
Be a nurse or P.A. instead of a doctor: the underrated perils of medical school - jseliger
http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/
======
mililani
First, I know the medical field quite well, as I'm working in it, and I can
emphatically say that nursing is quite saturated now. It has always gone
through boom and busts, and currently, it's going through a bust. Just read
the All Nurses forums to see all these threads about new grads being
unemployed and unable to find jobs for a year or more. It's definitely tough
out there and will only get tougher since SO much nursing programs have become
accredited in the past decade.

Secondly, being a nurse is a HARD job. It's a blue collar job, and it should
be (probably was) on Mike Rowe's Dirty Jobs. It's back breaking labor,
stressful, and debilitating. Most of my family work in health care, and so
far, my cousin has three herniated discs from lifting obese patients over the
years, my wife had several blood tests done from being exposed to Hep C
patients, and I've known several nurses who have suffered extreme burn out.

Being a PA is marginally better, I suppose, but you're dealing with the same
garbage.

There are some definite pros about becoming a nurse over a doctor for sure.
But, if you plan on staying on working the floor, become a doctor if you're
smart enough. It's still in nearly every regard better than being a nurse on
the floor. However, if you have more ambition, you can try to move up the
ladder in management and administration as a nurse.

Finally, there are lots of other oppty's for nursing besides beside nursing.
If one gets burnt out on patient care, one could move into case management,
school nursing, teaching, etc...

~~~
eitally
I second this. My wife is a biologist by training but went to nursing school
(this was back in 2000) to ensure she'd always have a job, in any economy. She
fell in with a nationally known urologist MD/PhD during the program and got an
offer before graduation to start working in his clinic attached to the
university. The pay was awful (~$35k/yr at that time) because of the glut of
fresh nurses minted by the uni each year. The work wasn't bad in a clinic --
standard office hours and no obligation to pick up shifts at the hospital --
and it was a great opportunity to get involved in real research (she published
in her first year there), but it was mostly repetitive and boring, and again,
the pay stunk. When my company relocated me out of state, she switched over to
drug safety & pharmacovigilance at a CRO, and then at a pharma. Most of the
roles in those areas require a health care provider background (either RN/BSN
or MD/RPh) and the stress & money are muuuuuuuuuuuuch better. I was a senior
IT manager with a team of about 80 people in 10 countries and she was making
more than I was (back in about 2009).

Nursing school is much easier than medical school, and there are still perks
to having that professional credential, and, as she and her colleagues always
joke, they can "always go back to the hospital if things get bad". That said,
my next door neighbors are both consulting radiologists and work from home. I
barely see them, but by all appearances they're making bank while exerting
hardly any effort. My childhood friends who've become doctors are a
pediatrician and an ER doc, respectively, and they work much harder but they
love the career they've chosen. To each his own: in every field there are
ample opportunities for the top performers.

------
iends
Don't be a nurse, be a dentist. 4 years of schooling beyond BS, no residency,
$146,920 per year median (BLS, 2010). In several states "dental culture" is to
only work 4 days a week.

In cities around the size of Raleigh, NC a practice with one experienced
dentist can generate 800k-1.2m in revenue and end up with a 250k-300k take
home. Of course it takes a few years to build up the patient base. Starting
salaries for dentist in Raleigh working for a larger practice is 150k-170k.
(Source: My wife is a fourth year dental student).

~~~
mathgladiator
What is the barrier to entry? i.e. What makes this hard? Is it just "being the
bad guy"?

edit: not to sound like a jerk, but I'm curious

~~~
tsotha
Four years of extra school is a pretty big barrier.

~~~
rdtsc
So is getting a PhD. Seems like being a dentist is a better alternative in
monetary terms than being an English major student + PhD, sociologist with a
PhD or even an engineer with a PhD.

~~~
tsotha
Oh, there's no question that's true. Most PhDs aren't even close to being
worth the money. Getting a tenured position these days is like hitting the
jackpot.

------
GuiA
French person here, a lot of my French friends from high school went into med
school. Free universities, no debts, heavy unionization, you can easily move
to nursing/pharmacology if you fail med school... free education solves many
social problems.

~~~
tsotha
It's not really free, though. It's just paid by someone else.

~~~
GuiA
It's free for the students; that's one of the points of the article, that
financial debt can be an obstacle to personal liberties.

~~~
tsotha
High taxes are an obstacle to personal liberties, too.

~~~
johnchristopher
So are children and stepmothers. Your point ?

> High taxes are an obstacle to personal liberties, too.

No. Taxes are spread out among the population. Financial debt is burdening
only one individual.

In Europe, in France and Belgium, we like to think solidarity is a good thing.

~~~
Crake
That's what's wrong with a lot of Americans, IMO. It's every man for himself,
screw your neighbors. If something bad happens to someone else, they deserved
it for reason X. (X being: they didn't work "hard enough," they were "lazy,"
etc when the person in question is often less lazy and harder working than the
person complaining about them)

I actually had a classmate tell me the other day that me being able to get the
medications I need to stay alive (because of the ACA) was going to drive the
country bankrupt and (direct quote here) "destroy America." In my experience,
my countrymen do not care for others very much--only themselves.

------
wellboy
That is the most harmful advice you could ever give to someone.

Who do a startup, if you can do a PhD, it's not that strenuous. Why do a PhD
if you can just do a Masters, it's not that strenuous. Why go to university,
if you can just go to a community college, it's not that strenuous. Why finish
high school, if you can just do an honest labor job, it's not that strenuous.

See the false assumption here? 5 years from now, these people will regret that
they didn't start 5 years ago. Hard work is builds you as a person, it makes
life more interesting, it gives you purpose and after these 5 years, you can
decide your own pace. You have the OPTION.

Not going for higher education, limits your options FOREVER. You can't change
it anymore, it's final. If you're not looking for meaning in life, go for the
lesser option, if you are looking for meaning, go for the highest option you
can think of and then even one more. The funny thing is, once you're getting
closer to your highest option, you discover that there is still more to
discover and that it is beautiful.

For that reason, shoot for the stars, don't listen to nay sayers, make your
life awesome you only have 1 and then it's over.

I'm still cringing, hope I could get my point across.

~~~
pessimizer
>Not going for higher education, limits your options FOREVER. You can't change
it anymore, it's final.

I didn't go to college until I was nearly 30. They still let you in.

~~~
wellboy
And that's the reason, why it is so harmful to not go for higher education. If
there were only more people thinking that way, you might have heard of it and
pursued it. Instead you had to throw your whole life around again at 30, where
you could have been much further already.

But awesome that you took the step.

~~~
pessimizer
I'm saying that it wasn't such a big deal, and it didn't affect anything
FOREVER. I did a lot of things before I went back to college, and I've done a
lot of things after.

>could have been much further already.

I do well. If this is peak income for me, it's an excellent peak income. I'm
not looking to go "further" unless random events happen to drag me there. To
be clear: if I had it to do all over again, I would have waited just as long
to go to college. Out of all of the things I would change, that's not one of
them.

edit: also, people who go to college do not have the monopoly on hard work. As
a person who did an awful lot of manual labor in my life, what I do now
doesn't even feel like proper work. I feel like I'm stealing a paycheck for
doing puzzles all day.

------
idiot900
I'm currently a resident (not in primary care), so I'm biased. But:

* Nursing sucks. It's terrible work. On top of that, you have to deal with jerk doctors and jerk patients. Not a single one of my many doctor friends would ever have considered nursing over med school. (Side note: if you meet a good nurse, thank them! Truly good nurses are rare.)

* PAs generally do not know all that much about medicine. With very few exceptions, it was frankly terrifying signing out my service to them every night, and never fun cleaning up their messes in the morning. But with resident work hour rules, there is no alternative.

* The bottom tier of medical students/residents aren't very good either. Pay doctors less and the smart ones will realize that maybe there is some other way to achieve life satisfaction, because money won't be a differentiator any more. Care will get worse but the general public won't notice or care. They will keep getting fat, diabetic, and ever sicker, insist on keeping their essentially vegetative elderly relatives alive at all costs, and then complain that healthcare is expensive.

------
rdouble
One unmentioned upside to being a doctor is you make a good salary anywhere in
the country. A GP can make $180K in a town where an engineer would be lucky to
make $40K, if any engineering jobs existed at all. PAs are mostly in the same
boat but top out around $90K. Nurses are usually in demand in most places but
the pay can be lousy. Every other well paying job is very location dependent.

~~~
rdouble
Also, one thing I forgot to add, is that PA school is very expensive.

For example, at the University of North Dakota, the PA school tuition is
$34,287 per year, with no discount to in-state residents. In contrast, the
medical school tuition is $24,998 per year for out of state students, and
$12,815 for in-state students.

------
Gatsky
It doesn't have to be this way. Why is it this way? There's a complicated
answer and a simple answer. The simple answer is because human resources
management for doctors is non-existent. It's an unknown, alien concept.
Example - it required a major paradigm shift just to make a rule that doctors
can't work for 36 hours in a row. So the question is, do you want to put up
with all this because nobody can be bothered coming up with a decent way to
manage a key part of the healthcare workforce? Or more correctly, because
doctors can't get their shit together to demand decent working/training
conditions?

~~~
Crake
In many ways, I feel like medical culture is very old-fashioned.

Truck drivers aren't allowed to drive if they haven't gotten any sleep, but
your doctor in the ER making the decisions that will either keep you alive or
let you die will almost always insist that 36 hour shifts are essential.
There's a lot of ego involved, as can be seen in the way that that same
physician will usually support limitations on truck drivers but will readily
believe in their own inability to make mistakes--even in the face of
scientific research showing otherwise.

~~~
idiot900
At my hospital, residents take 24-hour calls. The trouble with shorter calls
(say, 12 hours) is increasing the number of transfers of care. With 25
patients on a service, spending even five minutes on each means each "shift
change" would take two hours. So you spend closer to one minute on each, and
at that point it's easy to miss important details. We are skeptical of the
"scientific research" because we've all seen errors made because of poor
signout that were not happening before work hours were so restricted.

For the record, attending ER shifts at my hospital are closer to 8 hours, and
residents do 12 hours.

~~~
Crake
I'm familiar with the transfer argument, but frankly find it a little
alarming. Doctors are supposed to be very smart, but they're apparently unable
to write down some sort of bullet point list or short paragraph about the
state of a patient for the next person coming in? Good programmers document
their code. The equivalent goes for doctors, too.

It doesn't seem like you care much about it ("scientific research"), but IMO
it's much more likely to put programs in place to help doctors learn basic
literacy/documentation skills than to subvert the basic biological truth that
staying up for as long as most medical students/residents/etc are forced to do
puts them in a state equivalent to drunk driving.
([http://archives.cnn.com/2000/HEALTH/09/20/sleep.deprivation/](http://archives.cnn.com/2000/HEALTH/09/20/sleep.deprivation/))
I do NOT want someone crashing my health into a ditch because they were too
tired to miss something important. Also if you don't have enough doctors?
Maybe you should start training more of them, instead of artificially limiting
supply. (Residency placement slots are a whole other issue, of course, but
still not something that should stymie a first world country so.)

I've had way too much experience with rude, sleepy, and grumpy residents who
bungled my medical care in the last two years of frequent ER and inpatient
stays to have much trust in the profession as a whole. I mean, if you're going
to charge me $50,000 for your crappy medical care, could you at least not snap
at me? Or forget me in an observatory room for over 12 hours waiting for a
scan? They "lost" me in the system somehow until a nurse wondered why I'd been
sitting there so long, called radiology, and left the room to bitch them out
about forgetting me. Since the doctors couldn't be bothered to tell me what
they were checking for, I only found out 13 or so hours later that the scan
was to rule out a carotid artery dissection. I was in extreme pain the whole
time, which they did nothing to even try to alleviate. Incredible lack of
empathy.

I'm glad to hear that your hospital has gone to at least trying to adhere to
reasonable shift limits; it's a sign that at least some people in some
hospital systems have decided that policies leading to killing or crippling
patients is something that should be prevented, not encouraged. It's certainly
not something I've seen in the major medical systems in my state. :(

~~~
idiot900
> Good programmers document their code. The equivalent goes for doctors, too.

The information is there; there is simply too much of it to go over with the
next person in the limited time available. I understand your point about
commenting code - I meticulously document all my own code.

> Also if you don't have enough doctors? Maybe you should start training more
> of them

The training itself requires a huge amount of time and exposure to a large
variety of situations. There are only so many opportunities for learning, and
only so many hospitals which both can provide an appropriately varied case
load, have attendings willing to teach, and can afford it.

I'm sorry to hear you had a bad experience. I don't shout at my patients, or
leave them for 12 hours without any information.

> policies leading to killing or crippling patients is something that should
> be prevented

It's not clear to those of us actually doing the work that this is actually
true, when we examine our own personal experience.

------
atourgates
There are some good points in this article that most anyone thinking about
entering a medical profession should consider. But there's quite a bit of
anecdote and cherry picking of facts as well.

Here are a few counterpoints worth considering.

* The example used by the article for salaries is for primary care doctors, one of the lowest paid (and by any account underpaid) specialties. According to the Medscape physician compensation report [1], the highest paid specialties brought in between $350K and $400K 2012. I don't think there's many PAs or nurses making that.

* Yes, medical school and residency are hard. My wife regularly put in 90+ hours during a couple years of her education as a physician. But I'm certain there are plenty of developers on HN that put in 90+ hours during certain phases of their careers. Working very hard for a couple years won't ruin your life. By the time they're practicing - 52% of physicians see patients for 40 or less hours per week.

* The article says that, "nurses start making money when they’re 22, not 29", glossing over the fact that physician residents and interns do in fact get paid. Not a ton of money, but usually around $50K/yr. So really, doctors start making about the same amount as nurses by the time they're 25, and substantially more just a few years later. And yes, medical school loans are expensive, but nursing school is far from free.

* The success rate for physicians who start their own practice is very high. I've been shocked at the amount of unsecured credit that banks are willing to extend to my wife to start a practice. It's like we've stepped into a time-warp back to 2006.

* If you're interested in living someplace rural, you can, without any negative financial repercussions. In fact, you'll probably make quite a bit more money practicing medicine in a rural area than an urban one. There aren't many careers where that's true.

* If they had to do it all over again, 51% of physicians would start again in medicine (again, the Medscape compensation survey). I don't how how that compares to other careers, but it sounds fairly reasonable to me

Being a doctor certainly isn't easy, but there are some definite benefits. One
of the biggest is that it's one of the few careers left where you're pretty
much guaranteed to be well-compensated so long as you do well in school.

There are certainly pitfalls, and I wouldn't advocate it to anyone who's doing
it solely for financial reasons. But, if you have a passion for medicine,
there are still plenty of rewards to be had by being a physician.

[1]
[http://www.medscape.com/features/slideshow/compensation/2013...](http://www.medscape.com/features/slideshow/compensation/2013/public)

~~~
Gatsky
Just about the workload, I think that working hard in medicine is quite
different to working hard in most other situations. Certainly doing long
shifts in a major hospital often invovles:

1\. An entirely unpredictable work load, with no mechanism to compensate for
excessive demand. 2\. Dealing with problems for which you have not been
properly trained. 3\. Dealing with other doctors that are also extremely busy
and stressed, and therefore limited in how much they can help you. 4\. Having
to work while physically and emotionally exhausted or actually genuinely sick,
with no recourse to get help. 5\. Having to do all this while studying or
taking exams. 6\. Not being paid fully for the hours you work. 7\. Sometimes
being sworn at, racially vilified, spat at, threatened or attacked. Depending
on which job you do, this could come from your colleagues, nursing staff,
admin or the patients.

I think that certain other professions such as the police or military
personnel encounter similar situations, but I would hazard that they are
better trained, better supported and rostered better than doctors ever are. So
although many other people might work 90+ weeks, I doubt it is under these
conditions. Because that would be a dumb thing to do right? And only doctors
with their misguided sense of duty and high pain tolerance are willing to
front up again and again. Nurses can suffer the same problems, but in general
they are much better at protecting themselves.

------
rdl
I don't agree with this -- I've never been a doctor, but worked in a hospital
for a few years with doctors.

The hand waving to say "you will be a primary care physician" is the worst
part. Maybe you don't get our pick of specialty, but assuming you will be a
pcp against your will seems silly, too, since you'd know going in roughly how
good you are, and a lot of pcp are because they wanted to be.

It ignores one of the easiest/best ways to become a doctor -- the military.
You give up a bit of your early career salary in exchange for a different/more
interesting lifestyle for your early 30s. Still great pay.

If I were picking a career as a smart 18 year old, md/phd to go into research,
or something amazing in clinical practice like a trauma surgeon or neuro
radiologist, would be high on my list, independent of income issues.

------
drchiu
Disclosure - I'm an actual medical doctor.

* I agree with the overall theme of the article. That is, a lot of people go into medicine thinking that they will be "rich". And when they come out at the other end of the tunnel, they realize that the promises of job security and a comfortable lifestyle aren't really true.

Many of my classmates from medical school went into all of this with the false
impression that they will make a lot of money. This misperception is because
they see physicians from decades ago do really well, living in nice houses in
expensive neighbourhoods, driving nice cars, etc. But unfortunately that is
because 20-30 years ago, doctors' salaries were much higher relative to
inflation. If a doctor made 200k in the 80's, the purchasing power "back then"
was enormous. Not so today.

* The article does miss the point, as atourgates mentioned in the comments, that being a doctor is "one of the few careers left where you're pretty much guaranteed to be well-compensated so long as you do well in school."

I know a few guys who -- through brute effort -- bills upwards of 500-800k per
year. Now this is gross billing, not net take home pay, but that is impressive
nonetheless. It is, without a doubt, very hard work. You would have to work
pretty much 6 to 7 days a week, and really convince yourself that you like
money to make it all worthwhile.

* The last thing that the article barely touches upon which is important is how tough the job can be when dealing with (some) patients. Nowadays, the job is 90% customer service, and 10% medicine. Maybe less medicine -- certainly some days feel like that.

All this comes with the job's territory, but day-in and day-out of this can
cause a lot of psychological stress/burden/fatigue for the physician himself.

This kind of job is not for everyone. Quite literally you have patients upset
at you because they think the medication you prescribed for them doesn't work,
and in the end it turns out they were not adherent on the medication (ie. they
didn't use the medication or they didn't use it properly). It always reminds
me how close a certain scene from House MD
([http://www.youtube.com/watch?v=dMAS2S51bM8](http://www.youtube.com/watch?v=dMAS2S51bM8))
approximates real life.

* Would I want my kids to go into this kind of a job? Only if they realize what it involves. I really do think some of the happiest jobs out there are ones where you get to be creative solving different problems every day.

Although I'm happy I'm making an impact on other people's lives, it involves
very little creativity. A long time ago a specialist told me that "medicine
makes you dumb." Medicine today is algorithmic: if this, then check this, then
do that.

I don't think there is a simple answer whether medicine is "worth it." It is
different for everybody, and it really boils down to what your personality is.

