Debating on what to do (NP vs PA)

[Simonruba]

Hello everyone, first off I appreciate anyone taking the time to read this and giving me any sort of input as I am extremely indecisive on this topic. A little about me:
I am a 19 year old male who is currently attending a mid-size private college in NY and pursuing a Health Science degree, on track to graduate in 3 semesters. I also recently got my EMT certification and have been volunteering at my local ambulance corp for the past 7 months as an EMS member, and really enjoy it.

I have been set on going into healthcare since high school, and I have multiple members in my family who work in the health care field who have been an influence on my decision. I am looking to go into primary care, and right now, I am having an extremely tough time deciding whether to pursue NP or PA. I know some of you may be thinking, you're so young, why don't you just go to medical school? The truth is, I am scared of all the loans after medical school and don't see it as a wise financial thing to do. For a while, after researching a ton of PA schools, I am baffled at how expensive these programs have become over the past couple of years, around $100,000 for the whole program, plus I have to account for rent, food, car, etc. I wouldn't be able to pay this during school so this could skyrocket with interest to almost or over 200k.

Or, I can pursue NP. I can easily transfer schools smoothly right now (commute to school 20 min away) and get my BSN within 2 years, graduate, and work as a RN. I would have about 20k of undergrad loans after graduating, live with my family who provide housing and food, and work my ass off for 2 years as a nurse and save as much money as I can, as I am about 45 minutes from NYC and could potentially get a good gig at hospitals/clinics near me. This would give me a good head start at NP school, with experience and savings of at least 75k+. After my experience as an RN, I will pursue an NP degree from a top ranked school where I can get as much clinical and hands on experience as I can

NOTE: I know that there is an abundance of horrible NP programs right now and how they don't learn nearly as much as someone who goes to PA school who has a bunch of set up rotations for them and rigorous classes. I am willing to go to a top ranked school and get as much education as I can to be a competent NP, which I know I can and will be if I choose to go this route.

With my savings after being an RN, I would have minimal loans graduating NP school because I saved so much. That way, I can start working as an NP and have no loan burden on my shoulders. Also, I feel as a PA, pathways are pretty limited. NPs have serious political advantage over them, and have autonomy. I want to work in education when I am older and continue to learn and move up and have potential in my career, and I feel as an NP there would be less obstacles then being a PA as I don't see many of them in administration roles or things of that nature.
Thanks again!

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[Apollo1]

PA's & NP's essentially have the same responsibilities. You would need to determine which model of training is more aligned with your personal preferences; this would probably entail shadowing to some degree (and should be done prior to entering any form of advanced education).

NP's do have more autonomy than PA's, but this is a regulatory issue; historically, it's been easier for easier for NP's to push for independence (they're not under a Board of Medicine, laypeople are persuaded by advertising, etc.). Both fields have opportunities to be involved in education, so that really isn't a distinctive point. Nurses probably do have more vertical potential, but this is partly because you need more nurses than you do PA's.

Obstacles are going to be present, regardless. If your goal is something akin to administration, then being an NP or PA doesn't necessarily prepare you for that position. You might need to come up with concrete answers for what you want to do in life, and then proceed from there.

 

[mountainPA]

As a practicing PA now for several years, with experience working with NPs in both adult inpatient internal medicine, family practice, and urgent care, I can say personally that I have not noticed any meaningful practice differences. I will say that there have been certain preferences in terms of hiring between the two. My IM group definitely had a preference for PAs over NPs. Nothing was ever said in my the FM group, however the urgent care only hired NPs that had prior emergency department experience, while the PAs were required to just have some sort of full-time experience for greater than a year. My guess is it dealt with our broad experience of rotations in school, but again never formally discussed. I personally chose the PA route because of the rigor the program and the mobility that I saw PAs have while gaining healthcare experience in undergrad. Yes, it is expensive, but I am personally willing to pay more for a higher quality education and not have to worry about setting up my own rotations (a major issue for a lot of NP students). While it isn't fun taking out those kinds of loans, once you are out practicing, and you decide to continue to "live like a student" for 1-2 years, you will pay them off quickly. I know alot of NPs that have the same amount of debt coming out, but are a lot less happy with their education.

Now that I have a few years under my belt this "NP autonomy" vs "PA clinical mobility" has been noted, and I think should play a role in helping to make a decision. For instance, my IM group only hired NPs that were certified to work in the "acute care" inpatient setting. When I made the switch to FM several of them were rather jealous as their credentials did not allow them to work with children. In my FM role we had a pediatric NP and a pysch NP that only saw those patient populations. Only the PAs and the family NPs are allowed to pick up shifts in the urgent care as we are allowed to see both children and adults without restriction. Obviously this is my experience, but just some things to think about. I am also considering a surgical position in the near future, which is only open to PAs as this is more in line with our broad training.

Obviously the choice is yours, and I think it depends on where you want to end up and how much you feel like you enjoy the specificity to stay there long-term. I personally value career flexibility and can't image only seeing one patient population for the duration of my career. If you are set on women's health and psych, I would suggest the NP route all the way. I do know PAs in those fields, but there does seem to be a preference for NPs. If you are interested in surgery than PA would be the better option. Everything in between seems to be fair game (anesthesia being a notable outlier, but that is an entirely different story). The PAs and the NPs that I work with perform the same job function, work similar hours, and are compensated the same.

 

[pamac]

At your age, you have a lot of options, and even the expensive ones can work out in the end, so I wouldn’t be intimidated by the high price of PA school, if that is what you want to do. I’m and NP, and I’ll go over a few scenarios.



PA programs are thorough. If you really want to do primary care, you will have in depth training for that if you go PA. They were built to be generalists with a primary care foundation, and they take folks with little to no healthcare experience and turn them into providers that can function pretty well from day one. There are quite a few features that aren’t really downsides, but just realities of what the pathway entails. These are what I considered to be a bit frustrating for many people I’ve talked to, and also for me when I was considering becoming a PA.



The expense of PA school is automatically very high with few exceptions. Typically $100k or more. You also would have a hard time working during that time, and what little you could work probably wouldn’t be worth the effort or distraction. But if you are on the cusp of getting your undergrad degree and can beat the competition and get right into PA school, then it’s just two more years and then you are done and in the workforce making pretty good money. If you pay down your debt, then you have the rest of your career (and a little extra time) to make up for the expense. A lot of this depends on getting into school on your first or even second try. It’s really competitive, with often at least 10 applicants applying for 1 program seat. Overall though, about 40% of applicants get in on their first try on the whole (most folks apply to an average of between 8 and 12 programs, which skews the individual school numbers to be more intimidating).



Often, you have to relocate to a program at a different city than where you live or want to settle down. In this labor market where there is starting to be a glut of NPs and PAs, that puts you at a disadvantage for networking for a job after you graduate, because you may be looking for a job in a place you haven’t been for 2 years. You won’t have done rotations there, and you’d be missing out on applying with those clinical sites who had seen you work and familiarized you as a student with how they do things. Those rotation sites are great opportunities for getting hired. They know you and like you and often want to bring you on. You give that up when you go back home, where you apply as a stranger to a place that has lots of other strangers applications in the pile.



Independence might not be a big deal for some folks. It was huge for me. For many NPs, there isn’t a lot of difference at all between the NPs and PAs where they work, and in primary care it is probably the most like that of all the areas of practice. There are specialties that are harder to break into as either a PA or an NP, so there’s that to consider as well. I’m in psyche, and psyche PAs make a lot less most places I’ve seen than the NPs, and consequently there are less psyche PAs. But one thing I enjoy is the fact that I can go out and take my own clients and run my own business if I want to, and it’s all up to me. I don’t have to get permission from the state or line up a physician to supervise me (which if they are smart they will charge a PA or dependent NP for the privilege of doing). I’m my own provider and nobody is liable for me or my work. Nobody signs off on my work. There’s no red tape when I pick up work at a care facility or other places. Primary care NPs can have some of the same advantages in that regard, and open up their own gigs and cultivate business ventures. I have a friend who has their own little patient panel of psyche patients that they see in a rural town a few times a month and it nets them an extra $30,000 per year for a few days work per month on top of their full time job pay of $170k. It’s not my thing, but maybe some day I will decide to do that. PAs can get side gigs, but it’s not as fluid a process to run your own operation. At the very least it requires involving a physician to supervise and take on the liability that follows. But one more example for you.... I know a PA and an NP who both do context work at a nursing home. The NP makes more than the PA just by virtue of the Np not needing to practice under the supervision of the medical director of the facility. The PA is an automatic subordinate of the physician, and the NP isn’t. But in most cases outside of these kinds of scenarios, you probably wouldn’t notice much difference between the average PA or NP employee doing W2 work. But you need to get in touch with what kind of specialty you want to be in to decide what profession is better suited for the majority of the jobs out there. You also need to take stock of what business model you want to participate in.



For me, I really enjoyed the work I did as a nurse prior to becoming an NP. It’s fun and empowering to be in a role as a nurse. You gain confidence, and it’s not an entry level role like CNA or EMT, and you get to network with potential employers while you work and go to school. You get gold standard health care experience, and you interact with people in a high stakes environment. I’d venture to say the vast majority of PA students haven’t had that kind of responsibility before their first day of work after graduation. Before I became an NP, I had worked more codes and had more critical situations under my belt as a nurse than just about any PA these days. In clinical, I was alongside PA and NP students, and the NPs were quicker on our feet and had more insight and “street smarts” than the PA students. This isn’t always the case, and I certainly know tons of NPs without many skills. But the PA students tended to be very sharp and knowledgeable with the academic material.. pathophysiology, pharmacology, etc. I think that both PAs and NPs have thinks they need to pick up and improve on once they hit practice, and it seems like they are deficient in different things. And I hate to generalize too much about individual strengths and weaknesses because everyone is different. But I don’t knock PA training. While NP training can be more variable as to quality, it typically does the job. You probably won’t have to look far to find a decent program, and what some people assume is a “top tier” NP program can often simply be smoke an mirrors. “Expensive” and “affiliated with a well known university” doesn’t mean “better”. The same with PA programs. Georgetown’s NP program is not better than many other cheaper programs. They are selling you a name that your employer will probably not care about because you aren’t a physician, and therefore not the main event. I’ve seen plenty of big-name-school educated PAs working for peanuts for physicians educated in the Caribbean at a “safety school”. The most mileage you’ll get out of a big name school will probably be from the sweatshirt you get to wear from time to time. You won’t make more than the PA or NP that went to a “lesser” state program.

 

[pamac]

So another thing is the finances. Like I said at first, if you go in and get your schooling done, you can start to pay down your debt and then build up your finances after that. If you donut really quick, then who is to say thats not preferable to going to an accelerated BSN program that takes a year, and then working as a nurse making between $50k-$75k (or more) while you do 2-3 years of NP school in an online or hybrid online NP program? I’ve run the numbers different ways, and depending on how long you take to either get through nursing training or get into a PA program, it can even out based on different variables. The kid who applies to PA school and gets accepted and can go straight in after undergrad without taking that following year to go through the year long application process can be done very quickly. The nurse who takes their time and has a 6 year journey to finish their NP might be lapped financially bu the Pa student who is making $100k a lot sooner.



Just doing some basic math, if a student spends year 1 and 2 going to PA school that costs $100k, and spends $25k for two years for living expenses and ends up making $100k per year in years 3, 4, and 5 essentially has a pot of gold valued at $150,000. Add in a very modest $25k cost of living for the following 3 years and you have $75k.



The NP student who does a $30,000 1-year accelerated BSN, then starts working making $60,000 year for years 2 and 3, and starts making $100k for years 4 and 5 as an NP after going to a $35k NP program ends up with a pot of gold worth $130,000. Any variable that adds time to rather track eats into that pot of gold, but I feel like delays are more pronounced for person on the PA pathway because bigger chunks of money are left on the table. Again, these are very basic calculations with numbers that might not adequately reflect reality, but still serve to paint the picture. I’ve found that most Pa students don’t apply to school before they graduate, so that costs many of them another year while they attend PA school interviews and wait for acceptance letters to come telling them to start classes the following fall. And with that kind of delay, you lose a hypothetical year of PA income of $100,000, and spend another year of hypothetical living expenses of $25k for a total of an extra $125k potential profit. BUT, another year of not being an NP costs you $100k of hypothetical Np salary and $25k of hypothetical living expenses. HOWEVER, you make a hypothetical $60k as a hypothetical nurse, and that means you are losing out on $65k.



With me, the hospital I worked at paid for all my nursing school while I worked full time making above $60k during nursing school. They didn’t pay for my NP school while I was working as a nurse making above $75k, but my NP job I obtained after graduating qualified for federal reimbursement of my student loan debt I return for a commitment to work in a designated psyche clinic, and the salary for psyche NPs there is above $155k per year. I paid down my house using the money I didn’t pay towards education expenses. A PA also has avenues available to help with loans and such, and we all could take advantage of what is offered through the military. I was able to utilize employer incentives for nursing education that many hospital systems offer, which helped a lot. The smart thing, though, is to not plan to rely on those kinds of programs, and plan your budget as if they don’t exist. If you are able to utilize those things later on, that’s a fantastic surprise.

Pay rate manifests in different ways as well. So while a PA and NP coworker might make about the same as each other, certain specialties pay more or less, and those specialties might recruit predominantly (or even exclusively) from either PA or NP. In my area, in a family practice, a PA and an NP might both make $90k. But surgical PAs tend to make a bit more, and not many surgeons hire NPs to go in surgery. So in my area, PAs typically have access to higher paying jobs than the NPs do. I’d guess that PAs here do about $8k better onthe whole than the typical NP. However, psyche NPs here can easily command >$150k, and psyche PAs don’t make nearly that much.... typically around $90k-$100k. That’s because the physicians that would hire them don’t need to pay them more than that, and they are liable if a PA makes a mistake under their supervision. A patient completes suicide, and the lawyers look to the physician for a bigger payday. If they hire a more expensive NP, what they get is a specialist who insulated them against litigation. They still make lots of money of the NP. Value is measured different ways as well. My PA friend in derm makes lots of money, and is very valuable to their employer due to the loyal followingof patients that like seeing that PA. It’s worth it to have that PA around, even at a higher price. Their value has little to do with an independent license, liability, or supervision, or either whether that provider is a PA or NP. They pay that PA enough to keep them because a new and cheaper PA wouldn’t bring in as much revenue, and likely would go make money for a different clinic.