Does residency NEED to be so bad?

Discussion in 'General Residency Issues' started by humuhumu, Nov 25, 2005.

  1. humuhumu

    humuhumu nukunuku apua'a
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    Just about everyone agrees that residency is hell, even if you still like medicine. Insanely long hours, overnight calls, endless scutwork, draconian attendings, etc. Some people compare residency to a hazing, suggesting that the abusive work conditions serve primarily as an "initiation" into an elite "club," and are therefore an unnecessary holdover from less enlightened times. Yet this method of training does seem to produce competent physicians (with a few high profile exceptions).

    So, is that just the way it needs to be? Would a more humane residency training produce less competent physicians? Do you think there is still a need for reform, or should the whiners just suck it up?
     
  2. BKN

    BKN Senior Member
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    Well, we could go to the UK model with shorter hours and (many) more years of training. Does that appeal?

    If so, would the public pay the extra salaries?
     
  3. cowgirlcarrie

    cowgirlcarrie Member
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    Looks like you are getting ready to start medical school eh? Well residency is not a cake walk by any means. However, the 80 hr work week has made things a lot better. Sure not sleeping every 4 nights for months at a time can be hard on your body, but you also learn the most on those nights. You certainly don't want things to be prolonged! Medical school itself is going to at times be tough and stressful, so by the time you make it to your intern year you should be prepared to work hard. Plus, if you pick a field that you really love and you truly enjoy your work, then it will go by superfast.
     
  4. tigershark

    tigershark Senior Member
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    Theres many specialties with sane residency training. I'm interviewing for rads now and most programs are 8-5, no weekends, no call first/last year, and 4-5 weeks vacation a year. Work hard in med school and you'll be able to decide if you want to put yourself through hell or work the hours of a normal person.
     
  5. 8744

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    The problem is that residency training is hugely inefficient. Most of your time as an intern (75, 80, 90 percent?) will be frittered away wrestling paperwork and dealing with adminstrative things only periperally to do with patient care. The fact that a program needs 120 hours per week of your time to train you speaks more to the disorganization of medical training than to the complexity of the material. Even 80 hours a week should be more than enough.

    Face it, residents are cheap labor. At better programs you get good training in excahange for your low pay and long hours. In bad programs you are just scut monkies.
     
  6. GoPistons

    GoPistons Senior Member
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    disagree... residency is fine and it is not that taxing... I studied on average 8 hours a day including weekends during medical school... I think residency is much much easier than that... let's face it, you have to personally be involved in patient care to learn the nuances of patient care... patient care doesn't happen at home in front of a book...

    if you choose surgical residencies, you have to learn how to operate... that requires a tremendous number of total hours

    if you choose medicine, you have to learn to deal with random complexities... although most patients will have simple things (pneumonia, heart attack), you have to be present when there are rare cases...

    some of the work is scutwork and needless paperwork... but that's life... every profession has that... I don't think people truly understand what a real life job is really like... for the most part, they are boring, mindless paperwork, endless meetings with nothing getting done (try accounting, business, law, finance)... welcome to the real world...

    if one chooses medicine, be ready to learn a tremendous amount of information in medical school, and then be ready to spend the rest of your life learning how to apply that tremendous amount of information...
     
  7. beyond all hope

    beyond all hope Senior Member
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    Agree with Panda.

    Residency is inhumane and unnecessarily so. I'm nearing the end so I'm able to get a little perspective.

    Scutwork exists simply because hospitals are disorganized and teaching hospitals know that the residents will simply pick up the slack. It's tradition. Doesn't mean it's right. Often the most prestigious teaching hospitals are often the worst offenders because they know residents will put up with a lot of crap to be there.

    Sure, there's a certain amount of learning involved in scutwork at the beginning, but it becomes repetative and demeaning pretty quickly.

    Studies show that we make more errors when we miss sleep. Residents still do lots of nights and call simply because it's cheaper for the hospitals to do it that way.

    I'm not necessarily suggesting the hospitals are bad. They're often running on bankrupt. They sqeeze who they can to keep running, and residents simply take whatever we're given.

    I think that EM residencies are too bad (been in 2 of them) because everyone basically does the same thing. Whether you're an intern or a senior, you see patients, present them to an attending, and move to the next.

    The more hierarchical residencies, such as medicine and surgery, have the lower years doing all the scut while the upper-years make decisions. The scut may be paperwork, information gathering, blood drawing, tracking down lab samples, or even moving patients. The first two involve some learning, whereas the last ones are simply because it's easier to get a resident to do it than pay and train an assistant.

    Attending don't put up with the crap that residents do. If the hospital can't get it together to track down lab samples and draw blood, the attendings will leave. They don't work insane hours unless they're making insane money.

    Residency is unnecessarily cruel, and I believe that more humane residencies will make better doctors in the long run.
     
  8. BKN

    BKN Senior Member
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    About scutwork and chasing data. Choose a residency/hospital with blood drawing and IV services.

    Ensure that they have a good information system with at least dictated op notes, discharge summaries, lab values and digital radiography on line. If you can call up all of the information anywhere in the hospital or clinics, half the battle is won. All you have to do is think and learn.
     
  9. stephend7799

    stephend7799 Senior Member
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    DUDE you hit the nail on the head.. Medical training is one big inefficient system. I love the surgical program directors who say... how am i supposed to train a surgeon in 80 hours per week for 5 years.. Im like CMON gimme a break. They just want indentured servants for that long
     
  10. 8744

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    I guess it depends on your specialty and your program. While residency is not kicking my ass (I mean, seriously, I was a Marine Infantryman for eight years) I would say that my particular intern year is pretty taxing at times. On the rotation I am on now, for example, I pretty much get up wicked early, get home at about seven-thirty, spend an hour or two with my family then go to bed at nine-thirty because I like to get eight hours of sleep every day. I will repeat this for a month except that every third day I have call which as this is a busy service means zero sleep. Post call I go home at two or three, spend a couple hours with the family then pretty much sleep until the next morning. This is taxing because all I do is work and sleep. Maybe this is necessary but it is no way to live.
     
  11. carrigallen

    carrigallen 16th centry dutch painter
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    Interesting topic.

    I agree with Panda bear regarding inefficiency. Also, I believe there are two delusional ideas at work in residency training:

    1. "Trial by Fire" - The delusion that pain and abuse somehow makes us stronger and better trained. This is ingrained in almost all cultures, from Native American to Medieval Europe. The resident that gets no sleep for 36 hours has earned valuable "experience".

    2. Stockholm syndrome - A delusion in which victims tend to identify with their aggressor, rather than fellow victims. We feel the need to be loyal to those who endanger us. This is why interns are sometimes more loyal to the most aggressive attendings.
     
  12. Megalofyia

    Megalofyia 425 lbs and growing
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    I thought the idea behind residency was slave labor?
     
  13. 8744

    8744 Guest

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    Absolutely not the case here. I don't know the solution to the problem or even if it is a problem other than the fact that I don't like it. I'd do an extra year of residency if the pay was better and the hours shorter.

    I just want to reiterate that I cannot see how much of the work I have done as an intern is conneceted with learning medicine unless it is in the context of spending so much time at a hospital that something rubs off. (A medical "contact buzz.") Most of the stuff that keeps you here long hours is the massively redundant paperwork, most of which is lawyer prophylaxis.

    Take daily notes. In the real world, doctor's notes are pretty pared down and concise. In residency and particularly in big academic programs you document to death. If you think copying medications and lab values from a computer onto a hand written admit note is a good use of your time then God love you for it but I don't.
     
  14. mmmmdonuts

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    lol you guys are part of the problem. you go on this quest for the cushiest residency. Then when the rest of us need a CT taken or read the rads guy is all "hey i'm the only one here and no you cant get a study done on the weekend" or even during the weekdays you have to call five times to make sure the film gets shot. the reason you cant get a read overnight or a study done is because the rads guys are trying to get sleep or on vacation. Simple as that. You dont see IM or surg or peds going hey you cant get admitted cuz i'm the only one covering the floors come back in the a.m. or better yet on Monday. you guys set up your residency and/or practice so that you have lots of time off and minimal coverage and then turn around and complain that youre understaffed.
     
  15. tigershark

    tigershark Senior Member
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    No, we go on a quest to find a sane career, without the "martyr syndrome" of surgeons and internists.

    And the problems you describe are problems with the techs, not the radiologists. Dont let your apparently small exposure to an academic radiology dept fool you, any private practice rads group has 24/7 coverage and is easily acessible at any time.
     
  16. turtle md

    turtle md Hardware Included
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    This is true. I am at a community EM residency and radiology is always accessible. They work hard on call and I have respect for what they do. Wish I had the interest and desire to do it, but couldn't sit in a box all day.
     
  17. mmmmdonuts

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    working long hours equals being a martyr? ok thanks we know where youre coming from now.
     
  18. tigershark

    tigershark Senior Member
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    No, and that's not what I said. If you're ignorant of the so-called "martyr syndrome" prevalent in specialties such as surgery and medicine then please refrain from commenting.
     
  19. Mumpu

    Mumpu Burninator, MD
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    You learn by seeing patients. You see patients by being in the hospital. The more you are in the hospital, the more patients you see, the better you get. It's that simple. Personally, I'd rather do 80 hours/week for 3 years than 40 hours/week for 7.

    Paperwork is a necessary evil. Attendings do as much of it as housestaff.
     
  20. 8744

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    Whoa Nelly. You see a patients and then do an hour-and-a-half of exquisitely redundant paperwork admitting them. Then you discharge them and spend extra time doing all the discharge paperwork.

    When we discharge, for example, I have to write, by hand, prescriptions for all of their meds. not only does the physical act of copying the prescriptions take fifteen minutes for most of our patients but I have to dig through paper, notes, and computer data to make sure I am giving them the correct doses of both their home and hospital meds. Often this is on patients with whom I am not familar in the slightest except that they are on our service and I have rounded past them (another intern was following them). This takes about 45 minutes per patient unless everything in the chart is perfectly and legibly documented which is never the case.

    Not to mention the discharge summary.

    If any other business were run with this much inefficiency it would go bankrupt. Here you have me, a guy with almost twelve years of post-secondary education copying prescriptions onto a pad and doing other scut that a motivated high-schooler could do with aplomb.

    So while it's true that you need to be in a hospital to see patients, only a small fraction of your time with them will be spent obtaining a history, doing the physcial exam, and formulating a plan. In fact, the crushing burden of paperwork interferes with your ability to formulate a plan. You are rarely dinged for effectively deferring the plan to your upper levels but you will always pay a heavy price if the paperwork is incomplete. If you're rushed, where are you going to concentrate your efforts (I'm not talking about emergent patients who are great if only because you can eschew most of the paperwork)?

    Simple, on the element of your job which is the most pressing as far as the hospital is concerned which is usually compliance to thousands of beauracratic requirements and the Great God of Paperwork.

    Attendings do not do one tenth the paperwork an intern does. That's why they're attendings and usually take a hit in salary to work in teaching hospitals. They have, if you include the medical students, an entourage that would make a Rock Star who's duty it is to do all the scut.
     
  21. mmmmdonuts

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    it must be nice to not have to work weekends or nights and then say that people who do are are just martyrs. :laugh:
     
  22. tigershark

    tigershark Senior Member
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    I see reading comprehension is not one of your strong points. Funny how you cut out the part of my post where I said I was not calling them martyrs, you must be acting ******ed on purpose.
     
  23. Mumpu

    Mumpu Burninator, MD
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    You have to be in the hospital 60-80 hours a week because patients come in at a certain rate. If you spend too little time in-house, you won't see enough patients. Paperwork is just there to keep you entertained between admissions.

    Oh, and as far as inefficient academic programs, there are three hospitals where I live that are using or about to start POE: VA, county, and university. All the "efficient" non-teaching privates are still using four-carbon-copy sheets for orders.
     
  24. Cram

    Cram Junior Member
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    If this is so then via a purely educational experience, a 5 year residency could easily be finished in 2 years! (60% current scut) or in 5 years at 30 hrs/wk!!

    Sure it costs $ to do this, but couldn't someone get a grant to try to create such an experience?
     
  25. Mumpu

    Mumpu Burninator, MD
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    You are missing the whole point of long hours. Patients come into the hospital at a more or less constant rate. If you get one admission every 8 hours, you get 10 admissions in an 80-hour week or 5 in a 40-hour week. At the end of residency, the physician working 80-hour weeks will have seen twice as many patients. If there was no scutwork, you'd spend the same amount of time in the hospital except you would be watching TV.
     
  26. banner

    banner Senior Member
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    Patients come in at a constant rate??? I don't think so. You aren't talking as if you have not had much experience as a resident.


    Plenty of us have had the ER call us with the phrase "I have eight admissions for you. "
     
  27. ORBITAL BEBOP

    ORBITAL BEBOP Senior Member
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    Doesnt night float alleviate some of the sleeplessness of residents? Isnt this a good thing? I have personally not worked in a hospital with night float.
     
  28. humuhumu

    humuhumu nukunuku apua'a
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  29. Mumpu

    Mumpu Burninator, MD
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    Banner, different institutions I suppose. At my school lot of work was done to intermix the specialties (particularly IM and ER) a bit which has helped to alleviate the dumping somewhat. Most teams have a fairly constant number of admissions per call (if not per hour).
     
  30. orientedtoself

    orientedtoself resident
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  31. stephend7799

    stephend7799 Senior Member
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    The point of the matter is that you can absolutely train physicians without brutalizing them with the every third night or every fourth nite on call and having them stay in the hospital for the whole day after call.. 10-12 years ago all medicine programs were every fourth with no post call days off.. and surgical programs were even far worse.. I did a surgery internship 7 years ago and i was on call every third night for the whole entire year with no post call days.. Let me tell you.. that is a physical and psychological stress that im not quite sure I have recovered from.. call was not the cushiest either.. Your beeper would go off on average 10 times an hour.. maybe after midnite it would dwindle down to maybe 3 times per hour.. and each of these pages you would have to go do something.. So after this abuse I have absolutely nothing but disdain and contempt for the whole system. It used to be it was all worth it at the end because you became an attending, you were revered for your knowledge and your skills and you were well compensated for it. Now that medicine has become managed their is no more of this. physicians will most likely be employed and they will not be getting the lions share of the reimbursements.. Internists of 20 years ago were making the same salary as interenists today.. (dollar amount) So this is the part that has become most disheartening for me. We were duped. abused. and this is going to continue until nobody is entering the profession.. and people wonder why they cant find anyone to read an xray in the middle of the night.. or why there are nurse practicioners staffing emergency rooms in rural america..
     
  32. DeLaughterDO

    DeLaughterDO Ghost in the Machine
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    Ok, so this person is saying it is better to have someone who has already been awake for 16-20 hours admitting patients than someone who is fresh and only awake 3-5? Bullsh!t.

    I really like the comment on how hospitals should "encourage residents to take naps whenever possible." I think most already do - the problem is with the qualifying statement "whenever possible." When do students or residents get a chance to take a nap?

    Rarely, in my experience.
     
  33. familyfirst

    familyfirst Junior Member
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    That's so nice. I would train for longer in exchange for lesser hours. I made so many mistakes as an intern that either some nurses were nice enough to point them out to me or I just got trouble for it.

    As for British system, yes, physicians get a salary but most European med students/physicians don't have debts. They usually get through their education without much debts. That's what get we for in a capatalist system. It is a vicious cycle. People want the high end lifestyle and technology, must find a way to finance that. I don't know if there is really a solution. Perhaps we should train more physicians who are willing to go into health policy and influence and try to change the system. I am sure that many are aware that medicine is treated like a business and most of the people who are controlling the system are no MDs. Hopefully everyone will have a happy medium and a specialty he/she will be happy with and not to lose the initial goal/aspiration why they wanted to be a doctor. That's what I pray for myself everyday.
     
  34. cdql

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    I would agree to work shorter hours during residency and train for a longer period of time as well if there was no debt involved.

    It's hard to pay back ~$100K in loans (is this still the average or has it risen now?) on a waiter's salary!
     
  35. Hurricane

    Hurricane Senior Member
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    This came out of my med school??

    Yeah, because people who have gone 30 hours (assuming everyone actually adheres to the 30 hour rule) without sleep are so much safer drivers. :rolleyes: Not according to the New England Journal of Medicine. From Extended work shifts and the risk of motor vehicle crashes among interns:
    I agree that you learn the most when taking admissions, which for some reason tend to occur mostly at night. But I don't see how it's beneficial to be awake and in the hospital for the 12 hours prior to when the admissions come rolling in.

    I matched at a psych residency (and yes I know you hardcore IM and surgery types think we're all slackers :p ) where you do a couple months of nights in the psych ER taking admissions. Then for the rest of your inpatient rotations you're on home call. And you do a whole month at a time, which theoreticaly gives you more time to adjust than the 2 week shifts that most night floats do. I don't know if this is a good solution, but it makes sense to me. Ask me in a year. :)

    :laugh:
     
  36. DRDARIA

    DRDARIA Member
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    So true. Picking a residency program with a good computerized medical record system and good ancillary support was high on my priority list-- there is nothing I hate more than trying to wade through a two inch chart at 2AM, most of which is nursing notes and orders, searching for the previous H and Ps, (since the patient doesn't know or can't tell me their PMH and meds), and most recent discharge summary isn't even in the chart yet, since the patient was just discharged from their last admission two days ago, and is now having chest pain again....

    The problem is these systems are expensive, and residents are cheap, and many old-timers are resistant to computers, or simply don't realize that they actually DO improve patient care.
     
  37. God all that sounds terribly inefficient - hopefully your hospital can change this process around. 2 of the 3 main hospitals we rotate through also require a lot of paperwork, but even so it usually only takes me 15-20 minutes per discharge, including the dictation. It has to be this way, though, as sometimes we have anywhere from 3-6 discharges per day.

    It's tough as a surgical intern to deal with all this scut, since there are weeks when at least 25% of your time is spent in the OR - thus the 80-hour workweek is a tough one.
     
  38. fourthyearmed

    fourthyearmed Senior Member
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    One admission in an 8 hour period?? Sounds nice but I doubt that kind of patient load would keep a residency program in business. We average more like 12 to 16 in a 24 hr period which would be at least 4 per 8 hours.
     
  39. Lonestar

    Lonestar Senior Member
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    Residency is much to do with surviving than learning. Much more about politics than actually trying to become a good competent physician. I see no end to this. Unless, there is a way for the residents in each respective program to anonymously evaluate their respecitve residency program directly to the RRC, i don't see a way out of this. It is too one sided. Programs have all the power and residents have none. Trust me, there are malignant programs in all fields and in all corners of the states. Why do we allow this? simple, we don't have a voice. RRC is a joke unless they can clamp down and take residents suggestions/evals seriously. Oh wait, but all this "hard work" and "ass kissing" is good for us. Sounds like a slave labor camp to me. A slave labor camp for intellectuals being abused by other intellectuals.

    will finish hard labor in 2008. Disdain for medicine growing........
     
  40. stephend7799

    stephend7799 Senior Member
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    the only way to gain power is to get rid of the NRMP and let market forces dictate your salary...
     
  41. humuhumu

    humuhumu nukunuku apua'a
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    What about forming a labor union? I've heard of some graduate students and postdocs doing it...
     
  42. Qafas

    Qafas Jarhead
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    I agree with those who say that residency is much more grueling than it needs to be. If the goal were simply to train competent physicians, I think it could be done with each of us putting in much fewer hours, doing much less work, in the same number of years. However, that would require tremendous efficiency in the system, and great motivation amongst attendings to teach at every available opportunity. Neither of those is possible. While there are hospitals along the entire spectrum of efficiency, most of them are nowhere close to the top. There is an almost unthinkable amount of waste in most systems, both in terms of resources and time. They could hire more workers to reduce the amount of scut residents have to do. But, why do that when you've got residents who don't have much of a choice but to submit to whatever schedule there is? As for attendings, once again, there are great ones and there are horrible ones. But even the best of them don't teach at every available opportunity. That means that we don't learn from every patient, which is just as well. I can't speak for anyone else, but there is only so much learning I want to do on any given day. Not every patient has something to teach; sometimes, we just want to get our work done and be gone.
    I believe that if we went to, say, a sixty-hour week in a system with more efficiency, where highly-trained physicians aren't doing things a high-school graduate could do just as well, we could turn out physicians who are just as competent and probably less jaded. But there is no incentive for anyone to do that; except, of course, the residents. But, the residents don't have much of a choice in the matter. And, once we graduate from training, most of us will go on leaving the next generation of residents to fend for themselves.
    An average resident makes roughly $10-12/hr working 80hrs/week. Some fast-food restaurants pay their cashiers that much. If hospitals had to pay us according to our skill level by the hour, I guarantee that there would be a lot more help on the floors. Anyone disagree?
     
  43. penguins

    penguins Senior Member
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    I think you would be hard pressed to find a highschool grad who is smart/competent enough for such tasks. I mean, isn't your fast food item wrong more often than it is right? I think you make good points but I don't think there is anyone else to do the job. People slack off so much and just pass things on, I would think that without the resident to really make sure it gets done (because their butt depends on it), it wouldn't really get done.

    My 2 cents.
     
  44. mysophobe

    mysophobe Recovering Germophobe
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    According to Hot Lights, Cold Steel, ortho residents make $2.50/hr. Of course, they worked longer back then, so it may have gone up a few cents. :p
     
  45. Plastikos

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    How hard is it to run down to the file room and bring back a film? There are countless mundane tasks that are done by residents that many many ppl could do, especially at the lower end county places. Residents are not necessarily "too good" for these things, its just a waste of resources considering.
     
  46. If you work 80 hr/wk, 49 wk/yr, and make around $40k a year, then that comes out to around $10/hr. That's PRE-TAX. :(
     
  47. toxic-megacolon

    toxic-megacolon Toxic Member
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    If you factor in the second 40 hours as "overtime" since that's what most hourly people get paid time-and-a-half or double-time for every hour after 40, it brings it down even further!
     
  48. Qafas

    Qafas Jarhead
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    Thank you. That's exactly what I meant when I said a high-school grad could do many of the things that take up a resident's time each day.
     
  49. bigtimesmally

    bigtimesmally Member
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    Eventually, I think the system will get to the point where residents will work less than 80 hours. Who would have thought 20 years ago that a 80-hour week mandate would be put in place? So, just give it time.
     

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