I have had many realizations in my three years of practicing medicine, some small and some gargantuan.

One of the largest is that being a PA-C is much easier than being a PA-S.

There, I said it.

Many times with realizations, I wonder how my colleagues feel as well.

  • Do they ever miss the days of physician assistant school and their training?
  • Would they do it all again?
  • What about physician assistant versus nurse practitioners? Do we share an unspoken bond of enduring the unthinkable in order to practice medicine?
  • Is PA school harder than NP school?
  • Is NP school harder than PA school?

Keep in mind, this writer is only one person and I can only reflect and review on my particular experience with my PA education. Was I more prepared or less prepared than my colleagues?

That, is unclear.

But what we can do, is reach out to our PA and NP colleagues in regards to their training, level of difficulty and make some conclusions from there. In today’s article, you will hear from both PAs and NPs alike regarding their previous training, PA school education and reflections on learning medicine.

 

Applying to School

Applying for a seat in a physician assistant program does have quite a few requirements, as we know from previous articles. Candidates much achieve a 4 year bachelor’s degree (B.S or B.A.) in their respective major with many programs specifically requiring biology, biochemistry, organic chemistry, anatomy and physiology, microbiology, and physics, among other math classes.

Specific PA programs do vary in their requirements, so the candidate should do their homework and make sure that they have taken all the prerequisites. Hands on experience in health care, as an EMT, MA, phlebotomist, RN, or surgical tech (among others) is also required, in varying quantities based on the program.

In addition, it is a great idea to complete shadowing of a physician assistant, to gain experience in the field and gain insight into the day to day workings of being a PA.

Candidates are also encouraged to take the GRE, which allows programs to gauge test readiness. Letters of recommendation, volunteer experience, leadership positions, among many others are also considered. A great resource is the PAEA (Physician Assistant Education Association) which has a link that lists all of the schools and their specific requirements. www.Directory.paeaonline.org

As a contrast, nurse practitioner programs also require a 4 year bachelor’s degree, but this is usually a bachelor’s of science in nursing. BSN programs, with an accelerated track in the nursing model, have many of the same courses taken for PA school, some of which may include pathophysiology, biology, pharmacology, chemistry.

Once a student obtains their BSN, they are eligible to sit for their RN licensing examination. After licensure, many RNs work for 1 to 3 years or more before applying to NP programs.

The application process is based on the completion of a BSN degree, as many NP programs do require this, clinical experience working as an RN, leadership abilities, letters of recommendation, and GPA from the BSN program.

As a contrast to PA school, NPs must also consider whether they would like to obtain their MSN (Master’s of Science in Nursing) or move on to a DNP (Doctorate of Nursing Practice). MSN programs typically take about 2 years, while DNP programs can take up to 4 years.  In MSN programs, candidates also have the opportunity to take up general practice or specialty tract.

 

Length of Training for PA Programs

The length of schooling for a PA varies based on program. Some of the quickest programs allow for completion in 19 months, while some of the longest may take up to 3 years. The average length of programs is approximately 26 months (AAPA).

My PA program was 24 months on the nose, almost down to the hour. From the moment we arrived, it seemed like the work began and never really remitted until graduation. For many, PA school is divided up into two years, didactic and clinical. Didactic year is in the classroom, learning the pathophysiology, evaluation, and treatment of diseases, how to interact with patients and the clinical year is putting all of that information to the test, on real patients.

I can still recall our first assignment, reading about GERD and then taking a quiz on it the next day. It took me almost 2 hours to get through the article, but at the end I was confident I had nailed the main points, ready for the quiz and ready to get PA school off on the right foot.

I was wrong.

60% was my score and it still sticks with me to this day. I wondered whether there had been a mistake. Was I really supposed to be here? What had they seen in me during my interview?

 

Didactic and Clinical Rotations: PA School

The entire 365 days or so of didactic year remains somewhat of a blur to me, as it was both the longest and shortest year of my life. Our program was set up for classroom instruction from 8 am to 5 pm every day.

Yes, that’s right. A full time job of being in class, 40 hours per week. We had our clinical medicine lecture every morning from 8 to 12, which encompassed the pathophysiology, pharm, and clinical medicine of each of the main topics in medicine (dermatology, neurology, cardiology, etc). In the afternoon, we had more focused courses such as women’s heath, behavioral health, professional practice, and History and Physical lab.

Despite an hour lunch most days, we usually went from 8 am to 5 pm, with every precious minute being used to put one more concept or drug side effect into our brain for memorization.

For me, our history and physical class was a place to get away from the monotony of medicine. In it, we used mannequins and our fellow students to learn how to do neurological exams, examine ears, perform an abdominal exam, and much more.

Once 5 PM came, many of us tried to return to a sense of normalcy. It was usually too late in the day to go to the post office or run errands, so the students with families went home to their families, while many of us simply moved from one classroom to the next, or to the library to keep studying. I can recall many days where I awoke early to study, catch up on work, but also stayed late preparing for the numerous exams and assignments due that week.

During didactic year, the examinations were many and seemed like they would never end. It was not unusual for us to endure 4 to 6 major examinations per week, or even more if it came time to be the end of the semester. There was rarely time to wallow in a low score or rejoice with a good score, as it was always time to prepare for the next exam. Intermixed with all of the formal pen and paper (or computer based) exams were History and Physical practical exams, where we had to, in a timed session, do an entire neurologic exam, naming all of the interventions, what we were looking for, citing abnormal findings.

Don’t get me wrong, all of that still sounds awful, to this day, and I am more than three years out of school. One of our professors and close colleagues once told me that he tells prospective students about all of the above, up front, at their interview. It’s not meant to be intimidating, but to make students aware of how challenging becoming a PA is.

Despite all of that, there was an overwhelming sense of camaraderie within our students in our program. It was the “we’re in this together” mentality and really this made things much smoother. We studied together, cried together (some of us, I won’t admit it though), and bonded over the difficulty. We learned techniques to keep ourselves afloat, shared massive study guides, and all of us got through it, in our own way.

After a grueling week of final exams to be sure we were ready to see patients with a preceptor, we completed our didactic year and moved on to our clinical year, full of new opportunities, but new challenges as well.

Many PA program clinical years have different set ups for rotation, but with similar end result and goal. For our program, we had nine 5 week rotations, all with varying schedules. One rotation in pediatrics was 9 to 5, while an emergency department rotation may have been 3 12 hour shifts per week. Despite what we learn during the didactic portion, it can be difficult to translate into actual patient care. For example, what do you do when you think you might have heard an S4? Are you really sure what acute appendicitis might look like?

For me, it was a relief to be on rotations as it was refreshing to get out of the classroom and start seeing patients. For many of us, the relief was simply that instead of having an exam every day, we now had a larger, much more encompassing exam every 5 week. Although more intimidating in nature, no one complained.

In this case, our specific rotation had a text book assigned to it. Our program gave us a list of many conditions that we could possibly expect to see on our examination. For example, can you imagine knowing that there might be a question on your end of rotation exam about pulmonary emboli, but knowing that any part of that entire disease process was fair game?

Although rotation schedules varied and may have been difficult based on the sheer lack of hours in the day to keep studying, there was an overwhelming sense of confidence that began in us. Things started to make sense clinically and our confidence with patients grew. At the end of every rotation, it was a more inclusive exam, but our grades also were determined by evaluations from our preceptors, assignments during the rotation, and presentations on exam day.

Once all of our rotations were complete, our program gave us one final significant challenge: summative week. During this week, we had numerous exams (13 if I recall correctly), practical skills to complete, standardized patients, and had to simulate an office visit with a patient, make a diagnosis, order labs/imaging and then come out and immediately write a progress note with our plan.

All of this was difficult and presented challenges in its’ own way, but the grueling nature of didactic year prepared me to be mentally ready for clinical year and the grueling nature of clinical year prepared me to practice medicine.

Although PA school was harrowing and looking back on it still gives me lots of emotion, its’ rigor and sheer volume of information prepared to provide quality care to patients and hit the ground running as a new graduate with zero gaps in my clinical knowledge and full confidence seeing patients independently early out of school.

 

The Physician Assistant Experience

I always find it ironic and curious when I talk to another PA who did not attend my program. When we discuss our respective programs, the rigor, whether we would do it again, there comes a moment in the conversation where I really actually wonder whether they somehow also went to my program. The conversation, experience, emotion is so similar, it is fascinating.

Here are two quotes that I recently got from practicing PAs for this article, one who went to my program and one who went to a very different program across the country. My classmate said:

“….the information you have to learn in PA school is trying to drink from a fire hydrant. Year 1 is two years of medical school into one. Year 2 is be a resident for a year and then do it well enough to practice as if you’ve been a resident for three years”.

My other colleague mentioned something similar:

“….the most challenging thing of PA school is the amount of information expected to master in the short time frame. It is like trying to drink water from a running fire hose”.

As we mentioned above, it is imperative to consider the following: experiences from PA programs will vary based on the program and that includes rigor, class schedule, examination type and grading, etc. In addition, what may have been a very challenging experience for someone may be different for another student, as we all learn differently.

In addition to the fact that education and style, rigor and difficulty vary based on program, we must also keep in mind that medical education is changing. With technology advances, some PA programs and many nurse practitioner programs have shifted to online education for many of the clinical/lecture based education, which allows new opportunities for students.

 

Didactic and Clinical Rotations: NP School

Part of the great thing about medicine in general is that we have colleagues who we can help us out in a tough clinical spot, or trade tips on diagnoses.

In this case, I recently interviewed a colleague of mine who graduated from a Nurse Practitioner Program in the Northeast United States and is now practicing in an underserved community clinic.

In this particular case, my colleague attended a program that was three years in length. The first year, or equivalent of the didactic year in physician assistant school, was spent learning pathophysiology, pharmacology, statistics, research methods.

Exams were frequent and encompassing many topics learned, all accomplished while working full time as a Registered Nurse, gaining more hours clinically while learning the foundations to eventually make clinical decisions. Many students choose to continue to work during this period of time, but this can present challenges in terms of time management and particularly sacrificing family time for work and school.

Semesters were busy and this continued in to finals weeks, which were even more challenging for the difficulty with time and the amount of material learned during the semester. Final projects, research papers were also incorporated on things such as health care policy, legislature, and the medical profession.

After the first year of gaining competency in the pre-requisites, students move on to the clinical aspect of training, which in this particular case consisted of five 14 week rotations in adult medicine, pediatric medicine, women’s health, family medicine, and others.

It is important to note that depending on tract, rotations may be more focused on a specific topic that the student is planning on pursuing their career in. Depending on rotation schedule and time commitments, some students continue to work during this period of time as well.

At the end of each rotation, in this particular case, the student was required to come back to campus, very similar to my program and complete an end of rotation examination, practical examination.

With each rotation and continued clinical practice, confidence continued to build as graduation came closer. In addition, students in this program also had summative examinations which were worth a significant amount of the end grade for the course, which mimicked the eventual board examination.

 

To Wrap Things Up

Looking back on my PA education, I can not imagine working at the same time I was learning medicine. It just does not seem possible, so I give a great deal of credit to my colleague for working full time during the pre-requisite training and up to 24 hours per week during some of the clinical rotations!

We’ve learned quite a bit today in regards to both PA education as well as NP education. As colleagues with different letters behind our names, we both share a long clinical experience history and a long road to becoming health care providers.

The practice of medicine is a long and winding road, but worth it in the end.

References

American Academy of Physician Assistants, (2019).

Physician Assistant Education Association (2019).