salary

[JackADeli]

Never mind, not worth it. based on other threads, it appears you are just looking for some sort of debate/s. Good luck

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[45408]

Never mind, not worth it. based on other threads, it appears you are just looking for some sort of debate/s. Good luck

No? Based on what other threads?

Your time in college is your choice and not the issue for the residency, nor is your choices of research, or future fellowship. My primary education emcompassed 18 years, and what? should I have felt undergrad should pay me? Maybe, adding med-school to that, it encompasses 21/22 years, should med-school pay me, enable me to have a family??? Depending on the choices you make, you can be working as an attending by age 35 or less. You can then work until 70 if you like.If you want to read it that way fine. My point isn't even talking directly about decreasing training hours, call, etc... It is talking about the issues of increased income and the commentary that suggests an individuals family making decisions should be in some way the obligation of the residency. There are numerous residencies around the country. An individual should shop wisely. But, your career/specialty choice and family choices are really yours and yours alone.

If you want to read it that way, fine, but I think most people are simply saying that $10-14/hour for a resident's labor is a pittance, and the average citizen would agree. I don't know why you think I'm saying my life decisions should change my residency obligations, because I never said as much.

 

[JackADeli]

Never mind, not worth it. based on other threads, it appears you are just looking for some sort of debate/s. Good luck

No? Based on what other threads?...

TheProwler, wasn't directed at you, rather the post before my comment. I initially posted a reply and then decided to delete its contents. Based on the individual's need to just argue and insisting on distracting another thread looking for definitions of extortion, etc....

...The "salary" of a resident is supposed to technically be a stipend. A resident never was intended to be viewed as a longterm "career employee". The original intent was to provide adequate income to allow payment of basic living supplies to support the individual trainee during training. ...It is a slipperry slope and soon we will hear more and more about how much family support undergrads should receive!

The original intent was stupid then. Why should I have to eke out a few shekels for "basic living supplies" after spending nearly a decade in post-secondary education?

...putting children off until you're an attending is asking too much for many people. If you're willing to wait, that's great, but it shouldn't be obligatory. My program does pay enough for all of us who are married to have children, and I think that's how all places should do it.

...I don't know why you think I'm saying my life decisions should change my residency obligations, because I never said as much.

I will leave to everyone to choose and look at the sum total of points made on this topic and not just to you specifically. I have not said YOU should have different obligations towards your residency because of your life decisions. Though, I have known plenty that wanted that as well. Thus my examples of individuals complaining about getting priority for certain holidays and such.

What I am reading from your posts is that your residencies' obligations TO YOU apparently should be different or take into account your life decisions. Thus your argument/position that residency should be paying enough "for all of us who are married to have children".

...a little rhetorical... You write, "My program does pay enough for all of us who are married to have children, and I think that's how all places should do it...". Ok, so then who decides what "enough" is? Should it be "enough" for just a spouse? a spouse and a kid? maybe a spouse and a kid a year? a spouse, kid/s, in an apartment? maybe home ownership? Or is it up to the individual residents? i.e. you decide you want to own over rent and the program should provide more to enable you to do so? you decide to own, should there be alotted time off for home shopping, mortgage counseling, banking, etc...? Should there be a graduated pay system so residents that are single have "enough" with less then is given to those making a family? We should "means test" residents to determine their incomes...

 

[JackADeli]

...I don't think it's about residencies providing a wage that allows for a person to raise a family, if that was the case a lot of jobs wouldn't pay enough. To me it's the simply question of whether the wage is congruent with the work being done. I just don't believe that 10-14 dollars an hours is a fair wage for someone who has gone through 8 years of training prior to residency and who is providing care and taking the responsibility for patients at a level that is more advanced than a RN, NP, PA...

And, I follow what you are saying. However, the issue still remains that you are getting a stipend to help cover your living expenses during TRAINING. I understand everybody wants to keep pushing these comparatives between residents and mid-levels. You may have a broader based knowledge then a mid-level. In the end, you are not a midlevel and you are still in training.

Most mid-levels I work with have a high volume of precise experience that makes them worth their money. I will not expect nor have I seen a resident with that specific focused level of expertice. A mid-level that just does one lmited group of tasks over and over again, twelve months out of the year will be better at that task then a resident transiently rotating on the service. I do not train residents to be more technically skilled then my PAs at the limted scope they work. It is just as I do not claim to be the difficult peripheral IV placer. The nurses, even the low experienced floor nurses have put in more IVs during a week then I have done through my entire general surgery residency.

So, accept that you are not a mid-level. Accept that this "better then" comparison is very flawed. Understand you are being trained to do more and assume greater responsibility.

Your "responsibility" falls UNDER the attendings' responsibility. Your work as a trainee is not billable in the vast set of circumstances. Also, as I alluded to earlier, once "billable" aspects get rolled into residency considerations, residents will become even less focused on the appropriate balance of training. This potential conflict can not be understated. Mid-levels do not enjoy the protections of residency. They do not enjoy any protected teaching time, post-call home, work hour limits, etc... That is because they are done and working within there trained career. You are there with a focus on training.

The very continued comparisons to midlevels and claims for need for ~billable equivalence, etc... is a very big distractor. Residents seem to be forgetting why they are in residency. That is, you are there to be trained. You are not there as a career employee. You are not there to prove superiority to a mid-level.

...It's easy to say well you signed up for it, you knew what you were going to get paid but this isn't a fair arguement. If you go through medical school, you are obligated to finish a residency if you want to be board certified so it's not truly an option.

It is not just about board cert. It is about being FULLY trained and FULLY competent. You are definately NOT fully trained until you complete residency. You may not even be fully competent in your specialty once you complete residency. It may take some years of practice after graduating to achieve full competency. But, you should be "safe" when you complete residency.

 

[JackADeli]

Legally speaking, I don't think residency salaries are considered stipends as residents have been determined to be employees rather than simply students...

It gets a little convoluted from what the legal status is... But, recent decision to reimburse ~tax withholdings I think were based on residents being trainees under federal funding. Also, most residents work under a trainee license with presumed inherant supervision. Finally, if it is correct that termination from a training program does not enable collection of unemployment..... I just don't know.

...I don't think that the comparisons are done to say I'm better than a midlevel. The truth is residents realize they are not at the clincal competency of an attending but look at other clinicians and realize that they are as competent or more competent (in a broad sense) as midlevels and question the compensation differences...

IMHO, this is a grass is greener distration and looses track of the main purpose you are there. Yes, "broad sense", but I don't need nor do I want to pay bigger dollars for a "broad sense". I want a mid-level that is fast, efficient, follows my instructions, and I can depend on them to be there month after month for those tasks. That is not a resident. A resident is being trained/groomed to be the leader not the to be minutia. I can do many things any member of the team can do. But, their tasks are not my strength they are their strengths..

...There is an expectation of competency for MD/DO which is achieved through residency and years of practice. However, we let mid-levels perform some of the clinical tasks residents due without a true measure of competency (no residencies, limited post-graduate training) and compensate them well without true validation. Dont you see that as a concern? ...

Not my experience with mid-levels. They are supervised when fresh grads and watched as they repeat the same few tasks over and over again. Every institution I have been at has a probationary period for mid-levels and their credentials are applied for with a supervising physician attesting to their competency. Also, they are required to show numbers of procedures, etc... So, no, I do not see it as a concern as their competency is validated/vouched for through a physician assuming the responsibility for task specific training and liability. The physician has a vested interest, putting their license on the line, to not over extend their mid-levels.

...Further, some states allow for residents after an internship to be given a full medical license, without being BE/BC. If a state is saying that you are competent to hang up a shingle and practice medicine independenly shouldnt that be recognized in compensation to residents?

Each state has its own licensing quirks. Being fulling licensed/unrestricted does not equate full competency. The fact is compensation is now being paid differently based on complete or did not complete residency? board certified or not board certified? So, full license means you have enough broad based knowledge that the state trusts you will behave safe. It does not indicate general competency in any particular tasks nor does it indicate entitlement to hire compensation. My mid-levels are competent in what they do and do over and over again. They have since surpassed me in their ability to do some tasks faster and more meticulous then I because they have surpassed me in shear volume of experience doing it. So, my answer to that question, no.

 

[Hernandez]

It gets a little convoluted from what the legal status is... But, recent decision to reimburse ~tax withholdings I think were based on residents being trainees under federal funding.

http://www.scotusblog.com/case-file...dical-education-and-research-v-united-states/

for now, the IRS considers residents employees. for all legal purposes, unless the SCoTUS changes dicta, we are employees with none of the protections of employees,

 

[JackADeli]

I am not sure the IRS still holds the position as you describe:

http://www.irs.gov/newsroom/article/0,,id=219731,00.html
...The Internal Revenue Service has made an administrative determination to accept the position that medical residents are excepted from FICA taxes based on the student exception for tax periods ending before April 1, 2005, when new IRS regulations went into effect...

But, based on there proposed and fought rule changes, maybe they do and thus their multiple legal losses.

... for now, the IRS considers residents employees. for all legal purposes, unless the SCoTUS changes dicta, we are employees with none of the protections of employees,

It is not so much what the IRS considers as much as what the courts/law considers. The IRS needs to split the decisions to get to the supremes.

http://findarticles.com/p/articles/mi_m3257/is_1_63/ai_n31297914/

 

[Hernandez]

I am not sure the IRS still holds the position as you describe:
But, based on there proposed and fought rule changes, maybe they do and thus their multiple legal losses.It is not so much what the IRS considers as much as what the courts/law considers. The IRS needs to split the decisions to get to the supremes.

http://findarticles.com/p/articles/mi_m3257/is_1_63/ai_n31297914/

i don't think you've actually read the history of the FICA rule changes and the legal challenges in regards to how they are being played out in the scotus. the irs was wrong in their initial enforcement of their own regs in collecting the fica from residents, that has been refunded to many who payed into it during those time, the current lawsuit is directed at the now codified IRS regulation which does not exempt residents from student status in regards to the FICA tax, that's whats being challenged, mayo wants residents to be classified as students as it will save them money, the irs wants their fairshare, and if you're read the transcript of the oral arguments, i think the scotus is going to side with the irs on this topic.

 

[JackADeli]

...That's what I see more value in what the resident does and believe that their compensation should be in line with or exceed the midlevel despite the "training" tag.

In the end, you are NOT competing with the mid-level. Hopefully, you will never be an excellent mid-level. This need to point at everyone around you and start making comparisons and feeling under-valued as compared to the person next to you in another field is insane. Great, I think I should be compensated more then a pro-athlete. The school teachers believe they are more important cause, "the children are the future...". Plenty of specialties think they contribute more then they are compensated in comparison to others. By all means, get into residency, get all caught up thinking you are more valuable then this person or that person and being treated unfairly. Good luck. I have been at residencies that toyed with the idea of some compensation differential. Of course, based on hours and number of patients, surgery was going to be paid more then ER and IM. Both had caps in patients and hours (hours below surgery).

So, go ahead and get caught up in this mentality. You may just get what you ask for.... some sort of "financial justice". The problem is that when you graduate, good luck in finding a job that pays you "fairly". At that point you may cite how you spent so many years in residency getting paid "x". The response will be, yep you protested and got paid "x" as you asked. Now, to pay residents "x", we have cut attending level income and we (probably the government) are now going to dictate even more of your career... cause we paid you "x". In fact, while everyone was going bankrupt and unemployed, we paid you "x", gave you a steady and secure job with better benefits then many....

Of course, coming from the otherside are all the midlevels, wanting to be paid the same for doing "the same" jobs..... So, best of luck in setting your short sighted vision of fair market value as a trainee. Think long and hard about where and when you want to get your pay out. You will likely only get to cash the fair pay chips once.

 

[NotAProgDirector]

There are several arguments made on this thread:

1. That residents have many years of post-grad training, and hence should be paid more. This is silly. Ask anyone with a PhD and lots of post grad training -- they don't necessarily get paid much more than those who simply went to college (or less education, for that matter). Same with law school -- many graduate and are unable to find work at all. More school doesn't necessarily mean more money.

2. Residents do the same / better work than NP/PA's, and hence should be paid more. As mentioned, this is complicated. In IM, I'd rather have a PGY-3 than a PA (in general). However, PGY-1's are much less useful. Also, as mentioned, residents rotate on a bunch of services -- IM, ED, ICU, electives, etc. PA/NP's get assigned to a job and then just do it, day after day. That consistancy is worth lots, even though they may work less hours. Residents doing electives really don't help me at all.

3. Residents bring in much more money than they are paid, so they should get paid more. As mentioned, this is complicated. Residents cannot bill for anything, although they can make it easier for me to bill (or allow me to bill more "events"). It all depends on how you measure this as to whether residents make or lose money for an institution.

In the end, resident salaries are where they are because of economics and supply/demand. Residents must complete residency programs to be licensed / trained, hence salaries will reflect this. As mentioned, if I paid based upon true utility, PGY-1's might pay me for the first several months of training, and certainly for each elective month which doesn't help me at all.

 

[JackADeli]

...In the end, resident salaries are where they are because of economics and supply/demand. Residents must complete residency programs to be licensed / trained, hence salaries will reflect this. As mentioned, if I paid based upon true utility, PGY-1's might pay me for the first several months of training, and certainly for each elective month which doesn't help me at all.

Which is ~true. As pointed out through out this thread, plenty of private practice and community hospital physicians that run their services without the almighty 14Kt lined residents.

Everyone can grumble amongst themselves about how much more value they add and how unfairly paid they are. Or, you can loose your illusion by marching into your PD's office. Go, tell him/her how unfair the pay structure is, point at all the mid-levels and explain how you are worth more then them.... I am certain, as you pack your belongings and head home, out of a residency training, you will still be grumbling about fair and how much you are worth!

 

[JackADeli]

...I am not saying we as residents are competing with mid-levels. I compared residents to mid-levels because both are clinicians to some degree or another below the level of an attending. I don't think it's as much a stretch as you are making it to compare 2 different sets of clinicians based on training, hours, and level of responsibility delegated in order to determine a differential in compensation. I am also acutely aware that in medicine we are all fighting for a bigger piece of the same pie and that if one group (i.e. residents) grabs a bigger piece it could affect another group (i.e attendings). I would argue that instead of taking from attendings as you suggest, there might be a middle ground with non-attending staff (i.e PA/NP's) who based on my previous posts make significantly more than residents for less education, hours, and responsibility...

In other words, you sugest a comparison in compensation between residents and mid-levels, then discuss pay cuts to mid-levels for pay increases to residents based on educational/responsibility/job description.... I think I/we got this numerous replies previous. Again, it is in fact a comparison between fields. How you figure this comparison and then subtraction in income from one group to add to another is not a competition; I do not know.

You are not there to be a mid-level or even be trained as a mid-level. As to mid-level income, as noted, it is largely based on supply/demand market. Mid-levels are limited in number and availability. The need for them dramatically increased as a direct response to a strong market force, i.e. ACGME work hours. In other words, the need for residents to work less presented a need for additional mid-levels. This increased demand has helped fuel the income levels of mid-levels. In private practice, where there are often no residents, mid-levels again command good incomes if they are good. And, if they are good, they are worth it. Still, while the rise in academic centers need to hire resident substitutes/replacements (i.e. midlevels) stems largely from cuts in resident labor, now an argument to also increase resident income. So, let us cut mid-level incomes for resident income and/or benefit increase. Then we will see what caliber mid-levels teaching centers attract vs private sector. Best of luck.

 

[45408]

Which is ~true. As pointed out through out this thread, plenty of private practice and community hospital physicians that run their services without the almighty 14Kt lined residents.

Everyone can grumble amongst themselves about how much more value they add and how unfairly paid they are. Or, you can loose your illusion by marching into your PD's office. Go, tell him/her how unfair the pay structure is, point at all the mid-levels and explain how you are worth more then them.... I am certain, as you pack your belongings and head home, out of a residency training, you will still be grumbling about fair and how much you are worth!

Your program would have fired you for saying you didn't think you were paid enough? Wow.

 

[JackADeli]

...As someone who has gone through the training process it seems you are more pro mid-level than pro physician.

There in is the classic closing line.... Now, as I am not supporting your theories and agenda (arguably having more experience and training in these matters), I am thus ~traitor or on the ~enemy side. This is a discussion, however, about your comparative of RESIDENTS to the mid-levels. Very sublime.

The silly and unsophisticated marginalization argument aside, I wonder... How many PAs exactly are in any residency division. Are we talking 1 PA for 5 residents? In surgery, is that 5-7 PAs for all 25 +/- residents in the program? So, if they are earning $80k/yr. With, a good portion of it being billable revenue generation, how much does one purpose cutting their incomes? Will they stay or go into private practice to avoid pay cuts? If their cuts do not meet you salary increase needs, do you cut nursing? pharmacy? The janitorial staff? Maybe, as we watch an exodus of mid-levels to greener pastures, we should have government intervention and mandate all mid-levels complete a service tour at a teaching hospital....

Yes, it is competition no matter how many seperate paragraphs you split it. To say ~I am worth more then they [insert multiple paragraphs] thus they should have income taken and given to me... or their income should be cut to fund my income increase. At its core, your argument hinges on the belief that residents are better then mid-levels, residents are worth more then mid-levels, residents should be paid more and mid-levels be paid less.

The reality is that once a resident graduates from residency, they will seek a job. Based on current trends/markets, the grad will be ~overpaid for 1-3 years. That is, they will be given a clinical base pay guarantee higher then what they are billing/collecting. The strategy is to float them while they build a practice and market share/value. It is the same with mid-levels. Though, it is on lesser sums of money.

The mid-level will start at a teaching institution at $45-85k? They will work within one service, doing the same thing over and over, day to day, month to month. They may not be worth the base salary initially. However, with that consistency and dependability they will be worth it in about 12 months (unless the service is really low volume to begin with).

A resident is NOT training to be a mid-level. I do not want a resident on my service to be a mid-level. I want a resident to be on my service to learn what the need at this step of their training to move to the next step and ultimately to something more when they are fully trained. i definately do not want any resident that is staring at mid-levels and thinking the grass is greener and spending anytime debating with me how much more they are worth then the mid-levels. I have been there and I know what a resident is capable of and what they are worth. They are a future investment and I am not going to start paying-out and paying short today, prodigal son and all....

 

[infarct]

There in is the classic closing line.... Now, as I am not supporting your theories and agenda (arguably having more experience and training in these matters), I am thus ~traitor or on the ~enemy side. This is a discussion, however, about your comparative of RESIDENTS to the mid-levels. Very sublime.

The silly and unsophisticated marginalization argument aside, I wonder... How many PAs exactly are in any residency division. Are we talking 1 PA for 5 residents? In surgery, is that 5-7 PAs for all 25 +/- residents in the program? So, if they are earning $80k/yr. With, a good portion of it being billable revenue generation, how much does one purpose cutting their incomes? Will they stay or go into private practice to avoid pay cuts? If their cuts do not meet you salary increase needs, do you cut nursing? pharmacy? The janitorial staff? Maybe, as we watch an exodus of mid-levels to greener pastures, we should have government intervention and mandate all mid-levels complete a service tour at a teaching hospital....

Yes, it is competition no matter how many seperate paragraphs you split it. To say ~I am worth more then they [insert multiple paragraphs] thus they should have income taken and given to me... or their income should be cut to fund my income increase. At its core, your argument hinges on the belief that residents are better then mid-levels, residents are worth more then mid-levels, residents should be paid more and mid-levels be paid less.

The reality is that once a resident graduates from residency, they will seek a job. Based on current trends/markets, the grad will be ~overpaid for 1-3 years. That is, they will be given a clinical base pay guarantee higher then what they are billing/collecting. The strategy is to float them while they build a practice and market share/value. It is the same with mid-levels. Though, it is on lesser sums of money.

The mid-level will start at a teaching institution at $45-85k? They will work within one service, doing the same thing over and over, day to day, month to month. They may not be worth the base salary initially. However, with that consistency and dependability they will be worth it in about 12 months (unless the service is really low volume to begin with).

A resident is NOT training to be a mid-level. I do not want a resident on my service to be a mid-level. I want a resident to be on my service to learn what the need at this step of their training to move to the next step and ultimately to something more when they are fully trained. i definately do not want any resident that is staring at mid-levels and thinking the grass is greener and spending anytime debating with me how much more they are worth then the mid-levels. I have been there and I know what a resident is capable of and what they are worth. They are a future investment and I am not going to start paying-out and paying short today, prodigal son and all....

boom

 

[wild0ne]

.

 

[LADoc00]

It is quite well known in the past that residents made significant sums of money at least for Pathology departments by saving huge amounts, sometimes in the 7-figure range, on PAs academic centers didnt have to hire.

This creates a visible non-level playing field with community hospitals who often compete for outpatient pathology referrals with local physicians with cash hungry academic centers in the area.

Where a community hospital spent 1-2 FTEs/Pathologist on PAs/lab assts., academic centers could save those FTEs and hire marketing reps, doing advertising etc.

 

[JackADeli]

...As someone who has gone through the training process it seems you are more pro mid-level than pro physician.

...So yea, do I expect someone who has gone through residency to have a little more support for their fellow residents, absolutely...

Yes, and so your asertion/implication remains, i.e. since I do not support YOUR position or YOUR argument, I am in some way not showing sufficient support for residents or fellows in general. You are wrong.

I support medical students, residents, fellows, & practicing physicians. I just don't support YOUR arguments or YOUR position. From my perspective, having actually completed residency & fellowship, having spent years during & after residency actually fighting for trainees, I find your position both arrogant and ignorant. I find it to be very narrow minded and short sighted. You are arguing:

I am not competing with midlevels, I just think I am worth more and they should have to have pay cuts to support increasing my salary.

Well, I am seeing similar arguments at every level. As noted, here or elsewhere, grad students have made almost all the arguments in this thread in reference to them being educated, numerous years, more then students/trainees, etc. Mid-levels are arguing for independent practice AND "we should be compensated the same as a fully trained attending for doing the same work". Some specialties are arguing they are worth more then other specialties. Thus, the other specialties should have pay cut to increase these individuals' income.

All of this in fighting and claims of worth will get you what you are fighting for... but it may prove to not be what you are looking for. The different organizations are going to continue to promote these fights. Some specialists are going to continue to see cuts. Those arguing for them will likely NOT see increase pay. Rather, funding will go to expand the number of physicians and not the compensation. It will also go to pay the mid-levels. The uninformed public will likely say "it's fair" for mid-level Mrs. X gets paid the same for her care as an attending physician. The public will also start agreeing that you are making ~a greedy and innapropriate argument to demand pay cuts in one healthcare field to increase your pay while at the same time demanding less work..... These things are not occurring in a vacuum.

I don't have a crystal ball. I just view your argument as naive, poorly informed, poorly developed and short sighted. The most convincing aspect is your resorting to the ~he's just against us position. That is the last resort of the pathetic. I am not going to try and prove my allegiances/loyalty/patriotism. And, you are not in a position to question them.

Best of luck.

 

[Coastie]

Where a physician can bill for work done, a resident does NOT bring in any billable production.


False. Absolutely and utterly false. RNs, however, do not bring in billable production, yet their value is high. What about nurse managers?


The federal government pays the hospital a set amount of money to the GME to cover resident costs. yes, residents are an expense.

False again. Residents are a net gain. Depends on specialty, but they definitely are a net gain for the hospital. Every resident means fewer attendings and midlevels around.


The issue is the number of ACGME approved residency spots at a given institution does NOT in most cases equal the number of federally funded spots. Most institutions have far more residents then funded spots.

False. Residents are funded, 1:1. There may be some exceptions, but it is very very very rare.


Long and short, there are costs associated with TRAINING and thus with you being a TRAINEE.

Keep the kool-aid flowin'.

Unfortunately, it is generally unbillable "work" and thus costs for insurance and benefits without actual reimbursement... see below.

everyone can get into a little peepy match on "salary" and use the "fair" word if you like. The issue is/are:

1. The residents' "work" that everyone believes is underpaid and should be by some peoples' opinions in the $80k range is suppose to be primarily educational, aka student learning.

2. Where a physician can bill for work done, a resident does NOT bring in any billable production. In fact, it is illegal outside of moonlighting... at a completely different institution then the sponsoring residency institution.

3. The federal government pays the hospital a set amount of money to the GME to cover resident costs. yes, residents are an expense. Many here apparently will argue they are more positive revenue then negative revenue.... However, see number 2 above. Also, the hospital must pay for your malpractice premiums, healthcare benefits, often dental, optical, disability, life, etc.... It also goes to help subsidize the lower volumes the physicians in theory perform at academic institutions in order to teach, etc....

4. So, I suspect many would want to know how much the federal gov pays per resident, and in general this can be 80-150K/yr. The issue is the number of ACGME approved residency spots at a given institution does NOT in most cases equal the number of federally funded spots. Most institutions have far more residents then funded spots.

5. Most undergrads and grads students are apparently able to fund themselves on financial aid and summer jobs... but are paying for their education. It seems as if plenty of people go from the negative income of medical school to the positive income of residency and suddenly need daycare money, vacation, etc....

Long and short, there are costs associated with TRAINING and thus with you being a TRAINEE. You can not work independently as a physician until you complete all USMLE and get an unrestricted license. But, you work under the protection and "supervision" of the training hospital. You can not really compare to a PA or NP. Once you have an MD you can't be hired in a lesser role... because you are now a physician which carries licensure requirements and malpractice coverage, etc.... For example, if a patient dies at a local nursing home where you are working part time as a janitor... you can't say, "it doesn't count cause I was not working as a doctor I was acting as a janitor...".

So, to all you undergrads, med-students, interns, ec.... Understand what residency pays, budget and do NOT get the misinterpretation that you should be paid "x" cause your a doctor and want to start a family, etc... during residency. You need to plan and budget. If you planned and budgeted well during undergrad and med-school, then you should find yourself a little better off now that you are moving into a little more positive income.

PS: go ahead and use the word fair regularly during medical school and residency.... explain to everyone what is fair to you and how much you provide. Keep in mind, numerous community hospitals are in the "black" and have no residents.....

 

[Coastie]

Wow.

Really?

Midlevels are better at patient care and technical abilities than residents?

Really?

Now we see where the loyalties are hiding...

And, I follow what you are saying. However, the issue still remains that you are getting a stipend to help cover your living expenses during TRAINING. I understand everybody wants to keep pushing these comparatives between residents and mid-levels. You may have a broader based knowledge then a mid-level. In the end, you are not a midlevel and you are still in training.

Most mid-levels I work with have a high volume of precise experience that makes them worth their money. I will not expect nor have I seen a resident with that specific focused level of expertice. A mid-level that just does one lmited group of tasks over and over again, twelve months out of the year will be better at that task then a resident transiently rotating on the service. I do not train residents to be more technically skilled then my PAs at the limted scope they work. It is just as I do not claim to be the difficult peripheral IV placer. The nurses, even the low experienced floor nurses have put in more IVs during a week then I have done through my entire general surgery residency.

So, accept that you are not a mid-level. Accept that this "better then" comparison is very flawed. Understand you are being trained to do more and assume greater responsibility.

Your "responsibility" falls UNDER the attendings' responsibility. Your work as a trainee is not billable in the vast set of circumstances. Also, as I alluded to earlier, once "billable" aspects get rolled into residency considerations, residents will become even less focused on the appropriate balance of training. This potential conflict can not be understated. Mid-levels do not enjoy the protections of residency. They do not enjoy any protected teaching time, post-call home, work hour limits, etc... That is because they are done and working within there trained career. You are there with a focus on training.

The very continued comparisons to midlevels and claims for need for ~billable equivalence, etc... is a very big distractor. Residents seem to be forgetting why they are in residency. That is, you are there to be trained. You are not there as a career employee. You are not there to prove superiority to a mid-level.
It is not just about board cert. It is about being FULLY trained and FULLY competent. You are definately NOT fully trained until you complete residency. You may not even be fully competent in your specialty once you complete residency. It may take some years of practice after graduating to achieve full competency. But, you should be "safe" when you complete residency.

 

[Holderlin]

JackAdeli is the Rocky Balboa of SDN. Just won't go down. I'm impressed.

 

[hrandani]

You know I would really just be satisfied if my loans would stop accruing interest while I was in residency. It's ridiculous that I have to take out all this money and then I'm expected to just sit there and watch the balance grow while I'm on a fixed income that was set well in advance of me even entering medical school.

 

[JackADeli]

...False again. Residents are a net gain. Depends on specialty, but they definitely are a net gain for the hospital. Every resident means fewer attendings and midlevels around...

You say that with such assurance. There is no good data to make that claim. The fact is mid-levels in numerous locations came second. They were hired to support the residents. In fact, when doing the surgery residency interview rounds over a decade ago, the sales pitch by the residents went something like, "the PD is really supportive of residents and education... it was bad before him/her. But, when they became PD they hired PAs & NPs and really made our lives easier...". Today, I still hear the residents use PAs & NPs as a sales pitch to interview candidates.

In the community practices, I see very high volume groups with less attendings then are in academic practices, less floor nurses, and no residents. I do not see that residents have meant less attendings or mid-levels. That is just not the math I have observed

...Midlevels are better at patient care and technical abilities than residents?...

Your words not mine. I am certain taking things out of context may help you feel like you are winning some imagined point. However, that is not what I have said.

...Now we see where the loyalties are hiding...

Yeh, sure, whatever you say. Again, the refuge of the pathetic.

 

[NotAProgDirector]

Where a physician can bill for work done, a resident does NOT bring in any billable production.


False. Absolutely and utterly false. RNs, however, do not bring in billable production, yet their value is high. What about nurse managers?

Your answer doesn't really address the question asked. There is a difference between "billable work" and "adding value to the system". Residents on the inpatient service, or in the OR, cannot bill by themselves. Faculty can use their documentation as a starting spot, expand somewhat, and bill. In some situations, that can allow a faculty member to be more "productive". In others, not.

Residents can take call at night and cover services. This also does not generate any billing, but it does add value.

The federal government pays the hospital a set amount of money to the GME to cover resident costs. yes, residents are an expense.

False again. Residents are a net gain. Depends on specialty, but they definitely are a net gain for the hospital. Every resident means fewer attendings and midlevels around.

This is not so certain. Yes, having residents often means less midlevels or faculty are needed. However, has been mentioned on many other threads, there are many costs to running a residency program -- PD and other support salaries, recruiting costs, outpatient clinic support, site visit costs, curriculum development, etc. Whether or not these end up being a "win" / "break even" / "loss" depends on how much you include, and especially on each hospital's IME reimbursement rate. For some hospitals, it's very high and it's clearly a win. For many it's much lower.

The issue is the number of ACGME approved residency spots at a given institution does NOT in most cases equal the number of federally funded spots. Most institutions have far more residents then funded spots.

False. Residents are funded, 1:1. There may be some exceptions, but it is very very very rare.

You are just plain wrong here. Many institutions are over their caps. Caps were put in place in 1997 -- most residency slot growth since then is over the cap. However, it's false that most programs have "far more" residents than funded slots. Most programs are probably 10-20% over their caps.

Wow.

Really?

Midlevels are better at patient care and technical abilities than residents?

Really?

Now we see where the loyalties are hiding...

Like most arguments that people feel strongly about, emotions get in the way. This is not what Jack was saying.

Let's use an example. I'm in IM, so my example will be in IM. This will not hold for all programs / fields / etc, but it's a place to start.

Let's compare a medicine intern/resident to a midlevel. Let's say I want to staff a medicine inpatient service:

Intern:
1. Essentially useless for the first 3 months, then OK for 6 months, then pretty good for 3.
2. Works nights / weekends
3. I need to cosign every note to bill it -- and not just sign it, I need to write my own note that "incorporates" the resident note.
4. Interns do 4 months a year of medicine wards, plus a half a month of night float. They then do 2 months of specialty wards, a block of ICU, research, outpatient, and elective time.

So, let's say we include all the specialty wards and ICU (which is a "best case scenario, since I really only care about my medicine wards). I get 9 months x 50% (since half of the time the intern isn't really helpful) = 4.5 months of quality coverage time, including nights and weekends.

PGY-2 resident:
About 8 months of coverage in my program. This time, all 8 months are "quality", so total of 8 months.

PGY-3 resident:
Much higher quality care, but less time. PGY-3 residents have only 3 months of assigned inpatient time. The rest is all elective, research, and outpatient time which is of "no value" to me.

Total = 4.5 + 8 + 3 = 15.5 months of coverage time in 3 years.

Midlevel: Works for 3 years (to equal training time for resident). Works M-F on the wards, no nights and weekends. That's all they do. First 6 months is "low quality" (note longer time for midlevel to get up to speed assumed, which is NOT necessarily true). 3 weeks of vacation each year (let's call it 1 month). So: 6+11+11 = 28 months of coverage in 3 years. And I don't need to cosign any of their notes, so I could manage my own patients (and hence perhaps be more financially efficient than working with residents).

If my goal is to cover the wards, the midlevel can be the better deal. In addition, I don't need to worry about noon conferences, morning report, clinics, retreats, the "educational quality" of the admissions, the number of handoffs, etc. They just work. And, if I can keep them for more than 3 years, I don't need to recruit new ones each year and they get even better. They become part of the hospitalist "team", rather than just "rotators".

Now, if my goal is to cover nights and weekends, then the resident may be the better deal. And, the resident comes with federal funding. So, from the institutional standpoint, the resident is almost always going to be the "better deal" financially. But, from a "boots on the ground" standpoint, I might be happier with the midlevel as they just do the work, come to staff meetings, and are integrated as part of the team.

The point is, it's not so straightforward. No one is "right" and "wrong". It all depends on what you're looking for, and what your local situation is.

 

[NotAProgDirector]

You know I would really just be satisfied if my loans would stop accruing interest while I was in residency. It's ridiculous that I have to take out all this money and then I'm expected to just sit there and watch the balance grow while I'm on a fixed income that was set well in advance of me even entering medical school.

I feel your pain. But someone has to pay the interest. If "no one" pays it, then the Bank does. Who do you think should pay the interest on your loans? The government? And if so, why?

 

[Holderlin]

You know I would really just be satisfied if my loans would stop accruing interest while I was in residency. It's ridiculous that I have to take out all this money and then I'm expected to just sit there and watch the balance grow while I'm on a fixed income that was set well in advance of me even entering medical school.

This is the real issue, actually.

They really should allow a true deferment.

 

[Holderlin]

I feel your pain. But someone has to pay the interest. If "no one" pays it, then the Bank does. Who do you think should pay the interest on your loans? The government? And if so, why?

What are you talking about? That money was created out of thin air. No one has to pay the interest. Loan payments are profit on top of profit.

http://en.wikipedia.org/wiki/Fractional-reserve_banking

And given just how huge some of these monthly payments are these days I think a non-accruing deferment (opposed to a forbearance) should be allowed. But of course this is just another layer of corruption with the banks/AAMC...

A $2000-$3000/month payment for someone making 30-50k, some of whom have families, is f**cking ridiculous.

 

[JackADeli]

You know I would really just be satisfied if my loans would stop accruing interest while I was in residency. It's ridiculous that I have to take out all this money and then I'm expected to just sit there and watch the balance grow while I'm on a fixed income that was set well in advance of me even entering medical school.

...A $2000-$3000/month payment for someone making 30-50k, some of whom have families, is f**cking ridiculous.

Everything in these statements speaks to individual personal decisions and what should be individual responsibilities. Nobody forced you to choose the education and ultimately career path you chose. Nobody forced you to take the loans. Nobody forces andyone to get married and/or have children. As you note, the general amount of expected income as a resident is well documented and should be well known by you long before you even enter medical school.

Why should a MD/DO in residency have loan interest freeze? How about a law school grad that is working/clerking(whatever the term is) as a junior in a firm on minimal income until they can gain a full status, should their loan interest be frozen? How about PhD students, should their undergrad student loans interest be frozen while they do their research and years towards the degree? How about the nurse that wants to be a nurse practitioner, should their interest be frozen during NP school? DNP school? What makes a resident MD/DO special and deserving of an interest freeze? Is it that they, out of most other possible examples, are most likely to see the greatest financial return on their loans when done with training?

...Who do you think should pay the interest on your loans? The government? And if so, why?

 

[Holderlin]

Everything in these statements speaks to individual personal decisions and what should be individual responsibilities. Nobody forced you to choose the education and ultimately career path you chose. Nobody forced you to take the loans. Nobody forces andyone to get married and/or have children. As you note, the general amount of expected income as a resident is well documented and should be well known by you long before you even enter medical school.

Why should a MD/DO in residency have loan interest freeze? How about a law school grad that is working/clerking(whatever the term is) as a junior in a firm on minimal income until they can gain a full status, should their loan interest be frozen? How about PhD students, should their undergrad student loans interest be frozen while they do their research and years towards the degree? How about the nurse that wants to be a nurse practitioner, should their interest be frozen during NP school? DNP school? What makes a resident MD/DO special and deserving of an interest freeze? Is it that they, out of most other possible examples, are most likely to see the greatest financial return on their loans when done with training?

Because deferments on educational loans are granted to those who are still in school, and as you keep reiterating, Residents are trainees at a latter stage of their medical education. The precise status of these trainees seems to be in perpetual debate, but allowing deferments I think would be within reason, especially considering the magnitude of these loans.

And of course most of your examples don't make sense because deferments are granted for people in school. Whether or not interest is accruing depends of the loan of course and the individual.

 

[JackADeli]

Because deferments on educational loans are granted to those who are still in school...

And of course most of your examples don't make sense because deferments are granted for people in school...

Ok, so eliminate the law school grad from the example. I don't think that equates to "most" of the examples. Change the law school grad to a law student, now everyone is a student.

...Why should a MD/DO in residency have loan interest freeze? [How about LAW SCHOOL students, should their undergrad student loans interest be frozen while they attend law school?] ...How about PhD students, should their undergrad student loans interest be frozen while they do their research and years towards the degree? How about the nurse that wants to be a nurse practitioner, should their interest be frozen during NP school? DNP school? What makes a resident MD/DO special and deserving of an interest freeze? Is it that they, out of most other possible examples, are most likely to see the greatest financial return on their loans when done with training?

Again should they all have their student loan interest "frozen" or paid by the government...

 

[Orbo]

Everything in these statements speaks to individual personal decisions and what should be individual responsibilities. Nobody forced you to choose the education and ultimately career path you chose. Nobody forced you to take the loans. Nobody forces andyone to get married and/or have children. As you note, the general amount of expected income as a resident is well documented and should be well known by you long before you even enter medical school.

Not that I disagree with this notion, but medical school and residency thereafter is unique because of both the cost and length of training involved. You keep saying that getting married and having kids is a choice, and while it is, no other field of training can utterly consume a person's life clear into their thirties. Perhaps not quite so much a problem for men, but for women, especially those who do not enter medical school straight from undergrad, they simply cannot reasonably delay childbearing for that long.

Why should a MD/DO in residency have loan interest freeze? How about a law school grad that is working/clerking(whatever the term is) as a junior in a firm on minimal income until they can gain a full status, should their loan interest be frozen?

As mentioned, they're no longer "trainees" (although it can be subjectively debated that they are still training...). Regardless, it is also known that lawyers who don't "make it big" soon after graduation[ also can run into fairly substantial financial problems especially if not well supported by the parents.

How about PhD students, should their undergrad student loans interest be frozen while they do their research and years towards the degree?

Conveniently forgot that med students also go through undergrad, thus physicians in training have an additional burden on top of what PhD students encounter. They receive a stipend similar to residents but do not have the burden of medical school debt which is in addition to and substantially greater than undergrad debt.

How about the nurse that wants to be a nurse practitioner, should their interest be frozen during NP school? DNP school?

Heh, yeah sure, if their training was so difficult so as to not be able to work while going to online DNP school

Don't forget length of training as well. For one reason or another, most physicians in training do a fellowship, increasing the years spent living with meager salary on massive debt load to at least 4 years for virtually everyone, and 5-7 years for most. DNP is 2 years after BSN, which is 4 years. 6 compared to 4 + 4 + (5 to 7)...

What makes a resident MD/DO special and deserving of an interest freeze? Is it that they, out of most other possible examples, are most likely to see the greatest financial return on their loans when done with training?

Depending on what field of medicine one decides to go into, the "greater" financial return after training isn't really so substantially great. Big name lawyers can make equal or greater than big name docs. And, not wanting to open a new can of worms here, but it's well known that nurse anesthetists can earn more than a family med doc with far fewer years of training required. That much is fact. Hell, most DNPs make similar to what bread and butter family med and internal med docs make. Besides that, what makes us "unique" is simply the length of training plus inability to acquire other jobs in the process (besides moonlighting, which as some have pointed out is becoming more and more a thing of the past). Truth is, for some of my classmates who get no parental support whatsoever and aren't privy to scholarships, I really do worry about how they're going to manage their debt even after they reach attending.

 

[JackADeli]

...no other field of training can utterly consume a person's life clear into their thirties. ...but for women, especially those who do not enter medical school straight from undergrad, they simply cannot reasonably delay childbearing for that long...

Have you been to med-school? Do you understand human reproduction? Woman can and do delay childbearing into their thirties; not just within the medical field either. As to women enterring medical school later in life, again, a personal decision. The individual makes different decisions, doesn't enter college straight out of HS or doesn't enter medical school strainght out of college, now her drive to reproduce is somehow the residency program's problem to accomodate, cause what she put off is now their emergency????

This thread is full of individuals wanting cake, frosting, ice cream, and a bedtime story. Life isn't fair and there are consequences for decisions. Sometimes, adults need to make a decision and accept the ramifications of said decisions.

...Conveniently forgot that med students also go through undergrad, thus physicians in training have an additional burden on top of what PhD students encounter. They receive a stipend similar to residents but do not have the burden of medical school debt which is in addition to and substantially greater than undergrad debt...

There is no conveniently forgot anything. I am quite aware of the different scenarios. I just find all this ~grass is greener over there, I want to stay over here but give me their grass arguments very, very sad.

...I challenge you then, how do you bridge the gap in compensation disparity or do you not believe in increasing resident compensation at all?...

Love that one, "compensation disparity". You can find that one discussed all night long in the FM forum. Or, you can go down to your local PTA meeting and hear that one, or the local fire house, or the college campus grad student associations.... let us not forget the out of work laid off folks, they talk about disparity in compensation all day long.

 

[Orbo]

Have you been to med-school? Do you understand human reproduction? Woman can and do delay childbearing into their thirties; not just within the medical field either. As to women enterring medical school later in life, again, a personal decision. The individual makes different decisions, doesn't enter college straight out of HS or doesn't enter medical school strainght out of college, now her drive to reproduce is somehow the residency program's problem to accomodate, cause what she put off is now their emergency????

Naw really, women can reproduce into their 30s? No way I could have known such advanced knowledge. Really. Dude. There's this thing called life, and it comes with this thing called unpredictability. I shouldn't have to say this because you're obviously all-knowing, but women have increased difficulty conceiving the older they get. Some women are unlucky and have a hard time getting pregnant past a certain age. Nobody knows who those people will be or when that age is. For some it can be as "early" as their mid-late 30s. So women are taking chances with fertility the longer they wait. It's not uncommon for undergrad degrees to take longer than 4 years, or for a person to work for a year or 2 before starting medical school. Tack on a 3-4 year residency and a 2-3 year fellowship and you can EASILY be in your mid-30s by the time they're attending. Add on another year or so to stabilize the career and another couple years if *gasp* a couple wants more than one child, and really, it's not unreasonable to argue that fertility is a limiting factor.

God forbid if a woman wants to specialize within surgery. Then she might as well have her uterus removed since she won't be needing that useless organ, right?

So yeah, it is something that residency programs should be aware of especially as training times are threatened to lengthen. Fortunately program directors aren't all made up of gods like yourself and instead are men and women that realize that sometime during the > 10 years of medical training, life actually happens.

.There is no conveniently forgot anything. I am quite aware of the different scenarios. I just find all this ~grass is greener over there, I want to stay over here but give me their grass arguments very, very sad.Love that one, "compensation disparity". .

Well you asked why medical training was unique and you got it. And this is the best retort you can come up with? Weak.

 

[JackADeli]

... There's this thing called life ...women have increased difficulty conceiving the older they get. Some women are unlucky and have a hard time getting pregnant past a certain age. Nobody knows who those people will be or when that age is. ...So women are taking chances with fertility the longer they wait. It's not uncommon for undergrad degrees to take longer than 4 years, or for a person to work for a year or 2 before starting medical school. Tack on a 3-4 year residency and a 2-3 year fellowship and you can EASILY be in your mid-30s by the time they're attending. Add on another year or so to stabilize the career and another couple years if *gasp* a couple wants more than one child, and really, it's not unreasonable to argue that fertility is a limiting factor...

And, in that whole song and dance, the fact remains, everything is hinging on an individual adult making life choices and the implication is that somehow for some reason in some way a residency program should have responsibility for those choices. I am very, very happy to see women in healthcare. But, as you note, women know the costs, risks, etc... They make their choices and if the are infertile at age 18 or having a healthy child at age 40 so be it. Again, you are arguing some sort of social justice point of view. If we want to be "fair", why not say undergrad is funded for women to enable childbearing? I mean, looking at the charts and such, it may be unreasonable to expect a woman to put off pregnancy from age 18/19 and potentially have a drop of +/-25% in their chance of getting pregnant.

All the "god" and "all knowing" distractors are cute, albeit primitive. Since you have some difficulty in complete quoting and/or splicing of what I wrote, I repost below and individuals can look back to the links to see the actual statement to which I was responding:

...There is no conveniently forgot anything. I am quite aware of the different scenarios. I just find all this ~grass is greener over there, I want to stay over here but give me their grass arguments very, very sad.

....Love that one, "compensation disparity". You can find that one discussed all night long in the FM forum. Or, you can go down to your local PTA meeting and hear that one, or the local fire house, or the college campus grad student associations.... let us not forget the out of work laid off folks, they talk about disparity in compensation all day long.

 

[Orbo]

And, in that whole song and dance, the fact remains, everything is hinging on an individual adult making life choices and the implication is that somehow for some reason in some way a residency program should have responsibility for those choices. I am very, very happy to see women in healthcare. But, as you note, women know the costs, risks, etc... They make their choices and if the are infertile at age 18 or having a healthy child at age 40 so be it. Again, you are arguing some sort of social justice point of view. If we want to be "fair", why not say undergrad is funded for women to enable childbearing? I mean, looking at the charts and such, it may be unreasonable to expect a woman to put off pregnancy from age 18/19 and potentially have a drop of +/-25% in their chance of getting pregnant.

Nice way to pervert the idea, but you missed the point. Undergrad women are in their 18-23 as you put it and experience no significant loss in fertility as opposed to the delay for those in medicine who can expect to train from 23-low 30s, at which time does become a significant factor. But I don't want to belabor this point too much because it's simply an example of the larger picture, which is that medical training continues to effectively lengthen due to the preponderance of fellowships and those of us in the midst of it are starting to realize that the light at the end of the tunnel is too far and too dim to wait for, particularly as the tunnel just keeps getting longer. This might come as a surprise to you, but they start to realize that career can no longer dominate their entire 20-30s and if they want to be like real human beings and want to LIVE, which includes but is not limited to getting married, having kids, and owning a house, that it's actually not reasonable to force trainees to perpetually delay their goals, as medicine has and continues to do for increased periods of time and with dimmer and dimmer financial prospects.

This is not an issue of "grass is greener on the other side." This has to do with the fact that medical training is indeed far longer than any other career choice and continues to lengthen with increasing need to super specialize. And to continue to tell trainees to "suck it up" and that them wanting to start a normal life sometime within their late 20s to early 30s is a "choice" in light of the above fact and that they should suffer just like those before is the same old crap we've heard from the older generation. Yeah yeah we know you guys worked 200 hours a week (sarcasm hint: there isn't 200 hours in a week), walked in snow uphill both ways to work, and did everything in the hospital from saving patients to moping floors to doing hospital accounting. Yeah we heard it all.

Medical school costs are increasing. Length of training is increasing. These changes are significant and continue to increasingly burden trainees. The first step is to recognize the problem, something you refuse to do, and the second step is to figure the solution, which is a whole new other topic that I won't go into.

All the "god" and "all knowing" distractors are cute, albeit primitive. Since you have some difficulty in complete quoting and/or splicing of what I wrote, I repost below and individuals can look back to the links to see the actual statement to which I was responding:

Yeah, it was, but more so was insulting my intelligence is also a cute, albeit primitive distractor as well. Frankly I do get tired of arrogant know-it-all attendings many of which are actually not quite as bright as they imagine themselves to be but so long as they keep telling themselves they went through hell and back during training then it's ok to abuse the younger generation.

I cut out the rest of your post not because I have difficulty splicing your post (another insult to my intelligence, which, by the way, I do not appreciate) but rather because it had NOTHING to do with my point. You asked why medical training was unique as compared to other careers and you got the answer. The rest of your post went off into some tangent about comparing compensation which while was discussed by others in this thread, was not a point I was making. Thanks and you can continue to be a condescending douchebag as you have been throughout this thread. I'm sure your students just love you.

 

[JackADeli]

...medical training continues to effectively lengthen due to the preponderance of fellowships and those of us in the midst of it are starting to realize...

Again, these are choices. One doesn't have to do additional fellowship if you do not want to. You can do pedes, IM, FM, any number of specialties on the shorter side if you CHOOSE. The tunnel only gets longer by the individual's choice. Other then failing to meet standards for promotion, I know of no residency that while one is in it they are told,~ oh, by the way, instead of 3 years we are going to extend the required residency to 4 or 5 years of training.... The vast majority of longer paths take a dedicated choice and quite a bit of work to achieve. It is sad for an adult to realize such realities late in the game.

...it's actually not reasonable to force trainees to perpetually delay their goals, as medicine has and continues to do for increased periods of time and with dimmer and dimmer financial prospects...

Again, these are choices made by adults to pursue a specific career path. Nobody has forced anyone into this path or forced them to not get married or not have children. But, if you choose to have children, that is on you. It is not the residency program of 3, 5 or 7 years responsibility to make things up to you because you did or did not choose to put things on hold.

...training is ...career choice and continues to lengthen with increasing need to super specialize...

Again, it is a career CHOICE. And, lengthening to super specialize is another choice and not an obligation or need. In fact, most medical groups are constantly citing the trainees desire/choice to pursue fellowship and super specialization as contributing to lack of available providers. The vast majority of individuals I know that do fellowships and/or super fellowships often cite as one of the primary reason, a desire to NOT do what they are trained to do. i.e. many do breast fellowship (yes they like it too) but largely because they do not want to do general surgery or general surgery call or trauma call, the same any multitude of other fellowships. It is often they like one thing and want that diploma to justify avoiding much of the "bread & butter". So, no there is not a "need" to super specialize. It is clearly a choice.

What this discussion seems to boil down to is avoiding ownership for choices. There is a vast amount of ~I am forced to do or I needed to do as if someone held a gun to your head or held you hostage. That is just not reality. General surgery is and continues to be primarily a 5 year training program and does not require additional fellowship. FM is and continues to be a 3 year training program. I have not seen significant growth in length of training and in fact more and more "integrated progrms" are arising to specifically shorten training. Any added time or delay in gratification is your choice.

...Medical school costs are increasing. Length of training is increasing. These changes are significant and continue to increasingly burden trainees...

Costs at university and med-school may be rising but I do not see how medical school length or residency training length is increasing.

...Frankly I do get tired of arrogant know-it-all attendings many of which are actually not quite as bright as they imagine themselves to be...

I always love the pre-meds' & med-students' perspective and judgement, especially when they haven't even gotten to a point of first hand experience to then make these comments and judgements. I especially loved the fellow med-students in med-school that actively investigated to see if they could get jobs as expert witnesses. Yep, I'm sure you know how bright these attendings are, yep, that's not arrogant at all....

 

[Orbo]

Again, these are choices. One doesn't have to do additional fellowship if you do not want to. You can do pedes, IM, FM, any number of specialties on the shorter side if you CHOOSE. The tunnel only gets longer by the individual's choice. Other then failing to meet standards for promotion, I know of no residency that while one is in it they are told,~ oh, by the way, instead of 3 years we are going to extend the required residency to 4 or 5 years of training.... The vast majority of longer paths take a dedicated choice and quite a bit of work to achieve. It is sad for an adult to realize such realities late in the game.Again, these are choices made by adults to pursue a specific career path. Nobody has forced anyone into this path or forced them to not get married or not have children. But, if you choose to have children, that is on you. It is not the residency program of 3, 5 or 7 years responsibility to make things up to you because you did or did not choose to put things on hold.Again, it is a career CHOICE. And, lengthening to super specialize is another choice and not an obligation or need. In fact, most medical groups are constantly citing the trainees desire/choice to pursue fellowship and super specialization as contributing to lack of available providers. The vast majority of individuals I know that do fellowships and/or super fellowships often cite as one of the primary reason, a desire to NOT do what they are trained to do. i.e. many do breast fellowship (yes they like it too) but largely because they do not want to do general surgery or general surgery call or trauma call, the same any multitude of other fellowships. It is often they like one thing and want that diploma to justify avoiding much of the "bread & butter". So, no there is not a "need" to super specialize. It is clearly a choice.

What this discussion seems to boil down to is avoiding ownership for choices. There is a vast amount of ~I am forced to do or I needed to do as if someone held a gun to your head or held you hostage. That is just not reality. General surgery is and continues to be primarily a 5 year training program and does not require additional fellowship. FM is and continues to be a 3 year training program. I have not seen significant growth in length of training and in fact more and more "integrated progrms" are arising to specifically shorten training. Any added time or delay in gratification is your choice.Costs at university and med-school may be rising but I do not see how medical school length or residency training length is increasing.I always love the pre-meds' & med-students' perspective and judgement, especially when they haven't even gotten to a point of first hand experience to then make these comments and judgements. I especially loved the fellow med-students in med-school that actively investigated to see if they could get jobs as expert witnesses. Yep, I'm sure you know how bright these attendings are, yep, that's not arrogant at all....

The irony that the old guard who argues that health care reform will drive non-procedural specialties into the ground being the same guys saying it's not "required" to specialize in order to stay afloat is not lost to me. Medical school tuition (and all higher education costs, for that matter) continue to rise year over year well above inflation rates. The financial pressure to go into a well paying specialty, if the drive was ever great before, is even greater now. So you ask, are we "forced"? Well obviously nobody is putting guns to our backs to super specialize, but the financial incentives and pressures are certainly there.

Saying everything is a choice is a very easy cop-out answer to any question for anything. Does anyone NEED to live in so gracious as a 600sqft studio, or god forbid a 2000sqft house?? No, humans can well live in 100sqft if need be. Do we NEED to be so extravagant with our every day meals or can we sustain on the bare minimum nutrients that many in 3rd world countries subsist on? Do we NEED to drive to work everyday or can we just ride bikes instead and get up 2 hours earlier to make the commute? Yeah, these are ALL choices are they not? Just about the best cop-out of all cop-outs.

And just because you've been an attending for how-ever many years doesn't mean you have a better or more insightful perspective about the current financial outlook for trainees in the present. It is apparent from your previous posts that you barely acknowledge, if at all, that medical training is unique from other career options in length and cost. That alone strongly discredits your perspective on the current situation of trainees. You can hold firm on your "experience," which, yes you'll have more of in your specific field of training, but by god if I haven't seen time and time again massive mistakes made in the name of "experience," I might give it a little more credit. What I've seen commonly occur is experience being used to justify old dying habits and customs in the face of blatant need for change. Doctors, in particular, are notorious for being the best at this. I'm no socialistic liberal by any means, but this behavior just irks the hell out of me.

 

[JackADeli]

The irony that the old guard who argues that health care reform will drive non-procedural specialties into the ground being the same guys saying it's not "required" to specialize in order to stay afloat is not lost to me...

I'm not following what you are talking about or if you are trying to reference something from another thread out of context...

...Medical school tuition ...continue to rise year over year well above inflation rates. The financial pressure to go into a well paying specialty, if the drive was ever great before, is even greater now...

Beware the belief that you can estimate you specialty salary in the future... ortho was not always the big payer, anesthesia was predicted to be dying..... Are you going to be coming back tallking how unfair everything is because you chose a field with the belief you would earn/deserve 300K, 400k, or 500k?

The "drive" is internal (i.e. individual choice/s). It depends on how much someone is willing to accept/earn. I am the first to say I want to earn gazillions. However, I do not pretend that somehow my 200K student loans requires me to earn these large sums. Individuals can earn under 250k, make loan payments, have a car, a house, spuse, and children. I find alot of pre-meds and med-students on here speaking as if their yearly income must be equal to the sum total of their outstanding student loan debt. That somehow, while most everyone else makes large finance payments over 10+ years, some pre-meds & med students believe they should be able to pay off all debt within a year or two. So, the financial pressure is largely one of individual desire for wealth and not out of true need.

But, that still does not equate to training getting longer and longer. With limited exceptions, there has not been increasing lengths in training. As noted, the traditionally longer paths have been that way for a long time.... and efforts are moving to shorten them. There are some shorter path fields like IM/Pedes/FM that may have developed some one year additional training options. However, that does not equate to the over all reality. Currently, the fields that are seeing resurgance are primary care and there are numerous predictions and efforts to enhance "garden variety" primary care. It is also interesting that there was when I was in medical school numerous special options that cut or eliminated much of the medical school loan issues with commitment to primary care. Yet, these were often not chosen.

...Saying everything is a choice is a very easy cop-out answer to any question for anything. Does anyone NEED to live in so gracious as a 600sqft studio, or god forbid a 2000sqft house?? No, humans can well live in 100sqft if need be. Do we NEED to be so extravagant with our every day meals or can we sustain on the bare minimum nutrients that many in 3rd world countries subsist on? Do we NEED to drive to work everyday or can we just ride bikes instead and get up 2 hours earlier to make the commute? Yeah, these are ALL choices are they not? Just about the best cop-out of all cop-outs..

I think the cop-out is claim to be "forced" or some extrinsic "need" as opposed to accepting responsibility for your choices. I still recall living with family in a developing nation some decades ago. I recall living in a two bedroom, one bathroom (sic) home with five people, no clothing wash machines, no dishwasher, limited times of hot water. I remember knowing we were better off then many and were in a better neighborhood. So, yes, you can pursue a specialty that takes 5yrs, 7yrs, 10yrs, etc... Yes, you can pursue a hope for an income exceeding 300K, 400k, or 500k? But, these are choices and there are trade-offs.

... It is apparent from your previous posts that you barely acknowledge, if at all, that medical training is unique from other career options in length and cost. That alone strongly discredits your perspective on the current situation of trainees...

What is apparent is your deficit in reading comprehension.

 

[Orbo]

You can argue all you want about what is necessity vs. want, but that is besides the issue. In all areas of business, talent is attracted by incentives. Case closed.

 

[JackADeli]

... tries to rationalize that choosing to become a physician means you should know going in what lies ahead. I would argue very few potential medical students can truly grasp what they are getting into. How could they? When you choose to go to medical school, you are simply choosing to undergo the process of becoming an MD/DO. It is not an acceptance of less than equitable wages compared to other health care staff.

Nobody has a perfect crystal ball and that is not what I am or have stated. However, the duration of training is well and widely known and published. It should not take much for any mediocre level of intellect pre-med or med-student to do the simple math and understand how old they can reasonably expect to be at any point during their training path. Also, the amount of compensation during residency is no secret and is quite easily obtained.

The math we are talking about in considering these points is basic high school algebra level stuff. Any HS grad or even college undergrad can easily, if they so choose, ask some very simple questions and get some reasonable answers based on fairly dependable historic trends when it comes to:

1. how much/many years of undergrad does it take
2. how long is medical school (4yrs)
3. how long is residency x, y, z training?
4. what are the expected amount of work hours during residency?
5. what is the compensation during residency

The item individuals can not obtain consistent information on is an expectation of what they will earn when actually in practice. Still, items 1-5 above are readily researchable through many published library sources or simple web-searches. A undergrad or med-student crying they did not know these things has only themselves and poor forethought to blame. It is not "rationalization" to expect an adult to at least take the time to self educate on the basics of major life choices.

Clearly, at any point during the journey, an individual can choose to alter the path. Maybe they want to do research or a combined MD/PhD program. Maybe they fall in love with some ultra-specialization or maybe they want to do med/pedes instead of straight IM. Still, those are choices of their making. There is no extrinsic force or need.

For what it's worth:

http://benbrownmd.wordpress.com/

...

I am all for further information. Again, that information is not difficult for a university level, bright go getter to research and make an informed decision. Crying how unfair it is or how one didn't know is sad. The best thing you or I can do is be honest and accurate and provide the information to enable informed choices early and not developed parachutes for all those too lazy to bother and look or ask....

 

[JackADeli]

...Thanks and you can continue to be a condescending douchebag as you have been throughout this thread. I'm sure your students just love you.

Yes, your debate, discussion, and rational thinking ability are of the highest caliber. Thank you for keeping your adult wits about you.

...1. Undergrad can vary significantly from 2-5+ years. I finished undergrad in 2 years and know people who double majored with multiple minors who spent 5 or more years. How can a high school student who is supposed to go into their undergraduate studies with an open mind know what path they will end up taking?...

"Supposed to"... according to who? The variation is a matter of choice. You want to do multiple majors and minors, great do it, but understand the time it adds and understand if you have a dream/plan to be a physician you are choosing to add time.

...2. Med school fairly straightforward length with the exception of those who decide to puruse a PhD or some who take time off in med school for degrees such as an MBA...

As you note, they "decide" (i.e. choose). Which is fine, take time off or double major if you like. That is your choice. The numbers are easy to calculate.

...3. How can an undergrad know what length of residency they will have. If you do what you are suppose to and entere med school with an open mind your training can range from 3-10 years. I went to a med school that pushed primary care (3 year residencies) and ended up deciding between rad onc and neurosurgery (5 and 7 years). No one knows the length until the actually go through the rotations and makes a decision...

I think I outlined a very simple five point way in which anyone can gaugue the possibilities in my earlier post. You can very easily have a reasonable idea of the lengths of different pathways. And, if someone decides they want to go a long pathway, they should understand they may be giving up other opportunities to pursue this one. It would be nice to say everyone should have every opportunity at every stage and not have to worry about their decisions and the impact on the next stage. But, that is adolescent thinking and not adult thinking. Having an open mind does not require one to be ignorant. In enterring medical school, one should know a primary care track will reasonably take three years after med-school and general surgery can be expectedted to take five years, and any other combinations.

...4. The hours one works in residency varies significantly from 40 or so to 80+, just depends on the specialty, something really only MS-3 and and 4's learn somewhat. It's not til you get to residency that you really learn about the responsibilities you have and the hours it takes. You may see residents working and grasp the general idea but that's not true understanding...

Your right, reading and asking questions are not perfect and do not replace first hand experience. Even as a resident, you don't fully grasp the responsibilities faced by attendings or PDs. Still, that does not change the fact that you can look at published information and can speak with residents while you are in HS, undergrad, med-school. You can speak with family physician friends. You can "shadow" residents and attendings. Is it perfect? No. But, lack of perfection does not justify self induced ignorance and your head under the sand.

...5. You understand the compensation a resident makes. Understanding and acceptance are two different words. Med students don't have a choice in the matter, it's either get your degree and never use it or accept the pay scale. I word argue that's not really a choice.

Any undergrad has the choice before med-school. The incomes are no secret. You choose to enter med-school while the pay scale is what it is. That was your choice. Going into med-school and then crying "no choice" is ridiculous.

So, I encourage students to think long and hard about the choices they are going to make. You want to be a physician? Then you should look into what it takes. To be a physician requires completion of medical school and at least some duration of residency. It's your choice. It is an expensive choice. That is the deal.

...it's actually not reasonable to force trainees to...

...training ...continues to lengthen with increasing need to super specialize...

You can argue all you want about what is necessity vs. want, but that is besides the issue. In all areas of business, talent is attracted by incentives. Case closed.

You stated it as a position of necessity or a position of one being forced. Now that is besides the issue? Even in discussion you seem to want both sides whenever they may suit you.

 

[Holderlin]

Yes, your debate, discussion, and rational thinking ability are of the highest caliber. Thank you for keeping your adult wits about you."Supposed to"... according to who? The variation is a matter of choice. You want to do multiple majors and minors, great do it, but understand the time it adds and understand if you have a dream/plan to be a physician you are choosing to add time.As you note, they "decide" (i.e. choose). Which is fine, take time off or double major if you like. That is your choice. The numbers are easy to calculate.
I think I outlined a very simple five point way in which anyone can gaugue the possibilities in my earlier post. You can very easily have a reasonable idea of the lengths of different pathways. And, if someone decides they want to go a long pathway, they should understand they may be giving up other opportunities to pursue this one. It would be nice to say everyone should have every opportunity at every stage and not have to worry about their decisions and the impact on the next stage. But, that is adolescent thinking and not adult thinking. Having an open mind does not require one to be ignorant. In enterring medical school, one should know a primary care track will reasonably take three years after med-school and general surgery can be expectedted to take five years, and any other combinations.Your right, reading and asking questions are not perfect and do not replace first hand experience. Even as a resident, you don't fully grasp the responsibilities faced by attendings or PDs. Still, that does not change the fact that you can look at published information and can speak with residents while you are in HS, undergrad, med-school. You can speak with family physician friends. You can "shadow" residents and attendings. Is it perfect? No. But, lack of perfection does not justify self induced ignorance and your head under the sand.Any undergrad has the choice before med-school. The incomes are no secret. You choose to enter med-school while the pay scale is what it is. That was your choice. Going into med-school and then crying "no choice" is ridiculous.

So, I encourage students to think long and hard about the choices they are going to make. You want to be a physician? Then you should look into what it takes. To be a physician requires completion of medical school and at least some duration of residency. It's your choice. It is an expensive choice. That is the deal.
You stated it as a position of necessity or a position of one being forced. Now that is besides the issue? Even in discussion you seem to want both sides whenever they may suit you.

Jack you suffer from a number of logical fallacies, but the one that I think is pissing everyone off the most is the Irrelevant Conclusion.

Not one of the reasons you list have a logical bearing on what a Resident is worth at any given year of training.

People point this out and you draw another irrelevant conclusion, which in the latter stages of this thread revolve around "choice". And I must say before you get seduced by a word describing some obscure metaphysical quality, I suggest you read, among others; Nietzsche, Wittgenstein, Frege, Heidegger, Derrida, and Rorty to name a few. But before that you might want to start with basic Aristotelian logic.

You're just dancing. But I'm not confused. Just entertained.

 

[JackADeli]

Jack you suffer from a number of logical fallacies, but the one that I think is pissing everyone off the most is the Irrelevant Conclusion.

Not one of the reasons you list have a logical bearing on what a Resident is worth at any given year of training.

People point this out and you draw another irrelevant conclusion, which in the latter stages of this thread revolve around "choice". ...

My responses in reference to choice are clearly not directly addressing worth. They are addressing several individuals' positions that they are somehow forced to do x, y, z. Or, they somehow have an uncontrolled need to do x, y, z and thus based on this force or need should be compensated more. If it is not force, then yes, choice should be considered when one cries unfair and claims that because of x then y reason supports the need for more compensation. If an individual claims force or lack of choice as in part justification for ~compensation, choice must be considered or at least you need to ask if force or lack of choice argument is valid. Not to mention the subsequent extension that claims the training is in someway growing in length.....

I can appreciate individuals wanting to hit a reset button or retract what they wrote. I have been responding to the comments as they come and my comments are not directed towards all the preceding discussions. If you or anyone else is upset or deem the conversation to be irrelevant then I suggest individuals not start down that path.

If individuals want to continue and declare they are worth some value and thus underpaid, great. I have posed my arguments specific to that and they have posed their arguments to that as well. The issues of choice are in reference to the extraneous that some have tried to employ....

I again say it defies logic for any adult to claim they are "forced" or have no choice in this career path. It defies logic to say any adult could not know how long this path would take. It defies logic to say any adult is forced to not get married or have children. One of the most commonly cited reasons from colleagues in undergrad for not pursuing a career in medicine, "I don't want to be in school/training for 10+ years...".

 

[Holderlin]

My responses in reference to choice are clearly not directly addressing worth. They are addressing several individuals' positions that they are somehow forced to do x, y, z. Or, they somehow have an uncontrolled need to do x, y, z and thus based on this force or need should be compensated more. If it is not force, then yes, choice should be considered when one cries unfair and claims that because of x then y reason supports the need for more compensation. If an individual claims force or lack of choice as in part justification for ~compensation, choice must be considered or at least you need to ask if force or lack of choice argument is valid. Not to mention the subsequent extension that claims the training is in someway growing in length.....

I can appreciate individuals wanting to hit a reset button or retract what they wrote. I have been responding to the comments as they come and my comments are not directed towards all the preceding discussions. If you or anyone else is upset or deem the conversation to be irrelevant then I suggest individuals not start down that path.

If individuals want to continue and declare they are worth some value and thus underpaid, great. I have posed my arguments specific to that and they have posed their arguments to that as well. The issues of choice are in reference to the extraneous that some have tried to employ....

I again say it defies logic for any adult to claim they are "forced" or have no choice in this career path. It defies logic to say any adult could not know how long this path would take. It defies logic to say any adult is forced to not get married or have children. One of the most commonly cited reasons from colleagues in undergrad for not pursuing a career in medicine, "I don't want to be in school/training for 10+ years...".

Dancing...

Who ever said they were forced? And the subject of human freedom is beyond the scope of SDN.

The argument can be reduced to the statement, "residents are worth more than their average salary," regardless of an individual resident's expenses.

The only poster who directly addressed this with relevant examples, from a hospital's POV, was aProg, and his tone betrayed at least a partial concession that residents in the latter stages of their term are worth more than they are paid. "I would rather have a PGY-3 than a PA" and "...they can make it easier for me to bill..."

So, maybe a steeper salary slope would be a reasonable proposal.

 

[Orbo]

Dancing...

Who ever said they were forced? And the subject of human freedom is beyond the scope of SDN.

The argument can be reduced to the statement, "residents are worth more than their average salary," regardless of an individual resident's expenses.

The only poster who directly addressed this with relevant examples, from a hospital's POV, was aProg, and his tone betrayed at least a partial concession that residents in the latter stages of their term are worth more than they are paid. "I would rather have a PGY-3 than a PA" and "...they can make it easier for me to bill..."

So, maybe a steeper salary slope would be a reasonable proposal.

I did, and jackadeli with his one track mind interpreted it literally, as in medical trainees MUST superspecialize or they'll literally starve on the street

Just like how whenever someone says something is "needed," that thing really must be delivered or certain death or similar massive undesirable circumstances will occur.

 

[JackADeli]

Dancing...

Sure, your so cool
I have found it interesting the way in which you have changed your tune or tone as it were as the conversation progressed. You went from not knowing a residents worth to almost a religious belief in being worth more.

I appreciate the information you provide.

...I realize the impossibility of raising resident's salary, especially in these tumultuous times, and you clearly make sense, but the comparisons to an RN/PA still loom. I guess I think resident care should be reimbursable. You'd think they'd want this to bring in more money. In fact it makes perfect sense to allow a resident MD to be reimbursable as a PA. Does it not? Where would the issue be in this proposition?

And I have a wife and a newborn, so this is a huge logistical issue for me...

...Does anyone have an answer to the question of the real market value of the care that a resident provides in a year? I bet it's damn near 200k

...I just need to see more data, but I'm convinced residents are worth at least 75k.

Thanks for all the valuable information.

Sorry for encroaching on your forum, but it's the only way to get solid information about what is certainly the most formidable obstacle to becoming a physician.

I hope at the very least the moonlighting continues, and I guess I'll be happy with the 40-50k and make sure to match Rads with an IR fellowship

You hate residents

JackAdeli is the Rocky Balboa of SDN. Just won't go down. I'm impressed.

 

[Holderlin]

Sure, your so cool
I have found it interesting the way in which you have changed your tune or tone as it were as the conversation progressed. You went from not knowing a residents worth to almost a religious belief in being worth more.

Yeah, I drink a lot.

The passivising of my stance was a gesture of respect to my exalted Residents and Attendings, and accusing you of hating residents was clearly a joke.

But since my initial outrage and subsequent complacency towards resident's salaries there have been many informing posts, including your ongoing treatise, which were very revealing of both the perspective of many residents, and the way in which you conjure a defense of the current compensation, not to mention the fact that you just won't die, all of which compelled me to express my ever evolving opinion.

In short, you're not being logical or reasonable, but you know this, which makes your stubborn persistence almost trollish.

And I am cool.

 

[JackADeli]

...The passivising of my stance was a gesture of respect to my exalted Residents and Attendings...

But since my initial outrage and subsequent complacency towards resident's salaries there have been many informing posts, including ...the fact that you just won't die, all of which compelled me to express my ever evolving opinion.

In short, you're not being logical or reasonable ...which makes your stubborn persistence almost trollish...

Yeh, sure, you have formulated and evolved in opinion. Thus, better read of your statement is akin to:

~my (your) opinion has evolved, you (I) have remained unwilling to accept my (your) opinion and/or agree to my opinion and thus you (me) are wrong, unreasonable, and trollish... because you still don't agree with me (you).

Yep, thank you, I got it.

 

[Holderlin]

Can you please change your annoying stupid little AV.

 

[smq123]

Can you please change your annoying stupid little AV.

Okay. If we could just stay on topic and not critique/insult other people's avatars, that would be greaaaaat.

(And this is your last warning.)