Mark Twain supposedly said that there are three types of lies: “lies, damned lies, and statistics.” One statistic I hear often is how many years it takes to be an MD vs a PA. It seems pretty straightforward, right? “7+ years to be a medical doctor vs 2 years to be PA”. Except those numbers are not only inaccurate but they’re often purposefully meant to deceive.
PA vs MD: Round 1
PA education is ultra condensed. Unlike traditional first-year medical students who repeat classes in cell biology, microbiology, and biochemistry without learning anything about the practice of medicine until sometime in the second year, PA students hit the ground running.
The first PA program in the country (and the world for that matter), was at Duke University. Here is what the first semester in their PA program looks like today:
- Basic Medical Science
- Clinical Medicine
- Diagnostic Methods
- Patient Assessment and Counseling
- Evidence-Based Practice
Now here’s what the first year looks like in Duke’s medical school (MD) curriculum:
- Human Structure and Function – Integrates histology, gross anatomy, neuroscience and physiology
- Body and Disease – Integrates microbiology, immunology, pathology and pharmacology
- Leadership, Education and Development
- Clinical Skills (4 hours/week)
- Another vacation
- Cultural Determinants of Health & Health Disparities – Reflective writing and small group discussion
Do you see what I mean? I’m not saying spending time studying health disparities and the sociocultural influences on health and wellness is a waste of time but it does take a bit of the pomp and circumstance out of an entire year of medical school. No wonder 3-year medical school is the new trend…
PA vs MD: Round 2
So, at least at Duke, PAs arguable start studying medicine long before MDs. The next thing you have to consider when comparing PA vs MD education is that most PA programs don’t take so many breaks, let alone entire summers off and months at a time for test and interview prep. My PA program was 6 semesters, or 3 academic years, condensed into 24 months. What does a PA program look like when it functions more like a medical school? Let’s head over to West Long Branch, New Jersey to find out!
Students will have time off each summer between the first and second year and between the second and third year. We believe this time allows students the opportunity to relax from the high-intensity learning environment, which may enhance future learning opportunities.
I don’t see anything wrong with that structure. But can you say that Monmouth’s 3-year program is better than Duke’s 24-month program simply because it’s “longer”? I don’t think so, certainly not by just comparing the length of the program.
An honorary mention
And what about getting into the program? Let’s go back to Duke as they have both a medical school and a PA school. The Duke University School of Medicine recommends undergraduate courses in biochem, biology, stats, physics, sociology, psychology, and expository writing. Duke’s PA program requires anatomy, physiology, microbiology, stats, and 2 other biology and chemistry courses each. Oh, and 1,000 patient care hours (read EMT, paramedic, RN, clinic assistant, Peace Corps or other technologist, therapist, or clinical research assistant).
The purpose of this comparison is not to challenge or tear down any medical school curriculum but simply to show how stating that MDs have “4 years of medical school” vs “2 years of PA school” isn’t intellectually honest, especially if it’s meant to imply that the MD is, therefore, leaps and bounds ahead of the PA in clinical preparedness.
Next up, clinical rotations!
PA vs Medical Doctor: Round 3
During their second year of schooling, both PA and MD students start rotating through clinical clerkships, sometimes simply referred to as “rotations”.
Duke PA students spend their second year completing 10 rotations (eight required and two elective–at least one must be in a medically underserved area.)
Core rotations for Duke PAs, as for most other PA programs, include:
- Emergency Medicine
- Internal Medicine
- Women’s Health
- Primary Care
- Behavioral Medicine/Psychiatry
- General Surgery
Elective rotations could include anything from dermatology, orthopedics, cardiology to gastroenterology or pretty much anything else you could think of.
Medical students have a pretty similar second year except they complete only 8 core rotations and have 4 total weeks for electives. The “clinical skills” course meets two afternoons a month and there’s a “deeper more reflective dive” into health disparities with more reflective writing.
Year 3 for Duke MD students is entirely dedicated to research, study time, and vacation.
The fourth and final year of Duke’s medical school program is “mainly elective” and only requires 28 hours of coursework along with 8 more weeks of required clinicals. And let’s not forget that sweet, sweet vacay!
Physician Assistant vs MD: Round 4
I’ll admit that I‘ve never completed a residency but I don’t doubt that it’s a difficult and valuable experience. I remember being turned off by long work weeks, low pay, and demeaning attendings when considering med school myself.
The first year of residency is referred to as an internship and is the most basic requirement in most states to actually practice as a physician. According to one medical school’s website, this is finally where new grad MDs are “no longer in the backseat.” Dr. Buck Parker, a Utah-based general surgeon says “By the end of the first year, you’re functioning as a real doctor.” Physicians wanting to obtain board certification, however, must continue on and finish an additional 2 years for areas like pediatrics and family practice or perhaps 6 additional years for neurosurgery.
And speaking of being in the backseat, I have to inject some personal experience here. Given the condensed format of their training, PA student rotations are typically more like a residency than a medical school clerkship. The med students that have passed through my clinic on rotations are usually limited to working on one thing at a time; history taking, physical exam skills, etc. I once tried to include a second-year med student in some clinical decision making and he flat told me he wasn’t interested because he was “just working on getting a good history”. And it’s not just me, anywhere med students mingle with PA students and residents, there’s a clear distinction in progress towards autonomous practice.
But if you think that post-graduate residencies are only for physicians, you are mistaken. The Association of Postgraduate PA Programs (APPAP) maintains a directory of over 100 PA residencies ranging from 12-18 months in practically all medical specialties. PAs can go on to train in abdominal organ transplant at the Mayo Clinic, cardiothoracic surgery at Dartmouth, critical care at Emory, emergency medicine at John’s Hopkins, neonatology at the University of Kentucky or orthopedics at UCSF, for example.
PA residencies are optional. So where is the average PA during this time? While residency and fellowship training is always credited toward MD superiority, you can’t ignore the fact that PAs are actually working during this same time frame! I don’t think that work experience and residency training are necessarily interchangeable, each has its pros and cons, with the biggest differences being structure and accreditation. Residents attend lectures and rotate through specific assignments while the PA just does his or her job in whatever area they might be in, consulting with others as needed.
Here’s what I know
My first 4 years of practice was in a rural town of about 1,500 people. We were the only clinic in 25 miles (the entire county, actually). Most of my patients were either underinsured, uninsured or on Medicaid or Medicare. A1c’s of over 15% were common. As were severe mental health problems. A third of my patients only spoke Spanish. I had to grow up real fast.
Why is the time I spent in one of the most challenging practice environments not counted toward what makes a PA? If student A starts med school at the same time student B started PA school, by the time student A completes 4 years of schooling and 3 years of residency, student B has had 2-3 years of schooling and 4-5 years of real-world experience. Both clinicians come out with 7 years under their belts. To maintain their national certification, PAs would have to complete over 200 hours of Continuing Medical Education during this time as well.
I feel like at this point, I need to point out once again that the purpose of this exercise is not to diminish physician training–not in the slightest. Nor is the purpose to elevate PAs beyond reason. I’m making no claims regarding superiority–physician training is indeed more robust. My purpose is to illustrate how some well-intentioned individuals may suggest a seemingly impassable gap between physician vs physician assistant training that isn’t as wide as they’d have you believe.
Speaking with physicians, some will comment: “This wasn’t my experience. I did ___; I didn’t do ___; I studied for ___”, etc. I understand that. It’s perfectly normal to not want to be lumped in with the stragglers and underachievers. It kind of reminds me of the old joke, “What do you call the person who graduates last in medical school? Doctor!”
PAs feel the same way. When our experience and training are portrayed in a negative light, it’s usually based on the minimum requirements and presented in such a way as to abscond the fact that many, if not most, are far more prepared and qualified than implied. I do agree, however, that whether MD or PA, you’re only as strong as your weakest professional link.
Now as for this PA, I’m looking forward to adding another 4 semesters, or 2 years, of clinical training as I prepare to start the Doctor of Medical Science program at Lincoln Memorial University where I’ll further develop and validate skills in clinical medicine and primary care.