I fail to understand why step matters so much....

[NotAProgDirector]

I think it's important to define what problem you are trying to fix. Reading the posts above, it appears to be "salary". If that's the case, we already know that removing the match won't put any upward pressure on salaries. We know this because the IM fellowships are relatively new to the match. Before there was a match, the application process was just as you said -- people apply, programs interview, and can extend offers at any time. Feel free to search here for what applying to Gastroenterology and Cardiology was like before the match -- it was an absolute nightmare both for applicants and programs. But, importantly, there was no upward pressure on salaries to "fix" anything. That's because:

1. Most applicants are not driven by salary, but rather by prestige, geography, and other factors.
2. There were more applicants than spots. If you don't get a spot, your career is forever impacted. You can't just go get another cardiology/GI job. Hence, no one was willing to give up any offer.
3. Salary levels are set centrally by the GME office. Programs have no ability to change them.
4. Every year, people volunteered to complete a fellowship with no salary at all. If left to a free market, this would put downward pressure on salaries (which would not happen, because they are fixed by GME).
5. All PGY years are paid the same across the board. So GI fellows get the same as Nephrology fellows.

I think the comparisons to business/law don't hold, since lots of law and business students don't end up with ajob in Big Law or Big Business but do something else. In residency, that's not an option.

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[Med Ed]

Hard capping applications would likely result in SOAPing for a much larger percentage of mediocre applicants, which I'd argue is significantly worse outcome than overwhelmed PDs (for everyone involved).

I think that depends on where the cap is placed. If the cap were 300 then we'd have no change from the current situation. If the cap were 3 then you're right, it would be SOAPapalooza. Between those two figures a happy medium may exist.

In 2007 the average US MD senior applied to 32 programs, less than half of the current number. The overall match rate in 2007 was the same as this year (93.7%) and the percentage of students getting their top choice was higher (58.6% then versus 47.7% now). The percentage of students getting one of their top three choices was also higher (83.8% then versus 73.4% now). I think this is a function of more efficient process.

 

[Anakinmemer]

Thing is MBA and JD grads from top programs can start making money for their employers (and therefore themselves) almost immediately. Residency training is basically an apprenticeship, and until you're BE/BC and can bill for your services you aren't worth a whole lot in the grand scheme of things. Whatever you get paid as a resident, there are literally thousands of IMGs and FMGs who would do the same work for less money. That's not leverage.

Also remember that the large majority of GME in this country is federally funded through CMS to the tune of over $16 billion a year. That's the cost of getting new physicians to the point of independent practice. Residency salaries aren't glamorous, but they'll provide a roof and corn flakes, and as a trainee you don't have to worry about malpractice, life insurance, or disability coverage, and your health insurance is typically well subsidized. I strongly doubt there is a better deal for all residents and fellows hiding behind door #2.

There's a urologist in NYC making 7mil a year by largely relying on residents and fellows to do everything while he hopped between rooms, he actually got in trouble for it I think. (City’s hospital specialists are raking in millions of dollars)

I feel like senior residents/fellows do allow for much more billing than they get credit for with all the help they give. In terms of intern year yeah you are nothing but a negative to workflow. That is why I'm much more in favor of the start low end high payscale of training. You should be making 60k as an intern but there's no reason a fellow who is basically independent should be making only 80k. Even if they aren't directly billing they must be contributing enough to be making the hospital a lot more than 80k right?

I might be completely off base with this, that's just the impression I got from clinical year

 

[deleted1139416]

Thing is MBA and JD grads from top programs can start making money for their employers (and therefore themselves) almost immediately. Residency training is basically an apprenticeship, and until you're BE/BC and can bill for your services you aren't worth a whole lot in the grand scheme of things. Whatever you get paid as a resident, there are literally thousands of IMGs and FMGs who would do the same work for less money. That's not leverage.

Also remember that the large majority of GME in this country is federally funded through CMS to the tune of over $16 billion a year. That's the cost of getting new physicians to the point of independent practice. Residency salaries aren't glamorous, but they'll provide a roof and corn flakes, and as a trainee you don't have to worry about malpractice, life insurance, or disability coverage, and your health insurance is typically well subsidized. I strongly doubt there is a better deal for all residents and fellows hiding behind door #2.

But if that's the case, then why are resident strikes and unions so effective at improving salaries and benefits? The hospital could just say "screw all of you, we are going to fire every single resident because you slow us down anyways."

 

[deleted1139416]

@Med Ed Also curious about your thoughts on resident written notes versus attending written notes when it comes to litigation. I have noticed residents write much more detailed notes. Is this helpful in litigation in malpractice suits?

 

[VA Hopeful Dr]

But if that's the case, then why are resident strikes and unions so effective at improving salaries and benefits? The hospital could just say "screw all of you, we are going to fire every single resident because you slow us down anyways."

Because doing so would mean they have to replace all of those residents. That takes time.

Plus the ACGME would have something to say about that.

Resident unions help somewhat, but not nearly to the extent of unions in other fields.

 

[DOVinciRobot]

Yeah the idea that residents don’t make hospitals money is commonly touted in these threads whenever this topic comes up. It’s absolute garbage and not based in reality at all. To replace a surgical resident you need, at minimum, to hire roughly 2 mid levels. At our facility the PA’s and NPs make almost 3x what we do and work literally less than half the hours, and have significantly more PTO and benefits. With benefits, the loss of federal GME funds, and salary, you’re talking about 300k+ just to replace a single resident. This was highlighted by the abrupt closing of the UNM neurosurgery program when they had to hire 23 midlevels to replace the 10 residents.

Maybe in non-surgical fields the junior residents slow the attendings down but on the surgery side my presence allows the attending to run two rooms, frequently I am doing procedures solo with them only present for time out while they do something else. They write zero consult/progress/H&Ps/notes of any kind. Their “notes” are 95% of the time a dot phrase with a generic “I agree with this note.”

See: economic value of an on call neurosurgical resident physician to see the financial benefit of surgical residents even in the junior years.

 

[deleted1139416]

This was highlighted by the abrupt closing of the UNM neurosurgery program when they had to hire 23 midlevels to replace the 10 residents.

Wait.... WHAT?? A neurosurgery residency closed down so they could hire midlevels instead?!?!???? WHAT!!!!!!

 

[VA Hopeful Dr]

Yeah the idea that residents don’t make hospitals money is commonly touted in these threads whenever this topic comes up. It’s absolute garbage and not based in reality at all. To replace a surgical resident you need, at minimum, to hire roughly 2 mid levels. At our facility the PA’s and NPs make almost 3x what we do and work literally less than half the hours, and have significantly more PTO and benefits. With benefits, the loss of federal GME funds, and salary, you’re talking about 300k+ just to replace a single resident. This was highlighted by the abrupt closing of the UNM neurosurgery program when they had to hire 23 midlevels to replace the 10 residents.

Maybe in non-surgical fields the junior residents slow the attendings down but on the surgery side my presence allows the attending to run two rooms, frequently I am doing procedures solo with them only present for time out while they do something else. They write zero consult/progress/H&Ps/notes of any kind. Their “notes” are 95% of the time a dot phrase with a generic “I agree with this note.”

See: economic value of an on call neurosurgical resident physician to see the financial benefit of surgical residents even in the junior years.

As always, its not an absolute. Interns in non-surgical fields are absolutely a money loser. From past PD comments, usually somewhere during 2nd year that starts to change. But, even 3rd years aren't pure money makers given the number of elective rotations during which residents aren't earning any money.

Replacing the residents usually isn't even necessary. During my residency, our inpatient team consisted of 2-3 interns, 2 upper levels, and an attending. Usual census was around 20-25 patients. The attending could handle that patient load on their own.

 

[Anakinmemer]

As always, its not an absolute. Interns in non-surgical fields are absolutely a money loser. From past PD comments, usually somewhere during 2nd year that starts to change. But, even 3rd years aren't pure money makers given the number of elective rotations during which residents aren't earning any money.

Replacing the residents usually isn't even necessary. During my residency, our inpatient team consisted of 2-3 interns, 2 upper levels, and an attending. Usual census was around 20-25 patients. The attending could handle that patient load on their own.

Is the attending not going to work significantly harder without the residents for the same pay though? During my clinical year the attending came in for rounds and then left. If they were first contact provider for the entire 12 hour shift they'd have to deal with all the tasks the residents complete throughout the entire day right? Scheduling appointments, social work rounds, running to the lab, speaking with nurses, balancing electrolytes, taking patient complaints, coordinating consult teams, etc etc. All things that aren't glamourous and directly making the hospital money, but they do need to get done, and they require someone to be in the hospital to do them. Who does this if residents walk away? If they have to hire midlevels they are losing money as their pay is higher than residents

There are many employees in the hospital that aren't directly billing but are required for the hospital to run. Residents are no different. Sure you could replace them with midlevels or more physicians but that's losing money.

The only place I can see residents not really providing anything is in clinic if the attending sees the patient after anyway

 

[DOVinciRobot]

Is the attending not going to work significantly harder without the residents for the same pay though? During my clinical year the attending came in for rounds and then left. If they were first contact provider for the entire 12 hour shift they'd have to deal with all the tasks the residents complete throughout the entire day right? Scheduling appointments, social work rounds, running to the lab, speaking with nurses, balancing electrolytes, taking patient complaints, coordinating consult teams, etc etc. All things that aren't glamourous and directly making the hospital money, but they do need to get done, and they require someone to be in the hospital to do them. Who does this if residents walk away? If they have to hire midlevels they are losing money as their pay is higher than residents

There are many employees in the hospital that aren't directly billing but are required for the hospital to run. Residents are no different. Sure you could replace them with midlevels or more physicians but that's losing money.

The only place I can see residents not really providing anything is in clinic if the attending sees the patient after anyway

And don’t forget the call. All those pages for Tylenol and a bowel regimen at 2 am? That’s you now Mr Attending. All those consults for actual non-surgical issues but the ED isn’t sure and just wants to cover their bases before they discharge that patient at midnight? Yep that’s you too.

I roll my eyes whenever these conversations happen. Reality is residents provide a service far above what their pay level is once they move past the intern/hand holding stage, at least in the surgical fields. We are highly skilled and extremely cheap labor. A chief surgery resident getting paid 60k for what they do and claiming a negative economic value for the health system is laughable.

 

[Billiam95]

To reference the Sheriff of Sodium: would the HCA be the largest employer of residents if they weren't profitable?

 

[LucidSplash]

It is clear to me that many people here have never worked in an institution without residents or fellows. If residents vanished overnight, there would obviously be a difficult adjustment period. But then institutions would hire mid-levels. There is a period of training mid-levels and finding good mid-levels. But they can be hired to take first call, to do notes, to assist in surgery. They can also bill for services and there are codes for using them as an assistant in surgery.

Residents and fellows are important to the future of medicine and physician leadership. I prefer to work at places with residents because I enjoy teaching. But I currently work as locums and usually do not have residents. I do not find that I work “harder” at these places because there are mid-levels to help. They are of varying quality, and you have to learn who you can trust for assessments and how far. But that is also true of residents. The hospitals do not lose money on mid-levels. At least in surgical specialties, they make it easier for surgeons to be doing the thing that makes the hospital the most money - operating.

I prefer to work with residents because of my personal drivers and motivations. But this idea that residents are irreplaceable is easily disproved at the large number of hospitals which do not have them.

 

[ChordaEpiphany]

I’d actually be in favor of a different test to better stratify applicants because something has to do it. I just wonder if it would really change anything considering how much these scores are correlated to studying. And it’s not like they could change the material aside from getting rid of stupid stuff like memorizing the names of genes or which chromosome is associated with which disorder. The NBMEs attempt to add more relevant questions has resulted in pointless ethics questions.

I think a lot of it is the NBME just being fairly bad at their job. A better testing company with more to lose would probably have changed things up by now.

An example is Sketchy. People started getting basically every ID question on step 1 correct. Rather than dig deeper into the concepts of ID, they just added more bugs. Obviously when you rely on discrete information testing instead of reasoning or ability to pick up on abnormal presentations, you make testing less reliable and more prone to fluctuation. You need a larger exam to stratify by discrete knowledge vs. application of knowledge and reasoning.

As always, its not an absolute. Interns in non-surgical fields are absolutely a money loser. From past PD comments, usually somewhere during 2nd year that starts to change. But, even 3rd years aren't pure money makers given the number of elective rotations during which residents aren't earning any money.

Replacing the residents usually isn't even necessary. During my residency, our inpatient team consisted of 2-3 interns, 2 upper levels, and an attending. Usual census was around 20-25 patients. The attending could handle that patient load on their own.

This is a very low level view of the entire picture of an academic hospital. Residents make the hospital money multiple ways that aren't just, "see patient, write note."

1) Suppressing academic attending salaries. There's no way you could have an inpatient IM attending carry 20-25 patients/day including call/nights/weekends and pay them $225K without a team of residents shouldering the load. That's a higher than average census for an attending in a low acuity setting, let alone a tertiary care center with complex cases/referrals. As @LucidSplash mentioned, they would hire midlevels instead (which would be more expensive).

2) Increasing academic productivity. Residents also enable academic attendings to work fewer days and produce income (e.g., grants, licensing fees) and prestige (i.e., donation money) via academic productivity. Obviously more applicable at higher tier institutions, but these forces are at play at any university hospital.

3) Decreasing need for ancillary workers. Residents don't work 80 hours/week just doing patient care related tasks. Residents (too) often act as a glue that fills the cracks for any unsavory task. So many things beyond the attending's census would get upended if residents suddenly disappeared, and the cost to fill those cracks would be substantial.

4) Getting money from Medicare. I mean this alone covers a resident's salary/benefits, nevermind what they actually earn while working.

I think the idea that residents are worth 2x midlevels is likely only true insofar as they work 2x the hours, especially in neurosurgery. I doubt the contributions of a PGY1-3 in IM averages out to more than 1.5x a midlevel. When you factor in GME costs/rotations outside the main hospital, it's probably closer to even. That said, they're doing it for 50% of the pay AND the hospital is already getting ~$140K/resident. Interns are likely slower than a typical mid-career midlevel. Senior residents are likely safer and faster than midlevels. It probably averages out.

 

[VA Hopeful Dr]

Is the attending not going to work significantly harder without the residents for the same pay though? During my clinical year the attending came in for rounds and then left. If they were first contact provider for the entire 12 hour shift they'd have to deal with all the tasks the residents complete throughout the entire day right? Scheduling appointments, social work rounds, running to the lab, speaking with nurses, balancing electrolytes, taking patient complaints, coordinating consult teams, etc etc. All things that aren't glamourous and directly making the hospital money, but they do need to get done, and they require someone to be in the hospital to do them. Who does this if residents walk away? If they have to hire midlevels they are losing money as their pay is higher than residents

There are many employees in the hospital that aren't directly billing but are required for the hospital to run. Residents are no different. Sure you could replace them with midlevels or more physicians but that's losing money.

The only place I can see residents not really providing anything is in clinic if the attending sees the patient after anyway

I went to residency at an unopposed family medicine residency. If our attending for the week worked for the existing hospital service, they could easily absorb our teaching service load without breaking a sweat.

I have never been a resident at an academic center so it would not shock me if things worked differently there.

 

[VA Hopeful Dr]

And don’t forget the call. All those pages for Tylenol and a bowel regimen at 2 am? That’s you now Mr Attending. All those consults for actual non-surgical issues but the ED isn’t sure and just wants to cover their bases before they discharge that patient at midnight? Yep that’s you too.

I roll my eyes whenever these conversations happen. Reality is residents provide a service far above what their pay level is once they move past the intern/hand holding stage, at least in the surgical fields. We are highly skilled and extremely cheap labor. A chief surgery resident getting paid 60k for what they do and claiming a negative economic value for the health system is laughable.

Once again, you are generalizing your knowledge from a surgery residency and I'm telling you that it does not apply to my experience in a family medicine residency.

 

[VA Hopeful Dr]

It is clear to me that many people here have never worked in an institution without residents or fellows. If residents vanished overnight, there would obviously be a difficult adjustment period. But then institutions would hire mid-levels. There is a period of training mid-levels and finding good mid-levels. But they can be hired to take first call, to do notes, to assist in surgery. They can also bill for services and there are codes for using them as an assistant in surgery.

Residents and fellows are important to the future of medicine and physician leadership. I prefer to work at places with residents because I enjoy teaching. But I currently work as locums and usually do not have residents. I do not find that I work “harder” at these places because there are mid-levels to help. They are of varying quality, and you have to learn who you can trust for assessments and how far. But that is also true of residents. The hospitals do not lose money on mid-levels. At least in surgical specialties, they make it easier for surgeons to be doing the thing that makes the hospital the most money - operating.

I prefer to work with residents because of my personal drivers and motivations. But this idea that residents are irreplaceable is easily disproved at the large number of hospitals which do not have them.

I think the hardest part of any such transition would be some of the academic attendings having to actually do work in the hospital.

 

[Ho0v-man]

As always, its not an absolute. Interns in non-surgical fields are absolutely a money loser. From past PD comments, usually somewhere during 2nd year that starts to change. But, even 3rd years aren't pure money makers given the number of elective rotations during which residents aren't earning any money.

Replacing the residents usually isn't even necessary. During my residency, our inpatient team consisted of 2-3 interns, 2 upper levels, and an attending. Usual census was around 20-25 patients. The attending could handle that patient load on their own.

A rare time I’d disagree with one of your posts. Namely the second paragraph.

No attending hospitalist is doing that volume day in and day out for what they pay in academics without residents or midlevels to shield them from all of the BS. They signed up to show up at 10am and leave by noon. They’re there just to make sure the plans are sound and occasionally teach if they feel like it. Most of the attendings where I did my intern year don’t even know how to put in orders. There’s a reason no one wants to work on the resident retreat day. Night shift had to come in 2 hours early that day. The two attendings who’d been there all day (not one attending for 2 hours) were expected to be hours behind.

This doesn’t even address attendings in non-surgical/non-procedural fields almost never being in house overnight because residents and fellows just handle it for them and either call them to run it by them or just sign it out in the am.

 

[LucidSplash]

I think the hardest part of any such transition would be some of the academic attendings having to actually do work in the hospital.

They won't have to. The mid-levels will. I have worked in both kinds of places. From a surgery perspective, its about the same, except with mid-levels once you get into a certain rhythm, you don't have to do any teaching or let them do any of the procedures.

 

[LucidSplash]

I think a lot of it is the NBME just being fairly bad at their job. A better testing company with more to lose would probably have changed things up by now.

An example is Sketchy. People started getting basically every ID question on step 1 correct. Rather than dig deeper into the concepts of ID, they just added more bugs. Obviously when you rely on discrete information testing instead of reasoning or ability to pick up on abnormal presentations, you make testing less reliable and more prone to fluctuation. You need a larger exam to stratify by discrete knowledge vs. application of knowledge and reasoning.

This is a very low level view of the entire picture of an academic hospital. Residents make the hospital money multiple ways that aren't just, "see patient, write note."

1) Suppressing academic attending salaries. There's no way you could have an inpatient IM attending carry 20-25 patients/day including call/nights/weekends and pay them $225K without a team of residents shouldering the load. That's a higher than average census for an attending in a low acuity setting, let alone a tertiary care center with complex cases/referrals. As @LucidSplash mentioned, they would hire midlevels instead (which would be more expensive).

2) Increasing academic productivity. Residents also enable academic attendings to work fewer days and produce income (e.g., grants, licensing fees) and prestige (i.e., donation money) via academic productivity. Obviously more applicable at higher tier institutions, but these forces are at play at any university hospital.

3) Decreasing need for ancillary workers. Residents don't work 80 hours/week just doing patient care related tasks. Residents (too) often act as a glue that fills the cracks for any unsavory task. So many things beyond the attending's census would get upended if residents suddenly disappeared, and the cost to fill those cracks would be substantial.

4) Getting money from Medicare. I mean this alone covers a resident's salary/benefits, nevermind what they actually earn while working.

I think the idea that residents are worth 2x midlevels is likely only true insofar as they work 2x the hours, especially in neurosurgery. I doubt the contributions of a PGY1-3 in IM averages out to more than 1.5x a midlevel. When you factor in GME costs/rotations outside the main hospital, it's probably closer to even. That said, they're doing it for 50% of the pay AND the hospital is already getting ~$140K/resident. Interns are likely slower than a typical mid-career midlevel. Senior residents are likely safer and faster than midlevels. It probably averages out.

You've quoted me here. But you fundamentally misunderstand that mid-levels are not more expensive than residents overall, because mid-levels generate their own billing and revenue.

There will always be SOME institutions that will use residents. But the vast majority do not and are increasingly hiring mid-levels. If this was a value-negative proposition for hospitals, more would be trying to get residency programs or trying to insist that non-teaching physicians do without them. But they know they can hire more mid-levels and do with fewer physicians, which saves money overall. Your reply here mostly looks at large ivory-tower type places. These are the minority in this country.

I constantly tell students during residency interviews that while training at a big hospital where you never have to leave seems appealing, it seriously limits your perspective on how medicine functions in most of the country. Community rotations are vital so you can see how things work at a non-tertiary care center. A lot of this thread is proof of how important that is.

 

[DOVinciRobot]

It is clear to me that many people here have never worked in an institution without residents or fellows. If residents vanished overnight, there would obviously be a difficult adjustment period. But then institutions would hire mid-levels. There is a period of training mid-levels and finding good mid-levels. But they can be hired to take first call, to do notes, to assist in surgery. They can also bill for services and there are codes for using them as an assistant in surgery.

But this idea that residents are irreplaceable is easily disproved at the large number of hospitals which do not have them.

No one said we aren’t replaceable. However, the economic hit to an academic hospital system if the residents disappeared would be astronomic and the hospital would crumble. At my hospital if the general surgery residency alone closed it would be a multi-million dollar effort to replace all of the residents, multiple millions of dollars the system doesn’t have… I know because we have to sit through extensive meetings telling us how to cut down on costs to help improve the financial deficit..

We can’t even spare to hire a single extra PA to help out with trauma, let alone replace all of the residents…

Hospitals like you describe that are private and function without residents are foundationally built very different and have always been designed to function without residents.

Once again, you are generalizing your knowledge from a surgery residency and I'm telling you that it does not apply to my experience in a family medicine residency.

I agree 100%. A stand alone FM residency will be much easier to replace than a tertiary care center built entirely on the backs of residents.

 

[ChordaEpiphany]

You've quoted me here. But you fundamentally misunderstand that mid-levels are not more expensive than residents overall, because mid-levels generate their own billing and revenue.

I guess I'm failing to understand the difference between mid-levels billing vs. residents doing the work and the attendings billing on their behalf. It seems the difference here is a few clicks and an attending attestation on the note. Both populations need supervision and approval of their plans if working under the attending. Both populations see patients and write notes. Residents do what mid-levels do + scut + medical education.

Whether residents are a negative proposition for hospitals depends on the hospital. It's case-by-case. About 1/4 residents are NOT paid for by CMS. Clearly those institutions find use in hiring residents because otherwise they would hire mid-levels for those spots. I imagine there's an inflection point where it becomes worthwhile to go for residents over mid-levels depending on:

1) If the patient load supports a big enough residency class to form a reliable workforce. Residents need things like dedicated GME time and a variety of rotations. You'd need a big enough workforce to not have to constantly worry about gaps in coverage.

2) If they've already set themselves up as a teaching hospital. I imagine there's a lot of inertia around this given the startup costs of going from a community hospital focused exclusively on patient care to a teaching hospital hosting residents. If you already have residents, it's probably cheaper to hire more residents than it is to hire mid-levels.

3) If they need continuity. Mid-levels are much better for continuity. A mid-level can stay in the same office for 10+ years while residents are a revolving door. Huge boon for a productive attending the hospital wants to keep around.

Obviously a small community health center isn't going to find it worthwhile to start a residency program. Likewise, somewhere that's never hosted residents isn't going to upend its whole structure and risk collapse trying to save money on the gamble that residents will be significantly cheaper than mid-levels.

However, you can see clear examples of organizations that open new hospitals and utilize resident labor. HCA is not a charitable organization looking to train the next generation of bright young physicians, but they have tons of residency programs. That's because they have the resources to set things up most efficiently from the get-go. They choose to incorporate residents when they could just hire tons of mid-levels.

Overall I stand by my statement that residents are mid-levels are likely a wash overall. It's very situation-dependent. Mid-levels have a lower level of competence compared to a junior/senior, but make up for it with continuity and lack of teaching requirements. Some environments favor residents, others mid-levels.

 

[LucidSplash]

No one said we aren’t replaceable. However, the economic hit to an academic hospital system if the residents disappeared would be astronomic and the hospital would crumble. At my hospital if the general surgery residency alone closed it would be a multi-million dollar effort to replace all of the residents, multiple millions of dollars the system doesn’t have… I know because we have to sit through extensive meetings telling us how to cut down on costs to help improve the financial deficit..

We can’t even spare to hire a single extra PA to help out with trauma, let alone replace all of the residents…

Hospitals like you describe that are private and function without residents are foundationally built very different and have always been designed to function without residents.

I agree 100%. A stand alone FM residency will be much easier to replace than a tertiary care center built entirely on the backs of residents.

So, I have been describing how MOST hospitals work. Which I have stated, repeatedly, does not apply to large tertiary/quaternary academic ivory towers. But most places in the country where medicine occurs, and even where most training occurs, are not those places. There are many, many places in the country that are not private hospitals that function with a limited number of residency programs or none at all.

As I stated. There would be an adjustment period. But these places would not crumble. The would adjust with mid-levels and move on.

 

[VA Hopeful Dr]

A rare time I’d disagree with one of your posts. Namely the second paragraph.

No attending hospitalist is doing that volume day in and day out for what they pay in academics without residents or midlevels to shield them from all of the BS. They signed up to show up at 10am and leave by noon. They’re there just to make sure the plans are sound and occasionally teach if they feel like it. Most of the attendings where I did my intern year don’t even know how to put in orders. There’s a reason no one wants to work on the resident retreat day. Night shift had to come in 2 hours early that day. The two attendings who’d been there all day (not one attending for 2 hours) were expected to be hours behind.

This doesn’t even address attendings in non-surgical/non-procedural fields almost never being in house overnight because residents and fellows just handle it for them and either call them to run it by them or just sign it out in the am.

Luckily I already addressed this:

I went to residency at an unopposed family medicine residency. If our attending for the week worked for the existing hospitalist service, they could easily absorb our teaching service load without breaking a sweat.

I have never been a resident at an academic center so it would not shock me if things worked differently there.

 

[LucidSplash]

I guess I'm failing to understand the difference between mid-levels billing vs. residents doing the work and the attendings billing on their behalf. It seems the difference here is a few clicks and an attending attestation on the note. Both populations need supervision and approval of their plans if working under the attending. Both populations see patients and write notes. Residents do what mid-levels do + scut + medical education.

Whether residents are a negative proposition for hospitals depends on the hospital. It's case-by-case. About 1/4 residents are NOT paid for by CMS. Clearly those institutions find use in hiring residents because otherwise they would hire mid-levels for those spots. I imagine there's an inflection point where it becomes worthwhile to go for residents over mid-levels depending on:

1) If the patient load supports a big enough residency class to form a reliable workforce. Residents need things like dedicated GME time and a variety of rotations. You'd need a big enough workforce to not have to constantly worry about gaps in coverage.

2) If they've already set themselves up as a teaching hospital. I imagine there's a lot of inertia around this given the startup costs of going from a community hospital focused exclusively on patient care to a teaching hospital hosting residents. If you already have residents, it's probably cheaper to hire more residents than it is to hire mid-levels.

3) If they need continuity. Mid-levels are much better for continuity. A mid-level can stay in the same office for 10+ years while residents are a revolving door. Huge boon for a productive attending the hospital wants to keep around.

Obviously a small community health center isn't going to find it worthwhile to start a residency program. Likewise, somewhere that's never hosted residents isn't going to upend its whole structure and risk collapse trying to save money on the gamble that residents will be significantly cheaper than mid-levels.

However, you can see clear examples of organizations that open new hospitals and utilize resident labor. HCA is not a charitable organization looking to train the next generation of bright young physicians, but they have tons of residency programs. That's because they have the resources to set things up most efficiently from the get-go. They choose to incorporate residents when they could just hire tons of mid-levels.

Overall I stand by my statement that residents are mid-levels are likely a wash overall. It's very situation-dependent. Mid-levels have a lower level of competence compared to a junior/senior, but make up for it with continuity and lack of teaching requirements. Some environments favor residents, others mid-levels.

There are a ton of states where mid-levels require minimal or no supervision. Full practice authority exists in something like 27 states the last time I checked the numbers.

And the supervision that is required is often like 10-20% of charts need to be reviewed. In many places, this supervision is really a rubber stamp where some board certified physician agrees to put their license on the line to “supervise” mid-levels.

Mid-levels bill independently for many things. And the amount paid by insurance or medicare in most situations is the same as the attending would bill for the service. So in non-surgical fields, by having a mid-level do the work and bill, if the hospital employs the mid-level, the hospital or practice pockets the difference by needing fewer attending physicians (who would have higher salaries than the mid-level). Reference: ask any of your EM/IM/FM/Peds colleagues who practice outside a major quaternary center. Then, the hospital strongly encourages the hospital-employed surgeons to admit most things to hospital-employed medicine, which admittedly surgeons like. The hospital trains the hospitalist mid-level to maximize billing on inpatient notes. The surgeons have more time to operate, which is where surgeons best generate RVUs for the hospital. The “hospitalist” mid-levels miss a ton of **** but who cares in corporate medicine! The bottom line is better. And in this scenario, corporate doesn’t necessarily mean private.

Small hospitals unable to otherwise sustain themselves usually due to ****ty payer mix are increasingly bought up by corporations anyway. Or they are rural and close and the locals suffer but no one in the “nearby” big city cares.

There are something like ~220 “academic medical centers” in this country but there are over 6,000 hospitals in total.

As I’ve stated, the academic places are in the minority in the grand scheme of things. A lot would have to change at those places, but I suspect at least half of them would struggle a bit to figure it out if residents disappeared. The rest would be fine. And the rest of the non-academic hospital with fewer residencies or no residencies would just carry on, and hire more mid-levels as the pool of doctors got smaller.

Fast Facts on U.S. Hospitals, 2024 | AHA

There are 6,120 hospitals in the United States. The American Hospital Association conducts an annual survey of hospitals in the United States. The data here, published in 2024, are a sample from the 2022 AHA Annual Survey (FY 2022) and offer quick answers on number of hospitals, government...

www.aha.org

 

[2021Doctor]

To reference the Sheriff of Sodium: would the HCA be the largest employer of residents if they weren't profitable?

HCA Healthcare began building a network of GME training programs eight years ago and has since become the largest sponsor of GME training. In addition to training more residents and fellows, we’ve expanded our training to 337 Accreditation Council for Graduate Medical Education (ACGME) accredited programs, 5,334 residents and fellows, and 62 teaching hospitals across 16 states. HCA Healthcare’s large network of teaching hospitals provides significant advantages in the development of high-quality education, offers a broad spectrum of clinical experience and a range of excellent academic support services such as research, curriculum development and shared didactics.

HCA Healthcare overall offers GME training programs in 53 different specialties and subspecialties. The largest programs by total enrollment this year are:

Program # of Residents
1. Internal Medicine 1,823
2. Family Medicine 618
3. Emergency Medicine 470
4. Surgery 420
5. Transitional Year 308
6. Psychiatry 299
7. OB-GYN 225
8. Anesthesiology 191
9. Radiology 114
10. Pediatrics 102

Addressing the national physician shortage: HCA Healthcare welcomes class of 1,867 residents and fellows in 2022

 

[Ho0v-man]

Luckily I already addressed this:

I did my intern year at an unopposed community program. I’m describing my experience there.

 

[VA Hopeful Dr]

I did my intern year at an unopposed community program. I’m describing my experience there.

Then you went to a bad one, or more probably pre-lim programs don't care as much as other places.

My attendings got there at 6am. Earliest I ever saw them leave was 4pm, most stayed until 6-8pm. Their notes while not as comprehensive as intern ones, easily stood on their own. It was rare, but they would from time to time put in their own orders.

 

[Lawpy]

i lost track what we’re talking about now

 

[DrStephenStrange]

i lost track what we’re talking about now

I have no idea how this thread got to this point. I have stopped reading like 2 days ago lol.

 

[deleted1139416]

Bump - got my score back and scored a 260!!

I’m honestly an idiot in taking tests (and pretty much in general). I owe my score to just pure hard work and doing a million questions on UWORLD/AMBOSS/NBME/CMS/etc.

With that being said, I STILL strongly believe that residency selection should not rely so heavily on a single score. The reason I say so is because I know at least 3 people who scored extremely high (better than me) whom I would be miserable working with. One of them even looked at me dead in the eye and told me he doesn’t care about patients and just cares about money. He followed up with saying “doctors don’t really help patients, we just prolong the inevitable”. He somehow thought that made it better. His Step 2 score was 273. So yeah, I still believe that residency selection should go beyond board scores.

 

[NotAProgDirector]

Congrats! It's only one piece of the puzzle, programs definitely look at other aspects of applications.

 

[Kierkegaard's Bud]

Bump - got my score back and scored a 260!!

I’m honestly an idiot in taking tests (and pretty much in general). I owe my score to just pure hard work and doing a million questions on UWORLD/AMBOSS/NBME/CMS/etc.

With that being said, I STILL strongly believe that residency selection should not rely so heavily on a single score. The reason I say so is because I know at least 3 people who scored extremely high (better than me) whom I would be miserable working with. One of them even looked at me dead in the eye and told me he doesn’t care about patients and just cares about money. He followed up with saying “doctors don’t really help patients, we just prolong the inevitable”. He somehow thought that made it better. His Step 2 score was 273. So yeah, I still believe that residency selection should go beyond board scores.

Medicine is large enough to incorporate those people. Don’t conflate personal characteristics with systemic flaws.

 

[gyngyn]

Medicine is large enough to incorporate those people.

Although this is true, we cannot compel these folks to go into fields that do not interact with patients (or other humans).
I should know. I've tried.

 

[deleted1139416]

Medicine is large enough to incorporate those people. Don’t conflate personal characteristics with systemic flaws.

Can you explain what you mean by this? Don't really understand.

 

[Redpancreas]

Can you explain what you mean by this? Don't really understand.

He means that there are millions of medical students who graduate to become doctors. For every supposed sociopath with a 273, there's probably a Mother Teresa with a 273. And congrats on your score!

 

[ChordaEpiphany]

He means that there are millions of medical students who graduate to become doctors. For every supposed sociopath with a 273, there's probably a Mother Teresa with a 273. And congrats on your score!

No, he means the field of medicine requires a ton of personality types and skill sets to function at its best. The ideal isn't for every doctor to be a cookie-cutter A-minus student who all started a food kitchen in college. Yeah my ideal PCP is compassionate, but I want a meticulous surgeon. I want a shrewd department chair who hires wisely. I want ruthless and unyielding leaders of professional groups to advocate for the workers of the profession. I want the people getting NIH funding for basic research to be total nerds who wake up absolutely hyped about protein structures. In general, I want terrifyingly smart and capable people the upper echelons of medicine and a large base of intelligent and thoughtful individuals manning the trenches in community medicine, primary care, etc...

We're already pushing too much for compassion as a selective trait for the top tiers of medicine. It should be a primary driver of admissions to lower tier schools, not something that's a deal breaker if it's missing from the guy poised to discover the next multibillion dollar drug. You can see it in the way the profession gets pushed around, and both doctors and patients suffer as a result.

 

[deleted1139416]

No, he means the field of medicine requires a ton of personality types and skill sets to function at its best. The ideal isn't for every doctor to be a cookie-cutter A-minus student who all started a food kitchen in college. Yeah my ideal PCP is compassionate, but I want a meticulous surgeon. I want a shrewd department chair who hires wisely. I want ruthless and unyielding leaders of professional groups to advocate for the workers of the profession. I want the people getting NIH funding for basic research to be total nerds who wake up absolutely hyped about protein structures. In general, I want terrifyingly smart and capable people the upper echelons of medicine and a large base of intelligent and thoughtful individuals manning the trenches in community medicine, primary care, etc...

We're already pushing too much for compassion as a selective trait for the top tiers of medicine. It should be a primary driver of admissions to lower tier schools, not something that's a deal breaker if it's missing from the guy poised to discover the next multibillion dollar drug. You can see it in the way the profession gets pushed around, and both doctors and patients suffer as a result.

I’m guessing you haven’t seen Dr. Death have you?

 

[MateoGM416]

No, he means the field of medicine requires a ton of personality types and skill sets to function at its best. The ideal isn't for every doctor to be a cookie-cutter A-minus student who all started a food kitchen in college. Yeah my ideal PCP is compassionate, but I want a meticulous surgeon. I want a shrewd department chair who hires wisely. I want ruthless and unyielding leaders of professional groups to advocate for the workers of the profession. I want the people getting NIH funding for basic research to be total nerds who wake up absolutely hyped about protein structures. In general, I want terrifyingly smart and capable people the upper echelons of medicine and a large base of intelligent and thoughtful individuals manning the trenches in community medicine, primary care, etc...

We're already pushing too much for compassion as a selective trait for the top tiers of medicine. It should be a primary driver of admissions to lower tier schools, not something that's a deal breaker if it's missing from the guy poised to discover the next multibillion dollar drug. You can see it in the way the profession gets pushed around, and both doctors and patients suffer as a result.

This is how things like Tuskegee or the involuntary sterilization of Puerto Ricans happened

 

[ChordaEpiphany]

I’m guessing you haven’t seen Dr. Death have you?

This is how things like Tuskegee or the involuntary sterilization of Puerto Ricans happened

Pretty big jumps there. There's a huge difference between "sometimes it's okay if your doctor isn't Mother Teresa if they've also got other useful traits" vs. "let's hire sociopaths who will sterilize entire communities."

It's indisputable that we need a variety of personality types and strengths in medicine.

 

[MateoGM416]

Pretty big jumps there.

Because your take is that compassion isn't an important characteristic of a 'top-tier' physician. Nobody is arguing against your second point

 

[Kierkegaard's Bud]

No, he means the field of medicine requires a ton of personality types and skill sets to function at its best. The ideal isn't for every doctor to be a cookie-cutter A-minus student who all started a food kitchen in college. Yeah my ideal PCP is compassionate, but I want a meticulous surgeon. I want a shrewd department chair who hires wisely. I want ruthless and unyielding leaders of professional groups to advocate for the workers of the profession. I want the people getting NIH funding for basic research to be total nerds who wake up absolutely hyped about protein structures. In general, I want terrifyingly smart and capable people the upper echelons of medicine and a large base of intelligent and thoughtful individuals manning the trenches in community medicine, primary care, etc...

We're already pushing too much for compassion as a selective trait for the top tiers of medicine. It should be a primary driver of admissions to lower tier schools, not something that's a deal breaker if it's missing from the guy poised to discover the next multibillion dollar drug. You can see it in the way the profession gets pushed around, and both doctors and patients suffer as a result.

Compassion can be a foundation on which other skills are built, imho. You imply mutual exclusivity of certain skills which is not true.

 

[Esmolol]

It's all a big puzzle. Every piece is important. Without a piece - the puzzle is not complete and just looks bad. I like it how people are arguing which puzzle piece is more important...

 

[wingingit]

Pretty big jumps there. There's a huge difference between "sometimes it's okay if your doctor isn't Mother Teresa if they've also got other useful traits" vs. "let's hire sociopaths who will sterilize entire communities."

It's indisputable that we need a variety of personality types and strengths in medicine.

Compassion is not a negotiable skill that is a "primary driver of admissions to lower-tier universities". It is a requirement to be a competent physician. Without knowledge of the humanities, value for the human beyond that as a patient, and thorough understanding of medical ethics, we get things like forced sterilizations, eugenics, awful experiments, and lack of respect for the patient's rights.

Being a smart scientist or being good with your hands isn't the only thing one should have to prove to be a physician. As a profession that is given presence in life, death, illness, and the worst times of people's lives, people should know that their physician sees them as an individual, not as a room number, a diagnosis, or a test subject. People want to be comforted and healed, not just diagnosed and treated. Physicians are not mechanics.