New Resident Work Hours

Discussion in 'Clinical Rotations' started by titan, Jun 12, 2002.

  1. titan

    titan Senior Member

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    Here's an article I just came across....

    <a href="http://story.news.yahoo.com/news?tmpl=story&ncid=534&e=2&cid=534&u=/ap/20020612/ap_on_he_me/tired_residents_1" target="_blank">http://story.news.yahoo.com/news?tmpl=story&ncid=534&e=2&cid=534&u=/ap/20020612/ap_on_he_me/tired_residents_1</a>
     
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  3. Elliebelly

    Elliebelly Junior Member

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    On the surface, this looks like good news for us, but as I understand it, the regulations that were imposed in NY made little, if any, difference in residents actual hours. Schools found many ways to get around the regulations and were rarely penalized for going over the allotted hours. Some students and residents argue that for some specialties they HAVE to work 100+ hours a week to learn what they need to learn. That sounds dubious to me, but what do I know, I am only starting school in the fall
     
  4. ermonty

    ermonty Senior Member

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    Does the passing down of these standards by the ACGME really mean anything? I mean policies on paper are one thing, but actual enforcement is another.
     
  5. NuMD97

    NuMD97 Senior Member

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    The Bell Commission in New York, would never have been effectuated if not for the death of Libby Zion. The only reason this particular case came to national attention was because of the fact that her father, Sidney, is a famous journalist, and he made certain that the case got a lot of ink in the press.

    Even as early as the mid-70's residents had gone on strike at Columbia, to attempt to force an 80-hour week, to no avail. The Bell Commission recommendations, drawn up in the summer of 1988, did not go into force until the summer of 1989. What does that tell you? That change in medical training occurs glacially slowly.

    And even now, without naming the hospital, programs will still demand a 10-week "initiating period" without one day off. Not only is it cruel, it's physically impossible to pull off. And yet, in the course of interviews elsewhere, one program director noted that her program does the same, but for one month's time, and then commented that she didn't think it was in violation of the RRC guidelines. Oh no? Frankly, I don't agree.

    But who would be the whistleblower on programs such as these? Whistleblowers in general have a propensity of ruining their own lives by doing what is morally correct. And therein lies the rub. It's truly a shame.
     
  6. atsai3

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    The new ACGME regulations bascially hinge on residents reporting to the AGCME violations by their program. What resident would do that? Even if the ACGME could maintain confidentiality (which is not immediately apparent, e.g., extremely small residency programs) any resident knows that if s/he finks, the program could lose accreditation and get shut down. Then s/he has to go look for another program?

    In any case, it's amusing to see how the profession is never on the vanguard of reform. We've already seen an OSHA petition, bill sponsored in the House of Representatives months ago, bill just introduced in the Senate yesterday, and a class action lawsuit. The ACGME move is empty, if you ask me.

    -a.
     
  7. neutropeniaboy

    neutropeniaboy Blasted ENT Attending

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    In my opinion, this sort of regulation can't gain momentum on a state-by-state basis. Material like this has to be enacted on the federal level, with federal charges, and federal punishment.

    If New York has been this way since 1984 (and they really aren't following any such regulations), how many states have followed suit in the past 20 years? One? Two? The union clearly doesn't give a damn.

    In addition to the state v. federal levels, I think these bills don't give the executive bodies enough power to enforce the laws. One of several problems.
     
  8. Goofy

    Goofy Senior Member

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    While enforcement remains a big problem, there are programs that have already revamped their schedules drastically for the start of this year (unfortunately mine isn't one of em).

    What needs to happen, in my mind, is very simple. One big name program needs to be made an example of. Once the message is sent, other programs will scramble to lighten the load on residents.

    K.P.
     
  9. NuMD97

    NuMD97 Senior Member

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    If we are awaiting the results of a so-called "big-named" program, it might be interesting to see the results of the Yale surgery program losing its accreditation.
     
  10. Squidaronimous J

    Squidaronimous J Junior Member

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    I saw this news item this morning and was thinking about it, also.

    Left me with a lot of questions. Here's two:

    1) The rep for the ACGME said something to the effect of "Doctors from older generations may be upset by this ruling. However, once they realize that what a resident is doing today is different from what they were doing during their residencies they will agree with the changes."

    Does anyone agree/disagree with this? If so, what is different today than a generation ago?

    2) Is the malpractice insurance a hospital carries for a resident higher than for an attending? If so, is that one of the reasons that hospitals justify getting so many hours out of their residents? It costs more to insure them, therefore they need to work them extra hours to make up for the cost of educating them/ insuring them? Or do residents cover their own malpractice?

    Just wondering,
    Squid
     
  11. 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 Squidaronimous J:
    <strong>I saw this news item this morning and was thinking about it, also.

    Left me with a lot of questions. Here's two:

    1) The rep for the ACGME said something to the effect of "Doctors from older generations may be upset by this ruling. However, once they realize that what a resident is doing today is different from what they were doing during their residencies they will agree with the changes."

    Does anyone agree/disagree with this? If so, what is different today than a generation ago?

    2) Is the malpractice insurance a hospital carries for a resident higher than for an attending? If so, is that one of the reasons that hospitals justify getting so many hours out of their residents? It costs more to insure them, therefore they need to work them extra hours to make up for the cost of educating them/ insuring them? Or do residents cover their own malpractice?

    Just wondering,
    Squid</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Hi there,

    I can't answer the second question but I will offer an opinion on the first. As a recent graduate of medical school, I can tell you that I had to learn and deal with far more technology and information that the doc who graduated even ten years ago. The in-patients are sicker and more complex than even ten years ago. We simply have to know more and handle more.

    Ten years ago, a surgeon might have to deal with 30 to 40 patients but a good number of them would be minor things like appys and choles. Today, most simple cases are barely an overnight stay and most are outpatient.

    Even ten years ago, trauma science was just coming into it's own and much was unknown. Many severly injured patients who live today, would have died. I can tell you, after 30 hours, the death of an severly injured patient can be a relief in many ways both for you and the patient. When you have 16 grueling hours of keeping a patient alive who is "circling the drain" in ICU, the stress is intensive. Even ten years ago, many patients died outright that recover today.

    I don't know about malpractice insurance rates but they should go down with this ruling as patients will have more quality attention from both attendings and residents.
     
  12. Goofy

    Goofy Senior Member

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    Hi Numd,

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by NuMD97:
    <strong>If we are awaiting the results of a so-called "big-named" program, it might be interesting to see the results of the Yale surgery program losing its accreditation.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I think this is precisely why Yale was 'chosen'. Certainly any number of programs might be cited, and I hardly believe that Yale was the worst of the bunch (although very bad). It will indeed be interesting to watch. I suspect the necessary change will only be implemented after I am done training, but I will keep up the good fight long after I'm done.

    K.P.
     
  13. ICUDOC

    ICUDOC Member

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    Two quick thoughts.

    1.) Yale's problems were MUCH bigger than resident work hours. Hours at Yale are/were somewhat average to lighter for a large university program. They were also sited for lack of cases. Even when I interview 5 years ago, the word on the street was to stay away from Yale. Despite the name, it is no where near an academic powerhouse.

    2.) Over the last 50 years things in surgery/medicine have changed tremendously. The work hours for surgeons have always been long. However, for one as already stated the patient population was much different. Patients these days are much older, and have multiple confounding medical problems on top of their acute illness. Second, the turnover rate of hospitals is tenfold what it use to be. When my dad did his surgical training, he would have weekends where he was in the hospital, but would get an admission or maybe 2, and maybe a couple of calls. When Iwas a junior intern, my pager was going off and I was admitting all night. There is also tenfold the amount of paper work required. Discharge summaries, transfer orders, arranging nursing care etc. While the hours have not changed I am certain the amount of workload has doubled. Today's nurses are no where near what they were 20-30 years ago. Mostly due to liability, but their ability to make any little clinical decision has been taken away from them. Unfortunately, some nurses simply chart numbers, and call the intern for any little complaint the patient has. Ok when you ahve a service of 10 and a slow weekend, but when you are doing 10+ admissions and cross covering a couple of services these calls are painful. I also feel that the fast turnover rate and busy schedules of attendings has taken away from the educational aspect of the residency, which is what residency is suppose to be all about. Now I find it about keeping the service running smoothly and making certain patients are booked correctly and are discharged as soon as possible. Hopefully these work hours limitations will change things. It looks like we will have to rely on PAs/FNPs to fill the void, but it will take 2-3 PA's per resident to make up the hours. And from what I have seen, you are going to have to pay a PA a lot of money to perform the work of an intern. It is OK for a year, but even as shiftwork no PA in their right mind would want to do this.
     
  14. Chit Khaing

    Chit Khaing New Member

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    :confused: :confused: :confused:

    Isn't it a doctor-patient ratio problem in fact? A few years ago, I noticed that America is below par in terms of DPR among G7 countries. When work hour is reduced for an individual, how will the required servies be adjusted?

    The programs always say it is impossible to have "Educational benefit" without "Service commitment", although it is not easy to be in a fair propotion if the work load is not well balanced.
     
  15. ckent

    ckent Banned
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    Here is an article from the NY times that addresses the Yale situation and the new policy. I would just put a link to it, but you need to log in to read it.

    Limits on Residents' Hours Worry Teaching Hospitals
    By REED ABELSON

    Many of the nation's teaching hospitals, already under financial pressure, are raising concerns about the effect of new rules that will limit the number of hours worked by medical residents.

    "For academic medical centers, the impact is going to be profound," said Dr. Peter Herbert, the chief of staff for Yale-New Haven Hospital, a teaching affiliate of the Yale School of Medicine, who estimates that the cost for some hospitals could run into the millions of dollars.

    Advertisement



    The rules, which are being imposed by the group that accredits teaching hospitals, will limit the average workweek to 80 hours and restrict a resident's duty to no more than 24 hours at a time.

    Some hospitals consider residents an inexpensive source of labor. Some residents say they work 100 hours or more a week. Having significantly cut back on nurses and other staff, hospitals rely heavily on these new doctors, who spend several years training at a hospital after earning their medical degrees.

    In addition to caring for patients, particularly the poor and uninsured, these doctors often handle paperwork, transport patients and perform tasks once delegated to others.

    The new rules, which are aimed at reducing the risk of dangerous errors by inexperienced doctors who are sleep deprived, will take effect in July 2003. They are being applied by the Accreditation Council for Graduate Medical Education, which oversees the training of 100,000 residents in the nation's 7,800 programs.

    While some specialties already limit residents' workweeks, the new rules will apply to all training programs and could require many hospitals to change how they staff.

    Yale-New Haven Hospital, whose surgery program was threatened with a loss of accreditation because of the long hours residents worked, is hiring 12 physician associates to reduce the residents' workload, Dr. Herbert said.

    "There is a huge financial hit," said Dr. Jon Cohen, the chief medical officer for the North Shore-Long Island Jewish Health System, which, like other New York hospitals, has had to adapt to a law that already limits residents' hours.

    The cost of two to three physician assistants can run as high as $200,000 a year, compared with $50,000 to pay a medical resident, Dr. Cohen said. "No one knows where that money is going to come from," he said.

    Many hospitals acknowledge that the new rules will require significant changes in how they do things and how they view residents.

    "The big cultural change is the institutions have to recognize and treat residents as students," Dr. Cohen of North Shore said.

    Some say this will force teaching hospitals to think seriously about the best way to deliver care and educate residents.

    "The real challenge for us is to redesign the health care delivery model," said Dr. Thomas J. Nasca, dean of the Jefferson Medical College at Thomas Jefferson University.

    In New York, the cost of adopting the law limiting residents' hours was estimated by the state at $220 million a year, some of which the hospitals recovered through higher reimbursements.

    The New York law took effect in 1989, and a study done in the late 1990's suggested that many hospitals, particularly in New York City, were still asking residents to work longer hours than the law required. In recent years, however, enforcement of the law has been increased, and many hospitals have made more significant changes in their staffing.

    New York hospitals are not likely to feel much impact from the new rules, said Kenneth Raske, the president of the Greater New York Hospital Association, with the exception of some surgical programs where hospitals are still allowed to ask their residents to work longer hours. "The surgical programs need to have some flexibility," Mr. Raske said.

    Depending on how the hospital uses residents and the services they provide, the cost of complying will vary widely, the American Hospital Association said. "We really don't understand the cost or the adaptions," said James Bentley, the group's senior vice president for strategic policy planning.

    While some hospitals will hire senior nurses or physician assistants, others may rely more on other doctors and may curtail some of the areas where residents provide care, Mr. Bentley said.

    But hiring nurses or physician assistants may not add significantly to costs, others say. "The financial impact won't be catastrophic," said Mark V. Pauly, a professor of health care at the Wharton School at the University of Pennsylvania.

    Still, the new rules are an example of rising costs for hospitals, said Mr. Bentley, who said the association was working to prevent cuts in federal and state payments that would further weaken the financial condition of many of its members.

    Even specialities like internal medicine that already adhere to 80-hour workweek will have to adjust. At the University of Chicago hospitals many residents work 36 or 38 hours at a time to be able to provide follow-up care and attend educational programs, said Dr. Holly Humphrey, who oversees the residents in internal medicine. The 24-hour limit, even with a possible additional six hours for handing off patients or attending lectures, "is a big, big change," Dr. Humphrey said.

    She is concerned that residency programs will "take on a mentality of shift work," she said.
     
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  17. NuMD97

    NuMD97 Senior Member

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    Thank you, ckent, for the NY Times article. It was most informative. By the way, what was the date it was published?

    One thing from the article really made me smile:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> compared with $50,000 to pay a medical resident </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I really would like to know where this institution is, because frankly, I have yet to hear of one hospital that pays that kind of money, even at the senior level of residency training. I certainly wouldn't object to a $12,000 or so raise. Where do I sign up?
     
  18. ckent

    ckent Banned
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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 NuMD97:
    <strong>Thank you, ckent, for the NY Times article. It was most informative. By the way, what was the date it was published?
    </strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">It was published today, June 14th, on their website <a href="http://www.nytimes.com" target="_blank">http://www.nytimes.com</a> .
     
  19. atsai3

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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 NuMD97:
    <strong>Thank you, ckent, for the NY Times article. It was most informative. By the way, what was the date it was published?

    One thing from the article really made me smile:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> compared with $50,000 to pay a medical resident </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I really would like to know where this institution is, because frankly, I have yet to hear of one hospital that pays that kind of money, even at the senior level of residency training. I certainly wouldn't object to a $12,000 or so raise. Where do I sign up?</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Cohen's quote is revealing in that the true nature of the resident as "cheap labor" is evident.

    -a.
     
  20. NuMD97

    NuMD97 Senior Member

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    Thanks, ck. I found the two adjoining articles of interest as well.

    As far as what atsai 3 wrote:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> Cohen's quote is revealing in that the true nature of the resident as "cheap labor" is evident. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">That's my point. Somehow when they collect data for important stories like these, they screw up the bottom line. There ain't salaries like that. If there were, besides the issue of the working hours, the wages would not have been a part of that class action suit that is pending now.
     
  21. Pilot Doc

    Pilot Doc SDN Angel
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    Well, for one the <a href="http://www.ama-assn.org/vapp/freida/pgm/0,2654,4404121280,00.html" target="_blank">Lehigh Valley Hospital/Pennsylvania State University</a> surgery program pays their chiefs $49.8K per year. I'll grant you that's rare, but it does exist.

    Also, there is a wide disparity between what it costs to pay a resident and what a resident is paid. With health insurance, educational money and other benefits, I bet $50K is a reasonable figure. Moreso than $40K at least. There's also social security, although I gather that many if not all programs skirt around paying that.
     
  22. Ryo-Ohki

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    Why should a reporter include health insurance benefits in a salary when he is just citing salaries? Why should a reporter use a senior resident's salary when the subject is resident's salaries? It was just bad reporting. Period.

    Social security takes into account your top 35 years into a retirement computation. You may feel good that you are getting an extra 7% by not paying social security....but in the end, your employer, the hospital, is screwing you for their own benefit (they do not have to pay their portion of social security). As far as I know, all hospitals are paying social security on their residents (because residents are employees). Are any hospitals putting residents on a contract labor employment agreement? If they do, it's pretty much illegal and unethical. But I guess if the Bell Commission issue (80 hour work week) shows anything, it shows that hospitals will do illegal and unethical things when it comes to young MDs
     
  23. Pilot Doc

    Pilot Doc SDN Angel
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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"> The cost of two to three physician assistants can run as high as $200,000 a year, compared with $50,000 to pay a medical resident, Dr. Cohen said. "No one knows where that money is going to come from," he said.
    </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">The point of that paragraph is that replacing residents is expensive. It does not address the equity of resident salaries. (Or for that matter, if read carefully, salaries at all.) In that context, the cost of an employee is more relevant than his salary.
     
  24. Ryo-Ohki

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    My mistake.
     
  25. Winged Scapula

    Winged Scapula Cougariffic!
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    There are plenty of programs that pay their Chiefs $50K - most of the NY programs, most of the PA programs, and UCSF-Fresno, just to name a few off the top of my head.
     
  26. ckent

    ckent Banned
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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 Kimberli Cox:
    <strong>There are plenty of programs that pay their Chiefs $50K - most of the NY programs, most of the PA programs, and UCSF-Fresno, just to name a few off the top of my head.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">A GI fellow told us that he, as an internal medicine chief resident, was paid as an asst. prof (80,000), plus he got to moonlight so he ended up making over 100,000 that year. He then had to take a significant pay cut to come here for his GI fellowship (40,000).
     
  27. Whisker Barrel Cortex

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    The two programs I interviewed at in NY both offered salaries of approximately 50K to senior residents.

    Chief residents in internal medicine are different from chiefs in most other specialties (like surgery and radiology). Medicine chiefs have finished their 3 years in training and graduated residency. They then do a year when they do a lot of clerical stuff and, depending on the hospital, may actually act as ward attendings for a couple of months. Their salaries are usually much higher than a resident. Surgery and radiology (I don't know about others) chief residents are in their final year of residency and thus receive less. They are senior residents, not graduates.
     
  28. NuMD97

    NuMD97 Senior Member

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    Originally posted by Kimberli Cox:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> There are plenty of programs that pay their Chiefs $50K - most of the NY programs, most of the PA programs, and UCSF-Fresno, just to name a few off the top of my head. </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Yes, but I meant the average "resident in the trenches" not chief residents. I think the under $50 grand figure still stands under that definition.
     
  29. 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 NuMD97:
    <strong>Thank you, ckent, for the NY Times article. It was most informative. By the way, what was the date it was published?

    One thing from the article really made me smile:

    </font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif"> compared with $50,000 to pay a medical resident </font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I really would like to know where this institution is, because frankly, I have yet to hear of one hospital that pays that kind of money, even at the senior level of residency training. I certainly wouldn't object to a $12,000 or so raise. Where do I sign up?</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">I know of several community programs that pay upwards of 48k with opportunity to moonlight in the ER as an intern. Granted these are community programs for the most part, but I have heard of at least one university program that does it as well.
     
  30. NuMD97

    NuMD97 Senior Member

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    OK here's the site straight from the horse's mouth about stipends for all years of training, all across the country (specifically, see Table 5):

    <a href="http://www.aamc.org/hlthcare/coth-hss/2001report.pdf" target="_blank">http://www.aamc.org/hlthcare/coth-hss/2001report.pdf</a>

    Hopefully, this clears up the discussion.
     
  31. 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 NuMD97:
    <strong>OK here's the site straight from the horse's mouth about stipends for all years of training, all across the country (specifically, see Table 5):

    <a href="http://www.aamc.org/hlthcare/coth-hss/2001report.pdf" target="_blank">http://www.aamc.org/hlthcare/coth-hss/2001report.pdf</a>

    Hopefully, this clears up the discussion.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Hi Numd,

    Those tables are interesting. Sort of highlights the hapless plight of resident physicians quite well. Unfortunately they are only regional averages, so they don't offer specific information about the few with higher compensation packages.
     
  32. NuMD97

    NuMD97 Senior Member

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    As I said before, Klebs, the $50,000 range is the exception not the rule. If you want information about specific programs or a particular year, FREIDA would probably be your best source.
     

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