CAUTION: Hot Takes Coming Through

[CSCH]

ARROGANCE IN MEDICINE

It’s arrogant for MDs to think APPs cannot practice excellent medicine and have more knowledge or skills in certain areas than them because they’re not physicians. It’s arrogant for MDs to group all APPs together as if we have equal training.

It’s arrogant for NPs to think their online degree where they take at most one or two semesters of graduate level physiology or pathology and then basically just shadow another NP for maybe 500 hours is good enough to practice medicine.

It’s arrogant for APPs to think they should be able to practice fully independently after two years (or even after a residency/fellowship).

One of my mentors shared this question at the heart of clinician training: What gives you the right to take care of sick human beings?

The autonomy you receive should be proportionate to the training you have completed. PAs are rushing to stay relevant by mimicking NPs and demanding unearned autonomy, but who does this benefit? Certainly not patients.

I understand people’s frustration with the current setup. PAs are in the position of continuously seeing themselves get lapped. NPs get all the rights first, and we eat their table scraps. If you work in academic medicine, you see dumba** interns turn into attendings that you’re supposed to take orders from. You hit a ceiling quickly if you’re highly motivated. Even the admin positions are harder for PAs to get into. BUT the solution is not to jump on the NP bandwagon with bullshit online doctorates. It’s not to push for autonomy beyond what our training justifies just because we don’t want to get replaced by NPs.

There is a real, important role for a true PA—a true physician assistant. Some people who work as PAs are already fulfilling that role and loving it. They know they are doing something valuable. They focus on being a good team member. They are happy to let others be the leaders and bear the brunt of the full responsibility. The medical system is well-served by PAs who actually assist physicians.

There is also a real, important role for a PA who has reached the end of their path as a PA. Maybe assisting wasn’t the right fit for them after all. Maybe they enjoyed it for a time and now want something different. Maybe they got really excited by one thing and want to be an expert. Maybe they want to be more of a leader or learned they are more ambitious than they’d originally thought. Whatever it is, what those people are seeking is to be a physician. The solution to this is for them to go be a physician, but only after receiving the full training of a physician. What the system needs is more 3-year med schools that allow PAs (without any requirements that they agree to do primary care) to build on what they already have.

That’s my two cents. I’ve done PA school, an excellent residency, now in the process of getting one of those bullshit online doctorates. I’ve railed about how it’s so unfair that I don’t get full autonomy, how the “assistant” in my name is insulting. But I realized I’m doing all of this chasing a dream of becoming an MD. So I’m just going to do that, because I think my patients deserve one of two things: a physician assistant who knows their limits, or a doctor who has earned their autonomy.

I wish there was a better way forward for me, a three-year bridge that doesn’t require the MCAT and doesn't care about research experience. But there isn’t, so I’m doing the whole shebang, starting from the stupid MCAT, because that’s what it takes to earn the damn right.

And then maybe I’ll make that path for those coming after me.

[CAAdmission]

Why on earth would you do a DMSc if you are going to med school?

[CSCH]

Because I decided to go to med school when I was already partway done with it. I guess I'm a completionist.

[CAAdmission]

Got it. I was thinking you might be a PA Van Wilder. 

[EMEDPA]

Last time I checked, LECOM has a 3 yr PA to DO with no mcat required and 50% of the class not required to do primary care...I almost did this, took a few extra prereqs to apply, but family issues intervened. 

yup, still available:

Applicants to the program must:

1. Be a Certified Physician Assistant.
2. Have a minimal GPA of 2.7.
3. Have completed at least one physics course with lab (4 credits) and one organic chemistry course with lab (4 credits).
4. Be US citizens or have permanent residency.
5. Have scored in the 40th percentile or higher on the Medical College Admission Test (MCAT) taken after January, 2015.*

*Recognizing that alternative measures can be used to demonstrate the ability to handle challenging curriculum and that GPA is more predictive of successful completion of medical school, we consider the LECOM Academic Index Score (AIS) as an alternative for outstanding applicants who have not taken the MCAT. The AIS uses the overall total for undergraduate and graduate GPA in formula calculation with ACT and/or SAT Critical Reading and Math scores in consideration of offering interviews. A minimum AIS of 110 is required.

[ventana]

You lost me at assistant and new grad 

 

you clearly have no idea of what and how PAs function and practice and the barriers and job discrimination we face day in and day out. 
 

I am scared how you will treat PA (associates) in the future if as a new grad you already have figured out the entire profession. 
 

 

do you really think doc’s know it all?  Do you think a highly experienced PA really is that much different (in the primary care fields) then a doc??

I am treated and respected as a highly educated and knowledgeable medical provider yet I still have innumerable barriers to simply caring for my patients merely due to my degree.  I am a part of a team the exact same way a doc is.  We ALL need to know what we know and don’t know.   
 

I wish you luck but I am not sure you will find what you are looking for.  

[CSCH]

LECOM’s program has been exposed multiple times on this forum as run by anti-PA leadership. I also specified there should be more 3-year programs    .

What makes you think I am a new grad? In fact, I don’t see the phrase new grad anywhere in my post. It is precisely because I’ve been running up against those barriers that I’m pursuing med school. And what about what I said makes you think I don’t respect PAs? I disagree with PA full practice autonomy. I said nothing about PA scope of practice specifics, just that it should be proportional to training and there should be a well-established path from PA to MD. I don’t care if PA ultimately stands for assistant or associate. (I felt it was a colossal waste of money and will distract from more aggressively advertising how good PA training is because we’ll be busy pushing for a half-ass name change, and I supported MCP when it was in the running.) My point still stands. Please go back and read what I actually wrote without assuming things about me or my intentions.

[sas5814]

Lets talk about autonomy. Autonomy in a practice or a procedure is based on education and demonstrated competence. So there is no reason a PA couldn't be fully autonomous within appropriate parameters that change as the skill level of the practitioner changes. I don't understand why it has to be an all or nothing proposition. The "if you want to be a physician" BS makes me vomit in the back of my throat every time that tired old trope gets trotted out again.

I work in primary care in the VA managing a panel of 1100 very sick people. My supervising physician has consulted me a couple of times on cases she wasn't familiar with because she is an internist and we have to do everything so somethings aren't in her wheelhouse. I have been practicing for 33 years and have consulted her...never. What does all that mean? Mostly nothing. I actually only see or speak to her about once a month because we are both busy. Based on your talking points the VA has decided its ok for my panel to get second rate care because I'm not a physician. I'll ask at the next staff meeting and get back to you. I am up for re-credentialling and the creds office had to ask me who my SP was. That should give you an idea of the value of that relationship.

We have to seek autonomy for the simple reason we are going to disappear if we don't. It has nothing to do with being wannabees or any other such foolishness. It is a matter or remaining viable in the marketplace. NPs aren't going away and, agree or not, will eventually have independent practice in all 50 states. Its coming as sure as sunrise.

Don't get me started on title change. I have a 3 hour rant I can do (and have done) and that is the very thing that made me wash my hands of all things related to the advancement of the profession. We can't get out of our own way and the people leading us to our demise will be unaffected when we finally shrink to nothing because they either already are retired or will be. They will just shrug and wonder what went wrong.

[CSCH]

This is precisely the situation that our current system forces experienced PAs into that I dislike. I have no doubt you have earned the freedom that you have over years of treating patients well. Why on earth should you be subjected to the same supervision requirements that a new PA is? (But also why on earth should a new grad PA be granted by law the same freedom that you have?) I’m curious… if you were interested in a position of greater leadership, if you wanted to be faculty at an academic center and divide your time between clinical work and teaching and research, do you think you would be taken seriously? In fact, do you think you could transfer your level of earned autonomy to your next job should you choose to leave your current position, or would you be starting over entirely? In reality, you are functioning as a physician. You probably far outshine many current physicians. Except physicians can pick up and move and expect to be treated with roughly the same respect (barring admin and healthcare as a business nonsense) wherever they go because they are recognized as having completed a prolonged process of standardized training. There should have been a pathway for you to long ago go from PA sas5814 to Dr sas5814 because you are doing a different job.
 

I’m open to suggestions of alternate ways to transition older, exceptionally experienced PAs, but I doubt the MD community will be, at least not yet. My fear is that continuing to rely on an almost apprenticeship model would look like a step backwards to the unstandardized training Flexner banished in the early 1900s.

[CAAdmission]

16 minutes ago, CSCH said:

I’m open to suggestions of alternate ways to transition older, exceptionally experienced PAs, but I doubt the MD community will be, at least not yet.

The MD community will reflexively oppose anything they perceive to be a threat to their economic security. Sure, they will couch it in terms of quality and patient safety, but they only care about their wallets anymore. 

The docs speak out of both sides of their mouths. They always claim experience is king. On their discussion boards, I always pose a simple question. You are mangled in a car accident in a rural area. Who do you want to care for you - a physician 6 months out of residency or a PA with 20 years experience? They never answer. Ever.

The amount of knowledge current PA students must master is significantly greater than the last generation of physicians learned in med school. Resident work hours have also been dramatically cut without lengthening residency programs, resulting in significantly less patient contact. Docs do not possess superhuman knowledge. 

The sad fact is the docs refuse to recognize how close our training is to theirs. If there was a practical bridge program, large numbers of people might make the jump. Three years is not reasonable. 

[PAtoMD]

@CSCH congratulations on deciding to make the change. Its a tough decision and one that isn't taken lightly. I wish you success in this path. You were a poster with whom I aligned with during my PA school years and almost did a residency after reading your updates. Interestingly the PAs with whom I gravitated toward here on PAforum have started their own med school journey. For you and me we seemed to reach the same end goal that we were chasing the MD without actually going for an MD. 

 

I would stray away from LECOM if you can. However, I understand the appeal. There are many 3 year programs across the country. However, you get pigeon holed into FM only for the most part. 

 

PA training is similar to MD training. However, it is not the same. Currently in my second year and learning things that were not in my PA curriculum. Also, there is no substitution for residency training, which many of the contrarians in this thread didn't complete a PA one either.  

 

Again, good luck.

 

 

[sas5814]

1 hour ago, CSCH said:

hy on earth should you be subjected to the same supervision requirements that a new PA is? (But also why on earth should a new grad PA be granted by law the same freedom that you have?

I think that speaks to my thoughts on autonomy. If we had autonomy based on education and experience it would be a sliding scale that would change as we did. It would vary from field to field. For instance if, after all these years in primary care, I decided I wanted to work in ortho the scale and type of things I could do autonomously would change because my credentials would change. It would really be a matter of credentialing as it is with physicians.

19 minutes ago, PAtoMD said:

PA training is similar to MD training. However, it is not the same. Currently in my second year and learning things that were not in my PA curriculum. Also, there is no substitution for residency training, which many of the contrarians in this thread didn't complete a PA one either.

I agree and back in the day I often heard comparisons of hours in training that made me cringe. I just never found it to be a great argument. I think there is a fair comparison if you discount residencies which every physician does these days but I could never make that leap of logic. We aren't the same and the argument about autonomy shouldn't be based on that. It boils down to what is reasonable based on training and experience. As a hyperbolic comparison I could teach my 8 year old granddaughter to take a pulse and she would eventually be competent to do that without being tied to me. So why all the hue and cry? Just let people do what they have the chops to do. Unfortunately there is a lot of ego and money involved and often a dearth of reality.

[CSCH]

PAtoMD, thanks for your kind words. Your med school “blog” helped me feel less alone in my decision. I look forward to contributing on that thread when I get there!

 

I think a lot of the hue and cry, as you say, comes from the concern that while MD training is fairly standardized, PA postgraduate training is not. It’s really tough to define and measure competency (this is, in part, what I’m writing my DMSc thesis on). Physicians are still struggling to improve CBME, but they’re miles ahead of PAs. After school is done, PA training is largely an apprenticeship model. If the person who trains you decides to teach you a lot, you learn a lot. If they don’t, you don’t. Hence my earlier reference to Flexner and the revolution in medical education that happened in the 1910s.

[sas5814]

6 minutes ago, CSCH said:

It’s really tough to define and measure competency (this is, in part, what I’m writing my DMSc thesis on).

Indeed. Even standardized testing is really only designed to set a minimal acceptable knowledge base. 

The recent discussions and arguments about board recertification (physician and PA) has largely been about the actual value to the patient of these tests. 

In my fevered imagination we would have to walk before we run and developing a legit autonomous status would have to start with that initial core education and what it would reasonably permit a PA to do. We have to have a first step. After that it could grow and expand with a thoughtful, measured approach.

[CAAdmission]

2 hours ago, PAtoMD said:

Currently in my second year and learning things that were not in my PA curriculum.

Could you detail some of these? I hear this a lot, but still run across med students that don't seem to know which end of the stethoscope to stick in their ears. 

Is it mostly immuno-macro-molecular stuff that doesn't have meaningful bearing on 95% of patient interactions?

[PAtoMD]

25 minutes ago, CAAdmission said:

Could you detail some of these? I hear this a lot, but still run across med students that don't seem to know which end of the stethoscope to stick in their ears. 

Is it mostly immuno-macro-molecular stuff that doesn't have meaningful bearing on 95% of patient interactions?

Histology and pathology for starters. Being able to look at a slide and understand what is happening and its bearing on disease.

The most glaring example for me was when we were in our neuro unit. I was in the process of writing a best man speech. I was looking through old photos on my computer for inspiration. Came across the slide from PA school when learning the vasculature of the brain. My PA anatomy class had a fraction of the vessels I was learning in medical school. Neuro anatomy was way more intensive in medical school than PA school. 

Then a greater amount of exposure to imaging and reading x-ray, CT, MRI etc.

Disease states, even in my first year which isn't medicine intensive, had things I had not previously been exposed to or even heard of. 

 

[ventana]

by this logic only a cardiologist can treat HTN....  flawed logic is flawed

[PAtoMD]

36 minutes ago, ventana said:

by this logic only a cardiologist can treat HTN....  flawed logic is flawed

Whose logic? Not clear who you are directing to

[CAAdmission]

7 hours ago, PAtoMD said:

Histology and pathology for starters.

 

1 hour ago, ventana said:

by this logic only a cardiologist can treat HTN...

 

I won't put words in Ventana's mouth, but I think he is expressing a sentiment that I often feel. For practical purposes, there is almost an infinite amount of medical knowledge one could study. So when is enough, enough? Why would anyone see a family medicine doc when you can see an age-appropriate specialist in pediatrics, IM or geriatrics? An IM doc will try to convince you their training is "good enough" to treat your diabetes or HTN, but why not just see a cardiologist or endocrinologist?

I'd never knock someone for trying to get smarter and achieve as much knowledge as possible. But given a finite amount of time to study medicine, some traditional topics are a waste. Histology, for the vast majority of physicians outside of pathology, is a waste. Is it good foundational knowledge? Sure. But it has no bearing on 99% of interactions between someone like a family physician or internist and a patient. I'd even wonder what the knowledge retention of these physicians is 10, 20 years down the road if you started pulling out slides and looking at them.  

I've had to memorize the Krebs cycle and structures of amino acids a bunch of times. Is it good to know? I guess. Does it play any role in my daily patient interactions? Never. 

In primary care, most PAs know enough to safely practice independently 10 years out of school. I would go see any of them before I would go see a primary care physician 6 months out of residency. 

 

[PAtoMD]

8 hours ago, CAAdmission said:

In primary care, most PAs know enough to safely practice independently 10 years out of school. I would go see any of them before I would go see a primary care physician 6 months out of residency. 

I'll start with this because it has been parroted multiple times in this thread. You're not even comparing apples to apples here. It's a false equivalency. I'm not going to change your mind but if you're going to make a comparison make it better.

You ask me to delineate the differences in training thus far, and I did. You tell me its not important except when it is. I find that your arguing that proof of concept is moot and since it is foundational there is no sense in learning it. However, physician training is the gold standard for training independent and autonomous providers of medicine. The model is used ubiquitously across the world. 

Could medical school be trimmed? Certainly, I found that my first 3 months were a waste of time. There is a reason medical schools are making a push for an 18 month pre clinical curriculum. I believe medical students could benefits from more clinical exposure. Too many of my classmates have never interacted with a patient and it's clear. 

 

I'm not even touching the first paragraph because the whole thing is a slippery slope fallacy or no true Scotsman. 

 

I stand next to my statement that I'm learning things that were not even presented to me in PA school. I have a greater understanding of anatomy, physiology, and pathology. I'm sure once we start pathophysiology I'll understand disease process better. 

 

 

 

[CAAdmission]

29 minutes ago, PAtoMD said:

I have a greater understanding of anatomy, physiology, and pathology. I'm sure once we start pathophysiology I'll understand disease process better. 

In my program we did cadaver dissection with the same instructors in the same lab as med students. I think the practical and written exams were the same, but I can't swear to it. In physio, the courses were run in parallel with the same course materials (Guyton), as were the pathophysiology courses (Robbins). Our didactic differences were mainly no histo or cell level patho (addressed above), no embyrology, and immunology treated lightly. So I'm sure you are learning things you didn't cover in PA school. They just will not likely have much clinical utility in your day to day life. 

Why not go get a PhD in physiology (I know a PA that has one and wrote a dissertation on cardiac ion channels)? The answer is you think your knowledge is "enough." For what the vast majority of America's sick people, what PAs know is enough. 

 

[PAtoMD]

16 minutes ago, CAAdmission said:

In my program we did cadaver dissection with the same instructors in the same lab as med students. I think the practical and written exams were the same, but I can't swear to it. In physio, the courses were run in parallel with the same course materials (Guyton), as were the pathophysiology courses (Robbins). Our didactic differences were mainly no histo or cell level patho (addressed above), no embyrology, and immunology treated lightly. So I'm sure you are learning things you didn't cover in PA school. They just will not likely have much clinical utility in your day to day life. 

Why not go get a PhD in physiology (I know a PA that has one and wrote a dissertation on cardiac ion channels)? The answer is you think your knowledge is "enough." For what the vast majority of America's sick people, what PAs know is enough. 

 

That’s all and great that you were in parallel with the MDs. But you didn’t sit for the MD tests or sit in the classes from I could tell. I tutored master students over the summer and my peer tutored the PA students. Same instructors different breadth and depth of content. I have and am doing both. They’re different. 

 

Why not get a PHD? It’s not a clinical degree and wouldn’t change what I was looking for in a career. I’m sure you’re first in-line to state the DMSc or DNP isn’t a clinical degree so it’s useless. As a PHD would have been for my career.

The training is different. And that’s okay. The careers are different so the training is different. I don’t see why it’s a controversial point.

 

please join me in medical school and tell me it’s the same and that your clinical acumen won’t change! 

 

 

Edited September 8, 2022 by PAtoMD

[CAAdmission]

10 minutes ago, PAtoMD said:

Why not get a PHD? It’s not a clinical degree and wouldn’t change what I was looking for in a career.

Interesting. How would you distinguish "clinical" from "non-clinical" knowledge in a topic like physiology? I know a bunch of MD/PhDs. You seem to imply that the PhD is not adding to their "clinical acumen."

11 minutes ago, PAtoMD said:

please join me in medical school and tell me it’s the same and that your clinical acumen won’t change! 

I had the opportunity once, thought long and hard about it, and it just didn't make sense to do it. I'm certain by the end of it all, you will have memorized a great many more facts than I have. I'm just not sure doing so will make your patient care meaningfully different than mine in most medical fields. 

[PAtoMD]

11 minutes ago, CAAdmission said:

Interesting. How would you distinguish "clinical" from "non-clinical" knowledge in a topic like physiology? I know a bunch of MD/PhDs. You seem to imply that the PhD is not adding to their "clinical acumen."

I’m not going to comment further aside from stating it’s an intentionally disingenuous read of my statement. 

13 minutes ago, CAAdmission said:

had the opportunity once, thought long and hard about it, and it just didn't make sense to do it. I'm certain by the end of it all, you will have memorized a great many more facts than I have. I'm just not sure doing so will make your patient care meaningfully different than mine in most medical fields. 

You can continue to think that. I’m not here to change your mind. 

[CAAdmission]

9 minutes ago, PAtoMD said:

You can continue to think that. I’m not here to change your mind. 

That's good. Your current effort level would not likely be successful. I think it's hilarious that top of the thread begins with "Arrogance in Medicine." 

I'm legitimately asking the question of what training is "enough" to meet the majority of medical needs of the majority of Americans. Physicians have declared themselves the final arbiters of determining what "enough" is, and they have naturally equated it with their own training. 

There's a walking colostomy bag of an FP doc that runs a blog called Authentic Medicine where he likes to lay into "midlevel practitioners." This is the guy that calls us "LELTs" - less educated, less trained. I can never get him to answer the question of why anyone should come see him. After all, he is a LELT compared to a cardiologist, a dermatologist, and orthopod, etc. His viewpoint is much like that being espoused here. 

The major training advantage docs have is the intensity of hands-on training received in a residency program. But a PA working full time will eventually catch up. And I have worked in a couple of positions where I was responsible for helping to train resident physicians. You mention DNP above. I know essentially nothing about their training, but from what I have heard it is brief and not primarily hands on. No comment. 

If you want to bridge PA to MD that's fine, but there is no way that the knowledge gap between the professions needs three years to bridge. That's absurd on it's face.