MD vs. PA-C in IM

[filbert127]

Hello all,

Thank you for taking the time to read my post. My question for all of you is regarding the practical vocational differences between an MD and a PA-C. I am weighing my options between attending PA school and Med School. I know my professional interests do not lie in Surgery, so I feel I will likely (try) to end up somewhere in Internal Medicine.

My question is- to individuals with extensive experience in IM practice working closely with Physician Assistants- what practical differences do you see between the day-to-day workload, responsibilities, and lifestyle between a PA and and MD?

I have a decent (outsider's) understanding of the financial and academic investment that go into becoming an MD. However, I'm having trouble understanding the payoff of becoming an MD. I know that the Doc is the top decision maker- and that the PA's job is to "assist" the Doc.

Nonetheless, what confuses me is- most people I talk to tell me PAs are "basically doctors" (that is, in non-surgical specialties- I am aware of the major differences between PAs and MDs in surgery). So if a PA is "basically a Doctor"- why invest the time and money in becoming an MD?

To those in practice with PAs, could you share your field of practice and how your work (and resulting lifestyle) varies from that of the PA(s) you work with?

Money isn't that important to me, and neither is the prestige that comes with being a Doctor. So for what reasons- according to those who have a good understanding of both professions- should I pursue med school?

Thank you for your time, I appreciate your input.

PS I know these message boards can be vicious at times- so I apologize in advance if anything I said offends anyone, it wasn't my intention.

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[primadonna22274]

Have you shadowed both physicians and PAs? Even better if you have worked with both in a clinical capacity and can see the differences.

Practically speaking, the outpatient roles look similar. The tasks performed by both may look the same to the untrained eye. A PA with years of experience has gained a lot of knowledge and performs at a very high cognitive and professional level, but still lacks the deeper biochemical and pathophysiologic understanding of the physician because the training is more superficial for PAs.
Don't be offended--I have done both and know what I'm talking about. I often tell folks that PAs learn the what and what to do, and some of the how and why, and really that training has worked remarkably well for 45 years. MD/DOs first learn the how and why, and then the what, and what else, and what it could be, and why it isn't the other thing, and some of the what to do (although the what to do comes much later in 3rd/4th yr and especially during residency).
In many ways physician training is woefully inefficient. We learn a lot of stuff that arguably we don't need to know to effectively care for patients. On the other hand, Tradition rules Medicine and we are very slow to embrace change. Also I like knowing the minutiae I didn't know as a PA and that minutiae can help make a more informed differential diagnosis.
Inpatient IM PAs may also mirror their physician colleagues' knowledge base and technical proficiency over time, with good mentors. I haven't worked inpatient so am less qualified to comment on this. I do maintain that supervision and mentoring is critical to developing a widely competent PA because the folks who are admitted to hospital these days are SICK. We manage less complicated illnesses at home and and inpatients often have multisystem disease. A newbie PA can be dangerous in the inpatient setting without very strong prior knowledge and ongoing education.
The other thing to consider is how comfortable you are with always being a dependent provider. I was ok with it in my 20s. Once I hit 35 and a decade in practice I couldn't stand the idea of working the rest of my career under a supervising physician who was younger than me and had less clinical experience than me. Many PAs make peace with this--I just couldn't. I'm not a wallflower and my personality is not well-suited to kowtowing to a superior if I disagree with his or her assessment or management of a patient. I wanted ultimate responsibility and the only way to do it was to go back to medical school.
Hope this is helpful to you--best of luck in whatever you decide to pursue. Do the best you can, read every day and put your patients first. 🙂

 

[Trogghunter]

I am still a med student, but based on my inpatient experience, there is a fundamental difference. PAs don't write orders (at least in the MSU system), and they dont place lines or perform other procedures. I am actually not sure of what exactly it is that they do other than dictate discharges for their teams and perform consults which they still have to get staffed by the attendings. They also get stuck with grunt work like touring prospective fellows and nurses. I know two of them fairly well, and they're very intelligent, but they don't have the decision making role, and they always seem like they just tag along with their team of cardiologists. The physicians in the group say that they're invaluable as do the IM docs, but they dont get the same respect from the rest of the staff. One of them has been a PA for ~20 years and he loves it. He has great hours, makes a lot of money, and he loves his job. I cant speak for every hospital, but this is just what I have noticed. You really cant say that it's 'basically the same'. Doctors get so much more training that it's not equal...not even close.

 

[primadonna22274]

^^hospital-dependent.
Many places PAs definitely DO write orders, and have much more responsibility than it sounds like the PAs that you've seen. I could never work a job like that. Blech. Might as well be a scribe.
I have a friend who is an inpatient PA who basically runs the service. This is in Portland, OR. Quite a lot of variety in actual practice though.

 

[DrVanNostran]

From what I have seen PA's can write limited orders. Very practice dependent, but I am sure there is more autonomy is more underserved areas.

 

[DIce3]

In my state PAs can do everything that MDs can do in the outpatient area except write for class II drugs. This issue will probably be "fixed" soon. On the inpatient side, midlevels have to be "supervised." This means that an attending must put a squiggle mark under the midlevel's note but in actual practice, nothing else. Midlevels are here to stay and will probably be the dominant provider of primary care in the future. I think the pay difference between the two will shrink over time. This means that the extra time training will likely not be compensated for in the future.

The only very minor problem is that I see patients that midlevels have cared for every day. I am scared senseless. I could go on and on about things I saw just this morning that were done by midlevel providers. This would be true for any day of the year. Complaining is irrelevant. It is like the Borg and I am in the minority.

 

[deleted6669]

I am still a med student, but based on my inpatient experience, there is a fundamental difference. PAs don't write orders (at least in the MSU system), and they dont place lines or perform other procedures. I am actually not sure of what exactly it is that they do other than dictate discharges for their teams and perform consults which they still have to get staffed by the attendings. They also get stuck with grunt work like touring prospective fellows and nurses. I know two of them fairly well, and they're very intelligent, but they don't have the decision making role, and they always seem like they just tag along with their team of cardiologists. The physicians in the group say that they're invaluable as do the IM docs, but they dont get the same respect from the rest of the staff. One of them has been a PA for ~20 years and he loves it. He has great hours, makes a lot of money, and he loves his job. I cant speak for every hospital, but this is just what I have noticed. You really cant say that it's 'basically the same'. Doctors get so much more training that it's not equal...not even close.

This is very facility dependent. at some places pa's just admit and d/c (scut basically) while at other places they run the icu, place all lines, write vent orders, etc with limited input from physician staff.
at one of my per diem jobs the pa's take all icu admits at night, stabilize the pts, write orders, etc and the attending hears about them the next day on am rounds.that being said, pa is generally a career for those with extensive prior health care experience. if you are starting from scratch and are in your 20's I would recommend med school as it gives you many more options in the future. good luck whatever you decide.
like prima(above) I have considered returning to medschool on several occasions but as the only bread winner in my family it is not a reasonable option in my 40's supporting a wife/kids/mortgage, etc. if I was given the opportunity of a do-over I would have gone to medschool instead of pa school after a few years as a medic. the glass ceiling is very real and very depressing.

 

[duckie99]

Look bro... properly trained PA's can perform the same essential functions as a physician in most outpatient settings. This is true for every single specialty. I've seen PA's seeing tons of clinic patients for peds, surgery, derm, heme onc, etc. And you are wrong about surgical PAs... if anything they have more responsibility as the residents I worked with have huge respect for them. For example, on a CABG those PAs will open the pt and expose the heart before the physician even walks into the room. They will then harvest the veins. In PP I've seen surgical PAs work in a surgical group and are in the OR 5-days a week never having to see a patient otherwise. It helps the surgeons work a ton faster and see a lot more patients... But the question that is addressed is whether the care from a MD/DO vs PA is equivalent? I'd say for most problems that run on basic algorithm assessments it usually is. Does it take a MD to perform a healthy skin exam? IMO no. What about seeing a clinic f/u s/p cholecystectomy? IMO no. I've seen notes from PAs in subspecialty oncology clinics... But what about seeing a pt referred to cardiology by a primary care physician for some otherwise vague complaint? Then definitely a PA is no where near sufficient.

PA's are trained as a resident and operate at that level without the knowledge that a resident gains during residency or medical school. So a ICU PA could not possibly see a pulmonary clinic patient unlike a Pulm-CC MD. The ICU PA would have difficulty developing differentials as to the cause of plenty of problems that patient may be experiencing that a MD would not. The PA can admit, stabilize, etc as that is algorithm. Those things don't necessarily require a physician. So there's a huge palpable difference in the training and knowledge base of MDs vs PAs. Outside of mostly healthy outpt settings a physician's oversight is necessary.

That is not to say PA's aren't a very necessary component of the health care system as they fill a huge role. There are not enough physicians to go around to possibly complete all the necessary work so that is where a PA falls. The responsibilities of a PA will vary across institutions and groups but the basic functions are the same - work as a low tier resident doing what is likely mostly seen as scut work by physicians and then report to physicians, if only for legal purposes. PAs don't have the same knowledge base.

I would suggest PA school if the basic work structure and knowledge base limitations of a PA do not bother you (but in all honesty you likely wouldn't even notice such things in real life practice as you'll only be dealing with things you are capable of doing... it's just a perception really). Generally PAs have a different personality that physicians. That's part of what drove them in that direction in the first place. So obviously you are on a MD board and there will be bias. I have seen plenty of PAs with a chip on their shoulder when it comes to this fact but it is what it is and they are otherwise happy people. Lots of them chose that route for the obvious benefits over a physician... far less training time and debt, good pay (probably 80-100k most places), much better hours, no issues like malpractice insurance, being able to finish school and essentially start working in your desired field, ability to change fields much much much much easier than a physician, etc. After 20 years of practice you will find plenty of physicians who wish they chose that route because they now find things that are important later in life weren't appreciated earlier... namely family, kids, free time, etc and also they don't think the sacrifice one has to make to be a physician is worth it for some extra thousands of dollars and potentially some respect.

So there are definite pros and cons to being a PA. But don't be fooled into thinking a PA is equivalent to a physician. It is my advice that if you care deeply about your outside-of-work life then be a PA. That is their biggest advantage by far. Also, if you want to just do general IM the minimum training is 7 years (4 years med school and 3 years residency) - taking on all the debt, workload, hurt of family life that entails. It's tough if you're older (late 20s) and especially if you already have kids. Plus if it turns out you HATE general IM and actually love surgery (lots of people change their minds) you will have a minimum of 9 years of training (4 yrs med school and 5 years gen surgery residency). That is 9 years of debt, lost income, etc etc etc. However if you go to PA school that's 2.5 years and you can do essentially whatever field you want afterwards, have little debt, full pay with benefits, etc etc etc.

 

[primadonna22274]

Duckie: most of what you say is true but PAs absolutely DO have to worry about malpractice insurance.
PAs get sued, albeit less often than physicians.
As for PA personality, you're right on about that. I don't have the PA personality--which is a large part of why I'm in med school now.

 

[filbert127]

Thank you everyone, I appreciate you all taking the time to answer my post.

I believe PA school will be my desired route. Despite the altruistic naysayer's digressions, my interest in entering healthcare is simply to have a "good job"- which to me is, using strong, practical skills to contribute something to society with reasonable autonomy in exchange for a decent paycheck and good quality of life. Medicine interests me, but it doesn't, nor ever has been, "everything" to me....

My only motivations to consider the MD route are the increased autonomy, the fact that my grades are good enough that I felt as though I might be "selling myself short" by pursuing PA school, and that many of the more experienced PAs I've spoken to have recommended Med school due to my age (I'm 23).

However, I feel as though nobody- MDs included- ever has total autonomy. With time and good supervision, I will be able to find a setting and discipline that satisfies me, and I can contribute to. As far as as grades go, becoming a MD simply because I got an A in Organic is horrible logic, and PA school is becoming increasingly more competitive.

Lastly, and most concerning, is that the older PAs might be right- this "glass ceiling" might leave me wallowing in regret in middle age, but I'm 23, and I can't make a MASSIVE investment on the basis of somebody else's recommendation.

-Best of luck-

 

[gutonc]

Thank you everyone, I appreciate you all taking the time to answer my post.

I believe PA school will be my desired route. Despite the altruistic naysayer's digressions, my interest in entering healthcare is simply to have a "good job"- which to me is, using strong, practical skills to contribute something to society with reasonable autonomy in exchange for a decent paycheck and good quality of life. Medicine interests me, but it doesn't, nor ever has been, "everything" to me....

This paragraph here says everything you need to make your decision. If all you want is a good job in the healthcare industry...become a PA. I'm impressed with your approach to this. We'd have a lot fewer "I hate medicine" threads if more pre-meds had your outlook.

Goof luck.