Soon-to-be 60 hour resident work week limit?

[NotAProgDirector]

Yes and no. There are many more lawyers graduating per year, and there are a lot more "bottom of the barrel" types of law school positions. The competative nature of getting into medical school is roughly equivalent to that of getting into a top 50 law school, which is where I am making the comparison. I can tell you as someone who knows MANY lawyers, that the clients don't always pay. The system just makes more sense. There are specific public defenders and legal aid groups that intentionally go into charity law. No one expects every private law office to answer to the government's billing system or accept legal insurance or see people who have no intention of paying. Collections are variable from firm to firm and are often based on the success of the case in a lot of personal injury, a truly valid form of pay for performance.

Law is not the same, but it's the closest example.

As far as three years, I actually suspect that by eliminating the first summer, we could cut a few months off of preclinicals and add some clinical electives to the third year with the extra time. You wouldn't need a $30,000/year of tuition + $15,000 in travel costs to interview, because the whole match system wouldn't exist. Residencies would no longer be required. You would interview and accept (or reject) a training position as though you were applying to any other job. As someone who could become licensed and practice general medicine at this point, you will be on much more equal footing when applying to residency (if you even choose to do that).

I can tell you that my medical school has thoroughly trained me to deal effectively with ~99% of outpatient complaints. A year of TY type training would be more than enough for me to handle basic urgent care type medicine and enough to handle basic outpatient management of chronic disease. I would get better over time just like ANY OTHER professional. Now, those that wanted to specialize could do residency. Those that wanted broad FP scope type generalism could do residency. Those that just wanted extra experience could do it, but by making it no longer required, it would probably become much more reasonable. Pay would be better, hours would improve in most specialties to attract people, but the training would have to be good enough, or they'd just leave. No more getting stuck with your program for a license.

Occasionally a program may have greater work hour requirements. In this type of system, no overarching hours mandate is necessary. The market would dictate conditions. In surgery, nothing would stop you from scrubbing that extra case, and a program that created too much scut for its residents would have trouble without its monopoly mandate in continuing to function, so the residents might actually have time to do the extra case. Of course, if the program requires more than 80 hours, and the resident wants to work it, there is really no reason that it shouldn't be allowed. Of course, the program opens itself up to liability.

First, I really know nothing about law except for what I see on TV and read about in "1L". Assuming that stuff is just as ridiculous / inaccurate as any of the medical shows on TV, I really know nothing. I shouldn't have mentioned it.

About re-designing medical education, that I'm happy to discuss. I find your statement "I can tell you that my medical school has thoroughly trained me to deal effectively with ~99% of outpatient complaints." very interesting. I think it depends on what we're talking about. If you mean seeing healthy patients with a cough, or a sprained ankle, etc, then yes I think that might be possible. However, my clinic today was:

1. a 68 yo female immigrant from Germany who was recently discharged from an inpatient psych stay presenting for followup with multiple complaints.

2. a 34 yo male newly diagnosed with diabetes, severely obese, recently discharged for severe bilateral cellulitis, comes to be seen for new insulin management.

3. a 64 yo male returning for diabetes management, wondering about the pros/cons of exenatide.

4. A 72 yo female with acquired CVID and oral lichen planus following up for those issues, and new dysphagia.

(Short add-on clinic, only 4 patients)

I know for a fact that I couldn't possibly have handled this coming right from medical school. Perhaps you can, but I think that would be the exception rather than the rule.

However, with some redesign this could be possible. I could see a few ways to do this:

1. Create a track for people only interested in outpatient GIM care from the start. Minimize inpatient rotations. Honestly, you could probably shortcut much of the biochem and physiology, and shorten the training. Include some sort of practical clinical training.

(Actually, I think this exists. It's called PA School)

2. You could leave med school much the same, except for fourth year. You could give students the option of doing a practical, outpatient GIM fourth year (internship, essentially). This would be at / organized by the medical school and guaranteed, and would qualify you for licensure (but not board certification). Completing this, you could practice outpatient medicine -- there could be adult, pediatric, GYN tracks, maybe more. Or, you could enter the match looking for more intense training, more inpatient focused. If you fail to match, then perhaps there's a way to "bail out" and get back into the practicum year (although it might need to be extended due to the time you missed)

Medical schools may not have the resources to do this. Also, it may not do anything helpful unless we close IM, FP, GYN etc residencies --- if all current residencies stay open / same size, then if you choose the shortcut you might find that no one wants to hire you / no insurance company will pay you / etc. It would raise the question of the difference between someone who completes an IM/FP residency and wants to practice outpt medicine, and someone who chooses the practicum year.

Whether or not the match is the "right way to go" is a very complex question, addressed in many other threads. Honestly, if you get rid of the match you simply trade one set of problems for another, creating new winners and losers. As I have said before, the real problem here is our dependence on resident work -- if I could somehow cover all days / nights / weekends with non-residents, then I could take any number of residents into my program and teach them. If someone drops out, no problem -- no more work for everyone else. It's expensive, difficult to implement, may worsen the quality of resident training, and might lead programs to close altogether if residents aren;t needed.

I'm rambling now.

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[Tired]

As I have said before, the real problem here is our dependence on resident work -- if I could somehow cover all days / nights / weekends with non-residents, then I could take any number of residents into my program and teach them. If someone drops out, no problem -- no more work for everyone else. It's expensive, difficult to implement, may worsen the quality of resident training, and might lead programs to close altogether if residents aren;t needed.

This is a fascinating statement for a variety of reasons, not the least of which being that you are actually in charge of a residency training program.

What precisely is the problem with "dependence on resident work"? We have always trained physicians through apprenticeship, ultimately formalized into residency training programs. Presumably this grew out of a recognition that simply reading about human disease and injury was insufficient to develop real physicians, and the recognition that intangible qualities like "clinical judgement" are formed from experience, not didactics.

I will go out on a very big limb here (seeing as I'm an intern) and suggest that, if you did not depend on resident work, you could not teach them. I believe that the "work" is not ancillary, it is the cornerstone of the medical education process. No amount of observation or formalized lesson plans can ever substitute for seeing your own patients, taking ownership, making decisions, and even filling out the paperwork that goes along with it.

 

[Trifling Jester]

This is where things get really tricky. The scut listed above is completely unacceptable. In IM, it is completely forbidden by our accreditation rules. However, there is lots of "pseudo-scut" -- things that have some but little value. Discharge summaries are a good example -- you clearly need to know how to do them, but how many do you have to do to get good at them? Calling radiology to get a CT for your patient -- you could have a secretary do this, but what happens when the schedular on the other side says "We can do it in 6 hours", is that good enough? If you call yourself, you can triage how important it is. How to offload this from residents is unclear -- each resident could get a "personal assistant", but again it's unclear if this would really help.

That type of scut absolutely happens at residency programs throughout the nation, forbidden or not. Cutting the residency hours would likely push those programs to hire more/better ancillary staff.

As mentioned in another post, there are other types of scut that do not offer any educational value whatsoever. (I do not include DC summaries in this)

There are a myriad of totally useless forms mandated by jaco which fall to the resident to complete. Then the various hospital committees add more forms on top of them. There are "medicine reconcilliation forms," special forms for imaging, antibiotic forms, bed request forms, consent forms, etc etc etc. These should all be filled out by someone else. Residents don't learn by filling out forms.

-The Trifling Jester

 

[gutonc]

Note that aPD didn't say that residents wouldn't work, he just said "dependence on resident work" which is different. If residents disappeared from most teaching hospitals, the hospitals would very quickly grind to a halt. There are models out there where the gruntwork is done by mid-levels and the actual medicine is done by trainees. My (soon to be) Onc fellowship program works like this on the inpatient side of things. PAs and NPs essentially function as the interns on the service and the fellows act as a mix between senior resident and junior attending, making most of the treatment decisions, answering questions that the mid-levels have, calling consults, etc. There used to be house staff on the service instead of the mid-levels but the concensus among both the Onc and IM folks was that it was a pure scut service w/ minimal teaching. So now the scut is done by people who are just there for a paycheck which leaves time for actual learning on the part of the fellows. It's not a perfect system by any means (for one thing, I think there must be a law against PAs and NPs working on weekends so the fellows have to completely cover the service over the w/e) but it's certainly a model that works reasonable well in (admittedly) a very specific circumstance.

Honestly, what do you learn by running around writing down vitals and med lists, chasing after nurses who haven't given STAT meds and calling to ask the lab why the 0530 Chem7 isn't back @ 1000? You (the surgeon) learn the most in the OR, I (the internist) learn the most in reviewing data (labs, imaging, studies, etc) and formulating further diagnostic and treatment plans.

Pay people to do the scut, let the residents do the learning...I think that's what aPD was trying to say.

 

[Trifling Jester]

Surgery needs to cut a lot of the BS off. Have medicine admit most of their patients and manage them... they only do the surgery and drop them back to the main medicine team. Check on them occasionally and if need be, get called to retake them to the OR. This would cut down on sooo much time of the G-Surg.

I routinely refuse these types of admits. There is no learning involved in continuing home medications, and the medicine service would not benefit from this type of setup.

-The Trifling Jester

 

[elwademd]

I routinely refuse these types of admits. There is no learning involved in continuing home medications, and the medicine service would not benefit from this type of setup.

-The Trifling Jester

what do you want to do after residency?

the reason i ask is that many hospitalist programs expect a hospitalist to admit, follow, and manage these patients... outside of actually going to the or of course.

and in clinic, you never know what may show up as a walk-in, or as a scheduled visit either, and hopefully you'll at least have some "purely surgical" things/issues in your differential.

i suppose the benefit of doing it in residency is the experience you'll build and knowing what to do/expect post residency life.

 

[chromophobe]

Are you sure you want to let market forces control this? I get one email each week from an IMG offering to do a residency for free.

Jesus that's insane. I'm not sure I understood Tiger26's point, but what about the match prevents you hiring these IMGs now that wouldn't under a free market? I know the EU and Canada have formal guidance against hiring foreigners, but I didn't think the US did.

 

[Faebinder]

Jesus that's insane. I'm not sure I understood Tiger26's point, but what about the match prevents you hiring these IMGs now that wouldn't under a free market? I know the EU and Canada have formal guidance against hiring foreigners, but I didn't think the US did.

They would not get ACGME certified positions cause ACGME has already determined how many residents a place is allowed. Sure they can hire them but that wont get them a "certified" year.

 

[chromophobe]

What I meant was, why not hire them through the match for those spots and pay them peanuts? Is there a legal minimum wage for ACGME residency spots?

 

[Faebinder]

What I meant was, why not hire them through the match for those spots and pay them peanuts? Is there a legal minimum wage for ACGME residency spots?

yup..

 

[shawred]

1. Create a track for people only interested in outpatient GIM care from the start. Minimize inpatient rotations. Honestly, you could probably shortcut much of the biochem and physiology, and shorten the training. Include some sort of practical clinical training.

(Actually, I think this exists. It's called PA School)

Before I read the final statement in parentheses, I was thinking the same thing--"Don't we have PA school?"

 

[Tired]

There are models out there where the gruntwork is done by mid-levels and the actual medicine is done by trainees. My (soon to be) Onc fellowship program works like this on the inpatient side of things. PAs and NPs essentially function as the interns on the service and the fellows act as a mix between senior resident and junior attending, making most of the treatment decisions, answering questions that the mid-levels have, calling consults, etc.

See, I don't think this is a very good system at all.

1) You have cut out interns and junior residents from seeing your patients at all.

2) Much of the "scut" you describe is only considered scut by fellows and senior residents. These are actually chances to learn for an intern or junior resident, even if somewhat painful.

I have been on services with good PAs and NPs. What ended up happening was that the mid-levels would write most of the notes and do the bedside procedures, because they could bill for them directly. I would sit around most of the day, and was really only there to fill out the call schedule. The system you describe does not sound like a good way to teach, it sounds like a method of further devaluing residents and cutting them out of actual patient care activity.

 

[Faebinder]

See, I don't think this is a very good system at all.

1) You have cut out interns and junior residents from seeing your patients at all.

2) Much of the "scut" you describe is only considered scut by fellows and senior residents. These are actually chances to learn for an intern or junior resident, even if somewhat painful.

I have been on services with good PAs and NPs. What ended up happening was that the mid-levels would write most of the notes and do the bedside procedures, because they could bill for them directly. I would sit around most of the day, and was really only there to fill out the call schedule. The system you describe does not sound like a good way to teach, it sounds like a method of further devaluing residents and cutting them out of actual patient care activity.

I agree with Tired and I agree that much of the scut is regarded as "scut" by senior residents and fellows not the interns who are just getting around the system. At the same time, there are many programs that translate pure scut up the ladder.

Seriously, anything to do with discharge issues (damn rehabs, placement, can't get a friggin ride, can't discharge after 11 am cause insurance wont pay, arrange for VAC/insulin/Followups Appointments... blah blah blah blah).. that all makes for more scut.

 

[Trifling Jester]

what do you want to do after residency?

the reason i ask is that many hospitalist programs expect a hospitalist to admit, follow, and manage these patients... outside of actually going to the or of course.

That's fine. The private physicians can get paid to do the HP and DC summary and write some vitals down every day. But there's no learning involved in that, and I don't think it's something a residency program should tolerate.

and in clinic, you never know what may show up as a walk-in, or as a scheduled visit either, and hopefully you'll at least have some "purely surgical" things/issues in your differential.

i suppose the benefit of doing it in residency is the experience you'll build and knowing what to do/expect post residency life.

Refusing to admit surgical patients onto the medicine service doesn't keep you from learning about acute abdomens etc. You can always follow as a consult (if they really need help managing a medical issue), and as you've mentioned above you'll see all kinds of presentations in clinic.

-The Trifling Jester

 

[NotAProgDirector]

This is a fascinating statement for a variety of reasons, not the least of which being that you are actually in charge of a residency training program.

What precisely is the problem with "dependence on resident work"? We have always trained physicians through apprenticeship, ultimately formalized into residency training programs. Presumably this grew out of a recognition that simply reading about human disease and injury was insufficient to develop real physicians, and the recognition that intangible qualities like "clinical judgement" are formed from experience, not didactics.

I will go out on a very big limb here (seeing as I'm an intern) and suggest that, if you did not depend on resident work, you could not teach them. I believe that the "work" is not ancillary, it is the cornerstone of the medical education process. No amount of observation or formalized lesson plans can ever substitute for seeing your own patients, taking ownership, making decisions, and even filling out the paperwork that goes along with it.

We agree here 100%. The only way to learn medicine is by doing it. Watching it, reading about it, simulating it, dreaming about it, portfolios, curricula, learning plans, etc -- that's all fine, but they don't really build the skills you need.

As mentioned above, scut is relative. Some scut has no learning value -- transporting patients, for example. Much of what we talk about as scut has some learning value -- discharge summaries, drawing blood, etc. These are skills that are (perhaps) useful. In a perfect world you'd do enough of them to become good at them, then let someone else do them and move onto somewhere else. This usually doesn't happen.

A good example of what I was trying to point out is this: Let's say we have an inpatient service that has three interns on it, and that the patient load is perfect the way it is. The service is q3 call. With the new duty hours, clinic requirements, etc, it's essentially impossible to leave q3 call in place, so I want to switch to q4 call.

I don't have many good options. I could put a 4th intern on the service, making it q4. However, now each intern's caseload drops, and I have to remove an intern from somewhere else (i.e. the fourth intern has to come from somewhere. If my program isn't getting any bigger, then some other service loses somebody). Alternatively, I could have an orphan intern from another service take the q4 call, or perhaps randomly distribute those calls to interns on electives/outpatient -- but that doesn't make much educational sense.

I can try to make fellows cover.

I can moonlight it. That really fixes the problem, however it's really expensive and isn't a great longterm fix.

But I agree with your overall argument. That's why you learn more as an intern than as a medical student. As an intern, the buck stops with you. They're your patients, and if you don't take care of them, no one will... (not exactly, but you get the point).

 

[elwademd]

That's fine. The private physicians can get paid to do the HP and DC summary and write some vitals down every day. But there's no learning involved in that, and I don't think it's something a residency program should tolerate.

Refusing to admit surgical patients onto the medicine service doesn't keep you from learning about acute abdomens etc. You can always follow as a consult (if they really need help managing a medical issue), and as you've mentioned above you'll see all kinds of presentations in clinic.

-The Trifling Jester

i brought up those points because some people, after residency, don't have any level of comfortablity with those things, and then feel unprepared in post-residency life when they are expected to do those things.

 

[Tired]

I don't have many good options. I could put a 4th intern on the service, making it q4. However, now each intern's caseload drops, and I have to remove an intern from somewhere else (i.e. the fourth intern has to come from somewhere. If my program isn't getting any bigger, then some other service loses somebody). Alternatively, I could have an orphan intern from another service take the q4 call, or perhaps randomly distribute those calls to interns on electives/outpatient -- but that doesn't make much educational sense.

To me, call is the most educational part of internship. I can read, I see a ton of patients, I write a lot of notes very quickly, and actually make decisions that I can followup on to see if I was right.

The problem isn't the call, it's the pre-call days. Your interns need to write notes faster, put orders in faster, and you need to get through rounds faster. I did a month in the ICU (at capacity the entire time, of course) on q3 overnight call, complete with rounds every morning and didactics every day, and still managed to stay under 80hrs.

It can be done, you just have to find a way to convince your staff that "clinical teaching" does not have to involve 6hrs of verbal diarrhea every g**d*** morning.

 

[elwademd]

To me, call is the most educational part of internship. I can read, I see a ton of patients, I write a lot of notes very quickly, and actually make decisions that I can followup on to see if I was right.

The problem isn't the call, it's the pre-call days. Your interns need to write notes faster, put orders in faster, and you need to get through rounds faster. I did a month in the ICU (at capacity the entire time, of course) on q3 overnight call, complete with rounds every morning and didactics every day, and still managed to stay under 80hrs.

It can be done, you just have to find a way to convince your staff that "clinical teaching" does not have to involve 6hrs of verbal diarrhea every g**d*** morning.

agreed. there are times when rounds are a bit overboard. while i understand it is important to see a patient with the attending and talk about the patient, it's not always prudent to go down an exhaustive list of causes of anion gap acidosis in a diabetic with ketotic breath who told you in the er that he stopped taking his insulin last week.

oftentimes, i'd much rather hear practical approaches to cases or treatment plans, than to discuss some esoteric information that doesn't change the treatment plan.

 

[Tired]

And if call is really the issue, why aren't programs that utilize PAs and NPs switching them from day time work that can easily be accomplished by the multiple residents available, and moving them to nights where they can divide up call?

I'm not advocating this, because as previously mentioned, I think call is vital to my own education. But there is a general undercurrent from many residents and staff that call is a non-educational bureaucratic requirement. Yet other than one neurosurg program I spent time with, I have yet to see anyone put the PAs and NPs on the wards at night. What are they doing in clinic seeing patients, and writing daily notes, and coming to rounds? Why aren't they doing call?

Oh yeah, billing . . .

 

[Miami_med]

I agree with Tired and I agree that much of the scut is regarded as "scut" by senior residents and fellows not the interns who are just getting around the system. At the same time, there are many programs that translate pure scut up the ladder.

Seriously, anything to do with discharge issues (damn rehabs, placement, can't get a friggin ride, can't discharge after 11 am cause insurance wont pay, arrange for VAC/insulin/Followups Appointments... blah blah blah blah).. that all makes for more scut.

In a system where residents could be licensed without the current residency setup, those that chose to pursue residency training could bill for procedures on behalf of the program directly. In fact, It's a only a bizarre set of arbitrary rules that prevents licensed residents from doing this now. It would be illegal for me as a surgical chief resident to do a cholecystectomy without an attending present for the important parts of the procedure. However, it would be legal, though not practical, for me to drop out of my program, open a surgicenter and do the whole procedure and bill for it without an attending at all. The residency system is just too regulated, and that's the point. However, deregulation would never work without changing the system back to being practically optional.

 

[Miami_med]

First, I really know nothing about law except for what I see on TV and read about in "1L". Assuming that stuff is just as ridiculous / inaccurate as any of the medical shows on TV, I really know nothing. I shouldn't have mentioned it.

About re-designing medical education, that I'm happy to discuss. I find your statement "I can tell you that my medical school has thoroughly trained me to deal effectively with ~99% of outpatient complaints." very interesting. I think it depends on what we're talking about. If you mean seeing healthy patients with a cough, or a sprained ankle, etc, then yes I think that might be possible. However, my clinic today was:

1. a 68 yo female immigrant from Germany who was recently discharged from an inpatient psych stay presenting for followup with multiple complaints.

2. a 34 yo male newly diagnosed with diabetes, severely obese, recently discharged for severe bilateral cellulitis, comes to be seen for new insulin management.

3. a 64 yo male returning for diabetes management, wondering about the pros/cons of exenatide.

4. A 72 yo female with acquired CVID and oral lichen planus following up for those issues, and new dysphagia.

(Short add-on clinic, only 4 patients)

I know for a fact that I couldn't possibly have handled this coming right from medical school. Perhaps you can, but I think that would be the exception rather than the rule.

However, with some redesign this could be possible. I could see a few ways to do this:

1. Create a track for people only interested in outpatient GIM care from the start. Minimize inpatient rotations. Honestly, you could probably shortcut much of the biochem and physiology, and shorten the training. Include some sort of practical clinical training.

(Actually, I think this exists. It's called PA School)

2. You could leave med school much the same, except for fourth year. You could give students the option of doing a practical, outpatient GIM fourth year (internship, essentially). This would be at / organized by the medical school and guaranteed, and would qualify you for licensure (but not board certification). Completing this, you could practice outpatient medicine -- there could be adult, pediatric, GYN tracks, maybe more. Or, you could enter the match looking for more intense training, more inpatient focused. If you fail to match, then perhaps there's a way to "bail out" and get back into the practicum year (although it might need to be extended due to the time you missed)

Medical schools may not have the resources to do this. Also, it may not do anything helpful unless we close IM, FP, GYN etc residencies --- if all current residencies stay open / same size, then if you choose the shortcut you might find that no one wants to hire you / no insurance company will pay you / etc. It would raise the question of the difference between someone who completes an IM/FP residency and wants to practice outpt medicine, and someone who chooses the practicum year.

Whether or not the match is the "right way to go" is a very complex question, addressed in many other threads. Honestly, if you get rid of the match you simply trade one set of problems for another, creating new winners and losers. As I have said before, the real problem here is our dependence on resident work -- if I could somehow cover all days / nights / weekends with non-residents, then I could take any number of residents into my program and teach them. If someone drops out, no problem -- no more work for everyone else. It's expensive, difficult to implement, may worsen the quality of resident training, and might lead programs to close altogether if residents aren;t needed.

I'm rambling now.

I think we can all agree that your patients don't represent the bulk of outpatients in the community. That being said, there is no reason why 15 months of true clinical training followed by a second full year of internship wouldn't be enough to handle most of that. My experience (which is admittedly limited though it encompasses both the private and academic worlds) is that most of those patients would at the very least have specialist consults covering the major problems in the private world.

I was at a private office the other day. We saw:

Guy with gonorrhea, guy with depression, lady with DM and HTN, Guy with DM and neuropathy, and some other similar cases.

I am perfectly capable of seeing these patients now. Now I realize that there are some zebras, and I'm not advocating that I open my own practice today. However, I think that another year of internship (which is what I am advocating replacing a fourth year with), in which you DO have responsibility would probably do it. Would I be inexperienced? Yes. 50 years of residency would leave you inexperienced on your first day truly on your own..

With regards to keeping all residencies open, the market should determine that. The insurance companies largely follow medicare, and the hospitals are afraid to hire non-boarded doctors largely as a result of the legal environment, both of which are other problems. Our training system shouldn't be designed to keep on the right side of the lawyers, who will just continue to abuse it anyway.

Once upon a time, someone graduating from med school was a doctor, who could go practice medicine. An internship makes some sense, but this is really part of the schooling, and it should be required. All we are doing now is hyper-specializing everyone to such a degree, that we don't make any real money until our mid-30s or later, and the utility of having someone big toe fellowship trained outside of the biggest of academic centers is highly questionable. Do specialists get better outcomes much of the time? Yes, but this is progressively marginal. What's the difference between a breast surgeon and a general surgeon in a simple biopsy? What's the difference in efficacy of DM control between an FP, internist, or endocrinologist in most diabetics. It is probably not huge. We should really question if it's worth essentially flushing all of our trainees down a highly regulated toilet in which they will slave away doing scut work for $9.00/hr, because like it or not, that's what's happening a lot now.

Now, I expect that most will still specialize. The less regulated residency system however would both have to compete and would be employing DOCTORS (which they do now, but no one seems to remember now). They should be able to bill for procedures. We already admitted that the PA can do this, so why can't a resident in a non-ridiculous system? There's nothing wrong with an agreement in which the resident takes a salary and turns over this money to the program, but this could all be worked out privately between two people who make a valid agreement.

I'm all for residency. I have a generalized specialty (but a specialty) in mind. I'm afraid that the current system will essentially destroy my training. By forcing everyone into residency, we are often making people overtrain, and we are DEFINITELY making people agree to contracts that are not in their best interests by putting all power in the hands of the program. Residents that have nowhere else to turn are invoking all sorts of outside powers, and whether it be 80, 60, 40 or any other arbitrary number of hours that ends up being set, none of it is actually based on helping me or my patients. It's all arbitrary. It's really becoming something like this:

Become doctor---> Must get through residency to practice---> Not liking work/pay ratio---> Complain ----> Residency modified by some outside force----> All residents lose autonomy and training benefit----> Still working for low money and now getting less education-----> Still underpaid----> Repeat.

 

[DarksideAllstar]

120 hours! 80 hours! 60 hours! Gaah! How about just three 12s a week! Are ALL residency hours per week that long? And is that just for the first year, or the whole residency? I think I may have erred...

How can you possibly fit in 120 hours a week? 20 hour days seven days a week? That's ridiculous! Seriously!

I am on a fairly busy rotation (hemepath) in pathology (which is notorious for being an 8-5 gig) and over the last 4 weeks I have easily worked 60hrs/week (and thats with 10 minute lunches). This weekend I am on call, so you can tack on another 8-10 hours of being in-house to that. On some of our other rotations (surg path), you can easily work 70 hrs a week . This gets marginally better as you progress through 4 years (ie you become more efficient). I guess the short answer to your question is: yes, most residents probably work 60 hours per week.

 

[elwademd]

The insurance companies largely follow medicare, and the hospitals are afraid to hire non-boarded doctors largely as a result of the legal environment, both of which are other problems. Our training system shouldn't be designed to keep on the right side of the lawyers, who will just continue to abuse it anyway.

just to clarify, not all hospitals hire physicians.
in the state of california, the only physicians that are allowed to actually contract with hospitals are er docs and pathologists (because of state law prohibiting the practice).

in other states, including california, there are plenty of physicians that are hired by groups/healthcare organizations/hmo's/etc. that have privileges granted/extended to them by the hospitals within which they work.

the aim for most of these entities is to employ board certified physicians, but there are plenty of physicians that work without having passed their respective boards... ever.

 

[Miami_med]

just to clarify, not all hospitals hire physicians.
in the state of california, the only physicians that are allowed to actually contract with hospitals are er docs and pathologists (because of state law prohibiting the practice).

in other states, including california, there are plenty of physicians that are hired by groups/healthcare organizations/hmo's/etc. that have privileges granted/extended to them by the hospitals within which they work.

the aim for most of these entities is to employ board certified physicians, but there are plenty of physicians that work without having passed their respective boards... ever.

Fair enough

I should have said allow physicians hospital priveleges.

The trend is towards requiring certification, to the point where almost every graduate thinking of going into some sort of general practice today wouldn't even dream of failing to finish residency and get certified.

At a hospital near me for example, both IM and FM physicians are essentially on a rotatory call schedule for the hospital, which will call either and treats them the same. The FM physician, who has ~ a year (if that) of directed IM training, is allowed to admit to the medicine floor, but someone who has completed a medicine internship with equal to more training in that particular area is not. This is just an example.

 

[NotAProgDirector]

I think we agree more than we disagree.

I agree that my clinical experience is not representative of the vast majority of the country, and it's unfair to generalize.

I agree that if we had a 1 year, outpatient only (or minimal inpatient) experience for medical students in place of the MS4 year, then they could be competent outpatient docs for basic issues.

The problem I see is that these MD's are going to have a very difficult time competing in the future marketplace with PA's, NP's, and the new DNP/DPA (or whatever it;s called) that are being created.

Like it or not, Internists are being outsourced, just like auto manufacturing jobs. Several threads on this board lament this fact, that "docs of today are selling out the fortunes of the docs of tomorrow" -- I look at this as the natural evolution of the marketplace. All jobs in all fields are slowly being rendered obsolete. Polaroid didn't go out of business because of the fact that digital imaging made instant photography pointless -- it went out of business because it failed to adapt. (Note: actually, I have no idea why Polaroid went out of business, but I thought that sounded cool)

We have two choices -- keep going the way we are and suffer the same fate as those in Detroit, or innovate / remake our field to remain competitive. How to do so remains the challenge. We need to provide a service that is different enough from what PA's and NP's do so that the market is willing to bear the additional costs. As others have mentioned, I see that the basic primary care roles will be relegated to NP's/PA's due to the unsustainable growth in health care costs. If NP/PA's interact directly with specialist MD's for complex patients, there could be NO role for IM docs. If your statement "most of those patients would at the very least have specialist consults covering the major problems in the private world." is true, then an NP could manage these complex patients -- with the plan being "Cardiology, Endocrine, Psych consults". As internists, we need to carve out a niche or we will be squeezed out.

Perhaps that niche is hospital based medicine, which is not unreasonable.

Perhaps we have a role in the care of complex patients -- ie. community based NP refers patients of high complexity to IM, and we have schedules with longer visit times to accomodate the increased complexity. Complex geriatrics is a good example.

Perhaps that niche is overseeing NP/PA's. That works fine, as long as the NP/PA's want to be overseen.

Perhaps we have a role in research / studies.

Perhaps we have no role, and should be eliminated.

Much of the length/depth of training depends on how high you want to set the competency bar. If you train for 12 months clinically, you can probably manage 70% of outpatients competently. Another 12 months might increase that to 85%, and another 12 months to 95%. Diminishing returns, as expected. You just have to choose where to draw the line.

I'm all for redesigning GME, but I think we need to figure out WHERE we want to go before we figure out HOW we're going to get there.

I'm all for paying residents more. Letting residents bill for their own procedures is a really BAD way to address this. When I was an intern in the ICU on call q3 (no duty hours...), my PGY-3 resident was "proud" that he was moonlighting on our "swing" night. He would get paid a flat salary, plus some portion of each procedure he did. Every patient he evaluated got an ABG. Every single one, regardless of need. He could always think of a need. Every ICU admission got a PA cath and TLC also. Incenting people to do procedures is one of the major problems with our health care system already.

We could pay residents by letting them bill for their own care. This could be rife with abuse also -- why go to conference when you could see another patient? This is the way many in business are paid -- low salaries and lots of tips, or salespeople paid on commission. These types of models do not inspire teamwork, rather they inspire survival of the fittest. I'm not sure that's what we want either.

I propose paying residents more the old fashioned way -- by increasing their salaries. The only question is how to do this in a health care system that is on the verge of collapsing financially. I have no idea how to do this. Neither does anyone else, as far as I can tell. This election season, people are talking about fixing the healthcare system. I'd argue that you can't fix it -- you can only trade the problems you currently have for a new set of problems. Perhaps the new set of problems will be better than the ones we have, depending on who you are in the system.

I think we can all agree that your patients don't represent the bulk of outpatients in the community. That being said, there is no reason why 15 months of true clinical training followed by a second full year of internship wouldn't be enough to handle most of that. My experience (which is admittedly limited though it encompasses both the private and academic worlds) is that most of those patients would at the very least have specialist consults covering the major problems in the private world.

I was at a private office the other day. We saw:

Guy with gonorrhea, guy with depression, lady with DM and HTN, Guy with DM and neuropathy, and some other similar cases.

I am perfectly capable of seeing these patients now. Now I realize that there are some zebras, and I'm not advocating that I open my own practice today. However, I think that another year of internship (which is what I am advocating replacing a fourth year with), in which you DO have responsibility would probably do it. Would I be inexperienced? Yes. 50 years of residency would leave you inexperienced on your first day truly on your own..

With regards to keeping all residencies open, the market should determine that. The insurance companies largely follow medicare, and the hospitals are afraid to hire non-boarded doctors largely as a result of the legal environment, both of which are other problems. Our training system shouldn't be designed to keep on the right side of the lawyers, who will just continue to abuse it anyway.

Once upon a time, someone graduating from med school was a doctor, who could go practice medicine. An internship makes some sense, but this is really part of the schooling, and it should be required. All we are doing now is hyper-specializing everyone to such a degree, that we don't make any real money until our mid-30s or later, and the utility of having someone big toe fellowship trained outside of the biggest of academic centers is highly questionable. Do specialists get better outcomes much of the time? Yes, but this is progressively marginal. What's the difference between a breast surgeon and a general surgeon in a simple biopsy? What's the difference in efficacy of DM control between an FP, internist, or endocrinologist in most diabetics. It is probably not huge. We should really question if it's worth essentially flushing all of our trainees down a highly regulated toilet in which they will slave away doing scut work for $9.00/hr, because like it or not, that's what's happening a lot now.

Now, I expect that most will still specialize. The less regulated residency system however would both have to compete and would be employing DOCTORS (which they do now, but no one seems to remember now). They should be able to bill for procedures. We already admitted that the PA can do this, so why can't a resident in a non-ridiculous system? There's nothing wrong with an agreement in which the resident takes a salary and turns over this money to the program, but this could all be worked out privately between two people who make a valid agreement.

I'm all for residency. I have a generalized specialty (but a specialty) in mind. I'm afraid that the current system will essentially destroy my training. By forcing everyone into residency, we are often making people overtrain, and we are DEFINITELY making people agree to contracts that are not in their best interests by putting all power in the hands of the program. Residents that have nowhere else to turn are invoking all sorts of outside powers, and whether it be 80, 60, 40 or any other arbitrary number of hours that ends up being set, none of it is actually based on helping me or my patients. It's all arbitrary. It's really becoming something like this:

Become doctor---> Must get through residency to practice---> Not liking work/pay ratio---> Complain ----> Residency modified by some outside force----> All residents lose autonomy and training benefit----> Still working for low money and now getting less education-----> Still underpaid----> Repeat.

 

[sirus_virus]

Residents are underpaid because there is no system in place to prevent it. This type of exploitation is what calls for unionization, but lets not say that out too loud. Everyone in the healthcare business is seeing a huge rise in pay. Insurance companies, hospitals, HMOs, Nurses, PAs, sales reps etc. Even the vending machine companies are raking in cash from our hospitals, but when it comes to paying residents, everyone is clueless as to where the money will come from. Lets just be frank, if the hospitals don't have to pay residents, they wont; and if they have to, they will. It just does not make good business sense for hospitals to increase resident's salaries when they can get as many residents as they want regardless.

So the next time we will see a rise in residents salaries is probably when the present salaries fall below poverty level and residents start applying for government cheese.

 

[Miami_med]

I think we agree more than we disagree.

I agree that my clinical experience is not representative of the vast majority of the country, and it's unfair to generalize.

I agree that if we had a 1 year, outpatient only (or minimal inpatient) experience for medical students in place of the MS4 year, then they could be competent outpatient docs for basic issues.

The problem I see is that these MD's are going to have a very difficult time competing in the future marketplace with PA's, NP's, and the new DNP/DPA (or whatever it;s called) that are being created.

Like it or not, Internists are being outsourced, just like auto manufacturing jobs. Several threads on this board lament this fact, that "docs of today are selling out the fortunes of the docs of tomorrow" -- I look at this as the natural evolution of the marketplace. All jobs in all fields are slowly being rendered obsolete. Polaroid didn't go out of business because of the fact that digital imaging made instant photography pointless -- it went out of business because it failed to adapt. (Note: actually, I have no idea why Polaroid went out of business, but I thought that sounded cool)

We have two choices -- keep going the way we are and suffer the same fate as those in Detroit, or innovate / remake our field to remain competitive. How to do so remains the challenge. We need to provide a service that is different enough from what PA's and NP's do so that the market is willing to bear the additional costs. As others have mentioned, I see that the basic primary care roles will be relegated to NP's/PA's due to the unsustainable growth in health care costs. If NP/PA's interact directly with specialist MD's for complex patients, there could be NO role for IM docs. If your statement "most of those patients would at the very least have specialist consults covering the major problems in the private world." is true, then an NP could manage these complex patients -- with the plan being "Cardiology, Endocrine, Psych consults". As internists, we need to carve out a niche or we will be squeezed out.

Perhaps that niche is hospital based medicine, which is not unreasonable.

Perhaps we have a role in the care of complex patients -- ie. community based NP refers patients of high complexity to IM, and we have schedules with longer visit times to accomodate the increased complexity. Complex geriatrics is a good example.

Perhaps that niche is overseeing NP/PA's. That works fine, as long as the NP/PA's want to be overseen.

Perhaps we have a role in research / studies.

Perhaps we have no role, and should be eliminated.

Much of the length/depth of training depends on how high you want to set the competency bar. If you train for 12 months clinically, you can probably manage 70% of outpatients competently. Another 12 months might increase that to 85%, and another 12 months to 95%. Diminishing returns, as expected. You just have to choose where to draw the line.

I'm all for redesigning GME, but I think we need to figure out WHERE we want to go before we figure out HOW we're going to get there.

I'm all for paying residents more. Letting residents bill for their own procedures is a really BAD way to address this. When I was an intern in the ICU on call q3 (no duty hours...), my PGY-3 resident was "proud" that he was moonlighting on our "swing" night. He would get paid a flat salary, plus some portion of each procedure he did. Every patient he evaluated got an ABG. Every single one, regardless of need. He could always think of a need. Every ICU admission got a PA cath and TLC also. Incenting people to do procedures is one of the major problems with our health care system already.

We could pay residents by letting them bill for their own care. This could be rife with abuse also -- why go to conference when you could see another patient? This is the way many in business are paid -- low salaries and lots of tips, or salespeople paid on commission. These types of models do not inspire teamwork, rather they inspire survival of the fittest. I'm not sure that's what we want either.

I propose paying residents more the old fashioned way -- by increasing their salaries. The only question is how to do this in a health care system that is on the verge of collapsing financially. I have no idea how to do this. Neither does anyone else, as far as I can tell. This election season, people are talking about fixing the healthcare system. I'd argue that you can't fix it -- you can only trade the problems you currently have for a new set of problems. Perhaps the new set of problems will be better than the ones we have, depending on who you are in the system.

I think that we largely DO agree. I just believe that a more efficient model could be developed to compete. Let's face it, the current state of things makes it VERY difficult to compete against midlevel practice. The training is simply shorter. They can be paid for things that I can't be paid for, and the DNPs will soon be getting paid without any of the training that I am required to have. How does it make sense to be INCREASING the amount of time required to get medical licensing and priveleges for physicians while allowing DNPs to enter the market with no such restrictions and do the exact same thing with less training?

As far as outpatient medicine is concerned, this is one of the two things that I think actually drives our prices way up. Poor outpatient quality equals going to the ER which, coupled with EMTALA, equals very expensive. Midlevel physicians in completely independent practice CAN do almost anything a physician can do in 7 minutes, which is mostly desperately trying to keep up health maintenance and refer to specialists. Much of outpatient medicine is becoming like this, like it or not. If we changed the model to allow more time in the outpatient setting, I think that we'd SAVE money. Of course, this has to come with better reimbursement, or atleast reimbursement that reflects time spent, for outpatient medicine. Someone who hasn't been trained in physiology, pathophysiology, and given lots of clinical experience CAN'T compete as effectively when there's time to think. NPs in independent practice can compete because nobody has any time to think. Anyone can follow a protocol. The only model that pushes physicians out of the primary care setting is the current model. Primary care requires more medical knowledge. Anyone could be trained to do a colonoscopy, but only someone with good training can think through a complex medical problem.

If people paid for their own care, and doctors had ANY sense of PR, docs would win in primary care, because no one wants the under trained person. It's the current insurance model, lead by the buffoons at Medicare that even makes this an issue.

About paying residents more, the only way it's going to happen is if there's some competition. Between the match, the requirement of doing residency in order to practice after someone takes on six figure debt, and the fact that midlevels cann bill for things that residents who have MORE training cannot, no one is going to pay them more. Why should they? Ideally, I'd love to make some good money in '09, but since I can't legally bill or practice legally, and I can't quit practically (even if I wanted to), I'm not holding my breath. Basic economics essentially dictates that I need SOME leverage in order to compete, and the current system is set up to give me none.

Unionizing never really solves any problems. It's not going to solve the underlying defect and will only take us farther away from a free market.

 

[Apollyon]

Unionizing never really solves any problems. It's not going to solve the underlying defect and will only take us farther away from a free market.

Are you serious? Because, if you are, you are seriously lacking in your knowledge of history. Ever gotten a vacation from work? Thank unions. 40-hour work week? 5 day work week? Minimum wage? No child labor? Thank unions.

You say one sentence before that you need leverage, but have none. Collective bargaining by unions provides that leverage.

You are so wrong, and, what's worse, you don't even know it.

 

[Miami_med]

Union States- Michigan, Ohio, NY
Right to work states- Florida, Tennessee

Let's compare unemployment

By the way, there is a resident union at many hospitals. I have nothing against organization or collective bargaining, but most unions are large political machines that enrich their leaders by making demands that are divorced from market reality. What you are doing is classic union propaganda, in which something that was already happening within a maturing market is accelerated slightly through political means and attributed to being the sole result of the thing that accelerated it. I'm sorry. I'm not buying it.

You see a 5 day work week. I see droves of unemployed workers who were convinced that it was OK to keep demanding by an army of ever richer union officials who eventually bankrupted their corporate opponents with above market salaries and pension obligations. I don't need my union buddies berating me for 'working too hard for the man. I can't pick up my piece of wood until the painter's union guy gets here to take his one bucket of paint off the top, because that's not my job.' I've worked with plenty of unions. I even almost joined one once until I came to my senses.

Mark my words. Without changing the market conditions, all unionization does is push its workers above market prices. I don't want a doctor to become the equivalent of a Detroit auto worker or Pittsburgh steel worker, watching my job flee to the non-unionized adaptable workforce in another place.

I know just fine.

Are you serious? Because, if you are, you are seriously lacking in your knowledge of history. Ever gotten a vacation from work? Thank unions. 40-hour work week? 5 day work week? Minimum wage? No child labor? Thank unions.

You say one sentence before that you need leverage, but have none. Collective bargaining by unions provides that leverage.

You are so wrong, and, what's worse, you don't even know it.

 

[Tired]

You see a 5 day work week. I see droves of unemployed workers who were convinced that it was OK to keep demanding by an army of ever richer union officials who eventually bankrupted their corporate opponents with above market salaries and pension obligations.

Droves, huh? You must not have much of a handle on our historic unemployment rates.

 

[Miami_med]

Droves, huh? You must not have much of a handle on our historic unemployment rates.

The US has historic unemployment rates, and union membership is at a 100 year low. Take a trip to metro Detroit and see what unemployment is there. The union towns in the rust belt are all dying while all the remaining manufacturing in the US flees to the south.

 

[Tired]

The US has historic unemployment rates, and union membership is at a 100 year low. Take a trip to metro Detroit and see what unemployment is there. The union towns in the rust belt are all dying while all the remaining manufacturing in the US flees to the south.

Revive Detroit by paying auto workers three bucks on hour?

I've got a rock that keeps tigers away, want to buy it?

 

[Miami_med]

Revive Detroit by paying auto workers three bucks on hour?

I've got a rock that keeps tigers away, want to buy it?

#1) That's not what they pay in SC, AL, and TN where all of the jobs went

#2) It's better than $0, which is what they're paid now.

#3) We're way off topic

 

[Tired]

#1) That's not what they pay in SC, AL, and TN where all of the jobs went

What? I thought you said all the jobs fled south of the U.S.?

 

[orientedtoself]

on the topic of detroit. . . found this website that is a tour of the ruins of detroit. almost postapocalyptic.

 

[Miami_med]

What? I thought you said all the jobs fled south of the U.S.?

I said "to the south." No amount of misquoting me, putting words in my mouth, or using statistics that don't actually show what you're trying to say actually make your argument correct. I only bring this up, because you seem hellbent on using these types of arguments instead of actually explaining how we got from POS cars made in union factories in Detroit in the 70s during Stagflation and the rest of the economic mess in a period if high unionization to decent cars made in the south with historic unemployment during a period of low unionization. Many economic schools talk about the negative impact of unions on their own workers, most notably the Austrian school of economics.

I'm all about higher pay and better working conditions, but the lack of these are NOT because we don't have resident unions. They are 100% related to the underlying legal environment that forces residents into a limited number of servile positions in order to be capable of getting licensed to practice the profession they just spent 4 years in school learning.

 

[sirus_virus]

The bottom line is there is no system to check the injustice. Regardless of how bad unons are, they offer resistance to this kind of stuff. Right now there is absolutely no protection for residents. In fact, if I am not mistaken, residents are the only work group in the western world that have ZERO protection from this sort of employment abuse and exploitation. No protection from unions, market forces, or anything. I guess no one wants to do anything about it since residency is a transitinal thing, but that still does not make the exploitation fair. Not to mention that when you train people in an overtly exploitative environment, you have to worry what the end product will be.

 

[Tired]

I said "to the south." No amount of misquoting me, putting words in my mouth, or using statistics that don't actually show what you're trying to say actually make your argument correct. I only bring this up, because you seem hellbent on using these types of arguments instead of actually explaining how we got from POS cars made in union factories in Detroit in the 70s during Stagflation and the rest of the economic mess in a period if high unionization to decent cars made in the south with historic unemployment during a period of low unionization. Many economic schools talk about the negative impact of unions on their own workers, most notably the Austrian school of economics.

So when you said "all the manufacturing in the U.S." is fleeing south, you meant to the southern U.S.? Fascinating, since that's obviously not at all what you meant originally. But okay, whatever works for you at the moment is cool with me.

Unionization had nothing to do with the death of the auto industry in the U.S. It was all about (and continues to be all about) advances in technology and decreasing cost of the shipping industry. Manufacturing, like the rest of the world, is not static. Times change, industries change. It was simply no longer cost-effective to produce cars in Detroit. That's not because of the unions, that's because the cost of using slave labor in foreign countries + the cost of shipping from China became lower than the cost of paying American workers a living wage + the cost of shipping from Detroit.

The appropriate response to this change is not to try to compete with exploited workers in other countries by exploiting our own. The appropriate response is to promote workers' rights in all nations, and not reward anti-democratic nations with favorable trade policies.

I'm all about higher pay and better working conditions, but the lack of these are NOT because we don't have resident unions. They are 100% related to the underlying legal environment that forces residents into a limited number of servile positions in order to be capable of getting licensed to practice the profession they just spent 4 years in school learning.

Actually, you're not at all about higher pay and better working conditions. You're all for the lowest wages possible to maximize business profits with minimal government interference in the workplace, which you believe will result in overall economic growth and hence greater public good. At least be honest about your overall philosophy.

But I agree, resident unions are ******ed. I don't know why this keeps coming up on SDN. Unionization works when you have a large available, long-term labor pool that management attempts to exploit by having them effectively "bid" against each other, resulting in exploitatively low wages. These conditions do not apply in the world of residency. You don't have student unions because that's stupid, nor should you have residency unions.

 

[Faebinder]

So when you said "all the manufacturing in the U.S." is fleeing south, you meant to the southern U.S.? Fascinating, since that's obviously not at all what you meant originally. But okay, whatever works for you at the moment is cool with me.

Unionization had nothing to do with the death of the auto industry in the U.S. It was all about (and continues to be all about) advances in technology and decreasing cost of the shipping industry. Manufacturing, like the rest of the world, is not static. Times change, industries change. It was simply no longer cost-effective to produce cars in Detroit. That's not because of the unions, that's because the cost of using slave labor in foreign countries + the cost of shipping from China became lower than the cost of paying American workers a living wage + the cost of shipping from Detroit.

The appropriate response to this change is not to try to compete with exploited workers in other countries by exploiting our own. The appropriate response is to promote workers' rights in all nations, and not reward anti-democratic nations with favorable trade policies.



Actually, you're not at all about higher pay and better working conditions. You're all for the lowest wages possible to maximize business profits with minimal government interference in the workplace, which you believe will result in overall economic growth and hence greater public good. At least be honest about your overall philosophy.

But I agree, resident unions are ******ed. I don't know why this keeps coming up on SDN. Unionization works when you have a large available, long-term labor pool that management attempts to exploit by having them effectively "bid" against each other, resulting in exploitatively low wages. These conditions do not apply in the world of residency. You don't have student unions because that's stupid, nor should you have residency unions.

Agree with the third paragraph but disagree with the last. Residency is not a free industry. Of course the solution could be instead of unionizing residency, just give them their licenses earlier and let them moonlight. Suddenly, it's more of a free industry and no one is forcing residents to continue specializing.

 

[Miami_med]

So when you said "all the manufacturing in the U.S." is fleeing south, you meant to the southern U.S.? Fascinating, since that's obviously not at all what you meant originally. But okay, whatever works for you at the moment is cool with me.

Well, if you reread my previous posts about non-union states, of which I listed southern states, you'll discover that this is exactly what I meant.

Unionization had nothing to do with the death of the auto industry in the U.S. It was all about (and continues to be all about) advances in technology and decreasing cost of the shipping industry. Manufacturing, like the rest of the world, is not static. Times change, industries change. It was simply no longer cost-effective to produce cars in Detroit. That's not because of the unions, that's because the cost of using slave labor in foreign countries + the cost of shipping from China became lower than the cost of paying American workers a living wage + the cost of shipping from Detroit.

Except that many of these jobs are still in the US. My GM car for example was made in Murpheesboro, TN, not China. In fact, the opposite is often happening, with many of the Japanese and Korean companies moving the final steps in assembly into the US. They just didn't go to Detroit.

All of this being said, GM is still buried under its pension and healthcare obligations to retired workers. GM is one of the biggest proponents of a socialized healthcare system, not because of some idealistic fury, but because they have so many promised benefits that they are having difficulty competing. Forcing other companies to buy insurance saddles them with the same stifling obligations that are choking GM, allowing them to compete. All of these obligations were ushered in by the unions.

Case in point, I disagree.

The appropriate response to this change is not to try to compete with exploited workers in other countries by exploiting our own. The appropriate response is to promote workers' rights in all nations, and not reward anti-democratic nations with favorable trade policies.

What the heck does democracy have to do with it? Everyone talks about all of the jobs that are being outsourced and conveniently forgets that we DO have historic unemployment. Most of the jobs are in manufacturing that were lost. These are largely rust belt jobs in union towns in the great lakes region. Job situation in the US=good. Job in small microchasms of the US=bad. This is at a time with historically LOW union membership, and I hardly think that it's a coincidence that the places that ARE having trouble are in unionized industries and union states.

Actually, you're not at all about higher pay and better working conditions. You're all for the lowest wages possible to maximize business profits with minimal government interference in the workplace, which you believe will result in overall economic growth and hence greater public good. At least be honest about your overall philosophy.

I don't want to maximize or minimize business profits. I want workers and business to negotiate independently in a free market with no government interference. The problem with residency is that there is a massive amount of government involvement, both in the implementation and in its association with licensing requirements. You're right though, that I think that worker prosperity is secondary to the market. I think at the end of the day, the public is better of that way individually and thus as a whole.

But I agree, resident unions are ******ed. I don't know why this keeps coming up on SDN. Unionization works when you have a large available, long-term labor pool that management attempts to exploit by having them effectively "bid" against each other, resulting in exploitatively low wages. These conditions do not apply in the world of residency. You don't have student unions because that's stupid, nor should you have residency unions.

Atleast we agree on that

 

[Hurricane]

You don't have student unions because that's stupid, nor should you have residency unions.

We don't?? Then what was that place where I ate hotdogs and played air hockey?

 

[8744]

.

...Med school should be three years. The fourth year should be the equivalent of a TY internship with real responsibility. Residency should then be optional after that. If they weren't a licensing requirement, they'd have to pay real moey to fill...

I want to assure everyone that, despite the agit-prop from the mid-levels that the extra training isn't necessary, in no way will you be qualified or even safe to practice real medicine with just a medical degree and an intern year. Sure, they did this sixty years ago but a lot has changed since then. Even if I am an average resident I am no dummy and after almost three years of residency (with one to go) I still regularly come up against the limits of my knowledge. I think I know enough now to not kill a patient or two on every shift but while credentials are just paper, you have to get the training somehow and you cannot do it by yourself "on the job."

 

[Miami_med]

I want to assure everyone that, despite the agit-prop from the mid-levels that the extra training isn't necessary, in no way will you be qualified or even safe to practice real medicine with just a medical degree and an intern year. Sure, they did this sixty years ago but a lot has changed since then. Even if I am an average resident I am no dummy and after almost three years of residency (with one to go) I still regularly come up against the limits of my knowledge. I think I know enough now to not kill a patient or two on every shift but while credentials are just paper, you have to get the training somehow and you cannot do it by yourself "on the job."

I don't know Panda, many people moonlight at UC, do basic outpt. work after that. I think it's also enough to learn on thr job in a less formal setting.

 

[drfunktacular]

We don't?? Then what was that place where I ate hotdogs and played air hockey?

And the bowling with the fluorescent stuff! And don't forget the sleepy bear hallway!

 

[Dr.Millisevert]

I think that we largely DO agree. I just believe that a more efficient model could be developed to compete. Let's face it, the current state of things makes it VERY difficult to compete against midlevel practice. The training is simply shorter. They can be paid for things that I can't be paid for, and the DNPs will soon be getting paid without any of the training that I am required to have. How does it make sense to be INCREASING the amount of time required to get medical licensing and priveleges for physicians while allowing DNPs to enter the market with no such restrictions and do the exact same thing with less training?

As far as outpatient medicine is concerned, this is one of the two things that I think actually drives our prices way up. Poor outpatient quality equals going to the ER which, coupled with EMTALA, equals very expensive. Midlevel physicians in completely independent practice CAN do almost anything a physician can do in 7 minutes, which is mostly desperately trying to keep up health maintenance and refer to specialists. Much of outpatient medicine is becoming like this, like it or not. If we changed the model to allow more time in the outpatient setting, I think that we'd SAVE money. Of course, this has to come with better reimbursement, or atleast reimbursement that reflects time spent, for outpatient medicine. Someone who hasn't been trained in physiology, pathophysiology, and given lots of clinical experience CAN'T compete as effectively when there's time to think. NPs in independent practice can compete because nobody has any time to think. Anyone can follow a protocol. The only model that pushes physicians out of the primary care setting is the current model. Primary care requires more medical knowledge. Anyone could be trained to do a colonoscopy, but only someone with good training can think through a complex medical problem.

If people paid for their own care, and doctors had ANY sense of PR, docs would win in primary care, because no one wants the under trained person. It's the current insurance model, lead by the buffoons at Medicare that even makes this an issue.

About paying residents more, the only way it's going to happen is if there's some competition. Between the match, the requirement of doing residency in order to practice after someone takes on six figure debt, and the fact that midlevels cann bill for things that residents who have MORE training cannot, no one is going to pay them more. Why should they? Ideally, I'd love to make some good money in '09, but since I can't legally bill or practice legally, and I can't quit practically (even if I wanted to), I'm not holding my breath. Basic economics essentially dictates that I need SOME leverage in order to compete, and the current system is set up to give me none.

Unionizing never really solves any problems. It's not going to solve the underlying defect and will only take us farther away from a free market.

Unfortunately that's the American system. ie.. lets not subsidise or encourage tertiary education and lets dumb down medical provision to the lowest common denominator. If you do become a doctor, you will have to pay $$$$ in malpractice insurance and if you do make a mistake (we are human btw) you risk not only loosing your license and everything you worked for, but also your home and assets. This way all doctors will practice defensive medicine.. over Rx antibiotics, and order 100 MRIs for every patient with a headache. Also, on top of that.. lets motivate students to not attend medical school and instead enroll in all of these para-professional midlevel programs by giving everyone from nurses to the scrub tech a "clinical doctorate" as their entry level qualification and pay them a salary that is almost equivalent to what a physician would make and not require them to pay malpractice. Then lets have the lawyers and insurance companies control the system. Awesome... that's a great idea!

I think they should subsidize both state run universities and medical schools to a much higher degree than present. Residents should get paid an hourly wage. If they take call and/or work overtime.. they should reimbursed accordingly (ie. get time and a half).

 

[Dr.Millisevert]

Residents are underpaid because there is no system in place to prevent it. This type of exploitation is what calls for unionization, but lets not say that out too loud.

That's not a bad idea actually. We don't have to actually vote for restrictions of any kind on the hourly work week (60 or 80 hr limits ...doesn't matter) because it shouldn't be an issue... IF we simply demand changing the stipend system from a flat yearly stipend to an hourly wage (including getting time and half if you go over a certain contiguous time frame or come in on after hours call). This wouldn't really change anything except for the fact that residents would get paid a crap load more than they are and would help to limit abuse of residents.

 

[redbeans]

That's not a bad idea actually. We don't have to actually vote for restrictions of any kind on the hourly work week (60 or 80 hr limits ...doesn't matter) because it shouldn't be an issue... IF we simply demand changing the stipend system from a flat yearly stipend to an hourly wage (including getting time and half if you go over a certain contiguous time frame or come in on after hours call). This wouldn’t really change anything except for the fact that residents would get paid a crap load more than they are and would help to limit abuse of residents.

I do wish it was an hourly wage, where your work was fairly compensated. I have to remind my non-medical friends that though I'll be finally getting paid when I start residency, I'll be working twice as long for the same amount as them.

Unfortunately, don't you think if there was an hourly wage the hospitals would just create a salary cap and work harder to force you to go home after 60 hrs? This happens in the regular work world where the 1.5 overtime salary is only theoretical if your boss says go home.

And also, wouldn't it create a potential for abuse by people wasting time but clocking hours because they're "still at the hospital" even if they're just cruising the internet while slowly updating labs?

 

[Tired]

I do wish it was an hourly wage, where your work was fairly compensated. I have to remind my non-medical friends that though I'll be finally getting paid when I start residency, I'll be working twice as long for the same amount as them.

Wow, your friends must have some pretty crappy jobs.

And also, wouldn't it create a potential for abuse by people wasting time but clocking hours because they're "still at the hospital" even if they're just cruising the internet while slowly updating labs?

If it's good enough for the nurses . . .

 

[Dr.Millisevert]

Unfortunately, don't you think if there was an hourly wage the hospitals would just create a salary cap and work harder to force you to go home after 60 hrs? This happens in the regular work world where the 1.5 overtime salary is only theoretical if your boss says go home.

Yeah, I'm not sure. You would think they would want to. Maybe we should look more into it though because it seems to work for some people. This is how it works basically in Australia. (I know a surgery resident there who makes a base 55k AUD year salary but actually ends up taking home about 90k AUD or approx $83,500 US dollars every year AS A RESIDENT because of extra on call duty) Granted residency training programs there are on average 1-2 years longer than in the US (just like Canada).

But again.. it could work.. maybe we should send some AMSA student reps to Australia to figure out how we can make this work in the states and then unionise and demand a change.

And also, wouldn't it create a potential for abuse by people wasting time but clocking hours because they're "still at the hospital" even if they're just cruising the internet while slowly updating labs?

Dunno.. On the flip side. If you as a student knew you were adequately getting reimbursed for your efforts. You might actually be more inclined to do more work rather than slack off "just because I'm not getting paid for it anyways...so why bother"

Thoughts?

 

[8744]

I don't know Panda, many people moonlight at UC, do basic outpt. work after that. I think it's also enough to learn on thr job in a less formal setting.

Oh no, it's not. Suppose you finish your three-year plus one intern year medical school and decide you'd like to do emergency Medicine. While it's true that there are some minor things that you will be able to handle, depending on where you get a job, a significant number of patients will present with things you have either never seen or have no experience with. Even something as simple as intubation needs to be practiced under different circumstances, hopefully with some backup and advice for the difficult airways before we are thrown out on our own never having had to make the spit-second decision to cut open someone's trachea, not to mention never having actually been supervised doing it a couple of times. I shudder to think of what a botch I would have made of things if I was let loose on the public after just an intern year.

Surgery, as an another example, even more so than emergency medicine, needs extensive training "on the job." You can't fake your way through operations. That's why they have surgery residency programs.

Even if you are working under an experienced attending for an undetermined number of years without some structure you are going to be extremely unprepared. The practice of medicine is difficult. Eventually we are supposed to make it look easy but that's only because we work so hard at it. Are you going to get six months of absolutely necessary for an Emergency Physician ICU training in your informal residency? Probably not.

Now, if you mean that residency training has become too formal and regulated you may have a point but we have to have standards. Completing a residency, while an imperfect measure of competency, should be viewed as a minimum level of proficiency and is currently the best measure of quality we have.

Currently, mid-level providers fill the niche for low-acuity, booger-and-cough care. On the other hand, I had a young, fit, ostensibly healthy 25-year-old man as a patient yesterday who looked initially for all the world like just a bad case of the flu who turned out to be septic, deteriorated rapidly, and needed the whole nine-yards...intubation, ventilator, lines, fluids, pressors, and antibiotics. A NP or a PA, working in a Wal Mart clinic, would have sent the guy home, of this I have no doubt, because I almost did and was writing him up to go when his vitals headed south.

Kind of makes you step back and thank the Lord for being in a residency program where you can make the occasional mistake, receive the appropriate correction, and nobody but your attending knows that you almost ****ed up.