Get Ready for Residency Tuition

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maxxor

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Here's a perspective article written by some PhD Economists that lays the groundwork for the government and hospitals to stop "subsidizing" graduate medical education. They argue that since Residency training teaches general skills that can be used anywhere, the trainee should bear the cost.

http://www.nejm.org/doi/full/10.1056/NEJMp1402468

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What other profession takes on average 12 years to train? And then that 12 years to be tuition paid?

Medicine is losing its appeal.
 
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that is seriously not what that paper is saying at all... there is the ever so slightest implied theory that you are suggesting, but its really more of a subtle undertone that may just be suggested by the author. The author in no way outwardly implies that that should happen, or is even near happening. If anything he helps justify the cost of creating residents and places value on the care that they provide to the community and to the hospital itself...

"Medical students provide relatively minor amounts of service, acting mostly as apprentices or observers. They are primarily receiving a costly education in basic and clinical sciences, and they generate minimal revenue; thus, they pay tuition for the education they receive.

Residents receive some direct educational benefits, and their practice during training can incur costs for the hospital; for example, they tend to order more tests and services than fully trained physicians do. But unlike medical students, residents provide substantial amounts of service to patients, thereby generating substantial revenues for their hospitals, particularly after the first year of residency"
 
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that is seriously not what that paper is saying at all... there is the ever so slightest implied theory that you are suggesting, but its really more of a subtle undertone that may just be suggested by the author. The author in no way outwardly implies that that should happen, or is even near happening. If anything he helps justify the cost of creating residents and places value on the care that they provide to the community and to the hospital itself...

I can quote too:

"The point is not that general training should not be supplied but that it should not be subsidized; similarly, another job involving a substantial general-training component, such as a new MBA's on-the-job training in reading balance sheets, will have a lower salary than business jobs for which fully trained personnel are hired."

This is the argument the government will make when they want to cut GME funding. They will argue that residents are receiving substantial general training which should not be subsidized by the government or hospitals. When that funding gets cut, let's watch what happens when the discussion about the "high cost of training residents" starts up from the hospitals. They will turn to tuition.

The authors don't have to directly state tuition is coming. They just have to make these sorts of arguments, which then will get cited ad nauseum in various think tank policy briefs.

My argument to counter this thinking would be to say anyone with an unrestricted license (after PGY-1) should be able to bill at the same rate as an NP/PA.
 
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Let's talk hypothetical here...say they decide to start charging tuition for residency. Then what? What about students with huge loan debts? I'm just curious what the reaction would be from current/future residents. A revolt? Suck it up and pay? Fascinating (and scary) to think about...
 
Let's talk hypothetical here...say they decide to start charging tuition for residency. Then what? What about students with huge loan debts? I'm just curious what the reaction would be from current/future residents. A revolt? Suck it up and pay? Fascinating (and scary) to think about...
Ask the Dentists.
 
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OH GOD PLEASE NO
 
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I can quote too:



My argument to counter this thinking would be to say anyone with an unrestricted license (after PGY-1) should be able to bill at the same rate as an NP/PA.

My argument is that graduate students in economics are learning valuable skills, and those valuable skills (which can be applied to many situations) should come at a price. The government and universities should stop subsidizing the process of becoming a PhD in economics. Rather, students who wish to become economists should instead pay tuition. Perhaps around 30-$40,000 a year.

Edit: in fact, why not just skip the small talk and geld me already. It's not like I'll ever be able to afford to have children if this happens.
 
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I have a feeling many of the posters responding have not actually read the article. You should do so, as it's not actually suggesting resident tuition by my interpretation.

Here's a perspective article written by some PhD Economists that lays the groundwork for the government and hospitals to stop "subsidizing" graduate medical education. They argue that since Residency training teaches general skills that can be used anywhere, the trainee should bear the cost.

No, they don't. If you read pieces of the article it may appear that way, but you're missing the overall message. It's actually saying that residents are currently bearing the cost of their own training.

Here's the statement you're referring to:
The training provided to both medical students and residents is general training — that is, it can be used anywhere — in contrast to specific training, which can be used only at the place where the training occurs. (There may be a small amount of specific training involved — for instance, learning a software package used only at a particular hospital — but that is the exception.) Because general training is so portable, it would make no sense, in purely economic terms, for employers to subsidize its cost; they would not be able to recoup their investment, because once trained, physicians can and do practice wherever they wish. The point is not that general training should not be supplied but that it should not be subsidized; similarly, another job involving a substantial general-training component, such as a new MBA's on-the-job training in reading balance sheets, will have a lower salary than business jobs for which fully trained personnel are hired.

The authors use this paragraph as a springboard to explain why resident education is not actually subsidized, and how residents pay for themselves:

In his theory of human capital, Nobel Laureate Gary Becker explains why economists believe that residents, not the hospital where they obtain their training, bear the full cost of their education: they accept lower wages during training that offset training's significant costs.2 For example, if the total cost of training a resident is $80,000 annually but his or her services generate $130,000 in hospital revenue, then the resident would appropriately be paid a salary of $50,000 — the difference between the two.
In other words, residents create some gross income for the hospital (let's call it G), and training a resident costs a certain amount of money (less than the income generated, call it T). The difference (G - T) is resident salary, and the remainder is retained by the hospital to offset the cost of training (T). This is explained further in the later paragraphs:

Why are residents paid wages whereas medical students pay tuition? Both receive some amount of training and education and provide some amount of services, but the relative valuation of and time devoted to services received and services provided differs dramatically between residents and medical students.

Medical students provide relatively minor amounts of service, acting mostly as apprentices or observers. They are primarily receiving a costly education in basic and clinical sciences, and they generate minimal revenue; thus, they pay tuition for the education they receive.

Residents receive some direct educational benefits, and their practice during training can incur costs for the hospital; for example, they tend to order more tests and services than fully trained physicians do. But unlike medical students, residents provide substantial amounts of service to patients, thereby generating substantial revenues for their hospitals, particularly after the first year of residency.

In this example, a medical student generates a G than is significantly less than T, so the difference is negative, and the absolute value of that difference is tuition. For a resident, G is greater than T, and so residents are paid salary, with T retained by the hospital as payment for training costs.

This theory is well known to most economists, and there is empirical evidence that strongly supports it. If GME funds were subsidizing resident salaries, those salaries and the numbers of residency positions should have changed when GME funding was adjusted. However, despite large changes in GME funding, residents' salaries have remained constant over time; indeed, not only did the number of residents not decrease when GME monies were reduced but it actually continued to increase after several years of adjustment.

This is where the author argues that GME money is NOT being used to subsidize training. If it were, they say, resident salaries should rise with increases in GME training. They have not, which lends further evidence to the fact that the amount a hospital is actually willing to pay has more to do with the funds residents are capable of generating.

The point of the whole thing, which the authors make in the last few paragraphs, is that simply increasing GME funding is unlikely to solve the physician crisis, since the increased funding is unlikely to go to physicians in training and more likely to be added to the hospital general funds.
 
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I have a feeling many of the posters responding have not actually read the article. You should do so, as it's not actually suggesting resident tuition by my interpretation.



.

You are right, I didn't read any of the article. I have, however, heard this idea of resident tuition thrown around these message boards not infrequently recently. That's where the crux of my question was coming from. In a nightmare world where that actually happened, how would people react?
 
I have a feeling many of the posters responding have not actually read the article. You should do so, as it's not actually suggesting resident tuition by my interpretation.
.

Guilty, final exams all next week. I'm using this as my social surrogate until I can hang around actual people again. Anger comes pretty easily right now.

Thanks for providing the informed viewpoint.
 
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I think the conclusions were extremely vague. I read it. Admittedly while nodding in and out on the train. But I probably read it 3 times. And I still am not sure what the author envisions for the future of physican training other than: the funder of the resident-trainee should not not train for mobile skills, that the government funding should disincentivize the capturing of training funding by hospitals; and finally some vague implication that the physician is currently an overstrained, expensive entity that should be replaced or changed to something trained locally to perform a more profitable and specific role.

I have no sense of where the author thinks it should go from here. Sounds like NP's are the answer this author has in mind without saying it.
 
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I think the conclusions were extremely vague. I read it. Admittedly while nodding in and out on the train. But I probably read it 3 times. And I still am not sure what the author envisions for the future of physican training other than: the funder of the resident-trainee should not not train for mobile skills, that the government funding should disincentivize the capturing of training funding by hospitals; and finally some vague implication that the physician is currently an overstrained, expensive entity that should be replaced or changed to something trained locally to perform a more profitable and specific role.

I have no sense of where the author thinks it should go from here. Sounds like NP's are the answer this author has in mind without saying it.

IMO, the bolded is the crux of the article. The main point I think is that throwing money at GME funding will probably just result in hospitals with more money, not a different distribution of residents in primary care (or any other "improvements"). So I agree: interesting read but light on potential solutions, other than the brief mention of loan forgiveness toward the end.
 
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