Resident Hazard Pay?

[Mass Effect]

Ten miles is a massive increase in commute time in a lot of places. If you work in an urban area that's a way to screw you out of taking advantage of a competitive job market. Friend of mine has one on her contract for a 100% inpatient job, which is insane. Probably boilerplate for their health system, but the type of thing that experienced job seekers need to push back against before signing on the dotted line.

I agree. I'm just saying if you have one like that and can realistically do the 10-mile thing without much of a hassle, it may not be worth the fight. Lots of jobs in the suburbs where 10 miles from place of work may still only be only 3 miles from your house or may be one town over and doesn't add much to commute time. Depends where you are.

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[<L>]

Denver Health Executives Get Bonuses 1 Week After Workers Asked To Take Cuts clearly hurting badly for money

...but since I AM in a bootlicking mood today...

I have a hard time caring about this case, and it just sounds like an outlet for a grandstanding local politician to grandstand. The bonuses were delayed compensation for work completed almost five months ago based on the contract those employees were working under. My own 2019 bonus arrived in my bank account only about a month ago, because for whatever reason it takes institutions a really long-ass time to get them processed. Much like the execs, I'm likely not going to see that money in 2021 when my 2020 rate is calculated. No one would have given a crap here if they were paid out in February. They'll be taking their hit in time too. Whether or not physicians et al were paid bonuses around the same time is a part of the story that's missing here.

(this is also why I was happy to have my contract restructured a couple years ago for a smaller bonus % with more money up front when I got my raise. You don't want to risk a take backsies situation as happened to a friend of mine who works ED for Envision, but that's a whole different discussion)

 

[NITRAS]

There are instances in which a non-compete stating you can't take patients with you or you can't use the brand created for you by current employer can be upheld, but I have yet to see a general non-compete stating "if you leave us, you can't work anywhere in this city/community" be upheld for a physician (or in my previous career which is where my experience comes from).

If you know of any being upheld with such a general clause, let me know.

I work for a large institution that has pushed out 95% of the competition. They hold 3 years of non-vested 457f (was Roth $24ishk before COVID19). I’m a single physician. They are a billion dollar healthcare system. Some fights aren’t worth waging.

 

[VA Hopeful Dr]

There are instances in which a non-compete stating you can't take patients with you or you can't use the brand created for you by current employer can be upheld, but I have yet to see a general non-compete stating "if you leave us, you can't work anywhere in this city/community" be upheld for a physician (or in my previous career which is where my experience comes from).

If you know of any being upheld with such a general clause, let me know.

I have multiple times

 

[<L>]

I agree. I'm just saying if you have one like that and can realistically do the 10-mile thing without much of a hassle, it may not be worth the fight. Lots of jobs in the suburbs where 10 miles from place of work may still only be only 3 miles from your house or may be one town over and doesn't add much to commute time. Depends where you are.

Very much so, but you can roll this tool over a number of cities and see what that means in practice, especially if you are in academics. In virtually every city a 10 mile radius can wipe out every single academic medical center in the metro.

Draw a circle with a radius on a map

www.mapdevelopers.com

It's best to try to put your foot down early.

 

[RangerBob]

That's a dangerous assumption. It's state dependant and in many states they get upheld regularly.

This is what I’ve heard as well, from other docs and lawyers.

Aside from low malpractice premiums due to tort reform, it’s one of the other few upsides to practicing medicine in CA—non-competes are not enforceable here. It’s apparently the primary reason Silicon Valley grew-those tech companies kept trying to poach each other’s workers in Boston and other big cities, but couldn’t due to the non-competes, allowing startup culture to get up and going in the Bay Area.

 

[Mass Effect]

I work for a large institution that has pushed out 95% of the competition. They hold 3 years of non-vested 457f (was Roth $24ishk before COVID19). I’m a single physician. They are a billion dollar healthcare system. Some fights aren’t worth waging.

I think we're losing the point here. The point is that as a physician you CAN walk out. You have options whereas residents are tied to their program. Any arguing back and forth to suggest that attendings are tethered in a similar fashion is laughable.

 

[Mass Effect]

I have multiple times

And I know of multiple that were dismissed and/or not even challenged.

 

[calvnandhobbs68]

This is complicated, and you're never going to get a clear answer here. I've posted about this before, but you cannot make this statement flat out. that residents are profitable.

Let's use the simplest example here - an inpatient internal medicine teaching service (ignoring the students) might typically consist of an attending, a senior resident, and two interns. Depending on how their call schedule is arranged, they might see 10-20 patients - most common average is probably 15. The team sees those 15 patients, rounds on them, and bills insurance for those 15 patients. All four individuals are drawing an income here.

What would happen if the residents didn't exist? Well, there would just be an attending. And an attending hospitalist routinely sees... 10-20 patients. Probably an average of 15. By themselves. And bills the insurance for them. And only gets paid one income (though probably higher than an academic attending).

It's pretty obvious in this situation that if it wasn't for the government subsidy for resident salaries, that the former scenario here is a money-loser for the hospital. Yes, the academic attending has a much "easier" life - particularly when it comes to not having to write notes - but the hospital doesn't care about that. The net productivity of adding the residents is pretty negligible here.

The hospital additionally may have to eat the cost of any inefficiencies caused by teaching teams - this is most visible with Medicare patients, where the reimbursement to the hospital (as opposed to the physicians) is a flat fee based on diagnosis and complexity rather than being able to charge for every individual thing done. If the teaching teams keep patients one day extra in the hospital on average, or they order just a few more blood tests, the hospital loses significant amounts of money from any payor that reimburses based on DRGs (as opposed to paying a la cart).

In other scenarios - clinic work, surgical services, etc - the residents do allow the attending to see more patients and perform more work - but whether in the aggregate that is worth more than what you're paying the residents is hard to say, particularly for one major reason:

The residents have to be taught. You can't just give them scutwork and use them to extend your ability to bill - assuming you aren't a terrible person, you have to actually spend time and effort developing them into independent physicians. If they feel comfortable with a low level task, that's wonderful - but that also means it is time for them to move on to other tasks and you to give that low level task to someone else that is less comfortable with it (i.e. a lower level resident).

Every time someone analyzes whether residents are a net economic benefit or cost, the assumptions made get a different answer. I think that if the Medicare (and equivalent) subsidies didn't exist, most residency programs would actually be a net loss for the system, but you can easily argue against that.

Oh, and don't forget there's tons of other costs the residency program needs to pay for on top of the resident salaries:

A) Payroll taxes

B) Benefits - both direct benefits for the resident (medical, dental, whatever) and malpractice insurance

C) Program directors salary (typically half of it but it may be more or less depending on the specialty) - the PD isn't allowed to be full time clinical work so they have time to dedicate time to the program

D) Program administration (like the coordinator, educational activities, all the paperwork involved with keeping a program accredited, recruitment/turnover every year)

The cost of having a $55-60k/year resident probably does go up to at least $100k/person - which is what the government subsidizes each resident at. Opening new programs without a source of subsidy is often not feasible.

People have made these arguments in the past. “Look at all these extra costs that residents bring!! You aren’t even thinking about all this extra XYZ!!” Which could have kinda made sense untilll...the Hahnemann hospital closing.

Hahnemann residency programs draw winning bid of $55M from local health systems

A group of six local health systems outbid Reading-based Tower Health for the residency slots that had been assigned to Hahnemann University Hospital.

www.google.com

Why, exactly, do you think hospital systems would have bid $55 million for 550 residency slots, vastly outbidding what they were originally going to be sold off for ($7.5 million)? Is it because they’re just so interested in losing money they’d love another 550 money losing residency slots? Is it because they’re just so kind hearted they wanted to help those poor residents out? Uh huh.

The whole “residents lose money” argument was objectively proven wrong with this bid (which is now being challenged by the justice department btw because they just had their minds blown that this could even happen). And yes, this is taking the government funding into account. But they’re paying 100k a slot for the right to get these funded positions. Which means that they expect these positions to give them at least 100K of value each OVER what they’re spending on the residents (so hardly breaking even).

 

[VA Hopeful Dr]

And I know of multiple that were dismissed and/or not even challenged.

Which almost makes it sound like its location dependent. Kinda like what I said originally.

You asked if I knew of cases where its regularly upheld. I do.

Not sure why you have to point out that there are times when they aren't upheld. We all know that since in many states they are enforceable at all and I never suggested otherwise.

 

[VA Hopeful Dr]

People have made these arguments in the past. “Look at all these extra costs that residents bring!! You aren’t even thinking about all this extra XYZ!!” Which could have kinda made sense untilll...the Hahnemann hospital closing.

Hahnemann residency programs draw winning bid of $55M from local health systems

A group of six local health systems outbid Reading-based Tower Health for the residency slots that had been assigned to Hahnemann University Hospital.

www.google.com

Why, exactly, do you think hospital systems would have bid $55 million for 550 residency slots, vastly outbidding what they were originally going to be sold off for ($7.5 million)? Is it because they’re just so interested in losing money they’d love another 550 money losing residency slots? Is it because they’re just so kind hearted they wanted to help those poor residents out? Uh huh.

The whole “residents lose money” argument was objectively proven wrong with this bid (which is now being challenged by the justice department btw because they just had their minds blown that this could even happen).

You're making the assumption that all residents are equal. They aren't. I have no doubt that in some fields the residents make up for their value very quickly. Others may take longer if they do at all.

In this case, I suspect the cost/resident is less as they already have the infrastructure in place so the cost/resident for them is going to be lower.

I think it also depends on how the residents are used. My wife is IM, in her residency the ICU was single coverage by an upper level resident. That meant covering 30-40 beds depending on the census. The IM program where we went to med school had a single upper level covering 10-15 beds. The former place is obviously getting way more value than the latter (at the obvious expense of the residents). When I interviewed for FM programs, some had 2 residents/attending in clinic. Some had 4. Some places had a good payer mix, some were over 75% charity care in the clinic. You get the idea. So a blanket statement either way about whether or not residents make lots of money for the hospital is not likely to be accurate everywhere.

 

[calvnandhobbs68]

You're making the assumption that all residents are equal. They aren't. I have no doubt that in some fields the residents make up for their value very quickly. Others may take longer if they do at all.

In this case, I suspect the cost/resident is less as they already have the infrastructure in place so the cost/resident for them is going to be lower.

I think it also depends on how the residents are used. My wife is IM, in her residency the ICU was single coverage by an upper level resident. That meant covering 30-40 beds depending on the census. The IM program where we went to med school had a single upper level covering 10-15 beds. The former place is obviously getting way more value than the latter (at the obvious expense of the residents). When I interviewed for FM programs, some had 2 residents/attending in clinic. Some had 4. Some places had a good payer mix, some were over 75% charity care in the clinic. You get the idea. So a blanket statement either way about whether or not residents make lots of money for the hospital is not likely to be accurate everywhere.

I would disagree with that. This bid proves that the blanket statement that residents generally MAKE money for the hospital given the CMS money they bring in and the services they end up covering as a senior resident IS true. This is a blanket situation spanning multiple residency programs in a variety of specialities (550 residents total). So on the whole these slots were worth enough for them to bid 100K a slot overall. Which means they must expect to make up this 100k a slot somewhere along the line or else why would they bother bidding up that high?

The difference between the initial sell point and final bid is shocking as well. Hospitals were literally willing to pay 7x as much as the original sell offer of 7.5 million. Thats a pretty drastic difference, more of a difference than you would expect if you were saying something like “oh the IM 2-3rd year residents barely make up for the psych 4th year residents” or something along those lines (which is basically what you’re saying above, that individual residents may not be cost-effective for the overall system). Think about what it would mean to say that residents are somehow less cost-effective than some other setup. Hospitals would be telling CMS they would want to get paid EXTRA money for taking more residents on. At the very least they would be refusing to pay anything.

Does having existing residency programs so you already have the infrastructure in place to absorb those residents play a part? Sure but those big academic medical centers are the same places who say crap like was being said above, that residents just have all these extra costs they don’t think about. The numbers speak for themselves. Sure, could you get more done on an individual attending level, probably could. But the amount of money that funded slots bring in was OBJECTIVELY proven by the situation above to profit the overall system.

 

[VA Hopeful Dr]

I would disagree with that. This bid proves that the blanket statement that residents generally MAKE money for the hospital given the CMS money they bring in and the services they end up covering as a senior resident IS true. This is a blanket situation spanning multiple residency programs in a variety of specialities (550 residents total). So on the whole these slots were worth enough for them to bid 100K a slot overall. Which means they must expect to make up this 100k a slot somewhere along the line or else why would they bother bidding up that high?

The difference between the initial sell point and final bid is shocking as well. Hospitals were literally willing to pay 7x as much as the original sell offer of 7.5 million. Thats a pretty drastic difference, more of a difference than you would expect if you were saying something like “oh the IM 2-3rd year residents barely make up for the psych 4th year residents” or something along those lines (which is basically what you’re saying above, that individual residents may not be cost-effective for the overall system). Think about what it would mean to say that residents are somehow less cost-effective than some other setup. Hospitals would be telling CMS they would want to get paid EXTRA money for taking more residents on. At the very least they would be refusing to pay anything.

Does having existing residency programs so you already have the infrastructure in place to absorb those residents play a part? Sure but those big academic medical centers are the same places who say crap like was being said above, that residents just have all these extra costs they don’t think about. The numbers speak for themselves. Sure, could you get more done on an individual attending level, probably could. But the amount of money that funded slots bring in was OBJECTIVELY proven by the situation above to profit the overall system.

You keep saying that when it hasn't been unless you've seen the books for their residency programs.

The one person on this board who we know has basically said what I did a few pages back.

 

[calvnandhobbs68]

You keep saying that when it hasn't been unless you've seen the books for their residency programs.

The one person on this board who we know has basically said what I did a few pages back.

And so we have 1 person at 1 program vs public numbers from multiple hospitals for multiple residency programs (I would guess upwards of 15-20).

Money talks, especially money that has to be public, more than the crap that execs at the hospital feed their internal staff.

 

[VA Hopeful Dr]

And so we have 1 person at 1 program vs public numbers from multiple hospitals for multiple residency programs (I would guess upwards of 15-20).

Money talks, especially money that has to be public, more than the crap that execs at the hospital feed their internal staff.

So post those numbers then.

 

[calvnandhobbs68]

So post those numbers then.

What are you talking about?

First of all, what specific "numbers" did somebody post in this thread? Specific numbers for their residency program regarding the exact amount they bring in in GME funding/billing/floor coverage vs expenses? Cause I don't see it.

Secondly, the real hard number I'm talking about is $55 million dollars for 550 residency slots. I don't know how much more clear cut I can make it that hospitals PAID for these positions to the tune of 7.5 TIMES what they were originally going to be going for (I feel like I'm beating a dead horse here). That's not marginally cost-effective or barely cost-effective. So the books for Einstein, Jefferson, Temple, Main Line Health, Cooper University Health Care and Christiana Care Health System all obviously made sense enough for them to bid at least up to that amount.

 

[VA Hopeful Dr]

What are you talking about?

First of all, what specific "numbers" did somebody post in this thread? Specific numbers for their residency program regarding the exact amount they bring in in GME funding/billing/floor coverage vs expenses? Cause I don't see it.

Secondly, the real hard number I'm talking about is $55 million dollars for 550 residency slots. I don't know how much more clear cut I can make it that hospitals PAID for these positions to the tune of 7.5 TIMES what they were originally going to be going for (I feel like I'm beating a dead horse here). That's not marginally cost-effective or barely cost-effective. So the books for Einstein, Jefferson, Temple, Main Line Health, Cooper University Health Care and Christiana Care Health System all obviously made sense enough for them to bid at least up to that amount.

You're making a bunch of assumptions there. Hospitals, especially non-profits, will often do things that don't guarantee a ROI. A hospital I worked for a few years back fired all of their hospitalists/ED docs and brought in Team Health to manage that. The hospitalists/ED group were earning more than what they cost but the hospital didn't want to have to manage the groups. It cost them more than they saved to bring in TH but it saved them considerable administrative headache to outsource all of that. A hospital not far from here started an unfunded psychiatry program so that they would have psychiatrists on call for the ED and have a clinic their PCPs could refer to (they couldn't find any previously).

As for the value of acquisitions, doesn't always work out the way it looks like. My hospital was bought 2 years ago by another hospital. At our most profitable, it would take the buying hospital right at 10 years to turn a profit on the sale. The reasoning was to prevent a 3rd hospital who has been trying to make inroads into the area from buying us first, we were basically insurance to prevent a 3rd party from coming in and establishing a significant presence.

As for specific numbers, @NotAProgDirector hasn't posted the exact figures but he has expoused on this subject at length before if memory serves. I will modify my original thoughts on this though. I think its very possible to run a residency program that brings in a fair bit of extra money. I think the education at places like that probably suffers (like most of the new HCA residencies that are opening up), but I suspect that quality programs are roughly break even or make some money but not a huge amount. Otherwise, why wouldn't lots of programs be expanding their number of spots? I know my old program had plenty of volume but hasn't changed their total number of residents in probably 20 years. Same with my wife's IM program.

 

[calvnandhobbs68]

You're making a bunch of assumptions there. Hospitals, especially non-profits, will often do things that don't guarantee a ROI. A hospital I worked for a few years back fired all of their hospitalists/ED docs and brought in Team Health to manage that. The hospitalists/ED group were earning more than what they cost but the hospital didn't want to have to manage the groups. It cost them more than they saved to bring in TH but it saved them considerable administrative headache to outsource all of that. A hospital not far from here started an unfunded psychiatry program so that they would have psychiatrists on call for the ED and have a clinic their PCPs could refer to (they couldn't find any previously).

As for the value of acquisitions, doesn't always work out the way it looks like. My hospital was bought 2 years ago by another hospital. At our most profitable, it would take the buying hospital right at 10 years to turn a profit on the sale. The reasoning was to prevent a 3rd hospital who has been trying to make inroads into the area from buying us first, we were basically insurance to prevent a 3rd party from coming in and establishing a significant presence.

Your first point above is true. Hospital systems will do things at times that aren't on the surface profitable, especially if they're trying to fill some kind of need. For example, the unfunded psychiatry program. Trauma centers are another example. Although, might have to look at all the costs in play there. What are the costs of keeping patients boarding in the ED for forever when you have no ability to get easy psychiatry consults? Are some of your outpatient costs offset somewhat by the revenue you generate billing for those outpatient psych visits now? If you have an outpatient program, are you now offsetting ED costs by keeping outpatients stable and avoiding unpaid ED visits?

The value of that acquisition was that they cut a competitor out of your market. You can bet they had people calculating exactly how much they expected to lose from referrals/transport to other EDs/procedures/outpatient clinics in the area. Big systems don't think in terms of 1, 2, 5 years. 10 years to turn a profit on that hospital is no big deal. Every year after 10 years makes them money. Why do you think institutional investors buy 30 year US treasury bonds? Cause they expect the institution to still be around after 30 years.

In this case though, I would find it very unlikely that these systems all suddenly realized they needed an extra 90-100 residents each and were willing to go in the hole 9-10 million dollars each to obtain these terribly inefficient and poorly cost-effective assets. I would bet that each of these systems make a hard calculation about how much they were willing to bid for these slots and came to a conclusion about how much they would be willing to pay overall. Their ceiling was apparently over $55 million.

 

[Raryn]

I don't know, in the 8 years I've been posting (and the many years I was lurking before that), seems to me everytime a thread appears about the crappy parts of training, a bunch of attendings get on here and list all the million ways the trainee is a whiner and really in many cases their argument boils down to "I dealt with it and you will too." Not to say that's what's happening in this thread since this is a unique issue never faced by this generation, but the sentiment remains the same. I think from hearing attendings talk to residents on SDN sometimes, one would think there really isn't any problem with training besides greedy, overly spoiled brats of residents and that simply isn't true.

It should also be noted that in the past, whenever someone pointed out what I pointed out above, the classic response has been a chorus of attendings coming in to say "no one said there aren't problems with training" so I'll just cue that chorus now. If no one said there aren't problems with training why is every single thread on the topic over-run with attendings telling residents they're wrong, regardless of what the problem is? After a while you come to believe there are quite a few attendings on SDN who really don't think there are any problems with residency and fall short of flat-out saying that because they know it's an unpopular thing to say.

So here's the thing: If you add them all up, there are somewhere around 11,500 training programs in the US. That is adding up all the residencies (MD, DO, military) and fellowships that are accredited - there's more if you start counting the unaccredited fellowships. These 11,500 training programs with 11,500 individual program directors are spread out amongst >800 institutions all across the country.

I've been posting here for ~12 years and I don't think I have *ever* seen someone say that all of those programs were walks in the park and that there is no such thing as a malignant residency program. Clearly we all know that some programs have issues and that this is a real concern. There are plenty of anecdotes of abusive programs, and I know people personally who were in programs like that. And yet...

The vast majority of residents start a program and graduate that same program without issue. Last I looked at the data, only ~3% of people overall do two PGY1 years - and some unknown but still small number of people do a PGY1 at one categorical program and leave it to go do PGY2+ somewhere else (if you know a good comprehensive source on that, I'd love to see it). From everything I've ever seen, most of those part ways with their original program due to a voluntary decision on their part - for things like desiring a change in specialty. The number of people who get fired or quit in lieu of getting fired is *tiny* compared to the number of people actually in training.

Most of us attendings on SDN are young attendings - the people posting in this thread graduated residency/fellowship within the last few years and remember it quite well. I worked my ass off in residency. I broke duty hours a few times - winter shifts in the MICU sucked. But at no point did anyone abuse me. The majority of my weeks weren't 80 hours. My staff didn't yell or scream - they did their best to educate me. Sometimes they weren't the nicest about it, but someone having a slightly abrasive personality doesn't count as abuse. Did I have some evaluations I thought were unfair? Sure. But so do people I know in the corporate world too. If you averaged all my work hours over 3 years, I probably worked 55-60 hours a week on average - which isn't unusual for internal medicine in the least (outpatient rotations are nice). That's fairly comparable to the hours expected of any young professional - law, medicine, accounting, whatever. It was lower in fellowship.

You know who aren't publishing articles about their experiences in residency? Everyone with similar experiences to the above, who work for 3+ years in a typical program, don't have any disciplinary issues, graduate, and move on to be successful attendings.

I think the system should be improved to decrease the possibility of programs being over the top, but most people I know aren't having and didn't have issues. And inevitably, when we learn about someone who is having issues here on SDN, when the full story comes out - it's almost certainly not the programs fault. (With a few major exceptions that come to mind, like OSU urology a few years back).

 

[calvnandhobbs68]

As for specific numbers, @NotAProgDirector hasn't posted the exact figures but he has expoused on this subject at length before if memory serves. I will modify my original thoughts on this though. I think its very possible to run a residency program that brings in a fair bit of extra money. I think the education at places like that probably suffers (like most of the new HCA residencies that are opening up), but I suspect that quality programs are roughly break even or make some money but not a huge amount. Otherwise, why wouldn't lots of programs be expanding their number of spots? I know my old program had plenty of volume but hasn't changed their total number of residents in probably 20 years. Same with my wife's IM program.

Because they would be opening up UNFUNDED slots. Medicare hasn't funded new residency slots in forever (since 1996). I'm not arguing that brand spanking new unfunded slots may not be cost-effective. At that point, the hospital system is footing all the costs for the resident, so that very likely varies widely depending on the institution. For institutions with heavy supervision and depending on specialty, those very well may be money-losers overall, especially for 3 year residencies where you're just starting to get a independently functioning senior resident by year 3. However, the fact that new programs keep opening up every year makes me think even unfunded slots aren't so detrimental to healthcare systems that they aren't putting them out of house and home.

We're talking about FUNDED slots here. Slots that the government pays the hospital to keep open. Slots that are profitable enough that hospitals are outbidding each other for them. That's why Medicare and the Justice Department were getting involved in this case.

That's also why any resident in any funded slot should never, ever have their pay cut when people were complaining about other staff having pay cut 10, 20% etc. earlier. The government IS PAYING THE HOSPITAL for those slots and paying the resident's salary. Cutting a funded resident's salary would essentially be skimming more money from CMS.

Check this baby out for instance:

Variation in Medicare Graduate Medical Education Payments: An Opportunity to Redistribute to Meet U.S. Health Workforce Needs

Research Objective: The U. S. continues to face physician workforce challenges ...

academyhealth.confex.com

"The average Medicare GME payment per full-time-equivalent (FTE) increased from approximately $83,000 in 2000 to $160,000 in 2016. Per-FTE IME payment grew 84%, while DGME grew 68%. Most of the increase in the IME was driven not by the increasing residents-to-bed ratio (teaching intensity) but by rising per-discharge payment of Medicare’s inpatient prospective payment system (IPPS)."

 

[NotAProgDirector]

Why, exactly, do you think hospital systems would have bid $55 million for 550 residency slots, vastly outbidding what they were originally going to be sold off for ($7.5 million)? Is it because they’re just so interested in losing money they’d love another 550 money losing residency slots? Is it because they’re just so kind hearted they wanted to help those poor residents out? Uh huh.

The whole “residents lose money” argument was objectively proven wrong with this bid (which is now being challenged by the justice department btw because they just had their minds blown that this could even happen). And yes, this is taking the government funding into account. But they’re paying 100k a slot for the right to get these funded positions. Which means that they expect these positions to give them at least 100K of value each OVER what they’re spending on the residents (so hardly breaking even).

It's very possible that these hospitals will hire NO new residents. If they are already over their cap, purchasing more slots just equates to more income with no additional cost. In that view, this purchase makes much more sense and doesn't really address the question of whether residents are "cost effective". That discussion has be had in other threads, and isn't worth repeating here. The easy summary is that "it depends". If you have a few residents cover all of your night work, then it's probably very cost effective. if you have staff in house at night anyway supervising residents, or if there were an absence of residents you'd still have staff at home covering by phone, then the financial win is minimal. It gets much more complicated, and totally depends on the details. Some programs certainly structure things to get "as much out of their residents as possible". Others will focus on education and supervision and find a balance.

 

[calvnandhobbs68]

It's very possible that these hospitals will hire NO new residents. If they are already over their cap, purchasing more slots just equates to more income with no additional cost. In that view, this purchase makes much more sense and doesn't really address the question of whether residents are "cost effective". That discussion has be had in other threads, and isn't worth repeating here. The easy summary is that "it depends". If you have a few residents cover all of your night work, then it's probably very cost effective. if you have staff in house at night anyway supervising residents, or if there were an absence of residents you'd still have staff at home covering by phone, then the financial win is minimal. It gets much more complicated, and totally depends on the details. Some programs certainly structure things to get "as much out of their residents as possible". Others will focus on education and supervision and find a balance.

Interesting point but I find that somewhat unlikely. There was already a huge stink about this with CMS and the Justice Department looking to block the sale in the first place. The House Energy and Commerce Chairman and Ways and Means Chairman both already got involved in this urging CMS to appeal the decision. If this then ends up with the systems just absorbing the funded slots to fund their already existing unfunded slots (basically cutting national overall residency positions by 550), there's likely to be an even bigger stink with even worse optics.

The reason this is applicable here is basically people telling residents "stop whining, other staff are getting pay cut by 20%, even some attendings". Main point is that certainly residents in funded positions should never have their pay cut considering their salary is being paid for by the federal government with a fixed amount which has NOT gone down 20%.

 

[<L>]

It depends.

Most places will have non-competes. If your pay does get cut or furloughed, it will depend on if that is OK to do that in your contract or not (assuming that you have at least a 'base salary' and do not have a RVU threshold required to 'meet' in order to get your base). If that is not written in your contract or other supporting documents, you have the right to declare the contract breached, and thus the non-compete does not apply to you (since the hospital broke the contract). This can all be challenged in court but contracts are so variable it is hard to have a one-size fits all answer to this.

My take on the OP is relatively simple: I think residents (especially those who are being pulled from educational rotations) staffing COVID-19 units/floors should get paid hazard pay. It will likely be nominal and basically a show of appreciation. There are multiple hospitals in the NY/NJ area that ARE doing this, and most if not all do not have anything close to NYU's massive endowment to use as a fallback as necessary. So I don't really have pity for NYU as an institution on this. Sure, anytime you post something to twitter it is bound to get buried in a long-list of completely unreasonable (even to me) demands. But, across specialties, there are people who are willing to comment publicly about their issues with an institution.

Those comparing this resident to Eugene Gu or Stephanie Waggels or whatever are extremely off-base IMO.

I do understand that certain hospital systems may not be able to do so, but the extremely heavy handed response from NYU's leadership to the 'letter to the editor' is not a good look for them. Malignant NYC programs are going to continue to be malignant (shocker) in the face of adversity.

Also, IM Fellows who are now 'leading' floor teams should absolutely be paid much higher than a fellow salary, like a hospitalist. Physicians (attendings, residents, or fellows) should not 'volunteer' their time (when asked to work without payment) to treat COVID-19 patients.

Genuine question here: The resident in question here is at NYU's affiliate program at NYC's safety net hospital, Bellevue. Is NYU itself even the name on her checks or is it the NYC public hospital system? Either way, the university endowment and the hospital system balance sheets are separate issues all together. If they're going to dip into the latter, they need to prioritize subsidy for those under their umbrella whose jobs are likely to be wiped out by the pandemic so that they can put food on the table. Soon to be wealthy residents ain't that. Plus, say what you will about Langone, he sounds like a total piece of work, but he's put his money where his mouth is to help ease the financial burdens of new physicians. The other NYC institutions haven't done that.

I sure as hell am not saying she's Waggle (few people have ever risen to that level of performance), but the utter lack of skepticism of her claims of mistreatment, in some cases from people with prominent platforms are why I mentioned her and EG. (edit: to clarify, other than the over the top self-righteousness it's not her that invites the comparison so much as everyone else's credulous "this confirms my priors" reactions to it) As @Raryn mentioned earlier with more eloquence than I have, stories of programs being out to get residents or "retaliating" against them usually fall apart with a little scrutiny. People forget that both SW and EG had a lot of supporters when their stories first broke, and I'm sure that included plenty of people overreacting in this thread and on reddit. Most people with even a little experience in training greet these supposed outrages with some skepticism, but then again, that's not true for everyone.

(It is more than a little obvious that she's trying to work up her profile into a book deal someday in the near future. That's not really bad in and of itself. Danielle Ofri, who wrote one of the very few "what it's like to be a doctor" books that I didn't hate, is one of her attendings at Bellevue. Still I found it interesting that Ofri didn't back up Farrell's complaints on her own prominent social media platform.)

 

[CalmAndCollected]

Which almost makes it sound like its location dependent. Kinda like what I said originally.

You asked if I knew of cases where its regularly upheld. I do.

Not sure why you have to point out that there are times when they aren't upheld. We all know that since in many states they are enforceable at all and I never suggested otherwise.

Are you sure these cases were upheld by a court of law or just that the company threatened to enforce the non-compete and the physicians backed off?

 

[VA Hopeful Dr]

Are you sure these cases were upheld by a court of law or just that the company threatened to enforce the non-compete and the physicians backed off?

The 3 I have direct knowledge of went to court: the attorney I used to help set up my practice was representing one side in all 3 cases.

 

[VA Hopeful Dr]

Because they would be opening up UNFUNDED slots. Medicare hasn't funded new residency slots in forever (since 1996). I'm not arguing that brand spanking new unfunded slots may not be cost-effective. At that point, the hospital system is footing all the costs for the resident, so that very likely varies widely depending on the institution. For institutions with heavy supervision and depending on specialty, those very well may be money-losers overall, especially for 3 year residencies where you're just starting to get a independently functioning senior resident by year 3. However, the fact that new programs keep opening up every year makes me think even unfunded slots aren't so detrimental to healthcare systems that they aren't putting them out of house and home.

We're talking about FUNDED slots here. Slots that the government pays the hospital to keep open. Slots that are profitable enough that hospitals are outbidding each other for them. That's why Medicare and the Justice Department were getting involved in this case.

That's also why any resident in any funded slot should never, ever have their pay cut when people were complaining about other staff having pay cut 10, 20% etc. earlier. The government IS PAYING THE HOSPITAL for those slots and paying the resident's salary. Cutting a funded resident's salary would essentially be skimming more money from CMS.

Check this baby out for instance:

Variation in Medicare Graduate Medical Education Payments: An Opportunity to Redistribute to Meet U.S. Health Workforce Needs

Research Objective: The U. S. continues to face physician workforce challenges ...

academyhealth.confex.com

"The average Medicare GME payment per full-time-equivalent (FTE) increased from approximately $83,000 in 2000 to $160,000 in 2016. Per-FTE IME payment grew 84%, while DGME grew 68%. Most of the increase in the IME was driven not by the increasing residents-to-bed ratio (teaching intensity) but by rising per-discharge payment of Medicare’s inpatient prospective payment system (IPPS)."

I agree that residents should never take a pay cut for circumstances outside their control. However, asking for a pay increase while everyone else is getting a pay cut seems a bit much.

As for the rest, notAPDs response seems very logical. Larger hospitals are the most likely to have some number of unfunded spots. With this purchase a bunch of those just became funded. They paid roughly 110k per spot. Per the numbers you posted, they'll make that back in 1 year if they're using them to fund unfunded spots.

 

[VA Hopeful Dr]

Your first point above is true. Hospital systems will do things at times that aren't on the surface profitable, especially if they're trying to fill some kind of need. For example, the unfunded psychiatry program. Trauma centers are another example. Although, might have to look at all the costs in play there. What are the costs of keeping patients boarding in the ED for forever when you have no ability to get easy psychiatry consults? Are some of your outpatient costs offset somewhat by the revenue you generate billing for those outpatient psych visits now? If you have an outpatient program, are you now offsetting ED costs by keeping outpatients stable and avoiding unpaid ED visits?

The value of that acquisition was that they cut a competitor out of your market. You can bet they had people calculating exactly how much they expected to lose from referrals/transport to other EDs/procedures/outpatient clinics in the area. Big systems don't think in terms of 1, 2, 5 years. 10 years to turn a profit on that hospital is no big deal. Every year after 10 years makes them money. Why do you think institutional investors buy 30 year US treasury bonds? Cause they expect the institution to still be around after 30 years.

In this case though, I would find it very unlikely that these systems all suddenly realized they needed an extra 90-100 residents each and were willing to go in the hole 9-10 million dollars each to obtain these terribly inefficient and poorly cost-effective assets. I would bet that each of these systems make a hard calculation about how much they were willing to bid for these slots and came to a conclusion about how much they would be willing to pay overall. Their ceiling was apparently over $55 million.

That was kinda my point. The hospital wasn't making big money off of us, they were preventing a loss.

If we assume notAPDs point is completely wrong, then that could be what's happening in Pennsylvania as well. More residents means more capacity so they just deprived a competitor of that. Could be more than that as well but I'm not familiar with the dynamics up there to suggest anything else.

 

[Mass Effect]

So here's the thing: If you add them all up, there are somewhere around 11,500 training programs in the US. That is adding up all the residencies (MD, DO, military) and fellowships that are accredited - there's more if you start counting the unaccredited fellowships. These 11,500 training programs with 11,500 individual program directors are spread out amongst >800 institutions all across the country.

I've been posting here for ~12 years and I don't think I have *ever* seen someone say that all of those programs were walks in the park and that there is no such thing as a malignant residency program. Clearly we all know that some programs have issues and that this is a real concern. There are plenty of anecdotes of abusive programs, and I know people personally who were in programs like that. And yet...

The vast majority of residents start a program and graduate that same program without issue. Last I looked at the data, only ~3% of people overall do two PGY1 years - and some unknown but still small number of people do a PGY1 at one categorical program and leave it to go do PGY2+ somewhere else (if you know a good comprehensive source on that, I'd love to see it). From everything I've ever seen, most of those part ways with their original program due to a voluntary decision on their part - for things like desiring a change in specialty. The number of people who get fired or quit in lieu of getting fired is *tiny* compared to the number of people actually in training.

Most of us attendings on SDN are young attendings - the people posting in this thread graduated residency/fellowship within the last few years and remember it quite well. I worked my ass off in residency. I broke duty hours a few times - winter shifts in the MICU sucked. But at no point did anyone abuse me. The majority of my weeks weren't 80 hours. My staff didn't yell or scream - they did their best to educate me. Sometimes they weren't the nicest about it, but someone having a slightly abrasive personality doesn't count as abuse. Did I have some evaluations I thought were unfair? Sure. But so do people I know in the corporate world too. If you averaged all my work hours over 3 years, I probably worked 55-60 hours a week on average - which isn't unusual for internal medicine in the least (outpatient rotations are nice). That's fairly comparable to the hours expected of any young professional - law, medicine, accounting, whatever. It was lower in fellowship.

You know who aren't publishing articles about their experiences in residency? Everyone with similar experiences to the above, who work for 3+ years in a typical program, don't have any disciplinary issues, graduate, and move on to be successful attendings.

I think the system should be improved to decrease the possibility of programs being over the top, but most people I know aren't having and didn't have issues. And inevitably, when we learn about someone who is having issues here on SDN, when the full story comes out - it's almost certainly not the programs fault. (With a few major exceptions that come to mind, like OSU urology a few years back).

For the most part, I agree with you. I've said many times that residents who are fired almost always deserve to be fired and most of the complaints about programs are from residents in trouble for one reason or another. I also made it through without disciplinary action. But I'm talking in a broader sense. The reflex on SDN in cases where residents complain about residency in general is to fight back and say the equivalent to "I did it, you will too, it's not a big deal." But actually a lot of what happens in residency, even the best residency, can be a big deal. The system itself is exploitative and psychologically speaking, the things we sometimes see here is a reaction to the exploitation rather than whining or entitlement. But it seems the person complaining of legit problems in the system is treated the same to the ones complaining that they have to remediate after spectacularly failing a rotation when the two are nowhere near equal. A program doesn't have to be malignant to do questionable things (thinking of all the programs I've heard about with lack of PEE and not allowing residents to bring in their own PPE), even outside a pandemic.

 

[Mass Effect]

I agree that residents should never take a pay cut for circumstances outside their control. However, asking for a pay increase while everyone else is getting a pay cut seems a bit much.

As for the rest, notAPDs response seems very logical. Larger hospitals are the most likely to have some number of unfunded spots. With this purchase a bunch of those just became funded. They paid roughly 110k per spot. Per the numbers you posted, they'll make that back in 1 year if they're using them to fund unfunded spots.

If you look at it as a pay increase, that is absolutely tacky. But that isn't what it is. It's hazard pay and only for front liners, which is actually a thing, acknowledged by the Labor Dept, and even applicable to federal employees. It isn't so they can spend lavishly or reach attending status sooner. It isn't a bump that moves them into a different tax bracket. It's just extra reimbursement for risking their lives and their health. Even if they don't die, getting sick from this thing can have permanent health consequences. Nurses are getting hazard pay. Heard midlevels are as well (though I don't know that for sure). If that's the case, then why shouldn't residents? Are they less worthy somehow? And if so, how?

Who cares that 1 - 6 years from now they'll be attendings if they die in the meantime or suffer chronic health affects from infection? And I also have to mention the psychological toll this is taking on them that none of us can come close to understanding. At the very least, the hazard pay can pay for the therapy they'll need after.

 

[VA Hopeful Dr]

If you look at it as a pay increase, that is absolutely tacky. But that isn't what it is. It's hazard pay and only for front liners, which is actually a thing, acknowledged by the Labor Dept, and even applicable to federal employees. It isn't so they can spend lavishly or reach attending status sooner. It isn't a bump that moves them into a different tax bracket. It's just extra reimbursement for risking their lives and their health. Even if they don't die, getting sick from this thing can have permanent health consequences. Nurses are getting hazard pay. Heard midlevels are as well (though I don't know that for sure). If that's the case, then why shouldn't residents? Are they less worthy somehow? And if so, how?

Who cares that 1 - 6 years from now they'll be attendings if they die in the meantime or suffer chronic health affects from infection? And I also have to mention the psychological toll this is taking on them that none of us can come close to understanding. At the very least, the hazard pay can pay for the therapy they'll need after.

If the hospital in question is giving nurses/janitors/whoever hazard pay then yes, residents should be eligible for that as well. I wasn't aware that nurses were getting hazard pay. I do know that travel nurses who go work in hart hit areas are getting paid insanely well, but that's not the same thing. Its like complaining that locums doctors get paid more than the salaried ones.

 

[VA Hopeful Dr]

For the most part, I agree with you. I've said many times that residents who are fired almost always deserve to be fired and most of the complaints about programs are from residents in trouble for one reason or another. I also made it through without disciplinary action. But I'm talking in a broader sense. The reflex on SDN in cases where residents complain about residency in general is to fight back and say the equivalent to "I did it, you will too, it's not a big deal." But actually a lot of what happens in residency, even the best residency, can be a big deal. The system itself is exploitative and psychologically speaking, the things we sometimes see here is a reaction to the exploitation rather than whining or entitlement. But it seems the person complaining of legit problems in the system is treated the same to the ones complaining that they have to remediate after spectacularly failing a rotation when the two are nowhere near equal. A program doesn't have to be malignant to do questionable things (thinking of all the programs I've heard about with lack of PEE and not allowing residents to bring in their own PPE), even outside a pandemic.

Because much like the fired residents, pre-pandemic many of the complaints we hear about here just weren't that bad. Some are, and in those cases you'll see a good many of us agree that it was unacceptable.

Obviously lack of PPE is a huge problem, but to my understanding its not like everyone else in the hospital had plenty of PPE and it was just the residents who didn't have enough.

 

[operaman]

Genuine question here: The resident in question here is at NYU's affiliate program at NYC's safety net hospital, Bellevue. Is NYU itself even the name on her checks or is it the NYC public hospital system? Either way, the university endowment and the hospital system balance sheets are separate issues all together. If they're going to dip into the latter, they need to prioritize subsidy for those under their umbrella whose jobs are likely to be wiped out by the pandemic so that they can put food on the table. Soon to be wealthy residents ain't that. Plus, say what you will about Langone, he sounds like a total piece of work, but he's put his money where his mouth is to help ease the financial burdens of new physicians. The other NYC institutions haven't done that.

I sure as hell am not saying she's Waggle (few people have ever risen to that level of performance), but the utter lack of skepticism of her claims of mistreatment, in some cases from people with prominent platforms are why I mentioned her and EG. As @Raryn mentioned earlier with more eloquence than I have, stories of programs being out to get residents or "retaliating" against them usually fall apart with a little scrutiny. People forget that both SW and EG had a lot of supporters when their stories first broke, and I'm sure that included plenty of people overreacting in this thread and on reddit. Most people with even a little experience in training greet these supposed outrages with some skepticism, but then again, that's not true for everyone.

(It is more than a little obvious that she's trying to work up her profile into a book deal someday in the near future. That's not really bad in and of itself. Danielle Ofri, who wrote one of the very few "what it's like to be a doctor" books that I didn't hate, is one of her attendings at Bellevue. Still I found it interesting that Ofri didn't back up Farrell's complaints on her own prominent social media platform.)

I think the primary difference between Farrell and Gu/Waggle is that the former is actually good at her job. The latter clearly weren’t and their posts had more of a woe-is-me victim vibe while Farrell’s is more about issues facing everyone. She’s set to graduate and has a good fellowship lined up so any retaliation would be painfully obvious. Even if they wanted to, I’m sure the program realizes they can be rid of her faster by letting her graduate in June.

I agree too that stories of retaliation are generally overblown. I feel like every case I’ve seen where they filed a lawsuit and I could get the documents it became immediately clear that the resident in question had been terrible for a long time. Since most such cases get dismissed without having to put forth any such evidence, that means it’s a pretty select group and nearly all of them made it painfully obvious why they were getting canned.

 

[Mass Effect]

Because much like the fired residents, pre-pandemic many of the complaints we hear about here just weren't that bad. Some are, and in those cases you'll see a good many of us agree that it was unacceptable.

I must not have seen those posts because I genuinely don't remember a thread where residents complained about residency in general (not specific institutions) getting support from many attendings.

 

[Mass Effect]

If the hospital in question is giving nurses/janitors/whoever hazard pay then yes, residents should be eligible for that as well. I wasn't aware that nurses were getting hazard pay. I do know that travel nurses who go work in hart hit areas are getting paid insanely well, but that's not the same thing. Its like complaining that locums doctors get paid more than the salaried ones.

Per friends in NYC, it's not just travel nurses. Travel nurses started the argument, but some of the regular nurses are being paid pretty well for their work during this crisis, including overtime wages. May not be called "hazard pay" specifically, but you can call it what you want when that's what it essentially is.

 

[VA Hopeful Dr]

I must not have seen those posts because I genuinely don't remember a thread where residents complained about residency in general (not specific institutions) getting support from many attendings.

Depends what it is they're complaining about. Residency is hard there's no question of that, very little of the hard parts that are universal are completely without merit.

 

[VA Hopeful Dr]

Per friends in NYC, it's not just travel nurses. Travel nurses started the argument, but some of the regular nurses are being paid pretty well for their work during this crisis, including overtime wages. May not be called "hazard pay" specifically, but you can call it what you want when that's what it essentially is.

Union nurses, which is NYC has I'm told, have always historically gotten crazy overtime pay.

But if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too.

 

[Mass Effect]

Union nurses, which is NYC has I'm told, have always historically gotten crazy overtime pay.

But if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too.

Let's just agree to disagree right here. I will never think it's ok if nurses are getting paid more for working this crisis while residents are ridiculed for daring to ask, whether it's called hazard pay or not is irrelevant to me.

 

[VA Hopeful Dr]

Let's just agree to disagree right here. I will never think it's ok if nurses are getting paid more for working this crisis while residents are ridiculed for daring to ask, whether it's called hazard pay or not is irrelevant to me.

Did you not read my post? I was agreeing with you.

 

[Mass Effect]

Did you not read my post? I was agreeing with you.

You said the following: "Union nurses, which is NYC has I'm told, have always historically gotten crazy overtime pay. But if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too."

I'm saying that regardless of whether it's called overtime pay or hazard pay, they're getting paid more because of the crisis. Sure, it could be because they always get more overtime pay, but I don't think it's right that they get paid more (regardless of what's historically happened) while residents are ridiculed for asking for more money under the circumstances.

 

[BoardingDoc]

You said the following: "Union nurses, which is NYC has I'm told, have always historically gotten crazy overtime pay. But if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too."

I'm saying that regardless of whether it's called overtime pay or hazard pay, they're getting paid more because of the crisis. Sure, it could be because they always get more overtime pay, but I don't think it's right that they get paid more (regardless of what's historically happened) while residents are ridiculed for asking for more money under the circumstances.

That is literally what @VA Hopeful Dr just agreed with.

"if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too."

If the nurses are getting more pay because they are working overtime, and this is completely unchanged from what was happening pre covid, then this is irrelevant to this discussion.

 

[VA Hopeful Dr]

You said the following: "Union nurses, which is NYC has I'm told, have always historically gotten crazy overtime pay. But if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too."

I'm saying that regardless of whether it's called overtime pay or hazard pay, they're getting paid more because of the crisis. Sure, it could be because they always get more overtime pay, but I don't think it's right that they get paid more (regardless of what's historically happened) while residents are ridiculed for asking for more money under the circumstances.

I feel like there's a miscommunication here which is probably may fault.

I am saying that if a nurse, who was employed by a hospital in NYC before this all started, is getting his/her contractually spelled out overtime pay because they are working more hours because of COVID, that's not hazard pay or equivalent to it in any way. If that is all that is happening, then I would not be upset if residents were denied hazard pay since the nurses aren't getting it either.

Now, if it turns out that the nurses are getting paid above what their contracts state their overtime pay should be because of COVID, even if its still just called overtime pay, then I would agree the residents should get more money as well.

 

[<L>]

I feel like there's a miscommunication here which is probably may fault.

I am saying that if a nurse, who was employed by a hospital in NYC before this all started, is getting his/her contractually spelled out overtime pay because they are working more hours because of COVID, that's not hazard pay or equivalent to it in any way. If that is all that is happening, then I would not be upset if residents were denied hazard pay since the nurses aren't getting it either.

Now, if it turns out that the nurses are getting paid above what their contracts state their overtime pay should be because of COVID, even if its still just called overtime pay, then I would agree the residents should get more money as well.

Though as we have already discussed, residency funding is a tangled mess and doing this might not be so simple. Say you've got a program split between multiple sites, one with a well-funded mega health system hospital and one from a just barely hanging on public safety net hospital. (Rush+Cook County comes to mind). If one site is giving nurses/techs/therapists hazard pay but one isn't for work done at their site and one isn't the task of divvying that $ up is complicated.

while residents are ridiculed for asking for more money under the circumstances.

Seriously now. No one here is ridiculing them for asking for more money. Every resident in NYC, Detroit, Chicago, and Naw'lins has probably pestered their PD about getting hazard pay by now. It's a reasonable ask to be sure. Some will get it, some won't.

Putting your program on blast using twitter while complimenting yourself for your bravery in doing so deserves a "" though.

 

[FlowRate]

It's very possible that these hospitals will hire NO new residents. If they are already over their cap, purchasing more slots just equates to more income with no additional cost. In that view, this purchase makes much more sense and doesn't really address the question of whether residents are "cost effective". That discussion has be had in other threads, and isn't worth repeating here. The easy summary is that "it depends". If you have a few residents cover all of your night work, then it's probably very cost effective. if you have staff in house at night anyway supervising residents, or if there were an absence of residents you'd still have staff at home covering by phone, then the financial win is minimal. It gets much more complicated, and totally depends on the details. Some programs certainly structure things to get "as much out of their residents as possible". Others will focus on education and supervision and find a balance.

I haven't read the rest of the thread after your post but this is the most compelling argument I could think of that would justify paying for spots even if residents "lose money."

My own residency program split into two larger residency programs. There's no way all of those slots are funded. So there are certainly hospitals that would like to have some funding for their unfunded residency spots.

And in that light, they'd be paying $100k one time for a thing that returns you $100k EVERY YEAR. That is a complete no-brainer and an insane ROI. It's like investing in the market with a non-compounding 100% annual growth rate. If residents generate net income, you'd actually expect those slots to be valued much higher than $100k.

But the economics of residencies and academic medical centers are very, very complex. So I agree with others that trying to make any blanket claims about whether residents generate income or not misses the point. The most certain thing we can say is that most residencies don't put their hospitals out of business.

 

[Mass Effect]

That is literally what @VA Hopeful Dr just agreed with.

"if the local nurses that were working there pre-covid are getting higher pay just for working with lots of COVID patients, then residents should too."

If the nurses are getting more pay because they are working overtime, and this is completely unchanged from what was happening pre covid, then this is irrelevant to this discussion.

The bolded is my point. It isn't irrelevant to me. They're working overtime due to the pandemic, the same reason that residents are working more than they usually do.

 

[Mass Effect]

I feel like there's a miscommunication here which is probably may fault.

I am saying that if a nurse, who was employed by a hospital in NYC before this all started, is getting his/her contractually spelled out overtime pay because they are working more hours because of COVID, that's not hazard pay or equivalent to it in any way. If that is all that is happening, then I would not be upset if residents were denied hazard pay since the nurses aren't getting it either.

Now, if it turns out that the nurses are getting paid above what their contracts state their overtime pay should be because of COVID, even if its still just called overtime pay, then I would agree the residents should get more money as well.

So per my friends in NYC, the nurses are getting more overtime money than they usually do. I don't know how much or what their contracts say, but they supposedly have told residents that they're getting a lot more than usual. No idea if it's called overtime or hazard pay.

 

[Mass Effect]

Seriously now. No one here is ridiculing them for asking for more money. Every resident in NYC, Detroit, Chicago, and Naw'lins has probably pestered their PD about getting hazard pay by now. It's a reasonable ask to be sure. Some will get it, some won't.

I was talking about ridicule by NYU leadership, not here.

 

[VA Hopeful Dr]

So per my friends in NYC, the nurses are getting more overtime money than they usually do. I don't know how much or what their contracts say, but they supposedly have told residents that they're getting a lot more than usual. No idea if it's called overtime or hazard pay.

OK, so as I said if they are getting more than their contracted overtime rate because of this then I agree that the residents should get more too (as should housekeeping, RT, patient transporter, you get the idea).

 

[evilbooyaa]

Genuine question here: The resident in question here is at NYU's affiliate program at NYC's safety net hospital, Bellevue. Is NYU itself even the name on her checks or is it the NYC public hospital system? Either way, the university endowment and the hospital system balance sheets are separate issues all together. If they're going to dip into the latter, they need to prioritize subsidy for those under their umbrella whose jobs are likely to be wiped out by the pandemic so that they can put food on the table. Soon to be wealthy residents ain't that. Plus, say what you will about Langone, he sounds like a total piece of work, but he's put his money where his mouth is to help ease the financial burdens of new physicians. The other NYC institutions haven't done that.

I sure as hell am not saying she's Waggle (few people have ever risen to that level of performance), but the utter lack of skepticism of her claims of mistreatment, in some cases from people with prominent platforms are why I mentioned her and EG. (edit: to clarify, other than the over the top self-righteousness it's not her that invites the comparison so much as everyone else's credulous "this confirms my priors" reactions to it) As @Raryn mentioned earlier with more eloquence than I have, stories of programs being out to get residents or "retaliating" against them usually fall apart with a little scrutiny. People forget that both SW and EG had a lot of supporters when their stories first broke, and I'm sure that included plenty of people overreacting in this thread and on reddit. Most people with even a little experience in training greet these supposed outrages with some skepticism, but then again, that's not true for everyone.

(It is more than a little obvious that she's trying to work up her profile into a book deal someday in the near future. That's not really bad in and of itself. Danielle Ofri, who wrote one of the very few "what it's like to be a doctor" books that I didn't hate, is one of her attendings at Bellevue. Still I found it interesting that Ofri didn't back up Farrell's complaints on her own prominent social media platform.)

If anyone is getting hazard pay, then residents should be getting hazard pay.

Let's reflect on what actually happened in this twitter thread:
1) NYU residents requested hazard pay
2) NYU leadership, rather than being empathetical and saying something along the lines of "we respect the difficult positions you are in, but the entire system is taking paycuts, and we just don't have the ability to pay you guys anything extra, etc. etc." acted, behind closed doors, in a condescending manner, and told residents that they were being greedy and unprofessional (there's that word again). Certain aspects of the hospital leadership wanted to find out which of his trainees had responded to an anonymous survey in a certain matter (assuredly for retaliation). Residents were subtly threatened with "well if you don't like it then maybe you don't have to work here"
3) A good resident who is on her way out the door to a good fellowship didn't stand for this level of crap and posted about it on twitter.

It's one thing if the residents asked for hazard pay and were told no. The fact is that their own hospital's leadership (who cares about SDN members ridiculing them) ridiculed their own residents and acted in a condescending manner to them. Yeah, I'd be pissed too.

 

[sunshinefl]

So per my friends in NYC, the nurses are getting more overtime money than they usually do. I don't know how much or what their contracts say, but they supposedly have told residents that they're getting a lot more than usual. No idea if it's called overtime or hazard pay.

OK, so as I said if they are getting more than their contracted overtime rate because of this then I agree that the residents should get more too (as should housekeeping, RT, patient transporter, you get the idea).

Nurses frequently get incentive pay by whatever name you want, when no one else does. My husband is an RRT and the nurses at his hospital are getting “hazard pay” and respiratory therapy is not, and neither is anyone else besides nurses.

 

[<L>]

OK, so as I said if they are getting more than their contracted overtime rate because of this then I agree that the residents should get more too (as should housekeeping, RT, patient transporter, you get the idea).

So I got curious from this thread and texted a faculty member at one of the particularly hard hit hospitals I know of (non-NYC) that has been giving COVID hazard pay to the nursing staff. He told me that residents aren't getting any, but he also told me something I hadn't thought much about. Residents have been getting pulled to COVID services, but even with the hospital full, productivity is likely down significantly for their residents as a whole. Only a portion of a hospital's residents cover inpatient services at any time and outpatient care is now wiped out, so now we're in a situation where there's a huge chunk of their residents with no real work to do and it's getting worse as their hospitalization numbers have started to decline this week. They've got a bunch of residents doing unplanned research electives now.

I hadn't thought about that aspect of things much (inexcusable on my part since the resident clinic on my floor hasn't been run in a month), but it does emphasize something I've believed for a long time, even back when I was in training: Resident compensation being tied to productivity, especially RVUs or billing, is a Pandora's box that you DO. NOT. want to open.