New idea for NP/PA to MD

[pado13]

Starpower,
It doesn't matter what physician based organization is involved with accreditation, that does not equate to the same didactic format as medical school. Please stop, you are embarrassing all PA's with your arrogance.

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[Starpower]

Starpower,

Like I have stated before, I am a medical student and have a clue what I'm talking about. It doesn't matter what physician based organization is involved with accreditation, that does not equate to the same didactic format as medical school. Please stop, you are embarrassing all PA's with your arrogance. As I said before, I'm a proud PA, but your outspoken, egotistical attitude makes me cringe to think of you representing the profession.

I never said that it did. Ever. Please stop embarrassing people who can read.

As for my attitude, take it up with my Attendings who give me straight 5s and ask me to come work for them. Trust me that their opinion means a great deal more to me than yours.

You better believe I'm going to stick up for a profession that I've worked so hard to get into, especially to people who say "Why don't you midlevels get it?"

 

[Starpower]

There are a few programs with a 3‐year curriculum. I'm not a big fan of it, because 3 year PA programs are very close to meeting the minimum accreditation criteria for MD programs.



I like the idea of residencies for PAs. I prefer that they stay optional. Unfortunately, there aren't enough residencies available to those who want to do them. Something to the order of about 200 residency spots nationwide (there are over 5000 PA graduates and a decent number of those are going to apply for residencies).



Whoa! Listen, doc, I didn't say it was the same thing but shorter. However, that statement would be closer to the truth than it is further. Look, when PA's compare the PA curriculum to the MD curriculum, the goal is not to downplay the 4 years of medical school that all physicians must attend (not to mention the ensuing residency). The purpose of comparing the two programs is to show how PAs are educated in a similar manner to physicians in an effort to gain confidence of patients.

A lot of patients will decline a visit with a Physician Assistant for reasons such as associating Physician Assistants with Medical Assistants. And since it doesn't look like PAs are going to get a name change anytime soon, they have to start exposing their qualifications in terms that the general public will understand.

It's not productive, when explaining PA training to a new patient, to say "PA's go through a concise, but intense study of basic medical science followed by a full systemic approach to clinical medicine with problem based scenarios..." Say that and patients will look at you with complete confusion. PAs have to say it in terms the general public can understand. Unfortunately, this means PAs end up saying things like "PAs go to medical school just like physicians, but the program is shorter." The statement isn't untrue, but the word "medical school" is always associated with a Doctorate of Medicine, not a Master of Medicine (which is the degree that some PAs receive).

As I said before, PAs aren't trying to downplay the importance of physicians and their education. But until something goes their way, PAs have to use such catchphrases to gain confidence of the patient. Otherwise, PAs have to keep bothering their supervising physician because the patient "wants to see a real doctor and will call the PA if they need a bedpan changed."



I appreciate what you're saying, but let me put this in terms of what's happening at my school in comparison with the MD program.

In-depthness: Where I go to school, the PA program is not as in-depth as the MD program when it comes to the basic medical sciences (essentially, MD1). However, PA school is AS IN-DEPTH when it comes to clinical medical sciences (MD2). PAs go through the same systemic study of medicine, inclusive of PBL sessions.

Intensity: During the 16 months that a PA is in the didactic curriculum, s/he will average 3-4 semester-credits more (per semester) than the MD during any given 16 month period in the MD didactic curriculum. Hopefully we can at least agree that, for the short time they are in school, PAs face the same level of intensity as an MD student within that same time period.

PAs should never go to PA school with the idea of later going to medical school. However, occasionally PAs who intended to stay PAs will sometimes have a change of heart. So they go back to school.

It's likely that many PAs who go back for a medical doctorate will feel overwhelmed in the first year of medical school. Some won't. However, I feel very confident that most PAs will feel right at home in the 2nd, 3rd and 4th years. In fact, I'm going to make a bold statement here, one I believe to be absolutely true: for PAs who want to go into primary care as an independent practitioner, a 1-year bridge program is really all that's needed (followed by a residency, of course). PAs should be able to knock out the USMLE step 2 with the knowledge and skills they received from PA school. So the bridge program would focus on preparing them for step 1, along with some courses designed to help them deal with additional challenges they'll face as an independent practitioner. Moreover, 70% or more of that 1-year program can be delivered electronically.

The current bridge program, 2.5 years, is definitely overkill. However, it's a DO program and the osteopathic skills add to the time. An MD bridge really should not need be more than 2 years in length.

Your sound reason and logic is wasted on these cyber-bullies, but good on ya for giving it a shot. Seriously, most of these posters are probably medical assistants trolling for attention anyways.

 

[deleted6669]

ok everybody...take a deep breath and chill a bit.
pa's and docs are on the same team remember...
let's talk about things we can all agree on:
1. medical school has MUCH more depth when it comes to basic sciences.
2. pa's do 1 clinical yr and med students do 2. of course a physician learns more given an extra yr in which to do so. and obviously there is the residency as well...
3. both programs are intense, rigorous experiences and require dedication and long hrs
4. pa's as members of a team work with physicians who provide direction and training to help them improve their skills and knowledge base over time.
5. pa's are not fighting for independence like other midlevels.
6. both pa's and md/do's are bright folks and likely both did well in their undergrad careers given the difficulty of getting a spot in either program at the present time
7. pa's are not asking to be called dr's, in fact they go out of their way to let folks know what they are. this is a legal as well as moral requirement.
8. there are good and bad providers who are docs, pa's, np's, dds, dpm, etc so posting horror stories about the idiot xyz who did abc are counterproductive.
9.some docs like working with midlevels and some don't. it's a fact of life. nothing written here on sdn is likely to change anyone's position on the matter.
10. pa's and md/do can work together, playing to their individuals strengths for the benefit of pts.

 

[Narnian]

 

[Dwindlin]

So med students, listen up ... you have no idea what you're talking about when it comes to PA education. Talk about delusional.

How about pado13? Does he/she know nothing about PA education? He was a PA and is saying EXACTLY what the rest of us are saying. There are several others on this board and I have half a dozen PAs who I know very well in the school I attend. Do they know what they are talking about because they too are saying the same. Not nearly as in depth, or rigorous.

 

[Starpower]

How about pado13? Does he/she know nothing about PA education? He was a PA and is saying EXACTLY what the rest of us are saying. There are several others on this board and I have half a dozen PAs who I know very well in the school I attend. Do they know what they are talking about because they too are saying the same. Not nearly as in depth, or rigorous.

Wow, you all just love saying the same thing over and over again, it's some bizarre kind of glitch in your temporal lobes or something. I NEVER SAID IT WAS AS IN DEPTH.

Do me a favor. Read that sentence again.

I NEVER SAID IT WAS AS IN DEPTH.

Please repeat it again, out loud ... "he never said it was as in depth."

There. Can we move on now?

What I am saying is that the curriculum of PA education IS very deep, and that it IS rigorous. Never mind that it's not AS in depth or AS rigorous as medical school, THAT IS NOT MY POINT.

PA education is intense and rigorous, FOR A REASON.

Gee, now I wonder, what could that reason be?

Oh! That's right. Because they're being trained to work alongside DOCTORS.

So to anyone who would scoff at a PA->MD bridge, understand that YES, there will be much that they have ALREADY been taught (not everything, obviously, but much). And if you're REALLY interested? Get a PANCE review book and look it over, look and see what level of medicine PAs are actually required to meet.

pa's and docs are on the same team remember...
let's talk about things we can all agree on:
1. medical school has MUCH more depth when it comes to basic sciences.
2. pa's do 1 clinical yr and med students do 2. of course a physician learns more given an extra yr in which to do so. and obviously there is the residency as well...
3. both programs are intense, rigorous experiences and require dedication and long hrs
4. pa's as members of a team work with physicians who provide direction and training to help them improve their skills and knowledge base over time.
5. pa's are not fighting for independence like other midlevels.
6. both pa's and md/do's are bright folks and likely both did well in their undergrad careers given the difficulty of getting a spot in either program at the present time
7. pa's are not asking to be called dr's, in fact they go out of their way to let folks know what they are. this is a legal as well as moral requirement.
8. there are good and bad providers who are docs, pa's, np's, dds, dpm, etc so posting horror stories about the idiot xyz who did abc are counterproductive.
9.some docs like working with midlevels and some don't. it's a fact of life. nothing written here on sdn is likely to change anyone's position on the matter.
10. pa's and md/do can work together, playing to their individuals strengths for the benefit of pts.

Very well put, I'm going to copy this for a couple of FMGs I've been working with who have never encountered PAs before. I've been blessed to go on rotations where my Attendings have been extremely pro-PA, sans one (and the reason why he volunteered to precept is anyone's CME guess). For the most part, they are very aware of the PA model of education and they understand exactly what is coming into their office or onto their service.

 

[Starpower]

Here's our homework assignment for this week, to help some get a better idea of the level of knowledge we're expected to perform at:

A 27 y/o female G3P1112 presents to the emergency department complaining of abdominal pain for 3½ days, located left lower area, 9/10, radiating to her back, crampy, and has minimal relief with Motrin. She describes having vaginal bleeding for one day; described as heavy flow without clots, using approximately seven pads. She does describe feeling dizzy and lightheaded. No fever, anorexia, urinary changes, vaginal discharge, and N/V.

PMH: She does state that prior to marrying her husband she had numerous sexually transmitted infections—GC and Chlamydia. She has been tested for HIV and Syphilis which are both negative.

She had an elective abortion approximately one year ago, and an appendectomy at the age of 12.

No history of PID, endometriosis, UTI.

SH: Currently, she is sexually active with one male partner who has been her husband for the last four years. Birth control methods are not used.

Meds: Motrin 600mg PO QID

Allergies: NKDA


On physical exam,

Vitals - T 99 P 110 R 20 BP 94/68

General - patient appears alert in moderate distress

Skin - pale, warm, and dry

Back - negative CVA tenderness

Abdominal exam - positive tenderness/rebound/guarding of the left lower region.

Pelvic - bright red blood visualized externally, vagina has bright red blood, cervix os is closed. Left adnexa tender and enlarged. Right adnexa NT without enlargement. Uterus
NSSC.

Rectal - nontender without masses. heme negative


1. What are your differential diagnoses? Give rationale for each diagnosis.


2. What laboratory and diagnostic studies would you order? Explain why?


3. While waiting for the return of your laboratory and diagnostic test results, what would be your immediate management for this patient? Make sure to explain your thought process regarding your decisions.

 

[altap]

As I have said before, it is my belief that it is just a matter of time before PAs will claim equivalency and will clamor for independence from physician's supervision.

Imagine if these PA students become leaders of PA orgs in the future...

 

[Starpower]

As I have said before, it is my belief that it is just a matter of time before PAs will claim equivalency and will clamor for independence from physician's supervision.

Imagine if these PA students become leaders of PA orgs in the future...

Right, because I've blatantly said that PAs are equivalent to Doctors, and have clamored for independence ... not.

What I really don't want to imagine is working without a Supervising Physician! Even though I'm weeks from graduation, there is so much I don't know. Although I'm expected to perform with a fair amount of autonomy, there's no way I am looking to be independent. Keep that phone line open, por favor.

For someone like emed, who has so many years of experience, it's no big deal to work solo overnight. I understand that completely. My current Attending (ER/IM Doc of many years) says it takes about 10,000 clinical hours for PA students to reach the competency level of a Resident. So I've got some years to go, and after that, well, does anyone really ever stop learning? And if I am ever a "leader" in the ARC-PA, I'll be there right along with the American Medical Association, American Academy of Family Physicians, and American College of Surgeons (to name a few).

Hope that chokes your troll!

 

[Footpain]

Right, because I've blatantly said that PAs are equivalent to Doctors, and have clamored for independence ... not.

What I really don't want to imagine is working without a Supervising Physician! Even though I'm weeks from graduation, there is so much I don't know. Although I'm expected to perform with a fair amount of autonomy, there's no way I am looking to be independent. Keep that phone line open, por favor.

For someone like emed, who has so many years of experience, it's no big deal to work solo overnight. I understand that completely. My current Attending (ER/IM Doc of many years) says it takes about 10,000 clinical hours for PA students to reach the competency level of a Resident. So I've got some years to go, and after that, well, does anyone really ever stop learning? And if I am ever a "leader" in the ARC-PA, I'll be there right along with the American Medical Association, American Academy of Family Physicians, and American College of Surgeons (to name a few).

Hope that chokes your troll!

This is not necessarily true. It really depends on what a PAs duties are. I am in a group of 3 cardiologists and 2 cardiothoracic surgeons. One of the surgeons has a PA who has had over 21 years of experience in CT surgery. He is very good. But, the surgeon will only allow him to first assist and do some of the post-op followup visits. This surgeon is also VERY FAMILIAR with PA training because he was involved with PA programs in the past. The surgeon (again, he taught PAs in the didactic and clinical phase) stated that PA training is much less in depth and the fellowship that a surgeon does is different than what a PA will experience in their CT surgery residency program. Lastly, the fellowship programs are longer, even if only a year.

 

[Starpower]

This is not necessarily true. It really depends on what a PAs duties are. I am in a group of 3 cardiologists and 2 cardiothoracic surgeons. One of the surgeons has a PA who has had over 21 years of experience in CT surgery. He is very good. But, the surgeon will only allow him to first assist and do some of the post-op followup visits. This surgeon is also VERY FAMILIAR with PA training because he was involved with PA programs in the past. The surgeon (again, he taught PAs in the didactic and clinical phase) stated that PA training is much less in depth and the fellowship that a surgeon does is different than what a PA will experience in their CT surgery residency program. Lastly, the fellowship programs are longer, even if only a year.

I agree that surgery is a different animal than IM. Surgical interns and residents have to go through so much training, it's staggering. Not to mention the fellowships. Still, every service is different. I recently saw a PA employment ad for a Neurosurg service that demands the PA be ready for call and in-house followup. Also, I have seen PAs take over less intense surgical procedures, with the surgeon leaving to start another case in the next room over. That being said, if I do end up going into surgery, I will never, ever, be a surgeon. But I'll be happy as a First Assist until the day I drop dead. I'm going to be a PA, not a Doctor, and plan on working to the utmost of my capabilities, within the context that my SP and I decide is right for our relationship.

 

[Dwindlin]

What I am saying is that the curriculum of PA education IS very deep, and that it IS rigorous. Never mind that it's not AS in depth or AS rigorous as medical school, THAT IS NOT MY POINT.

Which is all any of us has said. Yet when we say it you jump onto the offense. I happen to like working with PAs, they are typically knowledgeable, easy going, willing to help teach, and aware of their limitations (this is not meant as an insult, it is important for ANYONE to know their limits). What I do not like is PAs who claim they "went to med school" or "we do the same as med students in just half the time," etc. Did you say any of this? No, I realize that. But you did jump to defend those who did (or eluded to it) quickly.

Anyways, best of luck with the rest of your program.

 

[Starpower]

atkinsje, to clarify, my beefs were with statements such as these:

PA ~> MD bridge = 4 years of medical school. Period.

Why don't you midlevels get it?

EDIT: PA school is nowhere as indepth or intense as medical school. Still another PA delusion. Why are some of you guys modeling your fight after NPs? PAs are our allies, but if more of them become like you, they'll be the enemy as well.

Remember when the s%$# hits the fan, the buck stops with the doc.

As far as medicine shortening the bridge even further than a 3 year bridge program, that is ludicrous.

These statements, to me, showed a terrible lack of insight regarding PA education, as well as not understanding the scope of practice that many PAs are responsible for. It bothers me when people speak so loudly on a topic, that they're not fully educated on. How can anyone say what is "nowhere" or "ludicrous", when they most likely can't even explain what PA education consists of, or what Physician organizations are involved in PA program accreditation?

If I came on too strong, it's probably because of these two FMGs I've been working with who literally think I'm a Medical Assistant; one of them handed me a urine sample to dip, and another asked if I was ready to do a history and physical on a patient. I was like, are you frigging kidding me? I'm going to run it by my precepting Doc, I think this will be a prime time to explain to them what a PA is and does.

Anyhow, interesting stuff, eh? And thanks for the well-wish, 2 more weeks to go.

 

[Footpain]

I agree that surgery is a different animal than IM. Surgical interns and residents have to go through so much training, it's staggering. Not to mention the fellowships. Still, every service is different. I recently saw a PA employment ad for a Neurosurg service that demands the PA be ready for call and in-house followup. Also, I have seen PAs take over less intense surgical procedures, with the surgeon leaving to start another case in the next room over. That being said, if I do end up going into surgery, I will never, ever, be a surgeon. But I'll be happy as a First Assist until the day I drop dead. I'm going to be a PA, not a Doctor, and plan on working to the utmost of my capabilities, within the context that my SP and I decide is right for our relationship.

Some surgeons like the one I described in my above post don't let PAs do surgical procedures. And remember he taught in PA programs. Also, PAs are never surgeons. I completed an internal med residency and a fellowship in cardiology and later I did an interventional one. Next, I will soon be doing a fellowship in electrophysiology. Therefore, I do many surgical procedures in the hospital, and I don't consider myself a surgeon because I am not one. Why would a PA be considered one?!

Again, I see this all the time: PAs acknowldeging the fact that they aren't doctors, yet the need to extol how find the line is between a physician assistant and physician is.

If PAs whom have become doctors are still disagreeing with you, why are you still fighting. I have taught PAs on rotations, and they have stated that med school was much more intense.

And when the s*&^ hits the fan, it DOES stop with the doc, whether or not you want to admit it. Why do we have all of this training?! The fact that you believe that I don't understand because I made that statement shows that you really think PAs are equal to physicians. I think you need a reality check.

It sounds like something else is going on with you.

 

[Footpain]

Which is all any of us has said. Yet when we say it you jump onto the offense. I happen to like working with PAs, they are typically knowledgeable, easy going, willing to help teach, and aware of their limitations (this is not meant as an insult, it is important for ANYONE to know their limits). What I do not like is PAs who claim they "went to med school" or "we do the same as med students in just half the time," etc. Did you say any of this? No, I realize that. But you did jump to defend those who did (or eluded to it) quickly.

Anyways, best of luck with the rest of your program.

I agree!

 

[Dwindlin]

mistake

eh?

 

[Footpain]

eh?

I meant it was my mistake. Not yours. I was going to write something more than just saying that I am in totally agreement with your post. I was going to emphasize the part that I bolded.

 

[Narnian]

As I have said before, it is my belief that it is just a matter of time before PAs will claim equivalency and will clamor for independence from physician's supervision.

Im not sure who would back that kind of a move! I know that my meager program will never petition for anything like this.
The medical school we are affiliated with would throw us out on the street like a snot-nosed, punk teenager! I think if that were to happen, it would be the death of our profession!

 

[Coastie]

atkinsje, to clarify, my beefs were with statements such as these:
These statements, to me, showed a terrible lack of insight regarding PA education, as well as not understanding the scope of practice that many PAs are responsible for. It bothers me when people speak so loudly on a topic, that they're not fully educated on. How can anyone say what is "nowhere" or "ludicrous", when they most likely can't even explain what PA education consists of, or what Physician organizations are involved in PA program accreditation?

If I came on too strong, it's probably because of these two FMGs I've been working with who literally think I'm a Medical Assistant; one of them handed me a urine sample to dip, and another asked if I was ready to do a history and physical on a patient. I was like, are you frigging kidding me? I'm going to run it by my precepting Doc, I think this will be a prime time to explain to them what a PA is and does.

Anyhow, interesting stuff, eh? And thanks for the well-wish, 2 more weeks to go.

Hey Starpower...

PA ~> MD bridge = 4 years of medical school. Period.

Why don't you get it? You're a midlevel, and that's GREAT, but it's not "doctor-lite".

Edit: BTW, as a PA student, the FMG gave you a perfectly fine task: Dip the urine, do an H&P. What did you expect? Them to pull your gown/gloves for your surgical procedure?

 

[Coastie]

That's an appropriate weekly HW assignment for a mid-level student.

I did endocrinology research and presentations that were extremely in-depth in both pathophysiology and pharmacology, included differentials....as an undergrad.

It didn't make me any closer to being an endocrinologist than 4 years of med school, 3 years of IM, and 3 years of fellowship.

PAs have a great role in healthcare, but the only route to being an MD is the "4 year bridge" known as med school. Period.

Here's our homework assignment for this week, to help some get a better idea of the level of knowledge we're expected to perform at:

A 27 y/o female G3P1112 presents to the emergency department complaining of abdominal pain for 3½ days, located left lower area, 9/10, radiating to her back, crampy, and has minimal relief with Motrin. She describes having vaginal bleeding for one day; described as heavy flow without clots, using approximately seven pads. She does describe feeling dizzy and lightheaded. No fever, anorexia, urinary changes, vaginal discharge, and N/V.

PMH: She does state that prior to marrying her husband she had numerous sexually transmitted infections—GC and Chlamydia. She has been tested for HIV and Syphilis which are both negative.

She had an elective abortion approximately one year ago, and an appendectomy at the age of 12.

No history of PID, endometriosis, UTI.

SH: Currently, she is sexually active with one male partner who has been her husband for the last four years. Birth control methods are not used.

Meds: Motrin 600mg PO QID

Allergies: NKDA


On physical exam,

Vitals - T 99 P 110 R 20 BP 94/68

General - patient appears alert in moderate distress

Skin - pale, warm, and dry

Back - negative CVA tenderness

Abdominal exam - positive tenderness/rebound/guarding of the left lower region.

Pelvic - bright red blood visualized externally, vagina has bright red blood, cervix os is closed. Left adnexa tender and enlarged. Right adnexa NT without enlargement. Uterus
NSSC.

Rectal - nontender without masses. heme negative


1. What are your differential diagnoses? Give rationale for each diagnosis.


2. What laboratory and diagnostic studies would you order? Explain why?


3. While waiting for the return of your laboratory and diagnostic test results, what would be your immediate management for this patient? Make sure to explain your thought process regarding your decisions.

 

[PharmBound2011]

Hey Starpower...

PA ~> MD bridge = 4 years of medical school. Period.

Why don't you get it? You're a midlevel, and that's GREAT, but it's not "doctor-lite".

Edit: BTW, as a PA student, the FMG gave you a perfectly fine task: Dip the urine, do an H&P. What did you expect? Them to pull your gown/gloves for your surgical procedure?

I'm actually surprised you said something like this, you're generally very well educated on the role of different practitioners and how they fit together. Eitherway, just wondering, what's your take on 3 year medical schools (for typical pre-meds, not PAs) ?

 

[FutureDoc4]

I'm actually surprised you said something like this, you're generally very well educated on the role of different practitioners and how they fit together. Eitherway, just wondering, what's your take on 3 year medical schools (for typical pre-meds, not PAs) ?

There are no "3 year" medical schools for premeds (that are legitimate in the U.S.)

You do see 6-8 year medical programs for those right out of high school. The way they work is that the medical school courses are counted toward the undergrad degree. So, it would be the following:

6 year program( these are extremely rare now): 2 years "undergrad' + 4 years of medical school

7 year program (more common) (e.g. Boston University): 3 years undergrad+4 years medical school
In the 7 year programs, they allow you to take 1-2 medical school courses throughout your "undergrad' years.

But, the way these programs really work is shrinking your undergrad...aka less time for electives and outside interests (as most still require you complete the premed requirements).

Please do research before posting.

 

[Starpower]

PA ~> MD bridge = 4 years of medical school. Period.

http://www.lecom.edu/index.php/leco...d-physician-assistant-pathway/76/0/1919/18477

... although it is disheartening to read your words, on this and other topics that you purportedly are well educated in/on/take your pick. I hope you don't take the same careless attitude of grandeur when it comes to the lives of your patients.

I honestly feel a bit sorry for you, and wish you well in your life/maturation.

 

[PharmBound2011]

Please do research before posting.

http://www.aafp.org/online/en/home/...nt-student-focus/20100408texas-tech-fmat.html

 

[Coastie]

I'm actually surprised you said something like this, you're generally very well educated on the role of different practitioners and how they fit together. Eitherway, just wondering, what's your take on 3 year medical schools (for typical pre-meds, not PAs) ?

I'm not sure what you're taking issue with: I'm very very very Pro-PA, but Starpower is quite mistaken on a few things. As a med student, I did stuff far more "menial" than a "urine dip and h&p".

I think 3 year med schools are a bad idea. They are billed for "primary care docs", as if primary care docs need less education. Idiotic idea by idiotic administrators...

 

[Starpower]

Incidentally, the FMG who I worked with today, is a very smart bloke. He didn't think I knew the RAAS system, which I thought was odd (he seemed surprised I knew what angiotensinogen was). He did whip my butt when it came to the adrenal cortex, something I haven't studied in a while ("arr, aldosterone, cortisol, testosterone, umm, zona f .... zona glom ...", but he gave me a great way to remember it, "GFR: salt,steroids,sex"). On the flip side, he wasn't aware that DA is a precursor to NE. Neither of us could remember where the hell DA came from. So, life is learning and re-learning. Big deal.

 

[Starpower]

As a med student, I did stuff far more "menial" than a "urine dip and h&p".

For 20 years years prior to PA school, I worked in making and delivering meals to people dying of AIDS, in caring for Alzheimer's patients, hospice patients, patients in AIDS hospice, Peds ICU, Alzheimer's care, two EDs, and did live-in care of a bedbound woman with MS for two years. How dare you accuse me of avoiding menial tasks. My point was that the FMGs had no idea what a PA is, they thought I was akin to a MA.

 

[Dwindlin]

There are no "3 year" medical schools for premeds (that are legitimate in the U.S.)
Please do research before posting.

You really should take your own advise. . .

Three Years to a Primary Care or Family Physician Degree
LECOM Erie Primary Care Scholars Pathway (PCSP) condenses four years of medical education into three years in order to graduate Primary Care doctors sooner. The PCSP eliminates some of the barriers that discourage medical students from pursuing careers in family medicine and the other primary care specialties.

Based on LECOM’s experience developing its unique Problem-Based Learning and Independent Study Pathways, the curriculum uses the Independent Study learning modules as a guide for this new curriculum. PCSP students will follow a year-round curriculum so that they complete the basic science and clinical courses by March of the second year. PCSP students immediately will begin core clinical rotations at carefully selected hospitals and physician offices.

Quote is from LECOMs site.

 

[PharmBound2011]

I'm not sure what you're taking issue with: I'm very very very Pro-PA, but Starpower is quite mistaken on a few things. As a med student, I did stuff far more "menial" than a "urine dip and h&p".

I think 3 year med schools are a bad idea. They are billed for "primary care docs", as if primary care docs need less education. Idiotic idea by idiotic administrators...

Well, I could I could be mistaken although it came off as a "you're a PA, go do your "urine drips and h&p' "...in retrospect I guess you didn't put it that way and probably didn't mean it at all that way.

 

[Dr Oops]

http://www.lecom.edu/index.php/leco...d-physician-assistant-pathway/76/0/1919/18477

... although it is disheartening to read your words, on this and other topics that you purportedly are well educated in/on/take your pick. I hope you don't take the same careless attitude of grandeur when it comes to the lives of your patients.

I honestly feel a bit sorry for you, and wish you well in your life/maturation.

I dont think he meant literally but that fact that thats how it should be. You come off as extremely arrogant.

PAs are midlevels. That was what the role was designed to be. Theres nothing wrong with that and people who are PAs should not be ashamed with doing their jobs and doing it well.

What they should be ashamed of is saying things like "we do everything the med students do, but in shorter time" or "we're almost at that level"

The guy who is currently a PA and is going to medschool flat out told you the difference is knowledge is quite large. If you have a problem with someone having more training than you and as a result knowing more than you than goto med school.

 

[Coastie]

http://www.lecom.edu/index.php/leco...d-physician-assistant-pathway/76/0/1919/18477

... although it is disheartening to read your words, on this and other topics that you purportedly are well educated in/on/take your pick. I hope you don't take the same careless attitude of grandeur when it comes to the lives of your patients.

I honestly feel a bit sorry for you, and wish you well in your life/maturation.

That's PA ~> DO, not PA ~> MD bridge...

I don't care that LECOM has different standards than every single other institution of learning in the US (even world), but for a school based in Ohio with a branch campus in Florida, I wouldn't put it past them to increase profits with a PA ~> DO bridge. Nobody else buys their style..

 

[Coastie]

For 20 years years prior to PA school, I worked in making and delivering meals to people dying of AIDS, in caring for Alzheimer's patients, hospice patients, patients in AIDS hospice, Peds ICU, Alzheimer's care, two EDs, and did live-in care of a bedbound woman with MS for two years. How dare you accuse me of avoiding menial tasks. My point was that the FMGs had no idea what a PA is, they thought I was akin to a MA.

You were clearly never in the military.

"Now that you're here, you're all equal now".

You're a PA student just like every other. If you're the lowest on the totem pole in rounds, you may get the privilege of disimpacting the 90 yo gomer. Maybe. Get it?

Urine dip and h&p sounds like a PA student task, not MA. What MA does an h&p anyway?

 

[Narnian]

Were you in the Military coastie? If so what branch and "MOS" were you?

 

[Coastie]

Were you in the Military coastie? If so what branch and "MOS" were you?

I prefer to stay anonymous on SDN.

 

[ARAI]

ARAI,

I agree with the physicians and medical students who are trying to convince you to stop fighting this. It is not a battle you can win. I am a PA in the middle of my second year of medical school. I graduated from a top PA school and can confirm that there is a huge difference in depth of knowledge in both first and second year. I am very proud of my PA education and would not change anything. Unfortunately, it is individuals similar to you who give many the impression that PA's have an inferiority complex and this hurts the profession as a whole. There is no need to justify your position, PA's are vital to healthcare. But it is crazy, naive, and ignorant to continue with your arguments. I have been involved in both and speak from experience. It is impossible to to compare the two so confidently if you have not experienced both, trust me on this.

Hi pado,

I appreciate your response. My intent isn't to make PAs sound like they have an inferiority complex. They truly don't. Having said that, there are times in which PA education is vastly underestimated and this may lead to situations in which a patient, nurse, physician or other health care professional will inadvertently speak down to a PA.

Thank you for your insight into physician training vs. PA training. I know that you will learn more in a MD program in terms of basic medical sciences. But you should have already been exposed to all the clinical medical sciences in your PA program.

Furthermore, I believe you could put a physician through a MD/DO program all over again and they would say the same thing you're saying. You always learn more the second time you’re exposed. At my school, the PA1 and MD2 students are learning the same subjects at the same depth. I've seen the lectures from both classes, they are not very different in terms of content.

Arai, PAs DO NOT, I repeat DO NOT GO TO MED SCHOOL. PERIOD. I have worked with PAs before, and noone has ever said they went to medical school. You will make an ass of yourself by doing so, because to say this to anyone is a BIG LIE.

Here's the deal: medical school no longer automatically means a "MD/DO program." Not in in the year 2010. If you want to get with the times, you'll understand that medical school can also encompass a "PA program."

Why?

PA students at my university attend the school of medicine, they study medicine, and they receive a graduate degree in medicine. But don't worry, no PA is going to say they went to medical school without adding the fact that it was a PA program and no PA will claim to be a doctor.

PAs are trained to work with a physician-leader. As a physician, wouldn't you want such a person to be trained by the same school that trained you? I would. So if a PA says they went to med school to become a PA, cut them some slack and appreciate that they are trying to make your job easier.

PA ~> MD bridge = 4 years of medical school. Period.

Why don't you midlevels get it?

EDIT: PA school is nowhere as indepth or intense as medical school. Still another PA delusion.

Most PAs don't want to be MDs. However, for those who later feel that they should be a MD, a 2-year PA-to-MD bridge is MORE than enough. It's not a delusion.

 

[pado13]

I respectfully disagree that a 2 year bridge is MORE than enough. 3 years is fine with me because you can cut out some of clinical rotations. but the didactic portion is not equivalent. period. i challenge all the pa's with this mindset to skim through a usmle step 1 book. i don't care what pa program you graduate from, you just don't learn the depth required to score successfully on first set of boards. And that is not taking a shot at PA's, there is just not enough time in school to cover it all. Additionally, not all PA programs are created equal. Just because your school has as "in depth" curriculum as the med students, does not mean all schools have this.

The best quote to sum up this whole discussion was what my supervising physician told me prior to going back to school, "You don't know what you don't know". I have not heard more true words of wisdom. I had no idea there was so much more to learn about medicine prior to medical school. To be honest, I had many of the same thoughts as many of you do, that we were trained almost identically as medical students. Man, was I wrong. And again, I'm not bashing PA's, much of the minutia learned in medical school you will not need unless you sub-specialize in that specific area.

 

[Dr Oops]

Hi pado,

I appreciate your response. My intent isn't to make PAs sound like they have an inferiority complex. They truly don't. Having said that, there are times in which PA education is vastly underestimated and this may lead to situations in which a patient, nurse, physician or other health care professional will inadvertently speak down to a PA.

Thank you for your insight into physician training vs. PA training. I know that you will learn more in a MD program in terms of basic medical sciences. But you should have already been exposed to all the clinical medical sciences in your PA program.

Furthermore, I believe you could put a physician through a MD/DO program all over again and they would say the same thing you're saying. You always learn more the second time you’re exposed. At my school, the PA1 and MD2 students are learning the same subjects at the same depth. I've seen the lectures from both classes, they are not very different in terms of content.




Here's the deal: medical school no longer automatically means a "MD/DO program." Not in in the year 2010. If you want to get with the times, you'll understand that medical school can also encompass a "PA program."

Why?

PA students at my university attend the school of medicine, they study medicine, and they receive a graduate degree in medicine. But don't worry, no PA is going to say they went to medical school without adding the fact that it was a PA program and no PA will claim to be a doctor.

PAs are trained to work with a physician-leader. As a physician, wouldn't you want such a person to be trained by the same school that trained you? I would. So if a PA says they went to med school to become a PA, cut them some slack and appreciate that they are trying to make your job easier.



Most PAs don't want to be MDs. However, for those who later feel that they should be a MD, a 2-year PA-to-MD bridge is MORE than enough. It's not a delusion.

just cause you take classes in a building that has a medical school doesnt meant you in medical school.

 

[ARAI]

Hi all. Been busy with school and hadn't found the time to address all your comments until now.

As for intensity, medical school is MORE intense and goes more in depth. There are many, many PAs that will testify to this. I knew a couple med students that came in with Masters degrees in physiology in addition to their PA training and still admitted to Med school taking the cake in terms of intensity.

More in-depth only in terms of basic medical sciences. It's equal in terms of clinical medical sciences.

I'm not going to argue with you about intensity. Yes, the first 16-months of PA school is more intense than the first 16 months of medical school, but it doesn't really matter. Why be this petty?

So med students, listen up ... you have no idea what you're talking about when it comes to PA education. Talk about delusional.

Many MD/DO students don't understand PA training. When you try to teach them, they disagree with you.

You tell them: "PAs are studying the same subjects you are."
They respond: "No they're not. They're PA students. They can't possibly be learning what we are learning. That's ludicrous."

Face it: after teaching medicine over a 4-year curriculum for 80 years in the US, educators have figured a more efficient way to teach the material needed to practice safe medicine.

How about pado13? Does he/she know nothing about PA education? He was a PA and is saying EXACTLY what the rest of us are saying...

I appreciate Pado's perspective, but it's just one perspective. I've heard plenty of PA-turned-MDs say of MD school "it's a cake-walk after PA school." Their words, not mine. Everyone will have a different perspective.

Wow, you all just love saying the same thing over and over again, it's some bizarre kind of glitch in your temporal lobes or something. I NEVER SAID IT WAS AS IN DEPTH.

Do me a favor. Read that sentence again.

I NEVER SAID IT WAS AS IN DEPTH.

Let's be more specific: in terms of clinical medical science, it IS AS IN-DEPTH. It is not as in-depth in terms of basic medical science.

As I have said before, it is my belief that it is just a matter of time before PAs will claim equivalency and will clamor for independence from physician's supervision.

Imagine if these PA students become leaders of PA orgs in the future...

We will never claim equivalency or independence. However, we may continue to push for a greater scope of practice and more autonomy.

And these PA students are going to become leaders of PA orgs.

One of the surgeons has a PA who has had over 21 years of experience in CT surgery. He is very good. But, the surgeon will only allow him to first assist and do some of the post-op followup visits...

Some surgeons like the one I described in my above post don't let PAs do surgical procedures. And remember he taught in PA programs.

Each Surgeon has their own protocol. There are surgeons who will let their PA do the entire surgery. There are some who only let PAs do minor surgery.

In most states, a PA can perform any surgery that does not require general anesthesia without the direct supervision of a surgeon. While it may not be common practice now, as time goes by and PAs become more specialized, you may see more PAs performing routine surgery under an epidural anesthesia (i.e., hernia repair).

Also, PAs are never surgeons. I completed an internal med residency... Why would a PA be considered one?!

PAs in surgery are referred to as "Surgical Physician Assistants." I have heard some use the term "Surgeon Physician Assistant/PA Surgeon." The point is, the "PA" is still part of their name.

i challenge all the pa's with this mindset to skim through a usmle step 1 book.

I'm glad that you agree that at least 3 years will suffice. Nevertheless, one of the reasons I believe 2 years is enough comes from having looked at the USMLE Step 1 Q-book and review materials; nothing terrribly surprising to me about the questions. And that's considering it's all basic medical science in which we do not receive as in-depth of instruction as MD/DO students.

 

[Starpower]

You're a PA student just like every other. If you're the lowest on the totem pole in rounds, you may get the privilege of disimpacting the 90 yo gomer. Maybe. Get it?

Urine dip and h&p sounds like a PA student task, not MA. What MA does an h&p anyway?

Clearly they had as much of the picture as you do. Anyhow, upgrade your comprehension, it was that the FMG asked me "are you ready to do a H&P?", knowing that I am 2 weeks from graduation. Then again, maybe she was just being insipid. I haven't worked with her again, although the other FMG and I had a smashing discussion today, about gluconeogenesis and glycogenolysis (two more topics he was surprised I was aware of!) Still, he was slightly better versed than I was, in hepatic physiology.

Let's be more specific: in terms of clinical medical science, it IS AS IN-DEPTH. It is not as in-depth in terms of basic medical science.

I have to disagree a bit. After sitting in on lunch conferences during my IM rotation on a Nephro service, there was much I had never been taught in regards to clinical medicine. Much of it was more obscure than more common clinical issues, but still. That's but one reason why the world needs Doctors.

Nevertheless, one of the reasons I believe 2 years is enough comes from having looked at the USMLE Step 1 Q-book and review materials; nothing terrribly surprising to me about the questions. And that's considering it's all basic medical science in which we do not receive as in-depth of instruction as MD/DO students.

Same here. I went with a Step 2 review; most of the Step 1 material, sans some minutia, I knew already (although some I had forgotten since undergrad). I do agree with pado13 tho, in that some programs, and more specifically some program preqreqs, can be more demanding than others. I tend to go more with the prereqs idea, since the ARC-PA is what it is for all programs (at least, supposed to be). I learned Biology at a major University, so I've studied from the 'big texts', but someone who didn't complete the same bio/chem/physio prereqs (altho more do than don't) would certainly be a disadvantage when up against 1st-year Med coursework. Truthfully, even some of my PA classmates who hadn't taken as much of the sciences as I and others had, were at a slight disadvantage (we knew certain pathways already, while they were saying "what").

 

[ARAI]

just cause you take classes in a building that has a medical school doesnt meant you in medical school.

The PA program here isn't just in the medical school building, it is delivered by the school of medicine, my jacket says "school of medicine," my degree will say "school of medical." Sorry that it makes you angry, but it doesn't change the fact that everyone in the PA program here is in medical school. Time to get over the notion that medical school automatically means MD/DO.

 

[group_theory]

The PA program here isn't just in the medical school building, it is delivered by the school of medicine, my jacket says "school of medicine," my degree will say "school of medical." Sorry that it makes you angry, but it doesn't change the fact that everyone in the PA program here is in medical school. Time to get over the notion that medical school automatically means MD/DO.

Many medical schools also give out PhDs. Can those scientists also claim that they went to "medical school" since their degree was granted by a school/college of medicine?

 

[Charles_Carmichael]

The PA program here isn't just in the medical school building, it is delivered by the school of medicine, my jacket says "school of medicine," my degree will say "school of medical." Sorry that it makes you angry, but it doesn't change the fact that everyone in the PA program here is in medical school. Time to get over the notion that medical school automatically means MD/DO.

Oh wow, my lab coat says "Kaushik, Radiation Oncology" since I do research in that department. I did not realize that I'm now a radiation oncologist! Awesome! I'm going to go give some advice to patients now. Wait till I tell the PD to get over the notion that a radiation oncology residency means radiation oncologist. Cannot wait to see the look on his face!!

 

[lgher]

In most states, a PA can perform any surgery that does not require general anesthesia without the direct supervision of a surgeon. While it may not be common practice now, as time goes by and PAs become more specialized, you may see more PAs performing routine surgery under an epidural anesthesia (i.e., hernia repair).

Don't hold your breathe waiting for anesthesiologists to change their anesthetic plans (ie. NOT under General anesthesia) so that we can accomodate PA's doing the surgery rather than surgeons. How many "routine surgeries" do you see done under epidural anesthesia.

Maybe you PA's can buddy up with the CRNA's and open your own discount "physician free" surgical center. Good luck recruiting patients.

 

[Footpain]

1) Here's the deal: medical school no longer automatically means a "MD/DO program." Not in in the year 2010. If you want to get with the times, you'll understand that medical school can also encompass a "PA program." ARAI

No it is not medical school. Everything from the application process to the curriculum differs. PA school does not require the MCAT; PA school applicants don't apply to the same application service that MD applicants do; PA schools don't require 1 yr of biology with labs, 1 yr of physics with labs, 1 yr of gen chem with lab and one yr of ochem with labs. And some med schools like mine also required biochem and cell and molec. In fact, each PA program varies with their own prerequisite courses. In applying to med school, the prereq courses don't vary that much between programs.

Also, there are some programs that are not even affiliated with a medical school. Some PA programs are not even graduate programs. Even if this changes, it is still a fact.

Since there is a big difference in the didactic portion of the training, a PA cannot state that he/she went to med school.

2) "More in-depth only in terms of basic medical sciences. It's equal in terms of clinical medical sciences." ARAI

If you know that the didactic portion of the training is much more, than you know that includes the clinical sciences, too. The clinical science training is a part of the didactic phase.

3) I'm not going to argue with you about intensity. Yes, the first 16-months of PA school is more intense than the first 16 months of medical school, but it doesn't really matter. Why be this petty? ARAI

As I said above, if you are going to admit that the didactic portion is more, than you should admit that going to PA school is not going to med school by any means. If any portion of the training is more, this is not a petty matter.

4)"PAs in surgery are referred to as "Surgical Physician Assistants." I have heard some use the term "Surgeon Physician Assistant/PA Surgeon." The point is, the "PA" is still part of their name." ARAI

I guess you misunderstood my point. I corrected someone by saying that PAs are never considered to be surgeons. I never said that they weren't surgical physician assistants. And being a surgical physician assistant does not make one a surgeon!

5)"You tell them: "PAs are studying the same subjects you are."
They respond: "No they're not. They're PA students. They can't possibly be learning what we are learning. That's ludicrous." ARAI

In comparing the first year of both curriculums, there are a few subjects that are not taught in PA schools that are taught in med schools. There is still the issue that there are former PAs stating that there is a big difference in training. I have been told this when I have taught medical students whom were former PA-Cs.

 

[Footpain]

Oh wow, my lab coat says "Kaushik, Radiation Oncology" since I do research in that department. I did not realize that I'm now a radiation oncologist! Awesome! I'm going to go give some advice to patients now. Wait till I tell the PD to get over the notion that a radiation oncology residency means radiation oncologist. Cannot wait to see the look on his face!!

This is a good one.

 

[Footpain]

Hi all. Been busy with school and hadn't found the time to address all your comments until now.



More in-depth only in terms of basic medical sciences. It's equal in terms of clinical medical sciences.

I'm not going to argue with you about intensity. Yes, the first 16-months of PA school is more intense than the first 16 months of medical school, but it doesn't really matter. Why be this petty?



Many MD/DO students don't understand PA training. When you try to teach them, they disagree with you.

You tell them: "PAs are studying the same subjects you are."
They respond: "No they're not. They're PA students. They can't possibly be learning what we are learning. That's ludicrous."

Face it: after teaching medicine over a 4-year curriculum for 80 years in the US, educators have figured a more efficient way to teach the material needed to practice safe medicine.



I appreciate Pado's perspective, but it's just one perspective. I've heard plenty of PA-turned-MDs say of MD school "it's a cake-walk after PA school." Their words, not mine. Everyone will have a different perspective.



Let's be more specific: in terms of clinical medical science, it IS AS IN-DEPTH. It is not as in-depth in terms of basic medical science.



We will never claim equivalency or independence. However, we may continue to push for a greater scope of practice and more autonomy.

And these PA students are going to become leaders of PA orgs.



Each Surgeon has their own protocol. There are surgeons who will let their PA do the entire surgery. There are some who only let PAs do minor surgery.

In most states, a PA can perform any surgery that does not require general anesthesia without the direct supervision of a surgeon. While it may not be common practice now, as time goes by and PAs become more specialized, you may see more PAs performing routine surgery under an epidural anesthesia (i.e., hernia repair).


PAs in surgery are referred to as "Surgical Physician Assistants." I have heard some use the term "Surgeon Physician Assistant/PA Surgeon." The point is, the "PA" is still part of their name.



I'm glad that you agree that at least 3 years will suffice. Nevertheless, one of the reasons I believe 2 years is enough comes from having looked at the USMLE Step 1 Q-book and review materials; nothing terrribly surprising to me about the questions. And that's considering it's all basic medical science in which we do not receive as in-depth of instruction as MD/DO students.

Some of you PAs (Oh wait you're not even a PA yet) are close to claiming to be equivalent, but when you get called on it, you deny it. You want more autonomy go to medical school. You can't have your cake and eat it too.

 

[Footpain]

Hi pado,

I appreciate your response. My intent isn't to make PAs sound like they have an inferiority complex. They truly don't. Having said that, there are times in which PA education is vastly underestimated and this may lead to situations in which a patient, nurse, physician or other health care professional will inadvertently speak down to a PA.

Thank you for your insight into physician training vs. PA training. I know that you will learn more in a MD program in terms of basic medical sciences. But you should have already been exposed to all the clinical medical sciences in your PA program.

Furthermore, I believe you could put a physician through a MD/DO program all over again and they would say the same thing you're saying. You always learn more the second time you're exposed. At my school, the PA1 and MD2 students are learning the same subjects at the same depth. I've seen the lectures from both classes, they are not very different in terms of content.




Here's the deal: medical school no longer automatically means a "MD/DO program." Not in in the year 2010. If you want to get with the times, you'll understand that medical school can also encompass a "PA program."

Why?

PA students at my university attend the school of medicine, they study medicine, and they receive a graduate degree in medicine. But don't worry, no PA is going to say they went to medical school without adding the fact that it was a PA program and no PA will claim to be a doctor.

PAs are trained to work with a physician-leader. As a physician, wouldn't you want such a person to be trained by the same school that trained you? I would. So if a PA says they went to med school to become a PA, cut them some slack and appreciate that they are trying to make your job easier.



Most PAs don't want to be MDs. However, for those who later feel that they should be a MD, a 2-year PA-to-MD bridge is MORE than enough. It's not a delusion.

You have no idea how PREPOSTEROUS that sounds. You really sound desperate to equate yourself to a physician. You never said that you did, but everything else you say eludes to it.

You are just a student, and haven't even worked as a PA yet. In time, you will understand (hopefully) what we are trying to say.

You never had physician training, so you can't state without sounding ridiculous that your clinical sciences training is just as in depth as a medical student.

You stated, "I'm not going to argue with you about intensity. Yes, the first 16-months of PA school is more intense than the first 16 months of medical school, but it doesn't really matter. Why be this petty?" ARAI

I think you mean the first 16-months of Med school is more intense than the first 16 months of PA school. At least I hope that is what you meant. Even if this is what you said, as I said above, it is not being petty at all. A difference is a difference.

 

[deleted6669]

both pa and md/do are intense( # hrs/week) and rigorous(volume of material responsible for). that being said the docs have to go into more DETAIL both in basic medical sciences AND in clinical medicine courses. they learn a lot of esoteric info about the biochemistry of disease(for example) that we only touch on.
the best comparison is pa-2 vs ms-3 clinical yrs.
at some institutions( mine for example) pa 2 and ms 3 students were scheduled interchangeably for rotation slots and held to the same standards. I know this is not the case everywhere.
the 3 YR bridge program from pa to do at lecom requires the students to complete all of ms1 and ms 2 to get the full science background and then gives credit for 1 clinical yr.( as it should).

 

[VA Hopeful Dr]

both pa and md/do are intense( # hrs/week) and rigorous(volume of material responsible for). that being said the docs have to go into more DETAIL both in basic medical sciences AND in clinical medicine courses. they learn a lot of esoteric info about the biochemistry of disease(for example) that we only touch on.
the best comparison is pa-2 vs ms-3 clinical yrs.
at some institutions( mine for example) pa 2 and ms 3 students were scheduled interchangeably for rotation slots and held to the same standards. I know this is not the case everywhere.
the 3 YR bridge program from pa to do at lecom requires the students to complete all of ms1 and ms 2 to get the full science background and then gives credit for 1 clinical yr.( as it should).

I'm not sure what to think about this. Why do you have to go back and learn basic sciences to the same depth that we do and then skip the year when we learn to put all of that into practice? I don't doubt that your clinical year that you equate to our 3rd year is very intense, but I think its worthwhile to do it again with the new foundation of knowledge that you get with the first 2 years of medical school.

I can understand why that would be frustrating, but I honestly don't see why you'd take the first two years without taking 3 AND 4 to apply the extra knowledge you picked up.