What's nightmarish about the installation? Is it because medical stuff is still on like Win XP?

Anything more than the most basic bare-bones install of Workbench (formerly Rstudio) quickly turns nightmarish. Try setting it up on a Linux dedicated server with AD auth with auto-mounting of network shares per-user. Posit's documentation isn't great (or even agrees with itself across pages) even in the simplest best-case scenario, and if you deploy anything that's even slightly complicated, it turns into a Hellscape. There's a good chance you will end up on one of the Posit employees' blog to read an incomplete explanation of setting up a feature because it's entirely missing or incomplete in the documentation. This isn't some crazy off-the-wall edge scenario either, it's an (allegedly) supported configuration and would be a typical deployment scenario in a multi-user R environment.

Their support is absolute shit too, it's truly fucking atrocious. First-level support will not solve your issue, I promise you that, and you won't get anyone who actually knows WTF they're talking about until you're escalated at least twice. And even then, they are very much up their own ass and have a VERY snobby attitude about the product, and always assume that it's the user at fault, even when you provide absolute 100% proof that it's their product at fault. It obviously couldn't possibly be their Super Precious Perfect-in-Every-Way Golden God Product, because as we've previously established before, it is a Perfect Product Which Does No Wrong, Ever. They also love to try and shirk responsibility and say that X is not a supported configuration for literally everything, and then claim that the documentation must be wrong when you point out in their documentation that it is.

Don't even get me started on the Lovecraftian nightmare that is R package management. It's even worse than the essay I just typed out, and they want to charge you essentially the entire Workbench license cost x2 to make it usable. Their logging is useless too, it has basically two settings, one of which is essentially "nothing," and the other is "firehose of bullshit that you need to follow along in their source code to try to find anything useful." That's not an exaggeration, I actually had to do that to diagnose an issue and provide proof to them that yeah, it is your half-assed shit product that's the problem.

So yeah, if you're not just Click-Click-Click-Next installing it, it very quickly becomes nightmarish. Posit desperately needs competition in the space, because they're absolute shit, but they can be absolute shit with impunity since they don't have any real competition.

I'll admit it's been awhile but about 10 years ago, it could be a thing. One guy needed almost a week of hands on to get it right.

How is Pak better than pacman, which is my preferred package management solution for R.

R is made infinitely better with tidyverse.