Why do residents make so little?

[shan564]

A lot of people on this thread don't seem to understand how supply and demand works to determine prices/salaries.

If it were easy to raise the salary, somebody would have done it by now just to attract better residents, who can subsequently take care of more patients with less supervision and make more money. Hospitals haven't formed a large cartel to control salaries. You get paid whatever the market determines your value is.

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[colbgw02]

And who wins financially? It's a very basic point here. By having residents, who do a ton of the work, at 50k or so a head, vs. 400k for a regular radiologist or more for a nighthawk, do you think the program is benefitting? Clearly the answer is *yes*.

This idea that all programs are this ivory tower gleaming with knowledge and hours of teaching is absurd. Most of the money is simply pocketed, and "teaching" happens in pockets here and there.

Let's do a little math.

Let's assume a program has 40 residents and that the residents read at a very high level, which - having seen the numbers at multiple programs - is around 6000 studies per year for an upper level resident. That's 240,000 studies a year read by residents. A busy private practice radiologist can read 24K in a year, which would translate to just 10 attendings to read the same studies. But let's assume that this private practice is a "lifestyle" one and only expects 18K studies per year. So, this private practice only needs 13.3 radiologists to do the work of 40 residents.

If those private practice radiologists were to serve as staff at this residency, that's a 3:1 ratio. Let's also assume that the ACGME RRC would throw a hissy fit if there were a 3:1 resident to staff ratio, so let's set that generously at 2:1, corresponding to 20 radiologists (in actually, it's typically much closer to 1:1).

Obviously, in this construct, anything that the faculty radiologists read without the residents is not relevant.

So, on one hand, we're paying 40 residents at $50K per annum and 20 staff radiologists - let's say $300K per year - for a total cost of $8MM. On the other hand, we can pay 13.3 staff radiologists - let's say at $400K per year - for a total cost of $5.32MM and a savings of nearly $2.7MM. And we still haven't calculated a dime for administrative costs of 1) having residents or 2) employing nearly 47 more people. Those 13.3 staff radiologists would have to be paid over $600K per annum to just break even with the cost of having the residents around.

There is no doubt that having a residency is a lifestyle choice that benefits attendings. And there is no doubt that having residents has benefits, many of which are important and worthwhile. But the idea that residents make attendings more efficient is a classic cart before the horse example. The attendings have become less efficient - and in some cases institutionalized - by the practice type permitted by the residents. That is a different, albeit it subtlety so, point from saying that residents make attendings more efficient.

 

[neusu]

Fundamentally, every program works as a business. The medicare allocation per resident has been shown, the average resident salary has been shown. Yes, there is a difference because of insurance.

Let's do a little math.

Let's assume a program has 40 residents and that the residents read at a very high level, which - having seen the numbers at multiple programs - is around 6000 studies per year for an upper level resident. That's 240,000 studies a year read by residents. A busy private practice radiologist can read 24K in a year, which would translate to just 10 attendings to read the same studies. But let's assume that this private practice is a "lifestyle" one and only expects 18K studies per year. So, this private practice only needs 13.3 radiologists to do the work of 40 residents.

If those private practice radiologists were to serve as staff at this residency, that's a 3:1 ratio. Let's also assume that the ACGME RRC would throw a hissy fit if there were a 3:1 resident to staff ratio, so let's set that generously at 2:1, corresponding to 20 radiologists (in actually, it's typically much closer to 1:1).

Obviously, in this construct, anything that the faculty radiologists read without the residents is not relevant.

So, on one hand, we're paying 40 residents at $50K per annum and 20 staff radiologists - let's say $300K per year - for a total cost of $8MM. On the other hand, we can pay 13.3 staff radiologists - let's say at $400K per year - for a total cost of $5.32MM and a savings of nearly $2.7MM. And we still haven't calculated a dime for administrative costs of 1) having residents or 2) employing nearly 47 more people. Those 13.3 staff radiologists would have to be paid over $600K per annum to just break even with the cost of having the residents around.

There is no doubt that having a residency is a lifestyle choice that benefits attendings. And there is no doubt that having residents has benefits, many of which are important and worthwhile. But the idea that residents make attendings more efficient is a classic cart before the horse example. The attendings have become less efficient - and in some cases institutionalized - by the practice type permitted by the residents. That is a different, albeit it subtlety so, point from saying that residents make attendings more efficient.

I don't think this has ever been a question. You can go in to academics, and have residents do your job, or you can go in to private practice, and pay a PA/NP to do it..

Guys, the writing isn't even on the wall, it's already they're taking our jobs. There is no use going in to primary care any more, the mid-levels already have it. You'll be competing against someone who has merely an undergraduate degree and 2-years of debt, no residency. They can undercut you left and right. I hope your patients stay with you, because they deserve it, instead of the "let's just send them to the ER" mentality

 

[Law2Doc]

...
As for your last comment, sure you do. Work cannot always be enjoyable. For most people, doctors included, its not. It's a means to an end. It provides context and meaning in life for most of us, but it would be a stretch to say that it is an enjoyable job (except dermatologists. They're a pretty happy lot)

Speaking as a career changer, if you don't enjoy what you are doing, you get off your a$$ and change it. You aren't some guy locked into a minimum wage job because you can't hack anything else. People intelligent enough to do medicine are intelligent enough to do almost any job, and a true case of 'golden handcuffs" forcing you to work at something you don't enjoy forever is rare and usually more of a mental construct than a reality. So yes, if you don't enjoy what you are doing, or still have the mindset that maximizing wealth is the goal and happiness be damned, that's really sad. I disagree that for most professionals (as opposed to Walmart stock boys and gas station attendants) employment is just a means to an end, or that all jobs suck. I'd say that's really a cop out by people too scared to go out and find something that actually gives them career satisfaction.

We spend the majority of our lives at our job. If you don't enjoy it, you have wasted the bulk of your life. You don't get that time back. It's yours to waste or not, but don't be that cliche guy who pretends that "my job sucks, so everyone's must". Because it's actually not true. Misery loves company but you can't create company pretending everyone else is miserable. There are people who find more career satisfaction than others and it's mostly because they don't have that cop out attitude, and if something is bad in their life they do something about it. Which is why I think the academics you are poking fun at might actually ave a big leg up on you by being "strangely enamored with pointless research" . Guess what -- they found something to be enamored about, and are sitting in their ivy towers enjoying life and laughing at all the poor sods in private practice who hate their jobs. You are just working as a means to an end, they actually enjoy some aspects of going to work. In the game of career satisfaction, which is what actually matters with this huge block of your life, guess who wins?

 

[Chickenandwaffles]

Let's do a little math.

Let's assume a program has 40 residents and that the residents read at a very high level, which - having seen the numbers at multiple programs - is around 6000 studies per year for an upper level resident. That's 240,000 studies a year read by residents. A busy private practice radiologist can read 24K in a year, which would translate to just 10 attendings to read the same studies. But let's assume that this private practice is a "lifestyle" one and only expects 18K studies per year. So, this private practice only needs 13.3 radiologists to do the work of 40 residents.

If those private practice radiologists were to serve as staff at this residency, that's a 3:1 ratio. Let's also assume that the ACGME RRC would throw a hissy fit if there were a 3:1 resident to staff ratio, so let's set that generously at 2:1, corresponding to 20 radiologists (in actually, it's typically much closer to 1:1).

Obviously, in this construct, anything that the faculty radiologists read without the residents is not relevant.

So, on one hand, we're paying 40 residents at $50K per annum and 20 staff radiologists - let's say $300K per year - for a total cost of $8MM. On the other hand, we can pay 13.3 staff radiologists - let's say at $400K per year - for a total cost of $5.32MM and a savings of nearly $2.7MM. And we still haven't calculated a dime for administrative costs of 1) having residents or 2) employing nearly 47 more people. Those 13.3 staff radiologists would have to be paid over $600K per annum to just break even with the cost of having the residents around.

There is no doubt that having a residency is a lifestyle choice that benefits attendings. And there is no doubt that having residents has benefits, many of which are important and worthwhile. But the idea that residents make attendings more efficient is a classic cart before the horse example. The attendings have become less efficient - and in some cases institutionalized - by the practice type permitted by the residents. That is a different, albeit it subtlety so, point from saying that residents make attendings more efficient.

Perhaps you work at some ivory tower type place, but most places are not like that and mine certainly wasn't. Like I stated, all procedures would be done by us in my program, attendings never did them nor did they even know how to do them for many of them. 2:1 ratio? Laughable. There were about 10 attendings for 13 residents TOTAL, with 3 different sites being covered, meaning that in the actual program on a daily basis there were maybe 6 attendings. Your numbers are far off, way off. Why do you think a private group would have a residency program, because they are losing so much money? Oh right, because it rocks having residents take your night call and weekend call and still collect 400k without having to pay nighthawk, or making 200k and having to work at an academic place.

 

[colbgw02]

Reading is fundamental. I said 2:1 resident to staff ratio, not staff to resident ratio. The fact that you had 10 attendings for 13 residents actually strengthens my argument because it means that hypothetical program has to pay for more like 35-40 attendings, instead of 20. It's also more in keeping with my experience (see parenthetical comment above where I said it's typically closer to 1:1).

You keep bringing up the procedures, as if that has anything to do with anything.

 

[Perrotfish]

A lot of people on this thread don't seem to understand how supply and demand works to determine prices/salaries.

If it were easy to raise the salary, somebody would have done it by now just to attract better residents, who can subsequently take care of more patients with less supervision and make more money. Hospitals haven't formed a large cartel to control salaries. You get paid whatever the market determines your value is.

Yes they have formed a giant cartel to control salaries. They collude to hire you through a giant centralized process to make sure that no one ever gets offered anything more than everyone else. They collude to blackball you if you quit or are fired, ensuring that a resident can't quit a job for one that's more lucrative or humane. They have conspired to lobby for one of the greatest feats of regulatory capture in American history: convincing the government to pay 100% of the salaries of their employees. These are all practices that are illegal in any other industry, and they are the classic characteristics of a trust.

 

[Chickenandwaffles]

Reading is fundamental. I said 2:1 resident to staff ratio, not staff to resident ratio. The fact that you had 10 attendings for 13 residents actually strengthens my argument because it means that hypothetical program has to pay for more like 35-40 attendings, instead of 20. It's also more in keeping with my experience (see parenthetical comment above where I said it's typically closer to 1:1).

You keep bringing up the procedures, as if that has anything to do with anything.

Like I said, 10 TOTAL attendings on a good day, covering numerous sites, with a handful of attendings in the actual place of the residency, which means that the "teaching" is non-existent. I keep bringing up procedures because they pay thousands of dollars, all billed by the private group, that is additional income that is solely resident generated, that attendings would also fail to bring on their own. I don't know where you are getting the 35-40 attendings from, that makes 0 sense to me.

Reality is that for most programs, and institutions, the places would fall apart without residents, reasons why hospitals and institutions keep having residents, not because in any way shape or form do these places lose $ by having residents around.

 

[colbgw02]

Welp, I give up. Enjoy your game of checkers.

 

[ferning]

Not sure if anyone brought up indirect gme funding, the 120k is only the direct

That should squash the argument

Ratio of resident to beds increases medicare payments by as much as 40% for teaching hospitals, its tagged on to everything. Even if they dont have a radiology program payments for imaging are increased

 

[Raryn]

Not sure if anyone brought up indirect gme funding, the 120k is only the direct

That should squash the argument

Ratio of resident to beds increases medicare payments by as much as 40% for teaching hospitals, its tagged on to everything. Even if they dont have a radiology program payments for imaging are increased

The direct funding is only ~$50k. The remainder is indirect.

 

[ferning]

I dont think we are talking about the same thing

google direct and indirect gme funding

I don't see how it could be allocated before a hospital bill is even submitted for payment. And that its the ratio of residents per hospital bed that determines the multiplier, not 70k per resident of indirect funding per year

I'll post the slide show I found online that explained it, but maybe I misunderstood

its all a scam anyway, residents increase clinical billing to medicare and supposedly more so than other providers because they are inexperienced and order more tests. The hospital (mostly private entities these days) increases their gross revenue from this.

Plus they get the salary of their labor, residents, paid for by the public (medicare wage tax).

public money funds private interests, the privatization trend thats bankrupted our society.

these private hospitals and systems maybe "nonprofit" to the IRS but that doesn't mean individuals are not profiting from this structure. These private nonprofits are not accountable to the public like a state or county hospital is. They don't have the same restrictions with contractors, disclosure of finances, investments,;or a fidicuary relationship to serve the public.

They just need to show at the end of the year there is no profit going to individuals or corporate entities part of the organization.

Their contractors can make all the profit they want and they can invest income into for passive income into ventures where others profit (when this money could have been better utilized improving services to patients or paying their workers better-which includes residents)


That's why privatization exists, it makes corruption and the misuse of public funds less risky and easier.

They don't have to report their finances as extensively, they don't have the same competitive bidding practices for contractors, revenue from the public isn't earmarked, and they can invest excess revenue for future passive income.

For all intensive purposes, they facilitate the maximization of profits for private for profit entities. The big boys who pocket the 2.5 trillion a year in healthcare expenditures. Insurance companies, pharm, IT, medical devices/supplies, labs/imaging centers

Those who have no restrictions on their revenue and whether it even stays in the US or ends up in an offshore bank account.

Why else would a private nonprofit hospital be so interested in EMR data and require their workers to waste so much time documeting each data point? that takes away from actually thinking about a patients condition and treatment plan and fatiguing a worker

That data is shared amongst all the big boys for marketing and commercial r&d that should be of no consequence to a private nonprofit hospital with a mission statement of providing healthcare.

Just know the real obstacles in life. Why patients don't improve and continue to get readmitted in worse condition. Even the education that supports clinical practice isn't free from corruption, so given adequate labor coverage and conditions I am not convinced of the safety when practicing medicine.

 

[ferning]

Having a teaching program absolutely benefits a hospital financially vs the equivalent of private attendings/PAs

You know how I know this? Because private "nonprofit" hospitals would not have residency programs if they did not benefit them financially!!!!

You know how I am sure? Because these hospitals and healthcare systems are actively seeking out residency programs for their hospitals and increasing their numbers!!!

They are not required to have a residency program in any way, shape, or form and would close their program at the drop of a hat if it benefited them.

Even though they are nonprofits, they are corporate entities and run like for profit ones in most ways. The decision makers are still CEOs and CFOs who only know how to run organization one way, maximize the bottom line. If that bottom line can't be used to reward shareholders, its invested to increase next years revenue. Or its used to grow by buying out a larger share of the market to ensure their organizations long term viability.


Serving the publics best interests is clearly not important in a private entities decisions because all that revenue comes from the publics pocket. And a large part of the cost to produce that revenue is paid by the public through the medicare wage tax.

Long term morbidity and mortality of the community isn't a factor, its almost totally irrevelvant from what I see.


It stuns me how physicians and students are so indoctrinated that they actually prioritize "cost saving" measures, a CT rather than an MRI. Another portable xray. Who exactly are reducing costs for?

Do you think theres going to be a left over pot of money that will be spent on building homeless shelters, stocking food pantries, and increasing vaccination rates? Do you think people are going to get a refund of their medicare wage tax? You're out of your mind if you think so

If you aren't then you should realize you are "cost saving" for anybody, you are maximizing the amount of profit that can be made from the limited amount of healthcare dollars that is available. On a per patient basis and on the larger scale of whats available in medicare/medicaid budgets.

Insurance, pharm, healthcare facilities, IT, and medical devices are not in direct competition with each other. They have an interest in facilitating the profits of each other, medical providers on the other hand do not.

PS
Residents are a young healthy group, so they actually lower medical, life, and disability insurance premiums for the rest of the employees.

Residents don't require the same costs when it comes to retirement funding as well vs a full time employee NP/PA, who isnt on a year to year contract

Residents are not paid overtime or holiday premium wages like a NP/PA employee would

As a labor group, residents are clearly more productive and effective if you average it out over pgy years. The fear factor alone that you will get bad evaluations, be publicly humiliated, or not have your contract renewed buys alot of extra effort
Plus they provide the labor of teaching medical students who provide huge revenue to these hospitals in the future wage tax called tuition.


A

 

[Law2Doc]

Not sure if anyone brought up indirect gme funding, the 120k is only the direct

That should squash the argument

Ratio of resident to beds increases medicare payments by as much as 40% for teaching hospitals, its tagged on to everything. Even if they dont have a radiology program payments for imaging are increased

I think this cuts the exact opposite way you are suggesting. It doesn't suggest residents themselves generate income and are valuable, it means the government has to sweeten the pot a lot just to make hospitals take that otherwise undesirable undertaking. Having worked with hospitals that ultimately decided to make more money by foregoing the onus of being a teaching hospital, I can assure you that residents are much more of a drain then a cash cow. You seem to want to average residents productivity out over PGY years, so you understand that more senior residents are valuable while more junior are not but you ignore the fact that in general, thanks to prelims, many residencies are pyramidal in structure, with many more people in their initial years than seniors. Its not uncommon to see surgery or medicine programs with a ton of interns and only a few categoricals per year, so when you average them out the intern drives the productivity level, not the senior ( who I agree might actually be doing useful work). And you focus on health, life, disability insurance when everyone else is talking about med mal, a much much bigger number for young an inexperienced doctors. Yes residents help teach med students but so do attendings, who again get slowed down by the process -- I think that's part and parcel of foregoing income to be a teaching hospital -- the tuition offsets the drain caused by med students much as the resident stipend offsets the drain caused by the residents.

In the end, the fact that the private practice across the street is seeing twice the patient volume as the academic center, thanks to no teaching obligations is the number you need to justify before you can show that residents add any value on their own. The more evidence you provide that the government has felt the need to sweeten the pot, the more you argue that you have to average out PGY years, the more you focus on small ticket items like life insurance, the more you undermine your argument.

 

[Doctor Bob]

I can only speak to EM programs, but having residents certainly costs us money and decreases our productivity. The staff can see patients much faster without residents; our left-without-being-seen rate drops on staff-only days and the door-to-discharge time drops off dramatically. Staff can each cover 16-20 beds by ourselves, but when residents are added in, the number of staff has to be increased in order to provide adequate supervision; so we end up each covering only 8-9 beds (and there is a lot of time sitting around twiddling our thumbs).

But our situation is probably not applicable to other fields because most other specialties have prolonged periods of time where the residents are acting without direct supervision whereas in the ED the attendings are always around.

 

[ferning]

How did I focus on small ticket items? Mentioning it once.

Oh malpractice, well hospitals self fund. They dont buy malpractice on an open market like an individual physician. They fund themselves internally, its called captive insurance. They become their own insurance company and get to take hospital revenue and put it into a fund where the profit that they cant make can be put into.

http://en.m.wikipedia.org/wiki/Captive_insurance

The IRS was very generous with this structure allowing them to write off premiums they pay to themselves, even if the money isn't paid out in a case. So lets hear the huge costs you are referring to and then realize that its not a real cost because they just paid themselves. Even into offshore bank accounts!!!

It can be invested as well while in the fund, as long as a reasonable cap is met, so future returns which were formerly payments from medicare/managed care isn't ear marked for patient care. This frees the corporate structure to pay themselves well and have money for other healthcare related ventures like lobbying for their interests at every government level for the vote that counts.

Here's another link to further confuse you, so maybe you won't take every reported "cost" told to you by a superior or reported in financial statements so literally.

http://www.captive.com/experts/popups/HospitalCaptives.html

In the end its a fixed labor market to keep resident wages and attendings by that effect lower. Residents and fellow make up a significant portion of clinically active physicians where you control downstream wages as well. Your department budget is not above the larger labor market, which could increase your demand and salary.

Furthermore, I never undermined my argument cause like you said they can choose to be a teaching hospital or not. If they choose to be then residents make "financial sense" which was the point I was suppprting. Which means they are not a drain or cross the hospital needs to bear, but benefits them financially in the end.

How payments are actually calculated is in the link below

http://lobby.la.psu.edu/011_Grad_Me...on/AMA_Medicare_Calculations_GME_and_IMEA.htm

And yes the teaching service takes longer, but the cost to pay an attending to work nights, weekends, holidays and to take call is a net financial benefit. Plus the med student on that service is paying upwards of $500 to be there to offset things. You forget its not the cost of an attending to cover these off hours at the present wage, but the future after this increase demand. Paying a physician to be on call increases physician labor demand which will increase the market wage.



I did not say "cash cow", but oh the hospital has the public subsidize labor cost directly, plus medicare repayment premium, plus keeping like 20% of the active physician wages fixed lower. The revenue a resident will bring in, not just your department but all departments varies. I thought my argument was clearly focused on a hospital's overall financial picture so I'll say now it is.

And sure I agree it is work for attendings to have residents, but this was never part of my argument. Your salary is of no pertinence and I'm sure you deserve every penny. And the way you describe it, it sounds the HOSPITAL should hire another attending to help. Attendings are labor and are in the same boat as residents, but I just find the GME situation particularly abusive to labor and beneficial to private entities. So maybe retorts like yours worked in your law school mock trial for a passing grade, but not in print.

I don't know why it has to turn into an argument where this worker group should get less because "I'm working harder". You're not being paid from the same limited pot and because you both produce revenue even before you get paid, you actually have no cost.

For the second guy, of course "staff" which I guess means attendings is more efficent than junior residents, but they cost more and not by the GME direct and indirectly

An attending is not the person deciding whether a healthcare system will start a residency program, its a board of directors or CEO.

Just the facts that a CEO is not going to pursue adding residents or a hospital to their system with more residents because they are a financial drain. Maybe its a financial drain on you personally or your department, but thats not my argument or the issue

And for a counterpoint to your anectdotal evidence, an EM program PD told me a resident brings about 1 million in revenue over their 4 years.

Your staff to bed ratio and you twiddling your thumbs really doesnt add weight against financial benefit of residents though. I haven't seen a part time EM program either that has shifts without residents to cause this "staffing" issue either. You just double up on PAs like that? Or $10 techs?

I mean you guys must have the worst residents ever, blithering idiots. For EM too i cant believe even interns cant hit the ground running and help with BS paperwork. Maybe while you are twiddling your thumbs you can actually teach the residents which it doesnt sound like you are.


Oh I just realized, If you arent able to get bonus benchmarks because of slow residents you take a financial hit. But you don't receive a similar bonus for teaching, hence you twiddling thumbs.

Guess what??

Thats a financial bonus for your employer, the hospital, as well because they don't have to pay out that 20-30k. On top of free medical resident labor, tuition from med students, higher reimbursement rate for all medicare payments, and the ability to pursue other revenue such as grants and research money. Thats a cash cow compared to the previous revenue streams available before becoming a teaching hospital. Its diversfied and what a hospital CEO would want not you chugging away in the ED

 

[ferning]

Ok I saw you are military academic so clearly your point of view is not germane to my argument made. But response applies to the other 99% of GME EM spots

For the military its a cash cow as well or else they would not front tuition at every medical school, they own you for 8 years after. Let's save the argument on the atrocity that is military servitude and exploitation of young low socioeconomic labor for private interests for another time.

I imagine you could find plenty of other non academic ED attending positions if you wanted. Maybe in the middle east or alaska but the drain residents have on your productivity must be worth you staying. Clear out the ED and take a nap for all I know.

But you guys seem like the type to argue with a person just to argue and I don't see your vested interest in letting people think GME funding is not profitable for hospitals. It is and some departments profit more than others and other attendings and staff have extra work which they should take up with their employers, the hospital, if it is inadequate.

The trickle of money that makes it your way for middle managing residents and keeping your future colleagues marginalized is not worth it in my opinion.

The fraternal hazing aspect should have gone out the door when people have invested hundreds of thousands of dollars for a GME spot. In so facto subsidizing their position beyond medicare funding.

That 120k may exist on the reported GME annual funding but how money actually changes hands between the government and hospitals is likely less straightforward like all government programs.

Each government/corp level owns the bonds of another (fed, state, city, higher education, health system, hospital). So what net transactions occur in a budget year is hard to gauge, except one fact that people lose money from their paychecks in taxes and privatized entities providing social services like healthcare increase their assets. These assets are bonds, equity securities, mutual funds, interest swap agreements, leaseholds, and real property. Restricted assets can become unrestricted and private contractors allows profiteering. Money that should rightfully be spent on community investments, increasing indigent care resources, allowances for patient bad debt.

Look at a healthcare systems IRS 990 form to see the financials involved for yourself. When billions is collected in patient revenue, hundreds of millions sit in excess liquid assets, 2 million in lobbying, and 10 million to indigent care or community investment. Then you can see the veracity of a "nonprofit" 501c3 mission statement.

And recourse? Futile when all resources are owned by a private entity, fueled by public money yearly. No capital investment available for alternatives and healthcare is monopolized anyway


Money paid out is indirect GME based off billing, multiplied by the ratio of residents to increase to medicare repayment up to 30-40%. For every image, test, RVU, etc.


That plus direct gme is a cash cow compared to a PA who yields no repayment premium, demands higher wage/benefits but ok less malpractice, and better working conditions.

And I have yet to meet a PA thats better than a PGY2. Surgery, cardiology, EM. There arent that many and the education differential shows. They are often older too and transitioned from other careers, costing more than a young worker.

If a medical school grad passing 2/3 of the licensing exams for an avg 65 hrs a week of exempt labor isn't, than we should let hospitals dictate it on an open market.

Without the cross to bear of guaranteed GME spots with a PC and other upfront funding, besides the billing premium. I'll bet the farm that we will see that it is valued as a cash cow or why have this arrangement????

Spots are allocated on a per state basis and in fortuity to hospitals that can dissolve the program leaving residents with years left in the lurch, just a year to year contract with the residents. They look pretty protected to me in this relationship from negative financial implications. We don't hear of hospitals trying to lower their spots or asking another hospital to bear the cross. They even have the option of closing select programs at their hospital if its financially beneficial to them.

Attending salaries would rise if these 125k physicians in GME spots were left to market forces or not fixed totally.

 

[SoCuteMD]

Nevermind, my point was already raised.

 

[deleted128562]

I will totally echo ferning on this. A few years ago I worked for a hospital system where it would have surprised no one if an administrator sold his mom to the slave trade for $5 and a bag of skittles. These guys thought nothing of changing the policy to only pay OT to nurses when they went over 40 hours instead of when they went over 36 (the normal full time hours for a nurse working 3d X 12h), because it would save the hospital like $50,000 in a year. They took away our high quality iSTAT cartridges and replaced them with total crap because it was going to save the hospital something like $1000 a month. They banned employees from using hospital scrubs unless they were working in the OR because of the laundry bills. And yet these very same administrators kept working to ADD residency slots within the system. So yeah, I'm just sure the hospital system was losing money on them.

Besides which, I find it generally OFFENSIVE for anyone to imply that a 24 year-old PA working 40 hours a week is worth $80K plus benefits to the hospital, but a resident who went through 4 years of med school and is working 60-80 hours a week with salary fully funded by CMS, is losing the hospital money. Stop and think for a minute what that implies about residents. (No wonder midlevels think they can take over our jobs!!) If that is really the case, then President Obama should issue an executive order to bulldoze every medical school in the country immediately, because evidently medical schools cannot do nearly in 46 months what a PA school can do in 26.

 

[ferning]

The information is there for anyone to see themselves: 990 forms, quarterly statements, annual audited. State Bond authorities. Insurance company accounting is quite different though

Here's an example from first page search results

https://www.vidanthealth.com/vidant/dynamic-detail.aspx?id=11996

I don't know if this a system with more ethical finances or not, but you can see with how many separate entities used it takes effort not to show profit.

Its not a hospital making 10 million and providing 11 million in patient care related services in the "red". If it was they would show that on the returns, but when they can't they get creative and spread money around internally without a thought of how it could be used in terms of their mission statement.

Guidestar.org has reports on others

Look at the effort that goes into it with slideshow by internal auditors

http://www.withum.com/pdf/Healthcare_news/PPT/Governance_July2012.pdf

Does that sound like the effort and concerns of a charitable organization? One of the many running in the "red"? They are concerned about people seeing their finances

 

[rokshana]

its 3 years(from some maybe 5) for heaven's sake! your getting paid a median wage (which is 51K in this country) for a short time and them you get the chance to join the top 10% of US population by earning 6 figures…

that 24 yr PA is going to be close to his top earning potential…you are not.

and seriously? you think that the programs don't have to put ANY money other than your salary into training you?

they are in it for making money…and unfortunately academic programs run in the red…they are not going to chuck out any money outside of what CMS gives to give you a 80-100K salary…and its not like other specialties don't do the same…at least we get paid for our training…law student do unpaid internships, work like dogs as 1st year associates that get paid little, college athletes are banned form taking any money for playing and the universities make MILLIONS off of them…

and as was said before…you don't have to choose this path…you could have just graduated from college and gone out into the work force…or gone the route of the 24 PA and skip the 4yrs med school and residency and could now make that 80K (with a top salary of maybe 120K). And its not like it suddenly changed in the 4 years you started med school…resident pay sucks in comparison to an attending salary…but you know what? if you compare your salary to the rest of the staffing at a given hospital…your right there in the mix.

 

[deleted128562]

its 3 years(from some maybe 5) for heaven's sake! your getting paid a median wage (which is 51K in this country) for a short time and them you get the chance to join the top 10% of US population by earning 6 figures…

that 24 yr PA is going to be close to his top earning potential…you are not.

and seriously? you think that the programs don't have to put ANY money other than your salary into training you?

OK you're right. Hospitals are losing tons of money on residents. I forgot about the well-guarded secret that CEO's at private hospitals just love losing money for their shareholders, and shareholders just love losing money on their investment, if it's so they can tell their friends and family that their hospital teaches residents. What was I thinking?

As for comparing my salary to the rest of staffing at the hospital, you're right. Nurses make about the same as I do. Which I suppose is fair considering all the nurses at my hospital work 80 hours a week and do 16-30 hour call shifts for that salary.

 

[ferning]

Yes, you clearly haven't spent much time in a hospital if you don't see the amount of labor with nominal educational value a resident puts in for the amount of education with some cost outlay.

I apologize if I brought this to degrading other providers because in the end were in the same boat. And we need more clinical practioners of all types, there is plenty of work to go around with adequate wages if the whole financial picture is looked at.

A person's labor value and wage is more than their education and training too. There are physicians I wouldn't pay 10 cents to see a patient and there are healthcare workers without a high school diploma I'd pay $100k a year and it be money well spent.

But if the same person spent 6 years in training or just 3 years, I'd generally pay the person with 6 more for same hours. But this doesn't mean I would pay higher wages for the 3 years, with the difference I make by enacting unfair labor practices to keep 6 years of trainig wage fixed low. I pocket that if I'm a CEO. And the person with 3 years now has to do more work without the benefit of additional training, but for the same wage.

But you're point is offensive, who are you to tell anyone else what they should do with their days let alone 3 years? You don't get a vote in deciding what conditions another person accepts in a job, doesn't accept, or at least would like to express their concerns.

And the game has changed since people entered med school post 2008 financial collapse and tuition increasing by 50% since acceptance, at rates that are high with huge margins, and now treated like irrevocable tax debt. People make misinformed decisions too and should still be allowed to voice their concerns without backlash

Having coworkers that put up with unfair labor practices just means you are more at risk for the same. I could totally see a healtcare system lobbying their state for 1 year of post graduate PA years for 40k a year. Or 3 years for surgery or 2 years for cardiology and without it your job prospects are limited. Thats the way it goes when corp sees what conditions labor will put up with, we are all a cost

And we shouldn't be talking in the financial terms of capitalism, healthcare is a societal service with cost. Think of it like you fire squad or public school, not google. The inappropriate and bankrupting cost is when private entities increase their assets.

 

[deleted128562]

Having coworkers that put up with unfair labor practices just means you are more at risk for the same. I could totally see a healtcare system lobbying their state for 1 year of post graduate PA years for 40k a year. Or 3 years for surgery or 2 years for cardiology and without it your job prospects are limited. Thats the way it goes when corp sees what conditions labor will put up with, we are all a cost

QFT. Times 10.

 

[padastra]

Let's assume a program has 40 residents and that the residents read at a very high level, which - having seen the numbers at multiple programs - is around 6000 studies per year for an upper level resident. That's 240,000 studies a year read by residents. A busy private practice radiologist can read 24K in a year, which would translate to just 10 attendings to read the same studies. But let's assume that this private practice is a "lifestyle" one and only expects 18K studies per year. So, this private practice only needs 13.3 radiologists to do the work of 40 residents.

Another issue with this type of calculation is that academic attendings and private practice attendings are fundamentally different, and so using a one-to-one comparison to extrapolate the marginal benefit (or cost) of having residents is not feasible. In my past rotation at a cardiac ICU, for instance, we have a cardiologist that comes and rounds with us for 3 hours in the morning (with a census of 15 patients). He then goes off to do some research or go to the cath lab for the rest of the day. Are you going to replace 24-hours of housestaff coverage with two cardiologists who are in the ICU for 3 hours a day? Obviously not.

Lastly, there's no market that magically pays fairly proportional to your added value. That is high school economics for those people who have only read the Sparknotes for Adam Smith and then came all over Ayn Rand. What you get paid has many factors, including the inefficiency of the market, lack of rational decision making, protectionism / monopolization etc.--and how much you need the job (e.g. if I found you in a desert dying of thirst, by "free market" rules I could ask you to pay your ****ing house--even if it cost me nothing to bring the water to you).

Does being in a desert dying of thirst sound like a ridiculous example? Ok, let's replace that scenario with a $200k degree which is worthless without doing residency.

 

[colbgw02]

So at (40/13.3) x $50-55k, that means you're getting a private radiologist-worth of work for just $150-165k, or a busy private radiologist-worth of work for $200k. Sounds like a deal to me, especially when that money is coming from the government.

This is not the appropriate way to calculate things because, in the academic setting, you have to pay for the resident AND the attending. The real calculation is private practice radiologist vs. academic radiologist (which, as you point out, is not a 1:1 calculation) + the residents. To use the same numbers, you can pay a PP attending $400K to read 18K studies, or you can pay 3 residents ($150K) plus greater than 1 FTE academic attending to do the same work. If the single academic attending makes $300K per year and reads about 12K studies (just to keep the numbers easy), then cost comparison is about $400K vs. $600K.

 

[rokshana]

Yes, you clearly haven't spent much time in a hospital if you don't see the amount of labor with nominal educational value a resident puts in for the amount of education with some cost outlay.

I apologize if I brought this to degrading other providers because in the end were in the same boat. And we need more clinical practioners of all types, there is plenty of work to go around with adequate wages if the whole financial picture is looked at.

A person's labor value and wage is more than their education and training too. There are physicians I wouldn't pay 10 cents to see a patient and there are healthcare workers without a high school diploma I'd pay $100k a year and it be money well spent.

But if the same person spent 6 years in training or just 3 years, I'd generally pay the person with 6 more for same hours. But this doesn't mean I would pay higher wages for the 3 years, with the difference I make by enacting unfair labor practices to keep 6 years of trainig wage fixed low. I pocket that if I'm a CEO. And the person with 3 years now has to do more work without the benefit of additional training, but for the same wage.

PAs regularly make low 100k with less debt and more work years, what do you get out of having residents make 50k a year with more debt piling and less work years for 200k later? If you think it has an effect on your job prospects or wage you are wrong.

Having coworkers that put up with unfair labor practices just means you are more at risk for the same. I could totally see a healtcare system lobbying their state for 1 year of post graduate PA years for 40k a year. Or 3 years for surgery or 2 years for cardiology and without it your job prospects are limited. Thats the way it goes when corp sees what conditions labor will put up with, we are all a cost

And we shouldn't be talking in the financial terms of capitalism, healthcare is a societal service with cost. Think of it like you fire squad or public school, not google. The inappropriate and bankrupting cost is when private entities increase their assets.

i certainly hope you are not addressing me with the comment of you haven't spent much time in a hospital…between med school, residency, working as a hospitalist , and now as a fellow i have spent the greater part of the last 8 years in a hospital…all, for the most part, poor, urban hospitals that take care of these who generally are self pay…you bet they run in the red…into the millions…

no one is saying residents don't work hard and long (and to those of us that did residency when interns did 30 hour overnight call or had no such thing as an 80 hour work week, they worked much harder for a lot less), but you are not getting paid an unlivable wage…most of the country lives on a salary less than that of the average resident….and yes, they have debt and raise families on that wage...

 

[padastra]

This is not the appropriate way to calculate things because, in the academic setting, you have to pay for the resident AND the attending. The real calculation is private practice radiologist vs. academic radiologist (which, as you point out, is not a 1:1 calculation) + the residents. To use the same numbers, you can pay a PP attending $400K to read 18K studies, or you can pay 3 residents ($150K) plus greater than 1 FTE academic attending to do the same work. If the single academic attending makes $300K per year and reads about 12K studies (just to keep the numbers easy), then cost comparison is about $400K vs. $600K.

Fair enough, I had actually re-read more carefully and edited it before you responded =P. I also edited because radiology is a bit different, where the attending has to essentially "repeat" a resident's work, whereas in e.g. IM the attending often is signing off on notes without the managing the floor aspect (which is a ton of work).

 

[colbgw02]

Fair enough, I had actually re-read more carefully and edited it before you responded =P. I also edited because radiology is a bit different, where the attending has to essentially "repeat" a resident's work, whereas in e.g. IM the attending often is signing off on notes without the managing the floor aspect, or putting in of a lot of small details (e.g. dose adjustments, fluid adjustments, etc.)

True. That whole hypothetical scenario I concocted doesn't work so well with other specialties where things get a lot more nebulous, as far as I can tell. I only ran with it because of the radiology-specific claims made earlier.

 

[padastra]

most of the country lives on a salary less than that of the average resident….and yes, they have debt and raise families on that wage...

What the average American makes, in my view, has very little relevance. If you are personally responsible for bringing in $10M in added-value to a company, you should command a salary that is proportionate. Obviously residents are not bringing in $10M each, but the point stands.

 

[deleted128562]

most of the country lives on a salary less than that of the average resident….and yes, they have debt and raise families on that wage...

I will acknowledge that my next door neighbor only makes about the same amount as I do. But then again he finished his education when he was 22, wakes up at no earlier than 7:00 every day, comes home to his family every afternoon around 4:30, never works a weekend or holiday, and spends most spring/ summer evenings tossing the baseball in the back yard with his kids while the steaks and hot dogs sizzle on the grill. He also has a pretty sweet retirement/ savings nest egg built up already. Oh, and if he screws up at work, no one dies or gets maimed.

 

[ferning]

50k for 80 hours a week is 25k a year, which is not the average salary anyway. No holiday or OT premium pay either, which even people on minimum wage get. A tenuous yearly contract is not what regular hospital employees get either, they have recourse and less fear not having that waived it front of them


To answer the title of this thread I think the historical reason residents are paid so low was back in the 60s, with the civil rights movement and public outcry at the conditions of the inner cities. The governments solution because they did not want to actually help anyone was medicare/medicaid and put all the fresh grads into GME spots at resource poor hospitals with the sickest, poorest people.

Actually a slap in face that still affects these communities, at least some of the older folks, who know would have friends and family walk into these places and never walk out. I mean you want to help someone you set them up properly.

yea we should continue to work long hours for low pay because thats what will equal good patient care.

Good things come to those who wait.....hard work is its own rewards....and all that bull

Indirect GME related to medicare DRG is all then, whether than DRG payment is on a teaching service. Even whether its a neurologist getting an enhanced DRG payment when a program doesn't have a neurology program. Hospital wide increased payments based on residentatient bed days

 

[DCBFan]

I will acknowledge that my next door neighbor only makes about the same amount as I do. But then again he finished his education when he was 22, wakes up at no earlier than 7:00 every day, comes home to his family every afternoon around 4:30, never works a weekend or holiday, and spends most spring/ summer evenings tossing the baseball in the back yard with his kids while the steaks and hot dogs sizzle on the grill. He also has a pretty sweet retirement/ savings nest egg built up already. Oh, and if he screws up at work, no one dies or gets maimed.

And that 51k median income is for the household, not the individual. Many residents are paired up with other residents so they easily out earn most Americans even in residency.

Your neighbor sounds like a smart guy though.

 

[rokshana]

I will acknowledge that my next door neighbor only makes about the same amount as I do. But then again he finished his education when he was 22, wakes up at no earlier than 7:00 every day, comes home to his family every afternoon around 4:30, never works a weekend or holiday, and spends most spring/ summer evenings tossing the baseball in the back yard with his kids while the steaks and hot dogs sizzle on the grill. He also has a pretty sweet retirement/ savings nest egg built up already. Oh, and if he screws up at work, no one dies or gets maimed.

when you are a resident, you really are that responsible for someone dying or maiming them…YOU might have caused it, but you do not take on the legal burden…your attending does…and tell that to the firefighter or policeman who risk their lives and sometime people DO die because of their actions…we are not the only ones who hold other peoples lives in their hand.

and did you somehow miss the fact that it well known that those going into medicine delay all of those things? that we delay earning, retirement, getting married, having children, etc? and even the fact that you make more in the ensuing years, you will never make up for the fact that your friend will have more in retirement because he started in his early 20s and you will have to wait until your 30s?

and there are plenty of people who work just as crappy hours, doing far more unpleasant work and get paid less with no change for advancement…you only have a somewhat crappy income for a very short time.

 

[rokshana]

50k for 80 hours a week is 25k a year, which is not the average salary anyway. No holiday or OT premium pay either, which even people on minimum wage get. A tenuous yearly contract is not what regular hospital employees get either, they have recourse and less fear not having that waived it front of them


To answer the title of this thread I think the historical reason residents are paid so low was back in the 60s, with the civil rights movement and public outcry at the conditions of the inner cities. The governments solution because they did not want to actually help anyone was medicare/medicaid and put all the fresh grads into GME spots at resource poor hospitals with the sickest, poorest people.

Actually a slap in face that still affects these communities, at least some of the older folks, who know would have friends and family walk into these places and never walk out. I mean you want to help someone you set them up properly.

But throwing a high concentration of inexperienced, overworked, low paid people was like screw you. "Let the new docs practice on you, then they'll come to our hospitals." Thats often why some inner city people wait till the last minute or till they stroked out to come to he hospital, the reputation and fear sticks for awhile. Especially with not a redress of damage.

But today we are all chicken mcnuggets of pathology box and sell. fellowships get pushed so people get paid minimum wage for 5 years what used to be 3 years.

We are not a healthier society when you look at the real measures compared to 40 years ago with clean stats. No magic pill to live forever but we are sold on everyone like it is cause its the biggest industry with our natural resources tapped, manufacturing off shores, and people stripped of owning land which they used to be able to make a living off of without all the BS or getting roped into a job.

Oh but yea we should continue to work long hours for low pay because thats what will equal good patient care.

Good things come to those who wait.....hard work is its own rewards....and all that bull

Oh but rokshana, poor people would waste away and die if they weren't given the gift of overworked low paid new medical grads right? Wrong its a slap in the face to them with 50 years of repercussions. Its not like you donate your salary now I'm sure living like a monk, low pay and bad hours weren't something you donated during residency it was something you were too chicken**** to do anything about

frankly i was fine with my pay as a resident and it wasn't an issue for me I've had jobs before that paid way less (including being an anatomy and physiology professor)and worked me as much…the fact that I was getting pain and not making tuition payments any more was great!…trust me those who know me that being a chicken**** is part of my personality…

and poor people waste away anyway…50 years later and we haven't really made that much of an impact in the healthcare in America…in fact i would say that 50 years ago more people got better care than they do now because they could actually afford to get care.

 

[Raryn]

its all a scam anyway, residents increase clinical billing to medicare and supposedly more so than other providers because they are inexperienced and order more tests. The hospital (mostly private entities these days) increases their gross revenue from this.

I don't even know where to start with ferning's minimally coherent rants up above. Could dissect them point by point, but I couldn't afford the time.

But I can say one thing about the one point I quoted: You have absolutely no idea of how billing to medicare works. Physicians bill day-to-day, so doing more procedures can increase revenue, it's true. But those are physician procedures.

The hospital bills, which cover all of the labs and all of the imaging are actually capitated. Whether or not the patient gets a daily CBC x 5 days, the hospital receives the exact same amount of money for the same patient admitted for the same diagnosis. Residents ordering more tests is actually a net loss for the hospital (at least when it comes to medicare patients) and makes the exact opposite point to what you were trying to claim. Now, not all the private insurances are capitated for inpatient admissions, but most hospitals keep the people with good private insurance off the academic teams.

 

[rokshana]

I don't even know where to start with ferning's minimally coherent rants up above. Could dissect them point by point, but I couldn't afford the time.

oh good…i thought i was the only one that couldn't make sense of some of his post...

 

[Igor4sugry]

I disagree significantly. Most hospitals cannot run without residents. Most attending are able to have much better/lighter schedules because of residents. In my residency for example, much is saved by not hiring attending staff to work nights/weekends/holidays because they are staffed by residents. All that would cost a ton if they had to hire an attending. Most attendings do much less work clinically than they would if they did not have residents. It is naive to think that attending do more vs. less work with residents!

Completely agree with this. Who else will work as hard as residents, combing over every note, every order, putting in all the orders, writing ridiculous amount of H&Ps, progress notes, discharge summaries, answering all the pages, running the codes, dealing with patient demands/nursing demands/social worker demands, etc.

 

[rokshana]

Completely agree with this. Who else will work as hard as residents, combing over every note, every order, putting in all the orders, writing ridiculous amount of H&Ps, progress notes, discharge summaries, answering all the pages, running the codes, dealing with patient demands/nursing demands/social worker demands, etc.

a hospitalist…and with a lot more patients on their census…the bonus is you get paid a lot more(and you're describing an INTERN…residents don't do all that stuff)

 

[colbgw02]

Completely agree with this. Who else will work as hard as residents, combing over every note, every order, putting in all the orders, writing ridiculous amount of H&Ps, progress notes, discharge summaries, answering all the pages, running the codes, dealing with patient demands/nursing demands/social worker demands, etc.

Some of this goes back to the point I was trying to make earlier about ancillary staff. Nurses, social workers, and - by extension - patients will bother a resident about all sorts of inane and asinine things that they would never dream of bothering a PP attending about. For instance, I remember fellow interns getting paged multiple times about soon-to-be, but not yet, expired PRN Tylenol orders on non-febrile patients in the middle of the night. In a teaching hospital, residents have to tolerate this behavior, but in private practice, this nurse would be sanctioned and possibly fired. Obviously this is an extreme example, but the point remains: not all work performed by a resident need necessarily be duplicated in private practice by an attending.

 

[Doctor Bob]

Maybe while you are twiddling your thumbs you can actually teach the residents which it doesnt sound like you are.

And you base that assumption on... what?

You went on a rather long rant based on an incorrect reading. So your points are meaningless to me.
What I said was... "having residents certainly costs us money and decreases our productivity"
You will note, I didn't say anything about the hospital, the GME department, the CEOs, the Bavarian Illuminati, etc.
Residents cost the individual staff money. When an EM group decides to form a residency, we do so because we enjoy teaching and are willing to take the pay cut. Nothing more. I don't have a dog in the fight of "do residents cost/make the hospital money".

So please don't rant and rave that we're (and specifically I'm) not teaching residents. Because it's just a bunch of crazy-talk to those of us who are willing to be paid less (sometimes significantly less) than market value for what we do in order to be involved in the education process.

 

[rokshana]

Some of this goes back to the point I was trying to make earlier about ancillary staff. Nurses, social workers, and - by extension - patients will bother a resident about all sorts of inane and asinine things that they would never dream of bothering a PP attending about. For instance, I remember fellow interns getting paged multiple times about soon-to-be, but not yet, expired PRN Tylenol orders on non-febrile patients in the middle of the night. In a teaching hospital, residents have to tolerate this behavior, but in private practice, this nurse would be sanctioned and possibly fired. Obviously this is an extreme example, but the point remains: not all work performed by a resident need necessarily be duplicated in private practice by an attending.

that resident probably pissed off the nurse…generally if you aren't a douche to them, that type of behavior doesn't happen…that "fellow" intern was being taught a lesson.

 

[Winged Scapula]

that resident probably pissed off the nurse…generally if you aren't a douche to them, that type of behavior doesn't happen…that "fellow" intern was being taught a lesson.

Not necessarily.

Many nurses have no idea that you aren't working an 8 hr shift and so think any phone call in the middle of the night is "fair" regardless of their feelings about the resident. Once I educated the nurses about our schedules these nuisance pages dropped dramatically.

 

[colbgw02]

that resident probably pissed off the nurse…generally if you aren't a douche to them, that type of behavior doesn't happen…that "fellow" intern was being taught a lesson.

nope. this happened to multiple people by multiple nurses from multiple floors, mostly on cross-cover patients where the physician didn't even work with the nurse. as WS pointed out, these are issues of ancillary staff having brain farts (or being lazy), which is tolerated to a much greater extent in academia because they can push around residents in ways they can't with staff. in PP, a nurse that bothers an attending with an inane issue does it one time, probably gets a talking-to by their supervisor, and corrects the behavior. that, or they pack their bags.

 

[rokshana]

Not necessarily.

Many nurses have no idea that you aren't working an 8 hr shift and so think any phone call in the middle of the night is "fair" regardless of their feelings about the resident. Once I educated the nurses about our schedules these nuisance pages dropped dramatically.

i think there are some calls that can be placed on that…but his example of a soon to be expired prn order? thats because the nurse doesn't like that intern...

 

[rokshana]

nope. this happened to multiple people by multiple nurses from multiple floors, mostly on cross-cover patients where the physician didn't even work with the nurse. as WS pointed out, these are issues of ancillary staff having brain farts (or being lazy), which is tolerated to a much greater extent in academia because they can push around residents in ways they can't with staff. in PP, a nurse that bothers an attending with an inane issue does it one time, probably gets a talking-to by their supervisor, and corrects the behavior. that, or they pack their bags.

i find that to be more for places that have nursing unions as opposed to just academia…

 

[Winged Scapula]

i think there are some calls that can be placed on that…but his example of a soon to be expired prn order? thats because the nurse doesn't like that intern...

I guess we can agree to disagree.

My residency hospital had nursing chart "rounds" at 0200 and every single resident/fellow would get phone calls about these sorts of things; if the order for a certain drug expired before the next dose was due, a call would be placed at that time because pharmacy would not deliver the dose without the updated order.. We got pharmacy to change order expiration to a standard 0800 regardless of when it was written which reduced these middle of the night calls.

It sounds like you had different experience with nursing calls. There are certainly some passive aggressive nurses who will abusively call residents they don't like but a lot if time it's because they have no idea of your schedule or IMHO just don't have the organizational skills to make calls during regular business hours.

 

[colbgw02]

i think there are some calls that can be placed on that…but his example of a soon to be expired prn order? thats because the nurse doesn't like that intern...

i'm not sure why you think WS and i are so wrong about this. it's not that hard to see how a nurse doing shift work doesn't realize that at 2am the intern has been at work for 20 hours already (this was under the old hour restrictions) and pages about something ridiculous. it's even easier to understand when you consider that less experienced nurses, who are less likely to understand what's important and what's not, tend to work the undesirable (read: overnight) shifts.

i did a TY, so we never stayed on a ward long enough to really get to know the nurses (or piss them off too much), but a colleague of mine had a great response when he got one of these 2am PRN tylenol order changes. he was very quick witted and snarky, and he wasn't afraid of burning bridges. it helped that he only had a few months before moving to a different hospital for his residency. the conversation went something like this:

lying down in workroom, trying to get some sleep...pager goes off...
D: yeah, this is dr. XXX returning a page
N: this is nurse YYY. i wanted to let you know that mr. ZZZ's PRN Tylenol order is going to expire in a few hours. could you renew it?
D: is the patient febrile?
N: no, i just wanted...
D: hold on. i'll be right there.

a few minutes later, dr. XXX shows up at the nurses' station, out of breath, obviously having run from the workroom
D: i'm dr. XXX. i'm looking for nurse YYY taking care of mr. ZZZ.
N: (smiling) i'm nurse YYY, i was just about to...
D: if you ever page me again in the middle of the night about this, i'll have you written up (walks away).

it was an idle threat, of course, but the nurse may have not known that.

 

[rokshana]

i'm not sure why you think WS and i are so wrong about this. it's not that hard to see how a nurse doing shift work doesn't realize that at 2am the intern has been at work for 20 hours already (this was under the old hour restrictions) and pages about something ridiculous. it's even easier to understand when you consider that less experienced nurses, who are less likely to understand what's important and what's not, tend to work the undesirable (read: overnight) shifts.

i did a TY, so we never stayed on a ward long enough to really get to know the nurses (or piss them off too much), but a colleague of mine had a great response when he got one of these 2am PRN tylenol order changes. he was very quick witted and snarky, and he wasn't afraid of burning bridges. it helped that he only had a few months before moving to a different hospital for his residency. the conversation went something like this:

lying down in workroom, trying to get some sleep...pager goes off...
D: yeah, this is dr. XXX returning a page
N: this is nurse YYY. i wanted to let you know that mr. ZZZ's PRN Tylenol order is going to expire in a few hours. could you renew it?
D: is the patient febrile?
N: no, i just wanted...
D: hold on. i'll be right there.

a few minutes later, dr. XXX shows up at the nurses' station, out of breath, obviously having run from the workroom
D: i'm dr. XXX. i'm looking for nurse YYY taking care of mr. ZZZ.
N: (smiling) i'm nurse YYY, i was just about to...
D: if you ever page me again in the middle of the night about this, i'll have you written up (walks away).

it was an idle threat, of course, but the nurse may have not known that.

because that has been the experience I have had…the nurses where i trained were not as dim witted as ya'll make out your nurses to be…they have worked long enough with intern and residents to know their schedules…I got along fairly well with the nurses (i fed them on a regular basis , esp the MICU nurses) and didn't really receive those repeated pages in the middle of the night and the pages i did receive usually were relevant…yes i got those the abx is going to expire at 2am or the restraints are going to expire at 3am, which i promptly wrote to last for only 12 hours so they would expire when the primary team would be there, but overall the nurse were nice enough to batch those silly kind of calls early in their shift….and no ones shift started at 3 am. However I had an intern that the nurses hated…esp the VA nurses…he never got a wink of sleep whenever he was on call (which of course made HIM hate the nurses and so the cycle continued)… and if you have ever worked at a VA…you cannot EVER be fired from there…the nurses do not fear you at all.

and btw, that kind of behavior is EXACTLY the snarky kind of behavior that gets you those repeated calls…because the nurse is FULLY aware that she can get you in trouble more often than you can get them in trouble (because technically she is right in requesting a soon to expire order and your idle threat will be deemed unprofessional and get you in front of your RPEC if its reported by the nurses that you are refusing to renew orders).

 

[rokshana]

I guess we can agree to disagree.

My residency hospital had nursing chart "rounds" at 0200 and every single resident/fellow would get phone calls about these sorts of things; if the order for a certain drug expired before the next dose was due, a call would be placed at that time because pharmacy would not deliver the dose without the updated order.. We got pharmacy to change order expiration to a standard 0800 regardless of when it was written which reduced these middle of the night calls.

It sounds like you had different experience with nursing calls. There are certainly some passive aggressive nurses who will abusively call residents they don't like but a lot if time it's because they have no idea of your schedule or IMHO just don't have the organizational skills to make calls during regular business hours.

i did…the nurses i worked with in residency and as a hospitalist knew our schedules….and they rarely called me for silly orders, but i also got along with the nurses (and many were older nurses who look to take care of "their" docs…i had one CCU nurse that always gave me something to eat when we were on call together). And when I started, we had paper orders….the nurses knew that we would have to come down to write them so…

but as the night float intern, one of the best pieces of advice i got from a senior was to go by each floor early in my shift (or right before i was going to try to get some sleep) and ask if there was anything they needed...