With some savages now calling for medicare to stop paying resident doctors, as they are more of students than employees, I was wondering how you guys feel about that. Do you consider yourself more like students or employees? I was always under the impression that resident doctors were highly exploited employees, but maybe I am wrong.
Is a resident a student or an employee?
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But with that being said, you could make "resident" an unpayed position or even charge tuition and there would still be plenty of suckers lining up to sell their mothers for a crack at it. Sad but true and the reason why residents:
1) Have no leverage when it comes to salary.
2) Can still be worked like 10 Franc French hookers on German Soldier appreciation night.
3) Have to endure working conditions that would probably violate OSHA regulations in any other industry (sleep deprivation).
1) Have no leverage when it comes to salary.
2) Can still be worked like 10 Franc French hookers on German Soldier appreciation night.
3) Have to endure working conditions that would probably violate OSHA regulations in any other industry (sleep deprivation).
You might be able to make that argument for interns but in states where you can get a license and go out and practice (albeit as a non-boarder "GP") after 1 yr we could argue that the community would lose all specialists.
Oh, so the community would lose out?
Whenever I see arguments that rely on the interests of the 'community', I check to see if my wallet is still in its place.
No, the current specialists and hospitals relying on indentured servants would lose out.
For years under Presidents Reagan and Bush I, the National Labor Relations Board continuously asserted that residents were students. When President Clinton came in, though, there was a sea change, and it was determined by the NLRB that resident physicians were indeed employees, as, ipso facto, they were working for money and providing a service.
Don't these politicians realize that we sacrifice most of our 20s for this priviledge. As it is now, the first half is spent accruing at least 100K debt, then the second half spent getting a measly 40-45K a year.
If they cut our salaries even more, I'd have to apply for welfare.
A resident is an employee. Panda Bear's description very accurately describes a small number of dental residencies based in hospitals. Our medical center HR makes it very clear we are employees with income = $0 and not students. The educational lenders (government and private) are very strict about the "student" vs "employee" designation for residents and won't let you borrow money as a resident to pay your residency tuition or living expenses.
If you are a resident with income >= $0, you will receive a W-2, pay and file taxes, and be an employee just like everyone else.
It's a sucky scenario and I hope it doesn't happen to medicine. It almost wouldn't make the struggle you guys go through worth it for the career.
Thanks Apollyon, I will be looking into the tip about the NLRB's classification of resident vs. student.
If all the students on the wards left the hospital for a day would the hospital still run? Would patient care be compromised? The answer to those is obviously yes and no.
Substitute student with resident. And begin counting the dead bodies piling up.
Substitute student with resident. And begin counting the dead bodies piling up.
Maybe at the academic centers but not in the private practice community. We do just fine without residents. To be honest our use for residents involves hiring them when they're out. If that's your position then you're really arguing for student status.
If you wan't to argue for employee status then you need to point out what you do for the community even if it sounds slimy. The "residents as midlevel provider" is just about the only argument that's going to get people to be OK with their tax dollars to keep paying for your training. Remember that couldn't give less than two sh--s about how many years you put in before you get a big paycheck. To them we're all Bill Gates.
The government likes to consider us "students" whenever it is convenient and employees whenever it benefits its cause.
For example, is there not a big lawsuit in the workings regarding residents and teaching hospitals having to pay social security/FICA witholding on our salaries? If we are "students" than our pay should be more of an educational stipend/grant rather than salary and therefore we should not be paying these taxes (the hospitals have an interest because they have to match what we pay).
I haven't read up on this issue in a few years but from what I remember, the line is very very gray regarding whether we are students or employees.
I do however see the government's point in that why is Medicare singled-out among insurers to pay for teaching of residents. Shouldn't the other third-party payors be sharing in the cost (i.e. the big HMOs)? In other countries that have government paid healthcare, the government does pay the salary of trainees but in a system such as the US perhaps everyone should share in the cost. What does everyone else think?
For example, is there not a big lawsuit in the workings regarding residents and teaching hospitals having to pay social security/FICA witholding on our salaries? If we are "students" than our pay should be more of an educational stipend/grant rather than salary and therefore we should not be paying these taxes (the hospitals have an interest because they have to match what we pay).
I haven't read up on this issue in a few years but from what I remember, the line is very very gray regarding whether we are students or employees.
I do however see the government's point in that why is Medicare singled-out among insurers to pay for teaching of residents. Shouldn't the other third-party payors be sharing in the cost (i.e. the big HMOs)? In other countries that have government paid healthcare, the government does pay the salary of trainees but in a system such as the US perhaps everyone should share in the cost. What does everyone else think?
The government shouldn't worry about doctors and resident training being a money drain on the US healthcare system. They need to worry about the cost of medicines. I say drug reform is something that seriously need to be address, but their lobbying power makes them untouchable.
It's funny how medicine is one of those fields where a service is rendered first, then we have to beg for out payment later. Try to go to a pharmacy and get a brand name Rx filled without any funding.
That's pretty tangential for this thread. If you want to talk about drug price controls you might want to start a thread on the "topics" forum rather than derailing this thread.
A Resident is an employee. You get paid for what you're doing, otherwise you'd be called an intern.
Oh dear God.... I better get through residency quickly before some vile politician eats my chance to have a career. 
The last democrate president made us unfunded when switching to longer specialties.... the next one might make us unable to finish residency.
The last democrate president made us unfunded when switching to longer specialties.... the next one might make us unable to finish residency.I guess my point was that if Medicare is trying to cut cost, taking away the stipend/salary of residents is not the answer. Not trying to hijack a thread.
I'll buy that. So the question is that if CMS is trying to cut costs why would they (or thier clientel) be better off cutting something other than residencies? Do they get their money's worth by funding residents?
By funding residency education, CMS ensures that there will be enough doctors to take care of it's medicare population.
Let me propose this scenario. If CMS goes out of the residency education business, there will be a huge drop in residency positions across all specialties. The few training programs that will survive has to be funded in some other way, because residents will not work for free.
As a result, the supply of residency trained doctors will be drastically reduced. The skills of these doctors will be highly coveted. Now, they'll have to choice of accepting patients from medicare, HMO, other private insurers, and even cash paying patients. With medicare reimbursement rates, I doubt that they can compete with cash paying patients. Medicare reimburse will have to go up.
So, by funding residency programs, they ensure that there will be a good supply of doctors in all specialties. To pay back their debt and compete with all the other doctors out there, physicians are forced accept a portion of medicare patients into their practice and are at the mercy of the current medicare reimbursements rates and possible cuts in the future.
CMS can pay now for residency education and get a discount on reimbursement in the future, or have their medicare population without enough doctors to take care of them.
Oh dear God.... I better get through residency quickly before some vile politician eats my chance to have a career.
No, the greater danger is that the government will either force a return of service commitment or alternatively extend the time it takes to finish a residency.
That's a red herring. The problem is that the system is controlled by the guild (in other words the medical establishment). Like journeymen, residents are both students and employees.
I don't want the government reimbursing hospitals for my training. If I could hang a shingle following graduation from medical school, there would be no need for me to be an indentured servant.
My point is that the guild and the government both profit from this arrangement at the expense of residents and consumers/taxpayers. Milton Friedman, while still young, pointed out that professional licensing was used by government to expand its powers while protecting the guild from competition. The loser, as usual, is the consumer. I'd like to add the resident to that list.
If you wish to challenge this assertion on the grounds of consumer safety, please be intellectually honest enough to state how you profit from this particular arrangement.
I think Mises had similar opinions
.I've often pointed out that if residency wasn't mandatory, physicians could actually train in the same manner as ANYONE ELSE IN ANY OTHER PROFESSION. We could get an entry level job, often paying significantly more than residency. People could actually bill for our services, and we could learn any particular specialty in however much time it took to learn it.
Even when dealing with other licensed professionals, no one else works this way. Lawyers who are just starting after law school are probably even more useless and have less actual practical training than new medical students, who have actually worked in the hospital during school. Yet, there is a constant parade of these students who get jobs with pay of 1-4x that of a resident without any formal post-graduate training process.
The cost of training a resident exceeds the revenue that a resident generates on average across the country. The excess cost is subsidized by payments from the medicare budget. So yes, taxpayers are subsidizing the education of residents. But in fact, they subsidize the training of medical students, lawyers, engineers, teachers, anybody who goes to a public college or university and earns a degree. The subsidization of education by the general public serves the general good by both increasing the segment of the population who can afford to train for these careers and esuring an adequate pool of skilled workers and professionals. This is the case for the medical professsion as well, It's just that the current system pays for resident education through medicare. I don't see how this is unfair to the taxpayer or the general good. There is a shortage of physicians and access to healthcare, decreasing resident re-imbursment can only worsen this.
My point exactly. If we are students then we could walk out.....
If we are employees then we should be able to get better pay....and not a stipend.
No it is not.
http://www.physiciansnews.com/law/497union.html
"At the most basic level, there is a constitutional right to associate and forming something called a "union" is fundamentally no different than forming a County Medical Society or the PPMA."
"The benefits obtained are first determined by whether the doctor is or is not an employee. Since the National Labor Relations Act applies to "labor" or employees, doctors who are employees can reap all of the benefits of union membership—in particular, the right to bargain collectively."
"Doctors who are not employees, who for example have their own practices, cannot bargain collectively whether or not they join a union. Because they are not employees, they do not have the right to bargain collectively and therefore are for that purpose no differently situated than if they were simply members of a Medical Society."
"Physicians who are not employees but are affiliated with a larger union may use that broader bargaining power to lobby or petition the government for health care legislation more to the liking of physicians. Coming together for this purpose is perfectly permissible for all physicians"
There is however no law presently that directly prohibits non-supervisory resident doctors from not only unionizing but also staging a walk out. We are having this discusion only because you have not seen the worst of circumstances(which is on it's way). When you get pushed far enough you will not care which law said what, and going on strike will be a knee jerk reflex. If you doubt me, ask german doctors.
I disagree. The government subsidy simply increases the cost of education. Have you noticed how college/university tuition has far exceeded inflation over a number of years? Government action, as usual, simply distorts the marketplace.
This is a good point, if they want to classify residents as students then residents could form a "student's union" and stage a walk out. Now that I think about it, resident doctors could grab the system's nuts if they choose to. It is only fair since the system has residents by the nuts.
There is no way to prove this as residents do not bill for their time. Intuitively, however, I have been on plenty of rotations as a resident where attendings billed for work that I had done (Admissions, clinic, etc.) with minimal supervision. While an argument can be made that having residents slows the attending down, you can make just as good an argument that residents are like physician "extenders" and allow the attending to generate more revenue.
(The Family Practice attending, for example, supervising five residents who are all seeing patients and for whom he bills. Nothing wrong with this, of course, but you see what I'm talking about. Academic physicians do not wrk for free.)
On my current rotation I do admissions all night for ten bucks an hour (more of less). If the hospital didn't have residents they'd have to hire a hospitalist for 100 bucks an hour or a relatively economical PA for 60 bucks or so. The hospital bills for these patients and most of the patients up here, believe it or not, have private insurance if not medicaid or medicare. Not only do I save the hospital as much as 90 bucks an hour but they get they do get grist for their patient mill.
Hospital accounting is so complex that depending on how you look at it, one accountant could swear on a Bible that the hospital loses money on residents while another could swear just as feverently that the hospital makes money. For my part, I don't think it costs a hospital anything to have residents except maybe some lost productivity from the new interns. The hospital certainly doesn't lose 100,000 bucks per resident per year which is what medicare pays a typical hospital with a big medicare segment. If that were the case, a place like Duke which has 2500 or so residents would be losing....let's see...let me keep track of them zeros....$250,000,000 per year for medical training. The place would shut down for lack of funds. That's absurd but that's what people who say hospitals lose money on residents would have us believe.
Let's look at it this way. Suppose I have a crappy inner-city hospital serving a largely indigent patient population (Shreveport....cough...cough New Orleans...cough cough....) and I 've been getting along or not getting along without residents and one day I decide to start a residency program or two. How is this, in of itself, going to increase my operating expenses? Do I have to build new facilities? New parking? Will I have to expand the crappy cafeteria already serving 10,000 meals a day to account for a handful of residents (hell, we'll let 'em eat for free and call it a perq).
Other than a little office overhead for the program (secretaries, a Program Director who will have to sacrifice some of his money-making clinical duties) it will not cost nearly the amount per resident payed out by the government to teaching hospitals that see medicare patients (all of them). In fact, because the direct payment is much more than the resident's salary and benefits, the medicare money is an important source of revenue to a hospital that otherwise has a difficult time getting paid for any of its services.
As another thought experiment, imagine if every resident walked off the job at New Orleans Charity Hospital (which is being closed down I understand post-Katrina). The place would grind to a halt as over-worked and frazzled attendings threatened a walk-out if the hospital didn't hire some hospitalists or even PAs to do the work that their former residents did before they answered the siren call of higher wages at Home Depot.
Generating revenue is a nebulous concept in a hospital, especially one that does mostly charity work. I bet I do work that is billed for more than my salary and I also wager that I represent a real cost savings to my hospital which would otherwise have to hire a doctor or an extender at the market wage (which, at our hospital, is 50 bucks an hour or what they pay residents to cover "gaps" in the call schedule).
So when you say "The cost of training a resident exceeds the revenue that a resident generates" you are swallowing, hook, line, and sinker, what our bureaucratic masters are dangling in front of you.
This is not to say that on some rotations I am not entirely superfluous and useless and completely in the role of a student but these are minimal the higher you get as a resident and once you learn enough to operate independently.
Other than a little office overhead for the program (secretaries, a Program Director who will have to sacrifice some of his money-making clinical duties) it will not cost nearly the amount per resident payed out by the government to teaching hospitals that see medicare patients (all of them). In fact, because the direct payment is much more than the resident's salary and benefits, the medicare money is an important source of revenue to a hospital that otherwise has a difficult time getting paid for any of its services.
As another thought experiment, imagine if every resident walked off the job at New Orleans Charity Hospital (which is being closed down I understand post-Katrina). The place would grind to a halt as over-worked and frazzled attendings threatened a walk-out if the hospital didn't hire some hospitalists or even PAs to do the work that their former residents did before they answered the siren call of higher wages at Home Depot.
Generating revenue is a nebulous concept in a hospital, especially one that does mostly charity work. I bet I do work that is billed for more than my salary and I also wager that I represent a real cost savings to my hospital which would otherwise have to hire a doctor or an extender at the market wage (which, at our hospital, is 50 bucks an hour or what they pay residents to cover "gaps" in the call schedule).
So when you say "The cost of training a resident exceeds the revenue that a resident generates" you are swallowing, hook, line, and sinker, what our bureaucratic masters are dangling in front of you.
This is not to say that on some rotations I am not entirely superfluous and useless and completely in the role of a student but these are minimal the higher you get as a resident and once you learn enough to operate independently.
Tell you what, in exchange for giving up my crappy resident salary, I am willing to pay the hospital, per month, what they lose by keeping me around in exchange for being allowed to bill at 50 bucks an hour for my revenue-generating activities.
Let's see....70 hours per week for 50 weeks a year is 3500 hours or $175,000 per year. Let's say only one third of my time is billable. Hey, I'll take it. That's still 60K a year or so and a lot more than I'm making now.
Let's see....70 hours per week for 50 weeks a year is 3500 hours or $175,000 per year. Let's say only one third of my time is billable. Hey, I'll take it. That's still 60K a year or so and a lot more than I'm making now.
you forget all the costs paid to faculty, administration, support staff, insurance, increased in unecessary tests, etc, which adds up. And I am not saying that hospitals don't generate revenue from residency programs, what I am saying is that the productive index of a resident as defined by the ability to generate revenue minus the costs of traning and supervising and supporting that resident is negative. And most of the excess revenue generated by residency programs is baisically spent subsidizing the poor re-imbursement of the medicare and medicaid payments that hospitals recieve for services otherwise, allowing hospitals to actually stay open even though most teaching hospitals see a disproportionate amount of medicare patients. Other revenue goes to research stipends for faculty and such.
Fundamentally, no one is getting rich or has there hands in the cookie jar when it comes to residency programs, after all, private practitioners make more money, not less, when they don't have residency programs in there hospital because they typically do not have the same obligation to see medicare and medicaid patients.
Fundamentally, no one is getting rich or has there hands in the cookie jar when it comes to residency programs, after all, private practitioners make more money, not less, when they don't have residency programs in there hospital because they typically do not have the same obligation to see medicare and medicaid patients.
Unless your cathing folks all day you don't generate 50 bucks and hour in payments, sorry.
actually it is illegal for physicians who have separate practices to unionize as it violates anti-trust laws as we are all considered individual competing interests, but no, if all physicians in a group are "employees" then they can form a union, as we have a house officers assiciation that is unionized. What I meant was that there cannot be national union that physicians join that participates in collective bargaining.
I don't know. I see, maybe, 2 patients an hour per shift. Some of them are garden variety primary care and don't generate much revenue at all. Some of them are critical patients which are billed at a much higher rate.
I'm talking about billing, of course, and not collections. But while I'm saddened and angry that people can't or won't pay their bills, that's not my problem. The patients still have to be seen and either I do it for $10.55 an hour or they pay an attending $120 per hour. It would be a fixed cost except they get it on the cheap for less than they pay the cafeteria lady.
In fact, since the patient volume in the ED is pretty constant (i.e. packed solid 24/7) and requires a certain ratio of physicians to patients, the cost of doing it is a fixed price for the hospital like their water or gas bill. Now, I know that they have had residents here for a donkey's age and have grown fat and happy eating of the low-hanging grapes and the cheeses and hams but that doesn't change the fact that they would have to pay somebody 100 bucks an hour or more to do the job if there were no residents. EMTALA is EMTALA whether you have residents or not.
Therefore, whether I generate revenue or not is irrelevant. If the payer mix leans heavily torwards the indigent the attendings don't generate revenue either...which is not my problem and it is unfair to place the burden of free care on my broad and good-natured shoulders.
Therefore, whether I generate revenue or not is irrelevant. If the payer mix leans heavily torwards the indigent the attendings don't generate revenue either...which is not my problem and it is unfair to place the burden of free care on my broad and good-natured shoulders.
I don't think so, but I don't care. Illegal or not is irrelevant....at some point in history, any and all unions were "illegal". You just form them, and fight for your rights. No one is going to give it to you, you stand up for yourself because no one else will.
I don't buy that for a minute. Personally, I order minimal tests and it is my attendings (well, not my EM attendings you understand but the Medicine attendings) who order all of those tests. Everybody over tests. Even in private practice. This is more defensive medicine than anything else.
As to the second part, that is not my problem (or shouldn't be). By that logic even the attendings are losing money for the hospital and they should make much, much less money than they do. Again, residents, many of whom are poor and almost destitute themselves, should not have to shoulder the burden of paying for indigent care.
Research is supported by grants. US News and World Report goes into raptures about this.
Support staff and administration can be minimal, as in my program, or bloated like it was at "Earl" but again, that's institutional culture and if that's what is keeping me from getting paid more I mightily resent all of those essentially useless bureaucrats sucking up my money. Most bureaucracy is make-work and serves only to support and sustain the bureaucracy. Again, shouldn't be my problem.
Let's be conservative and say that "Earl" spends half of the one quarter of a billion dollars they get for their 2500 residents on "support" (The other half going to salaries and benefits). I've been to the GME office and it ain't that big. That's $125,000,000 or several orders of magnitude greater than the annual budget for my home town, Pop. 38,000.
Where does the $250million figure come from? And I thought Duke had, max, 1000 residents and fellows (that's the number they put out).
I remember they said "2500" residents or fellows. But cut the numbers in half. That's still a bucket of money being sucked into administrative costs. And still, like I said, an order of magnitude more than the budget of a medium sized rural Louisiana parish.
Besides, while Duke does a lot of "free care," they do have a better payer mix then, say, LSU. The hospital is not losing money.
I'm not asking for 50 bucks an hour. I'd settle for the twenty bucks an hour they say they are paying me on my monthly statement. There is is, in black and white: "Hourly Rate: $20.13."
What they're doing is taking my annual salary and dividing it by 2000 hours which is a normal work year. The problem is I work way more than 2000 hours. So on one level the hospital says I'm worth twenty bucks an hour. On another level they say we are worth 50 bucks because this is the going rate for "gap" coverage.
Heck, I made 20 bucks and hour at my first engineering job fresh out of college with no experience whatsoever.
Yes sir.
I agree. No one is looking out for us. The hospital, pharmaceutical, and insurance companies have their lobyists with lots of pull but we don't.
Throughout history the disenfranchised have had to do illegal things to get noticed... all social movements begin with challenging "the system."
I just won't happen. Your allusions to coal miners and pinkerton guards is apples and oranges to residents. Residents have too much to lose (their careers, getting stuck with their debt and no way to pay it off) and will only be working under the conditions for a limited time.
That is if you assume crossing over will mean you have escaped the system's pitfalls. Even as an attending there are systematic changes that could be made in the healthcare system that will make you stuck with your debt and a frustrating profession. You just happen to be practicing in what could be the most hostile legal environment in the history of medicine worldwide, and that is a direct manifestation of physician powerlessness. That is one of many examples.
You talk about having too much to loose, trust me, you have a whole lot more to loose if you are powerless. There is serious danger in physicians being the only unprotected party in a system full of sharks and wolves, especially as we head towards major policy changes. I dont know anyone else that could/will fight for physicians but physicians. So while you might think fighting back wont happen, the alternative(loosing ground) is going to keep happening, and at some point you are going to have to choose which one you prefer. BTW, german doctors have been reduced to the equivalent of coal miners and they are fighting as such.
The only real way to calculate the price of something you own is to try and sell it. Likewise, the only reasonable way to calculate what you are worth to the hospital is to figure out how much it costs to replace you. That is economics 101. The wild speculation around here about the cost of residency coordinators and other assorted overhead is irrelevant.
Like it or not, the equivalent of a minion-level resident in the work department is a PA with some work experience. Depending on what they are trained in, they write scripts and orders with "supervision", scrub in on cases, etc. If that job sounds familiar to some residents around here it should, because it's what you do at work everyday.
I don't know how much the PAs are paid in your neck of the woods, but around here they drive nice SUVs to work while the residents take the "el". The reasons for this discrepancy are myriad, but you can start with the "match" process that helps squelch competition between residencies.
Like it or not, the equivalent of a minion-level resident in the work department is a PA with some work experience. Depending on what they are trained in, they write scripts and orders with "supervision", scrub in on cases, etc. If that job sounds familiar to some residents around here it should, because it's what you do at work everyday.
I don't know how much the PAs are paid in your neck of the woods, but around here they drive nice SUVs to work while the residents take the "el". The reasons for this discrepancy are myriad, but you can start with the "match" process that helps squelch competition between residencies.
Wait a minute. Now we're talking about two different things. I was talking about the unionization of residents, not the unionization of docs in general. Unionizing docs in general is more feasable but still not going to happen anytime soon. The system will have to get worse before that happens and it would have to get much worse quickly. Docs are happy to sit in the water until it boils while doing nothing.