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Become a nurse or physicians assistant instead of a doctor (2012) (jakeseliger.com)
65 points by quickthrower2 on Aug 6, 2019 | hide | past | favorite | 61 comments

New resident physician in the U.S. here. I actually really enjoy my job now but absolutely hated medical school. Would I do it again? Probably not even though I’m happy now. Four years of misery during my twenties was not worth it. And the stress of $250,000+ of student loans is ever present. And unless you’re at the top of your class at every stage of training, you have little control over where you end up geographically which is really bad when you have relationships to maintain. Long distance for several years sucks a ton.

So I’d only recommend going to medical school if you’re a top student who can get scholarships (so you don’t have much debt) and so you have some control over where you go (because you’ll be competitive for most programs). But even so, I went to a top Med school which was my first choice and I still ended up hating it. You’ll never know what program/city you’ll like until you try it but once you start it’s very difficult to change Med schools or residency programs in general.

Once in med school, how Meritocratic vs Subjective or Political is the road to top student status?

The pre-clinical years (usually the first two years, but many schools are condensing this phase into 1 or 1.5 years) are very meritocratic in that your standing depends on mostly multiple choice tests. And then you take the first medical licensing exam called Step 1 which largely determines your competitiveness for residency programs. The clinical years where you are actually working in the hospital in various fields is less objective as you are judged based on the subjective feedback evaluations of the residents and attending physicians.

However, you are mostly rated on how much you know, how confident you are and your social skills. So if you did really well in the pre clinical years and are not socially inept then you’ll probably get good evaluations.

But it’s a marathon. It’s an unbelievable amount of information you have to memorize and in the beginning it’s hard to stay motivated when you can’t see it’s direct relevance.

So overall I’d say it’s fairly meritocratic. If you can memorize things well and are social then you’ll do well barring any exceptional circumstances.

How does a person with your background end up on HN? Honestly curious.

I’m not who you asked your question to but I’ll put my opinion here for anyone interested: This website seems to be the place to read to be up to date in the tech and science sphere, which is similar to what I imagine lots of younger doctors and medical students are interested in. Me personally I love tech and read most articles except for the hardcore programming ones. A lot of discussion regarding medical science discoveries make it to the front page daily and it’s interesting to see what logically minded highly intelligent people outside medicine make of it. You’d be surprised a lot of medical colleagues I interact with aren’t the most tech savvy people and aren’t used to rapid iteration like the software engineering folks. That and entrepreneurship isn’t big in clinical practicing medicine so it’s an interesting aspect of life I know little about.

I also happen to be a programmer, worked part time as a web programmer in college and continue to write code for research projects. I’m interested in applying machine learning to problems in healthcare, most recently.

Anyone can read Hacker News, it's not some sort of exclusive club! As to why someone would, there's a lot of interesting non-technical articles posted here.

Or maybe they're also a tech enthusiast in their spare time!

That’s my point. I never said it was an exclusive club, I just implied it’s not that common to end up here unless you had specific interests.

It is nice to have a greater breadth of backgrounds. The overall quality of comments can only improve.

Unfortunately, I wonder if extreme bullying could preclude any opportunities if your abuser is a successful authority figure in medicine? That probably sounds crazy.

Edit: maybe someone that downvoted this could help me understand what is disagreeable about this comment?

I didn't downvote but your questions give me a strong impression that you are fishing for an answer that will allow you to conclude that 'top student' status is not (significantly) influenced by relevant skills but by other factors. Perhaps your comments would have been received better had you been more open about your own opinion/suspicions from the start. In their current form they feel like leading questions.

Ah that would an incorrect assumption. My question was genuine.

Edit: it is hard-enough as is for people who deal with abuse to openly talk about it. It would be good to give people the benefit of the doubt rather than accuse them of doing something wrong. Reality is not like that though, and many people living with ill will or abuse are often seen as "must have done something" to be experiencing that.

> it is hard-enough as is for people who deal with abuse to openly talk about it. It would be good to give people the benefit of the doubt rather than accuse them of doing something wrong.

I'm not sure why you act as if I am attacking you. Like I said I wasn't the one to downvote you, and I only offered a possible explanation for that downvote in response to a question that you asked. I'm sorry you were abused at some point and that wasn't your fault. But it sounds like that was in the past. Yet you are immediately taking a victim role in this conversation, and also in your replies to others in this thread. If you feel like people are out to get you all the time then chances are you are letting your past experiences colour your perceptions too much.

Irrespective if this question has any ulterior motives the answer is yes, definitely. It goes both ways, if you upset someone important there goes your chances in that speciality of medicine. On the flip side if your buddies with the important guys they can basically secure you a spot on a coveted program for instance. Medicine and it’s specialities are competitive to get into and there’s obviously way more demand than supply. So authority figures can pick and chose whom they want and also bad word spreads rapidly and you can be effectively blacklisted for messing with the wrong person. I’ve seen it a lot in my very young medical career. There’s some parts where it’s more of a factor and other parts where it’s less. I find it a fascinating topic actually but it’s one of those things that varies depending on many factors a big one being location/country.

Thanks for you answer; but I caution you to consider not assuming, blaming or accusing victims of abuse to having brought it upon themselves. When you say I "messed with the wrong person," I would hope to be able ask you not to assume that. In my case I did not recall even having interacted with this person before it started.

By the way I hope you are wrong in your judgement here regarding opportunity, but I fear that you are right.

There are no prestige occupations where authority figures can’t preclude opportunities. Academia, medicine, law, any large bureaucracy, in any one of them if you piss off the wrong person your career is over. There are bad fields for this and worse ones. You could work for Citibank, realise that your career was being deliberately destroyed by a superior and you might be able to move to a competitor and get over it. Same for the private sector more generally. But if you work in fields that are either directly government run or depend on government funding, like medicine or academia, if you realise someone with power has it in for you just leave. You’re not going to win.

The idea that extreme bullying is anything other than a normal feature of bureaucratic organisations with no competition is farcical. It’s like believing in fairness or the tooth fairy.

Ah, in this case I didn't interact with this person. I'm not sure what his obsession was with me. This started in our first year of university. It was not isolated to that person, they were just the most-aggressive.

From my understanding (2 doctors immediate family and several others extended fam), it can be quite political. Desirable specialties are competitive, whether for lifestyle (dermatology, radiology, etc.) or prestige/interest (things like pediatric surgery). Once you get into a specialty, the work does not stop, as there are usually progressive tiers of training and additional programs. You might do first 4 years residency in Dallas, then receive your next placement in Chicago for 2-3 years. These would be great locations, for most, from what I gather. Most aren’t so lucky.

IIRC the surgery fellowship (8 years after graduating undergrad, 4 years after med school graduation) application process gives a list of 10 cities (hospitals) which the intern is interviewing and applying for. They are allowed to rank their top three cities from this list, but there is no guarantee. They will travel to all ten cities and interview at all the programs.

Medicine is great for someone who wants to be in training until they are mid 30s - and that’s assuming you go directly to med school from undergrad.

My wife recently graduated from a top med school. Her experience was that it was probably 80% "meritocratic" (long hours, grinding it out, being there when someone needs help) and 20% "political" (knowing the right people in the department, knowing what research projects will be good to join and what projects are dogs). To be the top student, you need to know the material well and be productive at research and be a good service provider (good manners, thoughtful, empathetic, etc). The good news is that departments generally give very good opportunities and mentorship to anyone student who shows an aptitude for grinding. Basically, to be in the top 1/5 of the class is all about getting in your reps, and the things that separate the members of the top 1/5 of the class is who they know, who knows them, and the impact and scope of the projects and procedures they were trusted with.

I sort of understand why it’s difficult to switch residences, but why is it difficult to switch schools?

It’s difficult to switch residencies because each residency program has a fixed number of positions per training year which is largely funded by the government. And almost all positions are filled by the end of match so the only way you can switch is if someone leaves their position for some reason and they happen to be at the same training level as you.

Medical schools admit a variable number of students each year although they aim to have a specific number. It’s difficult to switch medical schools because Med school curricula are very different from program to program. And also there’s just no standard mechanism for switching, you’d just have to schmooze some of the higher up administrators. Med schools don’t really get any advantage by taking in transfers unless they had a mass exodus of students and needed the money. So there’s little incentive for administrators to even bother with transfers. In residency you want all your positions filled so you can keep the funding and have enough staffing so if a position opens you want to fill it ASAP.

My wife's school had 5k applicants for 108 spots. Schools can be ultra selective in who they accepts and are allergic to people they think won't graduate from their school.

Not finishing a degree at one school suggests you're more likely to not finish it at the next school.

Why would schools take that risk when they can choose from 4,999 other applicants instead.

very few transfer spots open, and the schools tend to have different curriculum programs (generally the same courses, but taught with varying focuses).

From the article:

Take JoEllen Wynne. When she lived in Oregon, she had her own practice. As a nurse practitioner, she could draw blood, prescribe medication (including narcotics) and even admit patients to the hospital. She operated like a primary care physician and without any supervision from a doctor. But, JoEllen moved to Texas to be closer to family in 2006. She says, “I would have loved to open a practice here, but due to the restrictions, it is difficult to even volunteer.” She now works as an advocate at the American Academy of Nurse Practitioners.

From Wikipedia:

In the U.S., because the profession is state-regulated, the scope of practice varies by state. Some states allow NPs to have full practice authority. However, in other states, a written collaborative or supervisory agreement with a physician is legally required for practice.


I have no idea how you would look this up, but when I worked in insurance, this fact had substantial impact on claims payments. For some states, we had to check that the nurse practitioner was supervised by a physician in order to pay the claim. For other states, we didn't.

I've known some nurses. One nurse who was married to a soldier told me it allowed her to have a real career as a military wife because she could get a well-paid job anywhere, nursing was always in demand and many places have chronic shortages. Military spouses typically suffer high unemployment rates and have trouble getting a job at all. There are very few jobs that allow you to have a real career in your own right as a military spouse.

I work in medical billing, so the other side of this mess - it gets really fun to ensure the right providers are in the right spots when submitting the claims. Rules not only vary by state but also the payer type (Medicaid, Medicare, commercial plans can vary just as much). We’re actually going through a bunch of work writing our own software to import charges into our billing system to give us more control over the ordering (there’s other reasons too, but this is a big one).

> In the U.S., because the profession is state-regulated, the scope of practice varies by state. Some states allow NPs to have full practice authority. However, in other states, a written collaborative or supervisory agreement with a physician is legally required for practice.

Different outputs for the same input is madness.

  > Different outputs for the same input is madness.
Not if you consider that we are discussing different implementations (state laws), written by different dev teams (lawmakers), with different design specs (cultural differences between states and parties in power in each state).

That’s the heterogeneity in the process.

Maybe the diversity is a good thing, but sounds more like stronger/weaker regulatory capture rather than differing patient safety/access goals.

Alternatively, if you'd rather have all the stress and relationship dysfunction with none of the salary benefits, become a paramedic...

Yeah, my brother had a good friend who was a paramedic for..I want to say 13 years. Then he became an alcoholic and eventually killed himself. It was horrible.

Unfortunately without anymore context we don't really know what you mean. Is being a paramedic really that bad a job? why?

Actually, I think the context he provided is sufficient.

Imagine the responsibility of saving lives like an ER doctor, seeing gruesome injuries and deaths on a daily basis, except you have a lot more deaths on your hands (what I mean to say is transporting/attempting to save those who are beyond saving), you have to go out into the field and travel, and your pay is nothing like that of a doctor. Paramedics have an extremely high burnout rate.

Paramedics are guaranteed to see the absolute worst medical conditions, emergencies, and disasters. They're the front line for most of the messed up stuff in the medical world.

Along with that, they are vastly underpaid, especially compared to other medical professionals, and have much more knowledge and training than you'd expect to boot.

It's rough.

I knew an NYC paramedic 10 years ago who was making $13/hr.

By now he would top out at about 30/hr [1]. Not great for 5 years experience. It seems the sanitation worker... the trash man... gets to about 35/hr over the same period [2]. Both jobs involve heavy lifting and unpleasant odors, but the paramedic training is more demanding and it's hard to describe the daily mental pounding paramedics have to absorb.

Paramedic is a fun job but tough. Hard to leave all of that at work.

[1] https://www1.nyc.gov/site/fdny/jobs/career-paths/ems-salary-...

[2] https://www.villagevoice.com/2014/10/24/want-to-become-an-ny... (not the most authoritative source but it was easy to find)

When a sanitation worker, you will work hard every hour. This could be seen as an advantage. I kinda dream of doing it for, say, 4 hours per week: get paid to work out.

While a paramedic, you will work pretty hard most of the time on a big city service, but can work up to a more rural service where you can have a lot of downtime.

That $30/hr is for FDNY EMS. Most paramedics in NYC don't work for FDNY, they work for various private companies, and get paid a lot less.

I should clarify that I'm referring to paramedics in the US, where the pay is (generally) pretty terrible, in comparison to other medical professionals (<$20/hr isn't uncommon, especially for private, for-profit ambulance companies).

As far as the job... it's high stress, often variable hours (which results in poor sleep), it can be physically and emotionally difficult, the erratic schedule makes relationships hard, etc...

You get to see really bad shit without support or and often with less respect than you deserve.

If that interests you, you want to be a paid firefighter, as you usually get union protection, the camaraderie helps, and you can rotate assignments if it gets to you.

Competition is intense for firefighting jobs here.

Since they do 24 hour shifts, people are willing to commute for several hours because it’s 7 shifts a month. And you’ll almost always get protected time to sleep during that time.

Most of their calls here are medical anyway, where they senselessly send a pumper out.

Most of Canada overfunds fire, and underfunds EMS.

This is an extremely poorly-argued point full of one-sided emotion. The fact of the matter is that no other career path even comes close to the risk-adjusted lifetime financial remuneration of becoming a doctor. Every once in a while, some other career will briefly take the spotlight, like pilots in the 90s, real estate agents, or maybe even software engineers today, but none of them last. Get your MD. Don’t talk to a 30-year-old resident about it. Look at how 60-year-old doctors are doing compared to a random sample of their peers. Not even close.

> The fact of the matter is that no other career path even comes close to the risk-adjusted lifetime financial remuneration of becoming a doctor

Does that stat include doctors who didn't place into residency. This year, 1 in 5 med school grads didn't get a residency. Some of them will match next year, but it's typically considered a one and done process. That something many older doctors tend to forget.

You basically go $1 million in debt (between tuition and lost wages) for a 1 in 5 chance of being a complete financial wreck with a mostly useless degree since you can't become licensed.

Once you've made it being a doctor can be great. However, the process of getting there is absolutely brutal.

NRMP Data: http://www.nrmp.org/one-nine-press-release-thousands-residen...

Do you really want to be a lifetime income maximizer, though, rather than a satisficer? Medical doctors need to put in an incredible amount of work and study in order to get into the career, and even more after becoming an MD.

Just to highlight what is already well known is a big downside of securing the “lifetime financial remuneration” is the sheer length of the training and juniper years. I’m not going to pretend that those in other careers don’t work hard (they do and reading some of the things on this website makes me feel I have it easy), however I can see why it’s not for everyone. The path in my country (Australia) is shorter than in America which at quickest is as follows 5 years medical school after finishing high school at 17/18. 2 years being a junior (average workweek is 50-60 hours which isn’t too bad). Then training for a specialist takes 5 years average workload is super variable anything from 40-80 hours a week. Then sometimes people do 1-2 years overseas to gain an edge on a certain area within their field. Then finally you come back as a boss (hopefully earning the big bucks at this time After securing a job in what can be a saturated market). Oh and don’t think about claiming overtime during this process, you get paid as if you worked 40 hours a week regardless. The above mentioned includes evenings public holidays night shifts etc.

It’s a long road and I can see why it would be hard if not impossible for others to carry through until the end depending on their age and life circumstances. I think once you consider not only the high income once you made it, but the long path (what I described above is streamlined assuming everything lines up perfectly and you outcompete your competition) it’s moderate to above average compensation at best. I contrast this to my friends in engineering and law whom have secured 6 figure salaries 1-2 years after graduating, have their weekends off and told me they haven’t studied since university. I do get the impression at least US software engineering may be the best way to secure a great income at a young age these days, hopefully it stays this way for you guys. Just wanted to stress don’t go into medicine for the long term financial remuneration because there’s likely something better for the work that you need to put in.

> The fact of the matter is that no other career path even comes close to the risk-adjusted lifetime financial remuneration of becoming a doctor.

Lifetime income is a very poor proxy for happiness. If you're optimizing solely for money, good on you, I guess, but I suspect that's not the case for most people.

> The fact of the matter is that no other career path even comes close to the risk-adjusted lifetime financial remuneration of becoming a doctor.

This seems like a very sad way to view the world.

Not a MD but married to one, plus my brother and some friends are docs. They would echo the sentiment in this piece. My brother has argued that being a PA, NP or especially a dentist has a better ROI as the training is way shorter and pay pretty good.

Some of my observed pros and cons of the medical profession:

MD pros

  * Respect
  * Pay
  * Satisfaction that a resuscitation saved a life (PA don't run those at my wife's group)
MD cons

  * Required overnight shifts for some specialties e.g. ED or hospitalist.  PAs at my wife's group don't do overnights.
Practitioners all have stories of friend of friend doc falling asleep at the wheel and getting into fatal accident. * PAs work under the supervision of the MD, hence all more medically challenging cases go to the MD along with the stresses e.g. running a code (resuscitation) or getting a difficult admission through.

PA cons

  * Seems like the PA coverage expands and contracts depending on how the hospital is doing financially, while the physician coverage is constant.
Cons for both MD and PA/NP

  * Dealing with drug seeking patients

Under MD cons I wouldn’t necessarily put night shifts. More often than not the way nursing units are staffed is a shift based roster meaning you’ll be doing evening and nights for your whole career. Contrary to popular belief a lot of medical work is business hours with on call for after hours work. Depends on the speciality some are shift based (ED for instance) but in general the nurses do more night shifts than we do over their career.

My wife is also an MD. She just talked her youngest sister into PA school over MD school.

To save costs many organizations are pushing PA's into rolls traditionally held by lower level doctors. Instead of two MD in an ER or clinic, you'll have one MD and one PA.

IMO, being an MD only makes sense if you're going into surgery.

I would have to disagree with the title of this submission. Rather I’d phrase it to you like this:

Healthcare is a team sport. There’s multiple well defined and some not so defined roles to fill. Some people are happy to take orders and just do what they’re told. Others want some autonomy but don’t wish to or want to care about anything other than their topic of interest. Yet others want of lurk in the background and assist after the main event is over. Etc. but you get the point. Where doctors come in is they’re usually either the one overseeing the ultimate care of the patient, or are called in as the subject matter expert in a certain field.

Or to sum it up crudely, you do medicine because you want to be the boss. You do nursing/PA because you want to work with a boss.

As an aside, the way our health system is structured in Australia makes NP quite unpopular. We don’t have PA here and NP operate under direct supervision. We have a decent proportion of them in rural areas (they basically keep the rural and smaller regional hospitals running) who earn doctor pay. But in our metropolitan areas only very few exist. Reasons I would guess is due to cost. They get paid above a junior doctor but you can assign more responsibility to a junior doctor and also abuse them more (you can’t pay an NP for 40 hours after working them 80 hours a week with no breaks).

Article asks about residents and whether they can unionize.

I'm a resident at UW in Seattle. Despite being located in a wealthy city, UW mostly serves the poorer populations of the WWAMI states and consequently doesn't make a lot of money. The University has historically done everything to avoid raising residency salaries.

It's an interesting read about the steps residents had to get to unionize: https://uwha.com/history/

The academic rigor that nurses and PA's must go through is not the same as a doctor. There are many instances where a nurse or a PA would unknowingly pass something off as normal when a more trained eye could save a persons life. We shouldn't be dumbing down our medicine. Create more medical schools while keeping the bar high for quality of care.

I stopped going to NPs years ago when I found I could get better information via just searching for my existing diagnosis and reading the uptodate article. They're certainly useful if you're at the grocery store and need a quick prescription...but that's about it. Granted, that's probably good enough for most medical issues and patients coming in with colds.

The frustrating part is that I've found many specialist clinics that will do a one visit intake appointment with an actual MD then pass you off to the NP for follow-up visits. The strange part is that the NP is billed at the exact same rate. I'd be happy if I was paying ~50 an hour for an NP versus 400 an hour for the specialist, but that isn't the case.

Wait until you don’t even get an NP, but get an even lesser trained Physician’s Assistant but pay the same.

This goes for all professions. If only $x-person was more highly credentialed then they wouldn't have made $y-mistake.

That's fine until $z-cost-of-service is > $some-number. I think we've reached that point in the United States where we can discuss reducing professional barriers to entry in order to bring down costs.

Your argument is sound, but the cost of tests/treatments and overall number of staff dwarf this amount. By training the top grade more and giving more weight to their clinical acumen, you could save costs on unseeded tests and treatment. Having said that as a physician I am biased.

The opposite can happen too — nurse practitioner immediately demanding unnecessary biopsy or other tests because they cannot confidently rule something out. This happened to me recently when I went to a np for a known problem I have had for years that was already diagnosed by multiple doctors. I also find np is much more likely to prescribe antibiotics. Of course this is all anecdotal. I used to be very much in favor of expanding the scope of what nurses can do but now I feel like that may do more harm than good.

Not only anecdotal, but unknown which one is more correct.

Any biopsy or test that comes back negative could be considered unnecessary, but we don’t know that in advance.

Is it worth testing for a 5% likely disease that would be serious if found? Not running it will save time/money 95/100. Doesn’t mean it’s the right approach.

A psych NP was the only person who correctly diagnosed my condition and treated it successfully. I went to 5 psychiatrists in 10 years who couldn't get it right. She had worked in a hospital setting for quite a while. I'm guessing the psychs did the minimum necessary.

Not sure why this was down voted. Having many medical professionals in my family, I have come to understand this particular issue. Not much different than an inexperienced airplane copilot or junior developer.

Those with less training (nurse anesthetists to be specific) tend to get themselves into trouble and only then call on a MD trained anesthetist for assistance. Furthermore, hospital networks are able to more easily "push around" nurse anesthetists which in the end creates an environment where bad decisions can occur.

To make a distilled analogy, this would be the potentially niave junior dev, pushed by management to ship code / tech debt, despite the advice or mentorship from a senior dev, and only asking for assistance when production is on fire.

However the topic of cost management and profit tactics in US medical system is a broader topic, hospital system administrators and their C-suite management in the USA love cheaper alternatives that are directly employed by the hospital (think nurses, PAs, nurse anesthetists, etc). The hospital system can directly enforce efficiency metrics (think, more money for the hospital, not better care for the patient) and doesn't have to negotiate contracts with a group of specialist doctors.

Except that nursing is very different from being a doctor.

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