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The Choice

October 10, 2013

Over the last month I have received several comments from readers who have made, or who are trying to make, the choice between nursing and medicine.  And may I just say what a great problem we have now, to be able to choose!  I’ve been thinking about this and I submit there are three considerations: philosophical, practical, and logistical.

1. Philosophical.  Many of you have heard of the “Medical Model”, the idea that doctors are trained to diagnose and treat disease.  Fewer are aware of the various nursing theories, developed by nurses to try to describe the philosophical underpinnings of nursing and attempt to define it’s boundaries.  For example, Dorthea Orem developed the Self-Care Deficit nursing theory, based on the idea that “all patients wish to care for themselves” and it is the job of nurses to restore them to this independence.  Roper-Logan-Tierney theory holds a similar view, that disease is defined by disruptions in patient’s ability to perform activities of daily living.  There’s a bunch of others along the same lines.  Some of the theory is, frankly, ridiculous verbiage. But it serves the purpose when you are trying to define differences between nurses and doctors.  At least as it was in the 1980s, the last time a big general theory was put forward.  Here’s an example of nursing theory vs the medical model:  say you have a 65 year old man who has been diagnosed with congestive heart failure.   The medical model knows that this means the left ventricle of his heart is weak and doesn’t push blood forward into the body so that blood backs up into the lungs causing fluid to accumulate and producing difficulty breathing.  If you give drugs to make the heart stronger or decrease the blood volume, the person gets better.  The heart is the problem.  In nursing theory, the patient has congestive heart failure but the real problem is he can’t breathe, can’t climb stairs like he used to, doesn’t have the stamina he used to have, etc.  In other words,  his normal functioning in life is disrupted.  You have to give the drugs but you also have to address the social, psychological, and educational issues that arise whenever a person can’t do what they’ve always done.  The disease is the same, the focus of treatment is different.  I will say the medical/nursing lines have blurred; a good nurse knows her medicine and a good doctor treats the whole person.  You get the idea.

2. Practical.  Of course in practice, all the gobbledy-gook above goes out the window.  Let’s face it.  Most doctors and nurses these days do mostly paperwork.  Neither gets to take care of people the way they want to.  Doctors only get to spend a few minutes with each patient.  All the actual care is done by other people.  If you really want to TAKE CARE of people, nurses arguably spend much more time actually laying hands on people and helping them in a physical way.  Most doctors do feel they are caring for patients, but it takes a different form.  Doctors tend to work longer hours and take more night and weekend call, but nurses are starting to take call also.  The thing about nursing is that nurses have a great deal of responsibility and not a whole lot of power.  A nurse’s job is not just to “take orders” but someone does have to do that and nurses do carry out the orders of doctors, work that can require a fair amount of physical labor.  But as the person who sees the patient the most, nurses also observe and report problems or complications that arise, and are usually the first to notice when something is not right.  The nurse might have to seek and “order” for the thing she knows the patient needs, but she/he is the patient’s first line of defense.   This advocacy is, in my opinion, the most important thing a nurse does.  A good nurse sees what her patient needs and makes sure it happens.  Again the lines are blurring, as more nurses have prescriptive authority and do more of the diagnosis.

3. Logistical.  Here’s the kicker.  The barrier to entry in medicine is extremely high.  There are so many hoops to jump through, so many meaningless math classes to ace, so many standardized tests, that some people who would make great doctors get weeded out.  It will take you 8-12 years to become a practicing physician.  The money, time, and hoop-jumping might not be worth it.  You don’t need to be exceptionally smart, you just have to be very persistent.  Nursing is an easier way to go educationally, but your knowledge base of medicine will be more limited, and you will be working under more supervision.  A nurse can go on to get graduate degrees that allow a greater scope of practice, but the educational process is not as complete or as uniform.

Either way you choose, be very very sure it is what you really want to do.  Both fields are demanding and rewarding and take a great deal of commitment.  Good luck!

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21 Comments
  1. Sheri:

    Amen and well put! You have an amazing well rounded perspective, there need to be more like you in this conversation. We need to stop thinking of this as a debate.

    It is interesting that studies are beginning to show that female PAs have slightly higher lifetime earnings than female physicians, and I am wondering if this may be true for nurse practitioners as well. Ultimately I agree goals are the same, it is how we get there that is different.

    From a FNP turned hospitalist almost 3 years ago after 8 years of primary care.

    • Thanks for reading! I agree the “controversy” is misplaced. The lifetime earnings data is interesting. I wonder if PA’s and NP’s tend to maintain full-or near-full-time work because of family friendly work hours, whereas female physicians face a less family-friendly atmosphere? I know this is a complete generalization and very individual.

  2. Shirie:

    I forgot you were previously a nurse, explains a lot in a positive way. I hope your entry made into KevinMD.

    The take on the wage disparity between physicians and NP/PAs was largely explained by the non or low income time spent for the additional 2 years of medical school and another 3+ years of residency and/or fellowships, all professions had similar amounts of time out for childbirth and childrearing. There is also the usual gender gap wage disparity rearing its ugly head as well though this exists in all three professions, yes including nursing.

    I think another factor that would be interesting to investigate is what percentage of MDs, NPs, and PAs that entered their careers after having done something else previously. I was a city planner and project manager prior to going back to the RN to MSN program at MGH and was 45 at that time.

  3. Liz permalink

    Hi Dr. Leng,

    I’m currently an RN (with my BSN), and I’m actively applying to post-bac programs with the interest of pursuing an MD degree. I think I’m interested in specializing in ID, or working in some capacity with the CDC or WHO. I wonder if you have any advice for how to bridge the RN to MD divide?

    I’m a bit intimidated by the idea of a career change. I’m also kicking myself for not just staying with pre-med in the first place. I try to maintain the perspective that my experience as an RN has helped form my perspective and gain a realistic idea of what medicine will be.

    Thanks for your time!
    Liz

    • Liz – thanks for reading! Oh boy. I thought I knew what I was getting into also, having an RN and an MSN and plenty of resident friends. I had no idea. There is no way to know how you will react to the reality of residency, call, and sleep deprivation. Those are the realities you don’t see no matter how long you’ve been a nurse. That being said, having an RN helped greatly in medical school when it came to practical skills like physical examination, IVs, reading medical lingo etc. and it probably helped when I was an intern. But the biggest mistake I made in med school was assuming that I knew more than everybody else. I didn’t allow people to teach me because I had already done that or been there. The best thing you can do in med school is to forget you were a nurse; or rather, allow yourself to be re-taught. Then when you’re a doctor, remember that you were a nurse and use that experience to inform your interactions with patients and staff. We RN/MD folks have a unique, valuable, and humanitarian perspective on patient care that can get squashed by the rigors of training if we aren’t careful.
      Good luck. It’s a long road.

  4. Wow, thanks for your very broad perspective! You are an excellent writer :). I’m impressed. Your articles are all very interesting. Have you ever worked in a nursing home before? I really wish you could write an article on your perspectives of LTC’s since they have become so popular. 🙂

    • Thanks for reading JM! I appreciate the encouragement. I have not worked in LTC’s but my opinion and impression of them is part and parcel of my strong belief in early and aggressive end-of-life discussions. Elderly issues are prominent in some of my early posts last year. I’ll definitely do a sequel or two in the near future!

  5. Naomi permalink

    Dear Dr Leng,

    I graduated from college with a BA in biochemistry, hoping to pursue medical school after taking a gap year. Now, I’m torn between MD and NP (which I would enter accelerated bsn/msn program). I love the science and the extensive medical training that comes along with being an MD, but I am also worried about the debt, stress, and years ahead before I can start to practice independently. On the other hand, being an NP, I would finish school sooner, with less debt, and will be a mid-level practitioner that could still diagnose and treat patients. Since you have been both NP and MD, I was wondering what makes you to choose medicine after being an NP? Any suggestions would help! Thanks so much for your time!

    Best

    Naomi

    • Naomi – thanks for reading! So many people ask me this question. If you love science and have a degree in biochemistry, I would go the MD route. I think being an NP will frustrate you. Nursing training is practical and hands-on, but it doesn’t have the basic science. If all you want to do is primary care, by all means being an NP is probably OK, although think hard about whether you want to work “under the supervision” of a doctor. The time and money are significant factors, and you are right to consider them. 8-10 years is a long time, and what you want when you start isn’t necessarily what you want when you’re done. I say do what gives you the most options. And remember, you can always change your mind. I did!

  6. naomi permalink

    Dear Dr. Leng,

    Thanks so much for your response! I agree with what you said hatt with my background in biochemistry, perhelps I’m more interested in being trained in the medical model. What do you think of PA? Thanks again for your time!

    Best

    Naomi

    • Naomi:

      I think the things Dr. Leng mentions regarding PAs is more correct regarding in many states needing to work under the supervision (though not necessarily license of) a physician. Usually, the education for a PA is a bit truncated, one year for didactic and one year for clinicals, approximately 2000 hours. I graduated from a RN/MSN program, one the earlier ones at MGH which probably between the class hours, science prerequisites for entry and the clinical probably exceed that of some PA programs, but it takes 3 years rather than 2. An now as of 2015, all NP programs are clinical doctorates which if you are entering for the first time, usually involves a 1 year post course residency along with a graduate thesis. It used to be easier to gain admission into the NP programs than PA programs, but I think both are now equally competitive due to the shortage of instructors.

      Currently I practice in hospital medicine as a hospitalist and people do ask me why I did not choose the MD route or if I plan to. I was 45 at the time and for me age was a factor, now you will see more folks in that age range starting programs, but they will be almost retirement age by the time they complete a residency. I am currently 60, plan to work another 8-10 years if my health allows for this.

      When I decided to pursue my program, I had to take 2 extra years while working full time to complete the science prerequisites prior to entering the program. Some PA and NP programs require almost a pre-med science transcript prior to applying. Mine did not but my undergraduate degree was too old and had gaps in the science classes I need to have.

      Good luck in your decision-making and let us all know what you eventually decide!

  7. anivelasque permalink

    Hi, Dr. Leng

    Thank you so much for sharing your insight on the choice between an RN or MD route. I’m currently at this crossroad, as I’m about to start my nursing degree but still thinking if I should become a doctor.

    Of course, the MD route is much longer and full of ropes to jump through. So, I really wish I could convince myself that being a nurse will be just as gratifying, just as important, just as meaningful as being a doctor.

    Can you tell me if there is any difference in how rewarding each career can be? Do you feel like your ability to help as a doctor is far greater than when you were a nurse?

    Thank you!
    Annita

    • Annita – sorry for the late reply. No, there is no difference in how rewarding each career can be. Any career is rewarding if it is really what you want to do and you’re committed to it. Both nurses and doctors help people, they just do it in different ways. Nursing is not medicine-lite. Nursing is not a compromise or cop-out for people who can’t or won’t go to medical school. Medicine and Nursing are completely different careers. Decide what you want (read Barry Schwartz book The Paradox of Choice, or How We Decide by Jonah Lehrer, or anything by Daniel Kahnemann) and commit to that. I guarantee it will be rewarding.
      S

  8. BayAreaRN permalink

    Awesome discussion, Dr. Leng! I am 34 y.o RN and about to start my pre-reqs for med school. Over the years I have read several stories of people who changed their careers in their thirties and even forties. My 3 kids (6, 8, 9) have been the main reason I gave up medicine. I studied nursing as my pre-med degree and got married right after my BSN. Two years later I was having kids and here I am. I’ve always seen this as a mistake but after 11years as a bedside nurse, I have NO doubt that I am unfulfilled and dissatisfied with my current profession. Let me preface this with the fact that I wanted to be a physician at the age of 8 and never questioned this dream for a second. I can’t deny that I wonder if I would be happier as a nurse practitioner or physician assistant. But this discussion has shed light on my current stance of striving for my childhood dream of becoming an MD and if my feelings change during my training I’ll deal with them at that time.
    Best wishes to all the MDs, NPs, PAs and RNs. We are all helping patients:-)

  9. SanJoseRN permalink

    This has been am ongoing struggle for me. I am a labor nurse with almost 12 years of experience. Here’s my predicament:
    FNP vs MD
    I’ve been thinking about grad school and the other day i felt peace about pursuing my family nurse practitioner (FNP) at UCSF. My problem is i want to do more for patients then floor nursing but I can’t put my family through the sacrifice of medical school. I also don’t like the long hours away from family MDs have to endure. FNP is not MD, I’m fully aware but my struggle has been with wanting to do more than I am doing now. If after becoming an FNP and it is not enough for me, when my kids are older I’ll go to medical school. For now, I can no longer stay in the same place and allow my latent potential to drive me crazy. I want to know and do more but remain in patient care, I believe FNP is the route for me at this time, if I put my pride of becoming a doctor aside.
    Literally the next night, I wrestled again with thoughts of becoming a doctor. I realized I really don’t want to be a nurse practitioner. I would rather embrace my calling and pursue medicine. However, since this has been an almost twelve year struggle, I no longer trust my reason in the matter. I am currently homeschooling my son who was struggling in school last year. The hope is, however, that I will send everyone back to school in the fall fall and use that time to relax. If I’ve learnt something, homeschool is not for me, no matter how perfect it sounds. My husband really wants me to rest during next school year as I’ve always taught or had someone at home ever since we had kids. He thinks a stress reduction may help me think straight about what I want to do next. My thoughts last night were that I could pursue a pre- med post bacc which requires some preliminary seminars before you start clases while I also apply for the FNP program at UCSF which requires a current college statistics class. Maybe the exposure will reveal which is a better fit for me. What are your thoughts Dr Leng

    • Sorry it has taken me so long to reply, SanJoseRN. Ultimately, you will be happiest doing what you really want to do. If either path is your true passion, you make it happen. The problem for all of us is determining what you really want. Sounds easy, is not. That being said, a few thoughts:
      1. I’m not sure what you mean by “doing more for patients than floor nursing”. As I’ve said multiple times on this blog, nurses do more for patients than anyone.
      2. An FNP is a primary care credential. Be aware of this. FNPs do primary care. There are some in hospital settings but in general FNPs become FNPs because they like primary care. So, do you like primary care?
      3. Are you sure medicine is a “calling?” Calling is a strong word and implies that you won’t be happy doing anything else, that nothing else will fulfill you and use all your abilities in the most optimal way possible. Medicine is a horrible choice if you aren’t absolutely sure.
      4. Consider the type of patient you would most like to see, and the kind of work you most want to do. Like kids or not? Like to work with your hands, sew, things like that? Like women’s health? Maybe critical care?
      Good luck!

  10. SanJoseRN permalink

    Thanks Dr Leng for the response and food for thought. It gives me much to think about.

  11. I know this post is from almost two years ago, but I found one of your more recent articles and you really spoke to me. I’m a newly graduated BSN RN. I’m working at a great hospital that treats me well but most days I find myself watching the doctors in awe. I know that as a nurse we are with the patients more, we are there advocates and spend 12+ hours each day with them. However, for someone who wanted to be a doctor since she was a kid, I can’t seem to get the idea out of my head. And truthfully, I don’t think I’ll be satisfied until I go for it.
    I wanted to ask you, what was your breaking point in fully going for medicine? Most nursing science classes do not transfer over for medical school. What were steps that you needed to take in order to even apply to med school? I go back and forth with myself constantly about what I want to do. Some days I like being a nurse, some days I want to be a doctor. I think that if I’m still going back and forth after only being a nurse for a couple months, I know my answer. I think the leap is what fears me the most.

    Thanks for reading. Looking forward to your reply.

    • Hey – thanks for reading my blog! I wrote that post years ago but I still get questions and comments from people all the time. There aren’t a lot of truth-telling resources out there for people with these questions. A few thoughts:

      You look at doctors with awe now. But don’t you remember when you looked at RNs the same way? I do. I remember how excited I was when I got to put that RN after my name. It doesn’t last long does it? I wouldn’t pay as much attention to how looking at doctors makes you feel, and focus on what they actually do all day. I thought I knew what I was getting into, working with doctors every day. I had no idea. At the end of the day the work must fulfill you, not the position. And it must fulfill you over the long haul, not just on some days. Also remember, you, as a nurse, know much much more about how to actively care for a patient than your average doc. Never discount that. Anecdote: One day when I was nursing a man coded and there wasn’t enough help so someone asked one of the docs to push the drugs – I had to show him how to work the port! For me, the tipping point was actually two-fold. First, I got the sense that nurses have a lot of responsibility but very little power. We notice what needs to be done and advocate for the patient, but can’t actually enact a lot of change. Now, there are plenty of nurses who disagree with me on this. The second reason I switched was not because of awe, but of frustration. Every morning I would watch the doctors on rounds and wanted to be part of the discussion, I wanted to be included. In the ICU’s nurses usually are, but at least where I worked the nurses went about collecting vitals and giving pills while those discussions went on around the bed. There were times when it was possible to care for a patient without any idea what the plan was. Plus I was young and stubborn.

      It is very important that people know that nursing classes, in most cases, do not transfer to medical school. In fact, nothing does. Basic science classes will get you some of the premed stuff, but if the class name says “…for nurses” it doesn’t count. I personally don’t think they should dumb down basic science in any field, let alone nursing, but even if they don’t, the name is there. For myself, I had a bachelor’s degree in music and a master’s degree in nursing, not a single credit of which was any use in the premed realm. I had to go do two full-time years of basic science and math at a post-baccalaureate pre-med program (in my case UConn, but there are others), then four years of med school and 4 years of residency. That’s 10 years and about $300,000. Do not make the leap without understanding the realities.

      Eyes open! Know your motivations. Don’t run from nursing to medicine because you think medicine is cooler. It is not. It is just different.

      Good luck!

  12. Thank you so much! You’re reply was extremely helpful. I have felt very similar things. I am proud to be a nurse, but as you said I feel as if I want to do more. I hope it didn’t come off as me discrediting nurses what so ever. It’s just my gut speaking to me trying to help me decide what to do. Thank you so much for your honesty. I truly appreciate it!

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