Resident Lawsuit

[meerkat111]

As some one who worked at a malignant residency before, I can tell you- there is no way my children are going into medicine with the way things are. Some of you old "bears" out there may know how to avoid these places but losing productive years of your life to scut treatment, abuse, fianancial loss and loss of social network and relationships, no thanks. BTW, most physicians do not know how other careers really work. I have had many years in another career b/f medicine. Thus, I can tell you we get the raw end of the deal. I also feel betrayed by some of the older physicians not working to protect the profession (while continuing the tradition of abuse) by allowing hospitals become businesses and treating physicians like just another employee who works in "production" mode (esp primary care). Heck, you didn't even protect us from the mid -levels or floor nurses! Or from chiropractors, PAs and NPs becoming doctor-like! So, don't tell me there is nothing wrong with the current system. I would write more but I have to go study and prepare for my day so I don't get abused again.

---

Members don't see this ad.

 

[oldbearprofessor]

In addition to having different views of residency than I do, some of you have a different view of parenting. I have no idea how one could stop ones children from going into medicine if that is what they wanted to do. Beyond that however, I am immensely proud of my child(ren) who have chosen a medical career and believe that the current system of training physicians in the United States is fundamentally a good one, although, like everything, can use some improvement. Some of the ideas floated in this thread should be discussed broadly, but major changes need to be done cautiously. Short-term training positions have existed in Europe, I am very familiar with it in the UK. There are problems with that system for both hospitals and trainees. In the US, when one starts a categorical residency, now that pyramidal training programs are gone, one can be assured that if ones performance is deemed adequate (recognizing that uncommonly this is very poorly evaluated), that one has a paid job through the end of your 3-5 years training. As far as specific in-patient vs out-patient residencies, there are issues to consider carefully about this. Tracking med students into in-patient vs out-patient pediatrics as MS-4s is not ideal in my view. Furthermore, from a neonatology perspective, I would not want my entering fellows to have never done any outpatient training before starting. Understanding the f/u care of our babies is important, in my view.

 

[ThoracicGuy]

In addition to having different views of residency than I do, some of you have a different view of parenting. I have no idea how one could stop ones children from going into medicine if that is what they wanted to do. Beyond that however, I am immensely proud of my child(ren) who have chosen a medical career and believe that the current system of training physicians in the United States is fundamentally a good one, although, like everything, can use some improvement. Some of the ideas floated in this thread should be discussed broadly, but major changes need to be done cautiously. Short-term training positions have existed in Europe, I am very familiar with it in the UK. There are problems with that system for both hospitals and trainees. In the US, when one starts a categorical residency, now that pyramidal training programs are gone, one can be assured that if ones performance is deemed adequate (recognizing that uncommonly this is very poorly evaluated), that one has a paid job through the end of your 3-5 years training. As far as specific in-patient vs out-patient residencies, there are issues to consider carefully about this. Tracking med students into in-patient vs out-patient pediatrics as MS-4s is not ideal in my view. Furthermore, from a neonatology perspective, I would not want my entering fellows to have never done any outpatient training before starting. Understanding the f/u care of our babies is important, in my view.

Perhaps something could be done like with Thoracic Surgery training. We now have tracks - Cardiothoracic and General Thoracic. Both have requirements from both cardiac and thoracic sides of things, just the percentages are different between the two. Have an outpatient and an inpatient IM or Peds training tracks and then you have people focus on one or the other. It could be an option for people. Maybe even make the first year the same between both tracks and people have to pick one vs the other for their second year onwards.

 

[AStark]

I don't think these distinctions in training programs are all that meaningful. In Canada, Thoracic Surgery is a subspecialty of General Surgery, and Cardiac Surgery is its own thing entirely (though CV surgeons can do Thoracic fellowships). Now we also have a direct entry Vascular Surgery residency.

I'm not sure that these divisions are really all that helpful - and I can't fathom how any med student could decide to go into Vascular (unless they loved being around ASA 4s all the time...).

As for the inpatient vs outpatient thing, I really don't understand how these can be readily differentiated at the postgraduate training level. In Canada, Family Medicine is mostly outpatient based in terms of training - at least in principle - but also includes stuff like medicine wards, inpatient surgery and peds, though sometimes not any ICU or CCU. However, family physicians can do anything from pure office practice to a mix of rural emerg, low-risk obs, hospitalist work, or just about any other combination you can think of. More to the point, you don't really get to choose which undifferentiated patients need what kind of care, and one of the major points of learning in residency (for me at least) has been the development of my judgement about disposition.

 

[Perrotfish]

Furthermore, from a neonatology perspective, I would not want my entering fellows to have never done any outpatient training before starting. Understanding the f/u care of our babies is important, in my view.

This kind of justification for extra training is common in medicine, and I've always personally considered it bizarre. Its like saying that to be a good farmer, you need to understand how to be a chef, so that you can understand what happens with your food when you're done growing it. How does that alter what you do in your job?

Much more importantly, I don't really believe that neonatologists believe that this is important. If they did, they wouldn't be willing to hire NNPs without outpatient experience, which virtually none of them have. Apparently fellowship directors only think its a good idea to have this experience when it is, from the fellowships' perspective, free. That's the problem with residency in a nutshell: whenever the good idea fairy descends upon someone, there is no system in place to keep that half-notion from becoming the iron law of the land for the next generation of trainees. They have no skin in the game, when it comes to the cost of their ideas.

The magic of a free market system is that your ideas are culled by economic necessity. Are there top engineering firms only want candidates with relevant experience? Absolutely! But they need to pay for the experience, because experience costs money in the real world, so they mostly make sure that the experience is completely relevant. Very occasionally you will find a management track program that, for example, thinks its important for future civil engineers to spend a few months working on-site with contractors, but mostly they avoid it because a very quick retrospective analysis shows that those programs are like dumping money into a hole in the ground. Similarly any NICU should be able to decide what experience beyond medical school, if any, they want their applicants to have and their trainees should be able to negotiate their reimbursement to reflect that experience, or alternatively to go down the street to another NICU that has more liberal views about what constitutes adequate training. I think you would find that, if forced to pay for it, neonatologists wouldn't care about gen peds experience for physicians anymore than they currently care about it for NNPs.

 

[dyeguy21]

This kind of justification for extra training is common in medicine, and I've always personally considered it bizarre. Its like saying that to be a good farmer, you need to understand how to be a chef, so that you can understand what happens with your food when you're done growing it. How does that alter what you do in your job?

Weak Analogy. It's much more equivalent to a farmer needing to know how to plant, grow, and harvest their crops. Someone that can only grow my food, but not harvest it is of no use to me.

Also, if you don't think understanding a complete process from start to finish at some level is helpful...read any process management book, anything by Mark Cuban, anything by Mark Lemonis, Six Sigma, what a value chain is, SIPOC, etc.

Much more importantly, I don't really believe that neonatologists believe that this is important. Similarly any NICU should be able to decide what experience beyond medical school, if any, they want their applicants to have and their trainees should be able to negotiate their reimbursement to reflect that experience, or alternatively to go down the street to another NICU that has more liberal views about what constitutes adequate training. I think you would find that, if forced to pay for it, neonatologists wouldn't care about gen peds experience for physicians anymore than they currently care about it for NNPs.

Except that in your analogy of a free market the patient would also need all this information AND be able to understand it. Their choice would be what determines the level of training necessary provided by a facility (as they would want to attract the most patients). The problem being that people have limited choice as to their providers and thus a standardized training level ensures that a reasonable skill set has been obtained across the board.

 

[Perrotfish]

Weak Analogy. It's much more equivalent to a farmer needing to know how to plant, grow, and harvest their crops. Someone that can only grow my food, but not harvest it is of no use to me.

If growing and harvesting the food are two separate jobs, then yes, you don't need someone to understand one job to do the other. In fact, for that specific example, the people who harvest food are usually migrant laborers who have no clue what farming entails, and yet are somehow still useful. Much more importantly this is another excellent example of how the free market is able to determine what skills someone needs to do a job without the involvement of a federalized-nationalized-conglomerate-clusterf**k. Agribusiness has somehow been efficiently hiring new farmers, year after year, without a standardized program of farm training or a legally mandated standard for farming certification. Doctors can do the same thing.

Except that in your analogy of a free market the patient would also need all this information AND be able to understand it. Their choice would be what determines the level of training necessary provided by a facility (as they would want to attract the most patients). The problem being that people have limited choice as to their providers and thus a standardized training level ensures that a reasonable skill set has been obtained across the board.

In a free market training model, the patient isn't the one doing the hiring, a group of licensed physicians is. They decide what's a reasonable starting skillset to teach someone their trade needs, and the incentive for them to choose the right skillset is that they are legally on the line for the actions of whoever they hire, until such time as that person becomes licensed. So you still have an expert consensus as to what is a necessary skillset, but this time the experts are motivated to find a way to make the training efficient, as opposed to the current system where they have every incentive to make training as long as possible, and no particular incentive to make it high yield.

 

[dyeguy21]

In a free market training model, the patient isn't the one doing the hiring, a group of licensed physicians is. They decide what's a reasonable starting skillset to teach someone their trade needs, and the incentive for them to choose the right skillset is that they are legally on the line for the actions of whoever they hire, until such time as that person becomes licensed. So you still have an expert consensus as to what is a necessary skillset, but this time the experts are motivated to find a way to make the training efficient, as opposed to the current system where they have every incentive to make training as long as possible, and no particular incentive to make it high yield.

Missing the point. A "free market" as you describe requires that producers AND consumers have equal and perfect knowledge of utility, quality, and price. As we are specialized workers we have unique knowledge of our market and the average patient would not be able to understand the need for potential services.

Medicine is also a very self-protected industry with high barriers to entry (med school, residency, licensure, certification, repeat certification), high switching costs, and low to almost non-existent bargaining power of consumers. Thus, to maintain a high level of competitiveness in the market the industry prefers multi-talented, yet specialized doctors. As a worker in the industry it also benefits you to be able to fill multiple roles within your own field.

In addition having someone be legally culpable for actions of trainees imposes regulation on the market, thus making it a non-free market. A true free market in this situation would allow training programs to create unsafe doctors who would eventually be naturally checked and balanced out of the system.

 

[colbgw02]

In addition having someone be legally culpable for actions of trainees imposes regulation on the market, thus making it a non-free market. A true free market in this situation would allow training programs to create unsafe doctors who would eventually be naturally checked and balanced out of the system.

This was what I was thinking, although you said it better than I could have. I don't think people are willing to tolerate the variance that a free market for physician training would provide. The emotional attachment to seeing an avoidable bad outcome is different in medicine than in engineering (or other - maybe all? - industries), so I think the inevitable trend is to top-down, standardized training, which is pretty much what we see now. I'm not advocating for the status quo, and I think a lot of our regulation is wasteful and unproductive, but I'm not sure a true free market is the way to go. It's smells a bit like the crazy side of libertarianism.

 

[deleted480308]

Aside from my semi-joking comment before...

The real problem with any of these "let's sue!" threads is that suing is the nuclear option. If you are going to sue your residency program, you need to be 100% willing to walk away from medicine. Because it is a very likely that you will not get to finish your training at that program, and a very real possibility (probability?) that you won't be able to get another training position.

There are very few residents willing to take such a chance after 6-10 years of medical education and six figures of debt.

Yep my response to almost anything they do to me will be, "thank you sir, may I have another"

I have kids to feed, I'm not screwing with that

 

[Perrotfish]

In addition having someone be legally culpable for actions of trainees imposes regulation on the market, thus making it a non-free market. A true free market in this situation would allow training programs to create unsafe doctors who would eventually be naturally checked and balanced out of the system.

Which has nothing to do with any conversation that anyone is having in this thread. This is a conversation about a centralized/federalized
training system, like the one we have in medicine, and a decentralized one, like the one we have in engineering. So I'm not sure who you're arguing with.

The emotional attachment to seeing an avoidable bad outcome is different in medicine than in engineering (or other - maybe all? - industries), so I think the inevitable trend is to top-down, standardized training, which is pretty much what we see now.

This is a common assumption, but I think that the midlevels have done a tremendous job showing us that its not actually true. They have created a training system that is not only not top down, but which increasingly involves no training whatsoever. 2 years masters, go to work, be a doctor. Increasingly they're practicing under their own licenses on day 1. There has been no outcry, no inevitable move to a top down multi-year training system, if anything they keep pushing towards even earlier independent practice, and are moving into even more complicated fields.

Now personally I think that the movement away from any kind of formal training for a large portion of practitioners is not necessarily a particularly positive development for medicine. However I think that it, at the very least, shows us that our training system is not inevitable and that we have, in fact, moved way, way too far in the direction of formal training. It doesn't need to be this way

 

[calvnandhobbs68]

Missing the point. A "free market" as you describe requires that producers AND consumers have equal and perfect knowledge of utility, quality, and price. As we are specialized workers we have unique knowledge of our market and the average patient would not be able to understand the need for potential services.

Medicine is also a very self-protected industry with high barriers to entry (med school, residency, licensure, certification, repeat certification), high switching costs, and low to almost non-existent bargaining power of consumers. Thus, to maintain a high level of competitiveness in the market the industry prefers multi-talented, yet specialized doctors. As a worker in the industry it also benefits you to be able to fill multiple roles within your own field.

In addition having someone be legally culpable for actions of trainees imposes regulation on the market, thus making it a non-free market. A true free market in this situation would allow training programs to create unsafe doctors who would eventually be naturally checked and balanced out of the system.

Yeahh but try not to take it to the other extreme. It's pretty clear he's not talking about a perfect free market in the Economics 101 sense. He's speaking more about bringing more cost savings measures to bear on the training system. Almost nothing in America is a real free market anyway. The markets for many professional services (lawyers, engineers, stockbrokers, consultants, etc etc) suffer from many of the same limitations you talk about above. The real unique thing (that you also mention) that sets medicine apart from those services is the low bargaining power of consumers. People don't get a choice about what happens to them in many urgent (and even non-urgent, thanks to our insurance system) cases, so it should benefit the patient to have a well established baseline competency that doesn't vary much from place to place.

I don't even know what you mean about being able to "fill multiple roles within your own field". Nobody is ever going to expect a neonatologist to cover a gen peds clinic for a day...or ever. Just like nobody is going to expect the GI to go cover the general internal medicine clinic. In fact, increasingly within medicine maintaining a high level of competitiveness means specializing as far as possible.

 

[colbgw02]

This is a common assumption, but I think that the midlevels have done a tremendous job showing us that its not actually true. They have created a training system that is not only not top down, but which increasingly involves no training whatsoever. 2 years masters, go to work, be a doctor. Increasingly they're practicing under their own licenses on day 1. There has been no outcry, no inevitable move to a top down multi-year training system, if anything they keep pushing towards even earlier independent practice, and are moving into even more complicated fields.

I guess I'm just not convinced of this. Midlevels, particularly NPs, have quite slyly managed to push for independent practice, but they've managed to find an outlet for the responsibility that should come with that. I mean, we both work in a health care system where midlevels practice with a tremendous degree of independence as compared to most other systems, and they nearly categorically dump complicated patients to physicians the moment such complexity is discovered. I can tell you that my work on the side tells me that this is even more true in other places.

In other words, I'm thinking you haven't heard any outrage because it's still being, and will be, directed at physicians, because that's who remains in charge when things go bad. I know I'm talking #anecdotes here, but I'm sure the comparison to midlevels is apples to apples. In fact, I suppose I'm proposing that physicians may represent sui generis profession, so I'm not sure even looking at other healthcare workers' training would be instructive.

Again, I'm not arguing that the correct system is untouchable, but rather that it works reasonably well, and that we should be hesitant to make wholesale changes. The systems for engineers, nurses, or any other profession could work in medicine, too, I suppose, but I think there's a reasonable enough chance that it wouldn't that the risk is not justified. It reminds me of when my board, the ABR, decided to change its certification process for no apparent reason when the old system had worked well for decades. It's caused a lot of angst, confusion, and expense, with little appreciable benefit - and potentially some detriment to my field's physicians' ability to practice competently from day one.

 

[dyeguy21]

I don't even know what you mean about being able to "fill multiple roles within your own field". Nobody is ever going to expect a neonatologist to cover a gen peds clinic for a day...or ever. Just like nobody is going to expect the GI to go cover the general internal medicine clinic. In fact, increasingly within medicine maintaining a high level of competitiveness means specializing as far as possible.

Receiving only specialized training limits your options for employment. If we put into place a system where you only did inpatient or outpatient care on top of specialization, with no generalized training beforehand, the trainee would be extremely limited in their employment options. This is likely not an issue right now, but if hiring increases, scarcity sets in and those that are able to adapt due to their broad training experience will fair much better. That doesn't mean a GI covering a general clinic, it does mean having one that is capable of dealing with both inpatient and outpatient issues and settings which was in defense of oldbearprofessor's statement.

 

[Perrotfish]

Receiving only specialized training limits your options for employment. If we put into place a system where you only did inpatient or outpatient care on top of specialization, with no generalized training beforehand, the trainee would be extremely limited in their employment options. This is likely not an issue right now, but if hiring increases, scarcity sets in and those that are able to adapt due to their broad training experience will fair much better. That doesn't mean a GI covering a general clinic, it does mean having one that is capable of dealing with both inpatient and outpatient issues and settings which was in defense of oldbearprofessor's statement.

Except that the only reason we can't adapt to market changes in the first place is the stupid training system. When the market changes in other professions they just move to lower level positions in new fields. That is, again, what the midlevels are doing right now and what we could easily do. Say you left medical school and went to work in a GI clinic and get certified as a GI doc. Then that specialty overfills and you need to move into general medicine. In a decentralized training system, you just move. You find a job with a general medicine group, you work as an unlicensed provider for less money for a couple of years like a midlevel, and then you're certified in a new field. You only need to be trained in everything from the outset if you work in a top down federally funded centralized training system where you'll never get an opportunity to retrain.

And its not as though the general training we receive before specialization now really leaves us with a practical way back into general practice, if we specialize. Medicine advances quickly, skills degrade quickly when they're not used, and when you practice only your subspecialty for a few years you're not exactly qualified to jump back into to general practice. Do you think that aged neonatologists like oldbear could jump back into primary care Pediatrics and pick up where they left off? Prescribing aminophylline for asthma and dealing exclusively with type 1 diabetes? Do you think you would want a long time CT surgeon poking around your abdomen because he was gen surg trained 30 years ago? Would you want a long time nephrologist managing your sepsis on the ward? One of the many reasons I don't believe broad training is necessary is because the subspecialists who insist on it clearly don't feel its important enough that they need to practice to stay current. Its only important when its of no cost to them whatsoever.

Out of curiosity do you have any ideas on how to reform medical training? Do you think our training system is just the best of all possible worlds?

 

[AStark]

I'm struggling to understand the rationale for radically changing the training system - at least to that degree - and I *strongly* disagree that subspecialists invariably lose or don't have to use their generalist training. Your nephrologist example is particularly poor - certainly at my (Canadian) centre, IM subspecialists routinely cover general medicine call, and the nephrology group in particular tends to be pretty good. I'd go further and say that there is absolutely such a thing as excessive specialization, and the concept of a nephrologist who couldn't (or hadn't ever) managed straightforward sepsis is actually rather frightening. There's also a big difference between, say, a new-ish GI doc who doesn't know how to manage DKA comfortably because he never did an IM residency and a late career CT surgeon who simply hasn't done an LOA for an SBO in 30 years.

The other side of things is that certification standards give rise to a fairly natural monopoly of, well, training standards. A GI group may or may not want someone who is ERCP-trained, but they certainly will expect a standard level of endoscopic competence, to say nothing of an appropriate knowledge base.

In terms of the actual residency training process, your "free market" approach seems to go much too far in the other direction. It actually sounds unworkable, and if anything would require far greater resources to implement. A decentralized system will require decentralized preceptors and evaluation methods, and there is potential for even more heterogeneity and lack of compatibility than already exists. Is this really feasible? We employ centralization and standardization to avoid the costs of ending up with very unqualified people in practice and financial impact of a decentralized, disorganized training system .

Now, in Canada, the Royal College is embarking on residency training reform to move toward "competency-based" methods: http://www.royalcollege.ca/portal/page/portal/rc/common/documents/educational_initiatives/cbme.pdf

The implication is that residency training would no longer be of a fixed length and could be potentially shorter or, potentially, longer, depending on the trainee's progress. I am not sure of the implications for flexibility in changing specialties during or after residency, but it appears that it might be somewhat more flexible. Having said that, I favour returning to our former system prior to the mid-90s where most new MD grads completed rotating internships, qualified for general licensure, and subsequently practiced as GPs, started a specialty residency, or worked for a few years and returned later to become, say, an anesthetist. At that time it was common for people to start in one program and end in another; the overall effect is that we had far more generalists.

 

[oldbearprofessor]

Do you think that aged neonatologists like oldbear could jump back into primary care Pediatrics and pick up where they left off?

Aged? Like this? I'll take that as a complement! You don't know me and don't know what I might do outside the NICU setting including community service that I and/or other "aged" friends of mine might do. Additionally, I know lots of pediatric specialists of all forms who moved BACK into primary care or hospitalist type duty after finishing fellowship training.

And yes, as you know, I think that only relatively small improvements are needed in our residency training system for pediatrics (the field I know best). The development of "tracks" has been one of these. We could use to more clearly define procedural skills needed during residency and improve our training of pediatric residents in them. We also could use clearer training in evidence based medicine, quality improvement and some other specific areas. These things are coming or are in development/started in many programs.

 

[Perrotfish]

There's also a big difference between, say, a new-ish GI doc who doesn't know how to manage DKA comfortably because he never did an IM residency and a late career CT surgeon who simply hasn't done an LOA for an SBO in 30 years.

Why is this a big difference? They're both specialists, who practice as specialists. They're both currently incompetent as generalists. Why is it better to be incompetent because you were, once, competent 30 years ago? How does that make you a better specialist or generalist?

In terms of the actual residency training process, your "free market" approach seems to go much too far in the other direction. It actually sounds unworkable, and if anything would require far greater resources to implement. A decentralized system will require decentralized preceptors and evaluation methods, and there is potential for even more heterogeneity and lack of compatibility than already exists. Is this really feasible? We employ centralization and standardization to avoid the costs of ending up with very unqualified people in practice and financial impact of a decentralized, disorganized training system .

The key to making this work is to allow preceptors and evaluations to grow organically out of the corporate profit motive. The ever expanding number of 'core competencies' that residents are being evaluated on isn't really necessary for our training. Not that you don't need to be competent in all of them, but o define and assess each competency separately in a standardized way. I keep coming back to engineering because it proves that a simpler system also works. There are no standardized methods of assessing core competencies (at least that I am aware of). There is the requirement that you do the job for a period of time under a licensed provider and take a series of standardized exams. However there ARE standards, because during your training the licensed providers have to take responsibility for your actions, and when you become you generally continue on at the same job and they need to work with you. So the training is appropriate, despite not being nearly as standardized or regulated, and the bridges don't fall down. Midlevels are increasingly proving that this model also works in healthcare, and we could dramatically cut down on the misery and instability of our profession by following suit.

Aged? Like this? I'll take that as a complement! You don't know me and don't know what I might do outside the NICU setting including community service that I and/or other "aged" friends of mine might do. Additionally, I know lots of pediatric specialists of all forms who moved BACK into primary care or hospitalist type duty after finishing fellowship training.

I don't know what you choose to do (or how old you are), but I do know what neonatologists are required to do outside of the NICU to maintain their generalist certification, which is nothing. Not one day of general clinic/hospitalist practice out of every year. Of the neonatologists at the NICUs I have rotates through exactly none work in general pediatrics. While I have no doubt that your looks and personality age like wine, medical skills age more like milk, especially if you don't use them. If you do a lot of gen Peds volunteering that's great and you're possibly qualified to move back into gen peds if you want to. But you're not representative. More importantly if you felt that kind of experience mattered for neonatologists, you wouldn't want it to be optional for neonatologist to have to practice in clinic to maintain those skills. The face that so many neonatologists function excellently as neonatologists despite being 30 years out of date in their gen peds skills is a pretty good sign those skills aren't necessary.

As for the specialists who move back into primary care, after not practicing for 20-40 years, that actually brings up the other problem with our system. While its way, way too hard to get credentials in our system, its also way, way too hard to lose them. As long as you pay to take the tests you keep your board certification. Practicing just NICU or GI or Pulm for 30 years? Still certified. We maintain the legal fiction that these people are competent as generalists, then let them sink or swim when they jump back into a profession that they aren't qualified for in any meaningful way. A lot of them swim (we have some excellent ex specialists in my program) but it doesn't change the fact that a period of supervision would be more appropriate. A more organic system could also come with much more appropriate expiration dates for certifications that pracitioners aren't using.

Anyway its been an interesting discussion, its fun to see the range of opinions on this subject. I will get back to slogging through my own training now.

 

[AStark]

Why is this a big difference? They're both specialists, who practice as specialists. They're both currently incompetent as generalists. Why is it better to be incompetent because you were, once, competent 30 years ago? How does that make you a better specialist or generalist?

No, one of these specialists started their career incompetent as a generalist. There's also a big difference between someone who lacks generalist competence at the beginning of their career and someone who gradually loses comfort with specific procedures 30 years later. To take an example from my own training, I don't suture much more than a triple-lumen or a Cordis anymore; I'm sure my subcuticular stitches would be rusty.

You're not wrong that specialists (or subspecialists) who abandon generalist practice tend to become rusty (at minimum) over time. But it's also completely wrong to suggest that many or most specialists inevitably abandon generalist practice. I don't know what your specialty background is, but I don't find your comments terribly applicable to, say, IM.

 

[Gastrapathy]

Meh, the birdfishman isn't far off the mark for adult GI. You won't find many of us that are comfortable doing general IM anymore. It was one of the worst things about military GI for most of us.

 

[mercaptovizadeh]

Meh, the birdfishman isn't far off the mark for adult GI. You won't find many of us that are comfortable doing general IM anymore. It was one of the worst things about military GI for most of us.

Yes, but arguably some of the specialists (ID, renal, and pulm/CCM come to mind) would not be quite as lost if thrown back into a generalist/hospitalist role.

 

[Mass Effect]

So analogously, I think one could make a valid argument for shortening medical school to three years as well. Look at how many schools are already condensing their preclinicals into 1.5 years or less instead of the standard two years. And not that the second half of MS4 year wasn't fun, but it wasn't exactly the most high-yield part of med school in terms of educational value. With some med schools charging $50,000+ per year in tuition, why not lop off the wasted year and give people who need a way out of medicine a fighting chance to be able to afford to get out? Because even a residency salary is better than another year of taking out loans.

Before anyone can shorten med school to 3 years, residency selection needs to be completely revamped. There is no time during a three-year curriculum to sample specialties, get letters, and interview for residency, unless we shorten pre-clinicals to one year, which I don't really think is plausible. Doing all your pre-clinical courses and Step 1 in one year just seems like too much to me.

 

[calvnandhobbs68]

Yes, but arguably some of the specialists (ID, renal, and pulm/CCM come to mind) would not be quite as lost if thrown back into a generalist/hospitalist role.

"Not quite as lost" doesn't necessarily mean "as good as a generalist at it"...I think that's the point to be missed here.

 

[AStark]

Before anyone can shorten med school to 3 years, residency selection needs to be completely revamped. There is no time during a three-year curriculum to sample specialties, get letters, and interview for residency, unless we shorten pre-clinicals to one year, which I don't really think is plausible. Doing all your pre-clinical courses and Step 1 in one year just seems like too much to me.

There are two schools in Canada which have three-year curriculums. Basically they don't quite get real summers. Somehow it's been working out for a few decades.

 

[deleted109597]

Eh, my biggest issue of training is that you have a group of people who are required to work for a defined time frame. You want to finish college soon? Take more classes. Or take 6 years, whatever.
But in medicine, there's this perverse notion that somehow, magically, people aren't prepared to be on their own prior to exactly 3 years (or 4, 5, etc), but are perfectly able to do so the very next day. We all know residents who could practice on their own prior to graduation, and others who you hope move very far away so they don't take care of anyone you care about. But in the current system, you can't let those ready to leave do so, nor can you reasonably keep those who shouldn't behind.

 

[Mass Effect]

There are two schools in Canada which have three-year curriculums. Basically they don't quite get real summers. Somehow it's been working out for a few decades.

I don't know anything about those schools to know how they do it. Do they cram pre-clinicals into 1 year or are they shortening clinicals? That makes a difference to the discussion.

Eh, my biggest issue of training is that you have a group of people who are required to work for a defined time frame. You want to finish college soon? Take more classes. Or take 6 years, whatever.
But in medicine, there's this perverse notion that somehow, magically, people aren't prepared to be on their own prior to exactly 3 years (or 4, 5, etc), but are perfectly able to do so the very next day. We all know residents who could practice on their own prior to graduation, and others who you hope move very far away so they don't take care of anyone you care about. But in the current system, you can't let those ready to leave do so, nor can you reasonably keep those who shouldn't behind.

There are a certain number of requirements they have to meet. In college, you can do those requirements on your own because it's self-paced. Med school isn't self-paced and that's why they can't get through sooner. But either way, no one decides in college that you're ready to leave so you can. You still have to finish the requirements, whether or not you're the smartest person on campus.

 

[AStark]

I don't know anything about those schools to know how they do it. Do they cram pre-clinicals into 1 year or are they shortening clinicals? That makes a difference to the discussion.

They both do pre-clinicals in the first year and a half, with clerkship starting a bit more than midway through the second year. It's really about not having real summer vacations and compressing some other elements. I think ultimately it's better to have the extra year to figure things out re: residency choices, but people seem to do okay. (The schools are McMaster and Calgary, former being the origins of both PBL and the MMI.)

 

[Frederica]

Eh, my biggest issue of training is that you have a group of people who are required to work for a defined time frame. You want to finish college soon? Take more classes. Or take 6 years, whatever.
But in medicine, there's this perverse notion that somehow, magically, people aren't prepared to be on their own prior to exactly 3 years (or 4, 5, etc), but are perfectly able to do so the very next day. We all know residents who could practice on their own prior to graduation, and others who you hope move very far away so they don't take care of anyone you care about. But in the current system, you can't let those ready to leave do so, nor can you reasonably keep those who shouldn't behind.

There is an ortho program in Toronto, I think it's the University of Toronto, in which competency benchmarks determine when a trainee graduates. It has been very successful and most of their trainees have graduated a year sooner than the prescribed number of years necessary, if the program is supposed be completed in 5 years, their residents are completing it in 4.

I had the opportunity to speak with a mucky muck in ACGME earlier this week. He believes, as do I thus, this is the future of training. In the US, it is going to take many years before this will be implemented. Partly because we rely on X number of residents/year to handle patient care, and partly because we don't like change.

 

[Mass Effect]

They both do pre-clinicals in the first year and a half, with clerkship starting a bit more than midway through the second year. It's really about not having real summer vacations and compressing some other elements. I think ultimately it's better to have the extra year to figure things out re: residency choices, but people seem to do okay. (The schools are McMaster and Calgary, former being the origins of both PBL and the MMI.)

But it's not just about not having real summer vacations. It's also about doing two years of clinicals in less than a year and a half, going by your post. I don't know if that system could work with the American match system. Granted, we could speed everything up so that ERAS opens in June of 4th year and interviews start right away with the match in November, but doing it that way means that people not going into the core specialties will not have done a rotation in their chosen field. The other option is to reduce the amount of time in every rotation so that people get more electives during third year, but that means students will be doing aways/auditions during third year which may not be practical for hospitals OR students.

 

[rokshana]

But it's not just about not having real summer vacations. It's also about doing two years of clinicals in less than a year and a half, going by your post. I don't know if that system could work with the American match system. Granted, we could speed everything up so that ERAS opens in June of 4th year and interviews start right away with the match in November, but doing it that way means that people not going into the core specialties will not have done a rotation in their chosen field. The other option is to reduce the amount of time in every rotation so that people get more electives during third year, but that means students will be doing aways/auditions during third year which may not be practical for hospitals OR students.

really, please? you really think that we do a full 2 years of clinicals? no...pretty much anything done after match day is just biding time...

the bulk of meaningful clinicals is done before the interview season starts...

and exactly necessary are away or audition rotations? they don't necessary add something to your education unless your school does not have a resdiceny or fellowship in a certain specialty...audition rotations are just that...to allow you to make an impression at a program that you are interested in...if away rotations were done away with, core rotations shortened by a week and basics done in a year and a half (which many US schools have already implemented) and voila...3 years...

 

[Mass Effect]

really, please? you really think that we do a full 2 years of clinicals? no...pretty much anything done after match day is just biding time...

the bulk of meaningful clinicals is done before the interview season starts...

and exactly necessary are away or audition rotations? they don't necessary add something to your education unless your school does not have a resdiceny or fellowship in a certain specialty...audition rotations are just that...to allow you to make an impression at a program that you are interested in...if away rotations were done away with, core rotations shortened by a week and basics done in a year and a half (which many US schools have already implemented) and voila...3 years...

When, in anything that I've written, did I say we do 2 full years of clinicals? In fact, I said exactly the opposite -- that students spend a lot of time prior to the match doing audition rotations that they wouldn't be able to do if we shortened clinicals to one year, which is pretty much what you said. You want to get rid of auditions? Great! That was what I implied in my original post -- that the entire residency selection method needs to be revamped. Thank you for repeating my point. But no matter how much we wish we could get rid of aways, they're necessary.

Most people will not match into things like derm without auditions. Most people won't even have time to do a single rotation in it if we have a one-year clinical curriculum. And many schools do not have a derm residency or a neurosurgery residency or whatever else, so students have to do the rotation somewhere prior to applying.

 

[AStark]

There is an ortho program in Toronto, I think it's the University of Toronto, in which competency benchmarks determine when a trainee graduates. It has been very successful and most of their trainees have graduated a year sooner than the prescribed number of years necessary, if the program is supposed be completed in 5 years, their residents are completing it in 4.

The Royal College's plan is for all programs to follow this "competency-based" format. It's not really clear over what kind of timeline, though.

But it's not just about not having real summer vacations. It's also about doing two years of clinicals in less than a year and a half, going by your post. I don't know if that system could work with the American match system. Granted, we could speed everything up so that ERAS opens in June of 4th year and interviews start right away with the match in November, but doing it that way means that people not going into the core specialties will not have done a rotation in their chosen field. The other option is to reduce the amount of time in every rotation so that people get more electives during third year, but that means students will be doing aways/auditions during third year which may not be practical for hospitals OR students.

Well, in my ostensibly four-year program we did all our core rotations in a year, with electives and remaining rotations comprising about 21 weeks. The Canadian match timeline clumps all interviews into three weeks in late Jan to early Feb, but students still have to make up their mind to some extent by June of their year of application.

 

[Frederica]

It's mostly the former, really.

They swore that the "Milestones" would be a substantial move towards competency based training. Instead its a messy repackaging of the existing standards and all programs are doing is rewording their evals.

I think the milestones are great, residents know what is expected of them and faculty have to really review the residents based on the anchors described instead of ticking of excellent in every category because it's easier to do that than deal with a resident who is upset that the did not get all excellents. Residents can now be more responsible for their education. However, it has not been easy to implement them. It is my understanding that the ACGME realizes the milestones and the process will need to be continually tweaked. Some of my faculty really hate them, which I attribute not really understanding them, and really does not want to understand them. I do believe that in a few years milestones will be easier and more accepted in medical education.

 

[Frederica]

The Royal College's plan is for all programs to follow this "competency-based" format. It's not really clear over what kind of timeline, though..

I think the ACGME will be watching to see how successful this goes in Canada.

 

[killerleaf]

After listening carefully to what the ACGME has been saying about milestones, the end result will be that residency length will be dependent on performance on the milestones. So, instead of saying that an internal medicine residency is a 3 year thing, it may be possible to complete it in 2 1/2 or 2 years, if the resident is one that is progressing quickly. They expect the majority to complete in "established" time frames, with a minority of those ending earlier, (or later). But eventually, the "endpoint" will be more fluid, and not set in stone. They are finally recognizing that it is silly to say, June 30, you are a resident and must have supervision; July 1 you are now on your own; and they are working to make this better. There will be opposition; and there will be programs that will fight it tooth and toenail, and refuse to actually change. It will take time; it is not going to change overnight; but there is hope.

 

[JGimpel]

Welcome to organized labor. Yes, the govt. compensates hospitals with training programs fairly well, from what I've heard, and you will not be making what a person with a full license and DEA would get paid since they can't fully bill for your work, if you get any credit for it anyways. If you've only had part-time jobs until now and not worked for a corporation, you would find it difficult to hear about working 60 to 70+ hours per week and having your nights and weekends spoken for some times. Hospitals are a business first, healthcare provider second, no matter what ideas of altruism have been shoved into your head so far.

Most of us hate what they're doing or have done to us along the whole training process, but we're locked into the same crap most professionals are in until we've spent a few years in practice after our training. Newbies in most fields always get more and worse hours. All work well over 40 hours per week, probably 60-70 hours like we do, and for many years if they're trying to get into the partner track without having to buy in. Just as tenure track has a deadline by which you should have been approved, the same happens with partner-based practices and you're usually stuck if you haven't been terminated after the decision not to promote you has been made. An example of one of the most common requirements you'll see in medicine is to be Board Eligible at signing with the deadline of being Board Certified after a certain year of employment.

The CEO of any company is going to make a ton more than most people working there, and most of the people in the country. They are valued at these multi-million dollar salaries because there are very few people that can do their job well and they're responsible for millions to billions of dollars of assets and liabilities. I wouldn't mind a piece of it, no matter how crazy the execs get pait. But hey, it may be possible for a few of us many years down the line and I'm sure nobody would complain about it on SDN if it happened. Stay away from Medicare and Medicaid and you'll be earning towards the higher end of the spectrum soon after you can phase it out of your practice. If inpatient primarily, see what the minimum participation percent is required to have priviledges there, in addition to what Medicare and Medicaid require to be an approved provider to their programs, pick the lower of the two, add a 2 percent cushion and have your biller watch this like a hawk.

Not sure if it's still the same case, but AOA programs usually pay less than ACGME ones and highly desirable ones in either camp don't have to keep up with the salaries because they'll still fill even if they offer little compensation. That being said, with moonlighting it shouldn't be too difficult to make in the 60-75K area when adding up everything. I know some residents that are at over 100K now! That's why it's very important to find out what the moonlighting rules, especially as to how many hours you're allowed to moonlight per week/month and when you can start because that is what could truly make a difference in your income. Some shady programs won't let you moonlight but a few hours a week. Why? Because then they can make you work for free at their facilities, of course! Quietly ask around how likely you'll be able to do the "report first moonlighting job, don't report the second" scheme. Many programs will look the other way, others will terminate you if you do. If you can work at the VA and Correctional facilities, your income can be huge, so don't be discouraged.

Lawsuits against your own will end your career in medicine before it's even started. No physician will hire or respect someone that's gone against another one. That's the code and why an attorney advised a group of us not to become expert witnesses against another doctor. Fellowship and hospital staff are only a phone call away from your old program and you'll be blackballed if you do any of this stuff. It takes a minute or two to look up a doctor's active licenses and see where they work and whom to call to fill them in.

Make sure you ask about other perks, like when you can start doing home call, subsidized meals (it all adds up and you won't even want to grab a Lunchables from the fridge when you get really tired), how much your Research, Education, Conference funding is and what it covers, etc. BTW, if you plan on getting an expensive car right when you join residency or any big ticket items since you're now entitled because you're receiving some sort of pay, throw everything else out the window because you have just played yourself and everyone that sees this will know it. Hanging the key with the big BMW/Merc/Lexus symbol so it's always visible from you pants or labcoat or always throwing your keys down on the table as often as you can so people see them will loose you a lot of respect from the people you work with and may be writing your LORs for you.

It all comes down to this: Nobody owes you anything in this world. If you want anything, you'll have to work for it and accept the bumps in the road as part of your "time served" in organized labor.

PS: In my opinion, resorting to arcane Latin references just for fun is usually used by the med students to one-up each other in fully derailed threads. I refuse to look up what sui generis is : )

 

[colbgw02]

tl;dr

 

[nedi292]

here is something you can do https://www.change.org/p/robert-m-w...american-jobs-when-americans-qualify-for-them