Doctor, nurse practitioner, and physician assistant. Three different healthcare paths with three overlapping but distinct outcomes. How can you know which is right for you? I’ll help you decide.
Many students interested in healthcare and medicine find themselves deciding between becoming a physician with an MD or DO, versus going down the physician assistant or nurse practitioner path. After all, they all have substantial overlap, however they’re also substantially different. If you’re the type of person who would be happy being a physician, you may not be as happy as a PA or NP, and vice versa. Do note that all three are fantastic professions, and no single one is better than the other. You simply need to decide what you value most and choose accordingly.
This is a big-picture overview of the three paths.
Let’s start with the different training paths, as this is one of the biggest differentiators and a big reason many choose the midlevel path over the physician path.
The doctor training path, whether MD or DO, is the longest by far. After your 4 premed years in college, you’ll complete another 4 years of medical school followed by 3 to 7 years of residency in your intended specialty. If you want to further subspecialize with a fellowship, add one or more years after that.
Both midlevel training paths, whether PA or NP, are comparatively much shorter.
To become a physician assistant, you’ll enter physician assistant school after college, which is 2 or 2 and a half years in duration. Whereas in medical school, you spend 2 years focused primarily on didactics and 2 years focused primarily on clinic time, in PA school you’ll have just one year of didactics and the remaining 12 or 18 months focused on clinical exposure. After that, there’s no residency, and you’re free to start practicing as a PA immediately.
To become a nurse practitioner, you can choose from two paths: traditional or direct entry. The traditional pathway involves first earning your BSN, ABN, or MSN to become an RN after taking your NCLEX exam. Next, they attend a master’s or doctorate program to become an NP. If you attend a full-time master’s program, it will generally take 2 years, but if you are undergoing a part-time DNP program, it can take up to 5. If you were to major in nursing in college and take your NCLEX, you could become an RN soon after graduation and become a fully trained NP just 2 years later.
The second pathway, or direct entry nurse practitioner programs, are for those who earned a bachelor’s degree in something else. These are 3-5 year programs, where you will take both the NCLEX to earn your RN but also complete a master’s or doctorate program to become an NP.
It’s not just the duration of training, but also the competitiveness and rigor of each path. Getting into medical school is by far the most competitive of the three. At some schools, like at UCLA when I was there, over 80% of premeds on the first day of college are no longer premed by graduation time. And of those who do ultimately apply to medical school, only 40% get accepted. The average matriculant stats are 83rd percentile on the MCAT and a 3.73 GPA.
After medical school, PA school is next in the order of competitiveness. The average GPA for accepted PA students is 3.5 and they average around the 40th to 50th percentile on the GRE. Note that they do have a lower average acceptance rate at 33% of all applicants, and this sometimes confuses students into thinking PA school is more competitive. When you consider the outcome if the average premed with higher stats applied to PA school, or the average pre-PA student with lower stats applied to medical school, it generally clarifies any confusion.
Do note that many PA schools also require over 1,000 hours of direct patient healthcare experience prior to matriculating. This doesn’t make it any more competitive, but you will need to spend considerable time putting in those hours. While premeds don’t need 1,000 hours of direct patient experience, they do need to put in several hundreds of hours across multiple extracurriculars including clinical experience, research, volunteering, leadership, and others.
NP school is the least competitive of the three and it has the loosest requirements. Some programs require 1 to 2 years of prior nursing experience, while others don’t require any. GPA isn’t highlighted as a primary factor, with most GPA cutoffs around 3.0, but this isn’t a hard rule. Middle Tennessee State University, for example, is reported to generally accept applicants with a GPA of 2.9 or greater.
When it comes to rigor, your clinical years in medical school and your residency years will be extremely trying. The norm is to be working 70 to 80 hours per week, but expect over 80 hours in most surgical specialties. With the PA and NP training paths, you won’t be expected to put in such long hours or for so many years.
In terms of cost, medical school is the most expensive, followed by PA school, followed by NP school. The average annual tuition for medical school is $40,000 to $60,000 and graduates have an average debt burden close to $200,000. The average annual tuition for PA school is about $45,000 with an average graduating debt burden approximately $110,000. NP schools average between $18,000 to $32,000 per year, with the average graduating debt burden between $40,000 and $60,000 depending on the source.
Expertise & Knowledge
Considering the training paths, it’s natural to assume that physicians have the deepest knowledge and expertise when it comes to the body and how to treat its various ailments. If you assume that, then you would be correct. Not only do physicians spend the most time focusing on the foundations, but they also spend several years focusing on their specific specialty in residency.
The knowledge of midlevels is substantial, but as the name describes, is less than that of physicians. NP’s and PA’s spend far less time in training than physicians, and therefore don’t have the same depth of expertise.
Physician assistants follow the medical model, similar to physicians, while nurse practitioners follow the nursing model. But note that after completing PA school or NP school, you’re fully trained and able to join the workforce, without any required residency for specialty training. PA’s and NP’s get a great deal of their specialty training on the job after joining a practice. While this is very useful in getting up to speed quickly with pattern recognition for common presenting concerns, you won’t be well equipped to identify and manage rare or complex conditions.
Given the on-the-job training, it’s also much easier to change specialties later in your career if you get bored of one or want a change of pace. That’s not feasible to do so for physicians, who would have to reapply to residency and complete another 3 to 7 years of structured training. PA’s are considered to have the most flexibility and are sometimes found in surgical specialties, either handling pre- or post-operative patient floor work or assisting in the operating room. NP’s have flexibility as well, but you’ll need to be intentional with which program you attend, as each program trains you toward a specialization, such as primary care, acute care, family, women’s health, and so on.
If you are interested in surgery, note that only surgeons with an MD or DO are qualified and have sufficient knowledge and expertise to perform surgery. With the PA or NP routes, the most you’ll be able to do in the OR is be first assist, helping the surgeon by retracting, suctioning, suturing, and the like. That’s the level of responsibility of a medical student or junior resident. This brings us to the hotly debated topic of scope of practice.
Scope of Practice
Scope of practice refers to what each type of professional is expected and allowed to do.
Historically, the NP and PA training paths were created to address a shortage of primary care physicians and were to serve as an adjunct to physician-led care, not as a replacement. In this model, NP’s, PA’s, and physicians all work together in harmony in service to the patient. Since physicians have the most robust knowledge and training, midlevels were generally working alongside physicians, and would easily be able to ask for assistance on more complex or rare presentations.
Physicians and midlevels have worked harmoniously as designed for several decades. However, in recent years, there’s been a growing power struggle between physicians and midlevels over scope of practice.
On one hand, NP’s and PA’s are lobbying for greater scope, meaning they want to do more things physicians traditionally do, such as independent practice. The primary arguments are two-fold: first, we have a shortage of primary care physicians, and midlevels can help alleviate that. And second, they argue that midlevels receive sufficient training to practice independently and safely.
On the other hand, physicians are pushing back, primarily focused on patient safety concerns. After all, NP’s and PA’s receive far less training. My physician mentors and colleagues have shared they find the NP’s and PA’s in their practice are valuable in handling much of the bread and butter, meaning the most common and simple cases. However, when it comes to a complex or rare presentation, the training differences are starkly contrasted.
But are physicians really more qualified? Comparing the expertise and capabilities of someone who receives over 20,000 hours of supervised patient contact compared to just 500 to 2,000 seems like a no-brainer. It would seem obvious that the physician with 20,000 hours will have greater clinical expertise than the NP or PA with a small fraction of that. The only way for all parties to be equally qualified, despite the massive difference in training hours and rigor, is if the following assumptions are true: either medical school is massively less efficient and medical students massively less intelligent or capable, or if midlevel training paths are massively more efficient and their students massively more intelligent or capable.
Scope of practice creep is very much about money. After all, if you’re able to do more and practice more independently, similar to a physician, then you can make closer to a physician salary. The average primary care physician makes $240,000 per year and the average specialist physician makes $340,000. In comparison, NP’s average approximately $110,000 per year and PA’s average approximately $100,000.
Note that laws governing the scope of practice for each type of healthcare professional vary from state to state, which adds further complexity to the situation.
The reason this is important and you should care is because of patient safety. If you or anyone you care about will ever receive any medical care, then this is deeply relevant to you. The fields that are currently most significantly affected by scope creep include anesthesiology and primary care. But go on Reddit or med-Twitter and you’ll see other specialties cropping up. Ultimately, the surgical specialties are the safest from scope creep issues.
If scope creep is ultimately harmful to patients, then why has it gone so far? Two main reasons: first, in the current climate of prioritizing emotions over facts, many organizations are focused on inclusion to a fault. Being equal as humans doesn’t mean that we all have equal training and capabilities. Second, and more importantly, the AANP and AAPA are much more effective at lobbying compared to the AMA and physicians. It’s easy to point to the insanely demanding schedules of physicians to explain why they don’t have time for advocacy work, but that has to change. If you are looking to learn more, get involved, and make a difference, check out the Physicians for Patient Protection.
How to Decide MD vs NP vs PA
In deciding between the three paths, there is no correct answer – you need to decide what is important to you. Are you willing to work extra hard as a premed and crush the MCAT to get into medical school? If not, the PA and NP paths are much more attainable. Do you prioritize shorter training and lifestyle, or being the expert of your field at the expense of your 20’s and even early 30’s? Do you want to perform surgery, or would being first assist in the operating room be enough? How important is income compared to these other factors?