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Notes -
You Did It To Yourself
Again, the endless seething by doctors over their ongoing replacement by “physician associates/assistants” (PAs) and “nurse practitioners” (NPs) rears its head. The many concerns that physicians have about NP/PAs are, of course, entirely valid: they’re often stupid, low-IQ incompetents who have completed the intellectual equivalent of an associates degree and who are now trusted with the lives of people who think they’re being cared for by actual doctors.
Story after story describes the genuinely sad and infuriating consequences of hiring PAs, from grandparents robbed of their final years with their families to actual young people losing 50+ QALYs because some imbecile play-acting at medicine misdiagnoses a blood clot as “anxiety”. Online, doctors rightfully despair about what NPs are doing to patient care and to their own ability to do their jobs.
But there’s a grand irony to the nurse practitioner crisis, which is that it is entirely the making of doctors themselves. If doctors had not established a regulatory cartel governing their own profession, the demand that created the nurse practitioner would not exist. The market provides, and the market demanded healthcare workers who did the job of doctors in numbers greater than doctors themselves were willing to train, educate and (to a significant extent) tolerate due to wage pressure. It is a well-known joke in medical circles that doctors often have a poor knowledge of economics and make poor investment decisions. This is one of them; the market invented the nurse practitioner because it had to. Now all of us face the consequences.
I had multiple friends who attempted to get into medical school. Some succeeded, some failed. All who tried were objectively intelligent (you don’t need to be 130+ IQ to be a doctor, sorry) and hard working. The reason those who failed did so was because they lacked obsessive overachiever extracurriculars, or were outcompeted by those who were unnecessarily smarter than themselves (there is also AA, especially in the US, but that’s a discussion we have often here and I would rather this not get sidetracked).
The problem goes something like this: smart and capable people who just missed out on being doctors (say the 80th to 90th percentile of decent medical school candidates, if the 90th to the 100th percentile are those who are actually admitted) don’t become NPs/PAs. This is because being an NP/PA is considered a low-status job in PMC circles; not merely lower status than being a doctor, but lower status than being an engineer, a lawyer, a banker, a consultant, an accountant, a mid-level federal government employee, a hospital administrator, a B2B tech salesman etc, even if the pay is often similar. To become a PA as a native born member of the middle / upper middle class is to broadcast to the world, to every single person you meet, that you couldn’t become a doctor (this isn’t necessarily true, of course). This means that NPs and PAs aren’t merely doctor-standard people with less training, they’re from a much lower stratum of society, intellectually deficient and completely unsuited to being substitute doctors (the work of whom, again, doesn’t require any kind of exceptional intelligence, but it does require a little). Almost nobody from a good PMC background who fails to get into medical school or, subsequently, residency is going to become a PA/NP for these reasons of social humiliation, even if the pay is good.
Nobody who moves in the kind of circles where they have friends who are real doctors, in other words, wants to introduce themselves as a nurse practitioner or physician associate. A similar situation has happened in nursing more generally. Seventy years ago, smart women from good backgrounds became nurses. Today some of those women become doctors, but most go into the other PMC professions. Nursing became a working class job, and standards slipped. Still, nursing is still often less risky (although there are plenty of deaths caused by nurse mistakes) than the work undertaken by NPs and APs. Nursing became if not low status then mid status, and is now on the level of being a plumber or something - well remunerated, but working class.
The result is a crisis of doctors’ own making. Instead of allowing (as engineers, bankers and lawyers do) a big gradation of physicians, all of whom can call themselves the prestige title doctor but who vary widely in terms of competence, pay and reputation in the profession, doctors have focused on limiting entry, reserving their title for themselves and therefore turning away many decent candidates. (Of course there is a status difference between a rural family doctor and a leading NYC neurosurgeon, but the difference between highs and lows is different to the way it would be if medical school and residency places were doubled overnight.) The karmic consequence of this action is that they are now being replaced by vastly inferior NP/APs who deliver worse care, are worse coworkers and who will ultimately worsen the reputation of the broader medical profession.
What will it take to convince the medical profession, particularly in the US, to fully embrace catering to market demand by working to deliver the number of doctors the market requires, rather than protecting their own pay and prestige from competition in a way that leads to ever more NP/APs and ever worse patient outcomes? The US needs more doctors, especially in disciplines like anaesthesiology, dermatology and so on paid $200k a year (which, much as it might make some surgeons wince, is in fact a very respectable and comfortable income in much of the country). Deliver them, and the NP/AP problem will fade away as quickly as it began.
My sister-in-law is a PA, and I'm friends with several others. I have no idea what you mean from the suggestion that PA's have lower status than any of these other people. Maybe because some people confuse them with medical assistants, but people who don't know the difference aren't among those whose opinions I care about. A lot of them end up being PAs not because they couldn't cut it as doctors, but because doctors themselves warned them against med school. The option is going to school for 4 years after college, spend another 4 years working ridiculous hours for poverty wages, and finally get to be a real doctor some time in your 30s. At this point you're in so much debt that the higher salary only allows for the kind of lifestyle a normal college grad would have, not that it matters anyway, because you're still spending all your time at work.
And who is exactly looking down on PAs anyway? I'm a lawyer. I don't know what you do exactly, except that it's in finance, but unless you're in senior management I'm going to go ahead and pull rank here. I don't sit in some sad fucking cubicle or worse, some trendy-looking open office. I have a private office—an actual private one, not one of those manager offices with the window or frosted glass door that's expected to be open unless you're on the phone or discussing something sensitive—that's almost large enough to include a sofa and has sports memorabilia and custom photo prints on the walls and a large picture window with a view of a forest. I have my own secretary, and an army of paralegals will stop what they're doing if they're needed. If I need something printed I call someone else and have them bring it to me. I get printouts of most things because my work space cannot be limited to two screens. I have a bookshelf full of binders I prepare for each case (I'd have someone do this for me, but I don't trust them to not fuck it up). I have people send emails on my behalf, and people stop by my office with stuff for me to sign. I don't do anything that could be conceivably described as "real work". 90% of my job is drafting informal memos that aren't assigned by a superior or even directed to anyone in particular but are simply placed in the file for my own edification and so there's a record of my thoughts in case another attorney needs to look at the case. Most of my actual time is spent looking through documents and pacing my office thinking about things so I can make a decision. The only supervision I deal with is case assignments and who is covering depositions and court appearances, if there's a scheduling issue there. I don't deal with project managers assigning me work and emailing me every five minutes.
Beyond work, I live in a 3-bedroom house in an upscale area that's filled with toys I use on the weekends pursuing expensive hobbies. So please tell me who exactly I'm supposed to be looking down on. A guy who runs a crane in a steel mill? A video editor? The owner of a dog grooming business? A low-level financial analyst for a large company? A schoolteacher? A mechanical engineer? An audiologist? A registered nurse? A college professor? An accountant who does asset valuations? The guy you call before you dig? A middle manager for the IRS? The guy who works for a large bank who's described his job to me several times and I still don't know what he does? These are all friends of mine, and I could go on, but this gives you an idea of what my social circle looks like. There are no doctors or lawyers I regularly see socially, though my cousin is a Worker's Compensation attorney. I don't know anyone, even among lawyers, who engages in the kind of ostentatious spending that's meant to signal status. I know people who are really into things like craft beer, but that doesn't correlate with income. I personally drink High Life and Coors Banquet as my regular quash. I don't think PAs are below me. And I'm not one of those unrealistic egalitarians who think that I'm everyone's equal; I wouldn't date a girl who worked at McDonalds (or, realistically, one who didn't have a professional job), but that's about as far as it goes for most people. I don't ask what people do for a living before I decide if I'm going to be friends with them.
There are no gradations of lawyers in the US. Once you pass the bar you're allowed to handle anything any client is willing to give you. You might not exactly be qualified to do so, but all the ethical canons say about that is that you have to familiarize yourself with the relevant law. Medicine, by contrast, has actual board certified specialties that require specific training.
Cool comment (seriously).
In your opinion what is the area of law that is at the optimization frontier for raw compensation and intellectual gratification? I have friends who do legal advisory work for the big banks, and they make crazy money, but they kind of hate everything. On the other hand, I know a guy from church who does small to medium local business law, fucking LOVES it, and makes more than enough money (though not Christmas-in-Aspen money). I have an older family friend who spent her whole career in family law and is now emotionally broken and sorta-kinda broke financially.
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