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Medical Students Sue Over Residency System

Discussion in 'Clinical Rotations' started by proffit, May 7, 2002.

  1. proffit

    proffit ovary mcnugget
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    <a href="http://www.nytimes.com/2002/05/07/health/07DOCS.html" target="_blank">http://www.nytimes.com/2002/05/07/health/07DOCS.html</a>

    May 7, 2002

    Medical Students Sue Over Residency System
    By ADAM LIPTAK

    Every March, graduating medical school students wait anxiously for Match Day, when a computer tells them where they will spend the next several years as medical residents in teaching hospitals.

    A class-action lawsuit to be filed in Washington today challenges the matching program on antitrust grounds. The suit says the defendants, including seven medical organizations and more than 1,000 private hospitals, have used the program to keep residents' wages low and hours long. Almost all first-year residents make less than $40,000 a year and often work 100-hour weeks.

    If the suit is successful, the nation's health care system faces an enormous financial liability and the prospect of being forced to change the way that generations of doctors have been trained.

    More than 80 percent of first-year residency positions are offered exclusively through the program, known formally as the National Resident Matching Program. The matches are based on ranked lists submitted by hospitals and the 15,000 or so students, and both sides agree in advance to accept the match.

    There is no room for negotiations about wages, hours or other terms of employment. As a consequence, the plaintiffs say, the hospitals, which share detailed salary information with each other, can force residents to accept below-market wages for the three to eight years, depending on specialty, of their residencies.

    "The match basically controls where you are going to spend the first part of your professional life," said Dr. Paul Jung, one of the plaintiffs, who is now a fellow at Johns Hopkins University. Yet, he said, "you're expressly forbidden from having any kind of agreement about any kind of salary or anything."

    Lloyd Constantine, who was New York's top antitrust official for a decade and is not involved in the suit, said the case raised important issues. "If this were coal or steel or autos, it would flat out be a felony and would probably be prosecuted criminally," he said of the matching system.

    Alvin Roth, an economics professor at Harvard, redesigned the system in 1997. He said it merely ensured that medical students obtain the best residencies they could. This fosters competition, he said, which the antitrust laws are meant to protect.

    But James F. Blumstein, an expert in health care regulation at Vanderbilt Law School in Nashville, said that the matching program "does prevent competition in the sense that you can't entertain competing offers."

    "It's not only salaries but also access to opportunities," he said. "It's hard to see what the pro-competitive justification is here."

    Defenders of the matching program say that it is a mistake to think about it in purely commercial terms. They say residencies serve an important social purpose in training doctors and providing care for patients. Whether the antitrust laws should take account of these kinds of arguments is the subject of debate.

    "It's not exactly a job, it's a continuation of a medical education," said Kevin Jon Williams, a professor of medicine at Thomas Jefferson University in Philadelphia, who has written extensively on the matching program.

    Sherman Marek, a Chicago lawyer whose law firm, along with 14 others, represents the plaintiffs, said there was nothing special about jobs that educate. "In any employment, the employee is acquiring skills that can then be taken elsewhere, so there is always an education element," he said. "Nevertheless, market forces are allowed to operate."

    Lawyers for the plaintiffs declined to speculate on how much residents' salaries might change if the matching program were eliminated.

    Representatives of the medical organizations declined to comment on the lawsuit or did not return calls.

    Residents' wages are certainly both low for the profession and uniform. According to the Association of American Medical Colleges, which operates the program and is a defendant in the suit, the average first-year resident, having completed four years of medical school, is paid $37,383. In the Northeast, the average is $39,060; in the South, the average is $35,552.

    Hundred-hour workweeks for residents are common, meaning that they often make less than $10 an hour.

    "They get less money than nurses and physician's assistants," said Michael J. Freed, a lawyer for the plaintiffs.

    The plaintiffs' legal papers say the uniformity of the wages proves that something is wrong.

    "Employers pay residents standardized salaries, regardless of such factors as program prestige, medical specialty, geographic location, resident merit and year of employment," the papers argue. "With few exceptions, employers pay salaries very close to the national average and very close to each other. By contrast, post-residency physicians earn widely varying compensations based on these factors, especially geographic location and medical specialty."

    But Professor Roth, the system designer, said the similarities in wages by themselves prove nothing. "If you're looking at prices, both competition and collusion look similar," he said. Moreover, "people would be willing to pay to take these slots," he said, referring to the most desirable positions.

    George L. Priest, a professor at Yale Law School who was a consultant to the plaintiffs, disagreed. "The salary data is highly suspicious," he said. "There is no good reason why doctors after four years of graduate school should make a quarter of what lawyers make."

    The low wages and long hours have serious consequences, Dr. Jung said. "I had to constantly battle fatigue as a factor affecting the quality of my life and the lives of my patients," he said.

    Dr. Jung, 32, said his residency at the MetroHealth Medical Center in Cleveland was dispiriting.

    Hospitals "use residents as cheap labor," he said. "I had the expectation, maybe na?vely, that a lot of time would be spent with patients."

    Instead, Dr. Jung said, he performed many menial and administrative tasks. "It was a lot more hours and a lot less patient care than I expected," he said.

    He added: "Residents want to be treated fairly, and patients want to be treated well. Patient care will improve if you let residents have more say in their working conditions."

    The Justice Department looked into the residency matching program in the mid-1990's. It reached a settlement with an association that administered a separate program for family practice residencies, but did not challenge the main program. Professor Roth said this meant the government had given the hospital matching program "a clean bill of health."

    Mr. Constantine said that the professional training aspect of residents' work made it difficult to predict the outcome of the case. "There is a level of sentimentality" among judges, he said. "They will listen to excuses they would not listen to in the context of a purely commercial situation," he said.

    Professor Blumstein said those excuses should not play a role in antitrust analysis. "The better view and the correct view is that antitrust law does not allow for worthy purposes to offset the anticompetitive actions," he said.

    The closest analogy, Mr. Constantine said, is the civil suit that the federal government brought a decade ago against the eight Ivy League colleges and the Massachusetts Institute of Technology challenging their cooperation in setting student financial aid. The case ended in settlements that limited the amount of information the institutions could share.

    Such information sharing is even more problematic when salaries are involved, he said. "The medical world really is closer to coal, steel and autos than to colleges giving out financial aid," he said.

    Critics compare the residency matching program to early decision programs at colleges. They say that colleges accepting applicants through early decision can offer less attractive financial aid packages because there is no competition for those students, just as hospitals can pay residents low wages because they have nowhere else to go.

    The stakes in the new suit are high. The complaint does not specify how much money the plaintiffs seek, but they claim to represent a class of 200,000 residents. If residents' fair market salaries were determined to be $100,000, say, the sums at issue for a single year would exceed $12 billion, and since this is an antitrust case, the damages would be automatically tripled.

    "It's not obvious that it's in the interests of the plaintiffs to bankrupt every hospital in the country," Professor Priest said. "But it's going to change the nature of medical care. They are going to have to bid for the services of these medical residents, and they won't be able to work them 120 hours a week."
     
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  3. NuMD97

    NuMD97 Senior Member
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    Thank you for the information. This will be very interesting to follow now, as it has reared its ugly head many times prior with each generation of trainees. Even if they settle out of court, the ramifications could be huge.
     
  4. halothane

    halothane Senior Member
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    Suing the NRMP is ridiculous. The pay and benefits are a stipend....we learn from residency. There are many countries in the world that do not even pay residents for training or some that even take tuition fee. The US residents by far are the most well paid and comfortable by world standards...if the law suit leads to a win many hospitals will go bankrupt. There may come a time when only some selected med. school graduates will qualify for a paid residency and make a lot of money while the rest might have to settle to do it without pay.....well I hope a slight improvement in work hours pay and stuff comes into effect but certainly asking for 100K for a resident will be crazy....plain an flat for our level of competence we do not deserve it.
     
  5. Fermi

    Fermi Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by halothane:
    <strong>Suing the NRMP is ridiculous. The pay and benefits are a stipend....we learn from residency. There are many countries in the world that do not even pay residents for training or some that even take tuition fee.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Central to this discussion is the issue of whether residents are students or employees. It seems that everyone involved in the situation suits the definition of "medical resident" to support their own view. If residents are students, then they should all have such benefits as full deferral of loan payments while in residency, but they shouldn't be allowed to unionize or negotiate stipends/benefits. If they are employees, they should be able to decide where they want to work based on salary, benefits, work hours, etc., rather than having to sign a contract to be semi-randomly locked into one place. In reality, they're probably a combination of both.

    I don't know the whole history of the NRMP match program, but I wonder why it has to be so rigid, as opposed to something more like everything else in the real world--you apply to a bunch of colleges, grad programs, or jobs, and if you're lucky, you get a few offers and you get to decide which one you want.
     
  6. halothane

    halothane Senior Member
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    Well since we are said to receive graduate medical education we still are students, only that we receive a stipend to help us get by during this period. Unionising for better working conditions, educations, benefits are ok....like a students union. But we cannot fall into the realm of employees, we are still trainees. Just like the post doc fellows or PhD fellows who get a stipend. We are all still students who are fortunate enough to get a stipend which compares to physician salries in some European countries. Lets rally for night floats, limited work hours, delayed loan repayment, better education and maybe even a better stipend but not to make it like another form of employment....demanding 100K salaries straight outa med school like the lawyers. I for one pray that the law suit falls thro...I feel that winning this law suit will be like killing the goose that lays the golden egg. The system right now works....and works to keep docs. the best paid professionals in the US lets not plunder it...the common man will suffer more. Why should residents be greedy for more pay...while residency is the only time they get to serve while not extorting huge amounts for their service.

    By the way the NRMP is rigid and has to get even more rigid ie prevent programs from offering pre match to IMG. Believe me that is the only way that a guy meant to go to Harvard does not end up in a second or third tier program. Scrap the NRMP and make it like a regular recruiting process and then the only qualification one will need to get into a good program will be to be at the right place at the right time.
     
  7. Careofme

    Careofme Senior Member
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    Halothane,

    I'm totally with you - I hope that the lawsuit fails too. A lot will come out of this, I believe, even if they lose. However (as mentioned on other forums) in the end, we, the medical students, are the ultimate losers if they win the lawsuit. Hospitals will go under which will mean less residency spots and thus a greater demand and even more competition than there already is. I think its a careless way to make changes but a good way to get this under the examination of the national spotlight where it rightly belongs.

    Careofme
     
  8. njbmd

    njbmd Guest
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by halothane:
    <strong>
    By the way the NRMP is rigid and has to get even more rigid ie prevent programs from offering pre match to IMG. Believe me that is the only way that a guy meant to go to Harvard does not end up in a second or third tier program. Scrap the NRMP and make it like a regular recruiting process and then the only qualification one will need to get into a good program will be to be at the right place at the right time.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Hi there,
    Dream on. Residents are employees and are treated as such. When you screw up, you are treated like an employee and fired. Programs still make offers outside the Match and will continue to do so. This lawsuit will probably not change much but the "black box" match might be more open. You still have to be in the right place at the right time.
     
  9. Goofy

    Goofy Senior Member
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    The shortsightedness displayed by some of you is utterly baffling.

    Halothane Kneejerked:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> Suing the NRMP is ridiculous. The pay and benefits are a stipend....we learn from residency. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">This comment lacks any kind of insight. Residency is a job plain and simple. If you are in favor of slavery I would implore you to step inside my timecapsule which will zip you back to ancient egypt. It is there that you will be able to toil in the hot son for 18 hours a day, and receive a modest helping of stale bread and muddy water.

    It's no wonder we are in the mess where in with thinking like this. Sheesh.

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">There are many countries in the world that do not even pay residents for training or some that even take tuition fee. The US residents by far are the most well paid and comfortable by world standards...if the law suit leads to a win many hospitals will go bankrupt. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Hey bub, here's a tip for you: I'm not from 'other countries'. My standard of living is based on what this great country offers. I'm not happy simply having running water and electricity. I don't feel exuberant because my standard of living is better than some peasant in Libya. If your interested in what third world countries offer, than leave, but don't expect the rest of us to accept slave labor simply because it is better than the abject poverty in Afghanistan.

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> plain an flat for our level of competence we do not deserve it. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Perhaps your clinical skill and training don't deserve it. How dare you speak for the rest of us. I find your demeanor and attitude deeply troubling, and hope that this sickness isn't emblematic of how my other peers feel. I am worth it damnit!
     
  10. Goofy

    Goofy Senior Member
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    Careofme said:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> However (as mentioned on other forums) in the end, we, the medical students, are the ultimate losers if they win the lawsuit. Hospitals will go under which will mean less residency spots and thus a greater demand and even more competition than there already is. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I find this attitude disturbingly in line with the scapegrace 'halothane'.

    Your thoughts reveal a troubling misunderstanding of how the Residency reimbursement schedule works. Even if hospitals are forced to fork over 100k to residents, they still come away like bandits. They are still consuming more than 100k of labor, with an extra 100k payment from the government. There is more than ample room for a pay raise for residents. I would recommend you actually educate yourself on how the system works before offering us your claptrap nonsense.
     
  11. Goofy

    Goofy Senior Member
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    I recommend that the two seperate threads on this topic be combined.

    Moderators?
     
  12. Whisker Barrel Cortex

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    Klebsiella,

    If you read halothane's post carefully you'll see the following lines: "Lets rally for night floats, limited work hours, delayed loan repayment, better education and maybe even a better stipend but not to make it like another form of employment....demanding 100K salaries straight outa med school like the lawyers." He is not saying the system is perfect, just that we are not regular employees. The knowledge and experience gained in residency is essential and you continue to be a student. I know as a future radiology resident who has to pass three sets of boards that I will be learning a whole new profession in the next 5 years.
     
  13. Goofy

    Goofy Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Whisker Barrel Cortex:
    <strong>Klebsiella,

    If you read halothane's post carefully you'll see the following lines: "Lets rally for night floats, limited work hours, delayed loan repayment, better education and maybe even a better stipend but not to make it like another form of employment....demanding 100K salaries straight outa med school like the lawyers." He is not saying the system is perfect, just that we are not regular employees. The knowledge and experience gained in residency is essential and you continue to be a student. I know as a future radiology resident who has to pass three sets of boards that I will be learning a whole new profession in the next 5 years.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Hi wbc,

    I appreciate your point of view however much I disagree with it.

    I have already overdosed on this topic on three seperate threads.

    I understand the point of view that residency is a learning process. All jobs are. Ask any lawyer what percentage of knowledge gleaned in law school is actually useful in practice. Most I know claim that over 95% comes from on the job training. This doesn't change the fact that you are an advanced degree professional (yes you actually get an MD after med school) working for a hospital. By your reasoning, I should never receive a fair compensation, as this profession is a life long process of learning.

    Even the hospitals agree that we are employees. Go figure
     
  14. halothane

    halothane Senior Member
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    Well Klebsiella is obviously very confident that he will tackle any case, perform any procedure and know his subject in and out straight outa med. school. If this indeed is his caliber I bow to him and he deserves to be on 'par' with a physician who is board certified in his speciality with a lot of experience in the same. I for one am going into anesthesia with only a couple of weeks training in med school and certainly do not feel on par with the anesthesia physician staff( I consider myself house staff). Well maybe it would be truly intersting if a fresh neuro surgery resident, ortho ...or any procedure intensive speciality resident felt he had all the competency, the skills and the ability to be on par with a seasoned guy in the field and felt entitled to what he has. Well to each his own. More pay to residents means cutting corners somewhere.....just hope its not educational resources and patient care. If indeed the law suit is a win then there will be cutbacks in residency slots. There will be a physician shortage as training a physician will become exorbitant and soon the US will be importing physicians like they did in the 60s and the 70s, only this time the imported docs. will be working without any US training.
     
  15. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    Halothane,

    I think that you're underestimating the enormous amount of work that housestaff do and the huge efficiencies in health care delivery that housestaff create. The federal government pays teaching hospitals approximately $120K per resident per year. Teaching hospitals pass on approximately 1/3 of that to residents in direct salary, plus maybe an additional 20% in indirect costs. The hospitals pocket the rest. The federal government had to place caps on the creation of new residency programs because training residents can be a real money-maker for some hospitals. This is why there are **so** many unfilled slots in the match this year and why some hospitals must depend on FMG's to fill them. For each slot they don't fill, they lose big, big bucks.

    The argument that reimbursing residents more money would raise healthcare costs really doesn't hold water. The cost of resident training as a proportion of the whole health care related GNP is miniscule. Modern health care is expensive and training modern physicians is costly. The public, the medical profession, and policymakers need to wake-up and accept these facts. If the US wants to continue to offer its citizens (at least the ones who can afford it) the most technologically advanced and therapeutically sophisticated health care in the world, they shouldn't expect it to come cheaply.

    See my post in the related thread on this topic and read the study showing that physicians have **the lowest** economic return on their educational investment compared to lawyers, MBA's, and dentists and tell me if you still believe that the current salary structure for housestaff (given their level of training, educational investment, responsibilities, etc) is fair.
     
  16. Fermi

    Fermi Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by halothane:
    <strong>Well Klebsiella is obviously very confident that he will tackle any case, perform any procedure and know his subject in and out straight outa med. school.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Sorry, Klebsiella is right at least on that point. If you went to work after college, you know that almost any profession will require you to learn most of your skills on the job; moreover, companies will often pay you while training, and will pay for regular continuing education as well. Sure, you're bringing your years of erudite undergraduate knowledge to the table, but this is the case with medical residents as well. We will have four years of intensive scientific, clinical and research training to contribute.

    Sure, we won't have a lot of know-how in applying that knowledge, but there's where my on-the-job training analogy comes in. I will admit that there are factors that definitely dictate reduced training salaries:

    1. Extensive nature of supervisory training by attendings (residents take up their paid time)
    2. Liability/malpractice insurance must be included as part of the compensation formula (this is a significant figure I'm sure)
    3. Residents are not licensed to practice medicine independently, which furthers the "student" classification

    However, residents do create a significant amount of revenue for their institutions: government training subsidies, the cheap 24-hour clinical care they provide (probably ~$7-10/hr), and, for those who do research, a generation of NIH $ for the institution. This proves that residents do have a significant amount to contribute to the institution's well-being, which supports the argument for enacting some flexibilities in training programs (e.g. salary increases, work hour regulations, etc.)
     
  17. Whisker Barrel Cortex

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    I agree with both sides of the argument in that the resident salaries as they are now are below what they should be for the balance of work done versus training provided. The way I view it, having residents at has the following benefits and costs:

    Benefits:
    1. Highly educated employee who works the job of two or more full time employees (for example PAs). Potential monetary benefit 2 X 80K
    2. GME reimbursement in the range of 58K-103K (at least in 1993, see link at end of post).
    3. Attending physicians can concentrate more on research duties because residents handle routine problems.
    4. Some increased prestige of being a teaching institution.

    Costs:
    1. Teaching takes time, especially early in residency that could be spent seeing patients and generating revenue for the hospital.
    2. Hospital covers malpractice insurance for residents, which is likely a pretty large sum. Can you imagine how high premiums on a freshly graduated physician would be if residents had to pay it on their own. I think it would be analogous to the extremely high auto insurance rates for younger drivers.
    3. Lack of efficiency. Anyone that has rotated through both an academic center and a private hospital can attest how much slower things can work with students and residents around.

    Although I can't come up with a monetary value for most of these, I think the hospitals do end up on the positive side of things as it is now.

    Here is a link discussing <a href="http://http://www.cbo.gov/showdoc.cfm?index=17&sequence=1" target="_blank">GME Medicare Funding</a> and how it works along with a discussion about whether to get rid of this funding. It is from 1993 and I believe the funding has actually decreased since then somewhat.
     
  18. Dr. Nick

    Dr. Nick Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Klebsiella:
    <strong> If you are in favor of slavery I would implore you to step inside my timecapsule which will zip you back to ancient egypt. It is there that you will be able to toil in the hot son for 18 hours a day, and receive a modest helping of stale bread and muddy water.

    It's no wonder we are in the mess where in with thinking like this. Sheesh.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">ROFLMFAO!!!
     
  19. Dr. Nick

    Dr. Nick Senior Member
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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Klebsiella:
    <strong>The shortsightedness displayed by some of you is utterly baffling.

    Halothane Kneejerked:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> Suing the NRMP is ridiculous. The pay and benefits are a stipend....we learn from residency. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">This comment lacks any kind of insight. Residency is a job plain and simple. If you are in favor of slavery I would implore you to step inside my timecapsule which will zip you back to ancient egypt. It is there that you will be able to toil in the hot son for 18 hours a day, and receive a modest helping of stale bread and muddy water.

    It's no wonder we are in the mess where in with thinking like this. Sheesh.

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">There are many countries in the world that do not even pay residents for training or some that even take tuition fee. The US residents by far are the most well paid and comfortable by world standards...if the law suit leads to a win many hospitals will go bankrupt. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Hey bub, here's a tip for you: I'm not from 'other countries'. My standard of living is based on what this great country offers. I'm not happy simply having running water and electricity. I don't feel exuberant because my standard of living is better than some peasant in Libya. If your interested in what third world countries offer, than leave, but don't expect the rest of us to accept slave labor simply because it is better than the abject poverty in Afghanistan.

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> plain an flat for our level of competence we do not deserve it. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Perhaps your clinical skill and training don't deserve it. How dare you speak for the rest of us. I find your demeanor and attitude deeply troubling, and hope that this sickness isn't emblematic of how my other peers feel. I am worth it damnit!</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Ahh, screw it - I just gotta quote the whole damn brilliant post. Priceless! A classic, a masterpiece! Ahahaha, I couldn't agree more.
     
  20. MacGyver

    MacGyver Membership Revoked
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    Actually, malpractice insurance coverage for residents is not as high as you think it is.

    The reason for this is that in lawsuits, its the attending who is ultimately responsible for his residents who answers the final call about any mistakes. In fact, most of the time, the plaintiffs in such suits dont even bother to name the resident as a defendant (unless its a hugely egregious issue, somewhat rare)

    So, although the avg attending malpractice insurance coverage could be anywhere from 60k to 120k per year, resident coverage averages only 15k-20k per year. So clearly, even after paying resident insurance, hospitals are making a good profit per resident position. Thats why the number of residencies have increased greatly beyond population growth in the last 20 years. The way it stands now, its in the hospitals best interest to open as many residency slots as the govt will possibly allow, and even if some of those go unfilled, the chances that the hospital will get 200k per year per american medical grad in residency is such a huge profit boon to the hospital that they figure its worth the risk.

    Look at the past 20 years people. The number of residency slots across the board has gone up at a much larger rate than the pop growth, and the percentage and number of people who are underserved has not changed at all. IMGs have made up the difference, and not constitute nearly 30% of all physicians.
     
  21. bigfkd22

    bigfkd22 Member
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    Something to think about....
    A 40 hour work week at $15 =$600
    plus 40 hours of overtime 40*15*1.5=$900
    Thats $1500 a week or 78k a year. I dont think this is out of line. If they dont want to pay overtime dont work us 80-100 hours a week.
     
  22. pete.

    pete. Member
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    One perspective I've not yet seen:

    A nurse comes straight out of school, passes boards, no internship / residency and can make 40-50K/yr for a 36 hour work week, sometimes with the addition of signing bonuses - and nurses don't even get paid what they're worth.

    Please don't tell me that my 4 years of training won't put me on par with that.

    I don't have all the answers, but I do know that there are certainly shortcomings that need to be addressed with the present system.
     
  23. Jamie Metcalf-Kelly

    Jamie Metcalf-Kelly New Member

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    I am in the middle of lawsuit against a program and the sponsoring hospital for wrongful discharge based on my complaints about unsafe working conditions and hours. I was placed on probation a week after my complaints . What I have realized in this process is that as "residents" we are neither students or employees but a class of our own with no rights. This is no accident. Just as slavery was justified by claiming that " slaves" were a lower form of life and therefore not entitled to the same rights all human beings are entitled, so are "residents" categorized. That saddest part to me is when the "slaves" or the "residents" buy into the system and believe that they have no right to expect better.
    The medical education system as it exist is inhumane, dangerous and in total contradiction to every theory of learning known. We don't learn because of residency . We learn in spite of it. For me the final litmus test in this situation is how "free" are you to leave a bad residency ? When I had a job I could always leave to find another. When I was in undergraduate or graduate school I could change schools. If you leave a residency because you object to working conditions finding another "slot " is difficult if not impossible (depending on how offended the program director is by your voicing complaints). You will become labeled a "problem resident" and because you need this same director's letter to another program you will probably be blackballed . I have been.

    I have lost a lot, but I would much rather be Rosa Parks and refuse to to comply with a system that is clearly flawed and denies us and our patients the dignity in our lives we should expect in this country. JMK M.D.
     
  24. Goofy

    Goofy Senior Member
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    Jamie,

    Good luck to you sister, you are fighting the good fight. Hopefully this kind of litigation will lead to precedant that will bring about meaningful change in a corrupt system. I'm behind you and would love to see others post notes of support.

    Let us know how things turn out.
     
  25. Ferris

    Ferris Member
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    I've heard that there is another female surgery resident at UAB that is in the middle of similar legal action.

    Good Luck
     
  26. carddr

    carddr Senior Member
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    JMK: now that is raw courteous!!! Keep us posted on outcome.
     
  27. Ligament

    Ligament Interventional Pain Management
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    Some of you are so damn brainwashed.

    You are completely ignorant of the money involved in the medical industry if you thing hospitals will go under because of anything to do with this lawsuit.

    If some do go down, and they will irregardless, THEY DESERVE TO! There are so many hospitals that truly DESERVE to fold because they are such models of mediocrity.

    Every hospital I have ever been in is a monumental example of how to run a poor business.

    Almost every doctor I have worked with that accepts health insurance or medicare/medicaid is a monumental example of a poor businessperson, but thats another story.

    regards.
     
  28. Ryo-Ohki

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    It seems like a few of you are still wet behind the ears.

    I would love to love to have you slav....err...residents in my future hospital venture.
     
  29. brownman

    brownman Member
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    Damn,

    I done leave for a little while, and all damn hell breaks loose. Ok, let's get this party started:

    Having run a successful business for the last two years (sold it to a publically traded firm), and coming back to medicine to hopefully change that system as it exists, I have come to some major conclusions.

    Conclusion number one:

    THE CURRET RESIDENCY SYSTEM IS COMPLETE BULLSHIZZZ....

    PERIOD.

    It exists purely to fund a defunct medical system with cheap labor. WE ARE ASIAN SWEAT SHOP EMPLOYEES; that is all we are. We exist to squeeze out a profitable product, by reducing the margin of cost. Because we exist the healthcare system can continue to be exceedingly inefficient. I love the battered wife syndrome of: "we deserve to get paid dick...because we are apprentices, and apprentices are paid nothing so they can learn their craft". Hey numnuts, you aren't learning glass blowing, or blacksmithing, and this isn't the 1600's. The only people who apprentice these days are fetching donuts for executive producers. YOU ARE IN THE BUSINESS OF SAVING LIVES, AND YOU GET PAID THE EQUIVALENT OF A MCDONALDS WAITER. THE SYSTEM WHICH YOU LOVE TREATS YOU LIKE DIRT. YOU CAN BE FIRED WITH NO RECOURSE AT ANYTIME, AND YOUR FUTURE EMPLOYMENT CAN BE COMPRIMISED. EVENTHOUGH YOUR PRESENCE IS THE MOST VALUABLE NECESSITY TO ENSURING THE SURVIVAL OF PATIENTS EVERYWHERE, YOU MAKE LESS THEN THE TECH WHO YOU WORK WITH, AND YOU HAVE NO RIGHTS WHATSOEVER, WHILE THE TECH IS IN A UNION ALONG WITH THE NURSES AND OTHER AUXILLIARY STAFF, AND CAN WALK OUT ANY TIME. Do you realize who's bitch you are? The hospital doesn't employee you....THEY OWN YOU...and because you have this, "don't rock the boat, that could be scary" mentality, you continue to take it in the ace while the system cleans up. DON'T LET IT CONTINUE TO HAPPEN...FIGHT FOR YOUR INALIENABLE RIGHTS AS A HUMAN BEING. The rest of medicine is headed towards market forces, why can't residents.

    2) LISTEN...ALL OF YOU. Do you know what happens to a company that doesn't meet revenues, that doesn't curb costs, that spends freely, and continually misses forecast. BANKRUPTCY. That's right...you become a failure. So what you do is you shed your bad assets (indigent care, pro bono work), charge more for your premium services (high quality primary care physicians and specialists), and have competent billing and accounting procedures. YOU OUTPERFORM THE OTHER GUY IN YOUR INDUSTRY. You discover where your liabilities are and you trim them. IF YOU WANT TO PAY YOUR PHSYICIANS ****...THEN YOU SHOULD EXPECT THEM TO NOT TAKE YOUR JOBS.

    3) If residents get paid commiserate value then I would get more of them, pay them what I pay nurses, and cut down on nursing staff. I would use mid level providers and nurses to provide the assistance role. This way I get premium care (from intelligent residents), I can reduce cost (I can get one resident to do the job of a PA and a nurse), and the residents are happy (less hours, more pay). THESE HOSPITALS HAVE GROWN TOO DEPENDANT ON THE FEDERAL GOVERNMENT. The Federal Government is an inefficient business that does nothing to advance anything. Working in the government is like trying to watch a first run film in a third world country; it'll be the year 2002 and you'll be watching Rocky 3.

    4) HELLO FREE MARKET: Does this mean smaller med school sizes? No. Does this mean less medical students gradated? NO. It means that the market will determine demand. IF A HOSPITAL JUST CAN'T AFFORD TO PAY IT'S RESIDENTS 20,000 MORE; THEN TAKE FEWER RESIDENTS. ONLY ACCEPT PATIENTS WITH VERIFIED BILLING. CHARGE ABOVE GOING RATES FOR A SUPERIOR PRODUCT. I don't stand in line, I get high quality care from top residents and attendings. AND GUESS WHAT..THE INDIGENT POPULATION THAT CAN'T SEEM TO PAY...EVER...HAS BEEN FAILED BY THE GOVERNMENT. If the government wants to fund those who don't work, don't pay and don't contribute to the economic cycle they can either a: GO TO CANADA, or B: run the government hospital system more efficiently. EITHER WAY I DON'T CARE..BECAUSE AT LEAST THE RESIDENTS GET HUMANE HOURS, BETTER PAY (ATTENDINGS TOO) AND THE QUALITY OF SERVICE IS HIGHER.

    Do you know why Cisco Systems is better than anyone else in networking? Because: THEY HAVE A SUPERIOR PRODUCT THAT THEY CHARGE MORE FOR, AND AN AGRESSIVE SALES STAFF THAT BRINGS THAT REVENUE IN. Do you know why certain law firms can bill at $300 dollars an hour? BECAUSE THEY HAVE STAFF THAT IS FAR SUPERIOR, AND THEREFORE HAVE A SUPERIOR PRODUCT TO OFFER. If you provide a superior product, and superior service...YOU WILL BE REWARDED WITH INCREASED REVENUE, AND INCREASED SATISFACTION.

    AND DO NOT TELL ME THERE IS NO WAY THIS CAN HAPPEN, BECAUSE TEACHING HOSPITALS ARE PUBLIC HOSPITALS, AND BLAH, BLAH. Well then, choose were you learn. 60 Hours a week in a well run private hospital, taught by attendings who have the time to teach. OR A HUNDRED HOURS AT A PUBLIC HOSPITAL WHERE THE TEACHING MIGHT BE BETTER, BUT THE CONDITIONS ARE HELL AND YOU GET PAID SHIZZZ....

    You choose....
     
  30. SunnyOne

    SunnyOne Member
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    Ok people, the sides of the argument have been strongly stated and re-stated, with both camps doing a good job to tear down the other. But the reality is that we're all going to go down the same road. So, who has ideas for solutions to these problems? This is a complicated issue, but if you could overhaul the whole system, what would you do? How can a residency system be constucted to train doctors well, in a fair manner?
     
  31. Docgeorge

    Docgeorge Bent Over and Violated
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    I've got a question.All though I am not yet in the medical field.Hopefully I'll get in to med school next year. We talk about all the things that are wrong with post graduate medical training today,however what can we do to fix it. To whome can we air our concerns. I dont mean hear in the forum, but in the real world. How can we get the weels of change into motion?
     
  32. The Pill Counter

    The Pill Counter Senior Member
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    Wow, Brownman's solved it!! It's those damn homeless people, and the idiots in accounting who don't know how to add up the bills! If we'd only known this sooner, we could have saved everyone a lot of grief.
    Hey, Brownman, say hi to Rush for me.
     
  33. rtk

    rtk Member
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    I agree, Brownman's got it!

    We all get more sleep, there's more money to go around and we don't haveta deal w/ those smelly, uninsured patients if we'd just ship 'em all off to Canada... An excellent/altruistic approach!

    Write your congressman.
     
  34. brownman

    brownman Member
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    Well I assume some of the points are sarcasm but let me tell you how it can be fixed,

    The current system as it exists is a faulty one for three major reasons:

    1) The level of reimbursement is not commiserate to the level of indigent care. Previously hospitals double or triple billed medicare/medicaid to cover for the expenses for indigent care (plus put some money in their pocket). Because the federal government had set such high reimbursement rates, and wasn't accounting charges, you could double and triple bill medicare and medicaid, and get away with it. And that was exactly what hospitals were doing. Guess what...private payers had to accept government rates at the very minimum, if they were going to compete in the market. If a company has contracted to use you for their healthcare, you had at least better be getting government rates. If you didn't, everybody would use medicare and you the insurance company would not have that line of business. Hospitals were getting at two ends: indigent care was profitable, wealthy patients was profitable. Now that is not the case. Government does not allow multiple billing, and has dropped reimbursement tremendously. The hospitals that were never forced to be efficient, because the government was the unstopable piggy bank, now had to cur costs. THESE GUYS HAD NEVER CUT COSTS IN THEIR LIVES. They were totally panicked, had no idea what to do. And as teaching hospitals they had always relied on the government. They took in indigent care, because it was profitable. NOW INDIGENT CARE IS A HUGE MONETARY DRAIN. And the way hospitals try and stay afloat is by taking more private patients, and private insurance...maxing out their bed space. But they have a fundamental problem...indigent care IS THE MOST NON-COMPLIANT PATIENT POPULATION AROUND. They have horrible health patterns and behaviors, utilize multiple hospital resources, and have low remediation rates. In addition, you can't overcharge private patients to pay for them, because third party payors have dropped their rates (to match the government). And because these hospitals are government dependant (resident reimbursement, etc, etc), they are forced to cut costs with reducing profit margins. AND THE PROBLEM IS...THEIR DOCTORS...SO THEY THINK THEIR WHOLE LIFE SHOULD BE ABOUT INDIGENT CARE. That is a non-profitable business. And the only sector of the american economy that participates in a non-profitable business...IS THE US GOVERNMENT. Hence, indigent care should be completely socialized...and private care should not....because indigent care is a social problem; where as private care is not. It's having two lines of business and attempting to meet fixed cost with shrinking revenue. That's called reduction in top line growth..which is death for a business.

    2) People aren't responsible for their healthcare. A ten dollar co-pay does not make you responsible for your health. There is no concept of what health care costs to the consumer, because they are sheltered from the process. If market driven health care becomes a reality, people will be forced to be more concious of their health care decisions.

    3) There is no ability to conduct private practice. Fee for service gets crushed by competition in almost any environment.

    So what should we do you ask?

    That's a long answer. But in realtion to residents salaries and hours. If you open up the market, then you get well run private and communtiy hospitals getting the best residents, and inner city or university hospitals getting the worst. The same goes for specialities. And on top of that you get a stratifiation in salary. Go to a financially healthy hospital, with a good mix of private patients...get paid well. Those hospitals would love to have you. They can teach you...you do a lot of the work, and they can have less ancillary staff. They can maintain the number of residents...and increase the number of ancillary staff (they can afford it). Indingent care will be students from lower tier schools etc, who will take offers there and work their time. Doesn't mean their any less talented physicians, but they don't look as great on paper or etc. The argument that some will take a lower salary to match in something competitive is flawed. If I could afford the cash, I would go after the best. If I'm a cash starved hospital, I'm not going to the Harvard grad with the 240 board score. I'll offer him a job, but he probably won't take it. Indigent hospitals will bring the talent that their salary offers can provide. They will also take a lot more residents and reduce their nursing staff, because they will be government dependant and government subsidized allowing them to keep lower rates (they fix their cost based on reimbursement) and maintain profit (potentially).

    Will this work...no idea. Is this the way most hospitals are headed? Yes. They need to collude to get back patient volume or else HMO's will win the numbers game. Strides are already being made by hospitals. And please...don't cry for the indigents of the world...this country is built on the principle of making something of yourself. My parents came here with nothing, I grew up with nothing, but now I've made something of myself. The indigent are being funded by the government...let them continue to be...but then the government directs the burden. Because they can't have it both ways. The can't reduce remibursement, and expect hospitals to care for everyone that comes through the door. Because then...you'll be shutting your doors.

    Before I leave...I want you guys to think. Think about how much time you spend on the care of your patients and how much time your attendings do. Think about how much time your nurses spend on patients, and how much time they spend asking you what they should do for your patients. Realize that you are the cheapest, most efficient service at the hospital...and that you spend a majority of your time on bull**** (patient charts, getting films, admin, etc). What you do in a 15 hour day...can be done in ten. AND DID SOMEBODY JUST THINK OF NIGHT FLOAT YESTERDAY? or has that been a concept that can always be used. What percentage of your day is inefficiency that can be solved by modernization, more efficient use of resources, or more efficient ancillary staff. There is no reason that you as a resident cannot work the hours of a nurse and make a nurses salary. In fact you could work more hours, make slightly less, and still be an economic value for the hospital.

    RULE NUMBER ONE OF BUSINESS: THE ONLY TWO WAYS TO MAKE MONEY ARE INCREASE REVENUE OR REDUCTION OF COST...you determine where indigent care falls in that category..

    RULE NUMBER TWO OF BUSINESS: INEFFICIENCY DICTATES MAN POWER...EFFICIENCY DICTATES PROFIT. That is the theory behind fields from supply chain management, to airline tickets (thing about how southwest and jetblue set up their tickets). This means that if you're inefficient..you need more people working longer hours to get a job done. What better workforce then residents...who you can bribe into doing it...under the guise of learning.

    RULE NUMBER THREE OF BUSINESS: THE MARKET DETERMINES THE WINNER, NOT THE INFRASTRUCTURE. You will hire more expensive people if you can bill more for their services and you can tap into sources of capital that exist. Compare billing for an IVY league resident at a quality hospital (which will be billing a private insurer) vs. billing a mediocre resident at an indigent care hospital (where you bill the government).

    ok...I know a lot of people believe in indigent care and non-insured. For them I say, please apply for 36,000 dollar a year residency positions, and best of luck to ya. Take that job offer....but don't make excuses for the system. It is flawed and it needs to change. I hope someday, what I believe is the vision of the modern clinic or hospital I can put into fruition....till that day, I will be declared a fascist. That's ok..someday when you realize that medicine is a business, maybe you'll work in one of my clinics, and realize that only profit can allow for good. Otherwise altruism COSTS MONEY, or your soul. And residency takes both...
     
  35. Ryo-Ohki

    7+ Year Member

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    Good post.
     
  36. droliver

    Moderator Emeritus 10+ Year Member

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    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Ryo-Ohki:
    <strong>Good post.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Am I the only one shaking my head here? :confused:
     
  37. Ryo-Ohki

    7+ Year Member

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    Care to elaborate?
     
  38. dbiddy808

    dbiddy808 Senior Member
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    I'm with droliver.
     
  39. Sanman

    Sanman O.G.
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    Brownman,
    As far as going to to a private hospital well better funding, people have that option now. One of my friends decided to do this and is a happy IM intern. However, all he deals with upper middle class white collared people. Real patient diversity if you ask me. As far as the rest, I think you're right, but those would require large systemic changes and who knows when that will happen.
     
  40. </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by brownman:
    <strong>
    1) The level of reimbursement is not commiserate to the level of indigent care </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">One of the best puns yet on this message board; you made me laugh out loud!

    <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Clappy]" title="" src="graemlins/clappy.gif" /> <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" /> <img border="0" alt="[Clappy]" title="" src="graemlins/clappy.gif" />
     
  41. doc_hubby

    doc_hubby Junior Member
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    I have to agree that browman makes some very good points and many of them I wouldn't mind to see implemented personally as well. They make seem to make logical sense as well as economic sense. However logic and human action often at odds with each other and we are not likely to see them come into harmony on this topic either.

    The ideas do bring up some very interesting questions though:

    1) First, why aren't these reforms being implemented at the majority of hospitals and clinics, instead of a small minority implementing only one or two? Could it be that there is social resistance from the indigent (who don't want to be left out in the cold) and the politicians (who have to allocate the tax dollars)?

    2) Money is not the bottom line. One can certainly BUY influence; the last election is a prime example of that. However, money only facilitates what the heart and mind dictates. Offering a simple financial solution would likely work on the small scale and it's a damn good start, but it won't fly on an industry scale. Even in business, the sole purpose for those involved is not simply money, being in business is a challenge, it's fun, it's a roller coaster ride and it can be dead boring - but it's EMOTIONAL folks. Humans wouldn't be involved in it if it wasn't. Politics is fueled my money, but it's works by human emotions. There will need to be political changes as well as financial.

    Which brings me to three:

    3) Why does the medical establishment change so slowly? It's a religion/culture, a way of life and of living that helps those who enter it to self-justify the long hours and short pay in the begining of the career, every bit as much the better hours and outrageous saleries later in the career. Belief is the key here. It's true, what browman says about residency taking your soul, it's really the last step before the induction when you become a licensed physician. The vocation of "Healer" has been around for many thousands of years and that is the greater part of the conceptual problem of seeing residents as slave labor. When one is called to a vocation such as medicine, one supposedly serves a higher purpose and calling. I'm not saying this is always true, maybe it rarely applies these days, but this is how the public currently sees it and this is the mindset that people in general pass on to there children. A mindset that mostly looks down on money and using another person's suffering to make more for yourself. Doesn't matter that the insurance company many be paying the bulk of the bill, this how most people perceive the situation. Sure, the apprentice plumber gets paid more and has better benefits, she has a better union to protect her. Residents often have the lives and well being of the patients in their hands. Does this justify lower pay? Not at all, but it does help to make the concept resident compensation an even more emotional issue. All of this too theoretical for you? How about this: How long does a business last if no one believes in it? Let's consider Andersen Consulting. Why are businesses avoiding them? Is it because of the mistakes they made or because people have lost faith and don't believe in that particular company's ability to act correctly.

    4) What's the product? Let's not overlook this one small item on our capitalist list. The patient. Currently the health industry is headed towards the same billing practices as lawyers - bill the patient for what they are worth and then cut them loose to government supported medicine. And with that practice will come the same level of disrespect.

    5) To sum up, these are only a few of the main political and cultural issues that I can see impeding the reform of resident compensation. Many of you may feel this is crap, so be it, especially if the extent of your self-reflection is imagining how good Armani would look on the guy in the mirror. :rolleyes: My opinion and 2-cents worth. These are a few of the things that will have to be addressed though, beyond any lawsuit or administrative changes to the way things currently work.
     
  42. SimulD

    SimulD Senior Member
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    I have a question ... I'm a first year, so cut me some slack.

    When you're on call and really tired and you are making decisions, is it okay to call a chief or attending and wake them up? Would I get in trouble, if it was something easy? Would they be pissed at me?

    Because, if I had free reign on calling someone for help, I'm not sure if the 30 hour shifts would bother me as much. My major fear isn't the poverty, long hours, and miserable life (it's funny how those things aren't major fears, hehe), but it is that if I make a decision that kills someone and it is due to my lack of sleep and lack of having a superior to call on.

    I just think I'd need help for the first 6 months (maybe more), and if I didn't get it, trying to sleep in the call-room would be impossible, because I'd be scared sh-tless that I gave 500 mg of a drug instead of 50mg.

    Simul
     
  43. NuMD97

    NuMD97 Senior Member
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    SimulD:

    Rest easy. The way it works is you go up the food chain. If you're a PGY-1 in whatever specialty, your first call is to your resident who is (or should be) immediately supervising you. If you can't reach the resident (for whatever reason) then you can call the Chief Resident. One usually doesn't call the attending until all other resources have been exhausted. The fact that you worry is a good and healthy sign as far as I'm concerned. I hope you never lose that feeling totally. All the best.

    Nu
     

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