PA to Physician bridge: Why not?

[lawguil]

Allopathic and Osteopathic students don't take the same test, though Osteopaths can take the USMLE if they wish. I don't know of any school which provides "practice" USMLE tests; at least none of the many schools where I interviewed, and none where my friends go. Part of the reason for this is that step 1 is 8 hours long and has 350 questions; no school makes their students do that. Any redacted test is not indicative or representative of the full thing.

Also, where would you have learnt the in-depth knowledge of subjects like medical biochemistry, histology, immunology, and others that are NOT part of the PA curriculum, in order to "do better than the median" on these exams?

You might have taken some in-house test, but it was certainly not that.

Also, I did not say that there was no place for midlevel providers, but many overstep and overestimate the boundaries of their knowledge base.

I'm glad you're taking a traditional route; perhaps at the end of it, you will realize in retrospect how vast the difference really is.

"Credit for knowledge known" is touchy, especially when it can vary so much on a case-to-case basis, when idiot-savants can memorize Robbins and make a 100%, and when licensing and accreditation issues are involved. It sets up a nasty precedent and slippery slope. Hence, it is in the best interest of the integrity of the MD degree and profession that shortcuts be avoided at all cost.




The biggest and most faulty assumption here is that the first and last 2 years of med school have nothing to do with each other. One's performance in the wards is partly based on one's knowledge base from the preclinical years; yes, this includes coming up with thorough differential diagnoses that include the biochemistry, histophysiology, immunology, etc. of the condition and being able to integrate that into a concrete explanation. Just last week, an attending asked me about a patient we saw with atypical Down syndrome and I had to recall that it was a Robertsonian 14-21 translocation and actually explain to him what that entailed, how it happened, at what point during embryogenesis it took place, and how I would explain that to the parents. We then saw a patient with xeroderma pigmentosum, and I was pimped on what set it apart from cockayne's syndrome and WHY one results in more cancerous lesions (nucleotide/global excision repair, etc.) and theoretical therapies and potential pharmacological interventions. Just examples, but the clinical years aren't just about being algorithm-driven body mechanics. Sure, there is a lot of learning procedures, patient care, ward management, how to work up a patient, etc. but that is usually the easy part compared to acquiring and integrating all the information in the first place.

Such a scholar! First you made up your mind and now you'll spend the rest of you life manipulating evidence to support it! It's difficult to entertain your credibility! Carry on with your command style rhetoric.

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[anon-y-mouse]

Such a scholar! First you made up your mind and now you'll spend the rest of you life manipulating evidence to support it! It's difficult to entertain your credibility! Carry on with your command style rhetoric.

If I recall correctly, you're not even in the medical profession at all. Talk about irrelevant. If you can directly refute what I said, do so.

 

[Faebinder]

Let me discombobulate this for you.

Step 1: 6 weeks has been found to be the optimal time to study because beyond that time, you forget what you reviewed in week 1, etc. However, it is only possible if you've actually *learned* the stuff in the first place. The actual learning itself takes a much longer period of time, i.e. during the classes themselves.

Step 2: 4 weeks or so is optimal, but this is misleading because students study for the NBME shelf exams at the end of every rotation, and those NBME exams are written by the same people who write the USMLE. Hence, the study time is much much greater. Foreign graduates have to study more for it because they hadn't studied for that material for the official / regular NBME shelf exams.

Yup that was exactly how it was.... Your words are very wise and other med students should heed them. The learning process is not those 6 weeks before the exam.

 

[lloydchristmas]

obviously at a much lower rate, a physician's training is more comprehensive.

Yes, this is true. But the thing we are all trying to accomplish is helping people, right? So if midlevels misdiagnose twice as often as docs and docs get it right 99% of the time, aren't 98% of the midlevels patients receiving quality healthcare? And keep in mind some of the best and most productive medicine is preventative, which is usually pretty simple. It just takes someone there to do it.

So I'm a midlevel who goes to this wild and new 3 yr combined FP med school/residency. Now, since I have better training, albeit not the traditional route.... and so obviously I have to improve my diagnostics since it's at least some medical school. So now what are the percentages? I just don't see the reasoning behind the argument, "I'm in medical school, so I don't think anyone should be able to do it any differently than I'm doing it."

 

[anon-y-mouse]

Yes, this is true. But the thing we are all trying to accomplish is helping people, right? So if midlevels misdiagnose twice as often as docs and docs get it right 99% of the time, aren't 98% of the midlevels patients receiving quality healthcare? And keep in mind some of the best and most productive medicine is preventative, which is usually pretty simple. It just takes someone there to do it.

So I'm a midlevel who goes to this wild and new 3 yr combined FP med school/residency. Now, since I have better training, albeit not the traditional route.... and so obviously I have to improve my diagnostics since it's at least some medical school. So now what are the percentages? I just don't see the reasoning behind the argument, "I'm in medical school, so I don't think anyone should be able to do it any differently than I'm doing it."

That only makes sense if "twice as often" is the actual figure. If not, throw the whole thing out the window because you have no metrics. Hence, alternate routes are basically irrelevant because there are no such metrics. Actually, to be honest, I don't think it's too difficult for a midlevel provider to diagnose and find the basic etiology of the 10 most common problems. Hell, even as a med student I've made a ton of diagnoses with the basic information I have, and can read an MRI pretty damn well. However, I realize what I don't know, what I will be learning (and get tons of practice with), and have the tools to understand and reason out medical problems from a molecular, cellular, tissue, organ system / gross level. To "shortcut" this process and still give a full MD is potentially compromising lives. "Some med school" is not the same as going through the whole thing; there is a reason why the LCME standards are brutally stringent.

 

[lloydchristmas]

That only makes sense if "twice as often" is the actual figure. If not, throw the whole thing out the window because you have no metrics. Hence, alternate routes are basically irrelevant because there are no such metrics. Actually, to be honest, I don't think it's too difficult for a midlevel provider to diagnose and find the basic etiology of the 10 most common problems. Hell, even as a med student I've made a ton of diagnoses with the basic information I have, and can read an MRI pretty damn well. However, I realize what I don't know, what I will be learning (and get tons of practice with), and have the tools to understand and reason out medical problems from a molecular, cellular, tissue, organ system / gross level. To "shortcut" this process and still give a full MD is potentially compromising lives. "Some med school" is not the same as going through the whole thing; there is a reason why the LCME standards are brutally stringent.

Yes, I realize these numbers are anecdotal. But I'd say they're pretty close if not even overestimated, at least in the rural scene.

And knowing what you don't know, as you said, is the best way to be a good provider at whatever level. This is where many NPs screw up and get in trouble.

Shortcutting doesn't sound good to anyone except those who would benefit. Patients and traditional docs wouldn't like the idea. But, consider the alternative. We're heading for socialized medicine, which will drive doctor numbers even further down. What's better, a NP who went to a shorter version of med school/FP residency or no doc at all?

And I hesitate to call it a shortcut, as it takes a minimum of 6.5 yrs to get a undergrad, min 1 yr experience, and grad school for the NP. Then you add in the "shortcut" 4 yrs or so and come up with nearly the same time frame for trad vs. midlevel bridge, and even longer for UMKCs 6 yr BS/MD program. Yes, I know the training is more intense, and better, and blah blah. If you want to argue this, see the last sentence of the previous paragraph.

Bottom line is you don't like the idea because you're not practicing family medicine at least in a shortage area where any help is greatly appreciated and you aren't a midlevel. I like it because I am, and I am. I think we'll just have to agree to disagree on this topic.

 

[anon-y-mouse]

Yes, I realize these numbers are anecdotal. But I'd say they're pretty close if not even overestimated, at least in the rural scene.

And knowing what you don't know, as you said, is the best way to be a good provider at whatever level. This is where many NPs screw up and get in trouble.

Shortcutting doesn't sound good to anyone except those who would benefit. Patients and traditional docs wouldn't like the idea. But, consider the alternative. We're heading for socialized medicine, which will drive doctor numbers even further down. What's better, a NP who went to a shorter version of med school/FP residency or no doc at all?

And I hesitate to call it a shortcut, as it takes a minimum of 6.5 yrs to get a undergrad, min 1 yr experience, and grad school for the NP. Then you add in the "shortcut" 4 yrs or so and come up with nearly the same time frame for trad vs. midlevel bridge, and even longer for UMKCs 6 yr BS/MD program. Yes, I know the training is more intense, and better, and blah blah. If you want to argue this, see the last sentence of the previous paragraph.

Bottom line is you don't like the idea because you're not practicing family medicine at least in a shortage area where any help is greatly appreciated and you aren't a midlevel. I like it because I am, and I am. I think we'll just have to agree to disagree on this topic.

You have no way of knowing what the numbers are actually like unless you have tracked the outcomes of thousands of other providers.

It IS a shortcut, and you really can't hesitate to call it that. Why? Everything else you did before that degree is pretty much irrelevant to one's practice (other than building maturity and developing cognitive / study skills). You *can't* equalize timeframes based on what a person did before they started medical training of any sort. "Midlevel or no doctor at all" is a loaded, manipulative argument and is a bandaid solution for the problem. Increase compensation and incentives to practice in rural areas, and train more physicians (fully, not with some halfassed compromise of a bridge). Unfortunately, while the increasing autonomy of midlevel providers may benefit rural populations to some extent, it compromises patient care in areas where plenty of doctors are already available. So, only allow "compromises" (of any sort) in rural areas? How does one define a rural area? What prevents that inferiorly trained provider from going through the shortcut, escaping hicksville and fast-tracking to the big bucks in the big city? And for the reasons I've already outlined in previous posts, giving someone a shortcut MD dilutes the meaning of the degree and is potentially misleading. There are ways of addressing rural medical care shortage, and a fasttracked MD would be the most dangerous and foolish of them.

 

[lawguil]

If I recall correctly, you're not even in the medical profession at all. Talk about irrelevant. If you can directly refute what I said, do so.

No I'm not in the med field...I simply teach them.

 

[lloydchristmas]

You have no way of knowing what the numbers are actually like unless you have tracked the outcomes of thousands of other providers.

It IS a shortcut, and you really can't hesitate to call it that. Why? Everything else you did before that degree is pretty much irrelevant to one's practice (other than building maturity and developing cognitive / study skills). You *can't* equalize timeframes based on what a person did before they started medical training of any sort. "Midlevel or no doctor at all" is a loaded, manipulative argument and is a bandaid solution for the problem. Increase compensation and incentives to practice in rural areas, and train more physicians (fully, not with some halfassed compromise of a bridge). Unfortunately, while the increasing autonomy of midlevel providers may benefit rural populations to some extent, it compromises patient care in areas where plenty of doctors are already available. So, only allow "compromises" (of any sort) in rural areas? How does one define a rural area? What prevents that inferiorly trained provider from going through the shortcut, escaping hicksville and fast-tracking to the big bucks in the big city? And for the reasons I've already outlined in previous posts, giving someone a shortcut MD dilutes the meaning of the degree and is potentially misleading. There are ways of addressing rural medical care shortage, and a fasttracked MD would be the most dangerous and foolish of them.

You're right. I'm convinced.

 

[anon-y-mouse]

No I'm not in the med field...I simply teach them.

?

 

[MyChoice]

Lots of good information flowing, but we are not listening to one another. Anon seems to be concerned about the short cuts leading to short-comings in the medical profession. A valid concern, but not necessarily based on a valid premise. Just because a pathway is an alternative, does not make it inferior. The original medical & surgical apprenticeships took over a decade in many instances, but programs have evolved beyond the original design. Not to mention the new residency rules: more more than 80 hours per week averaged over a 4 week period, & NEVER more than 30 hours continous. Residents from 10 or 20 years ago would scoff at the fact that nowadays, residents should have to do additonal years to account for the drastic reduction in time spent. If this were true, do you really believe the governing bodies would have made these changes. I think not. I think that the system has realized certain flaws in judgementthat were based purely on tradition and were not evidence-based. The data, at least thusfar, has shown that today's residents are well-prepared and quite capable.

Another flaw in the current thought process is the ability of foreign medical students to access entry into the residency programs here in the US. If all short cuts are bad, what about the fact that in many countries, India for example, students go from their high school directly to medical school. The 4 additional years (college years) that the US system has stated on numerous occassions, allows for maturation and better preparation for the medical profession are non-existent in these other countries. And although I have met many students from European, Caribbean, and many other medical schools who appear to be quite capable and intelligent and well-trained, why have we created an alternative pathway for them to enter into the system rather than having them enter as first year medical students in the traditional pathway? As it was stated, this is a slippery slope, because there are just too many variables and any idiot savant can pass the exams, so why do we allow this?

Why, because the system is dynamic not static, and things change. More importantly, lives are at stake, and in the current format we are losing. Not just the battle, but actual lives. Patients are dying, and at a greater rate than ever before. At least according to the AMA, AOA, WHO, and every healthcare based think tank on the planet. (And if you ask me for the numbers then your medical school did a terrible job in preparing its students on the actuality of medicine in America and the world.) It takes months to get into PCP offices for routine exams, which are the basis of preventative medicine. Consequently, delays in diagnosing & treatment are rampant. Cancers are running unchecked because of the delays, and many others remain undiagnosed until the patient is symptomatic enough to force an ER visit or EMS call. If this isn't alarming enough, let's talk specialties. If one can even find a specialist in a given field who is taking new patients, it could be 6 months before the first visit. One of my closest friends is an endocrinologist in Virginia. Because of the Medicare/MedicAid rules, patients in this category must be reevaluated within a specific timeframe. Consequently, his new patients who do not have CMS coverage, either private insurance or self-pay patients, cannot get into his clinic for about 5-6 months. This is a guy who sees patients from 7:30 am to 7:30 pm Monday thru Saturday. And he is the only endo specialist in about a 100 miles radius.

Back to it. When it was stated that the knowledge and the practice must work together, that is absolutely true. One without the other is like a diagnosis without a treatment. What good is knowing what is going on if you don't do anything about it? Much the same with the issue of physician shortages in medicine. We know about it. We've known for a very long time. Dr. Eugene Stead from Duke new it in the 1960's. He dicided to take affirmative action, and he created the PA. Many of his time were skeptical and outraged by his and Duke's decision. But it was a step in the direction of trying to fix a broken system. Well, 40 years later the system is more broken than ever before, and no one seems to have any great plans on what to do. Maybe this is another good idea whose time has come? Maybe not? But why not give it a try? Even a pilot program in 1 or 2 or a few institutions to test the premise and see if it is viable. In this manner, physicians such as Anon could truly see if this will work. If it fails miserably, then they can say they told us so, and those in favor of such a program can't say argue with the facts; however, if it succeeds we all win. The profession, the persons interested in this pathway, and most importantly the patients and the medical system as a whole.

Enough from me. Let me hear your thoughts. All of you.

 

[anon-y-mouse]

Foreign graduates are deemed eligible to practice medicine in their own countries. Their education is in no way less comprehensive in the majority of cases; in fact, some would say they are more thorough and go slower in some ways (6 years is the standard for med school abroad)... although the depth and breadth of the material covered is roughly the same. By virtue of the fact that these people can practice in their own countries, it is professional courtesy to give them the opportunity to practice in ours. Actually, I have found that physicians who trained in "poorer" more overpopulated countries have a richer knowledge base due to having many many more patients. In any case, ours is the only country where we give so much leeway to lesser trained midlevel providers.

As for time spent in residency, a resident in a country like Britain spends more *years* in residency but their work week is much shorter. Ultimately, every residency I know has strict metrics and guidelines about how a resident's skillset should improve from year to year ("by year 5, a resident should have completed X craniotomies", etc.).

As it is, PA's have relative autonomy, however good or bad that is for patient. Creating a fast-track shortcut "bridge" doesn't help the healthcare crisis, as it doesn't intrinsically increase the number of providers; all it does is legitimize a less comprehensive path, boost the ego of midlevel providers, and put more money into their pockets as MD's.

A better solution is to increase the number of medical school seats; there are already more than enough people applying to medical school every year anyway, all willing to take out loans and make the sacrifices to become a physician. Increase the number of rural providers? More federal loan forgiveness programs for those who make a commitment to practice in an underserved area.

 

[lloydchristmas]

My response earlier was driven by a busy day. I saw a lot of patients. No one died. You can go ahead and think I misdiagnosed. Anons posts are pushing this idea that PA/NPs aren't competent enough to do what they do now, much less with additional training. I could tell you about how I was in ATLS class and sat next to a bunch of Fam Prac MD Residents, all whom scored lower than me, and my collaborating physician MD that failed the course. I could also tell you about the patients that I have cured that have had problems for literally years and have seen numerous MDs who couldn't fix them. I could tell you about the better control of Ha1c, cholesterol, and BP my patients have compared to the MDs in my clinic. But since I can't provide p values or randomized double blinded information, you will dismiss it anyway. Yes, I know this is the exception, not the rule. So make our USMLE harder to weed out the idiots. I don't care. If I fail, I don't deserve to have the title.

All I want is to know more and get paid better for what I'm doing. I don't think that's too much to ask. I can show administration all the numbers and they still will look at me cross-eyed and offer RN wages. It's baffling. I can spell out the numbers and increased profitability and decreased financial risk and offer them a deal that in any other business would be a no-brainer. But, if I were in the same office, talking to the same administrator, with MD behind my name, all I would have to do is say "I want this and this and this" and they'd do it and wouldn't ask any questions.

 

[deleted6669]

lloyd- we are wasting our breath with this guy. until we have a study that shows we aren't leaving corpses behind us every day at work he won't budge. he's only an ms3. at some point a pa or np will save his butt when he has made a critical mistake and then maybe he will give us some respect.
I have had the same experiences as you, even down to atls. my preceptor/examiner for my atls trauma code scenario was impressed enough by my performance that he was trying to sign me up to be an instructor until he learned pa's couldn't teach atls due to internal rules from the american college of surgeons. I have seen same day md bounce back pts in the er and admitted them with life threatening illnesses after a physician has seen them and sent them home with no workup. I staff an er by myself several days/month. am I a doc? no. but I do a fine job nonetheless and have the lowest QA/complaint rating in our group. if I don't know the answer to something I find a specialist in that area and ask them. do I still learn new things about emergency medicine? sure, all the time. that's what lifelong learning is about.
at least at work I get some financial respect in that I am paid(significantly) more than the fp and im docs who moonlight in the er. there is a reason for that. I know more em than they do. more of the medicine and more of the procedures.the fp guys don't know trauma and the im guys don't know peds, ob, trauma, or procedures. it's that simple.

 

[anon-y-mouse]

All I want is to know more and get paid better for what I'm doing. I don't think that's too much to ask. I can show administration all the numbers and they still will look at me cross-eyed and offer RN wages. It's baffling. I can spell out the numbers and increased profitability and decreased financial risk and offer them a deal that in any other business would be a no-brainer. But, if I were in the same office, talking to the same administrator, with MD behind my name, all I would have to do is say "I want this and this and this" and they'd do it and wouldn't ask any questions.

If you want that, you should go to medical school from start to finish like everyone else who is a physician. There's no free lunch, just because you've got lots of practice and success as essentially someone who follows set guidelines without fully understanding the etiology and mechanism of disease. If ATLS is anything like ACLS, you passed because you attentively went through the class and learned the standard algorithms the instructor taught you. Similarly, I'm sure your trials and errors have improved the way you manage DM (HbA1c is as you know just an indicator of the condition... and good for you, there are many confounding factors in interpreting the figure), but what about your patients with sickle cell disease or any sort of thalassemia (a lot more common than you might think). I don't know how I'd be able to reason out any therapy without having full knowledge about the underlying biochemistry and histopathology involved.

And as for ATLS, I can just picture it in a med-mal situation... "Judge, I was just following what a nurse taught me... no, sir, he told me to administer this drug based on what his supervisor said to him." Anyone can be taught procedures and with practice, those people can get really good at that task. What sets physicians apart is their greater knowledge of the "why"s of the situation. I'm really glad the ACS realizes how inappropriate it is for non-MD's to teach ATLS: physician *assistants* are not physicians' *peers*. Your knowledge of what to do in a code, emedpa, is based on 19 years of hard work in the emergency room, learning and perfecting procedures, seeing many sorts of cases, etc; while that's excellent, your background and grounding in the medical sciences is less than that of even a 3rd year medical student. I hate always referring to my PA classmate, but she constantly realizes how much her new knowledge shapes the way she will treat people as an MD, and always looks in retrospect at what she did -- filling in the holes of *why* she did what she did. She's taught me a few handy techniques to manage patients based on her past experience. However, fundamentals are basic and essential; there's not always going to be a "specialist in that area" if you don't know something. In any case, a little knowledge is very dangerous.

 

[lawguil]

If you want that, you should go to medical school from start to finish like everyone else who is a physician. There's no free lunch, just because you've got lots of practice and success as essentially someone who follows set guidelines without fully understanding the etiology and mechanism of disease. If ATLS is anything like ACLS, you passed because you attentively went through the class and learned the standard algorithms the instructor taught you. Similarly, I'm sure your trials and errors have improved the way you manage DM (HbA1c is as you know just an indicator of the condition... and good for you, there are many confounding factors in interpreting the figure), but what about your patients with sickle cell disease or any sort of thalassemia (a lot more common than you might think). I don't know how I'd be able to reason out any therapy without having full knowledge about the underlying biochemistry and histopathology involved.

And as for ATLS, I can just picture it in a med-mal situation... "Judge, I was just following what a nurse taught me... no, sir, he told me to administer this drug based on what his supervisor said to him." Anyone can be taught procedures and with practice, those people can get really good at that task. What sets physicians apart is their greater knowledge of the "why"s of the situation. I'm really glad the ACS realizes how inappropriate it is for non-MD's to teach ATLS: physician *assistants* are not physicians' *peers*. Your knowledge of what to do in a code, emedpa, is based on 19 years of hard work in the emergency room, learning and perfecting procedures, seeing many sorts of cases, etc; while that's excellent, your background and grounding in the medical sciences is less than that of even a 3rd year medical student. I hate always referring to my PA classmate, but she constantly realizes how much her new knowledge shapes the way she will treat people as an MD, and always looks in retrospect at what she did -- filling in the holes of *why* she did what she did. She's taught me a few handy techniques to manage patients based on her past experience. However, fundamentals are basic and essential; there's not always going to be a "specialist in that area" if you don't know something. In any case, a little knowledge is very dangerous.

Many educational scholars, if you will, would argue that US medical school education is fickle. It isn't the best way of educating physicians (emphasis added). Without wasting my breath, it has been said before by folks with much more credibility than any of us that a better, more cost effective, and practical way of educating physicians would look something like a PA to bridge program. Essentially a person would apply to medical school, complete PA training, PA's would then practice, reenter to complete the "bridge" program" if they so wish, and then residency training.

There are folks (within medical schools) that entertain these thoughts. Study a little about education, educational and group behaviors, cognitive and behavioral relationships, curriculum design and you might better understand why.

Educators might even go as far as to say that a PA who completed an MD/DO bridge program might actually be the first class physician as opposed to the second class physician who simply went to medical school.....sort of like the 21 month nursing programs where you earn your RN and NP in one simple step......We all now that if you do your RN, practice as an RN for years, then attend an NP program you have a better prepared practitioner. L.

 

[lloydchristmas]

If you want that, you should go to medical school from start to finish like everyone else who is a physician. There's no free lunch, just because you've got lots of practice and success as essentially someone who follows set guidelines without fully understanding the etiology and mechanism of disease.

Okay, now it's clear to everyone you've lost the argument. You're sitting there telling me what I do and don't know and you have no idea who I am or what I've done. Who the **** are you to tell me what I do and don't understand. I could belong to MENSA if I want. You think this medicine info is only available in med school and if you read it outside med school you can't possibly understand it. Maybe YOU couldn't fathom understanding it without someone walking you through it. In my opinion, it's easier to practice medicine your way because I have to teach myself. You're just a little bitty student and have no idea what the real world is like. Why don't you go outside and play hide and go **** yourself.

Lloyd Christmas out.

 

[lloydchristmas]

lloyd- we are wasting our breath with this guy. until we have a study that shows we aren't leaving corpses behind us every day at work he won't budge. he's only an ms3. at some point a pa or np will save his butt when he has made a critical mistake and then maybe he will give us some respect.
I have had the same experiences as you, even down to atls. my preceptor/examiner for my atls trauma code scenario was impressed enough by my performance that he was trying to sign me up to be an instructor until he learned pa's couldn't teach atls due to internal rules from the american college of surgeons. I have seen same day md bounce back pts in the er and admitted them with life threatening illnesses after a physician has seen them and sent them home with no workup. I staff an er by myself several days/month. am I a doc? no. but I do a fine job nonetheless and have the lowest QA/complaint rating in our group. if I don't know the answer to something I find a specialist in that area and ask them. do I still learn new things about emergency medicine? sure, all the time. that's what lifelong learning is about.
at least at work I get some financial respect in that I am paid(significantly) more than the fp and im docs who moonlight in the er. there is a reason for that. I know more em than they do. more of the medicine and more of the procedures.the fp guys don't know trauma and the im guys don't know peds, ob, trauma, or procedures. it's that simple.

Yeah, it would be a waste of time if I was worried about this kid convincing anyone. The boy will soon learn. It's good to hear you get financial respect. I'm hearing more and more about this, and I feel it's only a matter of time, but it's certainly the exception to find an administration willing to listen to reason. But, the more of us that do get paid well, and in turn reward the facility, the more they will talk amongst themselves and the average $$$ will continue to grow. When the docs retire where I'm at, no doc will want to come here. If I leave the whole hospital closes. If I stay, it remains open. I'm going to ask for $400,000. )

 

[Jiminy Cricket]

quite simple....because then everyone who didnt get into medical school would become a PA to get a back door approach to becoming a doctor....unless they had PA's apply to get into a seperate medical school, but what is the point of doing that when they can just get doctors who get into the traditional medical school route.

Beaurocratic bodies like the AMA will ensure that the number of doctors is always short of the need for doctors in order to ensure very high salaries.........if every PA could become a doc, numbers would soar and this is another reason why it just wont happen....that's capitalism baby!

 

[deleted6669]

quite simple....because then everyone who didnt get into medical school would become a PA to get a back door approach to becoming a doctor....unless they had PA's apply to get into a seperate medical school, but what is the point of doing that when they can just get doctors who get into the traditional medical school route.

Beaurocratic bodies like the AMA will ensure that the number of doctors is always short of the need for doctors in order to ensure very high salaries.........if every PA could become a doc, numbers would soar and this is another reason why it just wont happen....that's capitalism baby!

let's look at the backdoor theory:
high school grad to college. age 22 applies medschool...doesn't get in....age 23.....1 more yr to get experience/prereqs for pa school not taken by premed students...age 24....applies....get's in 1st time...age 25....2 yr program( add 60-100 k debt here)....age 27.....all the bridge discussions mention 5-6 yrs of work as a pa before the bridge option so now age 33.....apply to bridge...get in...start at age 34....3 yr bridge...age 37...3 yr residency....age 40
it would be faster to use dds as a way to get an md by doing the already established dds to md bridge option of oromaxillary/facial surgery(these folks can also apply to any other residency as soon as they get the md )
I don't see too many folks doing this just because they couldn't get into medschool. also consider that pa school is a fairly competitive process. many applicants apply more than once before acceptance.....

 

[lloydchristmas]

let's look at the backdoor theory:
high school grad to college. age 22 applies medschool...doesn't get in....age 23.....1 more yr to get experience/prereqs for pa school not taken by premed students...age 24....applies....get's in 1st time...age 25....2 yr program( add 60-100 k debt here)....age 27.....all the bridge discussions mention 5-6 yrs of work as a pa before the bridge option so now age 33.....apply to bridge...get in...start at age 34....3 yr bridge...age 37...3 yr residency....age 40
it would be faster to use dds as a way to get an md by doing the already established dds to md bridge option of oromaxillary/facial surgery(these folks can also apply to any other residency as soon as they get the md )
I don't see too many folks doing this just because they couldn't get into medschool. also consider that pa school is a fairly competitive process. many applicants apply more than once before acceptance.....

Exactly. Some short cut. I'd rather go to med school twice than go back through the NP process again.

 

[Jengirl18]

......does he actually think that only med students understand the pathophysiology and biochemistry behind Sickle Cell or the Thalassemias?

Jiminy: There were students in my PA class who got accepted to med school, but decided to go the PA route. Everyone that's a PA doesn't want to be a doc just so ya know...but plenty could have gotten accepted to med school if they wanted to. So, if there was a bridge program, many PAs would say "no way." Also, several of those who did not get accepted to medical school will not get into PA school either.

 

[anon-y-mouse]

......does he actually think that only med students understand the pathophysiology and biochemistry behind Sickle Cell or the Thalassemias?

Don't get defensive, it was just an example but it's the truth. You have inferior depth of knowledge in the basic medical sciences.

 

[anon-y-mouse]

Okay, now it's clear to everyone you've lost the argument. You're sitting there telling me what I do and don't know and you have no idea who I am or what I've done. Who the **** are you to tell me what I do and don't understand. I could belong to MENSA if I want. You think this medicine info is only available in med school and if you read it outside med school you can't possibly understand it. Maybe YOU couldn't fathom understanding it without someone walking you through it. In my opinion, it's easier to practice medicine your way because I have to teach myself. You're just a little bitty student and have no idea what the real world is like. Why don't you go outside and play hide and go **** yourself.

Lloyd Christmas out.

Wow, way to go with the ad hominems! Looks like professionalism is something else they forgot in the PA curriculum.

 

[anon-y-mouse]

let's look at the backdoor theory:
high school grad to college. age 22 applies medschool...doesn't get in....age 23.....1 more yr to get experience/prereqs for pa school not taken by premed students...age 24....applies....get's in 1st time...age 25....2 yr program( add 60-100 k debt here)....age 27.....all the bridge discussions mention 5-6 yrs of work as a pa before the bridge option so now age 33.....apply to bridge...get in...start at age 34....3 yr bridge...age 37...3 yr residency....age 40
it would be faster to use dds as a way to get an md by doing the already established dds to md bridge option of oromaxillary/facial surgery(these folks can also apply to any other residency as soon as they get the md )
I don't see too many folks doing this just because they couldn't get into medschool. also consider that pa school is a fairly competitive process. many applicants apply more than once before acceptance.....

Fairly competitive? The applicant pool is different. And yes, it totally is a backdoor, because there's no way that academically poor people would ever get to see a patient if midlevel training academies didn't exist.

Why did YOU become a PA, especially since several of your close relatives are physicians?

 

[deleted6669]

"Why did YOU become a PA, especially since several of your close relatives are physicians?"

I wanted a life. I have no memory of my dad( a physician) before age 12 because he was never there. don't want my kids to have the same experience.
and yes, pa school is competitive. my program had > 1000 applications for 200 interviews for 40 spots.this is fairly common.no one with the min gpa/experience gets into a quality program(notice quality program). same can be said of medschool. anyone can get into the carib and some lower tier us md/do programs but not everyone can get into the really good programs.

 

[Bandit]

I have weighed in on this subject many times. As a LONG time ER PA now in med school I feel I have a unique perspective ---even if others without the experiences of either disagree.

I am against any bridge that would grant medical science credit. The material is presented differently in med school and from a different perspective. There is in fact deeper understanding of material--mostly due to the extra time allowed to learn.

I would support advanced credit to skip physical diagnosis/exam H&P, ethics and all that crap.

BUT--if anyone thinks the clinical aspect of the education is the same--they are simply wrong. Minimally--they are identical with the slight edge to the PA programs.

Medical school is designed to create a doctorate level acedemic in the field of medicine. Residency creates the clinician.

PA school is DESIGNED to create a clincian.

PA grads are simply better prepared (for the immediate) in a clinical setting. The education, examinations, boards and overriding philosophy is clinical medicine.

This quickly reverses itself when comparing a new grad PA with a post residency physician. There is simply no comparison then.

 

[Jiminy Cricket]

I have weighed in on this subject many times. As a LONG time ER PA now in med school I feel I have a unique perspective ---even if others without the experiences of either disagree.

I am against any bridge that would grant medical science credit. The material is presented differently in med school and from a different perspective. There is in fact deeper understanding of material--mostly due to the extra time allowed to learn.

I would support advanced credit to skip physical diagnosis/exam H&P, ethics and all that crap.

BUT--if anyone thinks the clinical aspect of the education is the same--they are simply wrong. Minimally--they are identical with the slight edge to the PA programs.

Medical school is designed to create a doctorate level acedemic in the field of medicine. Residency creates the clinician.

PA school is DESIGNED to create a clincian.

PA grads are simply better prepared (for the immediate) in a clinical setting. The education, examinations, boards and overriding philosophy is clinical medicine.

This quickly reverses itself when comparing a new grad PA with a post residency physician. There is simply no comparison then.

very good post, right on the money

PA does not equal MD

not to say a PA wouldnt be a great MD if he/she went through the curriculum

I'm stating the facts, no need to get mad....it will never happen.

Your clinical training is superior to MD's because we get most clinical training in residency.

it is much harder to get into MD/DO programs in the US than PA programs. not to say that someone in a PA program couldnt have gotten into an MD program, but on average, the applicant pool to MD/DO programs is more competetive.

not all MD's are so busy they cant spend time with the fam....all in the priorities

 

[core0]

Foreign graduates are deemed eligible to practice medicine in their own countries. Their education is in no way less comprehensive in the majority of cases; in fact, some would say they are more thorough and go slower in some ways (6 years is the standard for med school abroad)... although the depth and breadth of the material covered is roughly the same. By virtue of the fact that these people can practice in their own countries, it is professional courtesy to give them the opportunity to practice in ours. Actually, I have found that physicians who trained in "poorer" more overpopulated countries have a richer knowledge base due to having many many more patients. In any case, ours is the only country where we give so much leeway to lesser trained midlevel providers.

Snip

A better solution is to increase the number of medical school seats; there are already more than enough people applying to medical school every year anyway, all willing to take out loans and make the sacrifices to become a physician. Increase the number of rural providers? More federal loan forgiveness programs for those who make a commitment to practice in an underserved area.

Actually you are wrong here again. The PA profession was actually founded on the example of foreign programs. examples of these are Feldshers in Germany and Russia. Barefoot doctors in China.
Please look at this:
http://www.pahx.org/period01.html

Increasing the number of medical school seats is a very expensive and time consuming answer. Lack of faculty is and will be a continuing problem. This is also seen to some extent in nursing and PA professions. It also historically has shown to be a poor match for need.

I will also think that you are missing one of the strengths of the PA profession. As dependent practicioners trained in medicine we offer unique flexibility in allocating medical resources.

I will use the example of GI - which is what I am most familar with. As with any specialty there is part of the profession which needs a fellowship trained physician and other parts that can be handled by those with less training. Visits for chronic conditions such as IBD, HCV and follow up visits for established conditions such as GERD fit into this spectrum. With little experience a mid-level can handle new patients with rectal bleeding, heme positive stool. With more experience mid-levels can handle more complex evaluations such as abdominal pain. The key is communication with the supervising physician and knowing your limits.

How does this work in practice. There is a nation wide shortage in GI. Any changes will take at least 3-5 years to have minimal effect. The shortage is usually in wait time for endoscopy. By using mid-levels for clinic visits the physician can have more endoscopy time reducing wait times. This allows the physician to do things only they can do and generally improves patient satisfaction by reducing wait times.

David Carpenter, PA-C

 

[deleted6669]

or the pa's can do the endoscopy like in my neck of the woods.....

 

[core0]

or the pa's can do the endoscopy like in my neck of the woods.....

Pretty rare. There are probably less than 20 PA's outside of VA that do colonoscopies. There are a couple of large endoscopy centers in LA that use PA/NP's supervised by GI. There are also a couple of PA's that in remote areas that do colonoscopies. The problem would be liability. FP docs are already seeing insurance getting dropped for excessive claims. Also the ability to scope is not the same as the ability to do GI. The biggest problem that I see with non GI (mostly FP) doing scopes is they do not recognize when there is a problem.

David Carpenter, PA-C

 

[deleted6669]

Pretty rare. There are probably less than 20 PA's outside of VA that do colonoscopies. There are a couple of large endoscopy centers in LA that use PA/NP's supervised by GI. There are also a couple of PA's that in remote areas that do colonoscopies. The problem would be liability. FP docs are already seeing insurance getting dropped for excessive claims. Also the ability to scope is not the same as the ability to do GI. The biggest problem that I see with non GI (mostly FP) doing scopes is they do not recognize when there is a problem.

David Carpenter, PA-C

one of the local hmo's uses gi pa's to manage most of their hep c pts, do most of the scopes(flex and colonoscopy) as well as excise hemorrhoids, etc in their colorectal clinic.
they go through a mini fellowship and are closely supervised via review of videotapes of the scopes.these guys make bank. m-f 9-5 no nights/weekends/call. salary $65-80 dollars/hr.....

 

[Jiminy Cricket]

one of the local hmo's uses gi pa's to manage most of their hep c pts, do most of the scopes(flex and colonoscopy) as well as excise hemorrhoids, etc in their colorectal clinic.
they go through a mini fellowship and are closely supervised via review of videotapes of the scopes.these guys make bank. m-f 9-5 no nights/weekends/call. salary $65-80 dollars/hr.....

I do agree that PA's are essential in cutting the fat out of healthcare expenses. You guys will be a more integral part of patient care with every year that goes by, hopefully making h.care more affordable.

socialized h.care rules.

 

[deleted6669]

I do agree that PA's are essential in cutting the fat out of healthcare expenses. You guys will be a more integral part of patient care with every year that goes by, hopefully making h.care more affordable.

socialized h.care rules.

I assume this is sarcasm. the gi docs make quite a bit more than their pa's so yes, it does save the system money.

 

[Jiminy Cricket]

Just curious - have you ever worked as a health care provider in a socialized health care system? If so, where?

England (part socialized part capital)

not sarcastic...u sound like u have a complex

 

[Jiminy Cricket]

Just curious - have you ever worked as a health care provider in a socialized health care system? If so, where?

England (part socialized part capital)

not sarcastic...u sound like u have a complex

 

[deleted6669]

England (part socialized part capital)

not sarcastic...u sound like u have a complex

not a complex, it's just that the avg non-midlevel who posts here hates both midlevels and socialized health care because they view them as decreasing their salary.
were you aware that england/scotland are both recruiting american pa's now to work and teach over there. I was offered a fairly nice em job over there that I may take a few yrs from now.

 

[core0]

one of the local hmo's uses gi pa's to manage most of their hep c pts, do most of the scopes(flex and colonoscopy) as well as excise hemorrhoids, etc in their colorectal clinic.
they go through a mini fellowship and are closely supervised via review of videotapes of the scopes.these guys make bank. m-f 9-5 no nights/weekends/call. salary $65-80 dollars/hr.....

That's a lot of what I do. HCV management is almost all done by mid-levels in the US. It's very time consuming and draining. Doesn't reimburse paritculary well (except the MD I met who billed all visits as OV 5 because they were complex). There are a lot of PA's doing flex sigs. I have that training as well, but don't do them. I have a hard time justifying a procedure that I wouldn't order for my dog. As far as colonoscopies haven't heard of PA's doing them. The problem you face is risk. If you can get to 600-1000 (the number for fellowship trained MD's) without an accident your OK. But you have to remember that the rate in training is 4x that in practice. If you have someone fellowship trained do any polypectomies then you remove most of the risk (this is what I understand the southern CA programs do). The numbers you quote seem to be inline for general GI in norther CA without doing scopes.

David Carpenter, PA-C

 

[deleted6669]

That's a lot of what I do. HCV management is almost all done by mid-levels in the US. It's very time consuming and draining. Doesn't reimburse paritculary well (except the MD I met who billed all visits as OV 5 because they were complex). There are a lot of PA's doing flex sigs. I have that training as well, but don't do them. I have a hard time justifying a procedure that I wouldn't order for my dog. As far as colonoscopies haven't heard of PA's doing them. The problem you face is risk. If you can get to 600-1000 (the number for fellowship trained MD's) without an accident your OK. But you have to remember that the rate in training is 4x that in practice. If you have someone fellowship trained do any polypectomies then you remove most of the risk (this is what I understand the southern CA programs do). The numbers you quote seem to be inline for general GI in norther CA without doing scopes.

David Carpenter, PA-C

the pa's I know who do these just do screening colonoscopies. if they find a suspicious lesion, etc then a gi doc repeats the scope and takes biopsies, etc.
this particular hmo scopes everyone over 50 and it is a large system so the vast majority of the scopes are nl.the problem is that this huge system only has 2 gi md's despite attempts to hire more. so the pa's really fill an importatnt void. they are doing things that just wouldn't get done in a timely fashion(or at all) otherwise.

 

[Jiminy Cricket]

not a complex, it's just that the avg non-midlevel who posts here hates both midlevels and socialized health care because they view them as decreasing their salary.
were you aware that england/scotland are both recruiting american pa's now to work and teach over there. I was offered a fairly nice em job over there that I may take a few yrs from now.

yeah, that's true.

our h.care system sucks....u ask any middle class American and he'll say the same thing...ask those who profit from the h care systems inadequacies and they'll argue it.

bottom line, US economy is going down, companies are moving overseas, people losing jobs and benefits .....the fat is going to get cut, regardless of who likes it or not. GM has more lobbying power than the AMA so, as a result, PA's, CRNA's NP's etc will have an increasing role in h care and eventually docs salaries will get cut.

everyone wants to make lots of money, i do too, but the reality is that these changes are inevitable bc they are most practical. u dont need to pay someone 200k a yr to give you antibiotics...u can pay someone 60 k for that.

your salaries are artificially high as well. when doc salaries decrease, u're salaries will decrease as well. 2 yr program = easy, cost effective and fast way to train more midlevel practitioners....dont get too self congratulatory bc when u're salaries get cut, i'm sure the PA bandwagon will shift to a AMA type lobbying stance to protect u're 100k salaries....probably by limiting the number of PA grads so that the demand for h.care is much higher than supply.....well, if companies are overseas and broke, this wont work anymore.....docs could be paid 80 to 100k and u guys would only have a job if u accepted the 50-60k salaries u'd be given.

so u see, economic trends are a bitch

 

[chimichanga]

RN salaries continue to rise despite the "giants" fighting amongst themselves

 

[core0]

the pa's I know who do these just do screening colonoscopies. if they find a suspicious lesion, etc then a gi doc repeats the scope and takes biopsies, etc.
this particular hmo scopes everyone over 50 and it is a large system so the vast majority of the scopes are nl.the problem is that this huge system only has 2 gi md's despite attempts to hire more. so the pa's really fill an importatnt void. they are doing things that just wouldn't get done in a timely fashion(or at all) otherwise.

I would call that system suboptimal. There is a risk to colonoscopy, and this increases that risk. At age 50 20% of patients will have polyps and at age 65 70% will have one or more. This is far from the vast majority are normal. In this case the MD's should be doing more scopes and the PA's seeing more clinic patients. This might be tolerated in an HMO, but I cannot see patients doing two preps in private practice. I had this same discussion with the Scottish health service. In this case they should consider virtual colonoscopy. They will get the same service without the risk of two colonoscopies if they are using a decent scanner.

David Carpenter, PA-C

 

[deleted6669]

doesn't virtual colonoscopy have too many false positives leading to too many unnecessary procedures/biopsies, etc?
I thought the only folks who approved of this were the radiologists who run the centers that do them.....

 

[Bandit]

Mr Cricket--you are a glittering jewel of ignorance. You know nothing of medicne, public health or to say the least--Emed.

You know nothing oif the prectice of medice, nor the liability --again, to say nothing of being dragged into court by every litigous idiot in this country. You know nothing of the economics of this world, and medicine. You see very little of the world young man (or young woman)

When you put in 10 plus years after you finally have a degree, build a practice, family, home and plan for your families retirement and security--then jump on those with different opinions. Untill then --try and listen and learn.

"if you are not a liberal when you are 20, you have no heart. If you are not conservative when you are 40---you have no brain."

W. Churchill

 

[Jiminy Cricket]

Mr Cricket--you are a glittering jewel of ignorance. You know nothing of medicne, public health or to say the least--Emed.

You know nothing oif the prectice of medice, nor the liability --again, to say nothing of being dragged into court by every litigous idiot in this country. You know nothing of the economics of this world, and medicine. You see very little of the world young man (or young woman)

When you put in 10 plus years after you finally have a degree, build a practice, family, home and plan for your families retirement and security--then jump on those with different opinions. Untill then --try and listen and learn.

"if you are not a liberal when you are 20, you have no heart. If you are not conservative when you are 40---you have no brain."

W. Churchill

evolution states that everyone wants to do what is best for their genetics to be carried on into the next generation. we want to make more money so that we can make a larger "nest" so to speak for our kids and their kids etc.

you guys talk a lot of crap about doctors but you are no different in the end.

you could learn a thing or two from someone younger than you....who made you the preacher.

neverless, u'll continue insulting me and i could waste more time playing this game thing with you all, but its too predictable.....i think i'll go kiss up to the senior surgical resident instead.

life is a battlefield....everyone wants more resources.

i always keep my eyes and ears open for new info to apply to my goals...that is the entire reason i'm even visiting the PA, NP etc part of this site. An open mind to new ideas is what makes good management, so thanks for the tip.

P.S. You might want to work on those spelling or typing skills.

 

[deleted6669]

wow...who pissed in your cheerios?
(who has the complex NOW?)

 

[prairiedog]

wow...who pissed in your cheerios?
(who has the complex NOW?)

maybe one of those useless medical surgical nurses you referred to ?

 

[core0]

doesn't virtual colonoscopy have too many false positives leading to too many unnecessary procedures/biopsies, etc?
I thought the only folks who approved of this were the radiologists who run the centers that do them.....

If you use a good CT (64 detector) with 3d and 2d reconstruction the rates are similar for large (1cm polyps) and medium (6-9mm polyps). They are less sensitive for smaller polyps. There is actually one study that shows better detection rates for CT than colonoscopy. The three concerns for this are that there is no study that shows decreased cancer mortality with this modality, the need to prep again for a polyp, the lifetime radiation risk.

If you have the situation that you describe you are decreasing the risk by decreasing the colonoscopies. You will have a percentage of false postitives and you will also end up working up extra luminal findings.

All the lawsuits around here have actually been for failure to diagnose extraluminal cancer (one ovarian and one pancreatic). They were using non radiologists to do fly throughs and not looking at the rest of the CT. If you have to have radiology over read you lose a lot of the price difference in the extra professional fee.

There is also a concern that this will simply shift the shortage from GI to radiology. In a case like the UK without liability you could get away with saying "we are only looking at the colon and if you have some other type of cancer we aren't going to look at it".

In the case like you describe, what the HMO's around here (probably the same one you are talking about) do is contract out the colonoscopies if they don't have enough GI's to do them. If their wait climbs over 6 months for screening they contract with the local GI's. They do the preop eval and the patients show up for their colonoscopy. The only problem is if there is a perf the people following it aren't the same as the people who did the procedure.

David Carpenter, PA-C

 

[Jiminy Cricket]

which one of you turned me in to the SDN police for inappropriate language?

if you think that my language is inappropriate on here, you must be an Evangelical or something.

just bc u cant stomach what i got to say...lol....loser.

 

[rogerrr]

Allopathic and Osteopathic students don't take the same test, though Osteopaths can take the USMLE if they wish. I don't know of any school which provides "practice" USMLE tests; at least none of the many schools where I interviewed, and none where my friends go. Part of the reason for this is that step 1 is 8 hours long and has 350 questions; no school makes their students do that. Any redacted test is not indicative or representative of the full thing.

Also, where would you have learnt the in-depth knowledge of subjects like medical biochemistry, histology, immunology, and others that are NOT part of the PA curriculum, in order to "do better than the median" on these exams?

You might have taken some in-house test, but it was certainly not that.

Also, I did not say that there was no place for midlevel providers, but many overstep and overestimate the boundaries of their knowledge base.

I'm glad you're taking a traditional route; perhaps at the end of it, you will realize in retrospect how vast the difference really is.

"Credit for knowledge known" is touchy, especially when it can vary so much on a case-to-case basis, when idiot-savants can memorize Robbins and make a 100%, and when licensing and accreditation issues are involved. It sets up a nasty precedent and slippery slope. Hence, it is in the best interest of the integrity of the MD degree and profession that shortcuts be avoided at all cost.




The biggest and most faulty assumption here is that the first and last 2 years of med school have nothing to do with each other. One's performance in the wards is partly based on one's knowledge base from the preclinical years; yes, this includes coming up with thorough differential diagnoses that include the biochemistry, histophysiology, immunology, etc. of the condition and being able to integrate that into a concrete explanation. Just last week, an attending asked me about a patient we saw with atypical Down syndrome and I had to recall that it was a Robertsonian 14-21 translocation and actually explain to him what that entailed, how it happened, at what point during embryogenesis it took place, and how I would explain that to the parents. We then saw a patient with xeroderma pigmentosum, and I was pimped on what set it apart from cockayne's syndrome and WHY one results in more cancerous lesions (nucleotide/global excision repair, etc.) and theoretical therapies and potential pharmacological interventions. Just examples, but the clinical years aren't just about being algorithm-driven body mechanics. Sure, there is a lot of learning procedures, patient care, ward management, how to work up a patient, etc. but that is usually the easy part compared to acquiring and integrating all the information in the first place.

OK I agree med school exposes students to far more and explores and explains the theory and background of medicine in far greater detail than a PA program does....however, do MDs really pull from the "basic medical sciences" taken in years 1 and 2 of med school to diagnose or treat patients? NO!!! Your talking as if MDs are discovering new disease processes and formulating treatment plans based on theory and knowlege of physiology. Even if a MD was GOD and could do this, this is not the way the medical field works. When you become an attending you will be sued very quickly if you think this way. Does a ER MD think back to the physiological mechanisms of lidocaine when he numbs someone? The early med school classes are important in the beginning of rotations. The basic knowledge and understaing of anatomy and physiology is the framework for a person beginning in the field to store information. Once a student understands the anatomy and physiology they can begin to not memorize but understand disease processes and the corresponding treatments. But the end result, understanding disease presentation and treatments along with any procedures mastered during rotations/residency are the only things that are going to be clinically relevant. Unless I guess you go into research. Maybe I'm just not smart enough to comprehend this but I find it hard to believe any attending reaches as far back as his first two years of med school. And as for the wonderfully clincally irrelevant information your attending made you memeorize, like a monkey, about down syndrome guess what?? Theres still no treatment for Down Syndrome, you have to educate the parents on what to expect parenting a child with down syndrome and referr them for support if needed. If you ever talked to a parent about, "Robertsonian 14-21 translocation and actually explain to him what that entailed, how it happened, at what point during embryogenesis it took place" they would have no idea what you where talking about and they would want to speak to someone else. Bottom line its great you've spent all this time to memorize this info your going to forget when you are finally an attending but the parents still have a child with down syndrome, and clinically thats all that matters. As a PA-S2 soon to graduate I have a bare skeleton of medical knowledge that I am building on and will continue to build on throughout my career. Bottom line, whereever this base of medical knowledge is formed, Whether in two years of medical school of PA School with some clinical experience, catching up with any important concepts or theorys along with school clinical rotations and a residency I truely believe a PA-C could complete a modified medical school with classes and rotations in 2 years followed by a normal residency and be every bit as competent if not better than a traditional track MD. In this field its all about continuing your education and continuing to study and learn throughout your career. Soo its great you've had to memorize all that useless information. Its probably not going to make you a better clinician or help you to catch a zebra. And probably won't change how you treat a patient in the future. MDs learn their job doing their job (residency) like every other profession. If a PA-C was allowed to complete a residency and become an MD he would be every bit as good as 99 out of 100 clinicains in that field in my opinion. But if jeopardy calls you may be able to use that information to make some money. Seriously any experienced clinicians think back to years 1,2 when diagnosing and treating patients. Do you not develop your real "understanding" and own "strategy" for diagnosing and treating patients during your residency??? I'm very curious