New Ruling on the NRMP Lawsuit

[Andrew_Doan]

Originally posted by dry dre
Your point is well taken, but don't assume that all residents have a patient population the majority of which doesn't pay. To follow this logic out, it would follow that residents in hospitals that are doing well should be paid more, which isn't so.

Yes, I understand that we do help to care for patients who can pay, but it is also true that residents usually are not very involved with the care of patients who have private insurance. Thus, residents do not generate as much revenue as many people would like to believe.

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[tofurious]

There is unequal access to care not because of how hospitals are managed. There is unequal access to care because 1) people who sign up for med school and say they want to practice family medicine in rural Montana end up practicing Dermatology in NYC; and 2) the HMO system continues to widen the gap between the haves and the have-nots with regard to healthcare: the haves get exuberant amount of unnecessary care such as excessive MRI(due to defensive medicine); this drives up the cost of health insurance, and the have-nots are less likely than before to afford health care. This is the consumer end of the healthcare business.

However, what we have been talking about is the provider end of health care. When hospitals must pay residents more, they will be forced to create guidelines that evaluate the necessity of ordering certain tests. While this is similar to the HMO system, it is the physicians who will be self-regulating instead of pseudo-physicians hired by the HMOs. This in turn should cut down the frequency of unnecessary tests/treatments. Perhaps as an unintentional consequence, closing of urban hospitals will also drive more physicians to more rural areas to alleviate the physician shortage in these areas.

I can already see folks from inner city hospitals cry foul, where hospitals will be double-whammied by underpaid residents in a high cost of living area and patients who can't pay. The high concentration of patients who cannot pay for even antibiotics is a larger problem than the spectrum covered by the lawsuit. Like I said before, if hospitals are simply using the difference between how much they get for each resident and how much they actually pay each resident to cover these patients, you have two choices: 1) accept things the way they are, or 2) make a statement that your personal well-being should not be voluntarily sacrificed in the name of the greater good. This choice can be made on a voluntary basis, by USMGs who want to go to inner city hospitals for less pay, but the decision should not rest with the conglomerate of hospitals and especially not profitable hospitals (when nurses, pharmacists, and attendings don't make less so more patients can get care).

 

[Andrew_Doan]

For the residents and medical students fighting for higher wages, you'll be joining the rest in fighting congress to continue the funding of medical training via Medicare.

Read this article:
http://www.acponline.org/journals/news/mar99/atrisk.htm

If Medicare yanks funding, then we are all going to be begging to be trained.

 

[DireWolf]

I agree with Dr. Doan. At the two teaching hospitals I worked at, the attendings almost always got the first shot at the patients with private insurance. The residents and medical students were then brought in for learning purposes only - not as the primary caregivers. However, residents and medical students were given the first crack at the patients without private insurance.

 

[Andrew_Doan]

Originally posted by tofurious
Like I said before, if hospitals are simply using the difference between how much they get for each resident and how much they actually pay each resident to cover these patients, you have two choices

The average reimbursement per resident is ~$100K. I don't know where the other site gets $200K. $50K of this covers our salary, FICA/Social Security Tax (contributed by the institution), and benefits. This leaves roughly $50K to help pay for faculty salary (yes, the physicians who train us need to be paid), our malpractice insurance (how soon we forget about covering our _ _ _?), and overhead. In private practice, a 50% overhead is very good, which is roughly what it is for the Medicare Reimbursement of GME programs. How about programs paying you more, and then requiring you to obtain your own malpractice insurance?

For those fighting for higher salaries now, you'll be fighting Congress when they yank GME funding from Medicare to save this program!

Read this article:
http://www.acponline.org/journals/news/mar99/atrisk.htm

If GME funding vanishes, then we'll be begging to train for FREE!

Furthermore, the math is not simple.

Read this article to understand how GME funding works:

http://www.im.org/ASP/Docs/Resources/burman-funding fellowship-residency positions.pdf
http://www.im.org/ASP/ResourcesFor/ASPfellowshipfunding.htm

 

[tofurious]

The article actually somewhat supports the notion that hospitals need to look for $ somewhere ELSE instead of from Medicare:

""Residents are still a less expensive source of care than any alternative. If you cut the residency in internal medicine, how would you take care of that practice, which is now essentially all Medicare and indigent patients? What will it cost to make your private attending physicians take care of the housestaff service? These conversations are occurring this year.""

"There is a fair amount of pressure on residency programs to do a residency program at the least possible expense," Einstein's Dr. Wallenstein said. "If you have one less nurse, then you've saved $40,000. If you have one less resident, you've saved $40,000, but you've lost $100,000 in reimbursement. So the idea is not to get rid of the resident; it's to try to educate him as inexpensively as possible, which is a very difficult situation, because the rest of the hospital is not about the business of education, but about the business of patient care."

Residents should be an investment in the future of medicine, not a source of funding for today's medical bill.

 

[Andrew_Doan]

Originally posted by tofurious

"There is a fair amount of pressure on residency programs to do a residency program at the least possible expense," Einstein's Dr. Wallenstein said. "If you have one less nurse, then you've saved $40,000. If you have one less resident, you've saved $40,000, but you've lost $100,000 in reimbursement. So the idea is not to get rid of the resident; it's to try to educate him as inexpensively as possible, which is a very difficult situation, because the rest of the hospital is not about the business of education, but about the business of patient care."

Residents should be an investment in the future of medicine, not a source of funding for today's medical bill.

The article is also missing the basic concept, as have many of you on this forum, that $100K reimbursement covers salary, benefits, overhead, and malpractice insurance for the resident. Thus, it is not fair to state that the hospital is going to lose $60K when firing a resident. Considering that malpractice insurance is very expensive, I will bet that the hospital will only lose $20-30K per resident. This money can be made back with attending physicians seeing more patients.

Look at the training as your education. It's a good thing. We're not really keeping hospitals in the black.

 

[Goober]

I read through the proposals and their solutions on the website.

First I was very disappointed that they blame lack of minority representation in competitive specialties on the match. Their reasoning is that minorities won't want to "waste" listing prestigious institutions or competitive specialties their rank list because they would be unlikely to match. They also state that programs cannot hire minorities directlywhich impedes AA programs. Finally they say that the computer algorithm generated in th 1950's perpetuate these biases and point to a study that favors hospitals in the case of a tie.

The people who wrote this have very little understanding about how the match works. First anybody who is interviewed by a program is obvisously of interest or why would they interview them? How would that keep minorities from ranking them? Lack URMs in competitive specialties has nothing to do with match, it has more to do with how many are applying to these specialties.
Second if somebody wanted to institute a Affimative action program through the match they easily could do so. Rank all your URMs at the top of the list. Lastly that computer algorithm has nothing to do with bias against races. I can't even believe that they brought that up.

As for their other proposals-

No residency program can offer studnets before October of their senior year.

How can you legally do this? If you treat a residency as a business, it is free to offer jobs to anybody it sees fit whenever they want. Even if this could be legally done, which I highly doubt is possible, programs would simply resort to doing verbal agreements. What about people who graduate and change specialties? They are already past their senior year and maybe they don't want to wait till October to get an offer.

Prevent "exploding offers" by requiring residencies to hold an offer for 10 days

How is this going to help? Basically this is going be the same situation I was talking about earlier. Person A drops this program for a better deal and then Person B takes his spot and a hospital could be left without a resdent in July when they thought they had one. They say that their won't be chaos because "look the non-US grads are doing fine without a match. " The reason why there isn't chaos is because US grads are not being screwed, if they were all hell would break loose. The programs that take FMGs outside the match are generally the least desirable and not sought after by american grads.

 

[tofurious]

This is starting to remind me of an AMA meeting, where everyone but the speaker is wrong...

Some information request first: I would like to know how much the malpractice insurance for residents is, since they are "closely supervised".

Affirmative action: yeah, I was not sure why that was an issue against the Match other than the fact that it would be virtually impossible to guarantee minority employment unless programs want to take the chance that they'll end up with ALL minority applicants by ranking URMs at the top of their lists. Although you can tell that this was probably a point some politicians would absolutely want the lawsuit to address if the plaintiffs want the congressmen's and senators' support.

However, the other issues are much easier to deal with. It only takes a "gentlemen's agreement" (e.g., ACGME requirement) to make sure that no offer is made before October, etc. As evidenced by the 80-hr work week rule, residency programs possess the amazing abilities to change when their accreditation is on the line.

 

[Apollyon]

Originally posted by tofurious
Lifestyle =
$$$$$ - work hours

In the case of ortho, the work hours are long, but $ is a lot more also than the other two.

While many people enter these fields for the above reason, it seems odd that they would be against raising the average salary of residents (of course, their pasture is also a lot greener after residency than say many medical specialty residents).

My post was sarcastic with those 3 fields (but I did think about ortho with long hours, otherwise on par) - just reversing the notion of longer hours and less pay. But I think you're right on.

 

[juddson]

Interesting thread. Wonder why they do not accept the law firm placement model. New attorneys start the practice of law knowing NOTHING. The first two years consists of a LOT of education, though the pay is still very good. I don't think the underlying interests in the two systems are that distinct. It might work.

Judd

 

[Andrew_Doan]

Originally posted by juddson
Interesting thread. Wonder why they do not accept the law firm placement model. New attorneys start the practice of law knowing NOTHING. The first two years consists of a LOT of education, though the pay is still very good. I don't think the underlying interests in the two systems are that distinct. It might work.

Judd

The average attorney starts at ~$42,650 (median income). That's close to where residents start. We're not working for free.

 

[tofurious]

You must have gotten your figure somewhere, but when I looked up "attorney salary", I found this website (http://www.payscale.com/salary-survey/aid-9235/rid-66/fid-6886/RANAME-SALARY) where the associate attorneys with 1-4 years of experience make from $50,000 to $105,000 per year.

Imagine making $105,000 as a PGY4...

 

[surg]

Just as a comment:
Entry level attorneys are at 50000 according to the same website
http://www.payscale.com/salary-survey/vid-17752

Also, there are more than a few attorneys graduating from low tier law schools that are unemployed or not working to their capacity and barely scraping by. The premium on highly ranked law schools is significant, whereas this is not as true in medical schools.

Just one other thought before I shut up. As an MD, there are many non-medical jobs that don't require residency that pay much better than residency if you are willing to go that route (e.g. management consulting with beginning pay packages ~100k). So one isn't necessarily locked into a low paying job just because they have an MD, yet very few people take this route. Not sure how that plays a part in this debate, but just something to think about.

 

[Andrew_Doan]

Originally posted by tofurious
You must have gotten your figure somewhere, but when I looked up "attorney salary", I found this website (http://www.payscale.com/salary-survey/aid-9235/rid-66/fid-6886/RANAME-SALARY) where the associate attorneys with 1-4 years of experience make from $50,000 to $105,000 per year.

Imagine making $105,000 as a PGY4...

Keep dreaming about the $105K/year as a PGY-4

Salary surveys are varied. Here is my source for new laywers:
http://www.wisbar.org/wislawmag/2001/12/molvigfig.html#2

Also keep in mind that ~1/4 of new law graduates last year could not find jobs. Iowa is a strong law school and 1/3 of the 2003 class could not find a job because of the economic downturn. Unlike medicine, law is not as sheltered from poor economic times.

You can't compare law to medicine. First, new law grads don't have to complete a residency to practice. They can hang up a shingle after graduation and passing the Bar. Second, a bad lawyer will not win cases, but a bad physician will kill people.

 

[juddson]

Damn!!

The median new lawyer salaries are low. I had no idea. I started my first year out of law school in 1999 at $100,000. I was 25. I went to a "BigLaw" school, and started at a "BigLaw" firm, but I would have guessed that even lower tiered places would hve paid in the $75k range. I'm surprised the median is only 50k.

Still, assuming that lawyers only make about 50k a year on average, I still don't see why the system would not work for medicine as well. I'm not sure anybody has explained why the differences in the job markets for doctors and lawyers should not make the legal job placement system work with MD's.

What is it about an open market in jobs that is unworkable in medicine? Couldn't many of the nasties of the old system be solved by requiring that offers be held open until a certain date? A fairly benign market control designed to prevent "price gouging" and "coercive" timing abuses?

judd

 

[Andrew_Doan]

Originally posted by juddson

Still, assuming that lawyers only make about 50k a year on average, I still don't see why the system would not work for medicine as well. I'm not sure anybody has explained why the differences in the job markets for doctors and lawyers should not make the legal job placement system work with MD's.

Judd,

Resident physicians are making $40K/year now. Not much different from the $50K/year for new lawyers.

In this discussion, it is neglected that new law grads are not in training; whereas, new medical grads need training.

New lawyers can bill for all their work. Hence, you can make $100K/year salary. Also, I doubt your partners are giving you daily lectures and 'rounds' about how to practice law.

Resident physicians CANNOT bill because we are in a training program. If I see patients or perform surgeries without an attending physician, then the hospital can't bill for my services. Our salaries are based on how much Medicare pays for GME. Because residents do not generate billing, there are no funds to increase our salaries. Additionally, most hospitals are in the red already.

 

[Apollyon]

Originally posted by Andrew_Doan
You can't compare law to medicine.

Second, a bad lawyer will not win cases, but a bad physician will kill people.

That's what I was thinking.

 

[Seaglass]

I would argue that the Law-grad system won't work based on money. A law practice is comparatively low overhead to running a hospital so there is more disposable income to attract applicants. Also there is arguably a huge difference between the best and worst law schools, while the difference between the best and worst US medical schools are considerably less. It would also definitely create tension in residency classes for some residents in a class to be making significantly more than their colleagues. Tie all that in to Dr. Doan's comments and the systems just don't look the same.

Casey

 

[mpp]

Why couldn't residency programs just increase their pay and benefits under the current matching system to attract more applicants? I think the reason is that it is just not affordable not because they are in some secret conspiracy against medical school graduates.

There are certainly some IM and FP residencies that matched less than half of their applicants during the last match cycle. I'm sure if they upped their salary by another 20 or 30 thousand per year they 'd get a heck of a lot more applicants to rank them highly and fill their program and hence make all that money that some people seem to think residents make for the hospital. But they don't. I doubt it's because MGH and Hopkins is secretly in a pact with them to keep their salary low and their benefits untolerable. I think it 's just a matter of economics. They just can't afford that money.

There is nothing magical about the match process that is keeping less-desirable programs from increasing salary, lowering hours, and giving good benefits to make them more desirable.

 

[mpp]

One more thing I thought of as a disadvantage of getting rid of the match. Imagine the competition to get the first interview at the top programs just to know that you won't have to settle for a program less desirable to you since you won't know if that top program might be full by the time you interview there.

I really can't see one single benefit of this lawsuit (except for the lawyers involved), even after reading their argument. It doesn't make any sense to me... perhaps I'm stupid...but I will be someone's doctor someday

 

[Andrew_Doan]

Originally posted by mpp
One more thing I thought of as a disadvantage of getting rid of the match. Imagine the competition to get the first interview at the top programs just to know that you won't have to settle for a program less desirable to you since you won't know if that top program might be full by the time you interview there.

I really can't see one single benefit of this lawsuit (except for the lawyers involved), even after reading their argument. It doesn't make any sense to me... perhaps I'm stupid...but I will be someone's doctor someday

I agree MPP. The competition would be fierce. Without a doubt, many of my colleagues and I would have gunned hard for a position early.

 

[margaritaboy]

Originally posted by mpp
One more thing I thought of as a disadvantage of getting rid of the match. Imagine the competition to get the first interview at the top programs just to know that you won't have to settle for a program less desirable to you since you won't know if that top program might be full by the time you interview there.

Yes, the suit has shortcomings. But again, I encourage all to read about it.

The situation you speak of above, I would think unlikely. According to the suit's website, a program could predetermine how many of its slots, if any, would be offered outside the match.

Many who have posted here have said applicants would be at a disadvantage, not being able to interview at a full spectrum of programs before being pressured into taking a early offer....IF the offer was acutely time limited. A fare objection. But, some people are also saying there would be an applicant fight for the first few interviews. How exactly would it be to a programs advantage to make a bunch of early offers, and forfeit the opportunity to interview a full spectrum of candidates? Fill early sure, but only interview a handful of people?

In other words, I'm not sure the gloom and doom of early program offers and applicants fighting for those early offers would come to pass. It seems as if the advantage is both to applicant and program to wait for a full spectrum of interviews, so you maximize your chance to get a winning applicant/program match.

 

[margaritaboy]

Theoretical Scenario:

I am moderately competitive residency of medium sized in an area of average popularity to live. I offer average pay and benefits. I have 10 PGY-1 slots to be filled. Going into interview season, I predesignate 3 positions that I can offer outside the match, with the rest being offered through the match.

Candidates A through Z apply to my program with A being a 4.0 GPA, 280 Step I, PhD, has found a cure for hang nails, and part time orphanage manager. Applicant Z is a total loser.

I receive their applications, and I contact the most competitive applicants first and offer them interviews, which they schedule during any time during our interview season. Invitations follow for the next most competitive etc. until all interview slots are filled or nobody else accepts an interview.

Candidate A is so wonderful, I immediately offer them a position. I would kill for candidate A, so I make to offer open ended. I know that they will likely end up going where ever they want. If they decide to come to my program at the last possible minute, I will still be so grateful I will do back flips.

I make early open-ended offers to two more very competitive applicants, C and F. Applicant B was competitive on paper, but a real a**hole during the interview. Applicant D cancelled his interview (maybe he had his heart set on a different part of the country?), and applicant E rubbed one of the interviewers the wrong way (still a good candidate, just not good enough for an early offer).

Other candidates also interview.

February: ROL are due, and open-ended acceptances expire on the same day. Sadly, candidate A has not accepted the early offer. But, candidates C and F have! Horary! That leaves my program with 8 spots available to the match.
I rank the candidate sequentially from A-Z, and learn that candidates G, H, K, & M have accepted offers at other programs, and are not available to be ranked as applicants on my ROL.

March: Match day. Amazingly, Candidate A had a last minute change of heart and ranked my program first (must have been the T-shirt we sent him along with PD phone call the week before ROL were due). A, E, I, L, O, P, T, & X match with us through the NRMP match.

How is this different than the normal match??
1. Per lawsuit - No candidate pays $$ for NRMP services
2. Programs and applicants are not penalized for giving/receiving offers outside the match.

You opinions and comments please.

 

[juddson]

everybody commenting on this thread should read, at least, the following affidavit filed in connection with the lawsuit.

from a legal standpoint (which is ONLY one point of view) it is compelling.

Section V.2. makes the points I was making above, which is essentially why the labor market for medical resdidents should be different than the labor market for anybody else (including lawyers and MBA's).

REPORT OF PRINCETON PROFESSOR AND ECONOMIST DR. ORLEY ASHENFELTER ON IMPACT OF ANTITRUST VIOLATIONS ON RESIDENTS

You can find it in the pleadings and orders section of the case website.

Judd

 

[Entei]

Originally posted by margaritaboy
Theoretical Scenario:

I am moderately competitive residency of medium sized in an area of average popularity to live. I offer average pay and benefits. I have 10 PGY-1 slots to be filled. Going into interview season, I predesignate 3 positions that I can offer outside the match, with the rest being offered through the match.

Candidates A through Z apply to my program with A being a 4.0 GPA, 280 Step I, PhD, has found a cure for hang nails, and part time orphanage manager. Applicant Z is a total loser.

I receive their applications, and I contact the most competitive applicants first and offer them interviews, which they schedule during any time during our interview season. Invitations follow for the next most competitive etc. until all interview slots are filled or nobody else accepts an interview.

Candidate A is so wonderful, I immediately offer them a position. I would kill for candidate A, so I make to offer open ended. I know that they will likely end up going where ever they want. If they decide to come to my program at the last possible minute, I will still be so grateful I will do back flips.

I make early open-ended offers to two more very competitive applicants, C and F. Applicant B was competitive on paper, but a real a**hole during the interview. Applicant D cancelled his interview (maybe he had his heart set on a different part of the country?), and applicant E rubbed one of the interviewers the wrong way (still a good candidate, just not good enough for an early offer).

Other candidates also interview.

February: ROL are due, and open-ended acceptances expire on the same day. Sadly, candidate A has not accepted the early offer. But, candidates C and F have! Horary! That leaves my program with 8 spots available to the match.
I rank the candidate sequentially from A-Z, and learn that candidates G, H, K, & M have accepted offers at other programs, and are not available to be ranked as applicants on my ROL.

March: Match day. Amazingly, Candidate A had a last minute change of heart and ranked my program first (must have been the T-shirt we sent him along with PD phone call the week before ROL were due). A, E, I, L, O, P, T, & X match with us through the NRMP match.

How is this different than the normal match??
1. Per lawsuit - No candidate pays $$ for NRMP services
2. Programs and applicants are not penalized for giving/receiving offers outside the match.

You opinions and comments please.

It seems like this situation caused a big headache for everyone involved and benefited only six people: applicants C, F, G, H, K, & M . All-star applicant A didn't benefit because he wound up matching anyway at a program he wasn't too crazy about (otherwise he would have taken their original offer.) The program itself got to sign two applicants early, but I wouldn't say that the program benefited because it had to cough up the fees for the NRMP services (as per the lawsuit). The 19 other applicants to the program didn't have an improved situation over dealing with the Match because if they wound up getting a spot, it was through the Match anyway. In fact, they probably had a worse time because they had to deal with the variable number of positions being offered by the programs. It seems like it would be very confusing to apply to programs that might have 10 spots or 9 spots or 8 spots available depending on what happens outside the Match, and not knowing what's available when the applicant ranks them. How does the applicant judge what number of programs is "safe" to rank if he or she doesn't even know how many spots are available?

Did applicants C and F have any other benefit to negotiating outside of the Match? Did they manage to secure a higher salary? What about applicant A? Was he offered a higher salary outside of the Match, but since he didn't take it, does he have to settle for the "Match salary?"

To me, this system definitely sounds like "benefiting few at the expense of many."

 

[Andrew_Doan]

The current match does offer choice, and it does promote competitive wages.

Consider these real life programs.

There's a medical internship in Des Moines that offers an extremely competitive salary package.
http://www.broadlawns.org/Oldpages/benefits.htm

This is an FP program that also offers a PGY-1 Transitional year.

Residents start at $39K/year, receive $1250 for moving expenses, health insurance, AND a townhome to live rent free. Free rent adds about $14,000 to the financial package, i.e., ~$18,000 before tax dollars.

Or you can work at U of Iowa, and start out at $39K/year without the moving expenses and free rent.

With the current system, I don't see how the match inhibits candidates or programs from picking their best choice. Also, these are two very different salary packages, and there's no salary fixing.

I doubt that abolishment of the match will increase incomes; however, it'll bring back a lot of headaches that occured before the match. You all should browse this site:

www.savethematch.org

 

[Entei]

Originally posted by mpp
Why couldn't residency programs just increase their pay and benefits under the current matching system to attract more applicants? I think the reason is that it is just not affordable not because they are in some secret conspiracy against medical school graduates.

There are certainly some IM and FP residencies that matched less than half of their applicants during the last match cycle. I'm sure if they upped their salary by another 20 or 30 thousand per year they 'd get a heck of a lot more applicants to rank them highly and fill their program and hence make all that money that some people seem to think residents make for the hospital. But they don't. I doubt it's because MGH and Hopkins is secretly in a pact with them to keep their salary low and their benefits untolerable. I think it 's just a matter of economics. They just can't afford that money.

There is nothing magical about the match process that is keeping less-desirable programs from increasing salary, lowering hours, and giving good benefits to make them more desirable.

This is my perception of how abolishing the Match will increase resident salaries. I'm all for more money, but no one seems to have a clear explanation of where the extra money is going to come from. Maybe it's because I'm the world's dumbest first year, but could someone actually explain this in simple words that even I could understand?

 

[Seaglass]

The suit plaintiffs state that participating hospitals have enough to both raise wages AND pay damages for lost wages. I already talked about the razor thin operating margins of hospitals in PA, maybe it's better elsewhere in the country.

C

 

[margaritaboy]

Originally posted by Entei
It seems like this situation caused a big headache for everyone involved and benefited only six people: applicants C, F, G, H, K, & M . All-star applicant A didn't benefit because he wound up matching anyway at a program he wasn't too crazy about (otherwise he would have taken their original offer.) The program itself got to sign two applicants early, but I wouldn't say that the program benefited because it had to cough up the fees for the NRMP services (as per the lawsuit). The 19 other applicants to the program didn't have an improved situation over dealing with the Match because if they wound up getting a spot, it was through the Match anyway. In fact, they probably had a worse time because they had to deal with the variable number of positions being offered by the programs. It seems like it would be very confusing to apply to programs that might have 10 spots or 9 spots or 8 spots available depending on what happens outside the Match, and not knowing what's available when the applicant ranks them. How does the applicant judge what number of programs is "safe" to rank if he or she doesn't even know how many spots are available?

Did applicants C and F have any other benefit to negotiating outside of the Match? Did they manage to secure a higher salary? What about applicant A? Was he offered a higher salary outside of the Match, but since he didn't take it, does he have to settle for the "Match salary?"

To me, this system definitely sounds like "benefiting few at the expense of many."

Huh? The two applicants that accepted my early offers neither gained nor lost anything from the traditional match (accept that they new early where they were going) and had they gone through the match would have ended up at my program anyway, since they were competitive and presumably wanted to go there since they jumped at the early offer. Not really different from the current match.

Applicant A got their first choice through the match. How does that inconvenience them??

Applicants didn't have to pay NRMP fees, but programs only had to pay for the number of positions they would fill through the match. In this case only 8, instead of a full 10. Is this drastically different from what happens now, aside from who foots the bill?

And the number of program slots offered in and outside the match is predetermined before interview season starts. Every applicant will know there is a minimum # of slots going into the interview for each program. How is this different from what we?re doing right now??

Objections regarding negotiated salary differential among residents have already been addressed in this thread.

The question of questions, however, is would this scenario really give applicants more group leverage? Would programs have added incentive to keep compensation and working conditions reasonable, knowing that their applicants could at anytime during interviews accept an offer at another institution? Or simply rank said program lower? Or does the above situation offer more flexibility for applicants? I don't know the answer to these questions. If it did offer these benefits, I think I would support the effort. If it didn?t, I?d probably not be inclined to support it at all.

 

[Entei]

Originally posted by margaritaboy
Huh? The two applicants that accepted my early offers neither gained nor lost anything from the traditional match (accept that they new early where they were going) and had they gone through the match would have ended up at my program anyway, since they were competitive and presumably wanted to go there since they jumped at the early offer. Not really different from the current match.

That's what I said. The only advantage to this new system was that they got the peace of mind of knowing earlier. It's not really different, so why change things?

Applicant A got their first choice through the match. How does that inconvenience them??

I didn't say it was an inconvenience. But again, the situation for A did not improve, so why change?

Applicants didn't have to pay NRMP fees, but programs only had to pay for the number of positions they would fill through the match. In this case only 8, instead of a full 10. Is this drastically different from what happens now, aside from who foots the bill?

Again, my *point* was that the situation is not very different from what we have now except for who pays the fees. It's not a big deal for a program to pay the fees for 8 applicants, but what about 50? 100? Where is the money going to come from?

And the number of program slots offered in and outside the match is predetermined before interview season starts. Every applicant will know there is a minimum # of slots going into the interview for each program. How is this different from what we?re doing right now??

Maybe I'm just confused as to how this system would work. A program would designate x number of spots to be filled outside of the Match. Well, suppose the program designates 9 out of 10 spots to be filled outside of the Match. We saw in this example that it's possible that, even though those spots were set aside, they might not all get filled. So, on the day when applicants have to finalize their ROLs, they don't know how many spots have already filled at that program. There might be only one spot available for the Match, or there might be more. It seems to me like that would create a lot of confusion and uncertainty, but all I know about the Match is that it's already rife with confusion and uncertainty. So, to my knowledge, I don't really know if it's different or not. At the very least, it doesn't seem to be much of an improvement except for those few people who get to sign early at their number one choice.

Objections regarding negotiated salary differential among residents have already been addressed in this thread.

But I think we can agree that we don't have any clear answers. I still want to know what happened to applicant A. Did he take the same job at a lower salary or not?

The question of questions, however, is would this scenario really give applicants more group leverage? Would programs have added incentive to keep compensation and working conditions reasonable, knowing that their applicants could at anytime during interviews accept an offer at another institution? Or simply rank said program lower? Or does the above situation offer more flexibility for applicants? I don't know the answer to these questions. If it did offer these benefits, I think I would support the effort. If it didn?t, I?d probably not be inclined to support it at all.

It would be really great if this new system could give applicants more leverage, but until someone explains exactly how this would work, I want no part of it. I don't want to be a guinea pig in someone's experiment in medical economics. What incentive does a program have to increase compensation for residents when these residents need a residency to do anything with that degree that they just spent 4 years and $200,000 on? Where does the extra money come from? What's going to stop people from taking pay CUTS just so they can train at a more prestigious program? Hell, I'd live off of ramen noodles for a few extra years if it'd put a hotshot name on my diploma, and I'm sure I'm not the only one.

 

[mpp]

I agree with Entei, I don't see how margaritaboy's scenario is any better than what we have today.

 

[margaritaboy]

Entei: What can I say. I must have misinterpreted your remarks. But when I read things like?.

Originally posted by Entei
It seems like this situation caused a big headache for everyone involved and benefited only six people: ... All-star applicant A didn't benefit because he wound up matching anyway at a program he wasn't too crazy about ... In fact, they probably had a worse time because they had to deal with the variable number of positions being offered by the programs. ...
To me, this system definitely sounds like "benefiting few at the expense of many."

?then for some reason I get the impression that you've made up your mind on the issue, and that you think things would be worse off.

But if you are saying that you think things would turn out essentially the same, then we are in complete agreement after all. I do think things would remain essentially the same. People would still end up going more or less where they might have otherwise with the traditional match. If you think the scenario is no better than we have today, then we are in complete agreement.

The point was not to say that lawsuit, if successful, would bring a utopian match benefits for all. It wouldn't. There would still be uncertainty, as there is now. But it might not be the gloom and doom that some think.

All it would really offer is options. Want to continue to go through the traditional match? No problem. Want to seek positions outside the match, if they are offered? Go for it. Want better pay or working conditions (applied uniformly across a program)? Well, there are definitely no promises here. In fact, many posts here make compelling arguments that those parameters would not improve. If that is so, then the lawsuit will not have my support. Would the costs outweigh the benefits? Maybe.

But I think these are open questions.

 

[tofurious]

Yes, things at programs such as the one used by margaritaboy probably wouldn't change much at first, although another program that can't fill/usually don't fill will offer more incentives up front to make sure they fill as many spots as possible outside the match, since the match has not worked in their favor. In turn, the programs slightly better than these bottom-tier programs (probably not bottom tier per se but the "package" they offer including location, pay, training style may be less desirable) will need to offer more for the candidates who would easily entertain slightly "worse" programs for more compensation. Currently, programs don't need to raise their offers to the IMGs because allowing them to work in this country with a J1 visa is incentive enough. However, if US seniors/grads are also offered spots outside of the Match, they will definitely only be enticed by something other than the right to work/stay in this country. While the outcome of competition will not touch MGH for a while, as more and more residents choose lifestyle over name (hmmm, does this remind you of any change in specialty choices?), even MGH will have to pay more to get quality residents to maintain their standards instead of subpar residents who are willing to live on raman alone.

 

[mpp]

Originally posted by tofurious
Yes, things at programs such as the one used by margaritaboy probably wouldn't change much at first, although another program that can't fill/usually don't fill will offer more incentives up front to make sure they fill as many spots as possible outside the match, since the match has not worked in their favor.

But why don't these programs just offer more incentives now to attract more candidates to their program through the match? Why would having applicants sign agreements prior to a match somehow make these programs realise that people are attracted by money? If they would raise their salaries, lower their hours, and offer increased benefits now they would likely increase the number of people that rank that program highly. I don't understand how a class-action lawsuit will suddenly open up the eyes of these programs.

On another note, if this case goes through and then I feel that the new program has left me with fewer options to match into a decent residency program if I can sue Drs. Greene, Jung, and Llerena for bringing about my hardship. Woe is me...

 

[Andrew_Doan]

Originally posted by tofurious
Yes, things at programs such as the one used by margaritaboy probably wouldn't change much at first, although another program that can't fill/usually don't fill will offer more incentives up front to make sure they fill as many spots as possible outside the match, since the match has not worked in their favor.

First, where is this extra money coming from for increased incentives? The average program receives less than $100K/resident from Medicare. According to administrators at my program, the $200K/resident quoted by the suit is due to some programs inflating their Medicare expenses, which is going to change. Beware that things will change drastically if Congress pulls funding for medical education out of Medicare.

Second, don't you read my posts? There are programs that already offer different incentives. Programs don't pay all the same. There's an FP program in Des Moines that offers an extremely competitive salary package.
http://www.broadlawns.org/Oldpages/benefits.htm

This is an FP program that also offers a PGY-1 Transitional year.

Residents start at $39K/year, receive $1250 for moving expenses, health insurance, AND a townhome to live rent free. Free rent adds about $14,000 to the financial package, i.e., ~$18,000 before tax dollars.

Or you can work at U of Iowa, and start out at $39K/year without the moving expenses and free rent.

Thus, there are already programs that try to increase their attractiveness with better financial incentives. Not by much, but it's competition. In the above case, if you do Broadlawns FP, then your real pay is: ~$58K. If you do U of Iowa FP (which is far better), then your real pay: ~$39K.

I'll give you a few more examples from my own experiences.

Iowa Ophthalmology offered me $39K/year PLUS health insurance for my family and FREE prescriptions. This brought my income to ~$43K/year.

Hopkins offered about the same base pay, but I had to pay for parking and health insurance for my family. This brought my pay down to ~$34K/year.

MEEI (Harvard's program) offered about $48K/year if I recall correctly.

In addition to the above, some programs offer 2 weeks vacation while others offer 3 weeks vacation. Some gave you computers, books, or PDAs.

The financial packages varied greatly. Perhaps not by much, but these programs cannot afford to pay residents more. My point is that programs do compete via their prestige AND financial packages. I don't understand why people continue to argue that the MATCH has allowed programs to cheat the applicant. When I interviewed, each program freely disclosed to me the financial package. You just have to ask!

 

[margaritaboy]

Dr. Doan, I think, has the crux of the issue. The suit is based on the premise that the match fosters unfair price fixing similar to a trust among programs. Getting rid of the match would then presumably increase benefits.

But, if our residency benefits are influenced by factors not related to the match, then presumably nothing would change after a successful suit.

People, I don't know what's right here. All I know is that I wish residents had a stronger voice. It was not 12 months ago that I was watching some of my colleagues get killed with 120hr weeks on the floors, and it is a shame that it was only an ACGME mandate that got them some relief. If this suit allowed us to successfully represent ourselves better, through choice, then I'd support it. But the benefits are far from clear.

 

[Goober]

Originally posted by tofurious
. While the outcome of competition will not touch MGH for a while, as more and more residents choose lifestyle over name (hmmm, does this remind you of any change in specialty choices?), even MGH will have to pay more to get quality residents to maintain their standards instead of subpar residents who are willing to live on raman alone.

Actually I highly doubt that this would occur. Choosing a residency is for a short' defined period of time- not the rest of your life. Choosing which residency also has a large impact on fellowships and future jobs. I very much doubt that MGH would ever have to pay more to maintain quality residents. Case in point- UCSD used to have the best MSK fellowship with Dr. Resnik for radiology for many years. They had people lining up trying to get in. They split the salary of one fellow to pay for 2 and the rest worked for absolutely nothing. But people were willing to do it to have the name and training when they got out in the job force.

 

[tofurious]

While many people who don't agree the Match is all evil are speaking up, the point of the new plan is let people have the choice. Some programs will have 1/10 split between out-of-Match and Match spots, and others will have 10/1. Some applicants will choose to go out of the Match, and others will stay in it. As long as there is room to make changes, good things will come out of this process (except really cheap alternatives such as outsourcing of radiology to India, which has already happened anyway with or without the Match). As of now, not many programs have the initiative nor incentive to make changes such as the one Iowa Family Medicine program. Nobody here is dumb enough to think that the AAMC and 16 institutions will actually pay back the owed back-pays, etc. The real goal of the lawsuit is to create room for changes, and to legally "encourage" the system to change with time. Since withholding service is not the way to go (as in strikes or other labor movement strategies), a lawsuit or a trend of losing qualified residency applicants in the future seem to be the only viable options.

(As for Andrew Doan: (why is eveyrone calling him Doctor? We are/will all be doctors) no, I actually didn't read your post in detail, because exceptions are exactly that and if we always rely on exceptions to evaluate general progress we would have never abolished slavery and allowed women to vote)

Quick post on why programs don't offer extras already: a lower-tier program will have no incentive to do so because whatever they offer, they can only hope that an applicant will rank them higher than other programs. If the position could be offered outside the Match, the program will have a more re-assured return and have the ability to negotiate with the resident applicant. As of now, perhaps only superstars like Andrew are getting these offers that come with the Match (actually, I got a couple too, so maybe not only superstars), but not every place comes with offers.

 

[Apollyon]

Originally posted by Andrew_Doan
When I interviewed, each program freely disclosed to me the financial package. You just have to ask!

The only thing being that this violates the common wisdom; people don't know what to think, but Iserson writes in his book to never ask about the compensation, since you look greedy and non-academic. Moreover, by definition, most people won't be superstars, and may not have (or feel they don't have) the ability to leverage one program against the other.

 

[Goober]

Originally posted by Apollyon
The only thing being that this violates the common wisdom; people don't know what to think, but Iserson writes in his book to never ask about the compensation, since you look greedy and non-academic. Moreover, by definition, most people won't be superstars, and may not have (or feel they don't have) the ability to leverage one program against the other.

Did you ever go to a residency interview where they didn't hand out their compensation package and benefits? It always seems like it is readily availble in the package of stuff they give you and nowadays almost always on their websites.

Iserson must have been talking about real jobs not residency.

 

[Apollyon]

Originally posted by Goober
Did you ever go to a residency interview where they didn't hand out their compensation package and benefits? It always seems like it is readily availble in the package of stuff they give you and nowadays almost always on their websites.

Iserson must have been talking about real jobs not residency.

No, Iserson was talking about residency (read his book). At all residency interviews I went to, the compensation package sheet was handed out, but no one said anything about it (with exception of health insurance in one sentence), since it wasn't negotiable anyhow.

 

[margaritaboy]

Originally posted by Goober
Did you ever go to a residency interview where they didn't hand out their compensation package and benefits? It always seems like it is readily availble in the package of stuff they give you and nowadays almost always on their websites.

Iserson must have been talking about real jobs not residency.

Iserson is talking about residency.

I have been to more than one interview where there was no such handout, and it was up to me to covertly pump current residents for the info. I've also noticed that the information on Freida is not always accurate.

I was actually suprised that more programs didn't make this information readily available. Unless of course they knew there was nothing applicants could do about it one way or another.

 

[1996]

Originally posted by tofurious
While many people who don't agree the Match is all evil are speaking up, the point of the new plan is let people have the choice. Some programs will have 1/10 split between out-of-Match and Match spots, and others will have 10/1. Some applicants will choose to go out of the Match, and others will stay in it. As long as there is room to make changes, good things will come out of this process (except really cheap alternatives such as outsourcing of radiology to India, which has already happened anyway with or without the Match). As of now, not many programs have the initiative nor incentive to make changes such as the one Iowa Family Medicine program. Nobody here is dumb enough to think that the AAMC and 16 institutions will actually pay back the owed back-pays, etc. The real goal of the lawsuit is to create room for changes, and to legally "encourage" the system to change with time. Since withholding service is not the way to go (as in strikes or other labor movement strategies), a lawsuit or a trend of losing qualified residency applicants in the future seem to be the only viable options.

(As for Andrew Doan: (why is eveyrone calling him Doctor? We are/will all be doctors) no, I actually didn't read your post in detail, because exceptions are exactly that and if we always rely on exceptions to evaluate general progress we would have never abolished slavery and allowed women to vote)

Quick post on why programs don't offer extras already: a lower-tier program will have no incentive to do so because whatever they offer, they can only hope that an applicant will rank them higher than other programs. If the position could be offered outside the Match, the program will have a more re-assured return and have the ability to negotiate with the resident applicant. As of now, perhaps only superstars like Andrew are getting these offers that come with the Match (actually, I got a couple too, so maybe not only superstars), but not every place comes with offers.

Actually, the type of situation that Dr. Doan mentioned are not exceptions. I think what he meant was that every applicant to the programs he described was getting those extra benefits, not just Dr. Doan alone. So to say that "only superstars like Andrew are getting these offers" is incorrect. Right now, programs are free to determine their own salary and benefit packages. There is no conspiracy or binding commitment among programs to "set" the salary at a certain rate. Among the 15 or so programs that I interviewed at alone, there is a very wide variety of salary level and benefits offered, including signing bonuses, health insurance benefits to families, etc. Some of these actually come from fairly pretisgious programs as well. The point is, there IS competition among programs for applicants under the current system, and they do so by having different perks and salary packages. Such information is freely available to the applicants before they formulate their rank list. I do not see how changing the match system will drive everyone to change their current compensation packages and decide to pay the residents more. Moreover, as is already discussed on this thread, residents at the same level in the same program should not have varying salary and benefits. Therefore, if everything would stay the same whether or not you enter through the match or outside the match, what are the added incentives to go outside the match other then to know a few months earlier where you're going to go?

 

[Andrew_Doan]

Originally posted by tofurious

(As for Andrew Doan: (why is eveyrone calling him Doctor? We are/will all be doctors) no, I actually didn't read your post in detail, because exceptions are exactly that and if we always rely on exceptions to evaluate general progress we would have never abolished slavery and allowed women to vote)

As of now, perhaps only superstars like Andrew are getting these offers that come with the Match (actually, I got a couple too, so maybe not only superstars), but not every place comes with offers.

You sound rather hostile in your post. I'm sorry if my comments offend you.

First, perhaps you should read my posts before making judgements and posting poorly informed opinions.

Second, my examples are not rare. Each program offers different income packages and benefits. Also, if applicants ask, then the program (either the faculty, residents, or program director) will gladly disclose what the program offers: PDAs, book fund, travel fund for meetings, white coat cleaning service, health care coverage for family, etc... You're not being greedy if you ask. There's a PC way of asking and a not so PC-way of asking. Additionally, many programs disclose this info openly on their websites. With a little homework via Google, I knew most of the financial packages of programs I interviewed at. My questions on inteview day either clarified or revealed the 'extra perks'.

Third, the examples I gave are not because certain applicants are Superstars. Jules Stein/UCLA provides laptops to all of their residents. Iowa ophthalmology provides PDA and books. Some programs offer thousands of dollars for books! I've met fellows who have 10X my library because they had a large book fund. There are no programs that recruit individual applicants with cash or prizes. No one is that good.

Fourth, top programs are not going to pay residents much more than $40-50K/year. There's no money; however, consider this: Hopkins Jr. Faculty often start lower than $80K/year! If places like Hopkins pay new faculty less than $80K/year, then why would these programs pay a resident who can't even bill nor knows enough to practice any where in the World more than $40k-50K a year?!

 

[mpp]

Originally posted by tofurious
Quick post on why programs don't offer extras already: a lower-tier program will have no incentive to do so because whatever they offer, they can only hope that an applicant will rank them higher than other programs. If the position could be offered outside the Match, the program will have a more re-assured return and have the ability to negotiate with the resident applicant.

But why can't they do this now? Why do we have to get rid of the match or make the match optional for programs to do this now? Why does the program need reassurance? (Although in your example they really have none since you can just drop them and take another spot that you interview at later).

The program wanting you and offering you a spot is equivalent to the program ranking you number 1-x where x is the number of positions available. Either way, they have no idea if you will take it or not. But at least you don't have to settle for your #2 location since you're not sure if #1 will ever offer you a spot. And if you don't think the programs won't act a bit threatening to fill those spots..."we're only going to give you 10 days to make this decision so you better decide now before your interview at Hopkins in 2 weeks...we've got plenty of applicants like you that want these spots"

 

[margaritaboy]

This thread has probably burned itself out.

But....

Final scenario:

Lawsuit successful, match becomes voluntary. Consequences:

1. Match becomes voluntary, applicants seek positions both in and out of the match without penalty.
2. As discussed above, the match outcome is essentially the same for both programs and applicants.
3. As discussed above, there is an added element of uncertainty.
4. As discussed above, there is NO increase in wages or benefits above normal inflation related adjustments.

Would NRMP-match supporters still oppose the suit if all the above turned out to be true? Just curious. All opinions welcome.

 

[Whodathunkit]

I don't mind the salary I'm paid now...I make more than alot of people.


You can't compare the fact that older doctors were paid even less. Older doctors I'm sure also don't owe in excess of $100,000 in loans for college/med school.

Times were different then.

 

[margaritaboy]

Originally posted by Whodathunkit
I don't mind the salary I'm paid now...I make more than alot of people.


You can't compare the fact that older doctors were paid even less. Older doctors I'm sure also don't owe in excess of $100,000 in loans for college/med school.

Times were different then.

Was your post a response to mine above? Or someone elses? I can't find a post that compares older doctors salaries with modern ones, nor their debt loads.

In any case I seem to be missing the point you are trying to make. Could you clarify?

 

[tofurious]

To Andrew: I didn't mean to be offensive, but I was responding to someone else's comments when you quoted me with "did you read my post?" That came across as accusatory, and I said NO.

Now that I've read your most recent post, I can almost say the same thing to you: did you read my post? I said that 1) the most prestigious places will not pay their residents more; and 2) there is competition at the best places for faculty even when their attending salary is very low compared to other places; what that does is to encourage people who are excellent academicians but who also need to make some $ to either pay back loan or support families to go somewhere else and make the non-Hopkins and non-MGHs better, which I think is good for medicine in general. And I was being half-sarcastic when I start using words like super stars. You made it sound like you asked for packages and therefore you were offered them. A systemic change should benefit both an MD-PhD from Hopkins and a MD from Wayne State, and whether you were personally offered packages is not a true indicator of whether these are common practices across the board.

mpp: you have obviously not seen some of the county programs where they are very often forced to take all FMGs to fill the spots, because of location. I think some of them would like to get more AMGs, and one way to do so is to offer the AMGs better overall packages to compensate for location/other shortcomings.

margaritaboy: opponents to the lawsuit are likely to still oppose the lawsuit, since that's what stern opponents do. They oppose.