The Reply

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I respect nurse practitioners (NPs) and physician assistants (PAs), and this article1Kendall L Graduate medical education has been threatened.Am J Med. 2020; 133: 1017-1018Abstract Full Text Full Text PDF Scopus (2) Google Scholar was not intended to disparage their respective fields. This commentary was written, in part, to show the subversive way that medicine is being manipulated by corporations, special interest groups, and the government. The lexicon originally used for physicians is now being used by others who didn't have the same education and training. The big question is what does the public understand by the word “resident”? What do our colleagues understand by the word “resident”? Using these terms is deceptive to the public and confusing to our colleagues, who may have no idea of the background of the person with whom they are communicating while collaborating in patient care situations. Nurse practitioners practice advanced nursing and not medicine, and this is, therefore, not graduate medical education. Likewise, PAs are not physicians. Any training after PA school should be called “post-graduate PA education.” To address Cappaert's assertion that a resident's salary would “strike many Americans as comfortable,” we should also consider that a resident frequently works 80-hour workweeks throughout their 3-7 years of residency training, amounting to $15/h. A minimum wage salary, while working 80-hour workweeks, for a job that is difficult with intense responsibility, isn't so comfortable, nor are the hundreds of thousands of dollars of debt that these residents carry from medical school. To address the other major aim of this article, graduate medical education (GME) is not under threat because nonphysician providers (NPPs) are thriving. GME is under threat because the government seeks to divert funding away from residency training, when there is already a shortage of residency slots. Our concerns about the quality of education and training are equally important. The world still needs competent physicians, which means the funding and the resources should not be diluted for other disciplines. If additional training is the goal for NPPs, then the government should create an entirely different funding stream for this purpose and allocate additional teaching resources for this purpose. However, the government should first address the current unmatched physician graduates by increasing funding for residency slots. It would be impossible to discuss all the vast differences in education and training between physicians and NPPs in this space. Suffice it to say, there is no abbreviated path to becoming a physician. The more you know, the more you realize you don't know. That is why the requirements to become a physician are long and difficult. To imply that NPPs can practice independently is to imply that the difficult science courses and prerequisites to get into medical school are superfluous. It implies that medical school, itself, is unnecessary. It implies that having an intricate understanding of the pathophysiology of disease is not essential. No one is saying that NPPs “pack up their stethoscopes, abandon their patients, and become investment bankers.” NPPs are valuable members of the treatment team; however, a physician should always be the leader of the team. Above all, we need to focus on ensuring the highest standards of training for medical students, residents, and NPPs. There are no shortcuts when human lives are at stake. Graduate Medical Education Must EvolveThe American Journal of MedicineVol. 134Issue 3PreviewI am a physician assistant working in urgent care medicine. Prior to that I completed a residency in family medicine at a Federally Qualified Health Center that serves a large uninsured and Spanish-speaking population. Full-Text PDF