No money to renew contract?

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heretics

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I got an advanced residency position outside the match. But I was just told that the spot was in fact an unmatched prelim spot--with funding for only one year. Program had assumed they would be able to get funding for an additional year so that I could graduate, but now due to budget tightening they are saying that I should look elsewhere in case no one takes maternity leave or dies. What to do? Who determines whether a program gets funding for an additional resident the following year or not? It seems like all those prelims who want to stay on in Medicine instead of continue in anesthesia or whatever they matched into at a different hospital sail right into the PGY-2 with no fuss. NB, multiple attendings have quit the hospital recently, who are not being replaced, but I assume that those salaries are independent of resident salaries?

Feel free to PM. Thanks.
 
Resident salary largely comes from medicare. And the number of residents medicare will pay for is predetermined (ie X amount of categorical [PGY 1-3 or 4 or 5 etc.] salaries and X amount of prelim [PGY1 only] salaries). The institution's hands are largely tied, even if they could use "private" money to fully fund a resident, I'm pretty sure that is against the rules. Alternatively, I think,someone correct me if I'm wrong, but residency programs can turn a prelim spot into a PGY2 spot for the purposes of funding, and would take one less prelim the next cycle, without having to change the total amount of funding coming to the instituion GME from medicare.

Staff physician salary are paid by what they produce or by what was agreed upon thorugh some sort of contractual arrangement, maybe a little of both. For the purposes of getting paid in the hospital, even though the resident does most of the heavy lifting, they largely cannot produce their own income in the setting as working as a trainee, even if they have their own license (this is in contrast to "moonlighting").
 
Resident salary largely comes from medicare. And the number of residents medicare will pay for is predetermined (ie X amount of categorical [PGY 1-3 or 4 or 5 etc.] salaries and X amount of prelim [PGY1 only] salaries). The institution's hands are largely tied, even if they could use "private" money to fully fund a resident, I'm pretty sure that is against the rules. Alternatively, I think,someone correct me if I'm wrong, but residency programs can turn a prelim spot into a PGY2 spot for the purposes of funding, and would take one less prelim the next cycle, without having to change the total amount of funding coming to the instituion GME from medicare.

I don't know about "converting" a spot (aPD or mcl could likely comment), but it's not uncommon (or against the rules) for programs to pay out of departmental or division funds for additional house staff not funded by Medicare. My fellowship program has done it on and off for a few years. I think it happens more in fellowships and small residencies than in large programs.

What's definitely not kosher is somebody's daddy ponying up $3-500K so a program will take little Jimmy into the Derm residency program (even though little Jimmy failed out of 3 offshore med schools, took 7 years to graduate and failed Steps 1 and 2 three times before finally passing).
 
I don't know about "converting" a spot (aPD or mcl could likely comment), but it's not uncommon (or against the rules) for programs to pay out of departmental or division funds for additional house staff not funded by Medicare. My fellowship program has done it on and off for a few years. I think it happens more in fellowships and small residencies than in large programs.

What's definitely not kosher is somebody's daddy ponying up $3-500K so a program will take little Jimmy into the Derm residency program (even though little Jimmy failed out of 3 offshore med schools, took 7 years to graduate and failed Steps 1 and 2 three times before finally passing).

I thought fellowship funding worked on different rules.

This stuff is so arcane.
 
Each program has two "caps" -- a Medicare / funding cap and an RRC training cap.

The RRC accredits programs, assesses them, and caps them at a certain number of residents based upon educational resources. Each specialty has a somewhat different way of doing this, but they look at patients + teachers + space + educational success in the past + following the rules + duty hours + etc. This cap is inviolate -- you are not allowed to train more residents than your RRC allows (exceptions are sometimes made in a crisis, like with Katrina when programs were allowed to increase their RRC caps slightly to absorb displaced residents, etc). At any time, a program can request an increase in their RRC cap -- usually they would get site visited and then the RRC would decide whether to increase the cap or not.

Separate from this is funding. Funding comes from Medicare, and is regulated at the level of the institution (not the program). Hence, Man's Best Hospital (MBH) might have 3 residency programs -- Medicine, Surgery, and Peds. They could have a Medicare cap (i.e. maximum number of funded spots) of 80. They could distribute those 80 slots amongst all three of their programs in whatever proportion they want. The number of slots available to each institution was fixed by the BBA of 1999 -- prior to that you could simply bill medicare for as many residents as you wanted.

If the number of RRC approved positions is larger than the number of funded slots, and if those positions are filled, then someone (either the institution as a whole, or the program) needs to pay for the overage. There is nothing illegal nor immoral about this, it happens all the time.

In reality, each program has a certain number of slots funded by the institution. I don't have to go to GME begging each year, I know they will fund X categorical, Y primary care, and Z prelim slots each year. If I want more than this, then I need to beg. Some years a program will use less than their assigned slots -- and that would allow some other program to go over.

Now, to get to the situation of the OP. First, if they told you they were signing you into a categorical spot and now telling you it's just a prelim / 1 year spot, you've been had. Because the position was outside of the match, there isn't much you can do. You can see if your contract specifically said it was expected to be renewed. Still, this is an uphill battle that you're likely to lose -- employers can lay off workers due to financial constraints.

GME decides if a specific program gets "additional funding" for a slot -- remembering that the total pot of money is fixed, so if you get funding, someone else doesn't (or some other spot goes unfilled).

Prelims staying in medicine is not exactly competition for you (unless you're trying to stay in medicine). If the IM PD has funding for 10 slots per year, and matches 6 categorical residents and 10 prelims and then picks 4 prelims to continue onwards, that's totally fine and reasonable budgeting of his/her slots. If the IM program is keeping extra people beyond their usual slots, then that's something you could try to compete against.

Just be aware that if your spot is paid for with outside funding -- a grant, or industry money, etc -- and that's now dried up, and now your dept goes to GME looking for money --> GME tends to hate this. I mean, really, if you're going to be a good PD you should have all years of funding for any resident in the bank before taking them on.
 
I agree with APD's last sentence...
if the PD was good then he/she would have taken care of this issue BEFORE taking you on. Essentially, you got screwed.

I'd like to know which specialty, just out of curiosity.
I know someone who had something similar happen in general surgery...it was a PGY2 surgery spot which the program implied would likely turn into a PGY3-5 spot but they couldn't "guarantee" that. Apparently they frequently do this, in order to get cheap labor in the form of PGY2 surgical residents they use and then throw away. I think there are still programs that do stuff like this, even though it is unscrupulous. Alternately, perhaps the hospital truly is having severe financial difficulties, and they'd hoped to fund your upper level spot (for next year) with departmental or other funds (not normal GME funds via Medicare) and now they can't. A third alternative is they don't like you that much and are using a lame excuse to explain why they aren't renewing your contract.

Regardless of what is true, I think you can only make known your desire to stay there. If the PD says it's a no go, then you start looking for a spot somewhere else ASAP. And don't burn any bridges with your current program, because you'll need references from them to move forward.
 
Thank you so much for your replies. This is terrifying. I am in internal medicine, and when I joined, they had a good year for funding and several new residents were hired --but evidently they were all true add-ons to the program--the RRC agreed that those slots were needed so they added an intern with 3 yrs of funding, couple of PGY2s with two years of funding, etc. That was all before I joined.


Where can I get actual documentation of this lack of funding? It is a county hospital but the GME director is at the academic hospital. Who actually holds the reins
 
Thank you so much for your replies. This is terrifying. I am in internal medicine, and when I joined, they had a good year for funding and several new residents were hired --but evidently they were all true add-ons to the program--the RRC agreed that those slots were needed so they added an intern with 3 yrs of funding, couple of PGY2s with two years of funding, etc. That was all before I joined.


Where can I get actual documentation of this lack of funding? It is a county hospital but the GME director is at the academic hospital. Who actually holds the reins

You can't.

If the funding comes through some other institution's GME office, they get to call the shots. If they decide to pull funding for your slots to feed some other need, there is nothing you can do.
 
If it's truly a funding issue, then I guess the OP can just go to another hospital for 3rd year? That's going to suck for training though...3years at 3 different places. No good for continuity clinic, either.
 
So this is a slightly related question then more for hope of APD replying.

I'm doing a prelim this year. A program I'm interested is adding a spot.

If it is offered outside the match as a categorical does it come with funding or does it have to go through the match?
 
The match is completely independent from funding. You can apply outside of the match. If a program adds a spot, then presumably they have funding (from somewhere) for that spot.
 
I guess my follow up question is if a program adds a spot is it a match violation to offer it outside the match?

i.e. approval for spot will happen in the fall can they offer it outside the match or would that automatically be a violation before they submit the number of spots for the March 2011 match?
 
If it's truly a funding issue, then I guess the OP can just go to another hospital for 3rd year? That's going to suck for training though...3years at 3 different places. No good for continuity clinic, either.

I know that some 3 year residency program review committees require the last two years to be at the same place (barring unforeseen circumstances, like a hurricane or program closure) to be eligible for board certification. Is it like that with IM?
 
I guess my follow up question is if a program adds a spot is it a match violation to offer it outside the match?

i.e. approval for spot will happen in the fall can they offer it outside the match or would that automatically be a violation before they submit the number of spots for the March 2011 match?

No. But you don't have to add a spot for the answer to be the same. Participating in the match is voluntary for me. If I want to prematch all of my spots with IMG's/DO's/US grads, I am free to do so. If I have 10 slots, I can prematch 2 and put 8 in the match, or vice versa. So, whether or not a program has increased their size, they can offer you a spot outside the match (assuming you are not a 4th year US student). If you are a 4th year US studnt, you must go through the match. If there's a spot outside the match you want, you could purposefully not match anywhere and then sign a contract afterwards, but that sounds crazy.

I know that some 3 year residency program review committees require the last two years to be at the same place (barring unforeseen circumstances, like a hurricane or program closure) to be eligible for board certification. Is it like that with IM?

No, technically you can do your PGY-3 elsewhere. However, getting a PGY-3 is difficult. Since we give our PGY-3's quite a bit of responsibility, and also mostly electives, I usually will not take someone unknown to me.
 
No. But you don't have to add a spot for the answer to be the same. Participating in the match is voluntary for me. If I want to prematch all of my spots with IMG's/DO's/US grads, I am free to do so. If I have 10 slots, I can prematch 2 and put 8 in the match, or vice versa. So, whether or not a program has increased their size, they can offer you a spot outside the match (assuming you are not a 4th year US student). If you are a 4th year US studnt, you must go through the match. If there's a spot outside the match you want, you could purposefully not match anywhere and then sign a contract afterwards, but that sounds crazy.

Wasn't there a proposal afoot around 2001 or 2002 to make all spots in a program either in the match or out - none of this splitting? Did this happen then stop, or never came to light?
 
Wasn't there a proposal afoot around 2001 or 2002 to make all spots in a program either in the match or out - none of this splitting? Did this happen then stop, or never came to light?
The NRMP tried to do this (much more recently, 2008-9 or so) and failed. They tried to make institutions all-in -- i.e. all spots in a single institution needed to be all-in to participate. They did this presumably because they felt that programs currently 50% in and 50% out might switch to 100% out, which wouldn't help. It failed because 1) some programs were worried that their entire institution might opt out (which seems really unlikely), and 2) they claimed that visa issues require more time available, and that a match in Mid March won't work for visas. Argument #2 is probably mostly old news, now that premium processing for H1b visas is available, but still it did not go forward.
 
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