The pathway to becoming a licensed physician in the United States requires nine to eleven years of formal education, and all physicians are required to pass a series of three high stakes standardized examinations called the United States Medical Licensing Examination (USMLE) before they can be licensed as to practice medicine. Most physicians also go on to become board-certified in their specialty field, which requires an additional examination following their residency or fellowship training. Compared to physicians, nurse practitioners and physician assistants have a far shorter course of training, and both are required to pass one standardized examination to be licensed to practice.
In 2008, the National Board of Medical Examiners offered down a simpler version of the USMLE Step 3, an examination all physicians take to receive a medical license. The pass rates for DNP candidates ranged from 33%-70%, and the experiment was discontinued in 2014 due to "low utilization."
Roy Stoller DO, an otolaryngologist and board examiner, joins Rebekah Bernard MD and Niran Al-Agba MD in a discussion of the differences between the exams that medical doctors and nurse practitioners and physicians assistants take.
Get the book! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
The pathway to becoming a licensed physician in the United States requires nine to eleven years of formal education, and all physicians are required to pass a series of three high stakes standardized examinations called the United States Medical Licensing Examination (USMLE) before they can be licensed as to practice medicine. Most physicians also go on to become board-certified in their specialty field, which requires an additional examination following their residency or fellowship training. Compared to physicians, nurse practitioners and physician assistants have a far shorter course of training, and both are required to pass one standardized examination to be licensed to practice.
In 2008, the National Board of Medical Examiners offered down a simpler version of the USMLE Step 3, an examination all physicians take to receive a medical license. The pass rates for DNP candidates ranged from 33%-70%, and the experiment was discontinued in 2014 due to "low utilization."
Roy Stoller DO, an otolaryngologist and board examiner, joins Rebekah Bernard MD and Niran Al-Agba MD in a discussion of the differences between the exams that medical doctors and nurse practitioners and physicians assistants take.
Get the book! https://www.amazon.com/Patients-Risk-Practitioner-Physician-Healthcare/dp/1627343164/
PhysiciansForPatientProtection.org
Rebekah Bernard MD 00.04
Welcome to “Patients at Risk,” a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I’m Dr. Rebekah Bernard, and I am joined by my co-host and the coauthor of our book “Patients at risk, the rise of the nurse practitioner and physician assistant in health care,” Dr Niran Al-Agba.
Niran Al-Agba MD 00.24
Good evening
Rebekah Bernard MD 00.27
The pathway to becoming a licensed physician in the United States requires nine to eleven years of formal education, and all physicians are required to pass a series of three high stakes standardized examinations called the United States Medical Licensing Examination (USMLE) before they can be licensed as to practice medicine. Most physicians also go on to become board-certified in their specialty field, which requires an additional examination following their residency or fellowship training. Compared to physicians, nurse practitioners and physician assistants have a far shorter course of training, and both are required to pass one standardized examination to be licensed to practice.
Today, we are joined by very special guest Dr. Roy Stoller, an otolaryngologist and board examiner, who is here to help us understand the differences between the exams that medical doctors and nurse practitioners take. Dr. Stoller, thank you for joining us.
Roy Stoller DO 1:23
Thanks for having me
Rebekah Bernard MD 1:25
Roy, tell us about your training and how you became a board examiner for physicians certifying as otolaryngologists.
Roy Stoller DO 1:34
Well, as you know, it all starts in university. Most of us who major in science - or don’t major in science -take at least up to 60 credits in the hard sciences. I was a psychometric/ psychology major, and as I went through these hard-core sciences, I really developed a sense of deductive reasoning, which I don’t believe I would’ve developed had I not had to take these hard science classes.
So, all medical students complete that regimen and then we take the MCATs which is a very comprehensive exam to kind of standardize at all the different students from across the country because as you know, medical school is very competitive. Less than 3 out of 10 or 4 out of ten eventually get in.
Once I got into medical school, completed 4 years of medical school which includes about 2000 and more clinical hours where we are supervised, we start to take our licensing exams. In the second year, we take the USMLE 1 which we all know that is one of the hardest exams to pass. What we all say is, “study for six months and pray.” It’s written by PhD’s in sciences and they do not let up on us!
We have to pass that exam to show we have the basis to continue. At the end of the four years in med school we take part two of the USMLEs which include a didactic and a clinical part. Most of us now pass at higher rates because we are getting more into the clinical sense. And then in our first year of internship and residency - which all states require at least one graduate medical education year - we take the third part. And we have very high passing rates because we’ve all been weeded out and studied so much. We’re kind of ready to go out. Between 90 to 98% of us pass that exam.
Rebekah Bernard MD 3:48
I always like to hear what different subjects different physicians choose. I was a sociology major - although of course just like you and every physician, I still had to take all the hard sciences – biology, chemistry, organic chemistry, physics, calculus, biochemistry - but I did choose to major in sociology just because I found it really interesting. You were said you majored in psychology and psychometrics. Niran, what did you major in?
Niran Al-Agba MD 4:16
It was actually physiology with a specialization in history of medicine.
Rebekah Bernard MD 4:22
Oh, that’s a really interesting major.
Niran Al-Agba MD 4:25
It was a little bit of more of a medical ethics. We went through a lot of the different medical cases like end of life. Dr. Kevorkian in Michigan was very controversial at that time and so there was ethics, history of medicine in the United States, other countries, healthcare systems and what’s different. That was a long time ago - 1992-1993 is when I was doing that.
Rebekah Bernard MD 4:48
But what we all have in common is no matter what we chose as a major, we all had to complete the same hard sciences. And of course, many physicians do choose to major in a science as well, I know many of my colleagues majored in biology or one of the other biological-type sciences, zoology, some of them did.
Niran Al-Agba MD 5:05
You know what’s interesting though, even if we don’t major in a science it doesn’t mean we get out of taking those courses. And I think that’s a really important point is that even when you’re a philosophy major for example you still need to apply to medical school and be approved on the application list for the prerequisites. You still need biochemistry, biology, chemistry, physics and a lot of those hard core sciences regardless. I think that’s a really important point that you have to have a science background to get accepted to medical school.
Rebekah Bernard MD 5:34
I think it’s one of those things that I forget how hard it was and how much I went through and it’s something that’s a little bit of a bonding experience I think if you talk to most doctors will ask them and they will all remember how awful organic chemistry 2 was for example – everyone has that in common
Roy Stoller DO 5:58
What was amazing was that I graduated early - I skipped some grades - and I was one of the youngest in medical school and they had PhD‘s in my class and oh my God, was medical school hard! You know we’re all straight a students now being put in the same classes and working with these really intelligent, very accomplished people. It’s just so competitive that it forced me to be the best that I could be.
Niran Al-Agba MD 6:26
How old were you when you went in?
Roy Stoller DO 6:30
I started med school when I was 22, I finished high school at 16
Niran Al-Agba MD
So did I.
Roy Stoller DO 6:37
I took a year off and I started a master’s in health science because I felt I needed to slow down. I didn’t think that was a good move that they put me through school so fast.
Rebekah Bernard MD 6:52
Yeah, you want to have a better experience and a little bit of life experience can be really helpful when you’re going into medical school – not that you have that must life experience in your early 20s, but at least there’s something versus going straight through – there’s something to be said for that for a lot of people.
Niran Al-Agba MD 7:09
I had my 21st birthday in my first year of med school, I entered at 20 so I completely agree looking back I often think that a few extra years … I shouldn’t have been in such a hurry
Rebekah Bernard MD 7:20
I felt that way too I was 21 and when I think of what one or two things I would have changed in life I would’ve taken a few gap years as they call it nowadays – it wasn’t really an option because nobody was really funding me - but it would have been great to have backpacked Europe or something awesome like some of people I knew did, instead of going straight through school.
But getting back to the competitiveness, Roy you were exactly right, the last acceptance rate that I have statistics on says that 39.6% of all applicants to medical school were accepted and it’s quite a contrast to other programs like nurse practitioner schools some of which boast 100% acceptance rate for some of them.
There’s only 179 medical schools in the country and of those medical schools they accept a little under 40% of all applicants so they really do you have to be the top - and the only people applying are those that have met the criteria in other words they have already taken those sciences and they have already taken the MCATs
So, lets’ talk about the MCATs because that’s really the first standardized test that most of us experience. Tell me what you remember about taking the MCAT?
Roy Stoller DO 8:29
Oh boy. I remember studying really hard because you’re going over all those hard sciences that you did for college and I remember we were tested in chemistry, bio chemistry, biology, physics, calculations, mathematics…
Rebekah Bernard MD 8:52
And there was some writing on there and some English and things like that you’re just a throw a little… make sure you weren’t just focused on sciences
Roy Stoller DO 9:02
I took the MCATs twice I believe, I guess I blocked it out – it is not a pleasant experience, only to be worsened by USMLE1 – if you think the MCATs are bad…
Rebekah Bernard MD 9:17
Yeah that’s the thing… you think, ‘this is just terrible’ and you don’t realize at the time of this is just a drop in the bucket to what comes in the next phase
Niran Al-Agba MD 9:26
To me, that’s actually the worst of all the tests – at least as I go back and think about it – I’m sure you guys probably agree - the US MLE1. They gave us 2 months off to study for it. Every day we’re hitting the books and the year I took it there was some sort of scandal or something where even fingerprinting us wasn’t good enough and the results were delayed and I remember just sweating it hoping that I just could pass
Roy Stoller DO 9:54
You know I read some of the flippant things on social media ‘I’m going to be a doctor,’ ‘oh I’m going to be a nurse practitioner,’ ‘I could’ve gone to medical school.’ 10% of my class dropped out. And I don’t get how people don’t realize just because you get into medical school doesn’t mean you’re going to be able to complete it. It’s not a guarantee - a letter of acceptance. That’s great to get a letter of acceptance, but the amount of work and dedication that you have to put in to get through, I don’t believe anyone really realizes it except us who have completed it.
Rebekah Bernard MD 10:30
You know that’s a really good point and to me also Niran, step one was my worst experience except gross anatomy, I was telling Roy earlier that my worst memory of my whole training was gross anatomy and it’s because I didn’t realize – when I studied the human body, the dissection, as it was laid out on the table in anatomic position. The arms were laid out with the palms up, and then when I went in to take the examination instead of seeing the body like that, they had taken off the arm, they had flipped it around and inverted it and stuck a little pin into a structure of the arm, and then on top of that instead of saying ‘what is this structure’ which is what I expected they said, what is the embryologic root of this structure? So, first of all I had to imagine what did this arm look like, put it back position that I studied it - which was hard enough - and also to figure out what it was and even further what the question was actually asking me, which was really detailed.
And of course, that was timed, so as I was sitting there sweating bullets and trying to figure out how I was going to come up with this answer, the little bell rang – ding! - and we had to move to the next table. And that was just the beginning of my nightmare which I still relive. And I actually failed that examination, it was the only time I had ever failed anything; I failed it miserably.
About half of our class failed that exam and I remember we were asked – this was medical school I don’t know if it’s still like this now – but at the time they said ‘at the end of our next lecture’ - and I just found out I had failed it so I was in shock - and they said ‘everyone that failed the exam please remain behind .’ So half the class gets up and leaves and the other half of us are sitting there just, like, mortified, dying and then we found out – it was kind of good to know we weren’t the only ones that failed- and then we got some special tutoring so that we actually knew how to study appropriately and thank God I passed the other ones because If you failed another exam, you failed the entire first year of medical school. You’d have to repeat the year and potentially you might not even make it at all through med school as Roy pointed out.
So, that was a horrible experience and then step 1 was also a horrible experience. We got a month off to study and I used to go to the law library to study – because the medical school library was really bad- not really bad but the law library was really nice -and I would get up at eight in the morning and go into the library and I would stay all day, take 30 minutes for lunch, go back, stay all night and have dinner and go back, and did that 12 hour study day for a whole month 7 days per week.
Roy Stoller DO 13:13
You’re reminding me of my final exams. When I had like 18 classes, I would literally start in the evening and just study the whole night through. Go in, take the exam, come home, go to sleep wake up, study the whole day into the night, study into the night, and then take the exam and no one would see me for 2 weeks. It was like, I have to pass my final!
Niran Al-Agba MD 13:36
I think what you both are talking about is this acquisition of expertise which I love to talk about and I actually studied in an area of University of Washington where Bill Gates had done his middle of the night computer work. So he talks about why he always donates to the U W because there’s this area there aren’t a lot of people and it’s not really unlocked 24/7 but the lights are on and it’s very quiet place. It’s a certain wing of the University of Washington and that’s where we spent - my study partners and I – we spent all of our time and sometimes it was overnight. Again, it’s this acquisition heading to the 10,000 hours of experience and learning and engrossing yourself in a subject so you are literally an expert. And it’s amazing even still as much as we laugh about our gross anatomy flipping parts over which was so disconcerting to me in the final exams like you’re talking about, I think when we are under the gun and we are in a situation that’s an emergency or something we draw on that.
I routinely draw on my anatomic stuff I learned, on the histology just so many things doing primary care that I still go back and think wow , that’s why I had to learn that
Rebekah Bernard MD 14:42
It was worth it.
Niran Al-Agba MD 14:44
Yeah I was worth it. We’re experts and I think that’s such a critical piece
Rebekah Bernard MD 14:47
And you have to put in the time to gain that expertise unfortunately there’s really no substitute for just logging in 10,000 hours - and doing it the correct way as I didn’t in my first gross anatomy exam. But I had to learn how to do it correctly.
So, step one that we take just to recap is eight hours long. It’s 280 questions and it evaluates the students’ mastery of science and that’s the first step exam that we take the end of our second year of medical school which is typically our sciences, our foundation although we are gaining clinical experience during that time too. But we really start our clinical years in the third year and so after we finish our third-year core rotations which are internal medicine, pediatrics, obstetrics, etc we then take another exam that’s called part 2, and that exam measures our clinical knowledge and our clinical skills, and it includes simulated patient encounters. That exam is nine hours and it’s 318 questions. And then after we graduate medical school, and we get into our residency training we then have to take a final step exam in order to be licensed as physicians. And that exam is two days long. The first day is seven hours of testing and it covers foundations of independent practice and then the second day includes nine hours of multiple-choice questions and computer-based simulation
Niran Al-Agba 16:13
The first-time pass rates for US Physicians - the most recent data we have - those who trained in the US in 2015 – the DO degree which is the Doctor of Osteopathic Medicine, 91% of those passed step 1 - the first time passing rate - and for MDs it’s 98%. The pass rate for physicians who trained outside of the United States was closer to 89%.
Rebekah Bernard MD 16:40
Still most people passing those standardized examination and you must pass them to move on. Now, Roy, you learned about something really interesting, which was that the National Board of Examiners did an experiment where they gave nurse practitioners a version of the US MLE step three can you tell us about that?
Roy Stoller DO 17:00
Well, you have to put that in context. So, in the era it’s about 2008, 2006 and Libby Zion unfortunately dies in New York City. [She’s] a teenager who ends up having a complication of medical intervention called serotonin syndrome - which are the time we really didn’t know about. But politically, it is investigated and the powers that be come down on the medical education system and say that residents are spending too many hours in the hospital. So, they cut our hours about 20%. So now you have resident physicians who are the backbone of the hospital system working 20 hours a week less and when you multiply that out by the hundreds and thousands of doctors that you have you now have a void.
Mary Mundinger in Columbia university is a PhD in nursing, and she is the mother of modern nurse practitioning. She’s on the board of United Healthcare - an insurance company - and they are constantly figuring out how to save money. She sees this as an opportunity to now package her nurse practitioners off as primary care practitioners. And although they constantly deny it, it was wrapped around so that they could replace family physicians. She hijacks the DNP degree - not a PhD - it is a doctorate degree that nurses used to educate other nurses and study Nursing Health Care policy - and she now create a doctorate that she can give her nurse practitioners. But she is missing is equivalence. So, she goes to the USMLE boards and petitions them to give a watered down version of our part 3.
Now, in context the USMLE3 by itself is not an exam that by itself tests for clinical competency. To get to that point, you first have to graduate medical school, pass all the exams, pass all the courses. And pass USMLE 1 and two. So, she’s skipping all that and cherry-picking questions of our easiest exam. She also cherry picks the DNPs she’s going to give it to – they are Columbia University cream of the crop DNP candidates, and when they give this exam to them they vary between 35% or 40% to 70% passing and they can’t ever get over that hump. So, instead of stating, ‘oh, we need to give them more education’ so if we want to prove equivalence, what do they do? They lower the standards, change the exam, and put forth studies that really don’t test equivalence, but they pretend to test equivalence, and they now have this pseudo manufactured nurse that looks like they can practice primary care.
Rebekah Bernard MD 20:19
Right, it was such an interesting experiment and I think it didn’t go the way they planned it to go. First, let me point out also, we mentioned that most of us study for two months for step one and there’s kind of this adage in medicine about the step exams they say, ‘two months, two days, two number two pencils.’ In other words, you study for step one two months, two days for step two, and you don’t even study for step three because this is what you do every day, so you show up with your number two pencils.
So, remember that if you ask most physicians which was their easiest exam they are going to tell you step 3. So, step 3 was the one that the DNP candidates took. And they started in 2008 and they had 45 applicants that took this exam, and they had a pass rate of 49%. And remember this isn’t even just the USMLE3 that physicians take, this was as Roy said, a watered-down version. In fact, the National Board of Examiners published a white paper and it stated “the DNP certifying examination is not designed to replicate the USMLE assessment for medical licensure. It does not include the in-depth assessments of fundamental science, clinical diagnosis, and clinical skills that are provided through USMLE for physicians.”
So, 2008 was the first time. 2009 they had 19 people test and only 57% passed.
2010 they tried it again 31 candidates: 45% pass rate. 2012 they had a little bit of improvement 22 people took it in 70% passed. But then in 2013, of the 28 that took it only 33% passed. And keep in mind that physician pass rate is about 98% for this same exam.
So, guess what happened? In 2014 they discontinued this examination and hopefully I’ll be able to show in the YouTube video a screenshot of a letter from the USMLE examiners that it was discontinued for “low utilization."
Niran Al-Agba MD 22:26
I think limited, so, limited utility, as if it’s not valuable because it can’t be passed so therefore, we’ll just not do head-to-head, we’ll just not compare apples to apples or even try you know the educations are completely not comparable.
Roy Stoller DO 22:42
But what’s interesting is that these nurse practitioner DNP candidates had already passed some version of their FNP tests, and that’s the test that they use to state now that they are equivalent to us. So, it’s not even this more complex, watered-down version of what we have. They are going back to a master’s degree that in the beginning the reason why they wanted to create the DNP was they didn’t think the master’s degree was enough. And now because they cannot develop this doctorate degree to that level they are going back to the master’s degree FNP and trying to pass that off as equivalent.
Rebekah Bernard MD 23:22
You’re exactly right. We’ve gone through the 3 steps and that’s what we need to become licensed physicians, but most doctors don’t just stop at getting a medical license. Almost every physician becomes board-certified and that means that they complete a residency period of training and it’s credentialed and follows standardization and they have to pass a board examination at the end of that period to be board-certified. Roy, you’re an otolaryngologist – an ENT physician- tell us what the ENT board exam is like
Roy Stoller DO 23:54
Well again, you have to qualify for it. So, most ENT physicians do 5 or six years of post-graduate training and that involves being supervised by countless number of surgeons learning how to do surgery, learning how to do clinical worknd at the end of every year you take an in-service exam which compares you to the other residents in the country and you have to get a score of that is respectable or you could lose your residency position. And the test is not easy. At the end of those 5-6 years, you take a written exam in ENT. It’s an all-day test and it’s written by specialists in the field like myself. And we focus on three components: Knowledge, application, and comprehension.
So, to the lay public, knowledge is: suppose you have conjunctivitis, what is that? It’s an eye infection. That’s knowledge. Application is, well what do you do about it? Well, you treat it. Do you treat it with antibiotics? Is it a virus or is it bacteria? Comprehension is where we like to test doctors and that is more deductive reasoning. Does your patient suffer from comorbidities like diabetes? Are they currently pregnant? What would be the complications if you don’t treat this or treat it ineffectively? So, when we write the boards for otolaryngology, we have 70% of the questions have to be in comprehension and not just knowledge base.
Once you pass that exam you go out to practice and in the middle of your practice year you are called back for your oral exams and you have four stations where you are tested – ear, nose, throat, and facial plastics and those questions are based on clinical settings and what we are watching is how well you function under pressure. And of course, we’re going to throw complications at you - that’s what happens because we want to see what you do when things don’t go well. And we fail people because when you put out a product of a board-certified otolaryngologist in the United states we want a certain standard.
Rebekah Bernard MD 26:18
And thank goodness you do because I certainly want to know that my ENT physician knows what they’re doing and same for my family physician or my pediatrician. Niran, tell us about your pediatric board exams.
Niran Al-Agba MD 26:31
Well it’s not quite as involved as Roy is describing but it’s two days and it’s eight hours both days and again, it’s rigorous and we have to pass it. Obviously if we don’t pass it we won’t end up being board certified as a pediatrician. It’s that kind of the second step that you talk about - it’s not just knowing that you know 90% of normal children walk by 15 months, right? That’s burned into my brain forever. But it is: the child can do this, this, this, and this; roughly how old is the child? So it kind of makes you really have to know your knowledge well and it’s something that we put out a certain standard of excellence and of knowledge and then application of that knowledge which is so important
Roy Stoller DO 27:21
What we don’t realize with primary care physicians such as the two of you is the extensive base of knowledge you need to have. And you guys make it look easy and why that is so, because honestly I’d say 80% of the patients you see are pretty straightforward and it’s that 20% that you guys have to pick up on and that’s what your tests test because I write questions for your exams and I know what I’m writing. I am not writing standard ENT questions. And that’s the difference when you see your physician versus a nurse practitioner or PA in pediatrics or family medicine. And I don’t think the medical community or the patients really appreciate what primary care the base of knowledge of what primary care has to know.
Rebekah Bernard MD 28:11
Yeah, it’s really rigorous. So, for family medicine the boards are nine hours and there are 320 questions. For internal medicine the exams are 10 hours - for subspecialists they have to take an additional four hours of questioning - and as Roy mentioned for some specialties like psychiatry and surgical fields are oral board examinations and those are really a very important part of their testing.
Just for contrast nurse practitioner exams, there are a couple options that they can choose, and the family nurse practitioner exam is 3 to 4 hours long and it’s 200 questions. In 2015 the pass rates – they have 2 different exams - the pass rates were 75% for one exam and 81% for the the other. And what’s interesting is that Lehman College, their family nurse practitioner program just lost its accreditation because their graduates weren’t achieving an adequate pass rate. They had to have at least an 80% pass wrote from their college to be accredited. So, they went on probation and they got their levels up to 78% but because they still didn’t get that 80% they loss their accreditation. I know that they are appealing that but on the point is that again consider the nurse practitioner boards kind of like our step three exam and for physicians are about a 98% pass rate and here we have 75% for one of the board certifications that they have.
Niran Al-Agba MD 29:35
We should talk about PA boards as well I mean I think that’s a worthwhile thing to add on. There is one certifying exam for them at the end of school the physician assistant national certification examination which is known as the PANCE. It’s a five-hour, 300 question test which has to be taken every 10 years to recertify and 93% of test takers pass and then after graduating from school and then passing this test they can apply for a license to practice and as we’re seeing in some states that means independent practice.
Rebekah Bernard MD 30:06
And they have to take the exam every 10 years and physicians also must take exams periodically it’s either every 7 to 10 years depending, but nurse practitioners don’t have to repeat their exams. They only have to take it one time. And recertification is just them submitting their hours and those hours can be volunteer hours so there’s no additional certification requirements like PAs and physicians.
Roy Stoller DO
I would like to say that the three of us all agree that nurse practitioners and physician assistants are valued members of our teams but those teams need to be physician-led and what we’re trying to convey here is the education and testing processes for these auxiliary healthcare practitioners does not meet our standards for allowing them to see patients independently. But they are valued members of our team and they do great things but they need to be supervised by physicians
Niran Al-Agba MD
Well and that goes with what we found, again what I share with people is that it’s not an opinion to say physician-led teams are safe it’s actually what is science has a evaluated so it’s evaluated the ability of nurse practitioners and PAs to practice which we absolutely find valuable but five decades of research shows that they provide safe and high quality healthcare when supervised by physicians and that’s what been studied so that’s what we know.
Rebekah Bernard MD
Thank you so much I appreciate both of you being with us.