Wednesday, February 19, 2014

Physician Assistants, Doctors, and Nurse Practitioners

Physician Assistants, Doctors, and Nurse Practitioners

Updated: 03/15/2016
Over the last 200 years, several million public books and publications were archived into a database where a word search counted the number of times “physician assistant” or “nurse practitioner” was used. You can see the preliminary results here. Not so surprisingly, "physician assistant" began to pop up around the same time as "nurse practitioner," however, more folks seem to quote nurse practitioners in their novels than physician assistants. Could it be because your average American is less educated about all mid-level providers? Is AAPA doing a poor job of promoting physician assistants in the United States? Are nurse practitioner lobbyist groups stronger than we anticipated? Or is it because there are simply less well-known physician assistants in the scientific community? These are questions I do not have answers for, but if you're curious about the difference between the three different types of advanced providers, please keep reading and enjoy!

The Physician Assistant Pathway

PA School and Admission:
  • PAs cover about 400 hours in basic sciences in about 26 months (AAPA, 2014)
    • 75 hours of those are pharmacology
    • 175 additional hours are in behavioral sciences
    • 580 hours in clinical medicine
  • PA students graduate with a minimum of 2000+ clinical hours
    • Emphasis on primary care in ambulatory clinics, physicians' offices and acute/long-term care facilities
  • PA school is based on the medical model and medical school curriculum
  • PA school is thought to be just as competitive as medical school, with 2.25 applicants per available seat for both allopathic medical schools and PA programs (Jones, 2007)
  • As of 2010, 154 PA programs were operational and 152 of those had accreditation (99%) by ARC-PA (McCarty, 2011)
  • PAs are almost always required to attend lecture 8 AM-5 PM
  • You see a more continuous flow of study from the didactic phase into the clinical phase
  • PA and medical school seem to match up pretty well in what content gets covered, although medical students may cover much more depth of knowledge in some areas
  • PA school is much less expensive than medical school, requires less time (about 2-2.5 years usually), and allows more time for a family
  • PA school requires lots of prerequisites that medical schools do not. For instance, medical schools often do not require as many social science credits (psychology), nutrition, microbiology, and many others
  • Most programs require a bachelor’s degree and admission can require direct health care experience with most students having at least 2 years of experience (Nicholson, 2008)
    • In the 2005-2006 academic year, the typical PA student who matriculated had 29 months of prior health care experience with a baccalaureate degree and a 3.4 overall GPA (Jones, 2007)
    • Data from the 2009-2010 CASPA application cycle shows 15,186 applications were submitted for 5,816 seats (ratio of 2.61:1). The overall GPA was 3.25 with an average of 6.22 program designations per applicant. This number does not include 27 of then 173 accredited programs who did not participate in CASPA. (Cawley et al., 2013)
  • PA program accreditation is overseen in part by representatives from the American Academy of Family Physicians, the American College of Surgeons, the American Osteopathic Association, and other physician groups, in addition to numerous PA representatives including ARC-PA (Accreditation Review Commission on Education for the Physician Assistant)

What Is A Physician Assistant?
There are many ways to describe what a physician assistant is/does. The PA role was introduced in the mid 1960's by Dr. Eugene Stead and Dr. William Anlyan at Duke University. Together, they established a 24 month PA program based on the fast track medical training of doctors in WWII. Today, more than 90,000 certified PAs are practicing according to the NCCPA. Here are a few that may help you:
  • PAs provide a range of diagnostic and therapeutic services which vary by practice setting. These include physical examination, diagnosing and treating illnesses, ordering and interpreting tests, counseling on preventive healthcare, assisting in surgery, writing prescriptions, education, research, and administrative services. (Legler et al, 2007)
  • PAs are healthcare professionals who practice medicine collegially with, and under the supervision of, physicians
  • PAs are dependent practitioners who practice medicine alongside the physician-led team
  • PAs are physician extenders that are trained to diagnose and treat patients. They are trained in the medical model and are trained to do about 80% of what a physician does.
  • PAs are generalists and are represented across all medical specialties.
  • A physician assistant performs many tasks of the physician, NP/RN, but they must work under the supervision of a physician and cannot operate an independent practice (but they can work autonomously, with minimal supervision).
  • PAs that work in the ED can take histories and perform physical examinations, order diagnostic tests and interpret the results, prescribe medications, suture, splint, perform minor surgical procedures (foreign body removal, incision, abscess drainage), resuscitation (central line placement, intubation, inserting chest tubes, and arterial lines), discharge patients, admit patients, or refer patients to specialists.
PA Pros
  • The overall supply of PAs is likely to increase by as much as 72% to 127,821 PAs by the year 2025 (Hooker, 2011).
  • The strength of the PA profession lies in the technical skills and procedures they can offer, including their excellent physical exam (PE) skills!
  • PAs may be found working in hospitals, clinics and many other types of health care settings.
  • The benefit of a PA is that PAs retain the right to change specialty whenever they want, a feature physicians and NPs do not have.
  • The PA doesn’t have to go back to school for additional certifications for surgery or if they want to change specialties tomorrow - and no residency is ever required! Instead, they simply have to find a supervising physician willing to train them and they’re set!
  • Additionally, there are more PAs assisting in surgery than NPs. They perform procedures such as central venous catheter placement, chest tube insertion, diagnostic peritoneal lavage, arterial line placement, pulmonary artery catheter placement, wound evaluation and treatment (Ho et al., 2010)
  • There are laws allowing PAs who practice in rural areas to have supervising physicians meet with them a few times a month or sometimes one times a month to go over a few clinical cases, which allows PAs to run entire clinics or hospitals in rural areas.
  • A cohort of PA professionals and students have began petitioning for a name change from “physician assistant” to “physician associate” or “physician extender.”
  • PAs are trained in all specialties, which is why they are called the “jack of all trades, but a master of none.” This refers to the fact that PAs receive training in all specialties, but not enough to necessarily call them a master or “doctor.” This is seen as a positive benefit, because PAs have a wide variety of skills and are well-equipped right out of school.
  • PAs now follow a 10 year re-certification process, similar to physicians, as implemented in 2014; 100 hours of CME over a 2 year cycle
    • All PAs take the same certifying exam, administered by NCCPA
  • Care provided by PAs is equivalent to that provided by physicians in terms of safety (Ho et al, 2010; O'Conner & Hooker, 2007; Farmer et al, 2009)
  • PAs develop greater autonomy and efficiency in inpatient areas (e.g. hematology/oncology, bone marrow transplant) which allows them to develop expertise in a specialized area (Parekh and Roy, 2010)
  • PAs offer great value to their employers by providing high quality medical and surgical care, for which most public and private third party payers reimburse; services by the PA are billed under the PA's name or under the name of the physician, depending on policy of the third party payer
  • The PA profession has grown 34% since 2006
  • PAs work with an average of four physicians, three other PAs and one NP (AAPA, 2014)
  • 34% of PAs work in primary care and 37% work in medically underserved counties (AAPA, 2014; Hooker et al., 2011)
  • Nationwide, the compensation package for a newly graduated PA is between $80-86,000
  • PA salaries, on average, are higher than NP salaries (Clinicaladvisor, 2013)
  • The average malpractice payment of PAs between 1991-1996 was $55,241, while that of physicians was $139,581 (Nicholson, 2008). A newer study provides similar results, with settlements for PAs around $100,000 and physician settlements around $200,000.
  • Supervising physicians and their PAs experience a lower rate of malpractice litigation than physicians overall. This means that you and your supervising physician have less of a chance of being sued than physicians without PAs! (Medical Economics, 2011)
  • PAs have lower rates of claims and suits than physicians
  • On average, 9.9% of PAs saw 25 patients or less per week, 26.2% saw between 26-50, 24.3% saw between 51-75, 24.3% saw between 76-100, and the upper 17.3% saw over 100 patients per week (ClinicalAdvisor, 2013).
  • On average, 29.4% of PAs wrote between 0-25 prescriptions per week, 35.1% wrote between 26-75, 19.4% wrote between 76-125, and the upper 16.1% wrote 126 prescriptions or more per week (ClinicalAdvisor, 2013).
  • No discernible difference was seen between the amount of time PAs and NPs spend on the job. Approximately 80% of all respondents work between 30-50 hours per week.  
  • Physician assistants and nurse practitioners, compared to physicians, function at comparable levels, and are accepted by patients at a comparable level (Hooker et al., 1997)
PA Cons
  • The important part about becoming a PA is realizing that you don’t always get to “fly the plane,” and you’ll act as a co-pilot in most situations, with a more relaxed style of autonomy than physicians or NPs. You have to be comfortable with this style of practice if you want to be a PA.
  • PAs must be assigned to a supervising physician, and the services they provide are limited to
    • Those the physician can provide adequate supervision for
    • Scope of practice and services limited to supervising physician's specialty (Kimball et al, 2008; Horton et al, 2001)
    • Their training (Kimball et al, 2008; Horton et al, 2001)
    • Their experience (Henry et al 2011; Morgan et al, 2008; Kimball et al, 2008)
    • Their competence (Henry et al 2011; Morgan et al, 2008; Horton et al, 2001)
    • The setting in which they practice (e.g. urban v. rural) (Henry et al, 2011; Kimball et al, 2008)
  • Every state has their own restrictions on the PA profession (pronouncing death, order home health or hospice care, signing death certificates, make decision to admit or discharge a patient to a hospital, cannot be listed as a PCP, etc.), and you can find them on the AAPA website. However, individual institutions might have their own restrictions that prevent PAs from supervising conscious sedation, ordering certain medications, etc.
  • AAPA works to fight for PA legislation, but is often demerited as being less aggressive than NP lobbyists.
  1. Obtain a bachelor’s degree (do well in prerequisites necessary) - Side Note: there are bachelor level PA programs available, but I do not endorse them
    1. Take the GRE (for most PA schools) or use MCAT scores
    2. Gain health care experience (HCE) hours
  2. Apply to Master level PA programs
    1. Obtain letters of reference
    2. Write essays & fill out supplemental applications
    3. Interview
  3. Acceptances - most schools offer on a rolling basis
  4. Year 1 (some programs 1.5 years) - Didactic Phase
  5. Year 2 (1.5-3) - Clinical Rotation Phase
  6. PANCE Examination - certification exam given by the NCCPA; Allows PAs to become certified in all specialties like psychiatry, family medicine, GI, endocrinology, dermatology, cardiology, neurology, and pediatrics - just to name a few.
  7. Residency or Fellowship (possible, but not required) - 1-2 years
Now the real questions come. Can you handle being asked to see the “doctor” instead? Do you have a strong backbone and can you withstand remarks about your profession from physicians and NPs and other medical personnel disrespecting you? Can you afford to take a pay cut from not being a physician or NP (in some cases, PAs make what physicians make)? Sure PA school might require the GRE, but it would probably beat the MCAT. If you feel passionate about practicing medicine, but you know medical school is not what you want, then PA school may be for you.

The Physician (MD/DO) Pathway

MD/DO School and Admission:
  • Physicians cover 150 weeks of material over 4 years
  • Equivalent to about 1.5 times the volume of what is taught in PA school
  • PA school is thought to be just as competitive as medical school, with 2.25 applicants per available seat for both allopathic medical schools and PA programs (Jones, 2007)
  • Most programs do not require students to attend lecture
  • While in medical school, you may see some programs giving students summers off, etc.
  • Medical students also cover basic background science (biochemistry/cell biology) much more than PA students, but the pace of PA school is what seems to make PA school appear more difficult.
  • Medical school takes up a lot of your time and resources - specifically, it is expensive, lengthy (4 years didactic, 4 years clinical + 3 years residency + 2 years possible fellowship), and does not allow much time for a family.
    • Eventually, there will be a 3 year fast track medical degree for students wishing to enter primary care.
  • Medical schools often require many more prerequisites than PA school, although they do require some very different prerequisites as well, such as organic chemistry and biochemistry.
  • Good medical schools require you take the MCAT and that you have an extremely competitive GPA (3.5+).
  • The American Board of Medical Specialties (ABMS) currently verifies doctor certifications and recertifications. Most of them require recertification every 6-10 years.  
What is a Physician?
Physicians, also known as allopathic physicians (M.D.) or osteopathic physicians (D.O.) are medical doctors who treat disease and injury using counteractive methods. Osteopathic physicians take on a more holistic perspective of medicine based on the believe of treating the whole patient and emphasize alternative and preventative methods, rather than pharmacological methods. 92% of physicians nationwide are allopathic, while only 8% practice as osteopathic physicians. 89% of physicians are board certified, and 69% of US physicians are male.

MD/DO Pros
  • A physician is the most autonomous provider, which means they are allowed to practice independently of any other provider, whereas PAs and (some) NPs must practice under physician supervision.
  • Few, if any, restrictions in practicing medicine and prescribing medications
  • As a physician, you will probably make more money and have a wider scope of practice by default
    • Physicians have reported earning higher incomes than nurse practitioners (Donelan et al., 2013)  
  • You will experience more respect from patients and coworkers, as long as you reciprocate this respect
  • Every specialty makes over $100,000, with 8 specialties earning over $300,000 annually (Medscape, 2014)
  • 40% of doctors see between 25-75 patients per week; 35% see between 50-99 patients per week; 25% see over 100 patients per week
  • 66% of physicians see patients up to 45 hours/week; 18% spend 50+ hours/week seeing patients
  • 22% of doctors spend 25 hours or more seeing patients in the hospital

MD/DO Cons
  • Like NPs, physicians do not have the lateral mobility PAs do in their career to be able to change specialities whenever they want
    • Unless they go back and do a residency in another specialty and become board certified in this new specialty
  • Medical school is extremely expensive
  • Male physicians earn 30% more than women; in primary care that gap is 17% (Medscape, 2014)
  • Physicians with board certification earn significantly more than those without it (Medscape, 2013). Unfortunately for physicians, they must continually maintain these expensive certifications.
  • 48% of physicians feel they are fairly compensated, while 51% of physicians in primary care feel they are fairly compensated
  • Given cuts to Medicare and changes in Medicare reimbursement, 9% of physicians plan to stop taking new Medicare patients and 2% will no longer treat their current Medicare patients. A whopping 29% have not made a decision yet on what to do.
  • Doctors are drowning in paperwork (paper or computer based) - 51% of doctors spend between 5-14 hours/week on paperwork; 17% spend more than 20 hours/week on paperwork
  • The medical school route is about 2-3 times as long as the PA route
  • It is more difficult to be a medical school student and have a family
  • The MCAT is much more difficult than the GRE or NCLEX
  • You have to take organic chemistry II and biochemistry and other prerequisites may exist for other programs
  • Residency is required
  • When asked if physicians would "do it all over again" - only 51% said they would choose to become doctors again. Only 42% said they would choose their specialty again. 19% said they would choose the same practice setting.
  • Physicians have reported working longer hours and seeing more patients than nurse practitioners (Donelan et al., 2013)

  1. Obtain a bachelor’s degree (do well in core science coursework)
    1. Take the MCAT
    2. Obtain health care experience (HCE)
  2. Apply to medical schools (Doctor of Medicine or Doctor of Osteopathic Medicine)
    1. Obtain letters of reference
    2. Write essays & fill out supplemental applications
    3. Interview
  3. Years 1 & 2 (2 years of didactic general education)
    1. USMLE 1 (U.S. Medical Licensing Examination) - sponsored by the FSMB and the NBME; covers concepts of the basic sciences to the practice of medicine (taken after 2nd year)
    2. COMLEX 1 (Comprehensive Osteopathic Medical Licensing Examination) for DO students - administered by NBOME; covers basic mechanisms of health and disease (taken after 2nd year); 2 part exam
  4. Year 3: Clinical Education (Rotations)
    1. USMLE 2 - examines whether students can apply medical knowledge, skills and understanding of clinical science (taken during the 4th year); divided into 2 exams
    2. COMLEX 2 for DO students - examines student’s ability to demonstrate knowledge of clinical concepts and decision making (taken during year 3 or 4); 2 part exam
  5. Year 4: Specialty Electives & Residency Applications “match” occurs again in your 4th year of medical school to match you with a residency program; interviews are required for this as well;
  6. Residency (2 years) - Can last 8-9 years for surgeons
    1. USMLE 3 - examines whether student can apply medical knowledge and understanding of biomedical and clinical science essential for unsupervised practice of medicine (taken after first year of residency); divided over 2 days
    2. COMLEX 3 for DO students - covers clinical disciplines of medicine; (taken after starting a residency program)
  7. Board Certification - take board exams! Pay your dues!
  8. Fellowships (1-3 years) - available for medical or surgical specialties to become specialized

If you need to constantly be in charge and always have to have the last word, maybe medical school is for you. Physicians will usually always make the last call, unless they trust the midlevel provider (PA/NP) they are supervising to make a decision for them. If you feel you have the time and the resources to dedicate to medical school, and you have a passion for medicine, then you should go for it. There are PAs who to this day wish they had chosen to go to medical school. Don't let yourself wonder, what if? If your desires tell you that you are destined to be a doctor, then you should go for it. Taking the easy way out because you didn't score well on the MCAT, you already have a nursing degree, or you don't have the grades to get into medical school aren't good reasons to choose PA or NP school. If you need help in another area, you should decide what you need to do to better yourself in that area to get yourself to where you want to be. There is no rush in life and if medical school is where you are meant to be, then you shouldn't care how long it takes to finish.

The Nurse Practitioner Pathway

NP School and Admission:
  • Nurse practitioners can have an initial 1-2 years nursing experience (up to 4000 hours), but most have the minimum (around 2000 hours)
    • Not all programs require that you have a degree in nursing prior to admission; some allow non-nursing baccalaureate degrees, however, all programs will require that you be an RN prior to admission
  • Some programs require the GRE, some do not, while others may require scores from the Miller Analogies Test (MAT)
  • One benefit of NP school is that most allow you to work part or full-time during school
  • Very few NP programs offer cadaver dissection
  • After NP school, 750-1400 clinical hours are required in a specialty, of which many NP students set up themselves, which explains why health professionals are so adamant that NP education is inferior and lacking in the clinical realm (this is purely presented as the opinion of some, not all)
  • NPs do not typically rotate in surgery during their clinical year, and spend many less hours on rotations
  • NPs have specialized training in one particular area (family practice, pediatrics, women’s health, psychiatry, etc.), which usually complements the area of their prior nursing experience. This experience amounts to anywhere between 500-1000 clinical hours.
  • Nurse practitioners face many of the same obstacles in federal and state advocacy that PAs do and you can find answers to their scope of practice here and here (page 22)
  • Nursing accreditation is overseen by nursing boards (ACEN - previously NLNAC and CCNE)
  • Most NPs claim to practice "nursing" for legislative and political reasons, however, they do in fact practice medicine

What is a Nurse Practitioner?
A registered nurse (RN) performs great range of duties such as recording medical histories, examining patients, providing treatment, and assisting in the administration of diagnostic tests whereas an NP can do all of the things that RNs are known for, but additionally they can also order diagnostic tests and interpret test results. The NP role extends to the 1930s, when nurses in the Frontier Nursing Service provided medical care to residents of Appalachia with minimal supervision by MDs. Not until the 1960s would the NP role see a big break, though. With the shortage of primary care physicians, medical specialization allowed NPs to expand into specialty and acute care areas. Today, more than 106,000 NPs practice in the US (AHRQ, 2010). Other descriptions of nurse practitioners include:
  • NPs are trained in a designated field and specialty and are also registered nurses prior to becoming a NP. NPs are trained in a nursing model, but practice medicine specific to their field of study.
  • NP practice emphasizes a holistic approach to patient care with particular attention to disease prevention, health promotion, and risk reduction.

NP Pros
  • NP is that they are now allowed to practice independently of physicians in many states.
  • 52% of NPs practice in primary care, while the remainder are distributed across a variety of settings and specialties
  • Patients reporting NP as their primary care provider (PCP) were more likely to be Medicaid recipients than those reporting care from a PA or physician (Hooker et al., 2005)
  • The costs of many NP schools are often much cheaper than PA schools
  • If you plan to work for Doctors Without Borders (Médecins Sans Frontières) or Global Health Service Corps, being a NP would be the only way to get onboard as a midlevel, as they do not accept PAs
  • NPs work collaboratively with physicians, but may diagnose and treat autonomously in as many as 28 states.
    • All NPs can practice advanced nursing independently REGARDLESS of the supervising physician's specialty*
  • NPs have authority to prescribe without permission from a physician or Board of Medicine, pending state requirements are met, in as many as 18 states.
  • NPs can effectively sign death certificates in 23 states, with access to sign death certificates in 2 other states pending setting and physician notice
  • In all but 14 states, NPs are allowed to sign workers' compensation claims
  • In 44 states, NPs are allowed to sign handicap parking permits.
  • 48 states allow NPs to make referrals for physical therapy, while 4 are pending this ability.
  • NPs may be certified in both a population-focused area AND specialty area of practice - but must be certified by a national specialty or certifying agency accepted by their state board of nursing
  • On average, 14.8% of NPs see 25 or less patients per week, 30.1% see between 26-50,  25.5% see between 51-76, 19.5% see between 76-100, and the upper 10% of NPs see over 100 patients per week (ClinicalAdvisor, 2013)
  • On average, 35.1% of NPs write between 0-25 prescriptions per week, 36.8% write between 26-75, 17.2% write between 76-125, and the upper 10.9% write over 125 prescriptions per week (ClinicalAdvisor, 2013)
  • No discernible difference was seen between the amount of time PAs and NPs spend on the job. Approximately 80% of all respondents work between 30-50 hours per week.
  • Increasing availability of NPs and how they compare to doctors in primary care shows they are likely to have higher levels of patient satisfaction and higher quality care (Hooker et al., 2005).

NP Cons
  • There is less consistency in many NP programs and many NPs disapprove of the standard NP curriculum and expectations
    • Ex. Direct entry programs - must be routinely evaluated to ensure the programs are providing sufficient clinical experience and preparation for safe, effective, and independent practice after graduation
  • Some NP rotations may not be of good quality because the students may have to find them wherever they can to meet the minimum requirements
  • Scope of practice regulated through state nurse practice acts (ACNP)
  • NPs require an additional certification to work in surgery, which explains why you see less NPs in surgery than PAs
  • Nurse practitioners must be recertified every 5 years

  1. Become an RN by obtaining a BSN (Bachelor of Science in Nursing) - 4 years
    1. Obtain State Licensure as RN (NCLEX-RN) as administered by the National Council of State Boards of Nursing
  2. Choose a Specialty and Gain Experience - 1-2 years
    1. One of the hallmarks of NP is that you must choose your specialty early on and stick with it. You don’t have the lateral mobility in changing specialty like you do with PA.
  3. Earn a Nurse Practitioner Master’s Degree from an Accredited Program - 1-3 years
    1. Graduates with non-nursing bachelor’s degree - can opt for a BSN-to-Master’s fast-track-program (typically 3 years)
    2. Nurses who want a master's degree in a different specialty than their BSN may opt to complete a post-master's graduate certificate program as a nurse practitioner. This can take five months to a year to complete, depending on the specialty.
  4. Apply for Certification - Requires 750-1400 clinical hours in a specialty

Side Note: The American Association of Colleges of Nursing (AACN) has recommended that all entry-level NP programs transition the Master of Science in Nursing degree to the DNP (Doctor of Nursing Practice) degree by the year 2015. Typically, “doctor” means “holder of a highest degree in university,” however, there is much debate about whether NPs should be called this or not. In 2011, the American Medical Association launched the “Truth in Advertising Campaign” to promote transparency so that patients could truly know who was providing their care. They contested that the confusion undermines the reliability of our healthcare system and puts patients at risk.This movement will put NPs on equal footing with those in pharmacy and physical therapy, requiring 32 additional degree course credits beyond a master's degree. This presents the challenge of a longer, possibly more challenging journey to become an advanced practitioner. The question arises whether more students, including nurses, will pursue PA rather than DNP?

If salary is what you are concerned about, you can find results from a 2013 survey of nurse practitioners and PAs here. For more up-to-date information on PA salary, read about the AAPA Salary Report article I posted recently here.

Choosing a pathway can be difficult at any age. It’s hard to know what you want to be when you know so little about being in that profession besides observing others. There are many “bridge” programs that allow you to bridge from a PA to a DO, PA to NP, etc. in 3 years or less. These are secondary options for you if you decide while in school that PA may not be for you, because it does happen and PA school isn’t for everyone. It is better to ensure PA is the right pathway from the get-go and to eliminate any detours along the way. You’ll save yourself a lot of money and time and you’ll give someone else the opportunity to attend PA school! From the words of an elder PA, “Life is not about doing something just because you might as well, or because you are capable of doing it. It’s about being whatever you want to be, at least for today. Tomorrow you might just want to be something else. Lead your own life. If you want to be a doc, then by all means, be one. If you don’t, then don’t. Don’t feel that there are laws of nature dictating that people of a certain age have to do anything in particular.”

For more information, I encourage you to continue your own research, ask a PA/MD/DO/NP you may know, or visit sites like and

Sources: (great comparison chart)
Medscape -
2013 AAPA Salary Report, AAPA -
Physician Assistant History Society -
The 2012 Pearson Report -
Agency for Healthcare Research and Quality -
The Nurse Practitioner's 24th Annual Legislative Update -
Physician Assistant: State Laws and Regulations, 13th Edition
Hiring Into Advance Practice Positions, Ponte et al. 2013
Physician Assistants: A Literature Review, HPRAC -
Physician Assistant Medical Practice in the Health Care Workforce (Nicholson et al, 2008)
Medical Economics (2011)
Perspectives of Physicians and Nurse Practitioners on Primary Care Practice (Donelan et al., 2013)
Physician Assistant Education in the United States (Jones, 2007)
Predictive Modeling the Physician Assistant Supply: 2010-2025 (Hooker et al., 2011)
Personal Communication (McCarty, 2011)
Hiring a Physician Assistant or Nurse Practitioner (American College of Physicians, 2010)
Patient Satisfaction: Comparing Physician Assistants, Nurse Practitioners, and Physicians (Hooker et al., 1997)
Patient Satisfaction with Physician Assistant, Nurse Practitioner, and Physician Care: A National Survey of Medicare Beneficiaries (Hooker et al., 2005)
Institutional Sponsorship, Student Debt, and Specialty Choice in Physician Assistant Education (Cawley & Jones, 2013)


  1. Thank you so much. Great info! I have been admitted to a nursing program however I have an interview for the pa program coming up. I'm a bit nervous n confused more than ever. I live in Los Angeles, any tips or advice you have for what position I should go for?! (Assuming I get in to pa) I really love the field but want to practice something rewarding, with growth..what do you think?! Thank you

    1. Nursing and PA are very very different roles and the education required for each is also different (nursing model vs. medical model). I would look into that a little more if you are still unsure. Obviously, I am biased, because I am pro-PA, but I truly think that is an individual decision you have to make whether you feel better fit for a nursing role or the role of a PA. I also wasn't sure if you meant "nurse" or "nurse practitioner."

  2. I have been looking many website for the right information about career in medical and I want to thank you for this post. It’s not easy to find such perfectly written information on this topic. Thanks for sharing

  3. Nurse Practitioners would like to have us believe they are "independent" clinicians. In the state of Pennsylvania, however, state law requires that a NP must have a signed written agreement with a physician if they wish to prescribe medication or perform any procedures. The law stipulates that the NP must be able to contact the physician at all times by phone. In reality this is almost identical to the requirements for PAs since the countersignature requirement was removed in Dec. 2013 and since PAs have been granted the right to practice without their supervising physician onsite.

    I am not trying to discredit the NP profession. I do believe, however, that NPs have misrepresented themselves as "independent" clinicians when in reality they are not independent clinicians.

    1. I"m sorry, but did you read any of the above written information about NPs? They are absolutely independent in as many as 28 states and have more that are pending legislation. Can sign Death certificates in 14 states with more pending. Can sing workers Comp claims in all but 14 states with more pending. In 18 states an NP can prescribe meds without a doctors approval, and that number is also growing. in almost all state now, an NP can give patients parking permit orders and refer patients to PT. Oh , and not to mention, NPs can work for "Doctors Without Borders" while PAs are not accepted. I feel sorry for the NPs in Penn. because they are restricted, but they have the option of moving to at least 28 other states that would allow them to practice "independently" as a clinician.
      I'm not trying to discredit the PA profession. I do believe, however, that PAs may be a little envious in some states at the independence that NPs have over them and have to post things like this above statement to make themselves feel better. The fact of the matter is, NPs have far more independence and autonomy than PAs do. NP may be restricted as far as lateral mobility goes when it comes to changing specialties. Sure PAs might have higher avg. pay in some fields and environments as well as the opposite, in some fields NPs are paid more than PAs. But in my state, an NP can open up their own private practice as well as many other states. I think you should read before you open your mouth and say things like the above stated comment.

    2. This is an old post. However, I agree. The NP role has more autonomy and has more independence. In addition, many NPs have better bedside manners, and able to view the patient in a holistically, rather than episodic.

  4. Your article was pretty awesome. I will note this article and share it to my friends to gather more information about PA.

  5. You have produced a meticulously written comparison of these disciplines, Paul, and as such, have provided a valuable public service. I haven't found a better organized treatise on the pros and cons anywhere else.

    In my opinion (licensed independent social worker), PAs are superior in today's healthcare milieu for the many reasons you cited, and most especially because they receive formal instruction in nutrition and the behavioral sciences. Recent studies have demonstrated that physicians receive no education in these areas, which is appalling since the majority of chronic disease conditions are preventable and now tied to metabolic syndrome, obesity, and what people eat. Doctors have no clue how to advise patients in these areas and end up over-relying on pharmaceuticals and invasive procedures for treatment, which only exacerbates the problem. PAs have more power to help prevent disease than doctors because they understand what we eat can make us sick or make us healthy.

    1. Have you ever researched what nurses actually do? Who does all of the patient education when a patient is about to get discharged or while they are in care? Its nurses. because nurses are the one that have formal education in a lot of preventive medicine. NPs have far more patient satisfaction than both PAs and MD/DOs combined. I'm not a nurse or a PA/DO/MD, but i do know that when I take myself and my children to the doctors office, the NPs have far more patience, bedside manner, and spend more time teaching me or my family members about drugs, diet, lifestyle changes and etc than the doctors or the two PAs they have there. In fact, I always request that we get a doctor or NP and not a PA.

    2. To anonymous and anyone else who could help me out, you say that the nurses do patient education before discharge and while they are in care. This is what makes me question my chosen major. I am currently a dietetics student (about to graduate in just 7 more weeks!). Being a dietetics student we take quite a few classes on the proper way to talk/ counsel/ educate patients. We take advanced courses in pathophysiology regarding medical nutrition therapy. While I have not had any hospital experience (shame, I know), this leaves me to ask, what is the role of a registered dietitian in a hospital if the nurses are the ones doing patient education??

    3. Hi sabsC,

      First off congrats on graduation! I can't remember why I chose not to respond to the conversation above, but I'd imagine that it was because its a point not worth arguing over. Everyone has different experiences with the providers they've encountered in person (PA, MD/DO, NP, nurse) and ultimately that isn't and shouldn't be a reflection of the entire community of providers. I'm sure you've heard this at some point throughout your education, but we shouldn't place the blame of one bad provider on all providers who work in the profession. Fact of the matter is that we don't all receive the same education and a lot more than just our education reflects what type of provider we will be. Some people are just more driven than others and some providers may feel that certain parts of patient education are not worth their time. Doesn't mean their right. It also doesn't mean that nurses, NPs or PAs are better than the other.

      The role of the RD is share and educate patients with exactly what you have been taught. That may not be fully realized until you spend some time in a clinical setting learning how that information can be applied. Just because a person says that nurses are doing all of the patient education doesn't mean that you should take their word literally. That's obviously a hyperbole because nurses can't educate patients on everything they'll need to know after their stay. The reality is that in most inpatient settings a patient will encounter many providers (MD/DO, NP, PA, dieticians, speech pathologists, respiratory therapists, physical and occupational therapists, etc.). Its likely that they'll take away some knowledge from each of these people and ultimately its up to the patient to decide how much of it they'll actually utilize. Everyone is equally responsible for playing their part in educating the patient and its up to all of us as a team to ensure that they're receiving the best care possible. The days of working against one another are over. Now we work in teams and anyone who tells you otherwise is not here to help you.

  6. As a "provider," it seems amiss to state that you know the training of medical students before you have actually attended medical school. I think it makes a lot more sense to take this person's word, who actually has ground to stand on:

    To note, while lecture may not be "required," medical students still have to know the material inside and out in order to pass the exams and pass the increasingly difficult 3 sets of board exams. Which means they study the content well, regardless of whether or not it is in a lecture hall. Autonomy and self-directed learning, as well as accountability for our education, is an implied part of medical training. Spin it whichever way makes you feel better as a PA, but medical students are far from lazy, especially with that whole one summer off that they get during the 7-10 years of training.
    Medical school training is centered around diagnostic and critical THINKING, because whether you recognize it or not in PA school, Medicine is not just memorizing lists of differentials. In fact, that is what oftentimes gets patients into trouble, because many patients don't fit a pattern, and that is when a doctor must be able to draw on a deeper knowledge base and different thinking approach. Without being able to draw on this base of knowledge, it can lead to needless tests, referrals, and increases the cost of medical care for our patients.
    There is a huge degree of sacrifice involved in medicine. Certainly, PA students sacrifice 2 years and some student loans - acknowledged. In medical school, you give up 7-10 years of your life to your education, and sometimes have to delay family and a decent income. Plus, you sacrifice financial security for a period of time. Quite frankly, it is worth it to me. Because I am not a "provider." I am training to be a physician, to care for another human being using my medical and scientific knowledge to help improve their life. Because I decided that I wanted to be the "doctor," to take the extra time and pay the extra personal and financial price to take the best care of my patients. While I need to pay off my loans, for myself and many medical students I know - you don't go into medicine for the money. You do it for the patients and for the cerebral nature of the field and for the clinical challenge and for the reward of healing patients. To me, that means gaining a greater depth of knowledge, and then gaining years and years of supervised practice experience, learning how to think critically like a physician, before practicing independently.
    While I am not denying a role in medicine for PAs and mid-level "providers," these roles are NOT physicians, and there is a reason for that. We have very different levels of training, and there is a logical reason why some patients want to see the Doctor. It really all comes down to experience before practicing independently.
    It is good to recognize that it depends on what you want out of your profession, I agree with you there. But please do not minimize these huge differences.

    1. I never meant to minimize the difference between a physician and a PA or NP. I think those difference stand clear for themselves. I appreciate your input and value your opinion on the matter, but I did address many of the things you talk about in the article. While I admit, this article was written to persuade PA students to choose the PA profession, I do not discourage anyone to disregard medical school for any of the reasons you listed above. I never called medical students lazy - I think you opened up the article for your own interpretation. I go to school with plenty of medical students who I know are some of the hardest working students out there. I know what they are up against because I have seen my friends study for their exams and I have seen the extent of the content they are required to know.

      I also see that you feel very close/passionate about your own profession, just as I am mine. Everyone is accountable for the material they are required to know - PA, MD/DO, or NP. It is up to the individual student to make the decision whether to study more/less. Not everyone I have come across is as passionate as you are about their education. Not everyone is as motivated as you are.

      While I appreciate the personal sacrifice physicians make for the greater good of our healthcare environment, I do think you should also consider that PAs do not always follow an algorithm either. You suggest that I grasp a better insight of physician training, but have you-yourself considered learning more about what it takes to become a PA? The amount of content we are required to know and the little amount of time we have to cover it all? PAs think critically just as much as physicians do. The one aspect of both professions holding us together is that we both practice medicine. While PAs may not always make the end decision, they are still very competent in the field they choose to specialize in. PAs have many decisions to make just as physicians do, because care is patient-specific. Sure, they may not be backed by a residency, but we have the option to engage in a residency to gain extra training. The deeper knowledge base you talk about I do not doubt one bit. I know that physicians learn in greater detail all of the things we do - but we are still very efficient at what we do and we should be respected by the physician community for doing so.

    2. Needless tests, referrals, and increased costs of medical care is not because PAs lack the education or base knowledge that physicians have. Even physicians will tell you (as they tell us during our lectures), that rising medical costs are due to practitioners trying to avoid being sued most of the time. They order everything instead of spending more time investigating the patient because it saves time.

      Also, it is naive to say that PAs only sacrifice "2 years and some loans." You make yourself sound more uneducated about our profession than you realize. Many PAs have at least 2.5 years of experience before they are event admitted to PA programs, with some having 10+ years of healthcare experience as EMTs, MAs, CNAs, paramedics, etc. I'm glad that you have chosen your profession, but it seems like you are scrutinizing our profession because you feel that I have belittled your own profession, when that is simply not the case. I have tons of respect for people pursuing medical school education - I just know that it was not very appealing to me. Hell - one day I will have my own supervising physician, why wouldn't I have respect for them?

      We all choose medicine for different reasons, but don't think that PAs chose their profession for the "money." We make our own sacrifices before PA school, during PA school, and after. We have to live with people condescending us because we aren't physicians. We have to deal with the limitations of practice given to us by the state, our employer, and the physician we work for.

      Just to be clear - "provider" is a term used to classify all practitioners of medicine, including physicians. While I agree that there are very different levels of training, we need to work cohesively and be in support of one another rather than at each other's throats harping on who is better trained/educated. Medicine is moving into a world of team based work, where physicians will no longer be recognized as always being the "leader." That's why some patients still see the physician as being the ultimate clinician. We have fostered a culture for so long centered around the physician that patients do not know the degree of training and education of NPs and PAs and how they can help bridge the physician shortage in America. Over time, I think this attitude will change, as I have seen it in my own experience prior to PA school.

      Best of luck to you in medical school. I'm sure you will make a great physician one day.

    3. This was a fantastic reply Paul, this guy seems as if he was appalled that you could compare a PA to a MD, like you just needed to know how much more educated he is than you will be. Anyways, this post was incredibly helpful and I'm following it now.

    4. I thought this was a well written discussion on the difference between all professions. These anonymous disgruntled posters are quite amusing. I am a RN who became a PA. PA school is not easy, otherwise many others would do it. I describe it best as compressed medical school. Yeah, it doesn't have some of the medical school fillers. I chose not to go to NP school because you couldn't pay me to take another nursing theory class, especially at the graduate level. The assumption is that the NP student will have a good basic nursing knowledge and is confident in their medical practice before going into graduate school. The fact is that isn't happening a lot of the time. My clinical experience versus my NP friends was vastly different. Plus, I had been a working RN in the ER and ICU longer than some of them had. It isn't a competition. It is about doing what is best for you, your life, your family life and what will help you give the best patient care. For the person who only wants to see a MD or NP, God bless you. I hope that request is always granted and you continue to miss out on the great experience and care that PA's can offer.

    5. Hi Jacqueline,

      I am very interested in your opinion on PA or NP. I currently have a Bachelor of Science in Nutrition and I was looking into PA programs and entry level MSN ( RN start to NP). My three main areas I am interested in are Women's Health, Trauma and Peds. I am very lost on which direction to go! any help would be amazing. I currently work as a medical assistant at a fertility clinic.

      Thanks in advance for any input!


    6. Jacqueline,

      Thank you for your thoughtful response above. I appreciate the ongoing support of all practitioners, including nurses, PAs, NPs, and physicians. Your open-mindedness and careful consideration of each profession allowed you to make the best decision for yourself and I'm glad you were able to convey that. That is my hope for all who are unsure which route may be best for them. No one can guide you every step of the way. Sometimes you have to figure out what works best for you based on the experiences you have had or haven't had and what your end-goals are. Best of luck to you in the future :)

  7. Thank you for the very informative post, I really enjoyed it. I have been a critical care nurse for almost 10 years and am in NP school now. I'm in a competitive well respected program, but if I had it to do over I would have gone PA. I'm disappointed in the focus on "nursing theory". I hate to denigrate my chosen profession, but I would much rather add clinical practice hours or a residency than learn all this theory balony that no one cares about. I am learning a lot in the clinical and pharmacology classes and will be prepared to take care of clients when I graduate, but am disenchanted with the nursing model. I wish there was some sort of melding of the nursing/medical model for mid-levels. I think PA's have a lot more versatility, but I do like that NPs can practice independently in many states.

    1. Thanks for your input, I appreciate you taking the time to read.

  8. I too am in FNP school and mine required a minimum of 2 years experience; I agree that there is way too much emphasis on nursing theory, rather than clinical practice. That being said, I have a very average background according to the AANP. This includes 2 years in EMS, 4 years in the ER and 2 years in ICU. How many clinical hours does that amount to? Figure an average of 40 hours a week for 8 years, in diverse settings. I have several friends that are PA's and none of them had prior medical experience. I would contend that this is the major difference between the models, and the logic behind the emphasis on theory over clinical experience. In general, most NP students already have many years of clinical experience and simply need to spend more clinical focus on building themselves as competent diagnosticians. If I was only interested in bang for buck and time in school...PA is best without question. No matter which route you choose, it will be the student and not the program that makes a good provider. As a side note...finding your own preceptors in the required specialties is BRUTAL and very competitive. I would only recommend programs that supply preceptors for your clinical rotations....and such programs are very scarce.


    1. Thanks for your input. I 100% agree that the type of provider you are depends on the type of student you are.

      There simply isn't enough data out there comparing PA and NP schools to make broad overarching statements about the two, but there is data supporting each of them individually. That's why there is so much debate about which one is "better" than the other, but I don't find that one is necessarily better than the other. I think they both have their pros and cons and they were meant to work in equilibrium rather than in some type of hierarchy like everyone in healthcare wants them to.

  9. I got lucky to get admission in a PA program at NYIT, and confused to take decision to go with PA or pursue MD . I am a freshman out from high school, my father was a oncologist and my brother is DO (Final year). my mom and brother BOTH is keep pushing me for PA. I am NOT sure what to do? can you help me. I am not best at biology, but will take challenge to do good. PA program is for 6 years, and if I decide to go for MD it will be 4 + 4 + MCAT, is that RIGHT?

    1. Yes, that would be correct. It's not that it takes 6-years to become a PA. Think of it this way - either way you have to get a bachelor's degree (4-years) and medical school is an additional 4 years, while PA school is 2-3. With PA school there is no residency afterward, you go straight into practice. With medical school, you must complete a residency that is probably between 3-6 years depending on your specialty of choice.

  10. This was a very informative post but I just wanted to note that your Match Day description for the MD/DO pathway is incorrect. Match Day is for graduating medical students who find out what residency program they are matched with. It is NOT for students who have just applied to medical school.

    1. Hi anonymous,

      Thanks for the update. I have made the changes to the article. I must have been misinformed by someone when writing the article. Thanks again!

  11. "Not all programs require that you be an RN prior to admission; some allow non-nursing baccalaureate degrees" this statment needs to be clarified. A RN licensure and a bachelors degree are two separate entities, you can have either one without the other, so your statement doesnt make sense. I have seen ZERO NP programs that do not require a person to be an RN prior to admission. (You cannot become an advanced practice nurse, without being a nurse first). The second half of your statement is true, i have seen a few NP programs that do not require the BSN degree specifically.. overall lots lf good info in this article! Im a practicing RN debating on PA, NP, or even CRNA :)

    1. Hi anonymous,

      Thanks for catching that! I wrote this article some time ago and I now understand completely what you're talking about. Thanks for clarifying.

  12. Thank you for this information. It was very helpful in differentiating between the three different practices. I would love however, to be able to compare apples to apples. In this case I mean credit hours. I am not trying to decide between any of them, I am writing an essay comparing NPs to MDs and I don't think a fair comparison can be made. When one considers the time and energy involved with medical school and residency (even the shortest program) compared to a NP program that is really part time and involves a ton of essay writing vs. medical knowledge. Can you possibly compare credit hours for me of a NP to a Family Practice MD? Thank you!

    1. Again, I agree with you. There is no good comparison because the educational models are entirely different. NPs are nurses foremost and have to obtain a bachelor's degree in nursing and usually clinical experience before entering.....some medical students have little to no experience prior to entering medical school. As far as credit hours, I don't think it really matters because credit hours are going to be different depending on the school you pick. It's a never ending cycle and in the end, one profession is going to feel degraded because you'll compare the 2 and different sources are going to say one is better than the other, etc. We can't make everyone happy, but there really isn't enough research on the topic in my opinion.

  13. What is the likelihood that someone who decided to leave their PA program be readmitted to another PA program later? (First time they were granted medical leave then the second time they decided to withdraw; therefore they were enrolled twice.) (Also considering that during this time off the student went to successfully complete another bachelor degree in BSN)

    1. Hi anonymous,

      I honestly have no earthly idea. I would reach out to someone at PAEA and see if they know the answer to that question.

  14. Thank you for the much needed information of the differences between these three roles. As you may be aware the PA role is also now being trialled and tested in the UK and is beginning to take off at universities. I am in my first year of nursing and am now considering applying for PA course without completing the nursing course. I was confused at the differences between the nurse and PA role when i decided to give nursing a try but now i can see there is alot of difference between the two roles and future opportunities. I truly hope i am giving up nursing for a worth while career :-)
    Please do comment to remove my doubts.

    1. There is a LARGE difference between PA and nurse. Do not confuse a nurse with being a nurse practitioner, however. These are not interchangeable terms. Please research more and let me know if you have any questions afterward.

  15. I love how Nurse Practitioners think they are SO much more "independent." You are NOT a physician. Most get their education online. You need to get off your high horse. I am a PA and work alongside NPs. Most of which have not even been taught how to suture or even how to write a prescription...don't go there. Just don't.

    1. Hi anonymous,

      I'm not sure if you are referring to myself or other commentators on this blog post, but I am not in NP school and I do not advocate for their profession or that they are "independent" or any better/worse than any other medical provider. This blog post is meant to inform people about the differences between the 3 without my own personal bias. I hope you did not get the impression that I had the opinions you stated above. I don't think classifying all NPs into one category based on one or even a few NPs you might have encountered does their profession justice either. Your own bias and misunderstanding about their profession does not help improve the image of our own as PAs. Badmouthing another type of provider does not help the situation and only makes it worse, encouraging the other team to speak out and giving them the opportunity to do so. Anonymity is just one way to cover up your own identity and speak out your own opinions without having to suffer the consequences of doing so and my blog is not the place for it. Thanks for your opinion, but please do not post things like this again.

  16. Thanks for this post! It was very informative and helpful for me in distinguishing the differences between NP,PA, and MD/DO. I also think that you have handled peoples' responses VERY well in regards to claiming that one position (MD, PA, NP) is better or more able to care for patients than the other. EACH position has their pros and cons but at the end of the day, we are all working toward the same goal: caring for a patient. And we all have (or should have) the necessary knowledge and expertise to do this effectively.

  17. I loved this post! As othrs have said, probably one of the most well put together and most informational articles I've read. I do have a question though, I am currently torn between pursuing a career as a PA or just going all the way for MD. I'm scared I may regret not going down the MD path. My theory as of right now though, is I can just become a PA and if I feel like I want to go back for MD that it would be possible. How long would that process take? I definitely don't mind the extra time. Just curious.

    1. As far as I know, there aren't any PA to MD schools. You'd have to go back to medical school for 4 years + residency +/- fellowship. There is a PA to DO school, which I believe is still 3 years long + residency.

  18. Hi! I am currently a sophomore at my university and I am taking PA prerequisites. I also really want to teach abroad when I graduate and I was wondering if you thought it was a bad idea to take a gap year before applying to PA programs.

    1. Definitely not a bad thing. Just make sure to mention that in your essays and your interviews.

  19. Best post I've seen to date online! As an informed NP student and experienced registered nurse with a BSN (4 years nursing experience + 3 additional years experience as a patient care/service technician and Monitor Technician), there a couple of things I would argue in your article. First, I would say tread lightly when you say that PAs have superior physical assessment skills. This is subjective and can only be evidenced by the actual performance of NPs which so far by the way, the data says we are doing a great job. Note, most NP students are already experienced RNs who have worked in a variety of areas like PCUs, medical surgical units, ICUs, CCUs, ERs, and the list goes on. Unlike most PA students NP students before entering their respective programs already posses a solid foundational knowledge about pathophysiology, pharmacology, physical assessment, the applied sciences of medical surgical nursing, nursing theory, etc. In contrast, all that is needed to satisfy the "medical experience" requirement by PA programs is and can be as something as basic as nursing aid experience. Second, I would also argue the average salaries NPs make in comparison to PAs. The data I have seen by the bureau of labor and statistics, as well as other independent studies (which I'll be happy to cite if requested), shows that NPs make on average a tad more than PAs and that the earning potential in the top ten percent of earners is slightly higher as well. Also note that often the data on salaries of PAs and NPs doesnt take into account the bonuses earned quarterly for productivity and what have you.
    That said, great job on this!

    1. Thanks Alexander! I really appreciate the positive feedback!

      I 100% agree with your assessment of both professions. There is a lot of ambiguity between the lines of each profession, and most of the data available to us is very subjective, if not, opinionated. I also ditto your response that data shows that NPs, as well as PAs, are performing very well in practice with excellent patient care satisfaction scores.

      I would love to see and add updated information to this blog post. If you'd like to leave me links to papers, I would be happy to read over them and make additions or edits. I will say that citing data on the "top 10%" of each profession is a little skewed. Consider that NPs have been in practice much longer and the PA profession is still a very new concept to many healthcare providers and systems of the U.S. This may play a limiting factor. I think overall, PAs and NPs are compensated equivalently with numbers only varying by a few thousand, which really is negligible once you consider that bonuses will skew the data (I think you actually mentioned this in your post), so we agree there.

      I think the point of this article is for students to choose what profession really fits them the best, not to undermine a profession or enhance another. Best of luck and I look forward to your response!

    2. Hey Paul, sorry about the late response. I realize that you are trying to be objective and I appreciate that. You also provide a pretty fair assessment of these professions. Just want to correct you on what I believe is a typo. Under NP Cons, you wrote:
      "Nurses who want a master's degree in a different specialty than their BSN may opt to complete a post-master's graduate certificate..."
      I think you meant to write, nurses who want a master's degree in a different specialty that their MSN. BSN education doesn't require nursing students to train for any specific population. BSN nurses sort of become "nurse generalist" capable of switching specialties at anytime. But I think you already know that. Its the APN programs that require a focus in a particular population. Then if for example, a family nurse practitioner want's to become a psychiatric NP too, then as you said, that will require a post-masters cert. Thank you again.

  20. As an NP student (and RN, BSN of nearly twenty years), I have to disagree with any insinuation that an NP program requires any less clinical medicine or pathophysiology. The curriculum is comprehensive, but directed toward those who have prerequisite education and a knowledge base to already safely practice as a nurse. We focus heavily on advanced pathophysiology, pharmacology, and use case studies as a core medical competency exercise throughout the program. Something I want to add, is that NP programs tend to weigh heavy on research. While all health fields are espousing the term "evidence based practice," NP programs require an impressive amount of research and scientific writing. I am in a dual program for primary care and nursing education, so I have the benefit of writing and critiquing other's curriculum. Something often overlooked in medical and PA education, is the care of the person as a whole, and importance of the relationship and exchange between provider and client. This is likely the reason behind the disparity in patient satisfaction scores between PA's and NP's, with NP's scoring higher than all other providers. We as nurses, are already utilizing positive communication and other techniques to heal, comfort and show caring. So, our platform is wider and richer, with medical/clinical diagnosis and treatment as addendum versus our only trick. Nurses may just come to the table with a hint of something that you cannot. Regardless, people prefer NP's. Is it a marketing issue? No. When you treat people with warmth, compassion and respect, they return. Assuming clinical and diagnostic skills being equal, why go to someone who dismisses your complaints or comments because they don't fit into a narrow diagnostic protocol or lab schema, when you can go to someone who will listen carefully, write the same prescriptions, order the same diagnostics/labs, and leave you feeling heard, understood, and cared for. One last possibility is the nursing practice of prevention. Not just early detection, but true primary prevention. Nurses are educated early on, to the value of nutritional strategies for health and healing. This is not something I have e ery experienced with PA's, or MD's. It seems traditional medical education forgot about the part where people stick things in their mouths, and cause a world of health problems for themselves. Even GI docs! They do not, in my experience, ask what or how much someone is eating when they present with GI complaints. That is amazing to me. So, we may have the common sense factor in our corner is well. Advanced practice nurses are changing the face of medicine, and I suggest MD's, and their PA's climb on board.

    1. Hi Lucylou17,

      Sorry for the delayed response. In response to your comments, I'd have to agree with you that this was a very poor insinuation that NPs are inferior in clinical medicine or pathophysiology. I did not have data to back this claim, although I personally read NPs online provide this information, which is why I originally stated it in the article. Please note it has been removed until data can be provided about NP education.

      If you wouldn't mind, please send me some links on data backing that NP programs are more research based, or what percentage of programs require a dissertation and/or evidence based medicine course? I believe 100% of PA programs require an EBM course and a few require original research, but little to none require any type of dissertation. This is strictly anecdotal.

      Also, please send me information/links to patient satisfaction scores comparing PAs and NPs. To my knowledge, there have been scores for each profession individually, but not tested against one another in the same setting. I think a holistic approach to patient care is taught in PA, NP, and MD/DO programs - this is the crux of patient centered medical care, which is the basis for medical education regardless of profession. Our experiences with prior providers of other professions really does have influence on our own biases and I encourage you to see through them as I have. One bad provider/student should not impinge on an entire profession. Please realize that the importance of the patient-provider relationship is enforced and taught in every single program, regardless of profession (yes, this includes RTs, PT/OT, dieticians, and social workers, etc.)

      I think any patient would prefer a more compassionate provider that engages thoroughly in their care, regardless of their profession, but you are incorrect to think that the choice in hiring is not influenced by "marketing", which I spoke about recently with employers all over the nation at a conference in D.C. Of whom, were APRNs and PAs alike and all mentioned that funding (specifically the cost and duration of on-boarding APP staff) was crucial in deciding whether an employer hires a PA or NP. This is not up for discussion as they provided numbers to back their responses. It is a problem that has divided our professions apart from one another, viewing each other as competitors instead of collaborators.

      There are many other points you have made that I feel are very unwarranted, such as your statement that other providers lack education surrounding nutritional status. What do you say to the provider with prior experience as a dietician, or the student who studied nutrition in undergrad? I don't think your statement is warranted. We all have nutrition education integrated into our programs. Primary care is also deeply rooted into our education, specifically preventive health. I'm not sure that your description of our profession is accurate, either and I suggest you "climb on board" and reassess your own biases toward other professions.

  21. hi Paul my daughter got admission to St.John University for the 4 year bach program.Do you think she should go to 4 yr undergrad take psychology major and take all the pre reqs and apply for masters or this bach program is better. Please give advice.Thank you

    1. Hi anonymous,

      For pre-PA coaching, I would refer to Savannah Perry's

      Code: DoseOfPA for discount on her services. She may be able to guide you further. Thanks for inquiring!

  22. Hi Paul,

    My daughter is a high school senior and wants to be a PA. She has always been interested in helping people and has been an EMT since she was 16. So this feels like the right path for her.

    She has narrowed her undergrad schools to Seton Hall and the University of Pittsburgh, both having very good PA programs. She likes Seton Hall's PA program as it is a 3 + 3 program and admittance preference is given to Seton Hall students for the master's program. She is less thrilled about its campus and location. On the other side, she really likes Pitt's location and campus, and I like it's relationship with the UPMC, which I believe will give her substantial opportunity for volunteer activities. I also think Pitt gives her a stronger degree should she change her mind about becoming a PA. Like most schools, however, Pitt does not give any advantage to its undergrads when applying to the PA school.

    Do you have any advice when choosing an undergrad school? I can think of a lot of pro's and con's when choosing between these two schools but would be interested in your views given out thinking.


    1. Hi Joe,

      You bring up some very important issues, and I'm glad you did. Your daughter will most definitely thank you for it in the long run. I think her having a better experience and coming out with a more valuable degree is a better option than choosing a program because of its preference for undergraduate candidates. If she is a smart and motivated individual (which it sounds like she is), she will get into many PA programs. If she has already begun obtaining healthcare experience at age 16, I would be surprised if any PA program did not accept her. She has some tough choices to make in the future - deciding whether the PA profession is right for her. I encourage her to shadow a few PAs in the area in different settings (inpatient vs. outpatient) and in surgery if possible to determine if the PA role is what she is looking for. Both PA programs are great and I think that even if she went to U-Pitt, she could apply for Seton Hall's PA program after obtaining a bachelor's degree. This would even give her more time to determine if the PA profession is right for her, which is what most programs are going to want her to decide early on.

      Best of luck to her!

  23. My daughter (high school senior) is on the fence related to PA or NP. She has been accepted to multiple schools - some for nursing and others which have the pre-PA advising track.

    It seems your future is secure by first receiving your RN then deciding to continue for NP or PA.

    1. Become more familiar with a hospital setting quicker due to clinical exposure.
    2. Have more time to consider and have exposure to NP vs. PA or even Nurse Anesthetist.
    3. Gain patient contact hours as an undergrad since after two years of nursing school you are qualified to work as an aide in the hospital.
    4. Employable at a good wage after graduation once the NCLEX is passed.
    5. Have a means to save up pay for graduate school.
    6. Have a higher level of independent assessment patient contact hours desired by PA schools as an RN.

    The only drawback to initial RN then PA school I see are the eight or so PA prerequisites as they are not all incorporated in the nursing curriculum. Some may be taken as electives, during the summer or part time (and most likely paid for by your employer) while working as an RN.

    There are part time NP programs which is not the case of PA.

    Pre-PA advising tracks seems less direct and financially riskier but satisfy the eight core prerequisites of PA schools.

    Are there many people who enter PA schools as a prior RN? Is it frowned upon by PA schools since nursing not "medically" based? Have you heard any drawbacks to this line of thinking from your colleagues?

    I am very interested in your thoughts.


  24. “PA Pros: The overall supply of PAs is likely to increase by as much as 72% to 127,821 PAs by the year 2025 (Hooker, 2011).”
    -- this is hardly a “pro”, as it suggests that in the near future too many PAs would be graduated and it’ll become very hard to get a job, especially for the new graduates.

    “Most programs require a bachelor’s degree and admission can require direct health care experience with most students having at least 2 years of experience (Nicholson, 2008)”
    -- in 2016 we see a broad diversity in required experience from 500 hours not required, but recommended in the most recently open PA schools to 6000 hours at places like Stanford.

    “PA and medical school seem to match up pretty well in what content gets covered, although medical students may cover much more depth of knowledge in some areas.”
    -- should be roughly 50% more covered in Medical school. Both MDs and PAs confirmed to me that with years of practice this gap in knowledge that exists at graduation time gets neutralized and in some cases eliminated, so that an experienced PA can be functioning at the same level as an MD.

    “PA school is much less expensive than medical school, requires less time (about 2-2.5 years usually), and allows more time for a family.”
    -- I don’t think that PA school is less expensive, it is just 50% shorter that medical school. At the same time one can make in the neighborhood of $400K as a physician in the particularly lucrative specialties, while a PA would never cross the $200K line regardless of specialty.

    “PAs now follow a 10 year re-certification process, similar to physicians, as implemented in 2014; 100 hours of CME over a 2 year cycle.”
    “All PAs take the same certifying exam, administered by NCCPA.”
    “Nurse practitioners must be recertified every 5 years.”
    -- Three separate thoughts here:
    1) NPs only need to do the continued education credits, and do not have to sit an exam, so their recertification process is significantly easier than that of PAs, who every 10 years of their lives need to retake the same exam they had to prepare for upon graduation from the PA program. Think that you’ll need to retake it at 60 years of age and at 70 years of age, unless you want to lose your license (which I’m sure at some point you’ll have to let go of, but as an NP you don’t have to)

    2) PAs who had taken any kind of a break from work – to have children or for any other reason feel that retaking that exam is very stressful and requires a lot of preparation.

    3) PAs who continue uninterrupted practice reported that it is easier to take that re-certification exam if you work in primary care, but is significantly difficult if you are in a specialty, since you do not use the knowledge that will be tested in this general PA exam on the regular basis.
    So, recertification wise, “pro” for NP and “con” for PA.

    * MDs have mentioned to me that it is much harder for them to change specialty than it is for PAs. So that is a definite “pro” for PAs and “con” for MDs.

    * On the other hand, if you want to serve abroad as a medical provider, it is quite easy to do that as an NP, because all NPs are also RNs, and a nurse is a profession recognized world-wide. It is significantly harder, almost impossible to find opportunities for serving abroad as a PA, however, as very few countries recognize that profession. So, that’s a “pro” for NP and a “con” for PA.

  25. One more comment -- on comparing GRE to MCAT:
    "Sure PA school might require the GRE, but it would probably beat the MCAT."

    I'm not sure what was meant by the above sentence in the original post -- perhaps that GRE is easier than MCAT? We can probably all agree that a 3.5 hour long GRE is easier than a 7.5 hour long MCAT (and cheaper). So, that is not the question. The question is why do they even bother requiring GRE, which is very similar to SAT and seems like a great waste of time; while MCAT (as difficult as it is) allows one to integrate the knowledge in all areas of basic science and uses clinical-based critical thinking questions, which is what one would need to master as a practicing clinician.
    Here is a more detailed comparison of the two exams:

  26. It's rather sad and unfortunate that we have come to this. I am a practicing nurse practitioner (2 years), with 12 years of nursing experience prior to becoming a nurse practitioner ( 3 years med surg, 5 years icu, 4 years ER). why must we argue about who is better trained? The argument is mostly between PA's and NP's. Like I mentioned earlier, I am a practicing NP and would never hire or work with someone who finished his or NP program online. I do not also support this idea of students finding their own preceptors. I graduated from UTMB and was had doctors and PA's has preceptors. A year residency has to be incorporated into the NP program.

    1. Thanks for your feedback. I agree, we should be treating one another with respect instead of chastising one another's profession for our differences. Its our differences that make us unique and each has their own strengths and weaknesses that add to the healthcare team. We should be more collaborative and less competitive.

  27. Hey Paul, I'm curious why you don't endorse PA programs that offer a Bachelor's option. The one in my area is offered through the University of Washington's MEDEX program and seems to be a good program. Let me know.


    1. I think MEDEX has a great program. The reason I don't endorse them personally is because every PA will have to switch to a masters degree or higher by 2020.

  28. My question is in regards of the 3 years of HC experience prior to apply to NP program? Is it 3 years as a nurse or can you have this experience as a surgical tech prior to graduate from a BS in Nursing and then apply to an NP program right after that?

  29. lot of things learnt from your blog. got more ideas for us. wonderful tips makes from yours. Executing and testing our status very helpful one.
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  30. Hi,
    I don’t agree that you can reasonably conclude that admission to PA school is “just as competitive as medical schools” solely based on the number of applicants per available seat (the author who you referenced did not draw this conclusion).
    To compare the competitiveness between PA school admission and medical schools admission you would have to take into account the caliber of the students applying to PA schools and the students applying to medical schools. One way to do that is comparing the average GPA and MCATs of admitted PA students and admitted medical students. Since most PA school matriculants take the GRE and all medical school matriculants take the MCAT, it is hard to make a direct comparison. However, we have to keep in mind that the MCAT is much more challenging than the GRE in every aspect (length, number of topics covered, difficult concepts,…). Furthermore, the average overall GPA of PA school matriculants is less than the average overall GPA of medical school matriculants. (Per the Jan 2017 statistic from the PAEA, the average overall GPA of PA matriculant is 3.50 in 2015. On the other hand, per the AAMC, the average overall GPA of medical school matriculants is 3.70 in 2015). Let me know your thoughts and please consider updating your post.

  31. Really great data CC. I think the problem is when PA schools have say 40 openings and average med schools have 300 seats, it really evens things out BUT because PA has all the hype right now, all those potential med students who want less responsibility and work hours but have Med School GPA swag are going to 'trickle down' to PA, its already sending the averages up to the skies. When USNews Magazine puts PA nicely above Physician in the 2017 Best Jobs then people are going to notice. Anecdotally, I know a guy who applied for PA degree to 40 colleges for three cycles (120), flew all over the country for 18 months and spent 8000 dollars and eventually got in. The truth of the matter is, PA school is very hyped but will soon not be a reality for most people because of the extreme competition. The numbers you are quoting BTW are extremely more strict then even in 2006 when GPA's of 3.0 were still seen. I am already reading 3.6 being closer to comfortable which is just .1 lower than Med School.

    Anyway TL;DR The PA Party is likely over and one should expect similar numbers that it took to get into Med School to get into PA School and baselines are shooting up every year.

    1. Hi,
      Thank you for your input, I acknowledge that PA school admission is becoming more competitive. However, it is not just as competitive as med school admission. I think I have discussed the issue of comparing the competitiveness of PA school admission vs med school admission based on the number of applicants per available seat. However, since you pointed it out, I just want to clarify a couple points: in 2015, PA schools have an average of 47 seats (per PAEA report), whereas med schools have an average of 136 seats ranging from 24 seats in UCLA Drew program to 245 seats in U Washington (per AAMC report). The numbers I've been using are straight from the PAEA and AAMC reports, both in 2015 for comparison. The number 3.6 GPA you mentioned as to be comfortable for PA school admission is difficult to verify because it's not in the latest PA Education Association (PAEA) annual report, maybe they will updated it with the next one.
      Finally, there is still one thing we have not discuss: the MCAT, which is unquestionably the most challenging part of medical school admission. I will illustrate the last point by quoting the 2016-2017 AAMC report: for applicants with GPA > 3.79 AND having the average MCAT score (50th percentile), the acceptance rate is only 33.8 %. Furthermore, medical school matriculants have an average MCAT score in the 83rd percentile, whereas PA school matriculants have an average scores of 55th and 64th percentile for QR and VR of the GRE, respectively. So the reasonable conclusion we may draw from those statistics is that medical school matriculants had to score in a higher percentile and had to do so in a more challenging exam compared to PA matriculants.
      TL, DR: PA school admission is competitive, agree. But it is not as competitive as med school admission. Med schools have on average 136 seats not 300 seats. Beside med school matriculants having higher GPA than PA school matriculants, MCAT is harder than GRE and this contributes to med school admission being more competitive to get accepted than PA school admission.
      I typed this fast, and I’m not trying to attack anyone (hopefully it doesn’t come across that way). My goal here is just to provide some current data so this post is updated to latest information.

  32. Hi! Thank you very much for this interesting and helpful article for me! To tell the truth, this is the first article about np personal statement which I can call really useful and important for me, because all the previous ones are not so specific and useful for me and they can not give all the answers to my questions. And I would like to mention also, that it would be great if the author will continue to write the articles like this, because they are really helpful not only for me but for many other writers as well.


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