering my post-baccalaureate options, my poorly-controlled bipolar made me doubt my ability to endure seven more years of torture. I felt I had a better chance of making it out alive (and I mean that literally) after two years. Also, many of the doctors I know were very encouraging and thought that PA school was a fantastic way to go for anyone looking to go into medicine.

    Even so, I suppose PA school is a consolation prize; I knew that by going to PA school I could never be a doctor, but it would still satisfy my desire to become a clinician, and enable me to do some good, even if I’m not the top dog. I’m doing the best I can.

    Anyway, I have no hard feelings, and I’m sorry about the previous rant.

  51. I do agree with some of what you have to say. I know this comment is late, but I hope you get a chance to read it. One thing I would like to point out to you is that in 2 yrs (+/-) PAs complete roughly 70% of medical school. Many PAs also have significant healthcare experience prior to entering PA school and have already learned the very basics of the beast called medicine to allow them to accelerate their learning. PAs also go to school from 8-5 (and a few days a week 8-8). Med students, in my experience, are done by 1-2pm with plenty of time to relax and study. There is a reason that the extracurricular interest groups aren’t offered to PA students, they simply don’t have the time. So, although PA students don’t have the full 4 years of medical school, please do not try to discredit the feet they must accomplish to achieve their goals.

    On another note. Considering the PA education in many ways is very similar to medical education and based on the medical model, would you be open to the revolutionary idea of allowing PAs to enter medical school in the second or third year? Considering past and current healthcare experience and the didactic and clinical education of PA school, accelerating PAs through medical school may create excellent doctors.

    I know many physicians think if you want to be a doctor go to medical school. But here is my story. My entire life I wanted to be a doctor. Unfortunately, I had some set backs with courses and subsequently convinced myself I would not get in so didn’t even take the MCATs in fear that I would have to spend more money to take more classes and chase something I would not obtain. I pretty much let my dream escape me. Now I am in PA school. I have been a damn good paramedic for the last few years and I KNOW I would be an excellent EM doc. I will like being a PA for a while, but there will come a point where I want more education, more knowledge, and more responsibility. Do you think that my passion for medicine, clinical experience, and PA education would warrant a second chance for me and possibly an alternate route into medical school?

    (Well look, being a good paramedic has very little to do with being a good emergency physician because the core concepts of ACLS, the core of a paramedic’s job, while intricate and difficult to apply especially in the confusion of the field, are a very small component of an Emergency Physician’s job. I spend an hour a week intubating, pushing ACLS drugs, shocking and otherwise running big codes and the other 59 doing other things. -PB)

  52. Ok, apology revoked. Obviously you do have something against PAs and midlevels.

    “…your subjective inability to master the material presented to you. Have you been to medical school?”

    PLEASE. And have YOU been to PA school? Do you even know anyone in PA school? Half my buddies from undergrad are in med school. I’m not that out-of-touch, mister.

    And what the hell makes you think that I’m unable to master the material presented to me?? I’m passing, but I work hard, and I’m not afraid to say that to you or anyone else who thinks that just because PA school is shorter it MUST also be easier, because sorry, IT ISN’T. I stand by my assertion that at least in the didactic year, we cover 3/4+ of the materials in half the time. It’s not that the material is particularly difficult (although some of it is), but what makes it intense is that we get so much so fast. As per the clinicals, yeah, two is more than one (hence my desire for a residency).

    (Again, ridiculous. The assertion is that you cover 3/4+ of the material by virtue of leaving out all of that useless stuff. First, I am gratified to learn that only less than 1/4 of the medical school curriculum is useless stuff. Second, and I repeat, you just don’t realize what you don’t know. -PB)

    We do have our own boards, thank you very much. At the end of our didactic year, we’re tested on EVERYTHING. At the end of our clinical year we are tested on everything again. And then we take the national certification exam. Now, let me see… that’s one exam after the first year, and two exams after the second.

    Yeah, you think you’re all high and mighty because as you’ve obnoxiously said multiple times, “two is more than one.” Yes, you went to two years of didactic and two years of clinical and 3-5 years of residency, and PAs have only 1 year f each and no residency. I GET IT. (Gee, somehow I did pass calculus…) What I’m saying is that you have no right to suppose that the intensity of a PA student’s didactic coursework could never match that of a med student’s. You are making a subjective assumption that is also not backed up by any facts.

    (If you read my blog, you would realize that there is no “high and mighty” in a resident’s life. We are always keenly aware of both our limitations and our relative ignorance compared to our attendings. That doesn’t mean, however, that we have to polish the mid-level ego at every opportunity and opine that, “Golly Gee Whiz, you coulda’ been a doctor except fer’ some useless stuff here and there.” -PB)

    I don’t know why I’m wasting my breath. I’m never going to change your mind because you are already convinced through-and-through that nothing could ever be anywhere near as challenging as med school and residency were for you. It must be fun to think that, because it both means that you’ll always win the pity award, AND that you’re soooooooo much better than anyone who didn’t go to med school …and so no one else could ever begin to understand.

    Get off your throne of a pity pot and consider that maybe the rest of the universe isn’t as ignorant as you would like them to be, and that it’s possible you COULD be a little mistaken here or there. Do some REAL research into what PA school actually entails instead of making broad (and incorrect) assumptions.

    You can write as venomous a response as you would like, but I won’t be coming back again to look at it. This is a waste of my time.

    I hope I never have the pleasure of working with you or anyone else who is as much of a self-righteous, closed-minded, pompous jerk as you have proven yourself to be here.

  53. Wow, good post, and some good, and bad points. The problem is, as with most things, you, as well as many others like to compartmentalize. I have been a practicing EM PA for a long time. I see many, MANY patients on my own, or with little supervision. I teach and lecture to the med students, and residents, perform cardioversions, chest tubes, LP’s, etc.etc.etc. The point is, I didn’t start out with that level of trust, but I have earned it over time. I also have continued to learn, and WILL continue to learn more. I have much more than a basic understanding at this point on the pathophysiology and process of disease management and diagnosis. I also am very active both academically, and within the health policy community/arena. My point with all of that, is that you need to evaluate EACH individual provider independently. I’ve known ER docs I wouldn’t let treat my DOG, let alone my daughter. I’ve also known ER docs that were the most awesome competent clinicians I’ve ever known. I’ve also known PA’s that were as astute as any doc I’ve ever known, and I’ve known PA’s that scared me to think of them in practice.

    I moonlight at an ER where there is no MD on site, I am the only provider there. There is an MD on call if I should get in way over my head, but thankfully, I rarely have to call them. NOTE- RARELY, NOT NEVER.

  54. PB-

    I just stubled upon this post, which happens to be interesting and decently argued. However, I must say Panda, you are extremely abrasive and seem very defensive when someone pokes a hole in one of your arguments (I’m guessing it comes from your engineering background)…in any event…talking tuition…Yale’s progam is as follows

    “The estimated total cost of attending the program is $127,000”

    While an est. 127k is not 150k, it is damn close.

    Also, don’t be so glum about the documented fact that pa’s have higher job satisfaction than do Dr.’s

    (What does that have to do with anything? I know several of the janitors in our Emergency Department and they have excellent job satisfaction. They are relatively well-paid for a useful but not very demanding job which gives them benefits and plenty of time off. -PB)

    That’s it. On then with your theraputic venting pd.

  55. I went to med school in a third word country(very poor) and the program is 6 years. I immigrate to the US in 1997 and i became a MD in the US in 2000 and finished with my residency in 2005 EM Currently working at Jackson Memorial UM. I do not see why you guys are spending ur time in talking to a guy like that. I do not believe he is a doctor, if he is…. oooooh my GOD. Estupido

  56. I am a PA, and have skimmed the thread.

    I must say that to a great extent I do not argue w/ what seem to be your basic tenets:

    –1. The MD is in charge. Always.

    –2. MLPs should be subordinate to the MD, not co-equal.

    Perfect. Speaking for the PA profession, I agree wholeheartedly.. we are **dependent** practitioners (as opposed to NPs desiring indepedent status)– and realize, or should– that without your support and backing, we simply cease being.

    If we agree on this, then, can I extrapolate a bit, and comment on what may have started this: this sense that – by certain PAs having been granted by certain MDs varying levels of autonomy, that very autonomy appears as independence, which is a contradiction to dependency.

    The MD-PA relationship should be close and constantly evolving…when you are speaking to me you should have the feeling that I am representing my supervising doc, and am complementing him in knowledge and capacity, And am only performing thise things in patient care that he is comfortable with me doing, as if he were doing them himself.

    There are varying degrees of competence, and , frankly, there are varying degrees of attention given to the MD-PA relationship by both parties. And this seems to me to be where the model fails.

    If you sense that the PA equates himself to an MD, you are right to admonish him and encourage him to do the time and the internship.

    And I suspect that there will be PAs that you will meet which will impress you enough to have no retiscence in calling/ discussing your patients with.. at least I hope so.



  57. I notice the turf battles between pharmacists and physicians are universal.
    What do we do?
    Abolish the profession of pharmacy?
    Then who would offer pharmaceutical care?
    I live in Kenya.

  58. The expertise of the pharmacist is not interchangeable with that of the physician, and vice versa.Infact no healthcare provider is biggeror smaller-all work is noble!
    We need to accept one another as legitimate and essential care providers.
    Since our common goal is to provide care to the patient, a way should be found to facilitate the maximum input of each member of the team.
    And, prescribing is a means to care.It is not an instrument of power.

Comments are closed.