NOTE: My statements are not necessarily my opinions. I often post point-counterpoint essays in which I strongly take one side of an issue and later counter that with antithetical views. This intellectual exercise helps me see the merit in opposing opinions and augments my creativity.

1. Your next doctor might not be one
2. Less medical education = more medical mistakes

My “Who will be your doctor when doctors quit?” article mentioned Physician Assistants (PAs) and Nurse Practitioners (NPs), who will increasingly be the doctors of the future even though they are not doctors. My article was not intended to denounce all PAs and NPs, but to illustrate that Obama and Congress are living in fantasy land if they think that substituting them for physicians won't endanger patients. The additional years of education that doctors receive fill their brains with information and skills that most PAs and NPs do not possess. Sure, they know some of what doctors know, but far from all of it. Is this additional increment of knowledge superfluous? Certainly not.

Anyone who claims that PAs and NPs are just as good as doctors is faced with an impossible task: explaining how PA and NP schools can take applicants with less raw brainpower (as evidenced by their lower GPAs and scores on standardized tests) and give them fewer years of less intense training, yet give them a comparable education. If less brainpower and education were the recipe for producing superior practitioners, why not take this to an extreme and have every white-coat wannabe drop out of kindergarten?

Clearly, education makes a difference—and anyone who would contest this needs more of it, along with a massive transfusion of common sense. Doctors spend 40,000 to 50,000 hours in training to become licensed—an amount that dwarfs what PAs and NPs receive.

Anyone who wants to take care of patients is faced with a choice: Go to medical school, or become a PA or NP. My ER sites ( and have prompted many people to write to me. Interestingly, when people explained why they want to become a PA or NP rather than an MD, none of them were daffy enough to suggest that less education would benefit their future patients. Instead, everyone who bothered to explain their choice focused on what was best for them: how it would save them time and money. Does that strike you as selfish?

It does me. Anyone who wants to take care of patients should possess a burning desire to put them first, even when that costs the practitioner money or poses an avoidable risk to the doctor.

I previously described how I once left the ER to run a code on an inpatient even though I had no responsibility to help him, no chance to make one penny from it, and—since I left the ER—no malpractice insurance coverage if things didn't go well. What was best for me was to stay in the ER; what was best for the patient was to have his code run by an experienced ER doctor (me), not the inexperienced residents, so I ran upstairs and quickly realized they omitted one basic thing that likely would have killed the patient. I did what was needed and saved his life.

Note to the NAACP: This patient was black. Imagine that: a doctor who supports the Tea Party going out of his way to help a black man he'd never met even though doing that couldn't help him and might result in a multi-million-dollar lawsuit if the patient didn't live. Most codes are not successful, so this was no minor consideration.

If I were racist, as Tea Party people are often alleged to be by their opponents, it would have been so easy to peek into the patient's room, see he was black, and dart back to the ER so the residents could keep botching the code.

I know of (and will later document) cases in which medical personnel waged a race war by intentionally killing black patients, as well as others on welfare. You will be stunned when I reveal other things some medical goons have done.

Now back to the topic of selfishness after that segue into it. In my opinion, the right to wear a white coat is earned not just by possessing the requisite medical knowledge but also by an ingrained conviction that doing what is best for patients—not oneself—is paramount. With this in mind, why would someone who wants to take care of patients choose a less rigorous PA or NP education instead of going to medical school? Is having more free time during their school years really worth it? Is spending fewer years in training really worth it? Perhaps it is to people who put themselves first, but not to their patients, who would benefit from having practitioners with more education.

According to the American Academy of Physician Assistants, “the average PA program curriculum runs approximately 26 months.” Someone who could have been flipping burgers 26 months ago could have your life in his hands after perhaps 5000 hours of education—a small fraction of what doctors receive.

This deliberate foreshortening of education benefits no one except the ones who take the shortcuts to wearing a white coat; patients are not benefited when their caregivers know less. That is not only true, but so obviously true I wonder why anyone would waste their breath trying to dispute it.

The United States needs more medical schools to train more doctors. If a person isn't smart and dedicated enough to become a physician or surgeon, does he or she really have The Right Stuff to be a PA or NP? No. By lowering the bar to wearing a white coat, patients get practitioners who know less. Sooner or later, patients will pay for that lack of knowledge.

When I worked with PAs in the ER, I'd take the more serious cases, and they took the easier ones. However, I'd still see some cases that weren't serious, since sometimes the ER was filled with such patients. About once per week, I had a case that I could solve only by recalling bits of medical minutiae that I doubted any PA or NP would know. I don't know how to put a price tag on the value of these “saves,” but from what I observe from malpractice judgments, it's clear that society places an enormous value on life and health. With this in mind, I wonder if society is getting the bargain it is hoping for by employing PAs and NPs. Their raison d'être isn't better care, it's cheaper care.

Let's do the math. Here's an excerpt from one of my ER sites in which I analyzed whether PAs are worth it:

Inevitably, there will be times in which knowing more makes a big difference. Let's say that it occurs only once in a career, and the age of the saved patient is 44 years since that is close to the current median age in the United States. Saving an average 44-year-old translates into saving over 30 years of life. I want everyone to sit down, take a deep breath, and really think about this.

What is the value of those thirty extra years? Are they worth a few more years of education and training? Of course. So why are we producing practitioners who are often just as good as MDs, but occasionally are not? After supervising PAs in countless cases, I know that the extra knowledge I possessed was useful far more often than once in a career. Sometimes it was once per hour. Most of those tidbits I gave to the PA were just minor suggestions to produce a better outcome, not grand revelations that saved lives. However, in an ER in which there is a lot of bad protoplasm that seems hell-bent on dying, extra education and training will make a difference at least every year, not just once in a career. Now we're talking about a minimum of an extra 900-plus years of life . . . all paid for by a few more years of sweat before donning the white coat. Is it worth it?

Patient's lives are precious, and saving 900-plus years of life in a career is worth a few more years of sacrifice. Anyone who doesn't believe that doesn't deserve a white coat in the first place. In reality, this estimate of saving 900-plus years of life in a career is very conservative.

Let's look at the facts. An ER doc or PA could see 7000 patients per year. In all likelihood, the greater competence of ER doctors will enable them to make a lifesaving difference more often than once in 7000 patients. I think the true figure is closer to ten, but even if it is just one, the justification for employing PAs becomes very shaky. No one can credibly claim that ER PAs are just as good as ER doctors. Sooner or later, perhaps just once in 7000 patients, a doc will really prove his worth by saving a life that could not have been saved by a PA.

I've heard the rhetoric about PAs being cost-effective, but I'm not buying it. I made about $60,000 per year more than the PAs I worked with. Besides the fact that the PAs and hospital were legally dead in the water without licensed physicians, that $60,000 was a bargain. It purchased supervision of the PAs that benefited hundreds of patients [at least when the hospital abided by the law, as I mentioned elsewhere]. Not in lifesaving ways, but incremental improvements to care that might just make patients feel better or recover more quickly. Based on the conservative estimate of one additional life saved per year, that $60,000 also bought another 30 years of patient life.

$60,000 divided by 30 years equals $2000 per year of life. Is it worth it? If my estimate of ten additional lives saved per year is accurate, the figure is a paltry $200 for each additional year of life—less than 55 cents per day! Are PAs “cost effective”? In the rush to economize on healthcare, are we being penny wise and pound foolish?

Granted, doctors aren't perfect, but the key to improvement is not to whittle away the educational process. Why on Earth do these new fields seize upon educational shortcuts as some sort of an elixir that magically results in medical care that is just as good or even better? I don't accept the validity of their absurd “less is more” claims.

I am obviously a fan of more education, not less. I fail to grasp why patients are better off with practitioners with limited training. I've heard PAs and NPs make all sorts of claims about their proficiency. Some of this strikes me as propaganda, and some of it is pure fantasy. It'll be a cold day in hell before I accept the notion that less education and training produces equally competent practitioners.

For heaven's sake no one should become a PA rather than an MD just to save time and money. The PAs may not suffer, but their patients will. If any PA wishes to dispute this, take me up on the following challenge: Let me perform a chart review of randomly selected patients treated by PAs, and see how often I could suggest other diagnoses or treatments that could benefit patients. In the above analyses, I bent over backwards to be conservative in discussing the incremental benefit of MDs versus PAs, but the actual benefit is greater than that.

How much greater? Close to 100% of the time, and certainly more than 50% of the cases. To make this even more fair, you can select the best PA in the world, and pit him or her against me. If I could not suggest other diagnoses or treatments that could benefit patients in at least 50% of the cases, I'd give $1,000,000 to your favorite PA organization so it could use that money to fund propaganda to, for example, try persuading people that PAs are just as good as MDs. Conversely, if I could suggest other diagnoses or treatments that could benefit patients in at least 50% of the cases, that same PA organization would pay me $1,000,000.

Now who wants to lose a million dollars? No PA or PA organization would be foolish enough to accept that offer, because I would not only win convincingly, but I would publicize the results to prove to the public that PAs cannot fill the shoes of an MD.

Update: Over seven years later, still no takers.

In my article, I discussed PAs not to demonstrate that they are human and can make mistakes (as any doctor can, too), but to illustrate how some manage to squeak by with knowledge that some Boy Scouts could easily surpass. Yes, ER doctors can make mistakes, but I've yet to meet one who didn't know how to examine a patient with a neck injury, or one who didn't know the correct term for a low potassium level. The good PAs should be just as alarmed as I am about the bad apples in their ranks who degrade their profession by their ignorance and their nonchalance about it.

Psychologist Dr. Raymond Lloyd Richmond gave a marvelously incisive response to someone who asked whether it is worthwhile to become a doctor of psychology instead of practicing with a masters degree. His response is very applicable to this topic.

The views expressed on this page may or may not reflect my current opinions, nor do they necessarily represent my past ones. After reading a slice of what I wrote in my various websites and books, you may conclude that I am a liberal Democrat or a conservative Republican. Wrong; there is a better alternative. Just as the primary benefit from debate classes results when students present and defend opinions contrary to their own, I use a similar strategy as a creative writing tool to expand my brainpower—and yours. Mystified? Stay tuned for an explanation. PS: The wheels in your head are already turning a bit faster, aren't they?

“The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”
F. Scott Fitzgerald

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