14-What Training for Whom?

I Want to Be a Doctor

Welcome to the I want to be a doctor podcast where insider information about what it takes to become a physician is available for anyone. I'm Dr. Robin Dickinson, a board-certified family physician and I will give honest answers to your questions. Today's question is from an 8th grader who asks what is the difference between a doctor, a nurse practitioner, a nurse, and a physician’s assistant?

You are not the only person who wonders that! It can be very confusing understanding all the different roles in caring for a patient.

The two main differences are the training and what the person is able to do. I’m going to answer the questions for the United States. There are differences around the world. For example, I earned a 4 year bachelor’s degree in history and biology before starting my 4 years in medical school and then going on to residency. In Japan, students go into medical school directly instead of first doing college or university but it’s 6 years of medical school before going into residency.

So here is what the training and responsibilities of each of these professions are in the United States.

A physician in the U.S. after graduating from high school first goes to college or university and earns a bachelor’s degree. That can be a bachelor of arts (which is what I did) or a bachelor of science. I chose bachelor of arts because I double majored in history and biology and minored in chemistry so it made more sense. I would have had to take more math classes and do a few other requirements for a bachelor of science but by the time I’d finished all my classes for both majors and the minor and also did various other classes that are required to get into medical school (for example, so much physics that I would have only needed 2 more classes to get a minor in it), I just wanted to have fun. So instead of getting a bachelor’s of science, I took classes like Old English, costume design, and other fun topics that I knew I would be setting aside when I started medical school.

During college, it’s important to also be preparing to get into medical school. This involves finding volunteer opportunities, ways to show that you’re a leader, things like that, and also preparing for the MCAT. The MCAT is the medical college admissions test. It’s a one-time exam that gives you a score that is used to rank you against other people applying for medical school. Some medical schools care deeply about the MCAT and others don’t. There’s a lot more that goes into it. The personal statement is extremely important to nearly every medical school. That is an essay you write that lets them get to know you as a person. It’s not a list of accomplishments--the rest of your application includes that--it’s a way of showing them who you are beyond all that.

Then there’s four years of medical school. The first two years are classroom. These can be lectures, discussion, lab, and so forth. The second two years are clinical rotations. During the 3rd year of medical school (the first year of clinical rotations), everyone does pretty much the same rotations. It’s foundational knowledge. The 4th and last year of medical school, everyone does different rotations depending on what specialty you want to go into and you apply for residency. You also have to pass the first two steps of the USMLE (the United States Medical Licensing Exam) for MD students or the first two levels of the COMLEX (Comprehensive Osteopathic Medical Licensing Exam) for DO students. The 3rd step or level is usually done during internship, the first year of residency.

When you graduate from medical school, you are a physician. People call you doctor because you are. But you don’t have a ton of experience so you do a residency. A hundred years ago, people didn’t need to do residencies. They just went to work as a physician. But there was a lot less to learn. We have so many medications, vaccines, lab tests, imaging modalities. The first antibiotic was discovered less than 100 years ago. The first xrays were done about 120 years ago. So doctors back then didn’t have nearly so much to learn. Now there is so much that we have to focus on just one chunk of the information. That’s where specialities come from--it takes years to learn what you need to know in just one realm of the human body.

Residency is different lengths depending on what kind of specialist you become. Internship is the first year of residency. That’s also called PGY1 which stands for post graduate year 1. There’s PGY2, 3, however many it takes. Neurosurgery is 7 years. Which makes sense--they are doing very delicate work doing surgery on the brain and spinal cord and we want them to have lots and lots of training. After residency, some physicians do a fellowship. This is another year or two of more focused, detailed training. For example, after doing the 4 years of college, 4 years of medical school, 1 year of internship in general surgery, and 7 years of residency in neurosurgery, a neurosurgeon can choose to do an additional one year of fellowship in order to be a pediatric neurosurgeon or an additional one to two years to be a neuro-oncologist specializing in surgery for neurologic cancers.

I’m a family physician so I did college, medical school, and then 3 years of residency. Our training is focused on treating the whole person in the context of their family and community through all stages of life. If I wanted to, I could do a fellowship in sleep medicine (caring for patients with sleep problems), sports medicine (caring for athletes), addiction medicine (caring for patients struggling with addiction), adolescent medicine (caring for adolescents), geriatric medicine (caring for elderly), hospital medicine (caring for patients in the hospital), or hospice and palliative care medicine (caring for patients with severe or terminal illnesses to focus on improving their quality of life). Family physicians actually do all this kind of care as part of our routine practice--the fellowship just lets us focus extra training in one area if that’s our particular interest.

After finishing residency, you have to take another exam, your board exam. That allows you to become board certified in your specialty. So I’m a board certified family physician. My friend is a board certified pulmonologist. But your education doesn’t stop there. We all have to do a certain number of hours of continuing medical education every year and pass our board exam on some sort of schedule. For family medicine, we have to retake our boards every 10 years.

Physicians are the most highly trained medical professionals and we have a lot of independence in how we practice. We are expected to follow evidence based medicine, doing what science says, and behave in an ethical manner. But beyond that, you’ll see a lot of variability in how physicians practice.

Physician assistants are just what they sound like. They assist physicians. They go to college or university and then apply to PA school. Most people will take the GRE (the graduate record examination). This is used to get into basically any grad school, which is what happens after college. There’s a newly-developed Physician Assistant College Admission Test (PA-CAT) that I’m guessing will be the standard over the next few years. Some will take the MCAT but the necessary score is lower. There’s a myth out there that it’s harder to get into PA school. It comes from the fact that a lower percentage of applicants get into PA school. But that’s more because there are fewer barriers to apply to PA school. Many people never bother applying to medical school because they can’t afford the application process, the cost of school and the many years of unpaid or poorly paid training, or they know they won’t get in. They may be brilliant students and wonderful humans, but there is a lot more to becoming a physician that can be hard for people to manage. PA school is much more accessible so people don’t thin themselves out ahead of time as much.

PA school is a 2 year program and then a PA can start working. Obviously, they have a lot less book knowledge and a lot less practical experience than physicians, so there’s a lot more on the job training. PAs can easily switch from one specialty to another if there is a physician willing to work with them when they are brand new and not as useful. I worked with a wonderful PA in my first job as a family physician. She had worked in dermatology previously and then switched to family medicine. Doctors can’t do that without completing a whole new residency and board exam.

PAs are always working under a supervising physician. They have to practice the way that physician tells them to. That physician reads their notes and oversees what they are doing. For some people it’s perfect and for other people it’s frustrating. I wouldn’t have made a very good PA because I would have always been arguing with my supervising physician. While it’s okay to have an opinion, ultimately, it’s the physician who is legally responsible. So the PA has a responsibility to find a physician to work with that they can agree with.

Nurse practitioners start as nurses so let’s focus on nursing first. A nurse typically does their pre-nursing requirements at a community college, college, or technical school. That often includes being trained and certified as a CNA, a certified nursing assistant. CNAs have the most hands-on care of a patient. They help people shower and toilet, brush their teeth, help them get in and out of bed or a wheelchair, and so forth. A CNA is a nursing assistant the way a PA is a physician assistant. A CNA is supervised by a nurse. After completing pre-nursing requirements, a person applies to nursing school. In the United States you can become an LPN, a licensed practical nurse, or an RN, a registered nurse. An LPN is about a year. LPNs are often called practical nurses because they have less classroom education and focus more on the hands on care. In general LPNs are somewhere between CNAs and RNs. They usually aren’t allowed to give medications and treatments or provide education to patients. RNs complete a 2 or 4 year program. LPNs cannot work independently, they still need to be supervised. RNs can work independently, which is called “working under your own license.” It means that an RNs has more freedom to think for themselves but will also be the ones responsible if they have an error of judgement. An RN is able to do a lot more including giving patients treatments and providing education. Nurses can change from one specialty to another very easily. I have a friend who was an operating room nurse (working in the operating room during surgeries) but wanted something a little less stressful so she became a surgical floor nurse, caring for patients recovering from surgery. Then that got kind of boring so she became a labor and delivery nurse caring for women having babies. Then she had kids of her own and transitioned over to post partum where she cared for women and their babies after the baby was born but before mom and baby went home.

A nurse can become a nurse practitioner by working as a nurse for a few years and then applying to nurse practitioner school. Nurse practitioner school can be anywhere from a year for an accelerated program to several years. Nurse practitioners work under their own license in most states. That means that in most states they don’t have to be supervised and can work independently.

Some people decide that being a PA or a nurse practitioner is a better fit for them than being a doctor. Each one has different benefits. I chose being a physician because I wanted to really understand all the details of pathophysiology and why we do what we do so that I can figure out all the exceptions and really complex problems myself. It’s not that other clinicians can’t figure things out--they are just starting with a different kind of background understanding so think about things differently. I co-taught a class with a nurse practitioner I know and she talked about how she still thinks like a nurse, thinking about people’s comfort and basic needs. I think more like a doctor while trying to pull in the benefits of thinking like a nurse or a therapist.

Ultimately, choose the career that’s right for you. None of them are better or worse than the other. They are just different.

That's it for today. Subscribe, share with your friends and mentors; and remember to live the life that is right for you with your personality interests and values.

Please send your questions to me at [e-mail]. That's podcast at d-o-c Robin like the bird school dot com.

Show notes are available on the podcast website linked below.

This episode was sponsored by Dr. Robin's School, the first premedical curriculum for kids, and recorded and produced in beautiful, downtown Englewood, Colorado.