To PAs/NPs: Knowing what you know now, do you wish you became a Doctor?

[ChillyRN]

A lot of doctors don't necessarily take financial advantage of their training.

You don't have to work in the ER to make good money.

For example, a family MD can:

1. Perform insurance medicine / IMEs.
2. Worker's comp assessments.
3. Concierge medicine.
4. Aviation medicine assessments.
5. Minor cosmetic procedures ( Botox, etc.)

The list goes on....

Typically, mid levels can't / or don't have the right connections for 1-4 (or 5). Lots of business opportunites out there. A lot of people are stuck in a rut, and don't think outside the box.

P.A.'s and Noctors are specialized in their one little medical area. This is one of the big differences between mid levels and MDs. We aren't as limited.

I know several NPs that do Botox in FP clinics. I get my botox from a NP in a FP clinic as a mater of fact. I was asked if I wanted to do it by my medical director, and declined. I was also asked to cert/recert Nursing home patients for the group as some side money making venture. I never did understand what that was all about but was told I'd would get $75 for every form I completed. I said no thanks to that too. Sounds like a lot of hassle to me, and I don't need the money. Besides, I like my like my one little specialized area.

However, this quoted post is true, there is opportunity to earn extra money in primary care if you want to deal with all that crap. I basically make $50 an hour to do a job that I freaking love and that is good enough for me. I don't need to do Botox and fill out reams of government paperwork. I would honestly rather do primary prevention counseling all day long for half the money. I love working with families. Most rewarding visit of the week was a 11 y/o girl who told me she faked having a sore throat just to come see me b/c I am the only one that listens to her. I love my job. Don't tell them, but I'd do it for half of what they pay me.

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[ghost dog]

I know several NPs that do Botox in FP clinics. I get my botox from a NP in a FP clinic as a mater of fact. I was asked if I wanted to do it by my medical director, and declined. I was also asked to cert/recert Nursing home patients for the group as some side money making venture. I never did understand what that was all about but was told I'd would get $75 for every form I completed. I said no thanks to that too. Sounds like a lot of hassle to me, and I don't need the money. Besides, I like my like my one little specialized area.

However, this quoted post is true, there is opportunity to earn extra money in primary care if you want to deal with all that crap. I basically make $50 an hour to do a job that I freaking love and that is good enough for me. I don't need to do Botox and fill out reams of government paperwork. I would honestly rather do primary prevention counseling all day long for half the money. I love working with families. Most rewarding visit of the week was a 11 y/o girl who told me she faked having a sore throat just to come see me b/c I am the only one that listens to her. I love my job. Don't tell them, but I'd do it for half of what they pay me.

The above (ie. 1 -5 ) are some examples off the top of my head. You couldn't pay me enough to do cosmetic procedures.

I think the important issue here is that MDs ( particularly family MDs) have a lot of potential to make lateral career movements if they get bored or start to dislike the career path they are on; as one of the above posters has stated, this is not necessarily as easy with mid-levels (i.e. additional training , etc.).

 

[jwk]

What is this certificate you speak of?

You don't have to have any formal certificate or program to be a "legal consultant". I think there are some "certification" programs for legal nurse consultants. But that's not a requirement, and of course, if you're not an RN, it's kind of hard to be a legal "nurse" consultant.

A lot of attorneys use a variety of medical professionals to review charts prior to initiating lawsuits, and/or to participate in the process once a suit is filed. Anyone can review charts, but you have to have some level expertise in a given area for that review to be taken seriously (and so you don't miss anything pertinent).

I've been doing anesthesia for more than 30 years. As an AA, I could provide expert testimony in cases involving AA's. BUT I can also review cases, charts, depositions, and testimony for anything dealing with anesthesia cases in the OR, L&D, endoscopy suite, etc., so even though I'm not an MD or a CRNA, I can review cases involving those providers. I also review cases involving related areas - airway management, autotransfusion, sedation outside the OR, etc.

An example - I reviewed a chart from a "bad-baby" case where everyone was sued - OB doc, anesthesiologist, hospital, nurses, etc. The OB was pointing their finger at everyone else in the case, denying any liability on their part. The review was done for an attorney representing an anesthesiologist. After doing an extensive chart review, I offered my opinion about the case and provided a list of questions that the attorney might want to ask in the various depositions taken from the people involved. After those depositions were done, I reviewed those as well, pointing out areas of concern with the testimony of those involved with the case. Based on those opinions and further depositions, the anesthesiologist was dropped from the case and incurred no liability.

And of course you can bill the attorney for your time involved. Don't forget to claim it on your taxes on Schedule C - you will likely get a Form 1099 from the attoney for your services rendered.

 

[chimichanga]

and the more experience you have, the more credible your opinions will be.

 

[ChillyRN]

The above (ie. 1 -5 ) are some examples off the top of my head. You couldn't pay me enough to do cosmetic procedures.

I think the important issue here is that MDs ( particularly family MDs) have a lot of potential to make lateral career movements if they get bored or start to dislike the career path they are on; as one of the above posters has stated, this is not necessarily as easy with mid-levels (i.e. additional training , etc.).

And I was agreeing with you. While I'd likely have more such opportunities were I a MD, since I am in a state that recognizes NPs as fully independent providers I see many such things for NPs as well. They are out there.

 

[sarjasy]

No doubt whatsoever. Try "doing the math" over the course of one's career. On average, primary care physicians earn roughly twice as much as PAs. Multiply that out over a 20+ year career, and I think you'll find that it more than makes up for the small difference in debt and up-front opportunity cost.

True, and I should have been more clear. Many rural clinics (due to pt. population) can't afford the $130-200K salaries for a physician. If a clinic needs a provider but can only pay $80K for a provider, the physician likewise can't afford to work there, given possibly high-levels of debt and given the 7+ years of postbacc training he/she has done. Furthermore, there is a large potential pool of possible PCP's among health professionals, which are mostly non-trad, and the numbers often don't add up for them to go to med school.

 

[sarjasy]

A lot of doctors don't necessarily take financial advantage of their training.

You don't have to work in the ER to make good money.

For example, a family MD can:

1. Perform insurance medicine / IMEs.
2. Worker's comp assessments.
3. Concierge medicine.
4. Aviation medicine assessments.
5. Minor cosmetic procedures ( Botox, etc.)


Typically, mid levels can't / or don't have the right connections for 1-4 (or 5)...P.A.'s and Noctors are specialized in their one little medical area. This is one of the big differences between mid levels and MDs. We aren't as limited.

You are truly growing increasingly insufferable. You start posts with something halfway intelligent (I emphasize "halfway"), but then always manage to get in your little dig. It is amazing to me that someone who advertises himself as an attending is so utterly lacking in the ability to intelligently engage in a discussion.

MD's aren't as limited? And one of the options you post is worker's comp? Aviation or insurance medicine? You'd spend 7+ years becoming an MD to do worker's comp? Seriously? That is what you call flexibility? Ambulance chasing for an attorney?

How about a Family Practice NP. As an FNP, you can work in the ER, work as a hospitalist, do pediatrics, geriatrics, OB/GYN, women's health, public health and work for any imaginable specialty (cards, nephrology, oncology, ENT, surgery, neurology, derm, cosmetics, etc., etc., etc). You can teach at grad or undergrad levels. You can do case management. You could do admin, anywhere from clinical director to VP or CEO of a hospital/health system. I could go on and on. All this is true for PA's as well (for the most part). Now, tell me about mid-levels being limited to "their one little medical area" and how MD's "aren't as limited." Please explain.

All of these are "lateral" moves at worst.

I look forward to your response, though, if history is any indicator, I won't get one.

 

[FCMike11]

You are truly growing increasingly insufferable. You start posts with something halfway intelligent (I emphasize "halfway"), but then always manage to get in your little dig. It is amazing to me that someone who advertises himself as an attending is so utterly lacking in the ability to intelligently engage in a discussion.

MD's aren't as limited? And one of the options you post is worker's comp? Aviation or insurance medicine? You'd spend 7+ years becoming an MD to do worker's comp? Seriously? That is what you call flexibility? Ambulance chasing for an attorney?

How about a Family Practice NP. As an FNP, you can work in the ER, work as a hospitalist, do pediatrics, geriatrics, OB/GYN, women's health, public health and work for any imaginable specialty (cards, nephrology, oncology, ENT, surgery, neurology, derm, cosmetics, etc., etc., etc). You can teach at grad or undergrad levels. You can do case management. You could do admin, anywhere from clinical director to VP or CEO of a hospital/health system. I could go on and on. All this is true for PA's as well (for the most part). Now, tell me about mid-levels being limited to "their one little medical area" and how MD's "aren't as limited." Please explain.

All of these are "lateral" moves at worst.

I look forward to your response, though, if history is any indicator, I won't get one.

Yeah you work in the ER (Fast track actually) prescribing Antibiotics...intellectually challenging I know, in addition you may splint someones arm and write a script for crutches.

What FNP works in Pediatrics? Or OBGYN? These are seperate specialties with seperate NP tracks....a FNP can not work in neonatology.
What evidence do you have to provide that a np can make an easier lateral move than a PA?

 

[Makati2008]

Yeah you work in the ER (Fast track actually) prescribing Antibiotics...intellectually challenging I know, in addition you may splint someones arm and write a script for crutches.

What FNP works in Pediatrics? Or OBGYN? These are seperate specialties with seperate NP tracks....a FNP can not work in neonatology.
What evidence do you have to provide that a np can make an easier lateral move than a PA?

Calm down Mike. That is just the way Sar is. I have always asked him why not go to medical school and he has given me some reasons that I consider not the strongest but they are reasons. He also has gives excuses about not going to PA school as well instead of NP and he also will boast his 99% scores on exams(which don't mean squat) on national exams.

But to be nice, he is actually right for the MOST part. NPs cannot practice the whole spectrum of medicine as much as a PA can though. I know for a fact in some states that Acute care NP's cannot do any ER work but instead must go back and get another certification/degree or whatever you call it to work in the ER(saw a NP have to give up her position due to this reason at an ER I was working).

Also Mike, be careful making insults aobut Fast track/UC. If your working in a major hospital then things will slip through fast track that you would miss if you weren't using your brain(I can think of a C2 fx I got in fast track, a caduate nucleus bleed I got in fast track, a P.E. I got in fast track etc....I know these are only personal examples but don't know what else to go off of.) At my old jobs NP/PA's both were required to cover both UC/Minor/Major portions of the ED depending on their shift.

 

[RDlv]

Bear in mind that FNP is sort of the "cheater" track as we are technically allowed to see all age ranges (I guess besides preemies, that is the realm of the NNPs, but definitely including newborns). And yes, we should be limited to outpatient/primary care settings, but a combination of lax state regulations and a hospital willing to hire gets many around that. A local Peds ER sent a notice to my FNP program director that they are willing to hire FNPs with some form of peds experience. I was also told by my neonatologist medical director that in another setting she had hired FNPs to staff level 2 babies in her NICU. So, lot's of fudge factor involved.

 

[sarjasy]

Yeah you work in the ER (Fast track actually) prescribing Antibiotics...intellectually challenging I know, in addition you may splint someones arm and write a script for crutches.

Both PA's and NP's tend to work fast track in ER -- are you bashing PA's too for not doing "intellectually challenging" work? At any rate, you are wrong. There are mid-levels that work main.

What FNP works in Pediatrics? Or OBGYN? These are seperate specialties with seperate NP tracks....a FNP can not work in neonatology.

I personally know a FNP that worked in pediatrics. Furthermore, any OB/GYN that wants to hire an FNP can. The primary determining factors that determine what specialties a FNP works in are 1) the employing institution and 2) the provider hiring them.

As for neonatology, where did I post that as an option for FNP's?

What evidence do you have to provide that a np can make an easier lateral move than a PA?

My post was defending the lateral ability of NP's and PA's. Where did I state that NP's can make an easier lateral move than a PA? That's not the point anyway. The post that I originally responded to said there were more options for a lateral move with an MD than an NP or PA - that is the point I was refuting.

 

[sarjasy]

Calm down Mike. That is just the way Sar is. I have always asked him why not go to medical school and he has given me some reasons that I consider not the strongest but they are reasons. He also has gives excuses about not going to PA school as well instead of NP and he also will boast his 99% scores on exams(which don't mean squat) on national exams.

Umm. What exactly is the relevance of this statement to the discussion at hand?

 

[Makati2008]

Umm. What exactly is the relevance of this statement to the discussion at hand?

Just stating some observations as well as how you can be insulting at times(like the half intelligent comment you made to a previous poster) and a tad arrogant.(I know I am a jerk at time and will admit it.)

 

[sarjasy]

Just stating some observations as well as how you can be insulting at times(like the half intelligent comment you made to a previous poster) and a tad arrogant.(I know I am a jerk at time and will admit it.)

I made the "half-intelligent" comment to ghost dog, who goes out of his way to insult nurse practitioners in every post he makes in this forum, e.g. his constant use of the word "noctors" and his earlier reference to mid-levels being "specialized in their one little medical area."

 

[FireCloud9]

You may be interested in this analysis - The Deceptive Income of Physicians - http://benbrownmd.wordpress.com

According to the author, who is a doctor, physicians make about the same as a H.S. teacher. The analysis also compares nurses.

Enjoy!

 

[zenman]

I made the "half-intelligent" comment to ghost dog, who goes out of his way to insult nurse practitioners in every post he makes in this forum, e.g. his constant use of the word "noctors" and his earlier reference to mid-levels being "specialized in their one little medical area."

Yes, like it's a bad thing, lol!

 

[ghost dog]

You are truly growing increasingly insufferable. You start posts with something halfway intelligent (I emphasize "halfway"), but then always manage to get in your little dig. It is amazing to me that someone who advertises himself as an attending is so utterly lacking in the ability to intelligently engage in a discussion.

MD's aren't as limited? And one of the options you post is worker's comp? Aviation or insurance medicine? You'd spend 7+ years becoming an MD to do worker's comp? Seriously? That is what you call flexibility? Ambulance chasing for an attorney?

How about a Family Practice NP. As an FNP, you can work in the ER, work as a hospitalist, do pediatrics, geriatrics, OB/GYN, women's health, public health and work for any imaginable specialty (cards, nephrology, oncology, ENT, surgery, neurology, derm, cosmetics, etc., etc., etc). You can teach at grad or undergrad levels. You can do case management. You could do admin, anywhere from clinical director to VP or CEO of a hospital/health system. I could go on and on. All this is true for PA's as well (for the most part). Now, tell me about mid-levels being limited to "their one little medical area" and how MD's "aren't as limited." Please explain.

All of these are "lateral" moves at worst.

I look forward to your response, though, if history is any indicator, I won't get one.

You appear to be misinformed on a number of levels. Physicians who performs work for Worker's compensation do so for the Worker's safety and insurance board ; this does not constitute medical legal work, or " ambulance chasing. "

Isn't it correct that if a NP wishes to pursue another line of work, they must undergo further training / take further courses in order to qualify for such work ? If they wish to work in the emergency room, I certainly hope that is the case.

Physicians have a greater ability to peform lateral career moves, as they are not troubled with such courses. Their initial training is significantly more in depth, and thus need not take such courses. My point of NPs being specialized is quite apt.

 

[sarjasy]

You appear to be misinformed on a number of levels. Physicians who performs work for Worker's compensation do so for the Worker's safety and insurance board ; this does not constitute medical legal work, or " ambulance chasing. "

If you say so.

Isn't it correct that if a NP wishes to pursue another line of work, they must undergo further training / take further courses in order to qualify for such work ?

No. Did you not read my original post on this? A family NP can go to work in surgery, cards, peds, OB/GYN, nephro, neuro, derm and many other specialties and roles. An adult NP can work in IM, geriatrics, ER or any of the specialties above (except peds and OB/GYN). An adult acute care NP can do hospitalist, intensivist, work as advanced clinicians in most all hospital units, or work in IM and many specialty clinics (e.g. cards, nephro, neuro). I can go on an on, but your assertion that NP's are stuck in their "little specialty areas" is completely false. The exception would be psych NP's and peds NP's (primary or acute) to a certain degree. All of this is true for PA's as well.

Physicians have a greater ability to peform lateral career moves, as they are not troubled with such courses. Their initial training is significantly more in depth, and thus need not take such courses.

Really? A FP physician can do neuro? Cards? Derm? Nephro? A FNP can.

My point of NPs being specialized is quite apt.

No. It is not. It is completely wrong.

 

[Makati2008]

If you say so.



No. Did you not read my original post on this? A family NP can go to work in surgery, cards, peds, OB/GYN, nephro, neuro, derm and many other specialties and roles. An adult NP can work in IM, geriatrics, ER or any of the specialties above (except peds and OB/GYN). An adult acute care NP can do hospitalist, intensivist, work as advanced clinicians in most all hospital units, or work in IM and many specialty clinics (e.g. cards, nephro, neuro). I can go on an on, but your assertion that NP's are stuck in their "little specialty areas" is completely false. The exception would be psych NP's and peds NP's (primary or acute) to a certain degree. All of this is true for PA's as well.



Really? A FP physician can do neuro? Cards? Derm? Nephro? A FNP can.



No. It is not. It is completely wrong.

Good points. Only part I disagree with is your saying that what you said for NP's is true for PAs. Our spectrum is from cradle to grave due to our generalist training. Now if you want to do something like Gas as a PA I think you made the wrong decision an should have went the AA route.

 

[sarjasy]

Good points. Only part I disagree with is your saying that what you said for NP's is true for PAs. Our spectrum is from cradle to grave due to our generalist training. Now if you want to do something like Gas as a PA I think you made the wrong decision an should have went the AA route.

What I meant is that all of the flexibility I mentioned for NP's is true for PA's as well. The flexibility to move among specialties is very comparable between FNP's and PA's. PA's naturally have an advantage among surgical specialties, but even then it is largely provider preference, e.g. an ENT could hire a FNP, but a PA may be better due to surgical training. NP's tend to have more flexibility in non-provider clinical and admin roles (e.g. case management, unit/clinical type specialty roles, teaching, administration).

 

[ghost dog]

If you say so.



No. Did you not read my original post on this? A family NP can go to work in surgery, cards, peds, OB/GYN, nephro, neuro, derm and many other specialties and roles. An adult NP can work in IM, geriatrics, ER or any of the specialties above (except peds and OB/GYN). An adult acute care NP can do hospitalist, intensivist, work as advanced clinicians in most all hospital units, or work in IM and many specialty clinics (e.g. cards, nephro, neuro). I can go on an on, but your assertion that NP's are stuck in their "little specialty areas" is completely false. The exception would be psych NP's and peds NP's (primary or acute) to a certain degree. All of this is true for PA's as well.



Really? A FP physician can do neuro? Cards? Derm? Nephro? A FNP can.



No. It is not. It is completely wrong.

I don't know if you are student , or an actual NP yet.

Are you telling me that , as a family NP, you could go straight from your family practice to an emergency room setting without any additional training or quality control measures in place ? I find this difficult to believe.

If this is in fact the case, I find this frightening indeed.

 

[sarjasy]

Are you telling me that , as a family NP, you could go straight from your family practice to an emergency room setting without any additional training or quality control measures in place ? I find this difficult to believe.

Yes. In reality, such an ER would probably be looking for a FNP with an RN level ER or ICU background and the appropriate certs (ACLS, PALS, TNCC, CEN, CCRN, etc.). While some mid-levels work main, most do fast track in which the majority of cases are a similar acuity as to what you would see in an urgent care or family practice setting.

Likewise, an FNP might go into cardiology right out of school, then switch to family, then later switch to derm. As far as "additional training" and "quality control," in some cases the NP may be precepted by a physician for a while until ready to see his/her own patients if they had no background in the relevant specialty. That would be the likely case for PA's as well.

 

[deleted6669]

Yes. In reality, such an ER would probably be looking for a FNP with an RN level ER or ICU background and the appropriate certs (ACLS, PALS, TNCC, CEN, CCRN, etc.). While some mid-levels work main, most do fast track in which the majority of cases are a similar acuity as to what you would see in an urgent care or family practice setting.

Likewise, an FNP might go into cardiology right out of school, then switch to family, then later switch to derm. As far as "additional training" and "quality control," in some cases the NP may be precepted by a physician for a while until ready to see his/her own patients if they had no background in the relevant specialty. That would be the likely case for PA's as well.

yup, same flexibility with pa's. pa's have the added option of attending a specialty residency or fellowship if they so desire. most listed here: www.appap.org
there are a few residencies out there for np's(less than 10 nationally I think) but far less than those offered to pa's.

 

[deleted6669]

While some mid-levels work main, most do fast track in which the majority of cases are a similar acuity as to what you would see in an urgent care or family practice setting.

the current model for pa's in em in most places is autonomy with fast track pts (level 4 and 5) and some degree of physician oversight for other pts. either through required chart review or presentation to an attending. at my rural job I can see anything but the doc needs to sign the chart before the pt goes home or is admitted.
most em pa's cover both fast track and main on a rotating basis. fast track only jobs are considered new grad jobs or jobs for those who must stay in a specific geographic area and are less desirable than those covering all parts of the dept.
this year marked the first time pa's could take (physician designed) specialty exams in a variety of specialties including em, ct surg, nephrology, ortho, and psych. those who passed received a "certificate of added qualifications" in their specialty. this will likely catch on and become more common and employers/hospitals/insurers will differentially hire those who have a CAQ vs those who do not. To be eligible for the CAQ em exam pa's are required to have a min of 18 mo of supervised em experience, acls, atls, pals, and a difficult airway course, a physician attestation form filled out and signed which states the pa is capable of performing a variety of adv. procedures, etc. see here for all exam requirements:
http://www.nccpa.net/Emergencymedicine.aspx
142 pa's nationally passed the em exam when first given in sept, 2011.

 

[ghost dog]

the current model for pa's in em in most places is autonomy with fast track pts (level 4 and 5) and some degree of physician oversight for other pts. either through required chart review or presentation to an attending. at my rural job I can see anything but the doc needs to sign the chart before the pt goes home or is admitted.
most em pa's cover both fast track and main on a rotating basis. fast track only jobs are considered new grad jobs or jobs for those who must stay in a specific geographic area and are less desirable than those covering all parts of the dept.
this year marked the first time pa's could take (physician designed) specialty exams in a variety of specialties including em, ct surg, nephrology, ortho, and psych. those who passed received a "certificate of added qualifications" in their specialty. this will likely catch on and become more common and employers/hospitals/insurers will differentially hire those who have a CAQ vs those who do not. To be eligible for the CAQ em exam pa's are required to have a min of 18 mo of supervised em experience, acls, atls, pals, and a difficult airway course, a physician attestation form filled out and signed which states the pa is capable of performing a variety of adv. procedures, etc. see here for all exam requirements:
http://www.nccpa.net/Emergencymedicine.aspx
142 pa's nationally passed the em exam when first given in sept, 2011.

How many PA's in total took this EM exam ? What percentage passed ?

 

[deleted6669]

how many pa's in total took this em exam ? What percentage passed ?

149 took it. 95% pass rate. Not surprising with the prereqs involved.
232 PA'S nationally passed caq exams that day with 142 in em and the rest between nephrology, psych, ortho, and CT surgery.
I predict that next yr >1000 folks will sit for these exams. the caq's at present are only given once/year but that will likely increase as the concept catches on.

 

[ghost dog]

149 took it. 95% pass rate. Not surprising with the prereqs involved.
232 PA'S nationally took caq exams that day with 149 in em and the rest between nephrology, psych, ortho, and CT surgery.
I predict that next yr >1000 folks will sit for these exams. the caq's at present are only given once/year but that will likely increase as the concept catches on.

I meant to delete this post.

I read further / more closely , and realized that this was a "physician designed" exam, and not the EM board exam.

 

[Summer1207]

Has anyone really answered the original question asked? Because I would like to and would also like to hear other's responses...about the question asked. Preferably younger future nursing graduates like myself who have been feeling as though they should have done med school. While obviously I'm currently applying to doctorate programs, I can't help but regret why med school was never my original choice. So yes, I graduate in May and as I'm applying to schools for my DNP, I regret it because I'm sorry but I want to do SO MUCH more. I don't think the desire will die. What would make me a great nurse would make me a KICK ass doctor?? Do other RNs share this same desire? Please tell me I am not alone and that it is normal to want this?

 

[physasst]

Been a PA for over 12 years....no desire to EVER, EVER go to medical school.

Did the opposite, finishing my research doctorate now, and looking at moving into full time research.

Will probably always moonlight occasionally as a PA to maintain some patient contact, but full time patient care.....nope...not interested anymore.

 

[FireCloud9]

Summer1207 - if you're desire is that strong, why not just do it? Go to medical school.

I considered it, but at my age (mid-late 40s), ruled it out.

I wonder the exact opposite.

Knowing what you know now, do you wish you became a mid-level instead of a Doctor?

After all, mid-levels seem like a more attractive spot when you compare the years of your life you have to give up for the education and training of medical school.

I believe I would find medical school intellectually stimulating, much more so than some other options, but most of the people that attend, willingly give up the best years of their lives to do it, while mid-levels seem to get the best of both worlds - without having to sacrifice the best years of their lives to do it.