'UW says its doctors in training want too much money'

[ThoracicGuy]

How about when residents moonlight--are they able to bill?

Usually they are paid a straight rate, not personal billing.

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[W19]

Usually they are paid a straight rate, not personal billing.

Do the hospitals bill for their service?

 

[mimelim]

Do the hospitals bill for their service?

Yes.

 

[DubVille]

"That's the way its always been done, so that's the way it should be", is an attitude that is going to bury American medicine. The mid levels have already said FU to that way of thinking and started lobby hard for independent practice and in a lot of states they are winning. I wonder if its a generational thing, younger physicians are probably more likely to challenge the status quo than submit to good ol boy club idealism. There is no reason residents couldn't be paid more, they should be paid more, and the fact that people with less education can bill for their efforts, while a docotor who have finished PGY 1 and has a license to practice medicine can't is insulting.

I would love to make more money but in my specialty (which is heavily outpatient) I am not bringing much to the hospital. Sure I write notes, order stuff, talk to patients and do the bulk of the face to face interaction but my attending could probably be nearly as efficient without me (they do a fair amount of teaching in room and after since they usually only see old follow ups on their own.) Plus when im doing procedures (emg, epidurals, botox, ultrasound guided stuff) I am slowing them way down since they cannot bill if not present. I guess I could start doing these independently while in residency, and would generally feel comfortable at this point. But what is the purpose of me billing for something the attending can do more efficiently? Who bills if its a tough case and I need help? If the attending had a production incentive via RVUs, am I "taking" their business? Additionally, how would the liability work? At my program you usually get a bonus for supervising midlevels, but their rvu production doesnt count towards the signing attendings production.

In my area to moonlight, you generally need to get your state licence (external moonlighting). Which can be obtained after finishing intern year and step 3.

Again, I would love more money, but realistically I'm not making much $ for anyone. Some other specialties may have more legitimate arguments.

 

[Cytarabine]

My med school gave 2 to the interns and 4 to the seniors lol.

Or you can go the MGH route and decide assigning individual vacations is too much of a pain and just assign each resident a 4 week block off

My friend's gen surg program mirrors mgh there. Seems soul crushing

 

[WingedOx]

My friend's gen surg program mirrors mgh there. Seems soul crushing

Knowing the couple people I do who are in/have been in the gen surg program at MGH and the insane amount of gunning they displayed to get in there...

...they made their bed. Let them sleep in it. People who match MGH aren't people without other options.

 

[Ischemia1032]

Obviously they are confused about two things. First of all, residency is training, you are studying, you are basically still in school except you are getting paid a bit to live. So actually, considering the hospital is putting in resources to train you, then you get what you get. Lastly, medicare funds residency, the government controls residency positions essentially, so while you are not technically a government employee, you are indirectly being paid by the government, and since when has the government paid anything but the minimum.

 

[NotAProgDirector]

This isn't a universal law of the universe. Why shouldn't resident physicians with a full license bill as a midlevel? It doesn't make any sense that they can't, other than "that's the way it's done".

The reason residents can't bill is because of GME payments. Medicare considers GME payments in lieu of resident billing. Again, be careful what you wish for. Medicare would love to get rid of GME funding and instead pay residents only for services rendered. That would be much cheaper -- and less money coming into the hospital is unlikely to be reflected in increased resident salaries.

There's an article posted above which demonstrates this nicely. They looked at a surgical residency and found that, if they were allowed to bill, they would generate 75% of the DME funds. Since IME is usually many times DME, this would be a huge decrease. And this is for surgery -- a procedure heavy field where billing is king. Try it with IM, FM, Peds, etc and it will even be worse.

As I've mentioned before (and will mention again, to avoid confusion), I am all for increasing resident salaries. Everyone wants their salary increased, and most people think they deserve a salary increase. Salaries for medical support services have risen like crazy -- NP's, CRNA's, PT/OT, billers and coders, IT, etc. This is part of the health care crisis. Hospitals are not making tons of money, so paying more for residents is going to need to come from somewhere. Resident salaries are (probably) below what they "are worth" from a business standpoint -- but perhaps not for all residents, all years, or all programs.

 

[Psai]

Obviously they are confused about two things. First of all, residency is training, you are studying, you are basically still in school except you are getting paid a bit to live. So actually, considering the hospital is putting in resources to train you, then you get what you get. Lastly, medicare funds residency, the government controls residency positions essentially, so while you are not technically a government employee, you are indirectly being paid by the government, and since when has the government paid anything but the minimum.

When they are giving it handouts to their buddies in haliburton and trying to build 100 million dollar bridges in the middle of nowhere

 

[Perrotfish]

Obviously they are confused about two things. First of all, residency is training, you are studying, you are basically still in school except you are getting paid a bit to live. So actually, considering the hospital is putting in resources to train you, then you get what you get. Lastly, medicare funds residency, the government controls residency positions essentially, so while you are not technically a government employee, you are indirectly being paid by the government, and since when has the government paid anything but the minimum.

They're not really confused. Residency isn't really training, and you're definitely not a student. Its work and you're an employee..

Basically academic medicine works on the same business model as college football. They have both managed to convince the government that they should be allowed not to pay their immensely profitable employees, despite the fact that they are paying themselves millions and taking taxpayer dollars besides. They've also convinced the government that their employees shouldn't even be afforded labor rights, and that the programs should be exempt from antitrust legislation so that they can collude to keep salaries low. To keep the employees from revolting they give a barely living wage stipend, and they make it clear that anyone who keeps their head down and doesn't make waves has a shot a really good job in 4 years. The only difference is that, at least in residency, most of us do at least get the job when we get free of them.

 

[Cytarabine]

They're not really confused. Residency isn't really training, and you're definitely not a student. Its work and you're an employee..

Basically academic medicine works on the same business model as college football. They have both managed to convince the government that they should be allowed not to pay their immensely profitable employees, despite the fact that they are paying themselves millions and taking taxpayer dollars besides. They've also convinced the government that their employees shouldn't even be afforded labor rights, and that the programs should be exempt from antitrust legislation so that they can collude to keep salaries low. To keep the employees from revolting they give a barely living wage stipend, and they make it clear that anyone who keeps their head down and doesn't make waves has a shot a really good job in 4 years. The only difference is that, at least in residency, most of us do at least get the job when we get free of them.

 

[W19]

When they are giving it handouts to their buddies in haliburton and trying to build 100 million dollar bridges in the middle of nowhere

It's ok as long as we don't spend it on welfare queens ...

 

[Baller MD]

Maybe you should address his whole quote instead of just nitpicking a small portion of it.

 

[wolfofparkstreet]

They're not really confused. Residency isn't really training, and you're definitely not a student. Its work and you're an employee..

Basically academic medicine works on the same business model as college football. They have both managed to convince the government that they should be allowed not to pay their immensely profitable employees, despite the fact that they are paying themselves millions and taking taxpayer dollars besides. They've also convinced the government that their employees shouldn't even be afforded labor rights, and that the programs should be exempt from antitrust legislation so that they can collude to keep salaries low. To keep the employees from revolting they give a barely living wage stipend, and they make it clear that anyone who keeps their head down and doesn't make waves has a shot a really good job in 4 years. The only difference is that, at least in residency, most of us do at least get the job when we get free of them.

Brilliant!

 

[Cytarabine]

Maybe you should address his whole quote instead of just nitpicking a small portion of it.

I had no intention of coming across as addressing the entire post with that reply, it was merely in response to the bolded statement which I found bizarre. Residency isn't really training? Come on, if anyone thinks they come out of med school even 10% to practice any specialty independently and unsupervised, I'd accuse that person of having a bad case of hubris. And if you come out of residency far more prepared to practice independently and unsupervised due to the learning, both in the form of formal didactic education and supervised apprenticeship of sorts, what did you undergo if not training? With that said and taking the whole post now into account, the analogy with college football might be apt on quick glance but I think it falls apart. Medical residents are very much in training during residency and nearly guaranteed a lucrative (depending somewhat on your definitions of the term) and secure job market upon completion of training, which is very much not the case for NCAA athletes. As far as "barely living wage", outside of places like LA and NYC and not considering individuals who have a significant number of dependents, most places I've looked into provide far more than "barely living wage". Residents aren't exactly living in slums or eating McD's everyday. Many own their own fairly nice homes, travel, etc. As far as bringing in outrageous money to hospitals, I'm not familiar with the data frankly, but aPD seems to have spoken to that previously.

Regardless, if we were to change the system in a way that allowed residents more liberty in negotiating their salaries, how would you envision that system being structured? There are more candidates desiring residency training than there are positions, and potential residents / residents-in-training have considerably more to lose by not completing training than programs do losing a resident - programs hold considerably more power in any sort of non-match based system.

 

[Slack3r]

Residency isn't really training...

I think all your surgical colleagues would beg to differ...

 

[Perrotfish]

I had no intention of coming across as addressing the entire post with that reply, it was merely in response to the bolded statement which I found bizarre. Residency isn't really training? Come on, if anyone thinks they come out of med school even 10% to practice any specialty independently and unsupervised, I'd accuse that person of having a bad case of hubris.

Regardless, if we were to change the system in a way that allowed residents more liberty in negotiating their salaries, how would you envision that system being structured? There are more candidates desiring residency training than there are positions, and potential residents / residents-in-training have considerably more to lose by not completing training than programs do losing a resident - programs hold considerably more power in any sort of non-match based system.

Let me clarify: Residency is no more training than any other entry level job. Your are not primarily judged as a trainee (like a medical student) but as an employee. Like any other entry level job, there is aggressive training to get you up to speed, particularly in the first few months, but your are judged primarily on your ability to do a job, and there is a job that you very much need to do. Any engineer who graduates from undergraduate who thinks he is ready to build a bridge would also have a case of hubris, but no engineering firm has the gall to tell their junior, unlicensed engineers that they are students, nor are they treated as such.

FWIW I would replace our system of medical education with the system that is currently in place to train engineers (my last profession). For those who aren't aware, there is a licensing system in place for engineers, but its way more informal and decentralized than medical training. I believe that any sufficiently large (say 6 attendings) group of board certified physicians should be allowed to supervise an unlicensed/uncertified physician. You take a series of standardized tests, and in the meantime you work under the supervision of the board certified physicians that hire you as a midlevel. Your salary would be negotiated based on the value you bring to the practice, and you could leave to find another employer at any time while taking your training time with you. When you work a sufficient number of hours under supervision, have the endorsement of your supervisors, and pass the tests you should become certified yourself. If this model follows the engineering model most physicians would then join the practice they trained in, in fact it wouldn't really be considered a major transition so much as a small promotion and raise.

I also believe that certification should also be broken down into much smaller areas. For example rather than having a board certified Pediatrician I should be certified separately in Nursery care, neonatal/perinatal basic care, pediatric inpatient care, pediatric outpatient care, and basic pediatric intensive care. That way we could stop having physicians waste years learning skills they have no interest in using, and at the same time we could make it much easier for physicians to transfer from one specialty to another.

Academic hospitals would still exist, but they would just be big firms, and would be in competition with small practices for the right to employ and train new grads. They would need to offer competitive pay and benefits packages or they would find themselves without any junior employees.

My position is that academic hospitals collude to take advantage of residents. In a free market they would pay more and offer more humane work environments. They would also be just like everyone else who hires a fresh college/graduate school graduate. There is nothing special about medicine that requires hospitals to violate antitrust legislation to keep employees from ever being rehired if they are fired or quit, or for the government to pay our salaries, or for our salaries and advancement to be fixed regardless of what we bring to the hospital or how fast we learn. Its just regulatory capture, nothing more.

 

[wolfofparkstreet]

There's an economic term for residency.....indentured slavery. It goes something like this:

"Hey, we'll pay you minimum wage for the right to train at our hospital. It's not like our country has a crippling physician shortage, so we'll create the illusion that you need us more than we need you through our lobbying of the brain dead politburo. Don't worry, you'll be making low to mid 6 figures within the next 3-4 years. Just don't plan on getting married, having kids or dying. "

http://www.payscale.com/college-salary-report/majors-that-pay-you-back/bachelors

Engineers straight out of undergrad are definitely making more than most residents. A resident should be considered "mid-career" as they would already would be out of undergrad 5+ years (with an advanced graduate degree). When you factor in the the time value of money and the debt of undergrad + medical school, to be paid minimum or slightly above minimum wage is a slap in the face.

fun fact: According to the New England Journal of Medicine, when adjusted for inflation, resident compensation has not changed in 40 years

 

[VA Hopeful Dr]

fun fact: According to the New England Journal of Medicine, when adjusted for inflation, resident compensation has not changed in 40 years

OK, and? Given that residents actually do less work than 40 years ago, I fail to see the problem here.

 

[Mad Jack]

That is one AOA program out of so many and you don't have to apply there if you don't have IM residency completed.
No AMG with 250k of med school debt will take another 150k, unless they're very very affluent. Either way you'll still get lower caliber stat applicants. It's Derm not Neurosurgery level attending salaries.

Just because you think creating a "fellowship" out of thin air deserves accreditation, it doesn't mean it should get it. You don't have that right when you are asking for taxpayer money which funds ACGME residencies and fellowships. So as a nonaccredited fellowship with no taxpayer funding and voluntary, you get what the market yields, even if it's 5k. Tough.

Roughly a third of AMGs have medical school fully paid for from the last report I read. That third would be the ones that snagged positions in derm derm, etc., if they charged tuition. This is actually a big reason certain ACGME rules exist, such as those requiring equal pay for all residents, as some affluent residents could simply use taking zero pay as an incentive to bring them on board, making their whole government subsidy gravy. A lot of people don't realize the sorts of shenanigans that went on before more stringent residency rules were adopted. Programs used to have all the power, and could do as they wished, which led to all sorts of terrible treatment of applicants and residents. We literally weren't even paid back in the day, aside from room and board, that's how bad things were. Now I fear the needle has swung too far, with residents gaining all the power via a system that has completely shielded them from market forces now feeling entitled to ever more from the programs that are educating them.

 

[Mad Jack]

There's an economic term for residency.....indentured slavery. It goes something like this:

"Hey, we'll pay you minimum wage for the right to train at our hospital. It's not like our country has a crippling physician shortage, so we'll create the illusion that you need us more than we need you through our lobbying of the brain dead politburo. Don't worry, you'll be making low to mid 6 figures within the next 3-4 years. Just don't plan on getting married, having kids or dying. "

http://www.payscale.com/college-salary-report/majors-that-pay-you-back/bachelors

Engineers straight out of undergrad are definitely making more than most residents. A resident should be considered "mid-career" as they would already would be out of undergrad 5+ years (with an advanced graduate degree). When you factor in the the time value of money and the debt of undergrad + medical school, to be paid minimum or slightly above minimum wage is a slap in the face.

fun fact: According to the New England Journal of Medicine, when adjusted for inflation, resident compensation has not changed in 40 years

Given how astoundingly useless and outright dangerous many interns and some second year residents are, I'd say that training is sorely needed. You're getting paid and full benefits while being educated, that's not a bad deal.

Effing millennials. I blame this all on millennial entitlement.

 

[Mad Jack]

I don't know about you, but I'd rather make more money sooner and enjoy it when I'm younger and healthier, than less money now and more later. (And by 'enjoy it', I mean pay off my debts, lol)

Either way my point was, residency is a long time to just brush off, whether it's 4 years or 7. Most Americans will have changed jobs numerous times to get higher salaries in that period.

And then you see PA's and NPs who just graduated with less education than you getting paid more and needing just as much supervision? That doesn't really make sense.

"I want all the money for shorter training and I want all that money while I'm training too, damn it!"

NPs and PAs don't require an entire GME infrastructure to maintain. They can bill. They usually have minimal supervision, and only a fraction of their notes need to be signed off on (or none at all, in many states). They're low overhead, high output. Residents are high overhead, high output. In many smaller programs, they barely manage to pay for themselves.

 

[wolfofparkstreet]

OK, and? Given that residents actually do less work than 40 years ago, I fail to see the problem here.

They may do less work but the point being the compensation being offered today would not sustain the same lifestyle that residents were able to afford in 1975 after accounting for debt payments.

Based on AAMC's numbers:
resident pay in 1975: actual= $11,685
inflation adj.(2015)= $52,000
reality in 2105= $55,400
% increase = 6.5%

UPENN's archives:
medical tuition in 1975: actual= $4310
inflation adj.(2015)= $19,180
reality in 2015= $50,444
% increase = 163%!!!

 

[VA Hopeful Dr]

They may do less work but the point being the compensation being offered today would not sustain the same lifestyle that residents were able to afford in 1975 after accounting for debt payments.

Based on AAMC's numbers:
resident pay in 1975: actual= $11,685
inflation adj.(2015)= $52,000
reality in 2105= $55,400
% increase = 6.5%

UPENN's archives:
medical tuition in 1975: actual= $4310
inflation adj.(2015)= $19,180
reality in 2015= $50,444
% increase = 163%!!!

As has been said many times in this thread already...

Why is increasing tuition for med school the responsibility of the residency programs?

 

[wolfofparkstreet]

Not saying it is but there should be an equitable increase in the pay residents receive

As has been said many times in this thread already...

Why is increasing tuition for med school the responsibility of the residency programs?

 

[VA Hopeful Dr]

Not saying it is but there should be an equitable increase in the pay residents receive

Why, because you're now in more debt? That's like saying everyone who works in NYC should get paid more (Regardless of productivity or demand) because the cost of living is higher there than in the midwest.

 

[wolfofparkstreet]

Why, because you're now in more debt? That's like saying everyone who works in NYC should get paid more (Regardless of productivity or demand) because the cost of living is higher there than in the midwest.

lol....Are you serious? I hope not. There's a reason why skilled and unskilled workers move to NYC rather than live in Terre Haute. What exactly is wrong with increasing resident pay to match the debt load of students? Manufacturers and retailers raise their prices in response to an increase in prices of raw materials. I just love it when capitalists become afraid of capitalism.

 

[medicineradman]

the biggest problem with everything here is student debt. I cant even believe the debt people are undertaking or that educational institutions are being allowed to get away with charging the rates they are charging. Why are parents not looking out for their kids and keeping them away from a lifetime of soul crushing debts? Parents sometimes don't know the issues either, I get that, but I would never recommend someone take on more than 75k in debt especially if they are going into family practice. If anything should be boycotted it should be college/med school tuition. We should leave this BS out of the hospital because it effects patients. There should be massive protests and even riots over college/grad school tuition

 

[VA Hopeful Dr]

lol....Are you serious? I hope not. There's a reason why skilled and unskilled workers move to NYC rather than live in Terre Haute. What exactly is wrong with increasing resident pay to match the debt load of students? Manufacturers and retailers raise their prices in response to an increase in prices of raw materials. I just love it when capitalists become afraid of capitalism.

Do you really not understand the difference between a baker raising the price of bread when flour gets more expensive and a job not raising salaries when education prices get higher?

 

[wolfofparkstreet]

Do you really not understand the difference between a baker raising the price of bread when flour gets more expensive and a job not raising salaries when education prices get higher?

I do, hence the reason I said that the capitalist are afraid of capitalism

 

[ThoracicGuy]

I do, hence the reason I said that the capitalist are afraid of capitalism

So do you want to negotiate your salary when you match? What if you don't like the match salary, then you can just quit there and go somewhere else? There is no capitalism in this and with the match system there never really will be. You could go back to the old system where you can apply and get an offer that you have only a few days to accept or not from a program. Will you get future offers from better locations? Maybe, but maybe not. So maybe you take what's offered and you miss out on your top choice. That'd be great...

 

[calvnandhobbs68]

Let me clarify: Residency is no more training than any other entry level job. Your are not primarily judged as a trainee (like a medical student) but as an employee. Like any other entry level job, there is aggressive training to get you up to speed, particularly in the first few months, but your are judged primarily on your ability to do a job, and there is a job that you very much need to do. Any engineer who graduates from undergraduate who thinks he is ready to build a bridge would also have a case of hubris, but no engineering firm has the gall to tell their junior, unlicensed engineers that they are students, nor are they treated as such.

FWIW I would replace our system of medical education with the system that is currently in place to train engineers (my last profession). For those who aren't aware, there is a licensing system in place for engineers, but its way more informal and decentralized than medical training. I believe that any sufficiently large (say 6 attendings) group of board certified physicians should be allowed to supervise an unlicensed/uncertified physician. You take a series of standardized tests, and in the meantime you work under the supervision of the board certified physicians that hire you as a midlevel. Your salary would be negotiated based on the value you bring to the practice, and you could leave to find another employer at any time while taking your training time with you. When you work a sufficient number of hours under supervision, have the endorsement of your supervisors, and pass the tests you should become certified yourself. If this model follows the engineering model most physicians would then join the practice they trained in, in fact it wouldn't really be considered a major transition so much as a small promotion and raise.

I also believe that certification should also be broken down into much smaller areas. For example rather than having a board certified Pediatrician I should be certified separately in Nursery care, neonatal/perinatal basic care, pediatric inpatient care, pediatric outpatient care, and basic pediatric intensive care. That way we could stop having physicians waste years learning skills they have no interest in using, and at the same time we could make it much easier for physicians to transfer from one specialty to another.

Academic hospitals would still exist, but they would just be big firms, and would be in competition with small practices for the right to employ and train new grads. They would need to offer competitive pay and benefits packages or they would find themselves without any junior employees.

My position is that academic hospitals collude to take advantage of residents. In a free market they would pay more and offer more humane work environments. They would also be just like everyone else who hires a fresh college/graduate school graduate. There is nothing special about medicine that requires hospitals to violate antitrust legislation to keep employees from ever being rehired if they are fired or quit, or for the government to pay our salaries, or for our salaries and advancement to be fixed regardless of what we bring to the hospital or how fast we learn. Its just regulatory capture, nothing more.

This is absolutely true. Residents, think about your initial orientation vs your medical school orientation. Your hospitals probably made it very clear to you that you are employees of the hospital and will be treated as such from a hospital standpoint. You aren't "students" in their mind anymore than the brand new NP or PA is a "student" there. You are an employee starting an entry level position. You have a contract that you sign year to year. Are you still learning on the job? Absolutely, just like any other new employee is there.

However, I do think it's a be careful what you wish for situation from the "free market get rid of the match and residency system as it stands and pay residents like NPs and PAs" standpoint. Would you get paid more? Probably overall but I agree that the more prestigious places would probably pay less and be able to get away with it. Be ready to kiss your electives and easier rotations goodbye though. If you want to be paid like an NP or PA, then be ready to assume the role of an NP or PA. How many research months or months working abroad or cardiology or ortho elective rotations do they get?

 

[meister]

Some PAs and NPs get permanent cardiology or ortho electives!

 

[VA Hopeful Dr]

However, I do think it's a be careful what you wish for situation from the "free market get rid of the match and residency system as it stands and pay residents like NPs and PAs" standpoint. Would you get paid more? Probably overall but I agree that the more prestigious places would probably pay less and be able to get away with it. Be ready to kiss your electives and easier rotations goodbye though. If you want to be paid like an NP or PA, then be ready to assume the role of an NP or PA. How many research months or months working abroad or cardiology or ortho elective rotations do they get?

People always forget this aspect of the free market approach. If you allow residencies to set their own prices, you can kiss 50k/year goodbye for things like derm and ortho.

 

[chipwhitley]

So do you want to negotiate your salary when you match? What if you don't like the match salary, then you can just quit there and go somewhere else? There is no capitalism in this and with the match system there never really will be. You could go back to the old system where you can apply and get an offer that you have only a few days to accept or not from a program. Will you get future offers from better locations? Maybe, but maybe not. So maybe you take what's offered and you miss out on your top choice. That'd be great...

Or we could just get rid of the existing GME system all together and implement a system like what @Perrotfish proposed, which makes sense to me.

 

[ThoracicGuy]

Or we could just get rid of the existing GME system all together and implement a system like what @Perrotfish proposed, which makes sense to me.

Yeah, that system would be far worse. Plus there really wouldn't be much standardization with that system. Those programs could offer a low salary for something competitive like derm or ortho and people will take it.

 

[evilbooyaa]

People always forget this aspect of the free market approach. If you allow residencies to set their own prices, you can kiss 50k/year goodbye for things like derm and ortho.

Seems like all the proponents of "free market capitalism" in residency salaries ignore the folks from dentistry who are PAYING TUITION to be in 'residency'. Very easy for similar issues to occur with the more competitive fields.

 

[chipwhitley]

Yeah, that system would be far worse. Plus there really wouldn't be much standardization with that system. Those programs could offer a low salary for something competitive like derm or ortho and people will take it.

I don't really think that's a problem. It's the free market at work. It might actually drive more people into areas of medicine that we actually need...

 

[chipwhitley]

Seems like all the proponents of "free market capitalism" in residency salaries ignore the folks from dentistry who are PAYING TUITION to be in 'residency'. Very easy for similar issues to occur with the more competitive fields.

That's because dentists can practice without residency and make a good living. If we could practice without residency, that would be another story entirely. You can't compare the two. One is completely optional whereas the other is mandatory.

 

[VA Hopeful Dr]

That's because dentists can practice without residency and make a good living. If we could practice without residency, that would be another story entirely. You can't compare the two. One is completely optional whereas the other is mandatory.

That is inconsequential for the point being discussed. If you think things are bad salary wise now, just wait until you give programs free reign to do as they please. Plenty of people who gladly pay to be accepted into something like ortho, derm, or ophtho. 50k is a bunch of money compared to 0k.

 

[Psai]

Seems like all the proponents of "free market capitalism" in residency salaries ignore the folks from dentistry who are PAYING TUITION to be in 'residency'. Very easy for similar issues to occur with the more competitive fields.

That's a completely different field and irrelevant to us.

 

[evilbooyaa]

That's a completely different field and irrelevant to us.

Yes, I agree that you can practice without a dentistry residency, but the principles still hold true IMO.

Do you disagree that the most competitive fields would consider dropping their salaries across the board (especially if say all derm residencies cut their pay by 15k/resident/year)?

In what world do derm (or other similarly competitive) residencies go, "Man, we really need to entice people to come to our residency. We're not getting enough 240 Step 1, AOA, all clinical honors applicants, so we should offer more money"

This makes medical school, which is already primarily meant for the wealthiest given the rise in tuition, segregated further. People with 300k in loans coming out of UG and med school are unlikely to take out ADDITIONAL loans just to practice the field they want.

It'd be easier for them to bite the bullet and do FM for let's say 65-70k/year in a 'free market'.
All that being said, in this hypothetical, when do FM programs say "screw increasing payment. We know a ton of FMGs/IMGs that are willing to work for free in order to have a shot of becoming a doctor in the US". Granted, this wouldn't be as severe as possible because the quality of candidates would likely be significantly worse given the larger amount of spots, but I'm sure there are SOME programs, especially ones that are IMG sweatshops already, that would have no issues cutting their salary and finding a warm body desperate enough to become a doctor in the US to fill the spot.

 

[Psai]

Yes, I agree that you can practice without a dentistry residency, but the principles still hold true IMO.

Do you disagree that the most competitive fields would consider dropping their salaries across the board (especially if say all derm residencies cut their pay by 15k/resident/year)?

In what world do derm (or other similarly competitive) residencies go, "Man, we really need to entice people to come to our residency. We're not getting enough 240 Step 1, AOA, all clinical honors applicants, so we should offer more money"

This makes medical school, which is already primarily meant for the wealthiest given the rise in tuition, segregated further. People with 300k in loans coming out of UG and med school are unlikely to take out ADDITIONAL loans just to practice the field they want.

It'd be easier for them to bite the bullet and do FM for let's say 65-70k/year in a 'free market'.
All that being said, in this hypothetical, when do FM programs say "screw increasing payment. We know a ton of FMGs/IMGs that are willing to work for free in order to have a shot of becoming a doctor in the US". Granted, this wouldn't be as severe as possible because the quality of candidates would likely be significantly worse given the larger amount of spots, but I'm sure there are SOME programs, especially ones that are IMG sweatshops already, that would have no issues cutting their salary and finding a warm body desperate enough to become a doctor in the US to fill the spot.

It's only competitive because more people want to do it than there are spots. It's not like competitive specialties are intrinsically competitive

 

[charmiedermie]

Salaries for medical support services have risen like crazy -- NP's, CRNA's, PT/OT, billers and coders, IT, etc. This is part of the health care crisis. Hospitals are not making tons of money, so paying more for residents is going to need to come from somewhere. Resident salaries are (probably) below what they "are worth" from a business standpoint -- but perhaps not for all residents, all years, or all programs.

Exactly, thank you.

 

[NotAProgDirector]

A community based GME training system has been discussed, and is not a completely crazy idea. In fact, I think the ACA specifically had language / funding involved to explore this, but it's certain to get tied up in politics. For surgical specialties, probably not a reasonable option. But for primary care, I could imagine some sort of a 2-3 year apprenticeship / junior position. Are there problems? Sure:

1. Quality control is going to be difficult. If residents are scattered to the winds, it will be difficult to monitor. A "board exam" is only of limited value -- I have some residents who, as interns, could probably pass the ABIM exam -- that doesn't make them ready to be physicians.

2. Academic centers tend to concentrate rare pathology. The idea is to get exposed to things that don't happen often, so that when you go out into practice the few times that they do happen, you recognize them and know what to do (or at least when to call for help). Spending all of your training time in an outpatient center will certainly help you learn to manage a panel of patients, the basics of common illnesses, etc. But how many MI's are you going to see in your clinic?

3. There is a sense that knowing something about the practice of medicine in venues that you're not going to actually practice is helpful. So, if you're going to be a PCP, working in the ICU is "useless" for your practical day-to-day life, but perhaps helps you connect / work with your patient who gets admitted to the ICU and is managed by someone else.

4. Funding -- Medicare currently funds GME. If we go towards a community based GME system, the question is whether funding will flow to the community. On the one hand, it seems a reasonable step. On the other, if the GME pie is cut into a million pieces, each practice will get a very small amount -- probably not enough to make any real difference. Then, physicians in the practice will need to keep seeing patients at their full-throttle rate, and how in the world are they supposed to supervise anyone? But, this is solvable -- presumably I could have a private group, have 4 learners, and then I see no one and supervise everyone they see, end up even or ahead. That's how we staff our clinics now. If it becomes a huge money maker, you'll see all sorts of clinics do this with probably lousy quality. If it's a money loser, no one will do it. So it would need to be set up so that it's basically even, or just slightly positive, to work. And if you're boosting resident salaries, that needs to be counted also.

5. Portability -- This is the trickiest part of the whole deal. Several people have suggested, and I agree, that part (if not much) of the problem is that residents are not free to leave one job for another. This has nothing to do with the match, it has everything to do with the ABMS requirements for a certain length of training, a strict cap on PGY census both from the ACGME and from medicare funding, and because programs are worried about taking a resident who is leaving another program. Taking a resident who leaves another program is always a risk -- if there were problems, they may continue; the curriculum at the programs may not line up, such that they don't know what they need to know, etc. But pure ambulatory community based training programs might be an ideal fit for someone who has not done well in a busy hospital environment -- not that the outpatient clinic isn't busy, but the skills and environment are different.

So, my thoughts: I think it's reasonable to consider community based primary care training. I think it would need to be more than just working for a private practice -- in order to see those "rare" things, trainees should work with specialists also. That makes the financial model much more complicated, as it will be difficult for an outpatient clinic to arrange for work in subspecialty clinics also. But this kind of model has been done before -- namely across the pond where trainees used to do "attachments" for 6 months at a time, some in general medicine, some in a specialty, etc. But that means moving / changing every 6 months, etc. So, although I support this idea in the abstract, I don't see exactly how it could really be implemented well, except at big medical centers -- which gets us back to where we are now.

 

[Perrotfish]

That is inconsequential for the point being discussed. If you think things are bad salary wise now, just wait until you give programs free reign to do as they please. Plenty of people who gladly pay to be accepted into something like ortho, derm, or ophtho. 50k is a bunch of money compared to 0k.

While that's certainly possible, that hasn't been the result in the other industries that do things the free market way (i.e. all of them). Any engineer would kill to have Google or Apple on their resume, its a golden ticket in the tech industry to have that kind of experience. However the top firms don't charge the junior engineers for the experience, they actually pay way above the market average. Ditto accountants, lawyers, business majors, finance guys, and midlevels. Top firms pay top candidates more, even while they're giving them the kind of top tier experience that builds their resumes. Top firms always care more about getting better talent than the competition more than they care about saving a few bucks by suppressing wages.

 

[VA Hopeful Dr]

While that's certainly possible, that hasn't been the result in the other industries that do things the free market way (i.e. all of them). Any engineer would kill to have Google or Apple on their resume, its a golden ticket in the tech industry to have that kind of experience. However the top firms don't charge the junior engineers for the experience, they actually pay way above the market average. Ditto accountants, lawyers, business majors, finance guys, and midlevels. Top firms pay top candidates more, even while they're giving them the kind of top tier experience that builds their resumes. Top firms always care more about getting better talent than the competition more than they care about saving a few bucks by suppressing wages.

And that might very well happen, but I tend to think not. Law, accounting, and Google all pay well from the start because they want to get and keep talent. Residency programs rarely keep us after graduation. Plus, we are not in a very good bargaining position. We need them far more than they need us. The same is not as true for the other situations you mentioned.

 

[W19]

Amazing to see attendings making 250k+/year who graduated 10+ years ago when tuition was not so high against residents getting a fair wage...

 

[chipwhitley]

And that might very well happen, but I tend to think not. Law, accounting, and Google all pay well from the start because they want to get and keep talent. Residency programs rarely keep us after graduation. Plus, we are not in a very good bargaining position. We need them far more than they need us. The same is not as true for the other situations you mentioned.

We only need them because we gave them the power. We can't get a job without them. If we were like any other healthcare professional (dentists, midlevels, etc) and could get licensed and work as a PCP right out of school, with residency as an option to further specialize, the situation would be very similar to the others mentioned. Of course this would require a massive overhaul of our education system, but I think that is long overdue.

 

[VA Hopeful Dr]

Amazing to see attendings making 250k+/year who graduated 10+ years ago when tuition was not so high against residents getting a fair wage...

So much wrong in this.

First, I'm only 5 years out and tuition at my school has only gone up 10k/year in that time while interest rates are unchanged. If an extra 40k in loans (which would be from 160-200k over 10 years is that big a deal for you, I would suggest you have some problems with math).

Second, since I opened my own practice 7 months ago I have not been paid once. I won't likely hit 250K for at least another 1-2 years and then will likely never make much more than that. Family doctors aren't surgeons.

Third, y'all keep getting caught up in this "fair" wage thing. 55k/year is reasonable. Could residents be paid more? Probably. Could they also be paid less? Definitely. There are so many better places to spend your outrage than this though.