PA vs MD: Why Comparing Years of Training is Misleading

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:

  • Anatomy
  • Physiology
  • Basic Medical Science
  • Clinical Medicine
  • Diagnostic Methods
  • Pharmacology
  • Patient Assessment and Counseling 
  • Evidence-Based Practice

Now here’s what the first year looks like in Duke’s medical school (MD) curriculum:

Year 1 – Basic Sciences
  • Human Structure and Function – Integrates histology, gross anatomy, neuroscience and physiology
  • Vacation
  • Body and Disease – Integrates microbiology, immunology, pathology and pharmacology
  • Vacation
  • 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!

The Physician Assistant program at Monmouth University in New Jersey is a 36-month or 3-year experience. Here’s what they have to say about the medical school-esque program:

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.)

Duke PA Program Year 2

Core rotations for Duke PAs, as for most other PA programs, include:

  • Emergency Medicine
  • Internal Medicine
  • Women’s Health
  • Pediatrics
  • 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.

Duke MD Program Year 2

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 were 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. What is it going to look like comparing DMSc vs MD?

4 thoughts on “PA vs MD: Why Comparing Years of Training is Misleading

  • December 5, 2021 at 2:25 pm
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    Your write up is insightful and makes interesting reading.The struggle is same here in Ghana where Doctors undermine PA’s.PA’s do all the work but credit goes to the Doctor with all the lofty renumeration ignoring the PA.

    Reply
  • December 6, 2021 at 6:51 am
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    Thesame comparison is used to restrict the scope of practice of the PA in the Ghanaian society. PA’s in Ghana are not even allowed to have specialty area of practice so as to keep them serving the masses while being under paid.
    How do we get rid off this partial mentality.

    Reply
  • April 26, 2022 at 8:38 pm
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    Though I appreciate this author’s attempt to call attention to the (often underappreciated) level of rigor in PA programs, there are a number of points in here that unfortunately misrepresent or gloss over certain important facts. I am also personally familiar with the programs discussed here, as a recent graduate of the Duke MD program who met (and worked along with) several PA students at our program during my clinical year.

    “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.”

    Deeply misleading. You won’t get admitted to the medical school without each of those recommended classes (plus general and organic chemistry, which you forgot to mention). Also, though theoretically you could be admitted without any clinical experience, it is in practice extremely unlikely and such an admit would undoubtedly offer other, extremely compelling background to compensate for that. We have to take the MCAT as well, and score pretty well on it to have a shot at getting into Duke. Not that PA students can slack off for their GRE’s, but the rough midpoint of their scores for admission are verbal 156 and quantitative 155. These represent the 72nd and 55th percentiles, respectively. For recent year MD admits, median MCAT scores have been around 519, which represents the 98th percentile of a far harder exam. PA student GPA’s middle 50% range at Duke runs from about 3.5-3.8, whereas the average for the med school admits is almost 3.9. The author ignores these data points completely when unfavorably comparing the admissions standards for our MD program to our PA program.

    “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. ”
    This is one of the first important distinctions between MD and PA training. Repeating these subjects in depth, and with a clinical focus, is key for developing a more comprehensive understanding of the clinical medical topics that come later. This time is not wasted, and skipping it to “hit the ground running” would not be helpful in making medical doctors better prepared to do their jobs.

    “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.” Despite the author’s denial, it certainly does sound like they’re insinuating that there is little value in studying health disparities and sociocultural influences on health. Also, FYI, PA students get Labor Day, Thanksgiving Holiday, Winter Break, Spring Break, and a summer break too. At least at Duke, in the comparison that the author is making, statements such as “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” are simply untrue. (source to verify what I’m saying: https://medschool.duke.edu/education/health-professions-education-programs/physician-assistant-program/curriculum/academic)

    “Year 3 for Duke MD students is entirely dedicated to research, study time, and vacation.” Which helps us explore a topic of interest in medicine in FAR greater depth than we would by almost any other means. And the “vacation” time during third year often ends up being mostly work time anyway as we’re trying to publish, studying for our board exams anyway, and writing/reading/collecting data on our third year project.

    “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!” 28 credit hours. Just to put this in perspective, this translates to roughly 7 months of full-time clinical rotations in fourth year inclusive of our capstone project. There appears to be extra time because 1) we graduate in May, so it’s not a full year technically, and 2) there is time built in to deliberately allow us to travel and interview for residencies all over the country. To describe this as “sweet vacay” trivializes our efforts and stresses during this year.

    “PA student rotations are typically more like a residency than a medical school clerkship.”
    Not even close to true. I worked most closely with PA students during my surgical rotation, and nearly every day the PA students left before the med students. They also didn’t have shelf exams to study for like we did for every single rotation.

    “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” Though I believe this particular incident could have happened that way, your first statement (that med students are usually limited to working on one thing during rotations) is also blatantly wrong. On each and every rotation I was expected to take a history, do a physical exam, present a differential diagnosis and take a stab at planning treatment/next steps. This is the norm in med schools everywhere.

    “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! ” First of all, residency is work. In fact, it is incredibly hard work. Second of all, the average PA works about 40 hours per week. This is easily verified on the internet, and corroborates what I’ve seen and heard from PA’s I’ve known and worked with personally. MD residents average 60-80 hours a week during their training periods, sometimes more. Even if only viewed from an hours per week perspective, the newly-minted MD in residency will quickly catch up to and exceed the number of hours of the PA who graduated 2 years before them. Additionally, as the author points out, residency is a unique experience that serves a special purpose beyond standard working days: new doctors are deliberately exposed to as wide a variety of patient presentations as possible on their service and provided structured learning experiences to enhance the clinical duties in a way that a 40 hour a week job simply can’t replicate. This of course doesn’t even touch on the board exams that we have to pass in our specialty (in addition to the board exams for our medical license), which are far more in-depth than PA equivalent exams.

    “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.” This is the best paragraph in the piece. In real life, I make a point to never downplay the experience, wisdom, and insight of all members of the clinical team. I also happen to agree that some out there (including some doctors) downplay the considerable clinical acumen PA’s bring to the table. I’ve seen such comments myself. Also, a healthcare team absolutely can be thwarted in it’s mission if any member of the team is weak, potentially; medical error is an all-too-common problem that we all must do our best to prevent. The reason I took so long to reply to this post is that I feel that in this article the author is guilty doing of that which is being criticized: namely presenting the training and experience of MD colleagues in a trivializing light and downplaying the very real distinctions between our respective medical training.

    Reply
    • April 28, 2022 at 9:35 am
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      Thank you for the thoughtful reply. You are absolutely correct that the aim of this piece was to show how superficial comparisons and relying on personal anecdote can be misleading at best, and deceptive at worst.

      Best of luck in your future career.

      Reply

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