DH 48 | Medical Training

 

Have you ever wondered what exactly medical training is like? In this episode, Dr. Trish Murray sits down to discuss this with Phil Brauch, a current medical student, and future sports medicine and functional medicine provider. Phil discusses how medical training can involve a wide spectrum of different medical fields. These include anatomy, pharmacology, surgery, nutrition, and many more. Join Dr. Trish and Phil as he dives into the world of medical training.

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What Is Medical Training Really Like? With Phil Brauch

I am excited because we have an opportunity to have a conversation with a person going through traditional medical training. His name is Phil Brauch and he is presently a student at Franklin Pierce University in West Lebanon, New Hampshire. He’s presently in my office as a physician assistant student. It’s not every day that I have a person training in the medical field in my office. It’s not every month that I have someone training in my office in the traditional medical model. I thought it would be interesting for people to hear a conversation between Phil and I about what is medical training really like. What does it involve? What are the different types of training that people can partake in, particularly about obviously physician assistant training? Phil, tell the people a bit about your education before you ended up as a physician assistant.

I went through a pretty long path and did a few different things before I decided to go to a physician assistant school. I’ve always been interested in health, sports and how can people live better lives. In my undergrad, I studied secondary education, that physical education, health and exercise science. I thought that was a good route to go to promote helping people live better lives. I did that and as I went through my education, I realized that physical education was the most mentally stimulating thing that I want to do. I got introduced to strength and conditioning and I thought that was more of an advanced physical education teacher. I wanted to strength and conditioning. I was fortunate to pretty much right out of college get into the NFL. I’m with the Indianapolis Colts and then I got a great experience and was also introduced a lot of different things that I wouldn’t have been introduced to. I got introduced to people in different settings. I got introduced to chiropractors, physical therapists, athletic training, sports and medical doctors. My mind was always racing and I was always reading on different ways to advance my own education.

You were working in the NFL for the Indianapolis Colts as a strength and exercise conditioning kind of position.

Yeah, we did strengthen conditioning and I would say I was very fortunate to work with good people. There were strength coaches at the NFL. In the same thing, there are some great strength coaches at the high school levels. It’s not necessarily where you’re working, but I was fortunate to work with smart people who challenged me and made me think and steered me in the right direction.

When you work in the NFL, because people are interested now I’m sure, you say you were exposed to physical therapists, chiropractors and other types of providers. Was that especially through the interactions of people that worked with the NFL player? 

Yeah, their own staff and with every team I work with. I also worked with the Cleveland Indians and worked at a spring training facility there. It was me and physical therapists rehabbing players all the time. That gave me more insight into rehab and physical therapy. We started on the education topic. I also got my Master’s in Health Promotion and Exercise Science. I did that online when I was working for the Cleveland Indians. I’ve always been interested in learning. I did strength and conditioning for years. I worked for the Chicago Bears for four years. I got to the point where I felt I was limited with what I could do as a strength coach. I have always had a thirst for knowledge. That continued on with my education. Why I want to get more education was wanting to learn more and having a wider scope of practice.

One of the other big decisions that went into it was the quality of life. I wanted to change and have a different career helping people from all different levels. Pro athletes are great to work with and obviously we’re working with an elite athlete and you get all the resources to be able to do things right and when it comes to nutrition, hydration, physical therapy, doctors and MRIs. It’s the gold standard of doing things. I also enjoy working with the everyday person and learning the skillset that I did at that level and being able to take it to every day and weekend warrior, not necessarily a pro athlete. I enjoy doing that.

The biggest difference between med school and physician assistant school is you don't go in-depth in histology that you need in med school. Click To Tweet

Before you did anything more now about physician assistant training, what’s your background in athletics? Were you an athlete?

Yes, I was. Athletics has always been my life. That was also another thing. I’ve always been an athlete and I’ve always worked in athletics, so it was hard. Now, I’m not in athletics. To be honest, that was completely foreign to me. It’s a world that I didn’t know. In high school, I played football, hockey and lacrosse. I played Division-I lacrosse in college, then I played professionally for a little bit after college and I played for the English National Team as well. I still love playing lacrosse, hockey and skiing. Athletic is still a big part of my life, but going back to why I wanted to get out of strength and conditioning, I wanted to enjoy my own life where if you work in pro sports, that’s got to be your passion and your love and you can make it 100% of your time to where I want to hopefully have a family with my own and spend more time with that and also be able to live wherever I wanted to live. The medical field will give me the opportunity to live wherever I want to live. It was multifactorial, both wanting more mental stimulation, wider scope of practice and then also being able to have a career that is based on living your life in the sports season.

We’re in different areas but my background was lacrosse as well. That’s interesting. I didn’t know that about you and I played for the New England women’s team at one time prior to having a significant back injury that took me out of that. That’s interesting. Let’s talk about physician assistants. What’s the history of that now? Let’s start getting into that type of training, but let’s talk a little bit about being a physician assistant. There are people that are physician assistants, there are people that are nurse practitioners, there are people that are doctors. For the physician assistant, you were talking before we came on, a little bit about the history of that and where that came from. Show that to people.

Don’t quote me exactly on the here, but I think it was in the ’60s or ’70s. Military medics were coming back with great medical experience for helping surgeons in the field and in war zones with surgery. They had this great skillset, but once they came back to the US and were in the non-medical, nonmilitary world, they didn’t have a job. PAs were invented at Duke University and again I forgot the name of the guy who started it. He was a physician who started it. You started a PA program mainly for medics who have these great medical experiences, but they didn’t have a career when they came back.

The background in physician assistants versus nurse practitioners is traditional, it’s been with people who have extensive prior medical experience. They all already have very medical knowledge before they go into school where a lot of med students go right from an undergrad to med school and they necessarily don’t have different life experiences or medical experiences. I know that’s pretty general statement. There are people who start med school like yourself at an older age without prior experiences, but that’s traditionally in the sense PA education’s about people who have prior health experience. The average age of the PAs team is around 33 to 35. I started it when I was 35 or just right about that time.

The last time I check, I started medical school at the age of 35. I’m 57 now, it’s interesting that many of us do other things before we get into our medical training. Physician assistants usually had some experience clinically in some way and many from the military and they weren’t able to transition that when they came home to a degree that gave them the ability to get on licensed to practice it. Anything in the medical field out in the regular layperson world. They started these physician assistant programs to make sure they could show that they had been training but also gaining any further training to license them so that they can see people and work with people. 

That was the original. Now, it’s very different. There was only one PA program back then and now with PA education, there are a ton of schools popping up. It’s competitive to get into because especially in primary care, you pretty much can do the same as a physician just with less education. It’s more on the job training than doing like a residency. You were in med school when you do med school and then you do a residency. You can do a fellowship or whatnot. In PA, you do your education and then you get a job. It makes it easier to go to different fields. I can work in sports medicine, I could go try to work in the ER or I could work in primary care, internal med or cardiology. I don’t have to do a residency to go to a different specialty or different fields.

DH 48 | Medical Training

Medical Training: Every physician assistant program has a different mission just like every school has got its own mission statement.

 

As a physician assistant though, in any job after you’re done, you will have to work under the auspices of a full physician?

Yes. It varies every state. t varies differently in what your contracts with your supervising physician are. PAs have also evolved. They have been more meant to work in underserved areas, mainly rural areas. If you’re working in rural medicine as a PA, you might not have a physician. Every situation is different, with your scope of practice. That’s determined with your supervising physician. It varies from state to state. Some states I think a physician can have five PAs underneath them. It depends on what specialty you’re in or if you’re in primary care or internal medicine. The role can be very different.

When you talk about a supervising physician, that really means that there is a physician overseeing the cases or the clinical involvement that the physician assistant has. The physician looks over a certain amount of charts a quarter on that page, especially based on the experience of that physician assistant. If somebody’s new and they’re new to me or new that any supervising physician you may have monthly chart reviews and meetings with the overseeing physician. Obviously, if someone’s been out there longer and the physician who’s overseeing gets more comfortable and sees the experience of the physician assistant, they may just review X percentage of charts once a quarter or something like that and that’s pretty typical I would think.

I imagine that with the residents or a younger doc who’s coming. It’s more about creating a team approach with the medical team, just like nursing and medical assistant. It varies greatly depending on the medical specialty. If you want to go into surgery, if I wanted to go into orthopedics and wanted to do surgery, I could never leave the surgery but I would first assist in the surgery. Where if I’m doing primary care in a lot of places, your PA can be your main primary care. You gave me more autonomy depending on what field you go into like psychiatry. I saw with my rotation in psychiatry, the PA was completely self-sufficient just because he’s not doing surgery and it’s under the area.

Here in the Mount Washington Valley where we are in the mountains of New Hampshire, there were two psychiatrists, one of which retired a couple of years ago and the other one works within an institutional setting. There aren’t any psychiatrists up here for private people to see outside of that institution. Many of the people that are seeing people around the psychiatric things of anxiety, depression, post-traumatic stress, a lot of the different diagnoses in psychiatric world are seeing either nurse practitioners or physician assistants like yourself trained in that specialty of psychiatry. That’s pretty common in the rural setting, maybe inner-city setting.

These areas where they’re underserved possibly by physicians or anyone in the medical fields for many of the different levels. There’s also another identity out there which is a nurse practitioner, an advanced nurse practitioner. What that means is that someone’s been trained in the nursing field as a regular registered nurse but then they went back for further training like yourself. You had a background already and then you went in for further training again and get advanced training. A nurse practitioner is considered an NP after their name and they are not a full physician either, but they can actually work independently of a physician and do not have to have a physician overseeing them in some way. Physician assistants do typically require under their license to have a physician overseeing the care that they do. 

The background in physician assistants versus nurse practitioners is traditional. Click To Tweet

Actually, in some countries like in the UK and Australia and New Zealand, the physician assistants are called physician associates. We’re considered as mid-level providers and for a lot of job instances, we are a mid-level provider open to a PA or a nurse practitioner.

That’s very common exactly out in the medical field. There are full physicians and then there are these mid-level providers, but then sometimes you get in these mid-level providers are independent and autonomous. They’re not really overseeing much by the physicians because they found a lot of experience. They’re trained in their specialty and they do an excellent job. You may see PA after someone’s name, which means they’re a physician assistant. You may see NP after someone’s name, which means they’re a nurse practitioner. You may see MD or DO after someone’s name, which means they’re in full position. It’s interesting. Phil, let’s talk about the actual training you’ve had. Your training program you told me is 27 months long total. You’ll be graduating next spring 2020 in probably May because most schools end in May.

We’re scheduled. We will finish up at the end of February. We started at the end of November of 2017.

You’re getting close.

We’re getting close but it was a weird start time.

With only a few months to go, you’re here with me on an elective and as people know with the Discover Health Functional Medicine Center, I’m focused on functional medicine and I’m also a doctor of osteopathic medicine. I’m a specialist in osteopathic manipulative medicine, which is all about pain. Prior to coming to my office, which is really more of the integrative and alternative types of things that I’ve gotten more and more into, even though my original training was an internal medicine as a traditional primary care doctor, I’m very familiar with the traditional training as well as alternative training. I love to have you talk about the people cause you’re in it right now. You had exposure prior to going into this position, assistant primary care training to obviously elite athletes as you’ve said, and prep practices, physical therapists, all different types of ideas. No one has fared on exercise physiology equipment and I’m sure. What is your training been like as far as primary care is concerned? Tell people about what you’ve been through over the last months?

DH 48 | Medical Training

Medical Training: In the medical world, BMIs give a much better indication of someone’s health.

 

Every PA program has a different mission, just like I’m sure every school has got its own mission statement. My school’s mission statement is we’re all medicine. It’s in the primary care setting. The first year of PA school, and this is pretty common in all PA schools, is called a didactic year. We pretty much do a year of medical school in one year. I will say it was a very intense year of learning pathophysiology of disease, anatomy and physiology and pharmacology. We went through all the different systems and all the diseases of each system: cardiology, pulmonary, endocrinology, dermatology, urology and nephrology. We went through all the different systems learned. Usually, it was in coordination with learning the pharmaceutical treatment, pharmacology for each system as we went through it.

Pharmacology relates to medicines that will be prescribed.

We didn’t have an anatomy lab our self, but we got to do cadavers. We had our own cadavers at the med school’s facility. We’ve got to do cadavers, which is great. I love anatomy and physiology. I wish we had gotten to spend more time with the cadavers, but I found that very beneficial.

How long was your anatomy class in involvement with the cadaver?

We did that for three semesters. It’s for about nine months. We did that for once a week. We got to spend time doing anatomy, with the cadavers. We also think we are very fortunate, too. One of our lecturers was the state autopsy firm. We all got to go to one autopsy, which was a weird thing to do. For science, it was very beneficial. I went to a few of those, seeing pathology, seeing the muscular-skeletal system in that state was again, weird but very beneficial for my medical education.

Anatomy is absolutely the foundation of medical training. Anyone going through medical training has to understand anatomy. We work with cadavers. We do dissections. In medical school, your first year as to become a physician, you did all of this in a year. Whereas in the medical school world, we would spend our first year predominantly in all the basic sciences. I can add any physiology, histology, pharmacology and all the ologies. The next second year is all the clinical systems you mentioned, cardiology, dermatology, endocrinology, gastroenterology and so on. You do spend like a month on each of the different systems. It was after those two years that then we go into a year all clinical in all clinical training. You’ve also been doing obviously your rotations. 

Every situation is different, with your scope of practice. Click To Tweet

I’ll reiterate. I think the biggest difference between med school and PA school is you don’t go in-depth to the histology that you do in med school. Maybe they deep pathophysiology but in the end, unless you’re a pathologist, you’re probably not using that every day. I just want to mention that. The first year was in the classroom and we had standardized patients where we practice our physical exam skills in that first year as well.

Clinical skills, we call them. You always did that at least once a couple of times a month at first. As training goes on, you’re doing it more.

We can do that more frequently. Now, I’m in my clinical rotations and I’ve got a full year of clinical rotations. I’ve got nine five-week rotations, eight of which are set by the school that I have to do. I had to do three rotations, one in internal medicine. I did two in family medicine. We could have done an elective like urgent care with that too. Then I did psychiatry, pediatrics. I have to do a surgery rotation, a women’s health rotation and then an elective and I think that’s all. I had to do an ER rotation for all of that. It’s a good and wide spectrum of all different medical fields.

People understand the similarities, differences, comparisons with traditional medical training of a physician assistant let’s say, versus a physician. When I was in medical school, for two years, year-and-a-half, we do the same thing. It’s just if I’m in internal medicine, I may be there for two months. That’s in a hospital setting. For family practice, I may be there for two months and that might be in an outpatient setting. We have to rotate through surgery, we have to rotate through gynecology and we have to rotate to pediatrics. It’s the same concept. You’re in the clinical training following physicians and residents around and getting your hands on people and things whenever you can and you’re allowed.

It’s been great working with nurse practitioners who have been called your preceptors. I’ve worked with nurse practitioners. I have worked with physician assistants. I’ve worked with medical doctors and I’ve worked with DOs. They’ve all taught me different things. It’s been beneficial to work with all the different medical professionals.

You’ve had a background in short of some integrative alternative things before and then you’ve gone now over the last year or more year and a half, almost two years into very traditional training. As you say, every time you did a clinical on a system, it was always about the pharmacology of the treatment of that system. Would you agree? Because I’m a functional medicine doctor and I did my training and I was an internist. I can tell you that the reason I left internal medicine primary care was that patient after patient, I had ten minutes to see them. They may have had ten to fifteen or eight medicines or whatever it was, prescription medicines. I had to figure out which interactions are going on and which medicine is the medicine to either add or increase or whatever.

DH 48 | Medical Training

Medical Training: The approach is that you’re at how the whole body functions as a whole.

 

To be honest, people were not getting better in my world from doing that. It may have maintained their stability. They weren’t dying from their hypertension or their cardiovascular disease, but they sure weren’t getting better. Their quality of life wasn’t improving and things like that. That’s what led me down my path to leave and look for other answers and pursue especially my love in pain and osteopathic manipulation and then later functional medicine. You’re in it. You’re on little different avenues. You tell them what you think.

My background has always been health and normally health with peak health in the pro sports world, you’re looking for that 1%. It’s the difference between winning and losing sometimes. It’s really fine-tuning and getting down to the nitty-gritty and optimal performance. In optimal health, not only strength and conditioning but I did nutrition, hydration, body composition, a lot of different factors where I’m using the body, having a BodPod and analyzing body fat. In the medical world that’s BMI, which mostly is about body fat. It gives a much better indication of what someone’s health is where it’s like, “I’m obese in BMI but I’m not obese.”

Let’s make sure people understood because that’s a good point. What Phil’s talking about is something called the BMI, the Body Mass Index. Phil is obviously a very muscular and in shape and healthy-looking guy. He’s been a professional athlete and all this stuff. I also in my background was a competitive bodybuilder. As a woman, I have a lot more muscle mass than the average woman. We are both scored as if you take our height and our waist circumference and our weight and our heights conference and you do the calculation of a Body Mass Index. We come out as being either overweight or even obese even though we are not. Because if you have more muscle mass and muscle density than the average person, you don’t fit into the Body Mass Index world. In the exercise world, why don’t you explain what you guys use?

We use different ways to measure body fat. One’s the BodPod, which I’ve always had. It’s like doing an underwater weighing to get your density, but you do that with air displacement. That’s how I’ve done it. You can also do it with a DEXA scan well. I’ve always had a BiPAP. That goes into the next thing of functional medicine in which I account to think of functional medicine too. It’s more individualized medicine. What can you as an individual versus looking at you with the norm? In conventional medicine, it’s all about what the norm is and not you as an individual. BMI is great for the norm but individually it’s not going to tell me my health.

That’s what conventional medicine or the standard of care is all about. In all different studies and drug trials, it’s not looking at you as an individual. It’s looking at what the population is. This goes into my background. I didn’t treat every athlete the same. I knew every athlete had different needs. Like every individual is different needs and having your variety of a skillset to help those individual needs. You are supposed to do them in conventional medicine but overall, it’s not looking at the individual. It’s looking about the individual but studies are more based on the overall health of the general population versus the individual.

The other thing about going through school is that you pretty much learn as we learn about different diagnosis and different sicknesses. We pretty much learned this is a diagnosis and if someone fits in this diagnosis, this is a pharmacological treatment. Of course, there are different diagnostic ways in which is the gold standard or clinical diagnosis. What we don’t learn about and this is going into a different thing, especially with chronic disease, which is the vast majority of issues that you face in primary care and internal medicine is they’re lifestyle-based. In school, we learned about pharmaceutical interventions. We learned that lifestyle modifications and nutrition are the number one thing you want to do but that’s as far as we get into it. We don’t learn about nutrition. Maybe you can on your medical experience, but you don’t get into nutrition. We don’t learn what a good diet is.

Create a team approach with the medical team, just like nursing and medical assistant. Click To Tweet

You don’t learn anything about diet or nutrition. Diet type is a four-letter word, but what about what we should eat to stay healthy? Not worry about like diet many people think means restricting calories. Sometimes I have to say to people, “I don’t want you to be counting any calories. That’s the last thing I want you to do. I want to eat as much as you want, but we need to talk about what that includes and what that doesn’t include.”

I was watching the debates and Peter Yang said we don’t have a healthcare model. We’ve got a sick care model. That’s what we learned. We don’t learn how to keep people healthy in school. We learn how to manage sick people. There’s a difference between chronic diseases and acute care. In acute care, if you have a heart attack, I want to be in the US for my treatment. Our acute care is exceptional.

If you’re in trauma, if I’m in a motor vehicle accident and I’m a mess, I want to be in the United States ER. I don’t want to be anywhere else.

For lifestyle and managing, diabetes, obesity and heart disease.

Chronic heart disease, heart failure, arrhythmias, autoimmune disease, inflammation, osteoarthritis, anxiety and depression.

It’s both lifestyle and nutrition and again in school, we don’t learn what I would like to learn about it. That’s why I’ve kept on my passion for nutrition and background. I’ve gotten really into functional medicine that’s why I chose to come here with Dr. Trish to do my rotation here. I also love osteopathic manipulation. With chronic disease in orthopedics, which I’ve done a lot of shadowing in and spent a lot of time with the orthopedics. They don’t really look outside the joint. They look at what’s the dysfunction of the joint and not looking at the rest of the body. That’s what I love about osteopathic manipulation and physical therapy. Their approach is that you’re looking at the whole body, how the whole body functions as a whole. I’ve been lucky to touch on all these different areas of medicine and know chiropractors and physical therapists. A lot of times you don’t want to chase the pain in that something’s causing the pain, which is a biomechanical dysfunction. It’s a lot of the times what causes the pain.

Possibly inflammation from the diet or from too much exercise sometimes or not enough or a problem in nutrition or possibly too much stress and cortisol. We have to individualize people’s care. We need to work with each and every individual on a personal level. Get to know them, develop rapport and work together to try and figure it out. Not everybody fits in the box of a pill for every ill. “Here’s your uniform, you have this disease and here now you’re going to get this bottle of pills.” Phil, thank you so much for coming on the show with me and sharing with people what it’s like to go through traditional medical training, how is it similar? How is it different? When I was in medical training, we had one class in nutrition. It was half the semester-long with one semester of a four-year degree that’s it. On that note, we’re going to end. People, thank you so much for reading and please read to more of our episodes. Thanks, Phil.

Thanks.

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