New Ruling on the NRMP Lawsuit

[tofurious]

From www.residentcase.com (be sure to read NRMP's statement that they would not care if the residents sued the individual hospitals, and how the hospitals said it was NRMP's problem):

February 26, 2004. The defendant association of teaching hospitals (AAMC) and residency accrediting body (ACGME) file answers to plaintiffs' complaint. Among other things, AAMC and ACGME deny in their answers that residents work long hours for low wages and contend in affirmative defenses that residents failed to act soon enough in protesting their working conditions ("laches"); that residents failed to take action to limit their own injury ("no mitigation"); that residents contribute their their own injury ("unclean hands"); and that residency is "education" rather than "employment" (a defense already rejected in the Court's February 11, 2004 order). NRMP files appeal of court ruling denying arbitration and certain defendants file appeal of ruling that all defendants are properly in court in the District of Columbia. Plaintiffs will contest these appeals.

February 12, 2004. U.S. District Court Judge Paul Friedman denies NRMP?s motion to compel arbitration; rejects ACGME?s argument that residency is education rather than employment; and rejects arguments by AAMC and various hospitals that the complaint fails to allege illegal conduct. Judge Friedman allows the case to move forward against 30 of the 36 original defendants. Six defendants are dismissed on jurisdictional grounds or for lack of detail in the Complaint as to their roles in the antitrust violation. Plaintiffs are considering whether to seek reinstatement of any dismissed defendants.

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[Kalel]

Personally, I think that this lawsuit, if successful, is just going to screw things up for applicants and hospitals. The NRMP and AAMC aren't greedy organizations trying to take advantage of med students, they are only trying to help the process.
http://www.savethematch.org/

 

[tofurious]

If you would actually read the alternative offered, you'd find out that the solution suggested by the lawsuit is not to completely eliminate the Match but to make participation in the Match voluntary. That way, you could participate in the Match for a job that starts at $35,000, and others could secure spots outside of the Match for a job that starts at $50,000.

 

[dry dre]

Originally posted by Kalel
this lawsuit, if successful, is just going to screw things up for applicants and hospitals.

So hospitals will have to start coughing up more money and/or start hiring other people to draw blood, chase down x-rays, etc. And residents lose how?

The NRMP and AAMC aren't greedy organizations trying to take advantage of med students, they are only trying to help the process.

Are you in the market for a bridge? Some magic beans?

 

[avendesora]

Originally posted by tofurious
If you would actually read the alternative offered, you'd find out that the solution suggested by the lawsuit is not to completely eliminate the Match but to make participation in the Match voluntary. That way, you could participate in the Match for a job that starts at $35,000, and others could secure spots outside of the Match for a job that starts at $50,000.

Somehow, I just don't think this would actually happen. I just don't see an extra 15K per year as a reason to go to "SmallTown Community" over "BigName Academic", especially when going to a better residency can in the long run help one obtain a more lucrative practice. You know that Stanfords and the MGH's of the world will be among the lowest compensation and will still be very competitive.

Also (I don't know, and am just asking) is there anything that keeps residencies from paying more today? If not, how is just not having the match going to entice them to pay more? I don't follow that argument that they will have to compete harder (pay more) to get top candidates without the match.

Again, maybe I don't understand all the issues as I have better things to do than become an expert on this, but I see this suit as an attempt to help the few at the expense of the many.

 

[avendesora]

OK, I just went and read the propaganda on the residentcase site.

It seems as though the point is to make residency application more like med-school application. Persoanlly I hated med-school application, but I can see how if you were a star and offered spots everywhere you interviewed it looks pretty good.

I personally liked interviewing at 13 programs, seeing the variety an strengths of each in turn and deciding at the end where I wanted to go. I know that at the time, my first interview looked pretty good and if they had given me a job offer that expired after 10 days I might have accepted it before my other interviews. In retrospect, though, I had NO CLUE what was out there when I started and I ended up not ranking this program. Outside the match I might have ended up there.

If any US students on here feel like you were "discriminated against" compared to foreign grads, raise your hand... Anyone?? Please, to suggest FMGs are treated prefferentially is silly.

I personally have talked to a couple FMGs at my institution who were offered pre-macth deals and felt very pressured and uncomfortable, but stuck out the match and ended up doing much better.

I suspect that if this "voluntary match" were to take place, strong programs would stick with the "match only" to assure they get the best possible class while weaker programs would go outside the match so they can offer incentives and pressure people to sign with them before fully exploring their options. Maybe this is the idea of the whole thing, I dunno.

Basically, it seems to me like this system would still favor residencies. But that's just my opinion. Either way, I'm glad I'm matching this year because if this goes though, the first year under the new system is going to be a MESS.

 

[margaritaboy]

As I understand it, there is no law that keeps residency programs from compensating residents more than what is traditionally offered. However, there is also no financially compelling reason to do so in lieu of the fact that residents have no power to negotiate the terms of their employment, have no alternative to the NRMP, and have no alternatives to residency for career advancement.

Residency applicants are captive employees, even before they sign their contracts. There is no incentive for programs to offer anything more than the minimum, because they know we have no means to shop around for a better deal.

Case in point: The eighty hour work week. Did programs decide to limit the number of resident work hours because of concerns for patient care, the welfare of residents, or the low pay? No. It was an ACGME mandate that programs must adhere to. There was no incentive to lower work hours because residents had no power to negotiate the terms of their employment, had no alternative to the NRMP, and had no alternative for career advancement. Similarly, there is little incentive to raise pay.

By allowing residents to pursue residencies inside OR outside the match, you are giving applicants an alternative to the NRMP, and at least some power of negotiation. Whether this will work or not, I am not sure. I do resent the current system, in which I am required to participate de facto, and pay hundreds of dollars to do so.

By the way how does this suit, "attempt to help the few at the expense of the many."? You could still go through the match, if you chose to, could you not?

Thanks for your thoughts and opinions.

 

[Seaglass]

Personally I totally agree with the "helping the few at the expense of the many" argument.

Say a program as $300k budgeted for resident salary for a class for a year. In the best-case scenario stars may negotiate for 50k a year while everyone else is getting 40k a year. This creates conflict/tension within a class. Add that to the fact that the amount of work/quality of work you get out of any one resident is not going to be significantly different than some other resident no matter how good your board scores are and you have to ask the question: what are programs really getting for their money?

IMHO the most likely outcome of doing away with the match will be residency chaos where 3rd years are being approached with positions/offers from shady programs. Of course the third years will not have seen very many progams and so will not be able to make informed decisions about where they want to go. Meanwhile overall salaries will fall to make funds available for these "star" candidates.

The answer to our workplace gripes is not to do away with the match, it is to unionize and use collective bargaining to improve hours, wages, and benefits.

Just my $0.02

Casey

 

[margaritaboy]

To be sure, I don't think the voluntary match that is envisioned by the lawsuit would necessarily make things simpler for us. In fact, it probably wouldn't. And you may be right, it may be a mess if the suit succeeds. Also, there are aspects of the suit that are weak, I must admit.

But I'm not looking at how easy or hard it would be for us. I'm trying to look beyond the immediate ramifications of the suit and see that it may open up residencies for competition in terms of salary, health benefits, and working conditions.

In other words, the root of the issue for me in our intra-residency compensation, benefits, and working conditions. The NRMP doesn't dictate what these parameters are, but creates an environment in which they are static, nearly uniform across programs (whom share this information with one another), and gives applicants no alternatives or leverage to change them.

 

[margaritaboy]

Originally posted by cg1155
Personally I totally agree with the "helping the few at the expense of the many" argument.

Say a program as $300k budgeted for resident salary for a class for a year. In the best-case scenario stars may negotiate for 50k a year while everyone else is getting 40k a year. This creates conflict/tension within a class. Add that to the fact that the amount of work/quality of work you get out of any one resident is not going to be significantly different than some other resident no matter how good your board scores are and you have to ask the question: what are programs really getting for their money?

IMHO the most likely outcome of doing away with the match will be residency chaos where 3rd years are being approached with positions/offers from shady programs. Of course the third years will not have seen very many progams and so will not be able to make informed decisions about where they want to go. Meanwhile overall salaries will fall to make funds available for these "star" candidates.

The answer to our workplace gripes is not to do away with the match, it is to unionize and use collective bargaining to improve hours, wages, and benefits.

Just my $0.02

Casey

The lawsuit doesn't propose doing away with them match. Does it?

According to the website, it also proposes standards about when applicants can be approached with offers, so that third year students would not be approached.

As to collective bargaining, I am with you 100%. Right now, we have no ability to barging . Having a voluntary match may give us the collective bargaining power we need. On the other hand, having interns with markedly differing salaries would be problematic.

But I think it may be the case that a program that wants to 'compete' would collectively raise all PGY-1 compensation benefits uniformly, for example, to attract the maximum number of applicants to the program.

 

[Docgeorge]

I dont under stand what the big deal about NRMP sharing info on what programs are offering what benifits. I mean if program X wanted to see what program Y was offering in terms of compensation all they would have to do is go to program Y website. It's posted there more often then not.

 

[Andrew_Doan]

An interesting side note.

If residency training is NOT education, then Medicare shouldn't have to fund our training.

At this time, Medicare pays millions of dollars to teaching hospitals for the purposes of resident training. Thus, if Medicare pulls out b/c we're not really receiving an education, our salaries may be cut considerably. This is what it was like before Medicare was established. My program director jokes that if Medicare pulls out, then residents will end up paying programs for their "education".

 

[Lumberg]

Clearly, this is a complex issue. I'd like to address some issues that have been previously raised.

Some have suggested if the lawsuit is successful that top programs may be in a position to lower salaries and benefits...people have gone so far as to say that residents in those positions may actually pay tuition! That is simply not realistic....top law firms pay their top candidates the best salaries...nfl teams pay their top draft picks top dollar, etc. After four years of graduate education we deserve to be paid accordingly. Our salaries are sometimes one-quarter of what our law/business school counterparts earn!

I'm sure all of us had altruistic reasons for entering into medicine, but I'd like to see a show of hands among you who are willing to work for free. In fact, by being able to offer candidates more incentive, some struggling programs may be able to overcome negatives like pt. population of poor location by attracting more highly qualified residents.

My sense is that unless some pressure is applied to effect change, residents will continue to provide cheap and overworked labor. The 80 hr work week law was passed in N.Y. sometime in the 1990's and was subsequently ignored until 1 month after this lawsuit was proposed.

Obviously, this is only scratching the surface but I'm grateful for the opportunity to keep this dialogue open and exchange ideas among colleagues who share the same passion for medicine and their careers. Medicine is an ancient and venerable art. I'm proud to be counted among its practioners, but this aspect of our education needs reform. The 80hr work week is a promising start. Now we, as the future leaders of our profession,need to enact change now.

'berg

P. S. To all of you MS IV's...good luck with the match!

 

[Goober]

Why did the match develop?

I have talked to a number of older docs who were in the system before the match was instituted and it was chaos. Students often did not know where they were going to be doing the their internship or residency until days or weeks before July 1. People were holding out for better deals so somebody deciding to take a spot and dropping another spot would cause a whole cascading effect which was repeated over and over again. The students most affected were those in the bottom half of the class who were more likely to be not the top choices of the residencies program.

Weaker residency programs in an effort to sign better students would try to sign them to a contract in their 3rd year and sometimes even into their second year.

The match seems the fairest way for everybody. If you want higher pay, you can do what some residents have done- unionize or simply moonlight.

 

[Goober]

If you think that residency training is not education, then go out and try practice medicine without it. What type of medicine is a medical school graduate qualified to do? Nothing.

BTW I am NOT against paying residents more, limiting their work hours, ect.

 

[Andrew_Doan]

Originally posted by Lumberg
Some have suggested if the lawsuit is successful that top programs may be in a position to lower salaries and benefits...people have gone so far as to say that residents in those positions may actually pay tuition! That is simply not realistic....top law firms pay their top candidates the best salaries...nfl teams pay their top draft picks top dollar, etc. After four years of graduate education we deserve to be paid accordingly. Our salaries are sometimes one-quarter of what our law/business school counterparts earn!

Your argument greatly depends on whether a new medical graduate can practice medicine without a residency. The answer is no. We all need a residency (thus it's education) in order to find a job as physicians. Law has something similar, and it's called an internship. There are plenty of lawyers making horrible wages out of law school who desire to do internships for the sake of further training/education (even from the most presitigous schools).

The huge difference between medical grads and every other field is that grads in other fields can work without a residency.

Remember that our wages come from Medicare. Before Medicare, good applicants were working almost for free in order to be associated with places like Harvard or Hopkins.

We still see this in medical training today. In fact, many fellowships pay much less than residency programs. That's right, you're paid less even with more training. You go from making $40K-$50k year as a resident to about $25K-30K/year in some fellowship programs. Furthermore, in certain competitive fellowship programs, fellows aren't paid and must moonlight on the side or come up with their own funding! Why? Because some fellowships aren't supported by Medicare or receive less Medicare support.

It should be emphasized that top programs will NEVER need to offer high wages to attract good residents b/c this training is an essential and indispensable phase in a physician's training. Also, without Medicare support, residents would likely not have a $40K/year salary. Having residents in a teaching environment is expensive and inefficient. If you think residents are irreplaceable, then you need to look at private hospitals that offer the same services as the University Hospitals. Most of these hospitals don't have residents, yet their staff physicians still take call, admit paitients, and offer trauma services.

One last point, I also find it interesting that there are residents who want their compensation increased, and there are those who are fighting to be classified as "students" in order to avoid paying FICA/Social Security taxes. If classified as students, then our salaries are stipends NOT wages. It sounds like we want the best of both worlds!

http://www.findarticles.com/cf_dls/m0BJI/4_31/71900956/p1/article.jhtml

This is a highly debatable question: are residents students in training or are they staff employees? We definitely can't be both.

 

[rustybruce]

Everyone here is missing the point except Goober. None of the residents I have spoken to on this issue are frustrated by their lack of pay and their level of "abuse". Not one said they wish they could have collectively bargained to improve their benefits. If you look at most of the places you interviewed, the benefits are damn good (how many of your friends got 4 weeks off their first year of work and health insurance for their husbands, wives, families or even gay lovers?)

On top of that, the Match is in place because the medical community was begging for it. The residency application process used to be a cluster f#$%. Ask one of your older attendings. First of all, they used to not even get paid.

As a competitive candidate in this process, I have never once wished that I could collectively bargain or sign a larger contract. Just because I believe I am competitive does not mean that residency TRAINING programs should offer me more money. This matching process is well-organized, fair, and effective. Plaintiffs and Lawyers are again doing what they frequently do. $h1ting on a somewhat mutually beneficial institution.


Besides, YOU KNEW ABOUT THIS BEFORE YOU STARTED THE PROCESS. DON'T PRETEND YOU ARE BEING UNFAIRLY ABUSED

 

[tofurious]

The sky is falling! The sky is falling!

Many concerns have been raised in this thread about the what-if's in the new system. However, a careful read of the website will answer all your questions such as differential salary within a program (no such thing; salary competition would be between hospitals and programs) or chaotic 10-day offers (a mandatory date programs must wait before making offers).

As for MGH and Stanford paying less, have you looked at staff salaries at these high caliber places versus a private practitioner in South Dakota? Attendings at famous places earn a LOT less (Hopkins) than those at the more mediocre academic places AND private practices. You certainly don't see these places populated with people in the bottom 25%tile of your med school, because people make choices between prestige, quality of life, location, pay vs. cost of living. This has also resulted in large number of smart and qualified people going away from these places because of better offers elsewhere and a rise in the average quality of programs/academic centers across the country. If it's acceptable to have open competition between hospitals for attending jobs based on reputation vs. pay and other items in the offer AND between medical schools with regard to training vs. $$$ (differential tuition vs. financial aid), why is it not okay to have it at the residency level as well?

 

[Samoa]

Originally posted by Lumberg
Some have suggested if the lawsuit is successful that top programs may be in a position to lower salaries and benefits...people have gone so far as to say that residents in those positions may actually pay tuition! That is simply not realistic....top law firms pay their top candidates the best salaries...nfl teams pay their top draft picks top dollar, etc.

If you think that top programs would not use their prestige to lower the salaries they offer, you are fooling yourself. To use an example from another field more similar to medicine than the NFL or a law firm, just look at specialty residencies in pharmacy. There is no Match program for these residencies, and the Match for a general residency is optional. It's widely acknowledged that the top programs pay a substantially lower stipend than the rest. In fact, the program I graduated from offered the premier psych residency, and paid a stipend that was barely above poverty level for that part of the country, and far below what other top programs were paying. It only got increased when they started losing good applicants because it simply was too little to live on without supplementation. And we were specifically told that a high stipend was an indicator of a low-quality program, and vice-versa, because of the market forces involved.

And this is in a field where you don't even HAVE to do a residency. Granted, it shortens your road to a clinical or teaching career dramatically, but it is not an essential requirement to get a license or sit for a specialty board exam, or to have that kind of practice. In a field where a residency is required for these things, it's hard to imagine an optional match being beneficial.

 

[margaritaboy]

Originally posted by Goober
Why did the match develop?

Weaker residency programs in an effort to sign better students would try to sign them to a contract in their 3rd year and sometimes even into their second year.

As I mentioned above, the lawsuit actually proposes a time frame in which applicants can be approached with offers, thus avoiding the above.

I must admit that I wasn't at all familiar with the suit against NRMP until I went to the website and read about it. A couple of posters have mentioned that it would be chaos to do away with the match, and that 3rd years would be approach with offers.

The case against the NRMP does not suggest doing away with the match, nor does it does it leave the issue of early offers to 3rd years undressed.

The lawsuit definitely has some shortcomings, some of which were evident on the website. But if we are to object to its purpose, method, or potential outcome, it only seems fair to question its actual positions on the issues rather than saying it is trying to do something that it isn't.

One question I have: Would offers outside the match be time limited (i.e. expire 2 weeks after they are offered)? Or would they be open ended like the med school offers?

As to moonlighting: Does every institution allow moonlighting? I thought the very idea of moonlighting was already being called into question from legal and ethical points of view. Don't get me wrong, if its there, I'll take it.

 

[margaritaboy]

S**t. There were like 5 posts in the time it took me to write one. I suck. Must....type....faster.....

 

[tofurious]

To Rustybruce: I don't think it's fair to considers others in this thread less competitive than you and their desire to be compensated better for our effort a frivilous one. I am a competitive candidate as well, but the alternatives presented to me at the multiple high caliber places I am competitive at did not differ a whole lot (salaries ranging from $39k to $49k reflecting only different cost of living). If you as a competitive candidate only offers the type of medical service whose fair market value is at $10/hr, a new system would STILL allow you to take a job like that. If others feel that their service to the hospitals is worth more than $10/hr, they should be free to entertain other offers, provided higher offers are ENCOURAGED.

This has nothing to do with how competitive you are within the system. The problem is system-wide, and chances are folks like you will keep the MGHs and Stanfords populated for long enoguh at low pay that it will not make a huge difference for these hospitals. That's perfectly okay since YOU KNOW ABOUT THIS going in, but please don't deny others the chance to settle for more $ instead of a diploma from MGH.

Ask yourself this: if the #4 place on your rank list offers you $15,000 more per year (after adjusting for cost of living difference based on location) than your #1 place, where would you go to train?

After enough people make such choices, what do you think the place you ranked #1 would do?

 

[rustybruce]

tofurious,

I guess the "competitive" part of my post was written wrong (emphasis now adjusted). My point was that I don't think that in a continued training process, people at the same institution should have different salaries just because some of the candidates might have been more highly prized. Schools have presented their salary packages upfront this year. That is a good change. But not much more needs to be done. This is not the real world.

By the way, you guys keep quoting Stanford as a school that would stay on the lower end of compensation. If you go to their website, you'll note one of the best benefit packages in the nation. Something like $3000 signing money and $1500 CME per year on top of great insurance.

 

[tofurious]

I know the Stanford package well as it was ranked #3 on my list. Do you know how much it costs to live in Palo Alto or nearby? $3000 moving cost is not enough to make up for the difference between how much I pay for mortgage now and how much I would pay for rent (and there is no way I can afford mortgage in the area).

 

[Docxter]

Just a interesting story I wanted to share. A few months ago, I was talking to the program director of a not-so-good radiology fellowship program at a national meeting. They haven't been able to get fellows in the past few years and they are having a very hard time with no fellows to share the work. This year, they are asked to be be dropped from ACGME accreditation so that they could bargain for fellows, increase their scope of work, and dramatically increase their salaries (up to 100k or so) in order to make their fellowship positions attractive.

 

[Lumberg]

This is a great discussion.

It is true that we all need residency training to complete our education. It is also true that hospitals throughout our country need residents to staff them. Our relationship is essentially symbiotic and I believe the residency/hospital relationship should continue more or less intact. To suggest that US medical school graduates would be unemployable because of this lawsuit is, in my opinion, far-fetched. What I'm urging is reform to improve working conditions, salaries and to provide would-be residents with negotiating power. No one is calling for a dismantling of our medical training system here!

Also, I am an MS IV. I will match in three weeks (hopefully!) so any changes that take place will not affect me directly. I knew exactly what I was getting into and I wouldn't trade a career in medicine for anything. That does NOT mean that we shouldn't work to make things better for those who follow and meekly accept the staus quo. Medicine has always resisted change, sometimes to its own detriment. In my opinion the time has come to address these inequalities in the Match.

'berg

 

[dry dre]

1) I agree that residency is partly an education process.

2) Residents provide utility (physician services, or at least physician-like services) to their hospitals, helping to bring in revenue for the hospitals.

3) Residents may order labs etc in excess relative to an attending, but not to the tone of ~$110k a year (the difference between attending and resident pay).

4) The financial arrangement between the hospital and the resident is unique in the modern work environment in that the resident has fewer rights--there is no reason this should not change. Well, if you don't like rights I suppose oldschool is good.

5) I think most residents would put up with 100 hour weeks so long as they were taking care of patients and learning and not doing scutwork.

Regarding sharing reimbursement information: this is proof of probable price manipulation activity. While certainly programs could write one another or read websites, that the practice of sharing occured is simply proof that the activity occurred, not to demonstrate that programs go out finding information the easy way.

 

[tofurious]

Another interesting question on residentcase.com I have not seen discussed here is the issue of how hospitals will survive in the future IF they are forced to pay residents more and many hospitals NOW are baring making even. The most pessimistic view would be that some hospitals would be closed down, while others will have to run more efficiently. The story of the hospital willing to hire radiology fellows at nearly $100k goes to show that hospitals *can* make ends meet, and I just wonder where the $ is going now.

There is one concern I have that I'd like some input on. During my graduate school years, it was common to see American college graduates decide against graduate school because of 1) low pay 2) delayed gratification and 3) equal job opportunities/satisfaction without the extra training. As a result, nearly half (if not more) graduate students in biological sciences are now foreign students who are willing to take a pay that is low in American standards but high in their home country, AND a work visa in exchange for the opportunity many American college seniors pass on. After much discussion in this and other forum about how the MGHs and Stanfords may be immune from the need to pay more $ to get the same quality of residents, I would like to hear what people think the chances are that many hospitals will begin to take more FMGs at lower pay instead of USMGs who will demand their fair market worth.

 

[Andrew_Doan]

Originally posted by tofurious
Another interesting question on residentcase.com I have not seen discussed here is the issue of how hospitals will survive in the future IF they are forced to pay residents more and many hospitals NOW are baring making even. The most pessimistic view would be that some hospitals would be closed down, while others will have to run more efficiently. The story of the hospital willing to hire radiology fellows at nearly $100k goes to show that hospitals *can* make ends meet, and I just wonder where the $ is going now.

There is one concern I have that I'd like some input on. During my graduate school years, it was common to see American college graduates decide against graduate school because of 1) low pay 2) delayed gratification and 3) equal job opportunities/satisfaction without the extra training. As a result, nearly half (if not more) graduate students in biological sciences are now foreign students who are willing to take a pay that is low in American standards but high in their home country, AND a work visa in exchange for the opportunity many American college seniors pass on. After much discussion in this and other forum about how the MGHs and Stanfords may be immune from the need to pay more $ to get the same quality of residents, I would like to hear what people think the chances are that many hospitals will begin to take more FMGs at lower pay instead of USMGs who will demand their fair market worth.

This is why Medicare became the main funding source for future physicians. This money is felt to be an investment for America because everyone benefits from the training of competent physicians. As long as there is Medicare, we won't have to worry about FMGs taking over, and we won't have to worry about working for free. I think we can all expect to make at least the current base salary of ~$40K/year.

 

[biplane]

One thing to think about.

A common line of thought here is "I deserve to be paid more." However, is that thinking short sighted? After all, residents provide cheap labor that is omnipresent in the hospital. In return they receive training and experience.

If hospitals were to significantly increase their salaries to residents and decrease working hours, wouldn't they A) hire more PAs B) pay attendings less or C) require attendings to work more overnight shifts?

In my opinion, none of those 3 options is attractive for someone who plans to practice medicine over a 30 year period.

Also, I think residents are trainees. PGYIs know precious little.

 

[biplane]

One more thing.

The situation regarding the 100k fellow. This is an extreme response to the currently wacky economics in radiology. People are turning down fellowships to earn more in private practice.

The rads departments can afford to do this because they are currently enjoying record surpluses. I seriously doubt, say, pediatric hematology can afford to do this.

 

[avendesora]

or chaotic 10-day offers (a mandatory date programs must wait before making offers).

One question I have: Would offers outside the match be time limited (i.e. expire 2 weeks after they are offered)? Or would they be open ended like the med school offers?

Actually, if you look at residentcase.org (as everyone should before trying to argue here) you will see that under their proposal offers need only to be open for 10 days. I think I might like their system a LOT better if they were open ended offers. Refer back to my first post RE: FMG's being pressured by pre-match offers and what would have happened to me if I had gotten a high-pressure offer at the first place I interviewed.

I like how everyone on here had some HS or college econ and now feels like they can apply what they remember to how medical economics works. You need to realize -- medicine does not operate like other businesses in terms of supply/demand, etc. Residency is first and foremost EDUCATION. If you don't feel this way, then I NEVER want to hear you complain that Program A "doesn't have enough teaching" or "didactics are poor". If you want your residency treated as just a job, then be prepared to be straight up working while you are on the job and do your learning at home.

The assertion that a top IM or Surg candidate is like a Barry Sanders or Michael Vick to a residency to me just doesn't hold up. In the long run, teaching hospitals actually operate less efficiently because they spend time doing just that, teaching.

I personally went into medicine with the idea that it would be delayed gratification, but worth it. I think some of you have forgotten that somewhere along the line.

 

[tofurious]

If you have friends in other fields, you will know that they also LEARN on the job. That's how people get good at what they do and advance. If you go into Internal medicine, how much more on constipation/diarrhea management do you need to learn? Do you stop taking care of such patients when they come in on your call night because you've learned all you can?

Like one previous poster said, residency is not pure training. It's an odd symbiotic relationship between hospitals and residents. Residents learn, and at the same time provide a service to the hospital. Even if my high school econ training (actually, I did better in college econ than all the econ majors) is not enough to give you the full model and its impact on health care, I know when I am underappreciated and underpaid.

 

[Docxter]

Originally posted by biplane
One more thing.

The situation regarding the 100k fellow. This is an extreme response to the currently wacky economics in radiology. People are turning down fellowships to earn more in private practice.

The rads departments can afford to do this because they are currently enjoying record surpluses. I seriously doubt, say, pediatric hematology can afford to do this.

I think that peds hem-onc department could maybe do that as well if they were under extreme pressure and shortage. Why would they want to do it if they can get fellows with 40-50k. The rads position I talked about would have the fellow work as an attending two days a week on the general service, as a fellow the other days. The fellow would also take a lot of call (both as a fellow and as an attending depending on the day of the week).

 

[AJM]

I'm getting tired of hearing people complain that they want more pay during residency. It seems very hypocritical to me that residents are going to court to get more salary from their TRAINING programs, when in 3-6 years they will be making 100K-250K starting salaries.

As a resident, I've been able to live very comfortably on my salary. I've been renting a nice place to live, paying off my loans, can take trips/vacations paid from my own pocket, and still have been able to save up some cash. And this is while I'm living in one of the most expensive areas in the country. A resident's salary is more than enough to live comfortably on, and WAY more than the national poverty level (where many grad student stipends are). IMHO, as a salary from an educational program for which you are qualified for absolutely nothing when you start, and licensed and Board eligible in your specialty when you complete, the pay is pretty darn good.

Keep in mind that being a resident does not mean you just have a job, but it also means that you are enrolled in a training programs with an educational curriculum. Programs have attendings give lectures, hold teaching sessions, and even spend time on rounds with housestaff, where they provide teaching in a small-group setting. Particularly in IM training programs, these lectures and teaching sessions are daily, and even several times a day, occurrences. You will not find this at a regular job -- they will expect you to be fully trained, and therefore you would not need all this attention by more experienced physicians. That's not to say that you don't continue to learn after residency -- but most of the learning and on-the-job training at that point is done by the individual looking things up -- they would not be job-sponsored daily lectures, etc.

 

[AJM]

One more thing -- If you want to do a direct comparison to see if the Match really does benefit the applicant, take a look at the Medical subspecialty fellowship application process. Every fellowship does things their own way, but there are a few (cards, pulmonary, ID), that participate in the fellowship match. This is exactly like the residency match, so applicants have the luxury to interview at several programs, do lots of comparisons, ponder over where they might want to be, and then submit a list of their preferences. On the flip-side, the GI fellowship application process is not a match, and it seems to work very much against the applicant. Typically, an applicant is pressured to interview at GI programs early before spots fill up, and therefore must apply just after internship for an opening 2 years from the time of the application. The applicant is lucky if they know that they actually want to do GI at that early point. Then, if they interview at a program, the program can give them an offer in a few days. The problem is that the applicant has a limited time to make the decision to take the offer (usually a week). They often have interviews at other programs that they really wanted to check out first, but don't fall into the imposed time frame. If they take the offer, they must withdraw the rest of their application, including cancelling the rest of their interviews. So in that way, there's a pressure for the applicant to make a decision, when they have not had an adequate opportunity to look at other programs. They often have to settle for somewhere that they're not as happy with because of this kind of time frame.

I personally would much rather undergo the match process than what the GI folks have to do.

 

[Andrew_Doan]

AJM,

Thanks for your insight. I also want to add that GI is extremely competitive, and applicants do not have the luxury of turning down programs in hopes of finding a better program. Thus, as AJM pointed out, applicants are forced to accept the offer from a less favorable or competitive program in fear of not being able to find another position.

 

[Lumberg]

AJM - Excellent points, but you are stating what works for YOU. That's fine, but I object to others legislating what's best for ME. That is the whole point of anti-trust laws in our country. Why deprive me and other resident applicants of our right to seek competitive balance? I'm not especially fond of unions and I'm certainly no anarchist. No one wants to return to the chaos and uncertainty of the pre-Match days, but lets open our minds and at least consider some alternatives.

The GI match analogy is instructive, but in other fields it is customary to investigate, apply for, interview and then accept a position WITHOUT seeing every other opportunity. As a matter of fact, in my previous career I was involved in hiring/firing and I never heard an applicant complain that they hadn't looked elsewhere before being offered a spot with us. The legwork of looking for a job is incumbent on the applicant...at least it was for me when I was in the business world. As for me, I'd rather have the latitude to determine pros and cons between positions and settle on the package that's best for me rather than have that decided for me. We disagree and that's ok...you decide what's best for you and let me and my colleagues do our best for ourselves.

 

[Apollyon]

How about irony - rolling admissions at some, one acceptance date at others, more applicants than spots, no regulation at all over people holding multiple spots.

What am I describing? The med school applications process.

The match is the other side of the coin, but a little TOO comfy between programs.

The irony is that there are more than enough residency positions (versus only one out of two (or more) for med school spots). The bummer is that I don't have a better plan.

 

[Andrew_Doan]

Originally posted by Apollyon

The irony is that there are more than enough residency positions (versus only one out of two (or more) for med school spots).

This depends on the residency program. In ophthalmology, for instance, there are 2-3 applicants per position. This is similar for other competitive residency programs.

The match process protects both the applicants and the programs.

In regards to competitive pay increases, I doubt you'll see much of a pay increase when hospitals are losing money and residents aren't billing physicians. Any procedure I do without an attending is FREE. We're doing society more of a favor by serving the indigent than increasing hospital profits. Don't fool yourselves into thinking that residents are increasing hospital profits by seeing patients because most of the patients we see cannot pay.

 

[dry dre]

Originally posted by Andrew_Doan
Don't fool yourselves into thinking that residents are increasing hospital profits by seeing patients because most of the patients we see cannot pay.

Your point is well taken, but don't assume that all residents have a patient population the majority of which doesn't pay. To follow this logic out, it would follow that residents in hospitals that are doing well should be paid more, which isn't so.

Regarding earlier posts....it is true that residents are in training, but is it so that upon graduation you are all of a sudden worth 3 to 7 times more to the health care system? You can sign a contract for 200k a year plus benefits while making 47k the week before you start. That's a pretty steep proficiency curve.

 

[margaritaboy]

Originally posted by avendesora
Actually, if you look at residentcase.org (as everyone should before trying to argue here) you will see that under their proposal offers need only to be open for 10 days. I think I might like their system a LOT better if they were open ended offers. Refer back to my first post RE: FMG's being pressured by pre-match offers and what would have happened to me if I had gotten a high-pressure offer at the first place I interviewed.

Yes. Thank you, I did read that.

Just because a minimum standard has been proposed, does it follow that every offer will conform to nothing more than the minimum?

I would also like the new system if offers were open-ended. But just because there is a 10 day minimum, doesn't mean that offers wouldn't be longer, or even open-ended.

 

[AJM]

Originally posted by Lumberg
The GI match analogy is instructive, but in other fields it is customary to investigate, apply for, interview and then accept a position WITHOUT seeing every other opportunity. As a matter of fact, in my previous career I was involved in hiring/firing and I never heard an applicant complain that they hadn't looked elsewhere before being offered a spot with us. The legwork of looking for a job is incumbent on the applicant...at least it was for me when I was in the business world. As for me, I'd rather have the latitude to determine pros and cons between positions and settle on the package that's best for me rather than have that decided for me. We disagree and that's ok...you decide what's best for you and let me and my colleagues do our best for ourselves.

You just made my point. With the GI process (which I think many of the competitive programs might go to if the match is done away with), you DON'T get latitude to determine pros and cons between programs. You are pressured to accept a potentially worse fit for you because of the concern that you might not get any other offers. The GI applicants don't get the opportunity to compare multiple programs.

On the other hand, the match offers a unique benefit to the applicant -- the ability to thoroughly examine and investigate programs the applicant is interested in. Your argument that the match "decides for you" as far as your eventual program is incorrect. You place your list of choices. If you don't want to go to a particular program, you don't place it on your list. If you don't get your first choice, it doesn't mean that you were arbitrarily assigned to a different program. Instead, it means that your 1st choice program effectively rejected you by not ranking you high. (so if you were interviewing in a process like GI, that program probably would never have offered you a position anyway). In that way, the match takes you sequentially down your list until you get to a program that would "accept" you. The order and content of your list is up to you - you are effectively making a decision of which programs you would choose and in which order prior to getting an "offer" (ie submitting rank list). the rank list is basically your way of saying "I would rather go to program #3 than program #4, so if it came down to those two programs, sign me up for program #3". Therefore you're just making the decision of where you want to be earlier on, you're not having a computer system decide for you. It's a system which ensures that everyone involved gets their best possible choice. It's not perfect (nothing is), but IMO it's much better than the alternative.

 

[Apollyon]

Originally posted by Andrew_Doan
This depends on the residency program. In ophthalmology, for instance, there are 2-3 applicants per position. This is similar for other competitive residency programs.

I was speaking in general. Of course, that brings up a separate question - why are there more applicants than spots for ortho, ophtho, or derm (for example)? Is it the long hours, poor remuneration, and stressful lifestyle?

 

[AJM]

Originally posted by margaritaboy
I would also like the new system if offers were open-ended. But just because there is a 10 day minimum, doesn't mean that offers wouldn't be longer, or even open-ended.

If offers were open-ended, that would be nice for the top candidates -- they can hold onto 5 or 6 offers for months and ponder over them. But what about the next tier of applicants who are waiting on the decision of the accepted candidates? Every spot that an applicant is holding onto while they are deciding is one less spot for another applicant waiting to hear whether they can get a position at a program. Let's say that there's then a uniform deadline by which applicants must make their decision -- they give up their remaining spots that day, and then there is a HUGE nationwide scramble for the rest of the applicants to get into respective programs. Hardly a good way to decide on residency programs, IMO.

 

[tofurious]

Originally posted by Apollyon
I was speaking in general. Of course, that brings up a separate question - why are there more applicants than spots for ortho, ophtho, or derm (for example)? Is it the long hours, poor remuneration, and stressful lifestyle?

Lifestyle =
$$$$$ - work hours

In the case of ortho, the work hours are long, but $ is a lot more also than the other two.

While many people enter these fields for the above reason, it seems odd that they would be against raising the average salary of residents (of course, their pasture is also a lot greener after residency than say many medical specialty residents).

 

[Seaglass]

Back with a few more comments. Would like to say that so far this is a nice debate. FYI I have read the resident case site and save-the-match.

1.

Thus, as AJM pointed out, applicants are forced to accept the offer from a less favorable or competitive program in fear of not being able to find another position.

Exactly. Offers cannot be open ended since then PD's could only offer as many as they have spots for. What happens if that person decides to go somewhere else? If you only have so much time to decide then you are likely to decide wrong.

2. False Argument- The match forces me into a contract.

As is has been previously You decide where you will apply and interview and where you would prefer to go. The Match cannot place you at a program you do not want to go to. You can certainly take compensation into account when you rank your programs. No one is stopping you.

3. False reasoning: look at the business world!

Please, look at HMO's. They were/are the business answer to medicine and they have been proven to be bad for patients and doctors. A pure business model does not translate to medicine well. People have already pointed out the fallacies of comparing to law school. You tell me how wages in Derm for example would be improved when there are many more applicants then available positions. Where is the market pressure to improve wages there?

4. False reasoning from residentcase: hospitals can afford it.

It is quite possible that the defendants in the case have endowments that can absorb something like a 10-20% increase in wages. I know at our hospital, one of the 30% of hospitals in PA that makes a profit, our operating margin is 4%. That is four percent. That doesn't leave a lot for upgrades and improvements in areas of patient care, much less relatively HUGE increases in salary for the 350+ residents at the hospital. (350*$10,000 = $3,500,000). Maybe these huge NIH hospitals can afford it, but smallers ones may not be able to.

that's all for now

Casey

 

[tofurious]

Originally posted by cg1155
...I know at our hospital, one of the 30% of hospitals in PA that makes a profit, our operating margin is 4%. That is four percent. That doesn't leave a lot for upgrades and improvements in areas of patient care, much less relatively HUGE increases in salary for the 350+ residents at the hospital. (350*$10,000 = $3,500,000). Maybe these huge NIH hospitals can afford it, but smallers ones may not be able to.

THe question I raised earlier was: what happened to the money Medicare and Medicaid pay for each resident ($200,000 per resident per year according to residentcase.com)? I think that if hospitals are run inefficiently and using the difference between $200,000 and $40,000 to make up for their loss, that's just B.S. and hospitals will need to operate more like a business. I personally think that nurses, pharmacists, PCAs, administrators, and even cafeteria workers are overpaid in hospitals. If reduction of ancilliary personnel and closure of hospitals are the only ways to save $, perhaps we will have fewer unnecessary admissions and the American public will demand fewer MRIs and other expensive tests.

 

[biplane]

Originally posted by tofurious
THe question I raised earlier was: what happened to the money Medicare and Medicaid pay for each resident ($200,000 per resident per year according to residentcase.com)? I think that if hospitals are run inefficiently and using the difference between $200,000 and $40,000 to make up for their loss, that's just B.S. and hospitals will need to operate more like a business. I personally think that nurses, pharmacists, PCAs, administrators, and even cafeteria workers are overpaid in hospitals. If reduction of ancilliary personnel and closure of hospitals are the only ways to save $, perhaps we will have fewer unnecessary admissions and the American public will demand fewer MRIs and other expensive tests.

Sorry, I find this sentiment apalling. There are already way too many people who are denied access to health care. We shouldn't be taking broad steps to cut back access. While I agree there may be inefficiencies in many hospitals, I do not believe your simple arithmetic accounts for the difference between government reimbursement and resident salary.

First, the overhead on any salary typically runs ~ 1:1. That is, your benefits and other infrastructure attributed to you typically cost as much as your salary. That is why med schools love NIH grants--there is substantial overhead included in addition to reimbursement for supplies, salaries, etc.

Second, there are huge losses associated with educational activities of faculty. When a 3rd year med student trails an primary care attending, there is little question that they get less work done. Or if the attending gives a lecture or has an academic day to write/perform research, he isn't billing for that either typically. The government money is designed to compensate for all these "inefficiencies" which are intrinsic to an academic medical center. The medicare money does a lot more than compensate residents.

I suspect many academic medical centers are already running close to break even. And that includes the 20-30% deans tax levied on all academic physician billings.

If you want to see what kind of education you get in a economically efficient hospital, see what happened to Georgetown or the uproar surrounding the possibility of selling Stanford Hospital to an HMO some years back.

 

[avendesora]

Originally posted by cg1155

3. False reasoning: look at the business world!

Please, look at HMO's. They were/are the business answer to medicine and they have been proven to be bad for patients and doctors. A pure business model does not translate to medicine well. People have already pointed out the fallacies of comparing to law school. You tell me how wages in Derm for example would be improved when there are many more applicants then available positions. Where is the market pressure to improve wages there?

Yep, I agree 100%. It seems to me (please correct me if I'm wrong) that the people vehemently opposed to the current system are not current residents, but medical students who have had previous careers in business.

Are there any actual current residents on here who believe they got a raw deal in the match, or believe they could strong arm more money from their program should the match be eliminated?

Because of the way healthcare is funded (so much $$ from the gov't) it just doesn't follow that applying "principles of business as usual" will work. In fact, when the MBAs descended on healthcare in the 90's is when things really started to go to s**t. The only people really winning in healthcare today are the suits.

Also, reading residentcase.org some more, the way they argue just bothers me. Their way of stating things that sounds plausible, but is really an exaggeration, etc. (Residents FORCED to do DANGEROUS things, USMGs DISCRIMINATED AGAINST, etc.) Correct through a technical loophole. maybe, but not real life.

...lawyer speak (turns aside to retch...)