Medical Students Sue Over Residency System

[gerickson03m]

Anyone have any information/links on what has happened to the lawsuit that was supposed to raise our wages? I'v looked and can only find articles from 2002.

http://www.nytimes.com/2002/05/07/health/07DOCS.html

Grant
- Soon to be surg intern at MCO (Ohio)

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[gerickson03m]

http://www.ama-assn.org/ama/pub/category/8610.html#specifics

This site has some good info. Basically the suit is in process and will go to trial in 2004. I personally feel that I'm not in medicine for the money but I do think that I deserve more money than someone working at McDonalds. Iv figuered it out and I will be getting about $5.50/h and this really sucks when you have 150k in debt. I'm just lucky I dont have a family!

 

[smackdaddy]

just out of curiosity how did you come up with those figures?
you should be able to beat out the mcdonald's guys.

 

[ckplay]

on one of my interviews, I was handed a benefits sheet which stated the wage to be $21/hour. we all got a kick out of that.

 

[Kirk]

Here are some numbers based on the new ?kinder, gentler? 80 hour work week.

$40,000 per year divided by 52 weeks = 769.23 per week (before taxes).

You can?t divide this by 80, as that is not a fair comparison: Federal law (Fair Labor Standards Act) mandates that any hours worked over 40 is paid time and a half. So, 40 hours base time plus 40 hours (overtime is an additional 20) = 100 hours.

769.23 / 100 hours = 7.69 per hour!

$35,000 / 52 = 673.07 / 100 = 6.73 per hour!

You overpaid residents should be happy!

 

[athena21]

the latest article said that the lawsuit won't go to trial until 2006! So, it prolly doesn't affect any of us...it would be interesting to see the result. Here is the article from the Chicago Sun Times March 21, 2003:

http://www.suntimes.com/output/news/cst-nws-match21.html

Northwestern University medical student Amanda Stiehl was thrilled to learn Thursday that she'll be attending the postgraduate program she wanted, even though it means modest pay for the grueling hours required of medical residents.

But this year, ''Match Day''-- when tens of thousands of medical school graduates received assignments to residency programs--arrived under a legal cloud that could revolutionize the matching process as well as how doctors are trained.

A federal antitrust lawsuit alleges that the residency matching program contributes to notorious work conditions for medical residents by allowing residency directors to share information about their programs. The setup, the lawsuit alleges, forces doctors-in-training to accept placements without negotiation. That allows residency programs to conspire to keep salaries low--often less than $40,000--and force residents to work long hours--often 80 hours or more weekly, the lawsuit alleges.

Many students consider the 51-year-old match system a time-honored tradition. And Stiehl, 25, who'll be training in psychiatry at the University of Washington, seems resigned to the hardships of residency, which she likens to ''grunt work'' expected of rookies in any profession.

But plaintiff Dr. Paul Jung, a medical officer for the federal Food and Drug Administration, said the entire process should be more fair to give doctors-in-training more negotiating power.

The class-action lawsuit, filed last May, which is not expected to go to trial before 2006, has prompted uncertainty among some of this year's graduating students.

A recent editorial in the Journal of the American Medical Association suggests the stakes are potentially huge. The matching program ''appears on its face to limit competition in a manner that previous cases have found illegal,'' wrote editorialists Frances Miller of Boston University and Thomas Greaney of Saint Louis University.

Motions to dismiss or settle the case are pending. If the plaintiffs win, they could be granted ''a potentially huge award three times the lost wages of a class of potentially thousands of residents,'' the editorial said.

''It's very much a frontal attack on graduate medical education,'' said Bob Burgoyne, an attorney for the Association of American Medical Colleges, which helps sponsor the match and says the allegations are groundless.

The lawsuit seeks damages for residents employed since May 1998. It also seeks a system that ''would have to allow open competition among employers consistent with antitrust laws,'' said Sherman Marek, a Chicago attorney representing the plaintiffs.

Under the matching program, medical school seniors interview at residency training programs, then submit lists ranking their program preferences. Program directors submit lists of preferred applicants.

A computerized process matches applicants to programs, and results are announced on Match Day, usually in March.

The lawsuit has no immediate effect on new rules, effective in July, from the Accreditation Council for Graduate Medical Education, which say residents can't work more than an average of 80 hours weekly. The council also is named in the lawsuit.

 

[smackdaddy]

Originally posted by Kirk
Here are some numbers based on the new ?kinder, gentler? 80 hour work week.

$40,000 per year divided by 52 weeks = 769.23 per week (before taxes).

You can?t divide this by 80, as that is not a fair comparison: Federal law (Fair Labor Standards Act) mandates that any hours worked over 40 is paid time and a half. So, 40 hours base time plus 40 hours (overtime is an additional 20) = 100 hours.

769.23 / 100 hours = 7.69 per hour!

$35,000 / 52 = 673.07 / 100 = 6.73 per hour!

You overpaid residents should be happy!

you forgot vacation which is 3-4 weeks off.

not all people are entitled to overtime by the fair labor standards act. professional, executive, and administrative people are exempt from the act.

 

[edmadison]

I hate to bring this up, but what makes you think that the lawsuit will result in better pay and hours. The lawsuit is intended to breakup the monopoly of the match. What will stop the competitive programs from offerering no pay, or even charging residents for positions. I know many who would pay for a derm slot. They will all get it back in the end anyway.

Ed

 

[Celiac Plexus]

Originally posted by edmadison
I hate to bring this up, but what makes you think that the lawsuit will result in better pay and hours. The lawsuit is intended to breakup the monopoly of the match. What will stop the competitive programs from offerering no pay, or even charging residents for positions. I know many who would pay for a derm slot. They will all get it back in the end anyway.

Ed

Breaking the monopoly will absolutely raise pay. Think about it... At first, some of the very best programs in the most competitive fields might try to low-ball salaries. But as soon as one program ups the ante, the others will follow. There will be an arms race of sorts with salaries.

Harvard, for example, is an extremely wealthy private school. They would absolutely want the best and brightest. Why would they REDUCE the pay for residents? So that they get angry, resentful residents to work for LESS than 35K/yr? It would be far easier for them, and smarter, just to spend a little more to keep attracting the 240 Step I, AOA /research types.

And the little bumf**k program in Idaho would seize the chance to attract a higher caliber of applicants by offerring more money, and better benefits. Even derm spots might see fewer applicants if fam medicine programs were paying 90K/year for residents...Certainly general surgery residencies would have to pump up salaries or that field would lose tons of applicants...

Pretty soon, everyone would be spending more on resident salaries just to keep attracting applicants.

How fast this would occur is debatable. However, asserting that residencies would pay LESS under a deregulated system would be very hard to explain in our market-driven economy.

 

[droliver]

Celiac,

your argument flies in the face of the fact that most academic programs are bleeding money as it is. Witness the exodus of primary care & subspecialists even more so, from academic practice. I've spent time @ the Harvard system several years ago, & even they were in a horrible crunch with how they were going to make their academic practice sustainable. Proposing that they would come up with additional money in bidding wars for medical students, who may or may not even become productive physicians is not likely. All you have to do is witness the reduction in size of the endowments @ many of the richest institutions from the stock market decline by as much as $500 million (a la the Clevland Clinic) to realize that the scenario you propose is a non-starter.

 

[eddieberetta]

I'm not sure that there will be an arms race in salaries, however it seems obvious that the market value of a resident is greater than 40K/year. For example, in some healthcare systems, PA's are being hired to make up for the reduction in resident coverage due to work hours regs. They are paid 70-100K (for perhaps a 50-60 h workweek). They have less training than a resident.

I don't think resident salaries would explode (I doubt that the incremental benefit of an AOA resident is enough to make it worth paying extra for ) . They would just come into line with the amount that is already paid to related health workers such as senior nurses.

Although many health systems are losing money, the increment in resident salaries is small compared to administrative spending. They could find the money.

However, organized medicine will fight this one to the death...

 

[gerickson03m]

Check this out from edmadison
"The lawsuit is intended to breakup the monopoly of the match. What will stop the competitive programs from offerering no pay, or even charging residents for positions."

And this from droliver
"...fact that most academic programs are bleeding money as it is...Proposing that they would come up with additional money in bidding wars for medical students, who may or may not even become productive physicians is not likely."

Sorry boys you just do not make any sense. Your first assumptiion is that residents COST the places they are at money. This is not the case. The institutions which have residents could not function without them, if all the residents left the institution would have to hire Doctors with 10X the sallary. AN example is general surgury, here they pay a pgy 5 $50,000 and he does everything solo, the attending is in surgery making the hospital money and the resident is taking care of a trauma case in the ER and making the institution even more money (unless the poor patient doesn't have insurance but thats another issue). Also Institutions get PAID by the government to have residents ~$100,000-150K. Another fact is that there are more open spots than people to fill them, this would in itself drive up the pay because the intitutions that have low pay would not attract anyone and would not fill.

droliver and edmadison are saying that the match system and NRMP/Government actually keep up our resident salaries. Why would the government design a system to "increase" resident salaries which take money away from their own coffers when there hasn't been a strike or court judgement against them? WHen have you seen them do this besides giving them selves a raise?

droliver and edmadison by making those statements also are insinuating that market conditions for medicine are different from anywhere else which flies is the face of the facts! Do governments say what the privit sector should pay their employees? NO ! ( there is minimum wage which is the opposite of the Residency system) So since there isnt any restriction on wages in the private sector, are the wages decreasing? NO! Than why would residents pay decrease? Fact is they wouldn't because supply and demand affect medicine also.

What if what droliver and edmadison say is right, resident's pay drops. Than the student which wants to be a doc would have to pay for 4 years undergrad/4 years med/ and 3-5 years or more for residency. SO ~10-13 years with no cash!! Who could or would want to do this. There would be no one wanting to go to med school, doctors would be rare and more valuable and since docs and residents would be more valuable their pay would increase. As you see either way the pay would go up.

I just killed your weak arguements (and yes I have spelling problems)

This just makes me think which side droliver and edmadison are on.

 

[smackdaddy]

Originally posted by droliver
Celiac,

your argument flies in the face of the fact that most academic programs are bleeding money as it is. Witness the exodus of primary care & subspecialists even more so, from academic practice. I've spent time @ the Harvard system several years ago, & even they were in a horrible crunch with how they were going to make their academic practice sustainable. Proposing that they would come up with additional money in bidding wars for medical students, who may or may not even become productive physicians is not likely. All you have to do is witness the reduction in size of the endowments @ many of the richest institutions from the stock market decline by as much as $500 million (a la the Clevland Clinic) to realize that the scenario you propose is a non-starter.

they would lose even more if they didn't have residents.
the crisis that the systems are in would be even worse if they didn't keep screwing the residents over with more responsibilities over the past several years.
some people might say that residencies should cover academic salaries, but i don't think so. at least not entirely? academic salaries need to be recovere from medicare allotments for the portion of time spent teaching and in resident attended patient care. research portions should be covered by grants. teaching medical students should be covered by medical school payments.
jmo.

 

[vuillaume]

I think we're now starting to get at the real issues. The simple fact is that health care economics are basically a jacked up mess. Our system (as are many systems) is neither purely market-driven, nor is it socialistic. The simple fact is that a dollar value is hard to pin on life or quality of life. In the absence of that, now that the "golden years" faded away in the early Nineties, many health care systems try to do the minimum they can get away with in terms of morbidity and mortality (therefore doing the minimum they can without scaring away enrollees). And we all know the cheapest thing for an HMO is to have a capitated patient die and incur no further costs on the system. (And, aside from historical reasons, why is health insurance tied to one's employment?)

All that aside, because we have this jalopy of a health care system, it's really difficult to say what a "free" labor market for house staff would really mean. A couple of you made a great point that it's unlikely that salaries would go down because residents are simply indispensible from training hospitals. We are much cheaper than PA's, NP's, OR Techs, &c. On the other hand, there are numerous ancillary costs related to resident education: OR cases take longer when a 3rd year resident is the primary operator, a new resident rotating on to a service has to learn the ropes where a PA who has been working in the same place for a long time would clearly be more efficient, and there's just a lot of overhead related to running a Graduate Medical Education office.

People are too focused on the microeconomic scale when looking at resident compensation. I think (and I admit I don't have any answers to the issues at hand) we have to step back and look at things macro. The greatest contribution that trainees make to society as a whole is the fact that they represent our future doctors. No trainees, no doctors. Poorly trained residents, poorly trained doctors.

I really don't have any strong feelings about this lawsuit, though I certainly wouldn't mind salary scales rising to a level commensurate with how other professions compensate people of the same level of education.

I guess what I'm getting at is that a solution has to be *comprehensive*. It has to address health care as a whole rather than fiddling with isolated aspects of the whole.

Academic medical centers are economically tough places to manage. They have to compete with private hospitals and HMO's that don't have to bear the costs of training medical students and residents, or time allocated to faculty for academic pursuits. Except for some unusual cases where an academic center has a virtually exclusive cachement area for patients (e.g. University of Pittsburgh, and University of Michigan), how can they possibly compete? On a micro level, U. Penn is an albatross whose contributions to academics and research to the local community are difficult to quantify economically. Yet if we let the Penns, Johns Hopkins, Stanfords, Mass Generals, Dukes, &c. of the world go under, the cost to society would be tremendous.

I guess I'm digressing, but I suppose what this lawsuit is really a manifestion of is that American health care system is a f***ed up mess, and residency salaries is just one small, but integral part of that. I wasn't crazy about the Clinton administration, but once his grand scheme for health care collapsed, we've just been whistling through the graveyard and studiously ignoring a seriously defective way of doing things.

 

[gerickson03m]

I agree with vuillaume. Big change has to take place. Increasing resident's pay would also help to decrease the future physician shortage, predictued at 200,000 by 2020. It could make the medical field more attractive becuase I think the high-tech field has taken away some of the glitz like it has in the 1980's.

http://www.ama-assn.org/sci-pubs/amnews/pick_02/prl20121.htm

 

[Celiac Plexus]

Originally posted by droliver
Celiac,

your argument flies in the face of the fact that most academic programs are bleeding money as it is...

How does this affect the demand for residents? Just because a training program is hurting financially does not lessen their dependence on residents. It would seem to, in fact, increase the need for residents since they represent highly-trained, meagerly-paid, money-generating (in the form of government payments 3X their salaries) employees. If a hospital did reduce the number of residents, it would need to hire PAs or techs to pick up the slack. Do you think that PAs are going to take 35K/yr to work 80 hours? I don't.


Proposing that they would come up with additional money in bidding wars for medical students, who may or may not even become productive physicians is not likely.


Really? If programs don't spend money to hire some lowly, unreliable, medical students, then what will they spend money on? More techs, and PAs? Again, do you think that a program will be able to get anyone, much less a PA to work for 35K for 80 hour weeks?

All you have to do is witness the reduction in size of the endowments @ many of the richest institutions from the stock market decline by as much as $500 million (a la the Clevland Clinic) to realize that the scenario you propose is a non-starter.

Programs receive funding from the U.S. government for training of residents. This payment is not subject to the slings and arrows of the Ceveland Clinic's endowment. It is a reliable stream of income (for now). I doubt that a program would fold because it chose to pay its residents an extra 5 or 10K per year. At my university, the surgery department has hired a complement of PAs to help out with the work now that the 80 hour rule is nearing effect. How much money do you think the federal government pays the university for THEIR salaries? Nothing.


P.S.- I do appreciate all of the time and energy you have spent moderating this site. That we seem to disagree on this issue does not diminish my gratitude for your care and effort in maintaining a really great site.

 

[ERMudPhud]

In this whole argument its worth remembering the reason the match was created in the first place. It might have created a monopoly but the original intent was to streamline the residency application process. Prior to the match it was a rolling admissions type process with applicants accepting and then later rejecting programs as better offers came in. This meant that applicants and programs often didn't know for sure who was going to be where until almost July 1st.

I don't understand how the match keeps programs from using salary to compete for residents. If program A pay 20K more than program B and if that mattered to me I could just rank program A ahead of B. Why hasn't that happened?

Finally, for the people saying that a hospital would have to hire tons of new people if they didn't have residents. I believed that when I was a resident but now that I am at a private non teaching hospital I realize that we manage just fine without any residents. We have all sorts of sick medical patients, high acuity trauma and even organ transplants without any residents around. We have a handful of Docs in house overnight and others taking homecall but nothing like a full house staff. However, the nurses and RT's do more and have more autonomy than what I saw as a resident. Residents provide many valuable services and if I or a loved one were sick it would be comforting to know they were around but the truth is that nonteaching hospitals always have managed without them.

 

[droliver]

Celiac,

no offense taken.

I think my point re. the issue of things like endowments & the like is that the money to pay for this will have to come from somewhere. The feds clearly have no intention of subsidizing an increase on the salaries for in-training physicians - they are actively looking for ways to cap medical spending & the reimbursements to physicians. The institutions themselves are almost uniformly in financial crisis & most have no discretionary funds that they could use to provide this salary subsidy we all would appreciate. Many training programs can simply not come come up with $$$ to hire allied health providers like Yale did (to buy itself off of probation) & I (as do several memebers of the RRC I talked to about this) expect there to be a number of programs folding because compliance with the new ACGME rules become too expensive & partial compliance assumes too much legal liability. As Vuillaume pointed out, the US model for health care distribution is a "jacked up mess" & in a painful & slow transition towards a single payer system.

I think ERMudPhud's observation is a valid one too. The process of finding a position previous to the match was very chaotic & did not serve to meet the needs of most prospective residents. The informality & instability of the whole thing was very disenfranchising to most students talking to many older physicians (including my father & uncle). As ERMudPhud also said, many hospitals function very well without resident coverage. There are certain types of care that would be impractical however without a lot of "worker bees" (ie. trauma & emergency general surgery @ tertiary centers), where resident coverage adds real value & improves patient care.

 

[soudes]

as was mentioned above, residents salaries are almost entirely paid for by the us government based upon the amount of Medicare patients seen (the follwing is from http://www.aamc.org/advocacy/library/gme/gme0001.htm )

The Medicare Direct Graduate Medical Education (DGME) payment compensates teaching hospitals for some of the costs directly related to the graduate training of physicians. Medicare does not pay the costs of the clinical portion of medical education of medical students that occurs in teaching hospitals. In FY 1997, DGME payments for residents were about $2 billion.

The added direct costs incurred by teaching hospitals in providing clinical physician training, or graduate medical education (GME), include: stipends and fringe benefits of residents, salaries and fringe benefits of faculty who supervise the residents, other direct costs and allocated institutional overhead costs, such as maintenance and electricity. Other direct costs include, for example, the cost of clerical personnel who work exclusively in the GME administrative office.

In April 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (P.L. 99-272), which dramatically altered the DGME payment methodology in two ways. Under this new method, Medicare uncoupled the relationship between direct costs and DGME payments by paying each hospital a portion of its per resident amount based on the DGME costs incurred by the hospital during a base year period and divided by the number of residents counted in the base year. The program audited each hospital's reported costs to determine the per resident amount. In addition, the Medicare program limited the number of years for which it fully supports its share of residency training. In August 1993, Congress again modified the DGME payment methodology (P.L. 103-66), making slight adjustments to the existing COBRA methodology.

The Balanced Budget Act (BBA) of 1997 (P.L. 105-33) made several changes to DGME payments. It placed limits on the number of full-time equivalent (FTE) residents that hospitals can count for DGME payments and required residents to be counted using a three-year rolling average methodology. The BBA also allowed Medicare to make DGME payments to entities other than hospitals, and directed the Secretary to establish a demonstration project for making DGME payments to consortia.

It is not unreasonable to then assume that unstitutions might be willing to increase some of the money from their own pocket to continue to attract high caliber residents.

 

[unregistered]

gerickson03m, no need for such harsh, disparaging words against other posters here. There are a couple points you don't seem to understand. First, residents DO cost their hospitals money. I know a lot of buzz on this thread tries to establish that academic medical centers could not function without residents, but this is simply mistaken. Having residents in a hospital actually results in a 12-14% higher operating cost (Schwartz WB et al, NEJM 313:157-162). Sure, hospitals get government $ for each resident they train, but this does not offset the cost to the hospital to train residents. There are at least 2 private hospitals in the Chicago area I know of that are trying to cut costs to stay financially solvent, and among the highest costs on their list of potential cuts are the residency programs they support.

Another point that does not seem to be grasped in this thread is one of residents and salaries. 4th yr med students do not solely or even primarily pick their ranklists based on salary. To say that top programs would have to up their salaries to attract the best and the brightest is simply mistaken. Many of these best/brightest would be happy to go to the elite academic program for a lower salary simply because it is the elite academic program. True, there would be some element of open market competition, but to assume that this competition is driven by salaries alone is wrong. While programs would compete with each other by upping their salaries/benefits, applicants would also compete amongst themselves by offering to work for less.

 

[smackdaddy]

you quoted an article from 1985. i wonder whether those numbers are still valid. and certainly in any case, the fact that two hospitals in chicago are considering closing their residencies does not imply anything about whether residencies are money makers or money losers. the disbursement of money to residencies is not uniform-some states get more per residents and others get less. the reiumbursement rates for health care provided differs as well. the residencies (and/or the hospitals) may be poorly run.
the nonquantifiable costs (how much longer the procedure will take because of people who are learning) make a definitive right or wrong answer difficult to calculate. and the sicker patients that traditionally get sent to these hospitals may be sent anyway. who knows? however the quantifiable costs of all the work the residents perform certainly are far less than the revenue they generate.

 

[Brewster]

I could not disagree more with the lawsuit.

I suppose the match system could be considered a monopoly that is contributing the the mediocre salaries of residents. But, having just finished the match process and facing the modest salary, I would say that I would gladly trade a few buck for the system we have now. From what I have read, the prematch residency selection system was a nightmare and one that I would not wish on anyone.

As for programs using salaries as a barganing chip, I agree with those who said that the top programs will continue to draw plenty of interest/applicants even if they lowered their salaries.

 

[soudes]

here is the biggest problem with the lawsuit: IT DOES NOT OFFER A BETTER SOLUTION!

do you know how it was before the match? students, as early as first-years, were bullied into selecting programs. a program would contact you and say "we are offering you an IM postion at X University. this offer expires in one month." students were put in a position to choose that program or risk not going to a better place.

on top of that, students could also be left out if they weren't careful.

this system may be flawed, but until a better solution is offered, the pursuit of this lawsuit is very dangerous for us students.

 

[smackdaddy]

you guys make me laugh. why should the lawsuit offer a solution? in the real world, anyone can sue anybody without needing to provide a solution. as to whether the basis of the suit has merit, many people think yes it does. now whether the benefits of allowing the system to continue outweigh the cost of the loss of competition is even more heavily debated.
in the world without the match, job offers would be dramatically different. people would have to make the same decisions they will make a few years later. certainly the transition years would be difficult, but afterwards, most people would know where they were likely to go and could plan ahead. the residency world would function like the rest of the world.
the match certainly helped in the past. whether it is still necessary in todays environment is debatable. salaries will probably remain the same or go down at top institutions but for the majority of places they probably will go up. either way, everyone still will be working 80 hours.

 

[edmadison]

Its funny how people interpret things you say. I just threw out the idea that the lawsuit may not have the result that the plaintiffs hoped and now I'm tagged as a tool of the NRMP. Let me rebutt:

I think residents are overworked and underpaid. I believe that hospitals take advantage of them because they are in a position of power. I think that many programs aren't interested in the least about training residents. I think there should be reform. I believe that the match is a monopoly and a violation of federal law. I think that if the lawsuit prevails, there will be chaos. As earlier posters mentioned, there will be a free-for-all for positions. Some folks will come out great. Less desireable programs will be forced to increase pay in order to attract applicants. On the other hand. Specialties that are high paying or programs that are prestigious will be able to pay less (or nothing) as applicants will be clammoring to get those slots. Its a no brainer, trade 4 more years of loans for hundreds of thousands a year (think derm). Just look at what people pay to go to Harvard. Do you get that much better of an education than at the University of Illinois for 5 times the cost?

Be hopefull, but be wary. Remember that the airline industry vigorously lobbied for deregulation. Look what happened: some flights dirt cheap, some outragously expensive, Braniff, Ozark, Eastern, Pan Am (twice), TWA out of business, United, USAir in bankruptcy and Northwest and American on the brink. Things don't always turn out as expected.

Ed

 

[soudes]

smackdaddy-
i did not claim that a better solution HAD to be offered, just that without one, it would be one giant scramble.

doesn't sound like much fun to me.

residency sucks. just like being an associate lawyer at a law firm sucks. just like being the low man on the banking totem pole sucks.

everyone has to pay their dues.

i think the best thing that can come from this lawsuit might be that the NRMP thinks of a better way (if one exists).

 

[GeneralTso]

Originally posted by soudes
smackdaddy-
i did not claim that a better solution HAD to be offered, just that without one, it would be one giant scramble.

doesn't sound like much fun to me.

residency sucks. just like being an associate lawyer at a law firm sucks. just like being the low man on the banking totem pole sucks.

everyone has to pay their dues.

i think the best thing that can come from this lawsuit might be that the NRMP thinks of a better way (if one exists).

Even the associate lawyer and I Banker makes roughly 5 times more at the bottom than residents do. Personally, I dont mind the dues paying when it comes to hours, work load, or hazing but being compensated no more than 40 K for several years is absurd given the debt loads most doctors face. Im not advocating that we are entitled to get six figure salaries during residency, but it should be more than the peanuts that everyone uniformally gets.

 

[powermd]

Originally posted by soudes
smackdaddy-
i did not claim that a better solution HAD to be offered, just that without one, it would be one giant scramble.

doesn't sound like much fun to me.

residency sucks. just like being an associate lawyer at a law firm sucks. just like being the low man on the banking totem pole sucks.

everyone has to pay their dues.

i think the best thing that can come from this lawsuit might be that the NRMP thinks of a better way (if one exists).

I reject the concept of "paying one's dues" as a justification for artificially-low resident salaries and lousy working conditions. To say this assumes that somehow a resident does not deserve to be paid for the value he or she creates, simply because, well.. just because. Residents probably aren't worth as much as attending physicians, but they certainly create a lot more value for the hospitals they work for than is reflected in their salaries. Simple evidence for this can be found in the higher market wages paid to nurses and PAs, who probably do not contribute as much value as residents do.

I personally like the match system for providing structure to the job application process for 4th year medical students, but I resent the fact that it legitimizes collusion among residency programs to avoid paying residents their likely higher market value. If that bankrupts hospitals, so be it. Health care payors, and subsequently ordinary citizens, will foot the bill. They won't have any choice if they want continued access to health care. This is right because people should pay for the value they receive, one way or another. No one is "entitled" to the work of another human being, at least not since the Emancipation Proclamation. Right now everyone but residents benefit from their hard work and low pay. It's time for that to change.

Craig, M3

 

[Sandpaper]

Amen brother. Never understood this concept of "paying dues". After the last couple of weeks of 80+ hours on the princely sum of $36k yearly, my hourly wage is approximately $8.80 an hour. That's less than the janitors at this institution.

 

[avendesora]

Curious as to where the money is going to come from to pay residents 2 or 3 times as much? In case anybody missed it, funding for health care in general is in trouble right now, with congress only at the last minute avoiding a CUT in Medicare reimbursement recently.

In fact, I would think that faced with paying residents 80K a year for 80h a week, some hospitals might opt for 2 midlevel providers in their place that they don't have to spend time lecturing, testing, or otherwise training.

Remember, Medicare pays for residents at some fixed price (100k per year? I'm not sure). Currently, hospitals make money on that deal by paying residents peanuts. If you take away that financial incentive, a resident suddenly becomes a less desirable employee.

Obviously this won't be an issue at well funded university programs, but I would think some community programs would have to make hard choices.

Now, granted, I'm not "there" yet -- currently about to finish third year. I'm not looking forward to making a subsistance-level income into my 30's, but I think that it might be necessary to maintain the system as we know it. I think the view of "I deserve to be paid more, and if it causes hospitals to go out of business too damn bad" is a little short sighted.

Also, as someone who will be going through the match in less than a year, I can only hope the current system is still in place. It's not perfect, but at least you are able to apply to and interview at lots of programs and match at the best one for you (at least in theory), and everybody gets a fair shot at landing interviews. I would not relish the thought of spending dozends to hundreds of hours during 4th year trying to land interviews, etc. That basically turns into a year long scramble, early bird gets the worm, connections are everything, etc.

Can the system be made better? Without a doubt. Should we scrap the current system without a new one in place? For my sake and others currently in school, please no.

[Addendum]:Like others have rightly pointed out, I don't think salary is even considered by most when applying to residencey. In fact, if you look through FREIDA, you will find that salary is already somewhat variable - by as much as 10-12K depending on location and program strength. In fact, the real variability is probably even higher - desirable programs=big city=high COL, but usually have lower pay. No one is going to apply to BFE Community Hospital in Idaho because it pays 8K more than MassGen (or if you are, that's sad). So I think I that I'm going to have to agree with those who think that even if residency application is deregulated salary will not be significantly affected. I'm usually pretty much a capitalist (fee for service, etc) but I don't think you can apply standard economics to this one because money is not the primary variable separating programs.

 

[neilc]

i am sort of surprised by this thread...lot's of money hungry folks out there!

residents are students. we need the education and the time to learn our new trade. i would love to make a lot of money, but it just isn't there for residents. i will be there to learn, and that is it. if they said they couldn't pay anything, just gave me a roof and some food, i would be there. happily.

we will make plenty of money in due time. there are no starving doctors in america. residency is a time to learn. to throw away a system that is a great help to hospitals and students in terms of logistics (the match) for an extra grand or two or whatever is short sighted.

money, money, money...jeez.

 

[vuillaume]

neilc,
I don't think that's really the point. When you consider other professions and the salaries offered to people of a commensurate level of post-baccalaureate education, house staff lag significantly behind the market rate.

I personally don't care that much about my own salary--I'm choosing an academic career after all and will make significantly less than a colleague in practice--but I have classmates that have debt burdens between $100K and $200K who are about to make a fraction of what a management consultant or investment banker makes.

Certainly, in this day and age, no one chooses medicine for the money, but--as I've noted before--the health care economy is a barely functional contraption held together with string and tape that does make unfair (if you look at the broader professional job market) demands on house officers.

The one point I'd make in neilc's favor is that the availability of jobs for physicians appears to be more stable than for junior law associates and that is worth something. But still, when comparing a hot young lawyer who goes to Cravath to a hot young med school graduate going to the Brigham, the disparity still exists.

 

[powermd]

Originally posted by neilc
i am sort of surprised by this thread...lot's of money hungry folks out there!

residents are students. we need the education and the time to learn our new trade. i would love to make a lot of money, but it just isn't there for residents. i will be there to learn, and that is it. if they said they couldn't pay anything, just gave me a roof and some food, i would be there. happily.

we will make plenty of money in due time. there are no starving doctors in america. residency is a time to learn. to throw away a system that is a great help to hospitals and students in terms of logistics (the match) for an extra grand or two or whatever is short sighted.

money, money, money...jeez.

Preface: I didn't intend for this response to get so long, but I guess I have a lot to say on these issues.

This is just another iteration of the old self-sacrificing "we don't deserve it" posture assumed by everyone in medical education, typically until one becomes a private practice doctor and no longer has to win the approval of superiors with feigned altruism and exaggerated enthusiasm.

Your points:
1. Residnecy is a time to learn
2. We will make adequate money after residency
3. There is no money to increase resident pay
4. I would work for just a roof and some food

1. Yes, residency is a time to learn. But so much has already been learned by the end of internship, a resident is easily worth at least what they pay a physician-assistant. If not considerably more. Hospitals receive about $100K per resident from medicare, plus the value created by the resident's work. Let's assume that equals a PA- so in total the hospital takes in about $160K in value, and pays out $40K to the resident. Not a bad deal for the hospital. I suppose you will now argue that the remaining $120K is used for lectures and testing- yeah, sure. More likely, that money is used to subsidize inefficiencies elsewhere in the hospital.

2. Yes, we will (hopefully) make market value salaries as attendings. That has nothing to do with what residents are paid in training. Which seems more likely to you? That a R7 vascular surgery fellow making $55K/year improves in skill and productivity such that his true worth actually changes from $55K to 350K+ a few days after graduating? Or is it more likely that he was never being paid his true worth to begin with? As an example of this, a friend who is graduating from an anesthesiology residency was offered $100K to do a fellowship at a program in Ohio. If she's only worth $50-60K, since she's "just a student", who's still "learning", why would this hospital be willing to part with an extra $40K for her services? I'll spell it out for you- because that's her true market value (or something close to it).

3."There is no money to increase resident pay"
Not true. There's trillions of dollars circulating in America, and if residents demand that they be paid their true market value, people will simply pay more for health care. That's how it works in every other industry in America. The only reason it hasn't applied to resident pay (yet), is the self-sacrificing posture mentioned above. You even said that you would be willing to work for peanuts. How noble of you. See below.

4. "I would be willing to work for just a roof and some food."
If only EVERYONE were like you, willing to work his or her ass off for nothing. The world would be a utopia. Well, maybe not. Perhaps you would prefer a different governmental system that caters to your philosophy. Unfortunately, history has shown that communism doesn't work. People need that carrot dangled in front of them to make them work. That's why capitalism has been so successful. People work for rewards in one form or another. That kind of system creates the competition that has driven the west's power in every single area of enterprise. By being willing to work for nothing, you tear down the system that creates wealth in all it's forms.

Craig, M3

 

[neilc]

lots of good points. it would be great to get more money, don't get me wrong. i just look at it as an extension of my school, so i never expected to make much til later. so, i just don't see the comparison with other professions, as residents are still students. i see your points, can't argue with them, but i still don't see residency as a "job" as much as i see it as extended education with a bit of money so i don't starve.

in re-reading my post, i also think i may have come off a bit aggressive. i don't really mean "money hungry" as some terrible thing. rather, i just think that some consider it more than others. i know it will have practically zero affect on my residency choice (not out of altruism, but because there are many more important things to get from a residency, IMHO). others see it as important. both are fine opinions, but i am just surprised that i am in the minority.

believe me, i am not into working for free, nor am i anti-capitalism. i just figured that as a resident, i will be a student, and will take my education how i can get it. after residency, all bets are off though! i wanna be as rich as the next guy!

anyhow, i am just a third year, and don't know much about this. plus, i am in school in europe, and a bit worried about getting a spot, so i am sure that may have something to do with me being a bit more lenient in the pay expectations. i am sure after a few nights on call i will want all the damn money i can squeez out of the hospital!

 

[Celiac Plexus]

Originally posted by neilc
lots of good points. it would be great to get more money, don't get me wrong. i just look at it as an extension of my school, so i never expected to make much til later. so, i just don't see the comparison with other professions, as residents are still students. i see your points, can't argue with them, but i still don't see residency as a "job" as much as i see it as extended education with a bit of money so i don't starve.

hospital!

FMGs typically don't have staggering six-figure debt. In fact most medical schools are state sponsored and have little to no tuition. Even at US state schools the debt load can approach six figures.

Plus, for many FMGs, making 36K/year is pretty damn sweet comepared to making 36k rupees/drachmas/rubles per year.

This issue should best be addressed by US trained MDs since they have the biggest financial stake in the system.

 

[handygirl]

1. The notion that we should be paid low stipends because we are students is so hilarious. How much of your time is spent in didactic learning during residency? Maybe 5%. The rest is spent performing patient care duties (for a bargain rate). "Learning" is a part of all professions, yet doesn't serve as a reimbursement penalty in other fields. Do you think fresh law school graduates are ready to broker corporate mergers or try supreme court cases after three years of school? Absolutely not--they perform menial tasks at law firms for several years and learn valuable skills, yet are paid appropriately.

2. Why do medical students not take salary into consideration when choosing residencies? Because they are all the same! When you take into account cost-of-living differences, salaries differ nationwide by an incredibly negligible amount. Wonder why this is . . .

To the residencies: get your priorities straight. Either pay us in a free labor market for our work, or start actively educating us (supervise our activities, spend more than one hour per week on teaching) like the federal government pays you to do.

 

[Apollyon]

Neil mentions "residents are students" - this is what the Republican party, and almost all medical educators, want you to think. That's why you're the "class of 2006", a junior or senior, and the like. What do the more stodgy and/or historical places call the pay? Your 'stipend' - even though it's just a word, does anyone in business call their salary (flat-rate pay) their 'stipend'?

Is this a bad thing, though? Not necessarily, especially if you are liberal (ironically). If you accept that you are still a student, and not an employee, then you will accept conditions less than that of another, (fully) trained and licensed professional (such as a PA or an RN).

However, US medical education has taken just a little advantage of this, and this was successfully pushed through the US Department of Labor during the Clinton administration - that the amount of actual labor performed by graduate physicians is superior to that amount of time spent in educational activities (ie, are you putting in the TLC without direct supervision, or is someone right there demonstrating, or watching you?), and you, therefore, are an employee in training, and, therefore, have the right to collectively bargain. Prior to this, 25 years of Republican lobbying had it in favor of the 'student/employee' model.

What would happen, otherwise? As others have said, either mid-level providers fill in, or attending physicians do the scut (or more autonomy is afforded the nursing staff). At my hospital, on call last night - "hold IVF during transfusion" - this order was not clear. It wasn't whether the transfusion was the IVF. It was "yes or no?" I am not making this up. The cost to retrain the staff to think for themselves would be a big one-time hit.

The very idea of being a 'resident' dates back to just that - when you lived there, right there, and you worked continually. Of course, this was also the time when you were single, poor, and (mostly) a white male. You didn't get paid, 'cause you didn't have anywhere to go, no one to spend it on, and no time. Thankfully, some ideas are long-gone.

The idea that hospitals in metro areas pay more shows that they are cognizant to the money idea. There's a reason Henry Ford pays residents on call (and some residents in the past would take a LOT of call, and make $100k/year).

Just an idea - if we are truly students, why do I have to be available during conference every day? Shouldn't I have protected time to get my lecture on hypothyroidism, without a page that the Colace order has expired?

Also, a friend told me that one of the attendings in her Transitional Year program was surprised to find out that no one knew that their GME funds in excess were paying for the clinic. Since she's in a TY, it doesn't seem reasonable that her education dollars are subsidizing a primary-care clinic.

So, how does this tie into a collusion lawsuit? "Hey, what do you have? I'll trade you a UCSF for a woman. She's black [honestly, do you think that, if they stoop to suppression of free trade, they're going to use the right term to refer to a group] ? I'll give you UCSF and Stanford." The holy grail is the Native American woman. The irony is that these students are homogenously disciplined students, who are academically motivated - their ethnicity or gender contributes little to their residency program choices, and nil to their performance as house staff - yet matters greatly to program directors and department chairs, to show diversity. However, the ethnicity might play into program ranking (by the applicant), if there is a signifigant debt-load, higher than that of an applicant that comes from a more-affluent household. This person who ranks program 'x' over program 'y' because they have housing at 'x', and unknowingly, gets screwed in a deal that sends them elsewhere, is getting the shaft.

One interesting thing is if this suit is successful, and the AMCAS continues in the same direction it is - that there could end up being a match for medical school admissions, without the schools without rolling admissions waiting until April to reveal whom they want, and multiple admissions holders playing it sly and playing one side against the other, whereas acquisition of residency positions would be the jumble. The chaotic mess that is now admissions would transfer 4 years down the road.

 

[soudes]

despite what some people think, paying your dues IS required is virtually every field.

sure, you could graduate law school and go out on your own, but you won't be guaranteed the big clients or big bucks unless you go through the "associate" crap. Like residents, they learn the ropes while working their asses off. they are payed well because in order to lure good students firms must pay more (here is our argument for bargaining). they pay a huge salary for what is really paralegal work....they do this because they are investing in you to bring in future money for them.

now, i am not saying that our salaries should be fixed at a low rate, but you are kidding yourself if you think you 'deserve' more than 60k. Yes, you are an MD. You are NOT board certified.

the day you become an MD, you can hang a shingle and start practicing, but have fun paying outrageous malpractice rates, and charging half of what a board certified doctor charges while working for the most undesirable of populations. the reason those board certified docs get the big buck is because they earned them; they are the most qualified. they worked their butts off learning how to be better doctors during their residencies. they had to be trained by other qualified doctors to learn how to be good doctors themselves.

that being said, i understand that residents offer an advantage to hospitals. but not to the point where they deserve to be paid anything close to what an attending makes.

should a 5th year ortho resident make only 50-60k when in one year his value magically jumps to 250-350k? No. Should a first year make 40-50k? Sure. Remember, the scut work that we all bitch about? Nurses get paid that or LESS for the same crappy work.

We will all be handsomely rewarded with money, prestige and happiness in time. Let's try to sound more grateful and less greedy.

Peace

 

[Apollyon]

Originally posted by soudes
the day you become an MD, you can hang a shingle and start practicing,

No, you can't - without at least an internship year, you cannot get licensed - and, if only a graduate MD, and you hang out a shingle, you would be guilty of practicing medicine without a license. Moreover, you can't get a DEA license until you get your state license.

We will all be handsomely rewarded with money, prestige and happiness in time. Let's try to sound more grateful and less greedy.

Noble, indeed, but that STILL doesn't pay the bills right now. At the same time, though, you are right - 60K should be sufficient for anyone.

 

[handygirl]

Since I was placing IV's, dispensing medications, hanging transfusions within a week of my internship, I should be paid as much as a nurse is (who doesn't have to do a residency, by the way). I can tell you that that is far more than 60k at my hospital. The PA's at my institution refuse to do a large number of tasks because they feel only physicians should do them (they don't have to do a residency either)--yet they make more than I do. I have far more autonomy in making medical decisions and treating patients than an equivalently-trained legal associate, yet they make three times what I do because they find their jobs in a free labor market and are paid commensurally for their skills.

If I'm not worth more than 60K per year in an unrestricted market, so be it. But one has to wonder why the powers that be are so afraid of this case . . .

 

[rtk]

You can't get blood from a turnip...

The argument that's 'a-buzz' on this board that hospitals are reimbursed $100,000-$200,000 per resident/year is plain WRONG! True that Medicare pays approx 2x's a resident salary to the training facility, and there is additional revenue generated by resident procedures billed to 3rd party payers, but the reimbursement does not nearly reach this level. And the money left over isn't just pure-profit... There are costs involved in training residents: Salaries, malpracitice, benefits such as insurance, meals, health-care; perks such as book allowances, meeting allowances, etc. However, a few of the biggest expenses related to training residents is in the form of fixed costs, attending salaries, and largest of all... indigent care. Yes, because the gov't pays these hospitals to train residents, the expectation is for these facilities to provide care for the uninsured masses. Is this extra resident pay commensorate with this HUGE expense: NO!

That is why, if you took a pole of hospitals across the country, the facilities in the worst financial stead are academic/university training facilities... The tertiary facilities that are best off are the ones who get support from big research dollars and charitable contributions.

So the argument for higher pay comes down to where does the money come from? Today there are more uninsured Americans than in any time in recent history; the US taxpayer pays ~20% of their tax dollars to entitlements programs, of which the majority of those funds are ear-marked for indigent health-care; US citizens pay more for their healthcare than in any other country in the world; and the US ranks 35th amongst all nations in health outcomes i.e.: M&M.

So the it's gonna be impossible to get more money from this current bankrupt system. It's gonna take sweeping reforms, but changing the system may increase the revenue stream. The largest chunk of health-care dollars and biggest profits in US health-care go to 3rd party payers, that is, private insurance companies. Perhaps decreasing top administrators 7-figure incomes could create more money to treat the uninsured or even train new-physicians. Of course, this will never happen.

Also, it's really and argument of symantics as to whether a resident is a student or a physician. Clearly, we residents are not students, however, until we get full liscensure, we're not full-physicians either. As I see it, my salary as a PGY-1 was a STIPEND unitl I was eligible for full practice rights as dictated by state law. Then I went out to the small town ER's nearby and did some moonlighting and more than doubled my income. Once you have marketable skills, you have a chance to make money... Your residency training gives you that opportunity.

So, perhaps the most important point of this suit will be improving resident work-hours... Hopefully... I just don't see how salaries can increase.

 

[smackdaddy]

why do you say they don't receive 100k+ per resident. every article i have seen has consistently stated that?

why should resident salaries pay for attending salaries? if the attending is 100% teaching residents, than certainly. but no attending is. the time spent teaching residents should be covered by these funds. the assertion that indigent care should be provided by medicare funds for residents is also questionable. why? if the residents disappeared, the money would disappear but the patients would not.

it's not an argument of merely semantics to ask whether residents are students. there are tax implications, disability implications, legal implications, and loan implications. these will dramatically impact your lifestyle during residency.

salaries can increase when they are made a priority. there is money in the system, it is just directed elsewhere. in any case, it is not the responsibility of the residents to find the money.

 

[vuillaume]

To clarify, I think smackdaddy was really trying to say that the $100K+ isn't pure profit once you subtract resident pay.

The way the system evolved is that Medicare funds pay for Graduate Medical Education. There is some formula that determines how much per trainee-head a teaching institution receives. It's expected that this will cover house staff salaries/stipends/slave-wages as well as educational overhead. If an attending takes the time to teach, that means his clinical efficiency decreases (yes residents watch his patients overnight &c., but overall, a smooth running private practice operates way more efficiently), in a sense, a teaching hospital ends up "paying" for the attending's decrease in efficiency.

Because our salaries/stipends/slave-wages are a government subsidy, it's difficult for Adam Smith's invisible hand to adjust our salaries to market levels for other professionals.

We can holler as much as we want, but we ain't squeezing blood from a stone.

While it's arguably true that the Match system, for all of it's value in making the process of placing residents fair, prevents free competition for resident compensation, that's secondary. The real limitation is scarcity of money, i.e. Medicare funds + the major systemic problems in our health care system.

 

[Apollyon]

Bravo! Well-said.

 

[beezar]

If the argument for the low pay of residents is that they are still students, it sure would be nice if that classification is consistent throughout.

For example, the federal government does not regard residents as students... they can't defer their loans for being "in-school," etc.