Friday, December 20, 2013

A woman asks, "Should I be a nurse practitioner or a doctor?"



She writes [email edited for length]:
 
I don’t ever do this sort of thing, but your blog seems to be pretty legit, so I guess I’ll go ahead this once.[Quite a testimonial for my blog, don't you think?] I’m a post-undergraduate student seeking to become either a nurse (with likely continuation to a nurse practitioner [NP] degree) or a doctor.  The problem is I don’t know which way I should go.

I know I have the ability to get through medical school, but I’m not sure if it is worth it as far as cost and benefit is concerned.  I do, however, like the idea of the autonomy that comes with being a doctor rather than a nurse.  I have a very analytical mind, and would enjoy the diagnosing and problem-solving that comes with being a doctor.  In fact, I’m not sure I would be happy without the authority to determine and pursue treatment I had researched myself.

On the other hand, I really like interacting with patients and getting to know them personally. Ideally, I want a job where I help people solve their medical issues, diagnose, have autonomy, and interact regularly with patients.  My main question is, does this happen more as a nurse practitioner or doctor?

I’d also like to know if you think medical school is worth it with the rising cost of education and likely fall in salary (at least in the US with Obamacare). I’m practical and even if medical school is really what I want, I cannot justify going after a degree that won’t be worth the cost. On the same note, if there is a great shortage of doctors, will NPs be stepping up into doctors’ roles more often? Is such a role assumption legitimate? And what will this mean for the medical community and individuals going into medicine?

[Note: She is in her early 20s with very little debt right now, will finance future education with loans, is not married, but eventually wants to have a family.]

Thanks for the kind words about the blog. 

Here's what I think. It sounds like you want to do primary care. If that is so, why go to medical school? You might want to consider becoming a physician assistant (PA) too. The NP or PA route will be far less expensive. You will be able to start practicing sooner, which means earning real money and paying off any debts instead of deferring. 

Future doctor shortage or not, I think nurse practitioners and PAs will dominate primary care and also be given more autonomy. It is inevitable. The truth is, many PAs and NPs are not very closely supervised even now.

I hope that others will comment.

54 comments:

  1. Well written. As an emergency MD, I have the luck of reasonable hours, reasonable scheduling and almost no hassles with paperwork. I'm happy I made that choice. However, I don't think I'd recommend it to my children. The cost of med ed, plus the opportunity costs of investing and time commitment of med ed and residency is too much for the return and the ongoing onslaught of the MD. People don't appreciate the time and effort that I made. NP/PA is a different commitment. That being said, I was a commercial banker prior to my MD. I didn't like what I was doing then. It was boring and had no redeeming value.

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    1. Since we all NEED GOOD ER Dr.s I, for one, DO APPRECIATE your commitment to this specialized field of medicine, being an ER MD is NOT easy, you see everyone and deal with what is gong on AT THE TIME STAT that walks in the ER or is brought in by Ambulance, so you are the one on the Front line and YOU ARE IMPORTANT and VALUABLE to everyone in the community and beyond. when I had an accident with a semi truck in winter, (he reared ended me going 55 and I was going 35 along with everybody else) he propelled me down a snowy icy embankment, it was terrifying, almost put me out of commission, I of course was taken to the ER and the Dr.s were pretty good considering what they were dealing with at the time. The rescue crew was magnificent as well, its just that with all the chaos at the time the ER Docs did a great job considering

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  2. As a PA for many years, I agree. I have autonomy, have been diagnosing, prescribing and treating and have never been told how to think or what to do. I have asked for help and learned much from all of my colleagues. I think it is the same for many NPs and PAs. Yes, it is frustrating sometimes but the next generation will be much less so.
    All the options are good ones, MD, NP or PA.
    In primary care we very much do the same things.
    Thanks for the opportunity to comment and also for your comment which is appreciated.
    Dave Mittman, PA, DFAAPA

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  3. I'll comment from the perspective of a PA who was originally going to go through medical school:

    I had a similar dilemma as you in that I knew I was capable of getting into medical school, and the aspects of practice autonomy, professional respect, and earnings attracted me to the profession. However, I also really wanted a good lifestyle, and the time and debt commitments were staggering. I already had about $60k of undergrad debt and I was looking at acquiring at least $200k more, and deferring both debts for a residency.

    Long story short, I applied to both and had the option to matriculate in both, and in the 11th hour I chose PA school. I haven't regretted it a day since. I've been a practicing PA for almost 2 years.

    There are a few things you need to be aware of:

    -If you choose to be a mid-level, going the PA route will be much more expedient and productive. You need an undergrad in a pre-med discipline, high GPA, good GREs/MCATs, and some healthcare experience. You can bypass going through nursing school and then NP school.

    Furthermore, if you have interest in being a physician, PA training more closely resembles physician training, and you will have full lateral mobility after graduation. NP training is more based on the nursing model, which many consider inferior, and most NPs are confined to a career in primary care. They do not receive standard surgical training in school.

    -Consider very seriously the level of debt you will have. I know when you are fresh and motivated and trying to get your foot into a program, debt is not the foremost concern, but it most certainly will be for the 20-30 years you are practicing and paying it off. It ain't real until you get that first $1,000-2,000 monthly bill. Oh and you have to pay that monthly bill for the next 10-25 years. PA school is not cheap, but you can effectively cut your future debt in half compared to medical school.

    -If you want a family, like most women do, be a mid-level. You will have a better lifestyle for raising children.

    -Make sure if you do become a mid-level that you are 100% OK with being a dependent provider. At my practice I operate independently (with an SP on site), but this is not the norm. In surgery especially, PAs are often known as the "surgeon's bitch". This of course varies by practice, but PA/NP roles in medicine range from glorified errand boys and girls to mostly independent providers whose daily practice is analogous to a physician. If you cant handle taking orders or not calling all of the shots, then go to medical school.


    The rub about medicine is you don't really know what you like and hate until you get in there and get dirty. I thought I was 100% going to do orthopedic surgery, and I got a job in orthopedic surgery and hated it. I ended up in a specialty that hadn't even crossed my mind in school, and it is like night and day.

    As a physician you are effectively confined to your chosen specialty for life. Good and bad, depending on who you ask.

    All in all being a PA, and probably an NP, is a great profession and we really are the future of primary care. You can expect it to grow and remain stable for the foreseeable future.

    -Micah

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  4. Excellent comments, and not just because they agree with me. Of course, keep in mind that the sample size is small.

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  5. As a nurse I must admit reading your post made me a little sad to see that your initial thoughts of nursing seems to be the 'Drs hand maiden'. I do not prescribe or order investigations but I do use my brain. I am an ICU outreach nurse I spend my shift integrating lab results medical imaging, patient history, physical exam, the concerns of the patient and the staff on the wards that have directly referred me the patient to decide if Interventions are required for the patient. This means having the respect of my nursing and medical colleagues who trust my judgement and clinical skills.I am advanced life support trained and after many years of experience will quiet happily step up and lead the code team. When I am not in my clinical role I am teaching. Teaching clinical assessment skills and critical thinking skills to a multidisciplinary team through simulation. I have thirst for knowledge, I have a masters degree, and read journal after journal and pick the brains of my colleagues to keep my knowledge base expanding and understand the evidence behind my practice, yes the medical staff prescribes and orders but most of the time its me who implements the therapy so I sure want to understand exactly why and what the risks and benefits of the therapy is for the patient, how else will I be able to put families of the ICU patient at ease while they watch their loved ones entire blood volume running through the ECMO circuit which to them looks like 2 big garden hoses and a old hand pump. I have sat and held the hand of a dying patient because there is no one else, I have done the simple things that often mean so much, like arranging for patients to go outside in their hospital beds just to feel a bit of sun on their face. I have been thanked with hugs and tears by patients and relatives for doing something that I see as just doing my job. So I would suggest before making the choice to be a nurse purely about $ or wanting to be autonomous and use your mind take a moment to think about the importance of a good team that surrounds the independent practitioner. Sometimes being a good follower is just as important as being the leader.
    Cheers
    @reachoutnurse

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    1. Thank you,this is all i need to keep up my good spirit of nursing.You are really a true dedicated nurse and i will grab this advice for myself.

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    2. I am a critical care RN who also has years in the ED--I am now an Acute Care Nurse Practitioner who specializes in cardiology and work autonomously. I perform specialized cardiac testing, write orders/prescribe and I do not have to have a physician sign off what I do. I am billable at a higher rate than the PAs in the state in which I reside in. NPs have great areas of interest/practice in which they can work in--not just "Primary Care". If I had to do it all over again choosing from PA, MD or NP--hands down NP. Best wishes with what ever route you choose.

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  6. Good points. We were focused on the NP vs. MD question. I don't think the writer really meant to demean the nursing profession. I respect your feelings on thus.

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  7. The following is from someone who was unable to get the site to accept his or her comments:


    Where to begin? These discussions are typically filled with anecdotal examples and personal feelings; whether they are expressions of elation or remorse, pretty strong emotions are tapped either way.
    The emotional attachment to our professions I believe comes from a deep place, in part because of the investment we all make to become that professional, maybe even the years dreaming and anticipating it and then the expected or perhaps less than expected return on our investments. We often get side tracked by the money and while it is an important metric I don't believe it can be examined independently as a measure of happiness or job satisfaction.
    I'll come out of the gate and say I am a practicing PA. I have been fortunate to work closely with some of my supervising physicians, with professional respect and esteem for one another we have bounced clinical problems off each other; I have often used his/ her vast fund of knowledge to help my patients and to become a better clinician in the process; I have been asked to provide clinical teaching and demonstrate procedures to residents.
    I have also practiced in terribly acerbic settings in which I have had little or no support from my supervising physician or the support staff, I was treated as an expendable errand boy who's value is derived solely from the fact that I can place medical orders.
    Can you guess which position paid more? Can you guess which position I was happier in?
    I agree with the comments of my colleagues, the PA profession can be incredibly rewarding, it can also be incredibly arduous and soul sucking. But I don't think that this is unique to PAs, I know for a fact that the life of an MD or NP can run the same gambit. The path to becoming a PA is irrefutably shorter than that to become an MD and today with the shift to a doctoral requirement for NPs it is perhaps the shortest route of the three, but it is an arduous path and a large investment none the less.
    The question is truly, what is going to make you, the individual, happy?
    In closing I want to reiterate how personal a decision it is. If you have a true passion for medicine and you truly want it to be your life not just your life’s work or you might make a very different decision than if you merely want a comfortable income. Perhaps you are motivated by an altruistic zeal and are simply rewarded by helping your fellow man? It takes a lot of soul searching. You may even be better off in another career path altogether. If you have no previous exposure you will learn it can be exhausting practicing medicine in a broken system. In the end there are no algorithms or decision trees. It takes self-examination and introspection. In the end the only regret you might have is not taking the time to deliberate and make the right decision.

    As a side note regarding incomes: A PA in a surgical subspecialty in a high income area may make twice what a primary care MD makes elsewhere in the country, but that is a choice that probably involves 70-80hrs a week and mandatory call. A PA in primary care is, without saying, going to earn less than his supervising MD but might see his/ her own regular patients in clinic 32hrs a week. Which provider is happier? Who am I to say?
    Based on national averages NPs earn a little less than PAs and based on the last figures I saw the national average for PAs is on $50/hr so that’s food for thought, if money is your primary motivator it takes a long time to pay off $200k in loans at 8.6% given that kind of scratch.

    @rocknicepac

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  8. Interesting point of view. Thanks. There's some good advice for the woman who raised the questions. It's a lot to think about.

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  9. The cost of med school in your country truly is staggering. I'm a med student in Finland and the education is free. Of course I have to pay my rent etc. but here students get some financial aid and have usually max. 20 000€ debt when they graduate . Of course the salary isn't the same as in the US, but there's no huge debt either.

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  10. Giga, thanks for commenting. I am not familiar with the way it works in Finland but in some Scandinavian countries, the income tax rates are 70 to 80% and the tax on automobiles is 150%. Someone is paying for your education and you will pay for someone else's education. Still, I doubt that the cost is as much as it is here in the US.

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  11. I have been a practiing surgeon for almost 30 years. I have employed PAs and work with murse practicioners. I ould sjust say this. It is not about the money it is about the autonomy. the PA and NP model both require practice within guidelines. If you are the sort of person that wishes to practice within paramaters ans clinical decision trees then midlevel might be for you. the training is shorter, the hours more manageable and there is greater patient interaction. On the other hand you will be essentially limited to caring for the worried well. If you want to push the limit, care for the truely ill, and test your own abilites, the choice is clear jes sayin

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    1. I've been a practicing NP for 15 years. I'm an expert in the Heart Failure specialty and also practice with our Hospitalist group as the ED admitter. I care for patients ranging from gastroenteritis to decompensated heart failure in CCU on Primacor, the ventilator, with a Swan Ganz catheter. As with all 3 provider levels and ANY profession you choose, whether it's in the medical field or as an elemetary school teacher, it's how much YOU put into it. I've been a nurse for 35 years and still read at least 2 articles/day, continuing to learn something new each day. I have NP friends who have independant private practices in Internal Medicine and Urgent Care, throughout the nation. As of January 2015, you will have to hold a Doctorate of Nursing Practice to be a NP, that's 8 years of schooling which does include clinical hours plus a residency...food for thought for the person contemplating her future. Best of luck in making your decision! We need all the providers we can get!

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  12. If you are having any doubts about becoming a physician, then the PA or NP career might be the better choice for you.

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  13. AS a PNP for the past 16 years, 18 years as an RN before that, with the last 12 years working sub-specialty in-patient on 2 different services at our local children's hospital. I don't know what the exact details are to being a PA in all states, but in my state, a PA is not considered an independent practitioner, while I am.

    As to Micah's comment that NP education is geared toward nursing vs. medical training. That is completely wrong. Yes, my under-grad was nursing based, but my NP training was medical based, to prepare me for my new role as an advanced nurse provider. I can write my own orders and scripts, our PA needs her's countersigned.

    When I worked in surgery, those residents were facing $250K in loans, and 5 years of clerkship - 3 as a resident, 2 as a fellow, and God help them if they wanted to sub-specialize - 15+ post-graduate years. Don't even mention the hours they had to keep.

    I feel I have the both of best worlds. I am currently in primary care again. I see my patients, if I have a question, there is no worries about bringing in the doc or running it by them. Heck, attendings do it all the time in the hospital. One can not be expected to know everything about everything - MD, NP or PA.

    The docs I work with place more value on their family time, so we don't see 35-50 pts per day every day. Sure, we could all make more money, but then the patients are short-changed. I can't spend the necessary time with a very troubled teen (like I did last week), when I know I only have 10 min or 7.5 min allotted per well-child check. As it was, I spent almost 45 with her, and yes, I really had to put the pedal to the metal after that, but I long ago found that if I apologize as soon as I walk in for keeping the pt. waiting, they are A. surprised, and without fail, say 'it's o.k.'. I acknowledge their supporting sentiment and thank them for it, then reiterate, it still stinks to be stuck in this little room. It takes probably less than 3 -5 seconds to have this discourse, but the visit is on a much nicer level.

    Good luck with your choice.

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  14. Unfortunately, NPs will soon be required to have a doctorate, so that means going to nursing school & then getting a DNP.
    However, NPs have more autonomy than PAs. NPs can have their own private practices, though in general, they need a 'collaborating physician.' However, this too is changing, & state by state, NPs are pursuing legislation (some bills have been passed) to sever that needed tie.
    I disagree w/ the statement above that the 'nursing model is inferior.' The nursing model is a holistic model that looks at a patient in his/her entirety -- physiologic, social, economic, spiritual, etc.
    Bottom line, I think the questioner would be best served by a career as either a PA or an NP. Life as an NP might be more satisfying, but might take longer.
    I'm glad I became an NP when it was still possible to do so w/ a post-bachelors certificate.

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  15. Go to business school. My Harvard MBA son is half my age and already earning more than I do with plenty of free time.

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  16. I am a Family Nurse Practitioner. I do function quite autonomously; but have the support of peers when indicated. It sounds like you would be happy as a PA or FNP; and get practicing sooner. I would suggest you network with mid-levels in a variety of services so you have a clear idea about the various types of practices in which you could get the experience and fulfillment you will require. I would imagine, with Obamacare around the corner, you will have more opportunities than ever! Good luck!

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  17. I am a nurse practitioner. I have pretty much all the autonomy I want. In my home state of Utah, I only need a collaborative agreement with a physician if I want to order scheduled drugs. I believe this requirment well go away in the next couple years. I do foresee nurse practitioners and physician's assistants as the future of primary care, and I think the opportunities will increase almost exponentially. The cost of education is rising, but is still considerably lower than the cost of medical school. And at least for now, the malpractice premiums are a lot lower too. I love the career I have chosen.

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  18. Self knowledge is so important in this decision. As an RN for 30 years, I realized early on that I was quite impatient with those who chose not to take care of themselves. Primary care was not for me. While my peers went the NP route, I recieved my masters of science in nursing in administration. Self employed for the past 20 years, I am certified in occupational health and case management. My hourly rate is $40.00-$80.00 in a rural city in the southeast. I contract with companies and self schedule. Perfect career path for a Mother of 3 who wanted to pick up the kids after school each day...

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  19. Most people like where they live. Thats why they live there. I would expect successful and fulfilled PAs and NPs ( and I am sure there are many) to say that they are successful and fulfilled. That being said, what is not being discussed is the value and satisfaction of knowing something more completely. Primary care provided by midlevels for straightforward problems is often on par with that provided by a family physician. However, the scope and comprehensiveness of training of a board-certified family physician results in a practitioner that can provide evidence-based care for a wider range of complexity and effectiveness. To say otherwise would deny the value of their much greater volume of didactic training, clinical experience, certification requirements and, yes, cost, in both money and years. You do get more with a family doc.

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    1. That is very well-put and a nice counterpoint to many of the other comments.

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    2. As a PA I agree. Physicians just have a greater fund of knowledge and broader experience with more clinical problems. After a few years in practice, most PAs can probably be on par with family physicians in terms of day-to-day primary care decisions, but the bottom line is there is a training disparity and we are called mid-levels for a reason. Similar to the comment above of the 30 year career surgeon, PAs and NPs, for the most part, are not making critical decisions on the truly ill. We are caring for them, yes, and treating them, but there are just some decisions a mid-level is not qualified to make. If you cant admit that as a mid-level you are deluding yourself. Still a great profession, but it's good to be intellectually honest.

      -Micah

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    3. I have been an NP for the last 12 years providing care for children receiving bone marrow transplants in a major pediatric medical center. I am the one making the decisions daily and when they are seriously ill. An NP can do anything they are trained to do and often have years of nursing experience in the field prior to becoming an NP. I do not care for the worrying well, I care for children who may die without therapy. I teach fellows and other MDs how to care for these kids and there unique needs. Our physicians spend their time in research and other areas, NP's provide direct care for these kids. Education starts after school ends.

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    4. Why is it that anytime someone asserts MDs are at the top of the medical food chain, NPs come out of the woodwork with an anecdote about they care for some complex medical condition/in a big hospital/for 20 years/are just as good as a doctor/TEACH doctors, ad nauseum?

      No one here has attacked the NP profession. We are defining pros and cons and the differences between a physician and a midlevel.

      One might get the impression NPs are in a perpetual pissing match with physicians....hence the "DNP" farce, hence the legislation and endless lobbying for independent practice, hence the lack of clinical hours to support their "doctorate".

      You're all valuable players in the healthcare system. We get it, and we see your big girl panties flying high and proud. But you'll never be a doctor. Unless you go to medical school.

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    5. Well, I was very impressed with the fact that this thread of responses had remained friendly and informative up to the last "anonymous" response above. Personal experiences are legitimate and provide insight into the laws governing NP practice in the state in which the NP lives. This "anecdotal" information is valuable for someone considering the profession.

      One might get the impression that "anonymous" is a non-NP with a big chip on his or her shoulder. Perhaps anonymous would like to put on his or her "big girl panties" and stop being insulting? It's pretty obvious he/she doesn't know much about the DNP.

      In response to the brilliant statement, "you'll never be a doctor, unless you go to medical school." There are lots of ways to be a "doctor" outside of medical school, yet you never hear of THOSE professions being insulted and forced to defend themselves. I think "anonymous meant, you'll never be a PHYSICIAN unless you go to medical school. It's funny, but you'll never be an NP unless you go to NP school, either.

      NPs and PAs provide much needed, high-quality patient care and are a vital part of the health care team. Either profession is rewarding, less time consuming and less financially taxing than medical school, and if you live in the right state, you also have autonomy.
      As an NP, I can tell you that I wanted to be an NP. Not a physician, not a PA, not anything else. Research the programs and see what's best for the life you want and the career you want. Just realize, that if you are a PA or an NP you will often deal with belittling insults like the ridiculousness written above.

      By the way, there is no "law" requiring the DNP by 2015. It's a goal. The certifying bodies do not require a DNP to sit for the exams.

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    6. Many providers find the term "mid-level" to be offensive. It implies NPs and PAs are not providing quality care. Same goes with "physician extender." All providers (including physicians) have different skill sets based on what they see in practice/how often they perform a specific skill. We all know what is in our scope of practice to perform and when to refer...so can we stop demeaning the skills of others by and instead work as a TEAM to provide the best care we can?

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  20. NP here. Love my profession. Utmost respect for the Docs and PA's. Having worked for a couple of years matching DNP students with preceptors, I see a huge change in the type of NP that is streaming into the workplace. MANY students go right from high school to 4 year BSN program, straight to NP track getting MSN and then continuing onto DNP. Little to no nursing experience outside of roughly 800 hrs of clinical. So, does this mean our future NP's will be academia oriented considering there is less "nursing" experience? I quit the job doing the preceptor matches - it was very hard to find preceptors to meet the demand of those enrolled in the NP track. A ton of preceptors would vent that they didn't understand why students with no nursing experience were being pushed through the DNP. No longer is it a requirement to have 2-3 years RN experience, and a job waiting for you after graduation. If I was a present day high school grad, I would still go into nursing, because at the core I am a nurse, and that's what I always wanted to be. If I wanted to be a mid-level provider, I'd go to PA school. If I wanted to be a "doctor" I'd go to med school. Good luck, and whatever route you choose, just remember we all work on the same team and the patient comes first. Egos have no place in the practice of medicine.

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  21. The American Academy of Family Physicians just released a survey saying that most patients prefer to be cared for by a physician. The American Academy of Physician Assistants wasn't too happy about that. Here's a link to the story http://www.medpagetoday.com/nursing/Nursing/43556.

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  22. This is a long story.I am an old PA. In the old country during WW2. I was always helping the injured who needed it. I have been a coalminer, part time worker if you could find a job. In 1954 I came to the USA with no education. worked in restaurant, was drafted serve 2 years in US Army as a none citizen of any country became a citizen in 1959.
    After working in many different jobs getting my GED I used my GI bill and started College at night, by now I was married with one son. For some reason my father in law I got me a job as a surgical research technician at NY Downstate Medical center in Brooklyn NY after a few years I got a new title Extracorporeal circulation
    technologist in the then new open heart program and a 2nd son. This is where my story begins. I heard over a few years that a PA program was starting and I started searching to find one in my area that was not too expensive. I found one on ST. Island, NY an experimental program going from Pharmacist Mate changing to a Physician Associate Program. After being turned down three times I got a call one day to see if I was still interested. By now I am 36 years old married with 2 children and no real money to work with no student loans where available to me. I got a loan on my house and paid only interest for 2 years. After graduation 1000s of letters send looking for a Job I finally found one in rural upstate New York setting up a Rural Heath Center. My supervising Physician was a great Teacher I would volunteer in the ER working with him at night and working alone at the Heath Center during the day 5 days per week including call. Over the years I worked 20 years for one hospital in all areas except Neurosurgery and ENT. Money was not the best in those days but the rewards from patients, Physicians and Hospital administrator's where the greatest in my live time. To day I am still working few hours in Urgent Care and volunteer in a free Health Center. At this time in my live now at age 77 year old the only problem I have is giving up my license. Being a Health Care worker for 47 years it's in my blood it's in my heart. So if you want to become a PA start by volunteering in the medical field where ever you can. Being a PA is not the last stop you can make some $ save and take the bridge to become an MD. GW
    PS: My wife my best partner plaid a big roll in my profession and after 53 years of supporting me she tells me to renew my license for another 2 years and I will.

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  23. It is an exciting time to be making a decision about a career in medicine. I am a retired MD who started out in FP, then considered OB/GYN and ended up in Orthopaedics I can appreciate your uncertainty and apprehension. In the last 10 years of my career I had the good fortune of training and working with a FNP who ended up making me tremendously more productive and had the skills and autonomy of 3rd- 4th yr. resident. She did not work in surgery but became an expert in perioperative care (better than most FP's and internists); osteoporosis and anticoagulation investigations; such that she could work indecently in the office and significantly improved my overhead despite her salary. Every busy MD should likely work with both a PA and a NP. Once they do they will never go back to being the "rate limiting step" in how patients access care in their practice.
    For this young lady it revolves around lifestyle, practice style with career challenge/academic stimulation and money.
    The first is best achieved in medicine by becoming a PA/NP as I know most have been able to find a job with the hours & days they want especially if a family and spouse are to be considered. It has become popular in medicine for young women to practice share, but in primary care this can create friction.
    The second is easier to achieve in medicine only if you are in private practice and are the boss. For PA/NP this can be achieved, but only if you seek out "the right job" and are prepared to be mobile and flexible. If the job has to be in your specialty and your home town then be warned you may not be happy (more on that later).
    Finally if your goal is to make more money and be retired by 55 then a MD is a good choice IF;
    1. You are prepared to work hard >60 and up to 100hrs/week as MD's are piece workers. The reason most Docs appear rich and are not is they do not realize that their gross billings are reduced by 50% by insurance rates and collections. Then the net billings are reduced another 50% by overhead. If they want to live like millionaires then they need to work> 100 hours week, or find a better paying second job, or a really good job for their spouse.
    2. One Spouse; as repeatedly dividing assets really defeats the principle of compound interest.
    3. Save 50% of what you bring home and learn to live on that.
    The arguments about time invested or debt are largely irrelevant as an old priest told me once;" pity the person who gets up in the morning to a job that he does not like and a spouse they do not love." These are often interconnected. An old boss once told me; "there is no such thing as the perfect job, the perfect place to live and the perfect person to share it with; but I would be a much better doctor if I could change who their boss and spouse was and give them a raise."
    Time and money will not help you if you are unhappy. Explore and make the right choice for you as 30 years is a long time to be unhappy. Your career is a journey not a destination. I think that medicine is a great career as long as you know your objectives and are flexible.

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  24. As a patient, my experiences with NP's have been at least as good as and in many cases better than my experiences with doctors. I have not been a patient of a PA so cannot speak personally about that. I'd say go for the NP or maybe PA.

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  25. What would be interesting is if they had a Masters level Medical Doctor - basically a PA, but with the possibility of going back and completing the doctorate level and residency later. That's basically the way my experience has been with PA's and nurse practitioners - Masters level clinicians.

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  26. I must agree with the Physician who made several points. As an M.D. with 55 years of experience he is correct. My own opinion is try for the top rung if you fall you can always land on a lower one. I have worked with PA's and NP's; both excellent ones and some I would rather forget. Most of my friends from years back are gone. Quite a few are still doing something part time, but cutting back.
    There is no doubt in my mind that I would go on to Medical school again. The experience you get in those extra years comes in handy when the chips are down.
    Happyily married for 60 years and now retired. Board Certified Family Practice

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  27. I too am really tired of the "pissing match" that goes on between physicians and non-physician health care providers (ie NPs and PAs). There have been a plethora of studies looking at patient outcomes defined in a variety of ways, and comparing physician and NP scores (I'm an NP so don't know if the same is true with PAs). They consistently show equal (or better in some areas) patient outcomes between the two groups. But that never gets mentioned in the physician NP/PA bashing that I'm so tired of hearing. Just a lot of talk about we couldn't possibly be as competent because we don't have the identical education and training. Where's the evidence-based conclusion in that? Physicians are probably over trained for many aspects of primary care. But I think what's most important is how well any of us care for our patients, emphasis on care, and whether we succeed in improving their health and their lives or not. There are incredible physicians out there, and there are incompetent NPs out there too. Good grief, there are way more than enough patients to go around! What matters in the end is how well an individual can help their patient, in any way you want to measure that, and I don't believe any one profession has an exclusive monopoly on that.

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    1. It is ridiculous, but I think people are more vocal online. What I think is disingenuous is when mid-levels try to reach out of their scope with "doctorates" or flowery anecdotes. Mid-levels have some great attributes, and are huge players in US healthcare. Regarding competence, it depends on what you are talking about. We are just as good in some areas, maybe better in some, but not as good in many areas, and this is just a factor of having less didactic education and clinical training. It's just a fact, and it should not affect our ego whatsoever. A lot of PAs/NPs simply dont know what they dont know, and it takes humility to recognize that.

      I think what matters at the end of the day is that we work together with physicians as a team, recognizing the scope of our roles, and utilize our training and skills to the best of our ability for patients' benefit.

      -Micah

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    2. Where do you go to "mid-level" school at? I've never heard of that type of program!

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    3. "Mid-level" refers to NPs and PAs. A mid-level school would be an NP or a PA school. I don't know the origin of the term. As far as I know, there are no "low-level" or "high-level" providers.

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  28. I offer the following advice to the young lady that asked the original question, but first I must explain my credentials. I am a researcher and an engineer. I have never worked in clinical medicine, but in my 70+ years I have learned a thing or two about human nature that has not been clearly noted in the above offerings. To wit: 1 - Money will not make you happy, because the more you make the more you want. 2 - Working by your own hands is unlikely to make you wealthy as you are only one person and there are no more of you. 3 - Investments make you the money you need. All you need is some work to make the money to invest. 3 -Working at a job you hate is worse than jail, or hell if you are religiously inclined. For that reason you should always choose a job that makes you happy even if it pays a little less. If you are happy the job will not be work, it will be play. (For many years people have paid me to play with their toys.) 4 - Never let your job come between you and an a working relationship. People are what make you happy. 5 - When choosing a course of study, choose the one that exposes you to the most varied of experiences. That way you are more likely to see opportunities that you might have otherwise missed and you will be more prepared to take advantage of those opportunities. I think in your case that would point toward the an MD or DO degree at a large school. 6 - Even after the degree never stop learning. When you stop learning, you begin to die. Finally, 7- There are no irrevocable choices. You are never to old to start over so make your best guess at the start knowing that there will be a chance to change your mind. This is a good thing to know for at your age most people have no clue what they will end up doing because they have so little life experience. As I said, I am 70 years old and a few years ago I commented to a friend that I still have not yet decided what I want to do when I grow up. My friend asked a mind numbing question in return: " Why do you want to grow up?" Perhaps when my new wife and I get back from our motorhome tour of the US I may just find that I will never grow up. LIfe is to much fun as a kid. Enjoy it while you can.

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  29. NP X 15 years. Love it. But, I wanted to be an MD and quite honestly my grades would have never gotten me into Medical school. If I did it over again, I would have become an RN first and THEN a PA. It is always nice to pick up extra work as an RN and here in Northern California, they are making over $70/hour. I wish I would have gone the PA route instead of NP because quite honestly, I think PAs get much better clinical training. NPs do get too much nursing theory which has been a waste of time for me. I need to know how to treat patients. Further, the NP hype about getting a doctorate is just one more way for NP schools to make money. In the long run though, NPs and PAs work together - we all do the same thing. We are NOT physicians and it is important we know the scope of our training. Too many NPs and PAs do not known what they don't know. Know your limits and consult/refer appropriately. Ultimately, follow your passion.

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    1. I was a nurse prior to becoming a PA as well. I am glad I did it that way. I really wanted the healing, holistic nature of the nurse and the medical model of the physician. I felt I would be best served by becoming an EMT first, then a nurse followed by PA. The amount of clinical hours in the NP program wasn't enough for what I personally needed. If I had been an ER nurse or ICU nurse for a dozen years...maybe I could have done it. I needed all the clinical hours I could get.

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  30. Well, my post is not about PA vs NP vs Dr. Just as a side not, a little story about me, my journey, and the real question at hand. You have the basics and more already, so I think the question is why do you want to do any of these? In the end, where do you want to be? Titles are good, for many reasons, but where is your passion at your age? Is it to cut, prescribe, listen or ????? I always wanted to be a nurse, a simple RN. I started out in 1971 as a nurses aide, then a certified medical assistant, an
    x-ray tech,...and as I worked in these amazing positions, I watched as doctors were no longer needing nurses and I was doing just about everything a nurse did in a doctors office, under their training and supervision. I worked for chiropractors as well and saw thier struggle, but now many have hospital privliges and work side by side with doctors. I then graduated Nurses school with an RN and worked in many different settings with my degree. Now, I watch as PA's and NP have been at the hospital intensive care and primary clinic care. I do not envy them. There is so much paperwork for hospitals now, that I rarely treated the patient. And the dr. offices now have so little time for the patients, that they have now got RT's in clinics doing the job of a CMA-C, to cut costs and corners. Yes, times have changed and now we have integrative medicine, holistic medicine, complementary medicine and functional medicine. The world is at our fingertips now with the world wide web. My point being, it is not just MD and PA. What are your talents? What is your burning desire. Being a MD, PA, NP, RN does not limit you to hospital vs clinic. I reach out to you, to let you know what a wonderful time in heathcare it is to be able to have a private practice and really have the time to sit and care about the Whole person. I am an RN with over 40 years of hospital, snf, assisted living, retirement home, ER clinic, etc,etc... But now, after all those years, I have found that Integrative Nursing is my burning desire. I work with clients that have searched out what medicine has to offer and are not satisfied. I have certifications in just about everything and that makes me hunger for more knowledge, even at 60. I make my own hours, my fees and assist others in their path to health. If it is out of my scope of practice, I refer to others, MD's, DC's, etc. in an effort to find an answer to their problems. When I can help them, I do it without meds. I use, Therapeutic massage, music therapy, acupressure, magnets, tuning forks, and the list goes on. I have alphabet soup behind my name but it is not who I am, it is what I do and those I care for. Quackery, you say...not so, with every service I provide, there is double blind research behind it. One option does not work for everyone. Once again, my point being, I use my constant upgraded nursing , & integrative medical education to assess them as a RN and assist them in healing their own self when possible. I love what I do, and would not trade it for working in a doctors office or hospital again. I have been there, done that ,and "this" is what I entered the Healthcare field for in 1971. Hands on, caring, listening and bringing the best to those who I serve. So when you do make your final decision, look beyond the Initials and dig deep in your heart for your goal, your dream, your desires and what you want to really be doing in 10 years down the road. My 2 cents. many blessings in your decisions.

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  31. Thanks for continuing to provide some excellent comments on this post.

    The author of the original question was unable to submit her comment and asked me to do it for her. Here it is.

    "Thanks for all the advice everyone! It's definitely been food for thought. I really appreciate all the different viewpoints. I think part of what makes this hard, is that I'm interested in what all of these areas have to offer. Each one has something unique that I really like. It has been helpful hearing all of your points and reading about your experiences. For me, going into the health field is really a passion - it's about serving others. It's not really about the money I can make in the various positions. I just want to know which area of service will fit best with my personality. I was initially inspired by a nurse I met who had a lot of great knowledge and clearly helped others in an important way. And I've since been inspired by MDs that I've known personally. I think both are great professions. I haven't met any PAs, but there is definitely something to be considered there. Thanks again! I hope everyone has a Merry Christmas and Happy New Year."

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  32. I believe there was an actual study done comparing the cost of medical school vs PA/NP school with the various expenses. (malpractice, time away from clinic for having children, ect) The results showed the if you were a young female who planned on having a family, being a PA or NP was the most financially feasible route to take. When comparing the cost of student loans to salary and factoring in malpractice as well as time away from clinic, PA/NP was the winner. However; that being said, you still have to have personal fulfillment.
    I am a PA. Prior to this I was an EMT, then a nurse then I became a PA. I do family practice and emergency medicine. I work in a level II trauma center where there is one other physician and a whole host of nurses. I am able to get as much or as little help as I need and I also work independently in a very small, rural ER where it is just me and one nurse. We take everything that comes through the door. It is a very rewarding career, as I am sure the NP and MD route is. I feel that you would get more one on one time with your patient as a PA or NP vs the MD route. The reason I personally went from nursing to PA is that I did not feel I had enough experience as a nurse to go onto NP school. The PA programs were based on the medical model rather than the nursing model. They had significantly more clinical hours. I felt that I personally needed as many "Hands-on" hours as I could get. I ended up with 2800 clinical hours. The more hours you can spend with actual patients, the better.
    It does sound like rural, family medicine is right up your alley and it sounds like you will be great at it. Good luck to you. All three professions are great!!

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  33. I wanted to add a little to add as food for thought concerning nurses/NPs that may have already been elucidated. I can also say I am biased as when I was choosing a second career path, I chose to be an NP.
    First of all, a NP MUST have a bachelor's degree in Nursing before they can pursue a Master's. So it is time consuming getting another undergrad degree if you want to go the NP direction without first having a nursing degree . This is very different as "Pre-Med" or a science degree is not required for the PA/MD, you can major in music during undergrad. As long as the preqs are completed for the PA/MD route (the majority which are also required classes for BSN education) and post-grad tests are completed then you can apply.
    Anyways, after graduation many nurses work as an RN which I believe truly contributes to a very real understanding of the perils and passions of the human condition. I worked full-time as an RN, and began my MSN part-time (3 years long) within 6 months of ABSN program graduation. Just through work alone, I had clocked over 7,000 hrs of patient care... that's only 3.5 years as a nurse, but had felt like a lifetime of valuable experience. As an RN you deal first hand with EVERYTHING the body and patient can/can't, will/won't be capable of- physically and emotionally for 12 hrs a day. There are many different "types" of nurses (and I can only tell you my experience), but I would be the person who asked the MD to order the additional labs, offer recommendations- meds, consults etc., or relay serious concerns because of my proximity and knowledge. There is also a huge educational component provided to the patients and families by your bedside nurse. I bring this up because I feel that the background experience and knowledge gained in 'nursing' foundation of the Nurse Practitioner is often overlooked. I think that it is important because this acknowledgment makes a better NP and is very distinguishing. It also helps during school, you integrate knowledge learned in both directions.
    As a recent grad I've been exposed to Medical Students through a shared a semester site with about 15 students who rotated through. I can say that I feel even the teaching component in how 'medical' clinical rotations are completed is a stark contrast. As the NP student, I was actually afforded much more autonomy and the attending MDs would explain that they really enjoyed having NP students mixed in (This was at a top 10 hospital in the nation). It was expressed they thought our experience had made NPs superior students compared to the 3rd/4th yr Med Students especially in terms of communication, patient satisfaction, and physical assessment, etc.
    There are many different NPs as well. Depending on your school, you may learn basic (or more advanced) surgical techniques. There are a selection of specialties to choose from: Family, Acute- Care, Certified Registered Nurse Anesthetists, Peds, Gerontological, and Women's Health NPs/midwives. Nursing and medicine offers so many options. I enjoy the FNP specifically because of that.
    *As I said previously, my comments are a reflection of MY experience, educational and work opportunities. But, to the point- NPs use critical and holistic thinking, we can do many of the same things a PA/MD can do, there are some things they can't do that we can- it's all relative. Just don't get stuck in 'the nurse or NP is inferior' stereotype because it does not help anyone's profession. We are not associated with a bedpan, it is not "easier", or a fallback option if you don't get into Med School etc. (trust me, I've heard tons of this). Evaluate the different teaching styles and values, go shadow an NP or PA. Ask people around you how if they liked the NP or PA they have received care from. Good Luck!

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  34. My undergraduate degree was in science at one of the most rigorous and respected universities in the world. I got interested in Medicine because everything else seemed too easy and I was interested in a career where I deal with people directly. My skills are in the top 1% in science and problem solving, but do not always "fit in" with what is essentially a politically charged and crony-led health care system. I have had varied success in practice and teaching and am now aiming to do more research. Having observed how health care has evolved in the US, I am very critical of and frustrated at the amount of financial waste and lack of quality that we currently have. My comments will be aimed at whether to become a NP, PA, or MD, so please don't think I am not critical of other aspects or professional behaviors of health care.

    The difference is not only what financial resources you are willing to commit to a profession, but how you will feel when working in the settings that are available. Nothing can replace a broad, rigorous, properly supervised education with a solid foundation in both science and professional experience. Currently, in my opinion, only Medicine has developed this well enough, even with its currently flawed specialization bias. PA education is strong in basic science, as they go through what I affectionately call "mini-medical school" and go through a brief enough clinical training to effectively practice with a supervising physician. The PA profession has not tried to be independent of physicians which creates a humility in their professional relationships that benefits their performance and care. The nursing profession has had no such easy task and path over the years, as the male dominated culture in the US has given rise to NP training as an outlet to gain deserved professional satisfaction.

    But the obvious is still unavoidable: much of what NP's learn is not supervised by physicians and is in my opinion the training is scientifically less rigorous. This does not improve with practice as the foundation isn't there to build on. The idea that someone who otherwise would not qualify for medical school by their abilities and training and takes a path to getting a clinically independent role is what is also being discussed here. What seems to be also in question is how responsibilities that are assigned and to the work that is done matching the abilities and training of individual professionals in out system.

    The number of years it takes to get to a professional goal is less meaningful when all is said and done, since the end result will be much more important. The cost is higher for medical school, but physicians start making money after only four years of medical school when they go into residency. There are many new MD/DO schools now that have a presence in rural areas so that access is less of a problem.

    Studies comparing NP's to others are, in my experience, sponsored by and performed by NP organizations. I am not aware of any study design that can appropriately answer such a broad question without introducing bias. If the best we can do is anecdotes from each side, we will likely end up just pissing each other off. I do, however, believe this all will eventually find its way toward a livable system. The saying still goes: the best patient care comes from caring for the patient.

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  35. Just want to let you know I've had two really great health care professionals: one was an ob/gyn MD and the other was a PA at a local clinic. Most the of the rest of the MDs were ... not so... but the PAs have been fine. I think they have more time with patients, and haven't had the humanity ground out of them through some of the unfortunate docs' training...

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  36. I know they say, it's never too late to get additional schooling, but at 59 is it too late for me to consider a Nurse Practitioner career? I have been out of work/the loop for a while but I may be able to get back into the working world again and several of my family members are in the medical field. One sister is a school nurse, one a retired nurse, my brother-in-law is a physician-pediatrician and those up to 21 yrs and his son my nephew works at a medical facility in business and my niece just got her degree and is now a Psychologist she will be working with those who have autism. So is it too late for me just turned 59? I also thought about being a chaplain

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    1. At age 52 I retired from Research and Engineering and began a career in consulting. At age 58 I retired from consulting and after sitting around for a few months started a Photography business. Now at age 70+ I am about to start a new career in writing about health so no it is not too late. One more fact. Dr Denmark, pediatrician, in Alpharetta was seeing patients at age 103. It is possible that you can also. You will never know unless you start.

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  37. MK, you would have to put in a few years of school and then clinical experience. I'm not sure that a nursing school would accept you.

    AP, it's a little different to spent 4 years in nursing school and mire time in NP training compared to starting a new business.

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  38. "I have been an NP for the last 12 years providing care for children receiving bone marrow transplants in a major pediatric medical center. I am the one making the decisions daily and when they are seriously ill. An NP can do anything they are trained to do and often have years of nursing experience in the field prior to becoming an NP. I do not care for the worrying well, I care for children who may die without therapy. I teach fellows and other MDs how to care for these kids and there unique needs. Our physicians spend their time in research and other areas, NP's provide direct care for these kids. Education starts after school ends."

    To the poster here it always annoys me when these nurse practitioners go into a pissing contest vs physicians....I have to be honest, if one of my kids was that sick I'd want a board certified MD in Onc at the helm of the care....not a nurse practitioner. You guys fill a gap in healthcare and you guys do a great job, but specialists in medicine you are not.
    I mean just look at the DNP programs 3-6 credit hours in "residency" in a clinical setting? I mean its a farce to compare that to MD education an residency and fellowship.

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