Resident Lawsuit

[BrockDoc]

I'm wondering if anyone has attempted or at least looked into starting a resident lawsuit or some sort of legal recourse for the way we are treated and compensated? I mean there are many issues that come to mind, but the most recent is that a resident recently left the program and we are told that we have no choice, but to pick up her call without any extra compensation. Imagine telling a worker in any other industry that you have to work extra without extra compensation. Imagine telling a midlevel or nurse that he or she will have to pick up an extra shift, but won't be paid any extra.

Residents across all specialties are paid much less than midlevels and work significantly more hours, do significantly better work, and take on significantly more difficult cases. Why are midlevels paid sometimes 3-4x the amount of money? I know that the reason given is that we are being "trained" and "educated." However, anyone who says that more than 50% of our time spent in the hospital is for the sake of education is delusional. I've actually also heard rumors of consulting companies coming to hospitals and telling them to utilize residents to their maximum capacity instead of midlevels because we provide a cheaper workforce. If you can reproduce those documents in a court of law, I would think you have a very strong legal argument for labor violations.

Honestly, I'm fed up. I'm not necessarily fed up with working...I work hard and study hard. I'm fed up with being compensated unfairly in comparison to midlevels. I'm fed up with the feeling that I am "owned," in that I can just be told to pick up extra call without any extra compensation. I think it's time that residents across the country and across specialties do something about how we are treated and compensated. A lawsuit might be a place to start.

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[123eyes]

...a resident recently left the program and we are told that we have no choice, but to pick up her call without any extra compensation. Imagine telling a worker in any other industry that you have to work extra without extra compensation. Imagine telling a midlevel or nurse that he or she will have to pick up an extra shift, but won't be paid any extra.

Haha what? Ignoring the whole in-training-cost-to-hospital argument, I'm pretty sure that's how it works in any other salaried field. "Sorry guys, but X took maternity leave and Y just retired, so you'll have to work harder to meet the deadline. We'll be increasing all of your salaries by 10% to make up for their absence." No. Nurses and other hourly employees are paid overtime for their extra shifts.

Also, resident salaries are largely uniform across the nation +/- COLA and a program with heavy call would pay a similar amount as one with light call, all other things being equal. Should programs which take on an extra resident, thereby reducing the call burden, therefore reduce resident compensation?

 

[Law2Doc]

Haha what? Ignoring the whole in-training-cost-to-hospital argument, I'm pretty sure that's how it works in any other salaried field. "Sorry guys, but X took maternity leave and Y just retired, so you'll have to work harder to meet the deadline. We'll be increasing all of your salaries by 10% to make up for their absence." No. Nurses and other hourly employees are paid overtime for their extra shifts.

Also, resident salaries are largely uniform across the nation +/- COLA and a program with heavy call would pay a similar amount as one with light call, all other things being equal. Should programs which take on an extra resident, thereby reducing the call burden, therefore reduce resident compensation?

Yeah, when I was a lawyer and somebody left, we all divided up that persons work until the firm hired and trained someone new. Dealing with being short handed without throwing in more pay is not really unique to residencies. The fact that maximum hours are capped actually makes this better than some jobs in this respect. But no, professionals don't get overtime in any field. The low wage nonprofessional employees are the only ones who get more if you expect them to work a weekend.

There isn't a basis for a lawsuit. You could always strike, but usually you need a specific finite articulated goal or nobody will follow your lead. And most won't follow anyway because residency is a very finite window and people are generally better off keeping heads down

 

[mercaptovizadeh]

Yeah, when I was a lawyer and somebody left, we all divided up that persons work until the firm hired and trained someone new. Dealing with being short handed without throwing in more pay is not really unique to residencies. The fact that maximum hours are capped actually makes this better than some jobs in this respect. But no, professionals don't get overtime in any field. The low wage nonprofessional employees are the only ones who get more if you expect them to work a weekend.

There isn't a basis for a lawsuit. You could always strike, but usually you need a specific finite articulated goal or nobody will follow your lead. And most won't follow anyway because residency is a very finite window and people are generally better off keeping heads down

There are plenty of legally questionable practices in medicine. One that just comes to mind is that many licensing/credentialing organizations ask if you have been *charged* with an offense, even if charges were dropped or you were exonerated and not convicted. That seems highly questionable to me. What does a charge even means legally once it has been dropped? And why should national boards be allowed to discriminate on this basis when legally you are on an even ground with everyone else?

 

[Law2Doc]

There are plenty of legally questionable practices in medicine. One that just comes to mind is that many licensing/credentialing organizations ask if you have been *charged* with an offense, even if charges were dropped or you were exonerated and not convicted. That seems highly questionable to me. What does a charge even means legally once it has been dropped? And why should national boards be allowed to discriminate on this basis when legally you are on an even ground with everyone else?

I guess. But not sure how that helps the OP who is more of an overworked and underpaid issue guy

 

[ThoracicGuy]

 

[BrockDoc]

First of all the fact that resident salaries are "more or less uniform" means that one could argue that this represents collusion amongst hospitals. I had no ability to negotiate a contract, salary, vacation time, etc... Anyone who thinks that hospitals are training residents out of the goodness of their heart is completely delusional. Residencies represent a way for hospitals to make money and cut costs. To put it bluntly, we are a cheap, well-educated, non-complaining, non-unionized, non-standing up for ourselves, labor force. My point is that you have residents doing triple the work of a midlevel but getting a third of the pay. Anyone who says that we are spending the majority of our time "learning" and "being trained" has never done a residency.

With the cost of medical school rising, medical school debt rising, and attending physician payments declining, it is time that residents are no longer paid peanuts while midlevels with quarter of the educations make $100,000 a year working 36 hours a week.

Hospitals are not noble organizations serving the community and educating future physicians. By and large, hospitals are run by CEOs who are just as greedy and overpaid as the billionaires on wall street.

 

[colbgw02]

Oh, I see we're gonna have this thread again.

 

[calvnandhobbs68]

Haha what? Ignoring the whole in-training-cost-to-hospital argument, I'm pretty sure that's how it works in any other salaried field. "Sorry guys, but X took maternity leave and Y just retired, so you'll have to work harder to meet the deadline. We'll be increasing all of your salaries by 10% to make up for their absence." No. Nurses and other hourly employees are paid overtime for their extra shifts.

Also, resident salaries are largely uniform across the nation +/- COLA and a program with heavy call would pay a similar amount as one with light call, all other things being equal. Should programs which take on an extra resident, thereby reducing the call burden, therefore reduce resident compensation?

Seriously, I'm betting this guy never had a real job before. Residents aren't hourly employees, there's no obligation to pay them more for working "extra" just like there's no obligation to pay any other salaried employee more for working more hours.

 

[calvnandhobbs68]

First of all the fact that resident salaries are "more or less uniform" means that one could argue that this represents collusion amongst hospitals. I had no ability to negotiate a contract, salary, vacation time, etc... Anyone who thinks that hospitals are training residents out of the goodness of their heart is completely delusional. Residencies represent a way for hospitals to make money and cut costs. To put it bluntly, we are a cheap, well-educated, non-complaining, non-unionized, non-standing up for ourselves, labor force. My point is that you have residents doing triple the work of a midlevel but getting a third of the pay. Anyone who says that we are spending the majority of our time "learning" and "being trained" has never done a residency.

With the cost of medical school rising, medical school debt rising, and attending physician payments declining, it is time that residents are no longer paid peanuts while midlevels with quarter of the educations make $100,000 a year working 36 hours a week.

Hospitals are not noble organizations serving the community and educating future physicians. By and large, hospitals are run by CEOs who are just as greedy and overpaid as the billionaires on wall street.

There are actually quite a few large training programs with resident unions. You were welcome to try to match there when you applied for the match if that was something that was so important for you.

 

[Gastrapathy]

Hey Brock, until you are an attending, why should they pay you at all? Because you think it would be unfair to be an unpaid "intern." Lots of programs would have zero difficulty filling without paying a dime. Don't be so sure you want the market to decide this.

Sorry killer. Resident salaries may not be fair given the workload but you didn't get paid anything for all those papers you wrote in college either.

 

[BrockDoc]

This is EXACTLY what is wrong with residents and physicians in general...afraid the stand up for themselves, afraid to ruffle feathers, and perfectly fine with some hospital CEO making millions off the back of our hard work. Physicians are the most risk averse people I have ever met and because of it the government, midlevels, and hospital administration continues to marginalize us, decrease reimbursement, and frankly, just walk all over us. It all starts in residency. People call residency intense medical training, but it really is a way to get physicians to be submissive to the system. Then when someone does suggest making a little noise to remind people that we still have a spine, my fellow physicians call me a whiner. Boy oh boy do those CEOs at the top really have a good thing going.

I'm ashamed of the direction this profession is heading in, and I feel it all starts in residency.

For the record, I work my ass off, pick up my co-residents call, study hard, and really care for my patients. What I'm disillusioned by what I see as a complete castration of this profession. Multiple books have been written in the past year about how burnt out and disenchanted physicians have become. The answer is simple: We need to stand up for ourselves!

 

[calvnandhobbs68]

This is EXACTLY what is wrong with residents and physicians in general...afraid the stand up for themselves, afraid to ruffle feathers, and perfectly fine with some hospital CEO making millions off the back of our hard work. Physicians are the most risk averse people I have ever met and because of it the government, midlevels, and hospital administration continues to marginalize us, decrease reimbursement, and frankly, just walk all over us. It all starts in residency. People call residency intense medical training, but it really is a way to get physicians to be submissive to the system. Then when someone does suggest making a little noise to remind people that we still have a spine, my fellow physicians call me a whiner. Boy oh boy do those CEOs at the top really have a good thing going.

I'm ashamed of the direction this profession is heading in, and I feel it all starts in residency.

For the record, I work my ass off, pick up my co-residents call, study hard, and really care for my patients. What I'm disillusioned by what I see as a complete castration of this profession. Multiple books have been written in the past year about how burnt out and disenchanted physicians have become. The answer is simple: We need to stand up for ourselves!

If you're so enraged and have thought so hard about this, please detail, point by point, what issues said "lawsuit" would address. It's already been addressed that requiring a salaried employee to work more than he/she would like to isn't really grounds for a lawsuit, so I think we can check that one off the list.

 

[dyeguy21]

Axe grind much? Gotta do this again. Mk.

The CEO "fatcats" that make millions...they are able to do that because they sometimes manage hospital groups that have 25-50 hospitals. The average is around ~$2mil, but that ranges from a low of around ~190K, all the way up to ~$20mil (however, that takes into account deferred payments, retention bonuses, and investment income). At the end of the day, hospital boards want to generate enough revenue to sustain the hospital and improve their standing. There are very few people that are capable of keeping up with the changing landscape of healthcare and still make a profit. Thus, the market determines CEO compensation, nothing more. And all of the top paid CEOs' plans aren't "ride the residents into the ground." There is an operating cost associated with everything you do, and despite how fast it seems you discharge patients, you still require more time than the non-teaching hospitals. Time is the most expensive thing in a hospital and medical students, residents, and teaching rounds require lots of it.

The middle workers are vastly more efficient and are at their highest earning potential. You have a larger life long earning potential than these people. Don't get upset because they are living a "better" life than you right now. You became a physician to care for people and to advance society as a whole, not work a 9-5 job and earn money to just exist.

You are being educated. You have morning report. M&M, noon conference, path conference, case presentations, board prep, sim sessions, and teaching rounds. Yes you have to do work, but that is part of taking care of a patient. All of these things are not free. From a management view, all of that time could be better spent serving the hospital by getting patients out quicker and saving cost.

Your definition of labor violations is a bit off. Someone saying to utilize residents to their fullest...wouldn't be a violation. Cheaper human capital is generally utilized more than expensive human capital. It's business 101.

Misc: Hospital admins aren't decreasing your reimbursement (seriously, this is something you have to know). Physicians still have spines, talk to a surgeon or your CMO if you doubt this. Your schedule is mostly determined by ACGME rules. Hospitals are not in a cabal, they are in direct competition. You apparently never worked in the real world as your are often asked to pick up extra work for no extra pay all the time, especially among professionals. When someone gets sick, unexpectedly dies, gets in trouble, has family issues, etc. you band together as a group, divvy up the work, and move on. Life's tough, work is hard, you're always gonna feel like you're underpaid.

 

[Perrotfish]

First of all the fact that resident salaries are "more or less uniform" means that one could argue that this represents collusion amongst hospitals. I had no ability to negotiate a contract, salary, vacation time, etc... Anyone who thinks that hospitals are training residents out of the goodness of their heart is completely delusional. Residencies represent a way for hospitals to make money and cut costs. To put it bluntly, we are a cheap, well-educated, non-complaining, non-unionized, non-standing up for ourselves, labor force. My point is that you have residents doing triple the work of a midlevel but getting a third of the pay. Anyone who says that we are spending the majority of our time "learning" and "being trained" has never done a residency.

With the cost of medical school rising, medical school debt rising, and attending physician payments declining, it is time that residents are no longer paid peanuts while midlevels with quarter of the educations make $100,000 a year working 36 hours a week.

Hospitals are not noble organizations serving the community and educating future physicians. By and large, hospitals are run by CEOs who are just as greedy and overpaid as the billionaires on wall street.

This is exactly correct. Residencies are a trust. Residencies (not really hospitals per se, but rather residency training programs) collude to limit your salary. They collude to prevent you from seeking better employment in a free market. They collude to limit your opportunities to ever seek employment again if you quit. This kind of behavior violates every anti-trust law on the books. It would be a great basis for a lawsuit.

And it was. In 2004.

Which prompted congress to exempt residency from the anti-trust laws. Oops!

As for the rest of your complaints, they're all correct about how much residency sucks, and is unfair. However you don't win a lawsuit on the basis of either misery or fairness. You can only win a lawsuit if the other party is on the wrong side of the law. You have no more basis for a lawsuit than the (much worse off) millions of minimum wage workers who are being paid less than $1000/month for a working a full time job. Their employers are as$holes, but they're not doing anything illegal, so there is no basis for a lawsuit.

 

[QofQuimica]

I'm wondering if anyone has attempted or at least looked into starting a resident lawsuit or some sort of legal recourse for the way we are treated and compensated?

What a novel idea. I can't believe no one has ever thought of this before, let alone posted about it on SDN since, what, 2-3 months ago?

This is EXACTLY what is wrong with residents and physicians in general...afraid the stand up for themselves, afraid to ruffle feathers, and perfectly fine with some hospital CEO making millions off the back of our hard work. Physicians are the most risk averse people I have ever met and because of it the government, midlevels, and hospital administration continues to marginalize us, decrease reimbursement, and frankly, just walk all over us. It all starts in residency. People call residency intense medical training, but it really is a way to get physicians to be submissive to the system. Then when someone does suggest making a little noise to remind people that we still have a spine, my fellow physicians call me a whiner. Boy oh boy do those CEOs at the top really have a good thing going.

I'm ashamed of the direction this profession is heading in, and I feel it all starts in residency.

Dude, so quit. This is still a free country. No one's holding a gun to your head forcing you to do a residency. But if you're not going to quit (and FWIW, suing your residency program would be tantamount to quitting), then yeah, you should just keep your head down, do your work and stop being a whiner. You're not exactly doing anything to improve the system by complaining about it on SDN.

 

[Law2Doc]

OP, like it or not, you chose this. Residencies have been around since before you were born. The hours were longer back then and the salaries were much lower, but the concept remains pretty much the same. No surprises. If you didn't know what you were getting into you never talked to people, read books, watched medical TV shows/movies or read SDN. It is an apprentice system, a concept that dates back to medieval times. You endure some period of being the overworked under appreciated assistant, but you see enough to learn a trade and go off on your own in 3-7 years.

Nobody enjoys all of residency, but it is a lie to say you don't learn things long the way. Hopefully a lot. Not in the classroom sense (which frankly is the lowest yield form of education) but you see and experience a lot. And learn how to manage patients. Hours are bad but could be worse, and at one time were. Pay is bad but could be worse and at one time was. Most people choose to kern their heads down and plow through, hopefully soaking up some skills as they go.

Comparing residents pay to a midlevel is *****ic -- you are only going to do residency for a few years while they will be midlevels forever. And you are likely going to a new job in 3 years while hospitals hope the midlevel won't. So this isn't your terminal salary. Compare average incomes over your respective careers and see if you still think they are ahead.

Whining about it is an age-old tradition. But I don't think you've got much of a Lawsuit here, and you don't seem to have specific concrete workplace abuses you'd want to strike over.

 

[BrockDoc]

First of all mid level pay over time is more than a primary care physician and certain specialties...when you factor in education debt and lost opportunity at investment (compounding interest, etc...). So, I don't think it's *****ic. I'm basically spending my years of training losing net worth, not gaining. Saying something always was and thus always should be is a *****ic statement to make.

Ok, fine a lawsuit won't work because the system is stacked against us. However, my concern is that this is a symptom of a bigger problem in healthcare. Using a surgeon who yells as an example of physicians who have spines just doesn't cut it. That surgeon will still comply with every EMR mandate the government hands down, every ridiculous Joint Commission rule they come up with. A primary care physician will complain about the 8 minute appointment, 50 patients a day, and reams of paperwork afterwards...but do NOTHING about it. The AMA is a joke and I see nothing to indicate that physicians are going to "grow a set" anytime soon. I know a resident lawsuit would fail, but something like that would get the point across that we are sick of being used as cheap labor and we are not going to mature into spineless physicians who become just another cog in the system. The American healthcare system is a piece of crap measured by numerous metrics. If we don't start caring and start standing up to the other players in this game then we will continue to see administrators pass out more rules, the government pass out more mandates, all of which allow midlevel creep and a cheapening of American healthcare.

"Dude, so quit." Go away. That doesn't even deserve a response.

 

[colbgw02]

I see SDN *TIS* trying to be funny, again. Happy Festivus! Have you seen the pole, Kruger?

 

[Law2Doc]

First of all mid level pay over time is more than a primary care physician and certain specialties...when you factor in education debt and lost opportunity at investment (compounding interest, etc...). So, I don't think Tis *****ic. I'm basically spending my years of training losing net worth, not gaining. Saying something always was and thus always should be is a *****ic statement to make.

Ok, fine a lawsuit won't work because the system is stacked against us. However, my concern is that this is a symptom of a bigger problem in healthcare. Using a surgeon who yells as an example of physicians who have spines just doesn't cut it. That surgeon will still comply with every EMR mandate the government hands down, every ridiculous Joint Commission rule they come up with. A primary care physician will complain about the 8 minute appointment, 50 patients a day, and reams of paperwork afterwards...but do NOTHING about it. The AMA is a joke and I see nothing to indicate that physicians are going to "grow a set" anytime soon. I know a resident lawsuit would fail, but something like that would get the point across that we are sick of being used as cheap labor and we are not going to mature into spineless physicians who become just another cog in the system. The American healthcare system is a piece of crap measured by numerous metrics. If we don't start caring and start standing up to the other players in this game then we will continue to see administrators pass out more rules, the government pass out more mandates, all of which allow midlevel creep and a cheapening of American healthcare.

"Dude, so quit." Go away. That doesn't even deserve a response.

Who exactly are you trying to say you "won't take it " from? The hospital CEOs?, GME?, the government? You are frustrated but not really directed usefully. You are all over the place. Growing a pair is only meaningful if you have a direction.

 

[dyeguy21]

It sounds like you just read an econ book and are upset about the world as a whole.

Know that there is no perfect economic system, however, here we believe in the theory of compensating wage differentials. There's nothing stopping you from using your knowledge to become one of the fatcats (in fact, they actually want healthcare professionals in those positions), again you can make more money than the middle levels.

To mirror Law2Doc, you seem to be mad at everything about the healthcare system. You want reimbursement to be better, CEOs to be paid less, residents to earn more money, doctors to change stuff they have no power over, etc.

Frankly...you need to grow a pair and fully take in reality. If all the answers were simple and everything was easy we wouldn't be worried about economic collapse and global war. Sit back and take it all in, not just your small slice of the world.

 

[NotAProgDirector]

The OP does make some reasonable points. I'm going to ignore the resident/mid level comparison -- that's a subject for another thread. But whether it's fair that when a resident leaves/resigns that everyone else just gets more work added is an open question. If you're running your own business (like your own private practice) then that's what happens -- but ultimately you're working to improve your own business. When you're a resident or a hospital employee you have no direct financial stake in the hospital, so it would seem "fair" to pay people for extra shifts.

In fact, that's exactly what my hospitalist group does. We each are assigned shifts at the beginning of the year. If we end up working extra shifts for any reason, we get paid more per extra shift. It is "easy" to do this, as we have a certain amount of money budgeted for salaries. If someone leaves, then we use the unused salary money to reimburse physicians who take extra shifts. Ultimately everyone is happy.

In residency, this becomes much more problematic. Money comes from Medicare to pay resident salaries, so when someone leaves there isn't "unused" money hanging around. Plus you'd need to spell out exactly how this would work -- are people paid extra for working nights? Weekends? Lost days off? Days where they are shifted from electives to service rotations? Plus, it would clearly need to be GME-wide. Once one program does this, all need to do it. Realistically this would require that residents have contracts stating a maximum number of shifts/nights/weekends/etc, and some contractual process for paying when those are exceeded.

As mentioned, the best way to get this would likely be via a resident union rather than a lawsuit. I have no idea if you'd be successful, but you could try. I do know that several programs with unions have contracts where residents are paid when they are called in to cover a co-resident. This sort of situation would be very similar.

So, you seem angry and frustrated, and want someone to do something. Therefore, you should consider organizing a union at your institution and push for language like this in your contract. Contact CIR and they can help you. Doing so is risky -- if your program isn't wild about the idea you could face all sorts of pushback and problems. Theoretically it's illegal to fire you for organizing a union, but there are plenty of stories of employers doing just that and claiming they were fired for performance issues. Then there is inevitably a lawsuit.

If you're unwilling to organize a union, then your complaining is just that. Complaining.

 

[mercaptovizadeh]

I think Brock makes some decent points, but is misplaced in lashing out against residency rules. As residents, we live in a bizarre limbo between student and worker, we are "being educated" and "useless" and "senior students" when it suits them, salaried employees when that model suits them, etc. Thank God for the 80 hr workweek!

But I do think there are other sketchy practices within medicine that do need some protesting. As I alluded to, there is no mechanism to punish residency programs who ask inappropriate questions at interview (you know, like anonymous reporting would lead to all subsequent interviews being video recorded in the future interview season and then interviewees could present evidence of inappropriate questions and communication that would lead to programs losing the eligibility to train residents for a year....). There is no restraint on programs and boards demanding to know legally protected information (e.g. juvenile criminal records that have been expunged or dropped charges are apparently something state medical boards think they have a right to know?). And there is no restraint on the price-gouging that goes on in the many board exams we must take ($800 for step 3 for a bunch of MCQs that can get scored and scaled on a curve by a computer within seconds?). There are many things like this that seem very sketchy.

 

[mercaptovizadeh]

The OP does make some reasonable points. I'm going to ignore the resident/mid level comparison -- that's a subject for another thread. But whether Tis fair that when a resident leaves/resigns that everyone else just gets more work added is an open question. If you're running your own business (like your own private practice) then that's what happens -- but ultimately you're working to improve your own business. When you're a resident or a hospital employee you have no direct financial stake in the hospital, so it would seem "fair" to pay people for extra shifts.

In fact, that's exactly what my hospitalist group does. We each are assigned shifts at the beginning of the year. If we end up working extra shifts for any reason, we get paid more per extra shift. Tis "easy" to do this, as we have a certain amount of money budgeted for salaries. If someone leaves, then we use the unused salary money to reimburse physicians who take extra shifts. Ultimately everyone is happy.

In residency, this becomes much more problematic. Money comes from Medicare to pay resident salaries, so when someone leaves there isn't "unused" money hanging around. Plus you'd need to spell out exactly how this would work -- are people paid extra for working nights? Weekends? Lost days off? Days where they are shifted from electives to service rotations? Plus, it would clearly need to be GME-wide. Once one program does this, all need to do it. Realistically this would require that residents have contracts stating a maximum number of shifts/nights/weekends/etc, and some contractual process for paying when those are exceeded.

As mentioned, the best way to get this would likely be via a resident union rather than a lawsuit. I have no idea if you'd be successful, but you could try. I do know that several programs with unions have contracts where residents are paid when they are called in to cover a co-resident. This sort of situation would be very similar.

So, you seem angry and frustrated, and want someone to do something. Therefore, you should consider organizing a union at your institution and push for language like this in your contract. Contact CIR and they can help you. Doing so is risky -- if your program isn't wild about the idea you could face all sorts of pushback and problems. Theoretically Tis illegal to fire you for organizing a union, but there are plenty of stories of employers doing just that and claiming they were fired for performance issues. Then there is inevitably a lawsuit.

If you're unwilling to organize a union, then your complaining is just that. Complaining.

If the program needs to reassign shifts but remains within work hours, then it seems fair. If residents are routinely violating work hour restrictions to meet the needs created by a resident who left, the program needs to figure out a way to hire a midlevel or pay hospitalists extra shifts to cover the slack.

 

[Law2Doc]

The OP does make some reasonable points. I'm going to ignore the resident/mid level comparison -- that's a subject for another thread. But whether Tis fair that when a resident leaves/resigns that everyone else just gets more work added is an open question. If you're running your own business (like your own private practice) then that's what happens -- but ultimately you're working to improve your own business. When you're a resident or a hospital employee you have no direct financial stake in the hospital, so it would seem "fair" to pay people for extra shifts.
...

Disagree with what you are saying is "fair". In most professional businesses (eg law firms) if people leave other people have to pick up the slack. Not partners, but salaried employees -- people with no financial stake. They don't get more money ( except insofar as their year end bonuses might in some way reflect more hours billed, which is not universal). Again residents already have it BETTER than all these people because their hours are capped. So no, I wouldn't say that it's only fair they get overtime -- professional salaried employees don't get comped this way.

 

[j4pac]

You don't have to go to residency. If you don't agree with the terms...don't go.

I understand your frustration...and I completely understand your frustration with the laisse faire physicians in our profession that are allowing the physician to lose all the power. But you need to know where to pick your battles and this is one not worth the effort and repercussions.

As a resident you have zero power and leverage. Zilch.

 

[mercaptovizadeh]

Disagree with what you are saying is "fair". In most professional businesses (eg law firms) if people leave other people have to pick up the slack. Not partners, but salaried employees -- people with no financial stake. They don't get more money ( except insofar as their year end bonuses might in some way reflect more hours billed, which is not universal). Again residents already have it BETTER than all these people because their hours are capped. So no, I wouldn't say that Tis only fair they get overtime -- professional salaried employees don't get comped this way.

Yes and no. Maybe it's a temporary stop gap measure, maybe it's the employer tightening the belt, but employers who have the funds generally will look for another employee to replace the prior just because it's better to have someone specialized for the job with equivalent experience and know-how, and spreading the rest of the workforce too thin will have diminishing returns in their overall productivity, the quality of the work they do, and morale. And, sometimes, it's just the right thing to do.

And these large tertiary medical centers have plenty of funds to hire another midlevel or pay the hospitalists for some extra shifts. Let's not kid ourselves.

I mean, if you want to advocate for the sweatshop-ization of American labor just because China does it (and America did, 100 years ago), you can. But be open about it (and feel free refer to how much better off we are than the slaves of Babylon 5000 years ago while you're at it), rather than pretending that there is no history or notion in America of social contract, social justice, labor law, labor union, diminishing returns when burning out the employees, etc.

 

[mercaptovizadeh]

And I do not think the current trends in the legal profession - where the top 20% or so coming out of pedigreed law schools and plopping into the velvety bosoms of family/friend/co-ethnic/co-religionist law firms, lord over the other 80% who languish for years on end working in shoe stores, Starbucks, temp jobbing, or in the dungeons of the public interest office - is the direction American medicine should be headed towards.

 

[Law2Doc]

And I do not think the current trends in the legal profession - where the top 20% or so coming out of pedigreed law schools and plopping into the velvety bosoms of family/friend/co-ethnic/co-religionist law firms, lord over the other 80% who languish for years on end working in shoe stores, Starbucks, temp jobbing, or in the dungeons of the public interest office - is the direction American medicine should be headed towards.

I didn't necessarilly say it was the direction to emulate. I was correcting aPD who seems to think that residencies dividing up a departed professional employees work when they leave without shelling out additional money/ overtime is somehow unique to residents. It isn't. It's common to ALL professional employees. The distinction is residents can't be given more than an averaged 80 hours a week workload, while a poor sap working at a law firm certainly could. Again this isn't necessarily what we want to strive for, but it's just not a good example of residencies acting different than other professional groups.

 

[BrockDoc]

I know a single resident lawsuit would be laughed at. However, if a large group of residents would stand up and say enough is enough, it would at least get noticed. I realize any such attempt would be a total failure, but I just want to feel like there is a pulse amongst my fellow residents/physicians. I've had friends in residencies with unions and they were pretty useless. It's just another fee to pay.

Comparing residents to partners in a law firm or business owners who have a person leave/quit/die/give birth/etc...is not a fair comparison. I have no skin in the game, so to speak. I could not care any less if my hospital went bankrupt. All I care about is my education. Now I have one less day off to spend with my family because my program could not match applicants appropriately. The fact that we have to pick up the slack for a missing resident is just proof that residency is all about cheap labor and not education. To me, that in it of itself deserves further investigation. How much extra money are these hospitals making off our backs?

My problem is that we will all just say "yes sir" to the extra call we have coming our way and we won't stand up against it. It's just the start to being a submissive physician for the remainder of our career. It all starts in residency. We all know the stats...physicians have higher rates of divorce, alcoholism, drug abuse, suicide, depression than many other professions. Part of that is because we don't have autonomy. Most professionals do have autonomy...at least when they reach the pinnacle of their careers. That no longer exists in medicine.

 

[AStark]

I haven't really had to "use" my union as such, but they do remain in ongoing (and somewhat protracted) contract negotiations. At some point, though, these negotiations will be concluded - hello binding arbitration - and we will probably get some semblance of retroactive pay. We do essentially have sector-wide bargaining, though, as there are no non-unionized residents anywhere.

In my program we work out call coverage holes by rejigging the schedule and, sometimes, turning some nights into locums. Since said locums pay fairly well, there's usually little problem getting them covered.

In any case, I'm not exactly sure what kind of solution you're looking for here. If you think collective bargaining is useless, then I'm really not sure what else you have in mind. What kind of civil law would underlie a lawsuit here?

 

[Law2Doc]

...
Comparing residents to partners in a law firm or business owners who have a person leave/quit/die/give birth/etc...is not a fair comparison. I have no skin in the game, so to speak...

Reading comprehension my friend. I specifically said (7 posts back) that we are talking about NON-partners, people without any skin in the game. just salaried professionals, ie associates.

Associates at law firms end up picking up the slack when one leaves. Residency is far from unique with this. And that's the case even if it means they might average over 80 hours a week in a given month. So you as residnt have it much much better because you have a duty hour ceiling.

I also think you are greatly overestimating the "autonomy" young professionals have in other fields. Grass is greener I guess.

And you keep trying to combine residency issues with issues one might have at the "pinnacle" of their career. So you continue to be all over the map. If you don't have a single area of contention that maybe can be addressed and instead are complaining about all of residency, career in medicine, healthcare generally etc you are really just one of those old guys sitting on a park bench griping about the government. One really can't ever fix what you can't boil down to a single finite issue or two, ideally one that affects you personally.

 

[Law2Doc]

I know a single resident lawsuit would be laughed at. However, if a large group of residents would stand up and say enough is enough, it would at least get noticed...

Dude, you can't even seem to articulate specific grounds for a lawsuit yet you continue to float it around like it a real option. A single resident lawsuit is actually exactly what you'd need -- you need some articulable complaint beyond lack if autonomy and "we shouldn't bend over and take it". And you need to top augmenting your issues to try and embrace both the resident and the doctor at the pinnacle of his career. That guy is pretty happy, not suing.

Sorry but based on your posts you aren't the guy to lead anybody into battle.

 

[BoardingDoc]

If you don't have a single area of contention that maybe can be addressed and instead are complaining about all of residency, career in medicine, healthcare generally etc you are really just one of those old guys sitting on a park bench griping about the government.

I don't know how much of that is likely to come at this point. Just digging through the post history paints a pretty clear picture of someone who has thus far been consistently unhappy with their choices in medicine. PGY1 IM looking to switch into IR, then a pgy3 looking to get into cards at the last minute because GI wasn't what they thought it would be, then apparently an IM BE/BC hospitalist looking to get back into residency for anesthesia. As people have pointed out, this seems to be far more of a rant against medicine than a rallying cry to action.

Also...

Now I have one less day off to spend with my family because my program could not match applicants appropriately.

Weren't you looking to match into an anesthesia program that was unable to fill all their spots? This outcome is surprising because....?

 

[dyeguy21]

Also, just as a side note...you should care if the hospital goes bankrupt. It means there will be no place for you to get your education and patients in your community would likely suffer from fewer providers of care. You would also have difficulty finding another residency spot and if you completed your residency it would be hard to convince employers that you know what to do to help their practice given that you just came from a place that couldn't produce profit. Again: Big picture, not your narrow view.

 

[Gastrapathy]

You couldn't care if your hospital fails because you are a temp. But you expect others who similarly lack any reason to be invested in your situation to care about you.

There is a hard cap on the workload permitted for a resident. You were never promised to work less than that. You admit that you go to work only for your own education. If that's the case, they were depriving you previously and now you are getting all those extra learning opportunities. If you aren't learning from your patients, that's not their fault.

 

[BrockDoc]

Ok, I'm wrong.

 

[meerkat111]

I understand some of the OP's frustrations. However, he can not change the system from where he is. Residency is the wrong place and time to rebel. Hopefully, he will once her graduates from his residency. We owe it to our children or the future generation to change this. Do you honestly want your children to go thr' this?

 

[oldbearprofessor]

Do you honestly want your children to go thr' this?

Yes, and they will since that is the way they will become practicing physicians. Anything can be improved, but the residency system we have now, does not, in my opinion, constitute something that fundamentally I would not want my children to take part in.

 

[Perrotfish]

Yes, and they will since that is the way they will become practicing physicians. Anything can be improved, but the residency system we have now, does not, in my opinion, constitute something that fundamentally I would not want my children to take part in.

We will agree to strongly disagree about this.

 

[VA Hopeful Dr]

We will agree to strongly disagree about this.

Give it a few years, then see if you still feel the same way.

 

[colbgw02]

We will agree to strongly disagree about this.

What reforms would need to occur to make residency acceptable for your children? Or would you prefer to see your children avoid medicine altogether?

 

[Perrotfish]

What reforms would need to occur to make residency acceptable for your children? Or would you prefer to see your children avoid medicine altogether?

This is always a tough question, because I could give a long list of small, easy reforms that would make the medical training process at least palatable. However to truly make this profession really better, to me, would involve a few big reforms. I would basically eliminate residency as it currently exists.

To me, the root of all evil in the residency system is that residents cannot, practically, quit their jobs. We are treated no better than indentured servants or apprentices ever were, back when that was a standard model for career training. Almost all of the other things that people complain about in medicine are either symptoms of that underlying disease, so the goal of any significant form would be to give residents the same freedom of movement between employers that other skilled entry level employees have.

I think the new model for medical training should be the current model professional engineering training. That was my last (brief) job. A lot of people don't know this, but you need a license to be an engineer, just like you need a license to be a doctor, and to get a job you need to develop area of expertise beyond the minimum required for the license, just like board certification for a doctor. I think most people would agree that signing off to ensure that a 70 story building doesn't fall down is every bit as life and death a task as managing septic shock. However their system of training for engineers is decentralized and free market. There is no federal funding, no formal training process, and if you don't mind working under someone elses license indefinitely there's no reason you need to pursue board certification at all. The result is that, without a single work hour rule or federally mandated inspection, engineering has a created a training process so benign that most people are only peripherally aware they're going through it.
So my reforms:

1) Like engineering, allow an unlicensed physician to work under a licensed physician, indefinitely. The NP/PAs have already established that such an unlicensed provider is valuable enough to hire

2) Like engineering, allow any group of licensed physicians to supervise the training of unlicensed physicians. No more giant, formal training programs. If you want to be a licensed Family doctors the first step should be to join a Family practice group` as an unlicensed physician

3) This is the key one: working for licensed/certified physicians should be the experience that brings you closer to being a licensed/certified physician. There is no difference between working under someone else's license and training, and we should stop pretending that there is.

4) Make those credits towards board certification separable and portable. Say you want to be a Pediatrician: well lets say you need 6 months of supervised experience on the Peds wards, 6 months of NICU/nursery, and a year of Peds clinic for that (simplified schedule). If you can get that all in one practice, great. If you get that by working at 4 locations within 2 years, or over 5 years, also great. No one needs to be trapped in one job because they are half way through the certification process. Also make these credits universal across certifications so that switching between similar specialties requires a shorter training process.

5) Harness the power of the Internet for the didactic requirements, and continue to use prometric for the formal testing. Let employers focus on just evaluating a trainees work.

When physicians in training really have the power to leave their current jobs for better jobs, not just theoretically but practically, this will be a profession worth joining. I promise, the 80 hour weeks, the abusive bosses, the pointless secretarial work: it will all disappear almost overnight.

 

[dyeguy21]

This is always a tough question, because I could give a long list of small, easy reforms that would make the medical training process at least palatable. However to truly make this profession really better, to me, would involve a few big reforms. I would basically eliminate residency as it currently exists.

To me, the root of all evil in the residency system is that residents cannot, practically, quit their jobs. We are treated no better than indentured servants or apprentices ever were, back when that was a standard model for career training. Almost all of the other things that people complain about in medicine are either symptoms of that underlying disease, so the goal of any significant form would be to give residents the same freedom of movement between employers that other skilled entry level employees have.

I think the new model for medical training should be the current model professional engineering training. That was my last (brief) job. A lot of people don't know this, but you need a license to be an engineer, just like you need a license to be a doctor, and to get a job you need to develop area of expertise beyond the minimum required for the license, just like board certification for a doctor. I think most people would agree that signing off to ensure that a 70 story building doesn't fall down is every bit as life and death a task as managing septic shock. However their system of training for engineers is decentralized and free market. There is no federal funding, no formal training process, and if you don't mind working under someone elses license indefinitely there's no reason you need to pursue board certification at all. The result is that, without a single work hour rule or federally mandated inspection, engineering has a created a training process so benign that most people are only peripherally aware they're going through it.
So my reforms:

1) Like engineering, allow an unlicensed physician to work under a licensed physician, indefinitely. The NP/PAs have already established that such an unlicensed provider is valuable enough to hire

2) Like engineering, allow any group of licensed physicians to supervise the training of unlicensed physicians. No more giant, formal training programs. If you want to be a licensed Family doctors the first step should be to join a Family practice group` as an unlicensed physician

3) This is the key one: working for licensed/certified physicians should be the experience that brings you closer to being a licensed/certified physician. There is no difference between working under someone else's license and training, and we should stop pretending that there is.

4) Make those credits towards board certification separable and portable. Say you want to be a Pediatrician: well lets say you need 6 months of supervised experience on the Peds wards, 6 months of NICU/nursery, and a year of Peds clinic for that (simplified schedule). If you can get that all in one practice, great. If you get that by working at 4 locations within 2 years, or over 5 years, also great. No one needs to be trapped in one job because they are half way through the certification process. Also make these credits universal across certifications so that switching between similar specialties requires a shorter training process.

5) Harness the power of the Internet for the didactic requirements, and continue to use prometric for the formal testing. Let employers focus on just evaluating a trainees work.

When physicians in training really have the power to leave their current jobs for better jobs, not just theoretically but practically, this will be a profession worth joining. I promise, the 80 hour weeks, the abusive bosses, the pointless secretarial work: it will all disappear almost overnight.

Like the thoughts the issue is the funding for these spots is set up in such a manner as to make this impossible.

Also: why do people hate paperwork so much? It is a necessary evil that you have to accept. Every single job has some measure of unnecessary paperwork. Engineers have unnecessary paperwork, Teachers have unnecessary paperwork, Accountants, even Janitors have unnecessary paperwork...it is inescapable, suck it up.

 

[Perrotfish]

Like the thoughts the issue is the funding for these spots is set up in such a manner as to make this impossible.

Also: why do people hate paperwork so much? It is a necessary evil that you have to accept. Every single job has some measure of unnecessary paperwork. Engineers have unnecessary paperwork, Teachers have unnecessary paperwork, Accountants, even Janitors have unnecessary paperwork...it is inescapable, suck it up.

The magic of a free market system for training is that it involves no funding. The federal government is not writing anyone a check to train professional engineers. NPs and PAs have adequately demonstrated that hospitals can get a lot of value out of a physician who isn't board certified even when paying 4 times a resident's hourly salary.

As for the paperwork, what I think people hate is the number of non-physician tasks that residents are made to do. Attendings do paperwork, of course, but a lot less, and mostly only the kind of paperwork that a physician needs to fill out (consents, disability forms, home care orders, etc). Most hospitals/groups go out of their way to make sure that physicians practice on the top of their license, because that's how you make money, and that means that when you need to track down medical record from an outside hospital its someone else's job. I think its frustrating as a resident that, when you're working 80 hours a week in 'training', 10-20 of those hours you are mainly working to keep the hospital from having to hire a 25K/year unit secretary.

 

[dozitgetchahi]

This is always a tough question, because I could give a long list of small, easy reforms that would make the medical training process at least palatable. However to truly make this profession really better, to me, would involve a few big reforms. I would basically eliminate residency as it currently exists.

To me, the root of all evil in the residency system is that residents cannot, practically, quit their jobs. We are treated no better than indentured servants or apprentices ever were, back when that was a standard model for career training. Almost all of the other things that people complain about in medicine are either symptoms of that underlying disease, so the goal of any significant form would be to give residents the same freedom of movement between employers that other skilled entry level employees have.

I think the new model for medical training should be the current model professional engineering training. That was my last (brief) job. A lot of people don't know this, but you need a license to be an engineer, just like you need a license to be a doctor, and to get a job you need to develop area of expertise beyond the minimum required for the license, just like board certification for a doctor. I think most people would agree that signing off to ensure that a 70 story building doesn't fall down is every bit as life and death a task as managing septic shock. However their system of training for engineers is decentralized and free market. There is no federal funding, no formal training process, and if you don't mind working under someone elses license indefinitely there's no reason you need to pursue board certification at all. The result is that, without a single work hour rule or federally mandated inspection, engineering has a created a training process so benign that most people are only peripherally aware they're going through it.
So my reforms:

1) Like engineering, allow an unlicensed physician to work under a licensed physician, indefinitely. The NP/PAs have already established that such an unlicensed provider is valuable enough to hire

2) Like engineering, allow any group of licensed physicians to supervise the training of unlicensed physicians. No more giant, formal training programs. If you want to be a licensed Family doctors the first step should be to join a Family practice group` as an unlicensed physician

3) This is the key one: working for licensed/certified physicians should be the experience that brings you closer to being a licensed/certified physician. There is no difference between working under someone else's license and training, and we should stop pretending that there is.

4) Make those credits towards board certification separable and portable. Say you want to be a Pediatrician: well lets say you need 6 months of supervised experience on the Peds wards, 6 months of NICU/nursery, and a year of Peds clinic for that (simplified schedule). If you can get that all in one practice, great. If you get that by working at 4 locations within 2 years, or over 5 years, also great. No one needs to be trapped in one job because they are half way through the certification process. Also make these credits universal across certifications so that switching between similar specialties requires a shorter training process.

5) Harness the power of the Internet for the didactic requirements, and continue to use prometric for the formal testing. Let employers focus on just evaluating a trainees work.

When physicians in training really have the power to leave their current jobs for better jobs, not just theoretically but practically, this will be a profession worth joining. I promise, the 80 hour weeks, the abusive bosses, the pointless secretarial work: it will all disappear almost overnight.

I like these ideas. I don't know how workable some of this stuff is, but it's the right type of thinking. The problem with residency training is that it's an arena where there has been very little critical thinking for at least the last 50 years. The whole physician training ecosystem is set up around the current system, and you go through it because 'that's what you do' and that's what your superiors did and they don't know anything else and they think you should do it too because, well, that's the only way you can possibly become a competent doctor.

But what if there are other equally effective ways? Nobody ever wants to ask this question.

 

[NotAProgDirector]

I mostly agree. The training system we have is antiquated and should be reformed.

One big change in the last ~5-10 years is the separation of inpatient, outpatient, and ED work. It used to be that "internists" (or FP's) did all of that. Now, that's rarely true. Therefore, I think there should be two different pathways:

Inpatient training would remain much as it is. It's probably best that is delivered in academic, tertiary care programs. One could argue whether it really needs to be 3 years long -- or 2 years, followed by a specialty or a third year of being a hospitalist (at a junior faculty level and pay). Or, inpatient training could be 2 years, and in/out combined training could be 3.

Outpatient training would be 2 years. It would be all outpatient -- no ICU, wards, etc. There would be lots of clinic, and subspecialty clinic. Community sites could definitely set up programs like this.

Fellowships could pick applicants based on their prior training. Endo might be more interested in people with outpt training, whereas Cards might prefer inpatient (or dual).

Funding could be via GME (the IOM report on GME suggested something like this), or by letting residents bill at the same level as PA/NP's.

I'm not wild about letting people just go to random offices to train. I do think that there should be some oversight and rules about what constitutes training. Else, I worry that new grads will simply be told to go "see some patients". That's what happens with NP/PA grads, and it's really bad.

Everything except the funding changes is in full control of the ACGME, and the Boards.

 

[Perrotfish]

I'm not wild about letting people just go to random offices to train. I do think that there should be some oversight and rules about what constitutes training. Else, I worry that new grads will simply be told to go "see some patients". That's what happens with NP/PA grads, and it's really bad.

The security in this system is that the unlicensed provider has no legal responsibility for their actions, the supervising licensed provider is on the hook for anything that happens. A new, unlicensed civil engineer could be told to 'go build a bridge' without any oversight or guidance, but that never happens, because he's not the one that faces penalties when the bridge falls down. I see no reason why it would work any difference with a new, unlicensed physician working within a licensed group.

Honestly I think the NP/PA system has proven how well this works. After all the dire predictions they did not, actually, appear to have bad outcomes. I can't imagine a medical student with two years of clinicals under his/her belt wouldn't do at least as well. The only problem I have with midlevel training is the much more recent system where they are now going out to practice under their own license, immediately. I feel like that's swinging too far in the other direction. As long as unlicensed grads can only work under someone elses license I don't think there would be a problem.

 

[QofQuimica]

To me, the biggest issue with the system is how much debt students have to go into in order to attend med school. By the time they are halfway through med school, most med students can't afford to quit even if they start their clerkships and realize they've made a huge mistake. How else are they supposed to pay off those six figure loans if they don't see it through and become attendings?

My background is in chemistry. If a grad student decides they don't like grad school any more and want to quit, they can quit, at any time, without being in six figure debt. Dropping out of grad school also doesn't mean they could never go back. In fact, I did quit my first grad school with my MS, worked for a while, and then went back (to another school) to get my PhD. This degree of training flexibility is obviously not possible for a medical student, because unlike having an MS in chemistry, having half an MD is a useless degree. However, the huge debt burden that most med students take on adds even more to their woes if they find they need to redirect their career path in the future.

So analogously, I think one could make a valid argument for shortening medical school to three years as well. Look at how many schools are already condensing their preclinicals into 1.5 years or less instead of the standard two years. And not that the second half of MS4 year wasn't fun, but it wasn't exactly the most high-yield part of med school in terms of educational value. With some med schools charging $50,000+ per year in tuition, why not lop off the wasted year and give people who need a way out of medicine a fighting chance to be able to afford to get out? Because even a residency salary is better than another year of taking out loans.

On a related note, another thing we do really poorly at is teaching trainees about how to manage their finances. Some of my unhappiest colleagues are the ones who are working the most hours trying to pay for the most stuff. Someone needs to clue in the premeds and med students that, while you can reasonably afford just about anything you want as a physician, you can't afford *everything* you want. And definitely not as a resident or even a brand new attending.

 

[Perrotfish]

To me, the biggest issue with the system is how much debt students have to go into in order to attend med school. By the time they are halfway through med school, most med students can't afford to quit even if they start their clerkships and realize they've made a huge mistake. How else are they supposed to pay off those six figure loans if they don't see it through and become attendings?

My background is in chemistry. If a grad student decides they don't like grad school any more and want to quit, they can quit, at any time, without being in six figure debt. Dropping out of grad school also doesn't mean they could never go back. In fact, I did quit my first grad school with my MS, worked for a while, and then went back (to another school) to get my PhD. This degree of training flexibility is obviously not possible for a medical student, because unlike having an MS in chemistry, having half an MD is a useless degree. However, the huge debt burden that most med students take on adds even more to their woes if they find they need to redirect their career path in the future.

So analogously, I think one could make a valid argument for shortening medical school to three years as well. Look at how many schools are already condensing their preclinicals into 1.5 years or less instead of the standard two years. And not that the second half of MS4 year wasn't fun, but it wasn't exactly the most high-yield part of med school in terms of educational value. With some med schools charging $50,000+ per year in tuition, why not lop off the wasted year and give people who need a way out of medicine a fighting chance to be able to afford to get out? Because even a residency salary is better than another year of taking out loans.

On a related note, another thing we do really poorly at is teaching trainees about how to manage their finances. Some of my unhappiest colleagues are the ones who are working the most hours trying to pay for the most stuff. Someone needs to clue in the premeds and med students that, while you can reasonably afford just about anything you want as a physician, you can't afford *everything* you want. And definitely not as a resident or even a brand new attending.

These are, undoubtedly, huge issues facing all of higher education. Its not just physician: every dentist, vet, lawyer, and midlevel is staring down the barrel of a large amount of non-dischargeable debt. So are a depressing number of undergrads, MBAs, masters students, and even PhD students (while a good PhD will tell you than an acceptance without funding is a polite rejection, there are plenty of dumb ones paying full price). And I agree that this system has effectively trapped a large portion of America's smartest into single career paths.

I would personally vote for bringing back bankruptcy as a method for discharging student loans, and making schools responsible for the principle of any loans discharged in bankruptcy court. Actually I believe bankruptcy needs to be a constitutional right. When lenders don't assume any riskwith their loans then lending becomes usury. The federal government has turned into the world's biggest loan shark.

I still think that the abusive nature of residency is the bigger issue facing medicine, though.