Medicine From The Trenches

Experiences from medical school and residency.

Common Myths about Physician Assistants

Introduction

As we move further into the 21st century, the presence of  mid-level practitioners will become more and more prevalent in medical centers and in general health-care. Long gone are the days of one’s total health care being managed by a physician only in the ranks of primary care. For some patients (and practitioners), the presence of a mid-level practitioner is both confusing and unwelcome. Physician assistants make up a portion of the mid-level practitioners that will be found in many modern health care centers (along with nurse practitioners) but patients will often be unaware of their training and purpose in adding(extending) what a physician can do for them.  Many of my physician colleagues will feel that physician assistants will somehow encroach on their areas of practice which is far from the truth. In essence, my physician assistants extend and reinforce what I am able to do in medicine. They function as my eyes, ears and hands in places that I physically cannot be present and  my PA colleagues provide a very high level of care for my patients. In my practice it isn’t you see the physician or the physician assistant but in most cases, you will be seen by both.

Myth No. 1 -Most people who become physician assistants couldn’t get into medical school so they are physician “wannabes”.

In 2012, the entry-level for most physician assistant programs is at the level of master’s degree.  Not only is a minimum 3.0 GPA required to apply to these programs, the competition to enter these programs is much stricter and more stringent than ever. Most of the folks who applied the Physician Assistant (PA) program at my university had over a 3.5 GPA and most who were accepted into the program had over a 3.7 GPA. This would indicate that the folks who were able to enter our PA program were definitely capable and would have been competitive for many medical schools in this country. Many of the people who entered our program sought to become a PA rather than an MD because they didn’t feel that they wanted to spend a minimum of 7 years before they could practice. Our program is 27 months from start to finish with our graduates being able to enter any area of medicine one would find physicians. In addition, they can seek additional training in anesthesia and critical care if they choose to work in these areas. The vast majority of our PA grads go into surgery, pediatrics , emergency medicine and internal medicine much the same as our MD graduates.

Myth # 2- PA school is easier than medical school so these folks give inferior care

In truth, PA school is a bit more difficult than medical school. In essence, I had two years of pre-clinical didactics before I entered the clinical phase of my medical school. PA students have about one year of pre-clinical didactics before entering their clinical phase and they are taught on clinical rotations alongside 3rd and 4th year medical students. PA students attend the same clinical lectures and are expected to carry the same clinical loads as the 3rd and 4th year medical students. We often don’t know whether a student is a PA student or a medical student unless we are able to read the name badges. I ask rotating students the same questions and expect the same level of functioning regardless of which degree they will complete. In the end, the PA student will leave at the level of a  PGY-1-2 resident and function at that level  for most of their career while the medical student will leave at the level of a PGY-1 resident and move through residency to become an attending physician. Most of the patients that are treated in clinics at medical centers are seen by a combination of PAs and residents on teams that are run by a chief resident or attending physician with no compromise of care.

Myth 3- PA don’t know things at the level of a physician so they might miss something in my care

Most PAs are very adept at self-directed learning in the same manner as a physician. Whether one attends medical school or PA school, one cannot expect that what is learned in school is all that is needed to be a competent practitioner. My state requires that I complete many hours of continuing education in order for me to maintain a license to practice with PA having the same licensure requirements. In addition to seeing patients, PAs are constantly upgrading and honing their knowledge often at the same conferences and meeting as physicians.  Physicians often consult each other in terms of taking care of complicated patients and good PAs will consult with more experienced PAs or physicians in the care of their patients. The PA that work on my service know the scope of their practice and do not exceed this. While the PA may be able to do 90% of what I do as a physician, they are very aware of when a patient is beyond their scope of care the same as any physician is aware of when a patient is beyond their scope of care.

Myth #4- If I see the PA, I have to see the doctor too so why the extra step?

Many of my patients may not be seen by me on some office visits where they see the PA only. If the PA feels that the patient does not need to be seen by me, they will take care of the problem and the patient gets out sooner. On the other hand, most of the PA who work in my practice will state that, I know the doctor wants to see you so wait a couple of minutes until she is available” while in the meantime, I will consult with the PA on how the care of that patient is going along. PAs in our practice will perform treatments, manage wound care and work patients up for surgery. In most cases, just as with the residents who are on our team, the PA will assist in the surgery of the patient that they worked up unless the case is of vital learning for a resident.

Myth #5- PA education is inferior to physician education

PAs are educated under the same model as physicians. They take the same coursework in some cases but they don’t spend the same amount of time in school as a medical student and they don’t spend the same amount of time in post-graduate training as a medial student would. The ability to practice medicine with less training is something that is very appealing for most of the people who enter PA school. At the end of training and upon passage of their certification examination, most PAs start out at around $78,000 and max out around $110,000 after a few years in practice. For many people, spending a minimum of 3 years in residency above 4 years of medical school (expensive) only to earn about $47,000 as a resident is not something that they can afford financially. Most PA programs will cost far less than medical school and will enable their graduates to get into the health care work force much sooner at higher salary. Additionally, physician assistants can apply for and qualify for public health care scholarships that will pay back their student loans which are far less than the average $158,000 that a medical student will owe after medical school.

Finally…

I wrote this post because many students have negative ideas of what the training and work of a physician assistant will involve. For many students who have a strong desire to work in the medical field but family and financial obligations that will not allow them to spend a minimum of 7 years in training above  the baccalaureate level, becoming a physician assistant is something that they might find appealing. In today’s world of medical practice, PAs diagnose, treat and prescribe right alongside physicians. Often it’s the PA who gets to spend more time with the patient and who will develop a more personal relationship with their patient because the PA is not subject to the time constraints that a physician is often subject to. Good PAs build upon their clinical skills learned in school and spend as much time upgrading those skills through continuing education and journal reading as any physician would. It’s no accident that physician assistants enjoy the highest job satisfaction of any profession in health care with other professions not even coming close to their level of satisfaction.

I would encourage any premedical student to take a long and objective look at the physician assistant profession in addition to medicine. You may find that it’s a good fit for your professional ideals especially if you enjoy one-on-one interaction with your patients. One of our frequent questions for entry into PA or medical school is ,”What other health care professions have you looked at and what did you find out about them?”.  I am always surprised at the number of students who have applied to PA or medical school that didn’t do a thorough investigation of health care careers besides physician or physician assistant. Certainly if one anticipates preparing for a career as a physician, one should definitely make sure that they have done a thorough investigation of everything that is available, including alternatives and make the most informed decision before they embark on a career that takes a minimum of 7 years beyond university. Additionally,every PA that works in my practice is far from envious of my practice and love the scope of their profession. As you look at becoming a PA, make no mistake in believing that compared to medicine, it’s inferior or easier because this simply isn’t accurate and you may find that this very modern career is a great one for you.

14 January, 2012 Posted by | can't get into medical school, medical school, physican assistant, pre-med courses | | 31 Comments

I can’t (and maybe don’t want to) get into medical school

Medical school has been the ultimate dream profession for many people (or their parents) for many years. In some cultures in this country, only four professions exist; medicine, law, dentistry and engineering. If a person didn’t get into one of those professions, then they were seen as a professional failure in the eyes of their parents. For some unfortunate students, not only are they not going to enter one of those professions, they are not interested in the subject matter or practice of one of those four professions. Almost weekly, a parent will enter my office stating that they will “disown” their child if I don’t “let” them into medical school. Many of these students  will say that they have little interest in the sciences (unacceptable to the parents who are paying tuition bills) and even less interest in medicine. When questioned closely, many of these undergraduates will reveal that their parents would never “allow” them to seek other professions and that medical school is the only choice.

In today’s climate of grade inflation and very high tuition costs, the sheer magnitude of maintaining the medical school  matriculant average undergraduate GPA of  3.7 is a burden that many are not able to carry. For some students, a very poor freshman year can mean the end of being able to get that uGPA into the average range let alone a competitive range. For others who might enter university poorly prepared in math and science because of attendance in a poor secondary school, getting their academics off to a strong start and keeping them there may be problematic. Along those lines, I encountered a young Latina woman who was valedictorian of her secondary school class (inner city). While she had maintained a very strong academic record at her secondary school, the quality of instruction was extremely poor.She would be the first in her family of very hard-working immigrants whose dream was for her to become a physician so that she could come back to the neighborhood for practice. This was a huge burden for this young lady who was determined not to let her family down.  She came to our university will poor study skills, poor reading skills and deficient math skills. He school had no IB or AP courses and offered few academic courses that would prepare her for becoming a biology major in preparation for medical school.

During her first semester, she proceeded to achieve a 2.0 GPA which lead to much discouragement and frustration. When she came to my office for assistance (she was in danger of losing her full-ride scholarship), I immediately contacted the school administration to allow her to shore up her academic skills before proceeding to lose her scholarship. She had determination and discipline but lacked guidance in being able to navigate the academic world (common in many students who are the first to enter higher education). She was allowed to spend the next semester working on basic writing, reading and math skills. Fortunately, she has and always had very strong problem-solving skills which is why she sought assistance when her performance was working in the first place. While she hadn’t failed any courses, those “C” grades would not be enough for medical school.

In the next semester, she excelled in her academic remediation. She was able to make great strides and shore up her deficiencies. She learned to put her drive and determination into her studies but she also learned that she was not particularly interested in science and math. Over the course of the remediation semester and summer, she became interested in psychology which she pursued with vigor over the next fall semester earning a 4.0 GPA for that semester. Her reading and writing skills were excellent along with a very strong interest in studying her population in terms of achievement. In short, her interests lay not in medicine but in helping her community and those in her community to be able to achieve in the academic world. She went on to earn a degree in psychology and entered graduate school to earn a Ph.D in psychology. While her family was not happy, she continues to research, study and write articles which have been the cornerstone for closing the gap in Latino achievement in academia. Her most recent achievement was tenure in her department at the state university where she teaches. In short, if medical school is not your dream, all of the drive and push from your parents and family will not provide what you need to get into medical school and practice well in medicine.

Another undergraduate student had come from a family where his mother and father were both physicians. He freshman and sophomore years had ended up netting a uGPA of 2.5. He loved the university life and spent many hours with his fraternity brothers working on extracurricular activities. His father brought him to my office so that I could “talk some sense into him” before he destroyed his future. After a tumultuous weekend with his parents, this student returned to my office resigned to “dig in” and get his work done. As we calculated what he would need to do in order to raise that uGPA, he said that he just didn’t have that kind of  drive.  He said that he would “do his best” because he didn’t want to let his parents down. He said that it didn’t help that his brother was in medical school and was very critical of his undergraduate performance.

Over the next couple of semesters, his academic performance improved but not enough for him to get his cumulative uGPA above 3.2. He became more and more discouraged. At one meeting, he expressed interest in looking at other careers besides medicine. He decided that he would look into becoming a physician assistant which didn’t take as long but would enable him to have a career in health care. While his family wasn’t pleased with his choice, after making the decision not to pursue medicine, he was better grounded and had more direction. He finished his undergraduate degree in biology with a cumulative GPA of 3.5 and entered a masters program in physician assistant studies. Today, he loves his job and loves that he can travel while practicing his craft.

I do not advocate trying to become a physician assistant because you can’t get into medical school but it is a profession that is worth exploring if you have a strong interest in the practice of medicine but can’t spend the minimum of 7 years above undergraduate school in order to enter the profession of medicine. In terms of love of their work, physician assistants have the highest job satisfaction in healthcare and earn a very strong salary which is quite appealing for people who have families whose needs won’t allow an additional four years out of the workforce. In terms of academics, the same strong academic skills in reading, writing and math are needed by a PA that would be needed by a physician. I would also caution that the academic achievement to become a physician assistant is just a bit lower than what is needed for medical school with the average uGPA of the PA class that entered our state university being 3.6. In short, getting into PA school isn’t that much easier than medical school but the training is shorter which is appealing to many people who have an interest in medicine but do not want the long training period.

Other careers worth looking at are anesthesia assistant which is a physician assistant who does anesthesia and perfusionist. The training programs for this profession are quite competitive but as with PA, the job satisfaction is very high. Anesthesia assistants work with anesthesiologists and provide anesthesia care in a variety of settings. This particular profession seems to attract people who have no interest in nursing and going the CRNA route but have a strong interest in working the operating room environment with anesthesia.  The perfusionist runs the heart-lung machine (and extra-corporeal membrane oxygenator ECMO) which is used during cardiac surgeries such as coronary artery bypass grafting or valve replacement. If ECMO is used in a nursery, it is the perfusionist that maintains that machine too. Perfusion technologists earn a very high salary and enjoy very good job security. There are a limited number of perfusion technology schools (and training slots) in this country but for many people who find that medicine is not for them, perfusion technology can be a very good healthcare profession.

For the undergraduate who has applied to medical school more than twice, the chances of getting into medical school will not increase and are likely to decrease. Just reapplying is not enough to achieve admission as whatever kept you out in the first place has to be corrected and upgraded.  Every year, the medical school matriculant average goes up along with the matriculant average score for the Medical College Admissions Test (MCAT).  To continue trying to raise an otherwise undistinguished uGPA (graduate doesn’t count) with one class here and there is a long and expensive process. One poor year as an undergraduate can be overcome but multiple drops and repeats of the pre-med courses (especially organic chemistry, calculus and general physics) do not bode well for medical school admission success. There are just too many medical school applicants out there who have completed their studies without drops and repeats. There are also many applicants who have very competitive uGPA/MCAT scores who will be admitted ahead of those who have  a less distinguished record. No amount of research or extra curricular activities will off set a poor uGPA; nor will a high MCAT score do the same. In short, the admission process into medical school is long, unforgiving and quite expensive with little guarantee of success in any given year.

Multiple retakes of the MCAT with final scores less than 30 are going to be problematic for many who desire to enter medical school. One retake of the MCAT if you were ill (or severely distracted) is warranted but several mediocre scores with no or a 1 point improvement will no work will. Not releasing scores on more than one retake with mediocre scores is not a sound practice either. Students who have a less-than-distinguished academic record can’t expect to “ace” the MCAT and get into medical school. This is why it takes both strong academic achievement and a strong MCAT in order to achieve admission success. Medical schools want to accept students who show evidence (by undergraduate achievement and scores on the MCAT) that they are able to master a very competitive curriculum. It is far from a certainly that once you are accepted into medical school, that graduation will happen. In short, medical school is a very strong academic challenge that many of the strongest students find daunting at first. It takes a consistent and high level of scholarship to achieve the performance in medical school that is needed to become a physician. Also keep in mind that USMLE (United States Medical Licensing Exam) steps are not retaken which means that multiple retakes of exams such as the MCAT do not bode well for USMLE success.

If you find that you are not successful in gaining admission into medical school, you need to do an objective and thorough inventory of why your application didn’t work. After your inventory, you need to figure out how and what you can upgrade that will ensure successful admission. If you are on a waitlist, I strongly advise getting the application together for reapplication for the next year as soon as possible with updates and reworking of things such as your personal statement. In the intervening time, upgrade anything that is within your power to upgrade and apply early (exceed every deadline). If you didn’t get any interviews or waitlist, then your application need a thorough upgrade (might take more than one year). If you can’t upgrade your uGPA (t0 a competitive range) significantly in one or two years, you likely either need to look into a Special Masters Program for credential enhancement (if you enter one of these you need to do well) or look into another profession. Getting a Masters of Public Health (MPH) isn’t going to offset a poor uGPA or MCAT nor is entering a Ph.D program as most medical schools require that you complete any graduate work that you start.

6 January, 2011 Posted by | application, can't get into medical school, medical school, medical school admissions | 1 Comment

   

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