residency salary???

[confuseddog]

Why do fresh RNs, PAs, and NPs make more as new grads than MD/DO residents? It literally makes no sense to me. How is this okay?

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[VA Hopeful Dr]

Why do fresh RNs, PAs, and NPs make more as new grads than MD/DO residents? It literally makes no sense to me. How is this okay?

Because they can either bill for their services (PA/NP), or can do their job completely unsupervised (RNs). Residents, generally speaking, can't do either of those.

They also don't have to have the infrastructure of a residency program: lots of attendings who aren't full-time clinical and so have to be paid for administrative time, support staff like program coordinators, residents are pretty inefficient at first, you aren't generally all that productive on off-service rotations but still get paid for it

If residents got paid on production like attending physicians your income would take a big hit intern year, each year past that you'd increase the earnings until in later years you could out earn average resident salary. But you also wouldn't necessarily earn anything on off-service months depending on the set up.

 

[Kaustikos]

Because they can either bill for their services (PA/NP), or can do their job completely unsupervised (RNs). Residents, generally speaking, can't do either of those.

They also don't have to have the infrastructure of a residency program: lots of attendings who aren't full-time clinical and so have to be paid for administrative time, support staff like program coordinators, residents are pretty inefficient at first, you aren't generally all that productive on off-service rotations but still get paid for it

If residents got paid on production like attending physicians your income would take a big hit intern year, each year past that you'd increase the earnings until in later years you could out earn average resident salary. But you also wouldn't necessarily earn anything on off-service months depending on the set up.

/close thread

 

[DrMetal]

Why do fresh RNs, PAs, and NPs make more as new grads than MD/DO residents? It literally makes no sense to me. How is this okay?

Because physicians are a self-deprecating group that can rarely think out of the box and better themselves as a whole. If we could, we'd have more residency spots---a task that could be achieved by leveraging more community hospitals and clinics, and by centralizing administrative and academic requirements---we'd make medical education cheaper, and we'd pay our trainees better, so they don't have to 'starve' for 3-7 years. It's embarrassing that a neurosurgery PGY6 makes < $50K.

None of this will change. We like it like this. It makes for a great exclusive club. You know who doesn't like it? The medical industrial complex that'll find ways to circumvent us (aka hiring more midlevels, more telemedicine, etc).

Mind you, this [marginalization of the top intellectual, especially for economic gain] has happened in several other professions and industries in the past (legal, engineering, the sciences, etc). We're just too dumb to see it happening in our own.

 

[VA Hopeful Dr]

Because physicians are a self-deprecating group that can rarely think out of the box and better themselves as a whole. If we could, we'd have more residency spots---a task that could be achieved by leveraging more community hospitals and clinics, and by centralizing administrative and academic requirements---we'd make medical education cheaper, and we'd pay our trainees better, so they don't have to 'starve' for 3-7 years. It's embarrassing that a neurosurgery PGY6 makes < $50K.

None of this will change. We like it like this. It makes for a great exclusive club. You know who doesn't like it? The medical industrial complex that'll find ways to circumvent us (aka hiring more midlevels, more telemedicine, etc).

Mind you, this [marginalization of the top intellectual, especially for economic gain] has happened in several other professions and industries in the past (legal, engineering, the sciences, etc). We're just too dumb to see it happening in our own.

So NS 6th years actually make less than 50k anywhere? I'm going to need proof of that.

Residency spots have been expanding rapidly in the last 10 years or so as have med school spots. One of the problems you can get with this is certain specialties need major academic centers to provide adequate training. Sure most hospitals can probably train FPs well enough, but the surgical subspecialties can't just start up everywhere.

It's funny you bring up law, they opened lots of new schools and now lawyers have a hard time getting jobs. You know, kinda like some of our specialties these days (rad onc/EM). It's almost like unfettered expansion eventually becomes a problem.

Physicians rarely have the power to actually make th changes you want. The med school dean can't unilaterally make changes to tuition. PDs can't unilaterally change resident salary.

 

[hallowmann]

You make some valid points, but this post completely ignores CMS funding—which I believe works out to around $150,000+ per year per resident.

It may even be more, this is a rough approximation that doesn't adequately approximate all the direct and indirect funding streams for residency via CMS. There's also varying amounts of revenue generation that isn't explained in direct patient care, including medical student teaching, engagement in research, reduced need for some support staff, etc.

Much like attendings are often manipulated into thinking they don't "generate" enough for a competitive salary, I'm sure a lot of the healthcare systems are making bank on residents with all the less direct revenue generation. I've genuinely had PCPs tell me that their department runs in the red, but completely ignore the money made for the healthcare system on referrals, imaging, labs, and eliminating lengthy ED visits. Sure, your clinic/staffing might cost more than your net collections (if that's even true), but you are generating a ton of money for the hospital by existing.

 

[DrMetal]

So NS 6th years actually make less than 50k anywhere? I'm going to need proof of that.

ok, lets say $80K. Still, it's rather ponderous that a NSg PGY7 will make $80K, then 11 months later make $800K as an attending. You don't see that widespread of income in other professions (at a law firm, the difference in pay between a junior and senior partner will vary, sure, by $200-$300K, but it's not an order of magnitude). A pgy7 Nsg should be making $150K+, which is at least the equivalent of the NSg NP.

We clearly don't pay our trainees (especially our senior ones) enough . . . and that's the first sign of employee abuse.

PDs can't unilaterally change resident salary.

Doesn't have to be done unilaterally. If they came together with the ACGME, they could make changes. The problem is, they don't want to.

 

[voxveritatisetlucis]

at a law firm, the difference in pay between a junior and senior partner will vary, sure, by $200-$300K, but it's not an order of magnitude)

Better off comparing to a junior associate vs partner. Difference could very well be even more than 10x if factoring in equity portion of compensation

 

[DrMetal]

Better off comparing to a junior associate vs partner. Difference could very well be even more than 10x if factoring in equity portion of compensation

I don't mean to belabor the legal analogy (what I know about the pay structure for lawyers could fit into a thimble), nor to be specific regarding numbers. I'm also not so concerned for PGY1s, nor for those of us who did shorter (3-year) programs (IM, FP, Peds, etc). (that's my personal case)

But if you're doing a fellowship and or extensive (and especially invasive) training, > PGY4+, you deserve to be compensated better, I would say at least the NP equivalent, or close to it.

Disagree with me on that point, and you're clearly drinking from the Kool-Aid. Do yourself a favor and at least spike it with some vodka.

 

[VA Hopeful Dr]

You make some valid points, but this post completely ignores CMS funding—which I believe works out to around $150,000+ per year per resident.

Sure, and that's helps cover admin time, ancillary staff, off service months and so forth.

 

[VA Hopeful Dr]

I don't mean to belabor the legal analogy (what I know about the pay structure for lawyers could fit into a thimble), nor to be specific regarding numbers. I'm also not so concerned for PGY1s, nor for those of us who did shorter (3-year) programs (IM, FP, Peds, etc). (that's my personal case)

But if you're doing a fellowship and or extensive (and especially invasive) training, > PGY4+, you deserve to be compensated better, I would say at least the NP equivalent, or close to it.

Disagree with me on that point, and you're clearly drinking from the Kool-Aid. Do yourself a favor and at least spike it with some vodka.

Cool, so anyone who disagrees with you is drinking the Kool aid. That sounds reasonable.

 

[DrMetal]

Cool, so anyone who disagrees with you is drinking the Kool aid. That sounds reasonable.

Uh, yeah. In this regard, 100%. Sorry, I like to advocate for the better treatment (especially better pay, commensurate with the amount of work being done) for all physicians, including and especially trainees. This is a bad habit of mine, I'll work on it.

 

[VA Hopeful Dr]

Uh, yeah. In this regard, 100%. Sorry, I like to advocate for the better treatment (especially better pay, commensurate with the amount of work being done) for all physicians, including and especially trainees. This is a bad habit of mine, I'll work on it.

Advocating is great, but assuming that literally everyone who has any different thoughts on the matter has drunk the Kool aid is insulting at best.

I don't think anyone here is saying it's a bad idea to pay residents more. But there isn't infinity money for that. Could we pay residents more? Absolutely and we should. Is there enough to pay them 150k+ per year? I can't say with certainty and kinda doubt it. But if there is without compromising their education I am 100% behind that.

 

[VA Hopeful Dr]

Also residents 100% make the hospital money. It’s literally the ONLY reason all these hca hospitals are opening as many residencies as they can: they did the math and realized how much work we do for pennies on the dollar.

No, they don't. At some point during training they do, but that is not universally the case. Interns absolutely don't. When that changes depends on the specialty.

 

[VA Hopeful Dr]

Im pretty sure it’s actually 250,000 per resident.

Prove it

 

[DrMetal]

Advocating is great, but assuming that literally everyone who has any different thoughts on the matter has drunk the Kool aid is insulting at best.

I don't think anyone here is saying it's a bad idea to pay residents more. But there isn't infinity money for that. Could we pay residents more? Absolutely and we should. Is there enough to pay them 150k+ per year? I can't say with certainty and kinda doubt it. But if there is without compromising their education I am 100% behind that.

Bumping up the salary of a General Surgery PGY5 from $60K to $100K does not require 'infinite money', even if done on a massive scale. It would help her feel more financially secure, she could buy a small home perhaps, payback some debt, or just save it. Hell, in some parts of the country (LA, NY, DC, Boston), even $100K/year is considered 'starving'. At the very least, it would make her feel better, as she contemplates being 34-yo and not making a third of what her legal and business friends make (for the same amount of education and training).

Our healthcare institutions could afford this, but there's no impetus for change here. In fact, on second thought, I'd be careful not to advocate for these pay increases too hard. If such pay increases happened, they may reduce residency spots and hire more mid-levels!

 

[VA Hopeful Dr]

Bumping up the salary of a General Surgery PGY5 from $60K to $100K does not require 'infinite money', even if done on a massive scale. It would help her feel more financially secure, she could buy a small home perhaps, payback some debt, or just save it. Hell, in some parts of the country (LA, NY, DC, Boston), even $100K/year is considered 'starving'. At the very least, it would make her feel better, as she contemplates being 34-yo and not making a third of what her legal and business friends make (for the same amount of education and training).

Our healthcare institutions could afford this, but there's no impetus for change here. In fact, on second thought, I'd be careful not to advocate for these pay increases too hard. If such pay increases happened, they may reduce residency spots and hire more mid-levels!

OK now we're getting somewhere. So it's not all residents that deserve to make more, just the ones in lengthier specialties. On it's surface that seems fair. How would you do this exactly? As it is, residents do get a pay increase every year. Would the yearly increase go up or it be a large increase for the last year or two? If the former, you'd likely have to include every resident at that hospital (where my infinity money comment is coming from). If the latter, you'd still need to justify paying that much more compared to costs of the resident versus what they bring in. That last part is what I see as being a potential issue. Do later your surgery residents actually bring in enough money to justify this? If yes, then full steam ahead. If not, you're asking the hospital to take a loss on this which isn't likely to happen.

 

[VA Hopeful Dr]

You can waste your time googling all you want. I have no interest in wasting my time with you, random internet stranger. I’ve seen the reports myself. But, have a wonderful evening searching lol

No? You're the one who made an absolute statement, it's on you to prove it in a discussion.

You don't have to, obviously, but since the number you threw out there is about twice the highest I've ever seen quoted before without proof I'm going to assume you're lying.

 

[Obnoxious Dad]

Why do fresh RNs, PAs, and NPs make more as new grads than MD/DO residents? It literally makes no sense to me. How is this okay?

Residents are earning more than their salary and benefits. They are also acquiring the credentials required to practice in a lucrative profession. Residents aren't slaves. They know the deal when they go into residency programs. It's basic economics.

 

[PTPoeny]

OK now we're getting somewhere. So it's not all residents that deserve to make more, just the ones in lengthier specialties. On it's surface that seems fair. How would you do this exactly? As it is, residents do get a pay increase every year. Would the yearly increase go up or it be a large increase for the last year or two? If the former, you'd likely have to include every resident at that hospital (where my infinity money comment is coming from). If the latter, you'd still need to justify paying that much more compared to costs of the resident versus what they bring in. That last part is what I see as being a potential issue. Do later your surgery residents actually bring in enough money to justify this? If yes, then full steam ahead. If not, you're asking the hospital to take a loss on this which isn't likely to happen.

If you want to increase the pay scale for longer residencies that would also increase the pay for fellowships which greatly increases the number of trainees involved and the cost to the hospital. Most hospitals have a standard pay scale for each PGY year.

Increasing the PGY-6 fellow pay over 100k will mean peds ID fellows are getting paid more than some of their job offers will be the following year, just as a point of reference. Maybe there are bigger issues with the current salary scales within medicine then trainee salaries?

 

[DeadCactus]

Because non-residents can quit and go resume their career somewhere else or they reasonably find a similar paying job in another industry. An additional factor is mandates on how many patients a nurse can care for and their more frequent use of unions unions. If a resident could pack up their stuff and go finish their training down the street, residency salaries would increase. If you had to have 1 physician per N patients, salaries would increase.

 

[Dr. ADT]

Residency salary is poor but temporary.

 

[Browns99]

Because physicians are a self-deprecating group that can rarely think out of the box and better themselves as a whole. If we could, we'd have more residency spots---a task that could be achieved by leveraging more community hospitals and clinics, and by centralizing administrative and academic requirements---we'd make medical education cheaper, and we'd pay our trainees better, so they don't have to 'starve' for 3-7 years. It's embarrassing that a neurosurgery PGY6 makes < $50K.

None of this will change. We like it like this. It makes for a great exclusive club. You know who doesn't like it? The medical industrial complex that'll find ways to circumvent us (aka hiring more midlevels, more telemedicine, etc).

Mind you, this [marginalization of the top intellectual, especially for economic gain] has happened in several other professions and industries in the past (legal, engineering, the sciences, etc). We're just too dumb to see it happening in our own.

Neurosurgery PGy6 making less than $50k..... totally not true.

 

[onamission!]

Some of you are showing how far removed you are from your residency (and likely how comfortable you are now in your practice$$$) to remember your own intern and residency days if you yourselves are proclaiming that residents don't generate more than enough money for the hospital to justify salary increases. That is laughable. The system IS rigged, ACGME IS a scam, interns absolutely DO generate way more money for the system than they are getting paid. But we all get it, it's all about who can benefit off the back of someone else in medicine now. Its crystal clear to every current trainee physician, no need to play with words.

 

[guytakingboards]

Bumping up the salary of a General Surgery PGY5 from $60K to $100K does not require 'infinite money', even if done on a massive scale. It would help her feel more financially secure, she could buy a small home perhaps, payback some debt, or just save it. Hell, in some parts of the country (LA, NY, DC, Boston), even $100K/year is considered 'starving'. At the very least, it would make her feel better, as she contemplates being 34-yo and not making a third of what her legal and business friends make (for the same amount of education and training).

Our healthcare institutions could afford this, but there's no impetus for change here. In fact, on second thought, I'd be careful not to advocate for these pay increases too hard. If such pay increases happened, they may reduce residency spots and hire more mid-levels!

This 100%. There’s no impetus beyond it being the decent thing to do. Which 99% of time means it’s not going to happen.

 

[DrMetal]

Residency salary is poor but temporary.

Neurosurgery PGy6 making less than $50k..... totally not true.

Exhibit A and B above, proving how dumb we physicians are.

We're a profession of lap dogs. Perhaps if our education/training actually taught us how to think and contemplate (rather than memorize and regurgitate), things would be different. But such is life . . .pass the whiskey.

 

[Browns99]

Exhibit A and B above, proving how dumb we physicians are.

We're a profession of lap dogs. Perhaps if our education/training actually taught us how to think and contemplate (rather than memorize and regurgitate), things would be different. But such is life . . .pass the whiskey.

Whatever you say Dr. Doom....

 

[DrMetal]

Whatever you say Dr. Doom....

and Gloom.

 

[Dr. ADT]

Exhibit A and B above, proving how dumb we physicians are.

We're a profession of lap dogs. Perhaps if our education/training actually taught us how to think and contemplate (rather than memorize and regurgitate), things would be different. But such is life . . .pass the whiskey.

Why is it dumb? I did not say it was fair. I said it was temporary.

 

[VA Hopeful Dr]

Exhibit A and B above, proving how dumb we physicians are.

We're a profession of lap dogs. Perhaps if our education/training actually taught us how to think and contemplate (rather than memorize and regurgitate), things would be different. But such is life . . .pass the whiskey.

You still haven't proved that a NS pgy-6 is making less than 50k anywhere in this country. In fact I brought it up previously and you brushed it off.

 

[VA Hopeful Dr]

Some of you are showing how far removed you are from your residency (and likely how comfortable you are now in your practice$$$) to remember your own intern and residency days if you yourselves are proclaiming that residents don't generate more than enough money for the hospital to justify salary increases. That is laughable. The system IS rigged, ACGME IS a scam, interns absolutely DO generate way more money for the system than they are getting paid. But we all get it, it's all about who can benefit off the back of someone else in medicine now. Its crystal clear to every current trainee physician, no need to play with words.

I would like to see some hard figures on that.

I see to recall a program director a few years back from IM who basically said that midway through 2nd year his residents started earning more than they were paid.

 

[DrMetal]

I would like to see some hard figures on that.

I see to recall a program director a few years back from IM who basically said that midway through 2nd year his residents started earning more than they were paid.

You still haven't proved that a NS pgy-6 is making less than 50k anywhere in this country. In fact I brought it up previously and you brushed it off.

Oh for the love of . . . . NEVER MIND!

[sarcasm/] You're absolutely right. Every Nsg PGY6 is paid exactly what they deserve, despite making half of what their NP counterparts make and working twice as hard.

The system is right. It should be defended, no change needed here. [/sarcasm]

 

[VA Hopeful Dr]

Oh for the love of . . . . NEVER MIND!

[sarcasm/] You're absolutely right. Every Nsg PGY6 is paid exactly what they deserve, despite making half of what their NP counterparts make and working twice as hard.

The system is right. It should be defended, no change needed here. [/sarcasm]

I'm not saying any of that and in fact said almost the exact opposite in this very thread:

Advocating is great, but assuming that literally everyone who has any different thoughts on the matter has drunk the Kool aid is insulting at best.

I don't think anyone here is saying it's a bad idea to pay residents more. But there isn't infinity money for that. Could we pay residents more? Absolutely and we should. Is there enough to pay them 150k+ per year? I can't say with certainty and kinda doubt it. But if there is without compromising their education I am 100% behind that.

For the other, we had an actual PD say the exact opposite of what someone is claiming. I want proof. I don't believe that's unreasonable.

 

[onamission!]

I would like to see some hard figures on that.

Again, laughable. Do you really think this information is public? Do you really think hospital CEO's,, program directors, etc. want this information made public? Just do the math.

 

[rokshana]

Again, laughable. Do you really think this information is public? Do you really think hospital CEO's,, program directors, etc. want this information made public? Just do the math.

Actuality is…programs publish to pay for the residents on their websites …and when you go on interviews that information is given to you.
And if a public institution, the salaries of everyone employed is available to the public.

 

[VA Hopeful Dr]

Again, laughable. Do you really think this information is public? Do you really think hospital CEO's,, program directors, etc. want this information made public? Just do the math.

That's just it, other than posted salaries I have no other numbers to work with. Hard to do math with 1 number.

 

[NITRAS]

I would like to see some hard figures on that.

I see to recall a program director a few years back from IM who basically said that midway through 2nd year his residents started earning more than they were paid.

I’ve spent the last month and a half trying deal with poorly supervised interns trying to kill people and waste money/meds/time/radiation. Definitely not a net positive.

 

[Dr.LeoSpaceman]

interns absolutely DO generate way more money for the system than they are getting paid

Ok.

My surgical interns aren't making money for the hospital. I'd actually be more efficient if I didn't take the time to teach them (which I enjoy). The things they do don't bill unless I'm there, or see the patient. But you know who does benefit? The interns.

If you want to interject some data into the discussion, you can look at the RAND Report on the topic. What you would find is, as expected, residents don't generate direct revenue. No surprise as they can't bill. So their ability to generate indirect revenue comes down to whether they improve efficiency of faculty, but most importantly, whether they are doing work that would need to be replaced by alternate providers. If an alternate FTE is not required, then they don't "make money". What is not considered, however, is how many FTEs would be required. The assumption is that they'd replace 1 resident with 1 alternative FTE, which is almost certainly not the case.

I think the bottom line is that yes, residents probably make money for hospitals. But I think residents routinely overstate how much that is.

 

[DrMetal]

bless the U.S. Military. I got paid ~$140K/year as a military Internal Medicine resident. The military values it's doctors, even the residents (sort of).

It would be nice to see you all get paid at least $100K as a senior resident.

 

[ace_inhibitor111]

Because they can either bill for their services (PA/NP), or can do their job completely unsupervised (RNs). Residents, generally speaking, can't do either of those.

They also don't have to have the infrastructure of a residency program: lots of attendings who aren't full-time clinical and so have to be paid for administrative time, support staff like program coordinators, residents are pretty inefficient at first, you aren't generally all that productive on off-service rotations but still get paid for it

If residents got paid on production like attending physicians your income would take a big hit intern year, each year past that you'd increase the earnings until in later years you could out earn average resident salary. But you also wouldn't necessarily earn anything on off-service months depending on the set up.

NPs on our ICU rotations do the exact same job as residents. Like, exactly the same, carry the same patients, place orders the same way, present the same way. We are all supervised by an attending. Residents also do certain procedures more often then NPs (which I am not complaining about) and work more frequently. Yet we get paid 2.5x less. It really is not about production, just administration taking advantage of residents.

 

[NITRAS]

NPs on our ICU rotations do the exact same job as residents. Like, exactly the same, carry the same patients, place orders the same way, present the same way. We are all supervised by an attending. Residents also do certain procedures more often then NPs (which I am not complaining about) and work more frequently. Yet we get paid 2.5x less. It really is not about production, just administration taking advantage of residents.

Look, NP’s are licensed, credentialed providers. Residents are not.

I’m not even arguing that resident’s pay is fair. I’m just pointing out that this is not an apples apples comparison.

 

[NotAProgDirector]

There is no simple answer to this because it depends upon the program, the year of training, and the field.

For example: Internal Medicine. In the first 6 months IM residents are getting lots of "on the job training" and are probably paid reasonably. One could argue that lots of jobs offer on the job training, although residency is atypical in that you're guaranteed to leave at the end of training so the turnover is huge.

By the end of training, IM residents should be essentially independent. Because of billing rules, the still need to be supervised so the institution still needs to pay a faculty member to see those patients -- although presumably they can see more patients than they would on their own. But even that is debatable -- lots of hospitalist gigs have 18 patients a day, and a 1 R / 2 I team can't see much more than that also. So even in that case, we're paying 4 people what we could theoretically pay 1 person to do.

But, even if we say that IM residents make things more efficient for faculty, many IM programs have significant elective time in their PGY-3 years. 6 months of electives / research / flexible outpatient training is not uncommon. Those experiences are great for the resident, but add no financial value to the institution. If you were paid what you were "worth" on those rotations, it would be zero.

Often discussed is that if you replaced residents with NP/PA's, you'd need to hire a whole bunch of them to cover the shifts -- and that's certainly true. But the question is whether we really wold hire them, or find another way to deliver care. Again, in IM, a 1R / 2I team with 20 patients can probably just be handled by a hospitalist alone - no one new would need to be hired. Night residents might need to be replaced -- but maybe the hospital just hires a small number of nocturnists to cover. Or the ED just writes "holding orders" for admissions and then they are seen the next AM.

All of this may collapse / be completely infeasible in other fields or programs. Surgical services are often run solely by residents with minimal oversight (or at least much less than IM services typically have). Whether GME pay rates should depend upon field is a very complicated issue. Likewise we could set rates based on hours worked -- but this would create big pay differences between the fields.

Id' really prefer if our pay structure paid residents extra for nights and weekends.

 

[Goro]

Why do fresh RNs, PAs, and NPs make more as new grads than MD/DO residents? It literally makes no sense to me. How is this okay?

For the same reasons postdocs don't make the same as PIs.and the latter travel better too! 🙁

 

[hallowmann]

Look, NP’s are licensed, credentialed providers. Residents are not.

I’m not even arguing that resident’s pay is fair. I’m just pointing out that this is not an apples apples comparison.

I mean this may be true, but this is kind of an arbitrary point made by the system. In most states PGY2s can be licensed and could become credentialed to bill especially with oversight. The fact that numerous residency programs actually DO employ residents for moonlighting and the like at this stage is a testament to that. I suspect that the only reason that most residencies and hospitals (especially big academic institutions) avoid this is in order to justify not paying residents more.

I was in residency for far too long, and my system was one that repeatedly said (I mean for years) that it was impossible or "illegal" to allow internal moonlighting for residents, despite tons of surrounding hospital systems hiring residents for moonlighting (low resource area). This was a constant question by our residency council (in addition to requesting retirement benefits which were offered to literally everyone in the hospital except for medical residents - even NP/PA residents and dental residents got it). They did some handwaving and justified it for the sake of malpractice, supervision, billing, etc. In the end, at peak COVID when they couldn't find enough midlevels to do the tele visits for COVID screening and URIs, all of a sudden all those problems disappeared and we were "generously offered" opportunities to moonlight internally if we had our full license, and we could get a great premium hourly pay that was about 50% less than what the midlevels got and 1/3 of what the attendings got to do the same work. (And you bet I signed up, because COL increased during COVID and my pay did not, and it suddenly became much harder to support my family on a resident salary without a bit extra even in a low COL area.)

There is no simple answer to this because it depends upon the program, the year of training, and the field.

For example: Internal Medicine. In the first 6 months IM residents are getting lots of "on the job training" and are probably paid reasonably. One could argue that lots of jobs offer on the job training, although residency is atypical in that you're guaranteed to leave at the end of training so the turnover is huge.

By the end of training, IM residents should be essentially independent. Because of billing rules, the still need to be supervised so the institution still needs to pay a faculty member to see those patients -- although presumably they can see more patients than they would on their own. But even that is debatable -- lots of hospitalist gigs have 18 patients a day, and a 1 R / 2 I team can't see much more than that also. So even in that case, we're paying 4 people what we could theoretically pay 1 person to do.

But, even if we say that IM residents make things more efficient for faculty, many IM programs have significant elective time in their PGY-3 years. 6 months of electives / research / flexible outpatient training is not uncommon. Those experiences are great for the resident, but add no financial value to the institution. If you were paid what you were "worth" on those rotations, it would be zero.

Often discussed is that if you replaced residents with NP/PA's, you'd need to hire a whole bunch of them to cover the shifts -- and that's certainly true. But the question is whether we really wold hire them, or find another way to deliver care. Again, in IM, a 1R / 2I team with 20 patients can probably just be handled by a hospitalist alone - no one new would need to be hired. Night residents might need to be replaced -- but maybe the hospital just hires a small number of nocturnists to cover. Or the ED just writes "holding orders" for admissions and then they are seen the next AM.

All of this may collapse / be completely infeasible in other fields or programs. Surgical services are often run solely by residents with minimal oversight (or at least much less than IM services typically have). Whether GME pay rates should depend upon field is a very complicated issue. Likewise we could set rates based on hours worked -- but this would create big pay differences between the fields.

Id' really prefer if our pay structure paid residents extra for nights and weekends.

I generally agree with this post, but to keep things in perspective, if you replace those 4 residents with 2 attendings (a hospitalist and nocturnist) you'd be paying each of them 3-4x the resident salary and you'd be losing the CMS funding that comes with those residents. We've seen hospitals in the past that shut down residencies often have to have an equivalent or greater number of attendings and midlevels to offer the same coverage (see the Neurosurgery residency that shut down a couple years ago).

As for whether the hospitals would shell out the money, absolutely they would not. They would pile on the few attendings, maybe hire some midlevels and pay them poorly (but better than residents) expecting them to function as physicians, burn them out and replace them with new grads, and then when all else failed they would pay for locums justifying the higher hourly rate by avoiding benefits and arguing that they come out ahead, which may be true financially, but is unlikely to be true with regards to patient care. Eventually the hospital will go under as no longer profitable or at the mercy of malpractice payouts, either be bought out by private equity, absorbed by the local healthcare giant, or just shut down. A tale as old as time... Is my cynicism showing a bit too much here?

 

[NITRAS]

I mean this may be true, but this is kind of an arbitrary point made by the system. In most states PGY2s can be licensed and could become credentialed to bill especially with oversight. The fact that numerous residency programs actually DO employ residents for moonlighting and the like at this stage is a testament to that. I suspect that the only reason that most residencies and hospitals (especially big academic institutions) avoid this is in order to justify not paying residents more.

I was in residency for far too long, and my system was one that repeatedly said (I mean for years) that it was impossible or "illegal" to allow internal moonlighting for residents, despite tons of surrounding hospital systems hiring residents for moonlighting (low resource area). This was a constant question by our residency council (in addition to requesting retirement benefits which were offered to literally everyone in the hospital except for medical residents - even NP/PA residents and dental residents got it). They did some handwaving and justified it for the sake of malpractice, supervision, billing, etc. In the end, at peak COVID when they couldn't find enough midlevels to do the tele visits for COVID screening and URIs, all of a sudden all those problems disappeared and we were "generously offered" opportunities to moonlight internally if we had our full license, and we could get a great premium hourly pay that was about 50% less than what the midlevels got and 1/3 of what the attendings got to do the same work. (And you bet I signed up, because COL increased during COVID and my pay did not, and it suddenly became much harder to support my family on a resident salary without a bit extra even in a low COL area.)

Program director’s rules can be arbitrary. I was not allowed to moonlight as a resident. The FM residents moonlighted all the time. . . but my PD wasn’t their PD.

My current institution allows IM residents in good standing to moonlight, without a license For like $70/hr. I’m not sure they are allowed to moonlight as a licensed physican in other institutions (I think the answer is no, b/c I’ve never met a PGY2 with a medical license,

Again, rules on moonlighting (as well as other things) are very arbitraty but this has very little to do with resident salaries.

 

[hallowmann]

Program director’s rules can be arbitrary. I was not allowed to moonlight as a resident. The FM residents moonlighted all the time. . . but my PD wasn’t their PD.

My current institution allows IM residents in good standing to moonlight, without a license For like $70/hr. I’m not sure they are allowed to moonlight as a licensed physican in other institutions (I think the answer is no, b/c I’ve never met a PGY2 with a medical license,

Again, rules on moonlighting (as well as other things) are very arbitraty but this has very little to do with resident salaries.

I wasn't talking about PDs. PDs were fine with moonlighting elsewhere. It was internal moonlighting that was not allowed at our institution again justified by the same things on this thread, which then suddenly disappeared when their need increased. Yeah, that's the same pay we were offered, still better than resident salary.

I think it could be argued that when you demonstrate you can pay residents more for things, it makes the argument for a lower salary weaker. That's the connection I'm making here. Suddenly residents are profitable, can bill independently, and can be paid more when its convenient for the institution.

 

[Entadus]

Look, NP’s are licensed, credentialed providers. Residents are not.

I’m not even arguing that resident’s pay is fair. I’m just pointing out that this is not an apples apples comparison.

Try restating this without the BS "provider" word (which was introduced to serve NP's and not physicians, let alone residents).

And I would beg to differ that resident physicians have no credentials. Even besides the MD DEGREE, as a 2nd year IM resident, not only was I licensed in my state, but was doing procedures (intubation, central lines) and running code blues/code rapid responses.

 

[guytakingboards]

Try restating this without the BS "provider" word (which was introduced to serve NP's and not physicians, let alone residents).

And I would beg to differ that resident physicians have no credentials. Even besides the MD DEGREE, as a 2nd year IM resident, not only was I licensed in my state, but was doing procedures (intubation, central lines) and running code blues/code rapid responses.

Sigh… seems like you’re trying to be purposely naive.

As a trainee, you were not credentialed as active medical staff at your hospital.

That breaks both ways. As a trainee you don’t have any of the liability and can pretty much participate in the care from any field (neurosurgery to fam Med to critical care) but you are not a staff physician and do not get paid like one. As active medical staff, you pretty much have to practice only your field, you get paid much better but also carry the liability.

If you get credentialed as active medical staff, you should get paid like one. That’s it.

 

[Entadus]

Sigh… seems like you’re trying to be purposely naive.

As a trainee, you were not credentialed as active medical staff at your hospital.

That breaks both ways. As a trainee you don’t have any of the liability and can pretty much participate in the care from any field (neurosurgery to fam Med to critical care) but you are not a staff physician and do not get paid like one. As active medical staff, you pretty much have to practice only your field, you get paid much better but also carry the liability.

If you get credentialed as active medical staff, you should get paid like one. That’s it.

Naive, yes, but purposefully so, definitely not. Trying to learn and I appreciate the discussion. I'll freely admit I'm no expert on these matters.

I think it's perfectly fair to mention the liability issue. If that's the main point, then sure, just say that. The post I responded to didn't explicitly mention it.

However, I still don't agree with your premise that employee salary/resident salary is mainly determined by liability risk (and thus that residents deserve lower pay than NP/PA due to this primary reason). Why would that be the case?

Some simple objections:
1) It's not true that residents carry zero liability. Residents are covered by liability insurance, typically $1MM per occurrence and $3MM total coverage. It's true that residents tend to have LESS liability than attendings, but zero?
2) It still ignores the productivity side. Take a high liability specialty like OB/GYN for example. Even if you assume the senior resident has no liability since their attending takes it all. The 3rd or 4th year residents are still covering the whole OB floor all night, 7 nights a week. If you didn't have those residents, you would have to pay someone else for all those deliveries, C-sections, and cross cover. By losing those residents, the total amount of liability would not change, but the amount of WORK done (babies delivered, incisions, sutures, prescriptions, etc) would need to be replaced. What market rate would be paid to replace them?
3) Not to focus too much on mid-levels, but as a group they also tend to have less liability (in practice, if not in theory) than attending physicians. In many states they still require supervision by an attending also. So why would they be paid more and residents be paid less if both tend to have less liability?

 

[VA Hopeful Dr]

Naive, yes, but purposefully so, definitely not. Trying to learn and I appreciate the discussion. I'll freely admit I'm no expert on these matters.

I think it's perfectly fair to mention the liability issue. If that's the main point, then sure, just say that. The post I responded to didn't explicitly mention it.

However, I still don't agree with your premise that employee salary/resident salary is mainly determined by liability risk (and thus that residents deserve lower pay than NP/PA due to this primary reason). Why would that be the case?

Some simple objections:
1) It's not true that residents carry zero liability. Residents are covered by liability insurance, typically $1MM per occurrence and $3MM total coverage. It's true that residents tend to have LESS liability than attendings, but zero?
2) It still ignores the productivity side. Take a high liability specialty like OB/GYN for example. Even if you assume the senior resident has no liability since their attending takes it all. The 3rd or 4th year residents are still covering the whole OB floor all night, 7 nights a week. If you didn't have those residents, you would have to pay someone else for all those deliveries, C-sections, and cross cover. By losing those residents, the total amount of liability would not change, but the amount of WORK done (babies delivered, incisions, sutures, prescriptions, etc) would need to be replaced. What market rate would be paid to replace them?
3) Not to focus too much on mid-levels, but as a group they also tend to have less liability (in practice, if not in theory) than attending physicians. In many states they still require supervision by an attending also. So why would they be paid more and residents be paid less if both tend to have less liability?

I'll repost my earlier post in this thread that explains this:

Because they can either bill for their services (PA/NP), or can do their job completely unsupervised (RNs). Residents, generally speaking, can't do either of those.

They also don't have to have the infrastructure of a residency program: lots of attendings who aren't full-time clinical and so have to be paid for administrative time, support staff like program coordinators, residents are pretty inefficient at first, you aren't generally all that productive on off-service rotations but still get paid for it

If residents got paid on production like attending physicians your income would take a big hit intern year, each year past that you'd increase the earnings until in later years you could out earn average resident salary. But you also wouldn't necessarily earn anything on off-service months depending on the set up.