Become a nurse or physicians assistant instead of a doctor (2012)
jakeseliger.com
jakeseliger.com
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.
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.
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.
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.
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.
Edit: maybe someone that downvoted this could help me understand what is disagreeable about this comment?
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.
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.
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.
By the way I hope you are wrong in your judgement here regarding opportunity, but I fear that you are right.
Or maybe they're also a tech enthusiast in their spare time!
It is nice to have a greater breadth of backgrounds. The overall quality of comments can only improve.
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.
https://en.m.wikipedia.org/wiki/Nurse_practitioner
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.
Different outputs for the same input is madness.
> Different outputs for the same input is madness.
Maybe the diversity is a good thing, but sounds more like stronger/weaker regulatory capture rather than differing patient safety/access goals.
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.
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)
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.
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...
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.
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.
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 seems like a very sad way to view the world.
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.
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.
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...
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)
* Required overnight shifts for some specialties e.g. ED or hospitalist. PAs at my wife's group don't do overnights.PA cons
* Seems like the PA coverage expands and contracts depending on how the hospital is doing financially, while the physician coverage is constant.
* Dealing with drug seeking patientsTo 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.
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).
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/
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.
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.
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.
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.