Med School Uncensored
The Insider’s Guide to Surviving Admissions, Exams, Residency, and Sleepless Nights in the Call Room
Alternative Careers in Health Care
Young students interested in working in health care often focus on the idea of becoming a physician—to the exclusion of all other possibilities. This chapter describes some of the non-physician careers I have encountered working in health care over the last decade. The information largely comes from conversations with colleagues, with data from the United States Bureau of Labor Statistics (BLS) providing details such as training and licensure requirements, employment numbers, and salaries. If you find any of these occupations interesting, you should perform additional research and reach out to people in the profession to learn more and acquire the most current information.
If there’s any health care provider as well known as a physician, it’s a nurse. Everyone knows that nurses provide much of the hands-on patient care in hospitals and clinics. They administer medications, make sure patients are comfortable, and monitor vital signs and changes in patient conditions. In the hospital setting, physicians often have dozens of patients under their care, sometimes spanning multiple hospitals. Nurses serve as the eyes and ears of physicians, continuously monitoring individual patients and reporting any changes. Nurses in hospital wards or critical care units become very familiar with patients and their families; they are the face that visitors and patients see day in and day out. This hands-on work and personal bond can be very rewarding.
In a clinic setting, nurses are the grease that keeps the machine moving. They oversee the rooming of patients, work with nursing assistants to perform initial assessments of patients, and provide brief presentations to physicians about why patients are in the clinic and if they have any concerning vital signs or physical conditions. Nurses provide patient teaching, help patients and families understand new diagnoses, and discharge patients from clinic.
Nurses in hospitals and clinics are most frequently encountered by the public. But the profession of “nurse” is as broad and varied as the profession of “doctor.” Just as there are family practice physicians, radiologists, surgeons, anesthesiologists, and dermatologists, there are many specialties within the field of nursing. For example, operating room nurses assist surgeons and anesthesiologists to facilitate procedures and ensure patients are safe, correctly positioned, and appropriately sterile. Emergency room nurses helping ER physicians triage sick patients as they arrive and manage the overall flow of the emergency room to keep things moving. Specialty nurses work in urology clinics, pediatric critical care units, and imaging centers. These nurses are experts in dealing with specific patient populations, such as the elderly, mentally ill, or children.
A major benefit of nursing is that many career paths can be pursued, and additional training and educational credentials can be obtained at any point in one’s career. For example, one can become a Licensed Practical Nurse (LPN) in as little as a year by attending a community college or vocational program. Two-year Associate’s Degree nursing programs offer an intermediate level of training. A four-year Bachelor of Science in Nursing (BSN) degree couples a standard four-year undergraduate experience with a nursing degree.
Like most professions, nurses with more training are rewarded with more job opportunities, responsibilities, and pay. There are many levels of nursing education and different routes to obtain each level. If interested, I encourage you to speak with an experienced nurse or nursing program to explore the various educational paths.
In addition to having many routes of entry, nursing is also a portable profession. For example, a nurse can change her focus from the operating room to pediatrics with relative ease. Such “specialty changes” are nearly impossible as a physician without undergoing an entirely new residency.
Job opportunities and salaries for nurses are generally quite good. According to the BLS, there were roughly 2.7 million registered nurses (RNs) in the United States, with an average annual salary of $69,790. Those working in hospitals and outpatient centers tended to earn the most, while those working in skilled nursing facilities (“nursing homes”) earned the least.
A nurse with a four-year degree can go back to school and earn a master’s or doctoral degree to become a nurse practitioner (NP). These are advanced practice nurses (APNs) who work with a great deal of autonomy and are increasingly demanded due to the continued shortage of physicians, especially in rural areas of the country. Their work is quite diverse and portable, and nurse practitioners are found in almost every specialty and type of health care facility.
There are nurse practitioners in psychiatry units, critical care units, specialty clinics, emergency rooms, and just about every other health care context. NPs can prescribe medications and perform some routine procedures. Depending on the specific practice environment, they may work with physicians in a health care team or alone as a primary provider. According to the BLS, in 2014 there were just over 120,000 NPs in the United States, with an average annual salary of $97,990. Those working in specialty services at hospitals earned the most, while those working in physician offices tended to earn the least.
Another variety of APN is the nurse anesthetist, also commonly referred to as a Certified Registered Nurse Anesthetist (CRNA). CRNAs work in operating rooms with patients undergoing surgeries and procedures. They are trained in airway management, as well as managing general anesthesia, deep sedation, and regional and neuraxial anesthesia. Depending on the practice environment, they either work in an anesthesia care team (ACT) with anesthesiologists or autonomously as a primary provider.
Most CRNAs spend at least a year or two working as critical care nurses. The work of monitoring sedated and intubated patients in an ICU is similar to that of managing anesthetized patients in the OR. They then usually receive a master’s degree in nurse anesthesia to become a CRNA. According to the BLS, in 2014 there were 36,590 CRNAs in the United States, earning a mean annual salary of $158,900. Those working autonomously in rural hospitals tended to earn the most, while those in physician offices earned the least.
Similar to nurse practitioners, physician assistants (PA) are mid-level providers who work in a broad variety of health care settings, including hospitals, clinics, operating rooms, and emergency rooms. Instead of first going to nursing school and then pursuing additional training as nurse practitioners, PAs earn a master’s degree in a physician assistant program immediately after college. These programs have similar academic prerequisites as medical schools.
Just like NPs, PAs also enjoy a great deal of portability in their work. For example, a PA can work for several years in a nephrology clinic with dialysis patients, and then transfer with some on-the-job training to work with an orthopedic surgeon. Some PAs even work in the operating room, assisting surgeons and performing routine surgical techniques. This can be a good option for those who are interested in working in the OR and learning surgical techniques without the exhaustive training, long hours, and responsibilities of being a surgeon.
According to the BLS, in 2012 there were approximately 87,000 PAs in the United States, with a mean annual salary of $90,930. Those working in busy hospital and clinic practices earned the most, while those working in government facilities earned the least.
Another mid-level provider is the anesthesiology assistant (AA). Similar to PAs, these skilled professionals earn a master’s degree in an AA program, usually after completing prerequisite science courses during college. Their work is nearly identical to that of CRNAs, though they exclusively work in anesthesia care team (ACT) models with anesthesiologists. Unfortunately, the BLS doesn’t have information available for AAs, but anecdotally, my experience is that they tend to earn salaries similar to those of CRNAs working in an ACT environment.
Most people think of a pharmacist as someone who hands you packages of pills from the local pharmacy. But again, there is a great deal of diversity in this profession. Pharmacists earn a Doctor of Pharmacy (Pharm.D.) degree, which is a three- or four-year program after college. Some colleges do offer direct admission after high school, giving students the ability to earn a Pharm.D. within six years of graduating high school. Pharmacists are experts in the chemistry behind medications, as well as how those medications perform their actions on the body and are affected by the body.
Though the common perception is of a pharmacist working behind a drug store counter, many pharmacists complete one- or two-year residency programs and work closely with physicians in hospital settings or in academic or industrial research settings. According to the BLS, in 2012 there were 286,000 pharmacists in the United States, earning an average annual salary of $116,670. Those working in general merchandise stores earned the most, while those working in hospitals earned the least.
Most people are familiar with the operating room scene of a surgeon yelling, “Scalpel!” while quickly being handed the instrument by a masked individual at the patient’s side. The person handing off the scalpel is a surgical technologist. They perform many critical duties in the OR, including preparing surgical instruments, ensuring sterility of the surgical field, and anticipating surgeon’s requests and expediently handing him the appropriate tools throughout the procedure.
Though being a surgical technologist means many hours on one’s feet, it can be fun and exciting work for those who enjoy the OR environment. To become a surgical technologist, one usually attends a community college or vocational program, sometimes earning an associate’s degree. Program lengths range between several months to two years. According to the BLS, in 2012 there were just under 100,000 surgical technologists in the United States, earning an average annual salary of $41,790.
Perfusionists are not well known to the public. These are highly trained individuals who work with cardiac surgeons and anesthesiologists to get patients safely on and off the cardiopulmonary bypass machine (also called the “heart-lung machine”) during heart surgery. In many parts of the United States, there are significant shortages of perfusionists—and there are only 21 training programs in existence. Perfusionists have a great deal of autonomy and are the experts of cardiopulmonary bypass machines, extracorporeal membrane oxygenation (ECMO) devices and other advanced technology.
Some perfusion schools require a bachelor’s degree for admission, while others require only two years of prerequisite science coursework. Most programs are two years in length, usually resulting in a master’s degree. According to the BLS, in 2002 there were approximately 3,700 perfusionists employed in the United States, with an average annual salary of $93,000 with ten years of experience.
This is another well-known profession that needs little description. But most people are not aware of the many specialties that exist within the field of dentistry. While most dentists practice general dentistry and focus on dental exams, cavity fillings, and tooth extractions, additional training is available in orthodontics (braces), endodontics (root canals), oral and maxillofacial surgery (facial and dental surgery), and pediatric dentistry.
Dentists are experts in dental anatomy, care, and disease, as well as pathology of the gums and surrounding facial structures. They work with patients of all ages and perform office-based procedures regularly. Some pursue advanced training to work in operating rooms. Dentists can frequently diagnose systemic diseases based on their oral findings. While it is increasingly difficult to operate a solo practitioner as a general practice physician, many dentists still operate their own clinics and are true entrepreneurs as well as clinicians.
According to the BLS, in 2012 there were 146,800 dentists practicing in the United States, with an average annual salary of $149,310. Orthodontists and oral and maxillofacial surgeons earned the most, with salaries approaching $200,000, while general dentists earned the least.
Largely for historical reasons, the diagnosis and treatment of disorders of the feet have long been handled by an independent group of professionals called podiatrists. A podiatrist does not attend medical school, but instead earns a Doctor of Podiatric Medicine (DPM) degree and completes a three-year residency program in podiatry. Podiatrists often operate their own offices—alone or with other podiatrists. They manage chronic issues such as diabetic foot ulcers and perform procedural and surgical interventions for acute injuries and chronic malformations. They also prescribe and fit patients for orthotic devices for conservative management.
According to the BLS, in 2012 there were 10,700 podiatrists practicing in the United States. There were only nine podiatry schools accredited by the Council on Podiatric Medical Education. The average salary was $116,440, with self-employed podiatrists earning the most.
Most people know a psychologist is someone who treats mental disease. Less commonly understood is the distinction between a psychologist and a psychiatrist. A psychologist is a mental health professional who has earned a master’s or doctoral degree in psychology. A psychiatrist is a medical doctor who has earned a medical degree and attended a four-year residency program in psychiatry.
Historically, psychologists have focused on talk therapy and counseling, while psychiatrists used their medical knowledge and prescribing power to manage psychiatric medications. As with many areas of the American health care network, the distinctions between these two professions are blurring. Psychologists have gained the right to prescribe psychiatric medications in a handful of states—and will likely continue to fight for these privileges elsewhere.
Many psychologists operate their own practices, working as entrepreneurs able to set their own schedules and choose which patients they treat. According to the BLS, in 2012 there were 160,200 psychologists in the United States, earning an average annual salary of $69,280. School and organizational psychologists earned the least, while private practice psychologists earned the most. The top ten percent of psychologists earned more than $110,000. For comparison, the BLS reports the average annual salary of psychiatrists in 2014 as $182,700.
According to the American Chiropractic Association (ACA), chiropractors are clinicians who respect the body’s ability to heal itself without medicine or surgery. Though their primary business is in the treatment of osteoarthritis, spinal disk conditions, carpal tunnel syndrome, and generalized back pain, a small number also purport the ability to use spinal manipulations to treat allergies, asthma, digestive orders, ear infections, and a variety of other systemic ailments.
Becoming a chiropractor involves earning a four-year Doctor of Chiropractor (D.C.) degree, usually after an undergraduate degree with a focus on the life sciences. In 2012, there were 15 D.C. programs accredited by The Council on Chiropractic Education. According to the BLS, in 2012 there were 44,000 practicing chiropractors in the United States, earning an average annual salary of $66,160. The top 10% earned more than $142,950 per year.
Optometrists are clinicians who prescribe eyeglasses and contact lenses. They also examine the eyes and can diagnose some systemic diseases based on their findings, referring patients to medical doctors for additional treatment. To become an optometrist, one must complete a Doctor of Optometry (O.D.) degree, usually after completing an undergraduate degree with a focus on the life sciences. In 2012, there were 17 accredited O.D. programs in the United States.
Some optometrists work as employees in retail settings, but many operate their own clinical practices and accompanying retail stores. Others work in hospitals or outpatient centers. According to the BLS, there were approximately 33,000 optometrists in the United States in 2012, earning an average annual income of $97,820. The top 10 percent earned in excess of $184,530 per year.
A large component of recovery from physical injury and deconditioning involves working with physical therapists. These skilled professionals do everything from teach patients how to walk again after traumatic injuries to prescribe special braces and equipment to aid conservative treatment of orthopedic ailments. They are found everywhere within the health care environment, including hospitals, clinics, and dedicated physical therapy facilities. Most work regular hours and have a good deal of autonomy.
According to the BLS, there were approximately 204,000 physical therapists practicing in the United States in 2012, with an average salary of $79,860 per year. Physical therapists attend professional school following an undergraduate education that includes coursework in the life sciences, anatomy, and kinesiology. Graduate programs typically last three years and result in a Doctor of Physical Therapy (DPT) degree.
As the name suggests, respiratory therapists care for patients with breathing problems. They manage ventilators for patients intubated with breathing tubes, and they also manage non-invasive ventilation support for patients with conditions like sleep apnea, emphysema, asthma, and postoperative airway obstruction. In some hospitals, respiratory therapists perform procedures such as intubations and arterial blood draws. Alongside intensive care physicians, anesthesiologists, and pulmonologists, they are among a small group of experts in managing ventilator equipment.
According to the BLS, there were approximately 120,700 practicing respiratory therapists in the United States in 2014, with an average salary of $56,730 per year. Most respiratory therapists have an associate’s degree, but some pursue additional training and acquire a bachelor’s degree in the field. Licensing exams are required in most states.
Medical sonographers work alongside cardiologists, vascular surgeons, obstetricians, and other physicians and are experts at using modern ultrasound machines to obtain images and functional measurements of the heart, lungs, vascular structures, and fetuses, among other things. During and after training, most sonographers specialize in one of these subsets of ultrasound imaging. For example, a cardiac sonographer works at hospitals or clinics in an echocardiography lab, performing comprehensive and focused ultrasound exams of the heart on dozens of patients each day. In addition to learning about ultrasound equipment and image acquisition, sonographers also receive training on ultrasound physics and cardiac physiology. They are trained to make initial assessments and focus their exams based on these findings, forwarding the exam images on to a physician specialist for further review, diagnosis, and treatment recommendations.
According to the BLS, there were 112,700 sonographers practicing in the United States in 2014. The average salary was $62,540 per year. Most sonographers have an associate’s degree, as well as professional certification demonstrating mastery of their skills. Some pursue additional education to obtain a four-year degree.
There are many paths one can choose to work as a health care provider and help patients with medical problems. Attending medical school and completing a residency program is one path—but it is by no means the only option. In addition to the health care professions I have described, there are many others that span a broad range of educational requirements, professional responsibilities, incomes, and lifestyles. Though it is true that physicians are among the highest paid professionals in the United States, many of these alternative careers have much shorter training periods and higher ratios of earning potential to expected student debt.