PA vs. Med School

While medical school is no walk in the park, the only part I have thought to be really hard was the first 2 years. Though 3rd year required more time and was less flexible, it's hardly been as bad as some make it seem. I imagine many of you work more hours than what I put in last year as a med student, but that would be excluding the study time outside of rotations. Residency doesn't really sound like all fun, but many people manage to raise a family during that time. I have a number of classmates who have had kids while in medical school. I haven't noticed any difference in their happiness compared to those I know that are not in medical school.

Anyhow, as far as pay, I'm not too worried... using myself as an example:

(I rounded up on figures for myself.)

33,000 - undergrad
300,000 - med school (includes cost of living)

Residency: 50,000 per year on average x3 year for EM = 150K (note: there IS variation in pay, some more, some less)
Attending pay: 250,000 x 25 years = 6,250,000 (again, some pay less and some pay much more, also fulltime for EM is usually 32-36 hours/week)

Double my debt for what I may be paying after interest to 666,000 \m/

6,250,000 + 150,000 - 666,000 = 5,734,000

Lets say I did PA route...

33,000 = Undergrad debt
39000 + 29000 + 6300 +(24,000/yr for cost of living x 2.25 years) = 128,300 = PA school debt (same univ. that I've attended for medical school)

Lets double my debt again... (128300+33,000) x 2 = 322,600

102,000 x 30 years of work = 3060000

3,060,000 - 322,600 = 2,737,400

Difference between MD route and PA route: ~2,990,000

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Again, I'm not too worried about pay, even if it takes a hit in the future. I didn't go into it solely for the money (though, I admit that I may not have gone this route if PAs, NPs, and MD/DOs all got paid the same). I'm still happy with my decision.

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Some data on pay that I used to ballpark things...
http://www.beckershospitalreview.co...tatistics-on-physician-compensation-2012.html

http://nurse-practitioners-and-phys...res/Articles/National-Salary-Report-2011.aspx
 
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Imagine if this thread was on all nurses . Com :ph34r:
:D
 
medicsb said:
Difference between MD route and PA route: ~2,990,000
[/QUOTE=medicsb;494963]

It's not absolute dollars that matter, though: it's the net present value of the investment.

Indeed, for most people who don't want to work more than 60 hours a week (and this holds even more true for those who don't want to work more than 40 or 50), being a physician (depending on your field) is often a zero or negative net present value investment. And when you adjust for years off, say, to have a child, it's a usually a really bad investment. Here's a recent (un-gated) paper published in a top 10 journal in the field of labor economics: http://faculty.som.yale.edu/keithchen/papers/GenderNPV_WorkingPaper.pdf

I'm running the numbers from your post in Excel now to see what the NPV is. I'm going to make the assumption that med school and PA school cost the same ($75,000), and that undergrad was $8250 per year, so let's ignore selection bias (i.e. people who become MDs may or may not be the same people who become Pas).

Of course, NPV doesn't account for the non-pecuniary benefits, but if we're just taking hard numbers, I'll preliminarily say: "does not compute."
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So, ignoring the cost of capital (i.e. assuming you can pay cash), and saying that both the PA and the MD work 30 years prior to retirement (30 years starting from after the completion of both "classroom" and "on the job" training, so Year 7 and on for the PA, but year 12 and on for the MD), the IRR is 26.38% for the MD and 36.32% for the PA. At a discount rate of 4% (a conservative value for the real interest rate), the NPV of the physician's income is $2.64 million, while the NPV of the PA's is $1.24 million.

Ok, I was wrong, given those numbers. :/
I still am not convinced that the MD, though, is a positive NPV investment.
 
Calculate it out for starting the process at age 30 instead of 18. And figure most residencies are 4 years and a 1 year fellowship is common (2 year common with 3 year residencies).
 
Summit said:
Calculate it out for starting the process at age 30 instead of 18. And figure most residencies are 4 years and a 1 year fellowship is common (2 year common with 3 year residencies).
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Oof. Yeah, that's gonna make it much, much closer.
 
Not really sure whether the money is the deciding feature for most people, whether or not they think it is. Status and quality of life may be bigger.

My view is that the mean for PA education (probably NP too, but I can't speak for them) is below that of an MD, but the confidence intervals certainly overlap. (Part of the trouble is that when it comes to anecdotal support, everybody focuses on the lousy midlevels they've encountered and ignores all the bad MDs.) This is after some years of experience, of course. A fresh PA grad is realistically only half-trained to properly practice medicine, but then, so is a new MD grad; if you give him four years (versus a residency) and maybe a couple others (missing years of "med school"), both sides probably trend toward a common baseline.

Anyway, I like to compare it to a familiar situation for EMS folks. The minimum criteria are low. So there are EMTs running around who you wouldn't trust to carry a bag of sand, and there are others who could probably be neurologists. If you want to be the latter, it's on you. (This also means that, as the latter, you will often deal with other professionals who are somewhat wary because they've dealt with so many of the former. Who here isn't used to needing to prove their credibility?)

All that is mainly about textbook sort of stuff... softer skills like bedside manner, well-roundedness, psychological health, and so on are probably not selected for with any greater rigor in an MD/DO program, and you could argue that with their upwardly-spiraling competitiveness, they are actually being downgraded. But again, we're just talking starting positions here, and everyone goes their own way after they put on a coat and hit the big old world.

I will say that it doesn't do PAs any credit when they inevitably bring up money in these discussions (versus the docs who usually bring up issues like education, patient care, dedication, etc)...
 
DO NOT lose what JPINFV said above.

However if she's never heard of OI, she can't consider it as a potential issue, or really definitively state it's not an issue.

Every single person taking medical instruction of any sort should be required to memorize that, only replace the word "she" with "I" and replace "OI" with "something".

Rightly said.
 
Let me make one thing clear. I do not mean that as a slam. We all have our limits (even physicians), and knowing that limit is important.
 
Dunno why these threads end up on an EMS forum, but since it did I feel sort of compelled to defend physicians just a touch.

Brandon Oto said:
I will say that it doesn't do PAs any credit when they inevitably bring up money in these discussions (versus the docs who usually bring up issues like education, patient care, dedication, etc)...
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I don't mean this to come off as nasty, but the reason for this observation is probably that it isn't possible for a midlevel provider to claim a desire for the greatest possible education or the strongest demonstrable devotion to patients as reasons for selecting "midlevel" over "physician," wheras those two characteristics are probably part of why many physicians chose the most rigorous route. midlevel makes total sense for many healthcare settings and for many people, but the reality is that people choose the less rigorous route out of self interest rather than patient interest (not that self interest in moderation is a bad thing, or that many physicians aren't plenty self-interested as well)


I do have to say I also disagree that 4 years of PA experience (in a non-didactic setting with lesser work hours than residency, and probably with a different role in the department) = residency, nor that 2 additional years of, (again, non-didactic probably somewhat repetitive experience) = coverage of all the basics skipped from the first years of medical school. PA's are great, but PA school is not simply a different route to eventually become equivalent to a physician.
 
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Brandon Oto said:
All that is mainly about textbook sort of stuff... softer skills like bedside manner, well-roundedness, psychological health, and so on are probably not selected for with any greater rigor in an MD/DO program, and you could argue that with their upwardly-spiraling competitiveness, they are actually being downgraded. But again, we're just talking starting positions here, and everyone goes their own way after they put on a coat and hit the big old world.
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This is a valid point... and all the textbook knowledge won't help if you can't communicate with the patient because you don't have rapport, or the ability to sell your patient on a treatment plan, or the ability to elicit the best from teammembers.
 
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jrm818 said:
I don't mean this to come off as nasty, but the reason for this observation is probably that it isn't possible for a midlevel provider to claim a desire for the greatest possible education or the strongest demonstrable devotion to patients as reasons for selecting "midlevel" over "physician," wheras those two characteristics are probably part of why many physicians chose the most rigorous route. midlevel makes total sense for many healthcare settings and for many people, but the reality is that people choose the less rigorous route out of self interest rather than patient interest (not that self interest in moderation is a bad thing, or that many physicians aren't plenty self-interested as well)
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In many ways, I agree. Nobody sits down and thinks, "How can I get the most possible training to become the best possible provider? I'll become a PA!"

But... very few people go to medical school with that logic, either.

The people making that distinction are mostly the established "PGY30s" who are looking around and watching things change -- the same people concerned over things like reduced residency hours. They're probably right, but that's neither here nor there, because again, I know exceptionally few people who are motivated by that reasoning when they pick a career path. Heck, for the typical fresh-from-college med school applicant I'd be surprised if any of their motivations were so lofty. (Not to play the "real life" card, but many midlevels -- at least traditionally -- are older and have enough experience that boring things like money are unfortunately more real to them. Most have also been collared by physicians and sternly advised not to go into medicine the way things stand today.)

Getting the most possible training so that you'll be "a doctor," or be "independent," or even "because it fascinates me" is not quite the same thing. If someone claimed they were, I'd ask whether that applicant would be happy if I could snap my fingers and give him the same competence, offering the same quality of care, but his job title would be "plumber" or "consultant designer associate" and nobody in the world would ever know what he did for people.

I do have to say I also disagree that 4 years of PA experience (in a non-didactic setting with lesser work hours than residency, and probably with a different role in the department) = residency, nor that 2 additional years of, (again, non-didactic probably somewhat repetitive experience) = coverage of all the basics skipped from the first years of medical school. PA's are great, but PA school is not simply a different route to eventually become equivalent to a physician.
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It's a very rough comparison, of course, and even with squinting is not congruent (sort of like trying to compare American vs. European styles of residency training -- it's not just about years). My point is just that the more time that passes, the less difference your initial training makes at all compared to your accrued experience, continuing learning, and general drive to improve. A lot depends on where you point your sails. I'm sure many users here are very familiar with that concept.
 
jrm818 said:
Dunno why these threads end up on an EMS forum
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This forum has had so many members go to MD/DO/CRNA/PA/RN/RT school that we can have fascinating limited interdisciplinary pissing matches by a bunch of students and green providers (I'm including myself here) and some experienced ones.
 
jrm818 said:
it isn't possible for a midlevel provider to claim a desire for the greatest possible education or the strongest demonstrable devotion to patients as reasons for selecting "midlevel" over "physician," wheras those two characteristics are probably part of why many physicians chose the most rigorous route. midlevel makes total sense for many healthcare settings and for many people, but the reality is that people choose the less rigorous route out of self interest rather than patient interest (not that self interest in moderation is a bad thing, or that many physicians aren't plenty self-interested as well)
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Every human action is done out of self-interest. Some people's self-interest is the pursuit of knowledge and excellence for it's own sake. Some people's self-interest is the pursuit of prestige and high income. Some people's self-interest is something entirely different.

The idea that physicians as a whole are a dedicated and benevolent group who self-sacrifice solely or primarily for the purpose achieving higher knowledge and benefit to society, while PA's and other midlevels are slackers just looking for the shortest and easiest path to "be like a doctor" is a stunning over-simplification, and more than a little naive.

I've known more than a couple RN's and paramedics who considered medicine as a career and were plenty smart enough to do so, but ultimately chose not to pursue it because they decided that, while they would certainly like the knowledge, income, and prestige that comes with being a physician, at the end of the day they feel they can do more good for their patients and/or communities and/or families in their current role. Have they shown less of a "devotion to patients" because they've chosen to serve patients in a different way than physicians do, and for much less compensation?

What about the rescue technician / EMT who who has literally risked his life for his patient. Has he shown "less of a devotion" to his patients, because he has so much less formal education than physicians?

What about PA's and NP's who choose to live and work in underserved areas for less income than they could earn elsewhere? What about those who chose to become an NP or PA rather than an MD specifically because they wanted to be able to afford to serve a poorer population? Are they "less devoted" to their patients than the person who went to medical school and now won't practice in that underserved area?

What about the surgical resident who once told me (an ICU nurse at the time), in reference to my having to clean up a patient who'd soiled himself, "that's the difference between me and you; I was smart enough to get into a field where I don't have to clean people up". Is that d-bag automatically "more devoted to his patients" than someone with less education?
 
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Halothane said:
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Very well said.

Personally, I am content pursing PA/NP. I am confident that I could get into medical school if I truly desired to. But I don't. I do not think that makes me lazy or any less dedicated to patients and medicine. I know that I will be able to make a positive impact in the capacity I choose. I am not trying to "be a doctor" without the education.
 
Another advantage of the PA route is what you might call "embedded optionality." That is to say, you can change fields of practice if something better, or more interesting, or more convenient, etc. comes up. That's worth something -- I'd like to try adding that to a model of cash flows.
 
I will like to become a pa, but I don't find a good college that can put me in that pa direction in NYC
 
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