Elimination of medical resident stipend pay

[EMTB2MD]

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Has anyone heard anything about Graduate Medical Education (GME) funding and the possible elimination of resident stipend pay? This unfortunately is a viable threat for us all.

A 4th year medical resident recently brought this to my attention as their school is currently discussing the impact a GME funding cut would have on their residency program. A lot of the current residents at this particular program have been writing their senators urging them not to cut GME funding. This is a little known issue outside the postgraduate medical circle.

The argument for GME funding cuts is very compelling. Just a 10% cut of GME funding could lower our national deficit by 9 billion over the next 10 years. The Simpson-Bowles deficit commission proposed a 60% cut to indirect medical education funding last year that would result in a 60 billion dollar savings through 2020. It costs hospitals over $100K to train an individual resident. If GME funding is cut even a little our stipends could be in jeopardy not to mention a severe impact in patient care. There is also concern that many residency programs would have to close completely. One program director at a school mentioned eliminating all specialty salaries with the exception of primary care if the current budget proposal goes through. There are numerous degrees out there that do not pay a stipend for postgraduate training. Could this happen with medicine?

As a nontraditional student the thought of not getting paid during residency is nauseating. If I were 22 years old and single entering medical school I might be able to go 8+ years without income (4 for medical school and 4+ for residency). It is a different ball game however when you are married with a family (or will be soon). I can sell my wife on 4 years without pay but 8+ is a more difficult sell.

I urge everyone to look into this further and call/write your senators asking them to preserve funding for graduate medical education.

Here is a link to the AAMC for more information: https://www.aamc.org/initiatives/gmefunding/

Another good read: http://www.acgme.org/acwebsite/home/ImpactReductionFederalGMEFundingTJN.pdf

 

[princekc]

Thank you for raising this issue. It is such an interesting topic and something we as non-traditional students must consider or factor into our equation as we pursue medicine. If my memory serve me well, topic had been extensively discussed somewhere here on sdn. A cut can be possible (yes or no), but at what % rate, that is very unclear. However, eliminating resident stipend, that is nearly impossible and would not happen.

 

[Moki]

Thank you very much for posting this information. This topic is of immense importance. Also scared the bejesus out of me! Time to start writing some letters. . . . .

I also suspect that if they do dramatically cut the stipend, only people who have outside finacial support will be able to enter medical school and practice medicine. Hell of a criteria.

 

[MT Headed]

Oh come on, don't be ridiculous. That would be like the government taking away our ability to refinance school debt at 2%. Or eliminating subsidized loans. It would change the field of medicine entirely.

Ain't gonna happen.

 

[EMTB2MD]

I hope you are correct! I've read a couple of responses from Senators and Congressmen that have alluded that GME funding cuts are inevitable. The only question is how deep the cuts are going to be. Depending on the severity of the cuts to GME funding it is possible that some residency slots / programs would be eliminated leading to some US medical school graduates unable to match into a residency. The funding cuts also include a ton of scholarships for people looking to practice medicine in underserved areas.

If it comes down to sacrificing patient care vs. cutting or significantly reducing a resident salary what do you think hospital administrators / program directors will do?

I have spoken with residents who are aware of the GME funding issues but aren't too concerned since they feel they will be out of residency by the time the cuts are made. This is much more our problem.

My whole goal starting this thread was to bring awareness to a potential GME funding crisis. We all need to come together and show our support for GME funding.

Oh come on, don't be ridiculous. That would be like the government taking away our ability to refinance school debt at 2%. Or eliminating subsidized loans. It would change the field of medicine entirely.

Ain't gonna happen.

 

[MT Headed]

I was being facetious. There are no 2% refinancing nor subsidized loans anymore. Shoulda become a doctor 5 years ago.

On a more serious note, I wonder if the future would be to take out student loans for GME too, to the tune of $45K or $50K a year, to replace the missing salary. Just add it to the ever increasing student debt. Sure the debt would balloon to $300K or $400K, but with IBR plans the payments would never become unmanagable. Eventually everybody might have to join Income Based Repayment and after 25 years get their loans forgiven.

At that point, what is to stop the medical schools and residencies from charging $1 billion dollars a year? Through IBR the payments would still never become unmanageable, and the exponentially increasing principle would be forgiven after 25 years anyway.

 

[PharMed2016]

I think we can all agree that the whole healthcare field is going down the crapper in the US.

People call me crazy for going back to school when in less than 4 months I could be starting my career and living comfortably.

 

[FrkyBgStok]

obama's "obamacare" has us all covered, we're good. and if romney gets elected, than his "obamacare" has us all covered too. winning. charlie sheen style.

trial and error. no idea what will fix this. wish i had any idea. it sure is screwed up. hopefully we can provide good quality care at a low cost, with doctors rolling in cash. that would be pretty cool.

 

[Kj615]

obama's "obamacare" has us all covered, we're good. and if romney gets elected, than his "obamacare" has us all covered too. winning. charlie sheen style.

Is this an attempt to enhance your post count? Expressing your political views/stand is unnecessary. Do not spit in the food! If you do not have anything to contribute at this pressing issue, then, I suggest you keep moving. I look forward to hearing others contribution/idea on the issue.

 

[Law2Doc]

This notion has been raised a couple of times over the years, but never really has gotten much congressional traction. In a time of physician shortages, the notion of taking steps to disincentiveise people from becoming physicians simply isn't palatable. However two things have occurred that might make this more likely to happen going forwards. 1. The economy is bad, and people struggling to make ends meet don't like the idea of paying for folks to train to make bank as a doctor, and 2. The rise of midlevels may make physicians seem more expendable and too expensive for the current "universal healthcare" setting. So yeah, I can totally see a move from government subsidized salary to more of a low interest loan type system at some point if the economy stays bad and people start getting the bulk of their care from NPs at Walmart. Most other professionals don't get federal money to pay their entry level positions. Congressmen, many of whom were lawyers by training, didn't get subsidized when they left law school and got their on the job training at their first job.

 

[QofQuimica]

Is this an attempt to enhance your post count? Expressing your political views/stand is unnecessary. Do not spit in the food! If you do not have anything to contribute at this pressing issue, then, I suggest you keep moving. I look forward to hearing others contribution/idea on the issue.

Chill out, dude(tte); he *is* giving his view on the issue.

OP, we had a discussion thread about this topic in the Gen Res forum a while back. The consensus is that, although some reductions in GME funding are likely, going to the extreme of making residents pay tuition is not realistic. Johns Hopkins already tried that experiment and failed. If residents won't pay to train at Hopkins, they sure as heck won't pay to train at a small, unknown community program. Hospitals may also be able to fund residents by other means, such as via industry sponsoring. I'll leave deciding whether that's a good idea up to you.

 

[FrkyBgStok]

Is this an attempt to enhance your post count? Expressing your political views/stand is unnecessary. Do not spit in the food! If you do not have anything to contribute at this pressing issue, then, I suggest you keep moving. I look forward to hearing others contribution/idea on the issue.

And where was your contribution? And where do I stand politically based on that post? It was sarcasm.

The point is the health care reform we have in progress now is a change, but it is screwed up. Republicans offer to repeal it and offer a program that isn't overly different. This forum is so full of doom and gloom, but making residents pay isn't going to help. Something may happen, but as Q said, people aren't going to pay for the crappy residencies. Plus it opens up a whole new problem with matching. There are definite problems.

Like I said, trial and error. Some things may change, some a lot. I don't know what the answer is. But calm down, stop being so pissed off, and help contriute. But don't jump all over me when you can't understand sarcasm.

 

[TriagePreMed]

Reduce deficit? LOL you mean more money for banks and military spending. I can totally see this type of bull**** happening, and if it does, I'm kissing medicine in this country good-bye. Hooray for triple citizenship.

 

[mauberley]

But don't jump all over me when you can't understand sarcasm.

To be fair, after reading SDN for so long, I wasn't sure if you were being sarcastic, sincere, or trolling.

 

[FrkyBgStok]

To be fair, after reading SDN for so long, I wasn't sure if you were being sarcastic, sincere, or trolling.

Haha. Get off SDN. Fine. Sorry I wasn't clear on that.

I guess my point is that we have these single people coming along saying they have the perfect change. And then when the change sucks, the next person comes along with another change that sucks. Helping the uninsured screws physicians, and vice versa, and every variance along the spectrum. We need to find a balance with it, and residency pay is one of those things that the majority outside say, "we want change" but the minority inside are saying "you guys are gonna regret this."

 

[QofQuimica]

It was clear to me.

Frky, use the emoticon next time, and then there shouldn't be any misunderstandings. 😉

 

[TriagePreMed]

It was clear to me.

Frky, use the emoticon next time, and then there shouldn't be any misunderstandings. 😉

Douchebag comment here, but I think people that misunderstood should use common sense instead of having to extra cater to them.

 

[Kj615]

To be fair, after reading SDN for so long, I wasn't sure if you were being sarcastic, sincere, or trolling.

That's my point!

 

[notbobtrustme]

Not going to happen unless we don't want to train anymore doctors.

 

[Law2Doc]

Not going to happen unless we don't want to train anymore doctors.

As long as doctors are earning $150k and up, I suspect enough people would forego a few more lean years to get there. Most people don't appreciate the notion of the time value of money, and just see the six digit salary at the other end. I have no doubt that although some people will bail on medicine if your residency was not paid, plenty wouldn't.

 

[Kj615]

It's very unlikely the cut will take effect. But, then gain, lately, healthcare/medicine has become increasingly unpredictable. If indeed, the cut takes effect, then, there should be a push to eliminate prohibiting intern/residents from seeking outside employment during the course their training.

With a cap for eighty hours per week; by entirely eliminating resident stipend, I'm sure, most would be willing to work outside of residency training (moonlighting, medical consulting etc) for the sole purpose of earning some form of income. As intern/residents, we would have expenses (as non-traditional student, mostly likely mouths to feed), thus, income derive from employment outside residency training would be appreciated.

 

[scarshapedstar]

The argument for GME funding cuts is very compelling. Just a 10% cut of GME funding could lower our national deficit by 9 billion over the next 10 years.

That's about as compelling as a lukewarm urine sample... I would hope even the most diehard teabagger understands that this is robbing peter to pay paul.

 

[mauberley]

It was clear to me.

*pat pat pat*

😉

 

[PharMed2016]

Here's my proposal; lets make a national formulary for what medicare and medicaid will reimburse. Other countries already have this as a way to control cost with the US as one of the few that doesn't. Don't tell me you need a brand medication when there are others in the class that are a hundred times less expensive and may work the same or better.

Example: Nexium vs. Prilosec - the former cost nearly 100x more yet really is no better than the latter if you look at the data. Some physicians are still convinced despite the evidence.

Politician A: "PharMed2016... your depriving patients of the best care possible..."

PharMed2016: "No, Mr. Politician... it is you who are depriving patients of the best evidence-based care and professionals to execute that care."

 

[Kj615]

Here's my proposal; lets make a national formulary for what medicare and medicaid will reimburse. Other countries already have this as a way to control cost with the US as one of the few that doesn't. Don't tell me you need a brand medication when there are others in the class that are a hundred times less expensive and may work the same or better.

Example: Nexium vs. Prilosec - the former cost nearly 100x more yet really is no better than the latter if you look at the data. Some physicians are still convinced despite the evidence.

Politician A: "PharMed2016... your depriving patients of the best care possible..."

PharMed2016: "No, Mr. Politician... it is you who are depriving patients of the best evidence-based care and professionals to execute that care."

This. Remind me of http://www.prescriptionaccess.org/docs/Nexium_DE.pdf

 

[montessori2md]

I'm interviewing for residency now and program directors are taking this seriously. Several specifically stated they have ensured that funding is in place (via community hospital paying for the residents) in the event that GME is reduced/eliminated.

A lot of residents/fellows actually lead to net gains for hospitals -just think about all the colonoscopies one gen surg resident could do, and an anesthesia resident is arguably much more affordable than a CRNA. Less lucrative specialties like peds and psych could have some serious problems.

I think if GME is eliminated it will likely be replaced via additional medicaid funding for hospitals supporting GME. It might be at reduced total dollars, but I don't think it will go from the current levels to zero overnight. If GME is eliminated, I think it will push less lucrative specialties towards extending length of residency. Instead of charging us money, they will require more work.

 

[PharMed2016]

I'm interviewing for residency now and program directors are taking this seriously. Several specifically stated they have ensured that funding is in place (via community hospital paying for the residents) in the event that GME is reduced/eliminated.

A lot of residents/fellows actually lead to net gains for hospitals -just think about all the colonoscopies one gen surg resident could do, and an anesthesia resident is arguably much more affordable than a CRNA. Less lucrative specialties like peds and psych could have some serious problems.

I think if GME is eliminated it will likely be replaced via additional medicaid funding for hospitals supporting GME. It might be at reduced total dollars, but I don't think it will go from the current levels to zero overnight. If GME is eliminated, I think it will push less lucrative specialties towards extending length of residency. Instead of charging us money, they will require more work.

It's reassuring that hospitals are already looking into this and have plans in place in the event this does happen.

 

[MT Headed]

I think if GME is eliminated it will likely be replaced via additional medicaid funding for hospitals supporting GME. It might be at reduced total dollars, but I don't think it will go from the current levels to zero overnight.

GME funding is larger than the resident salary. I've heard that resident salary is ~$50K, but GME funding per position is more like $100K. If GME funding is reduced 50%, then the resident salary could be reduced 100%. The hospital would still keep their cut, to cover the (constant) overhead of training a resident.

 

[silleme]

Here's my proposal; lets make a national formulary for what medicare and medicaid will reimburse. Other countries already have this as a way to control cost with the US as one of the few that doesn't. Don't tell me you need a brand medication when there are others in the class that are a hundred times less expensive and may work the same or better.

Example: Nexium vs. Prilosec - the former cost nearly 100x more yet really is no better than the latter if you look at the data. Some physicians are still convinced despite the evidence.

Not to derail the thread, but as someone who has been on every acid controller under the sun...the only one I don't have to sleep propped up on pillows at night IS Nexium, so for me, that's what I have to take. I've even paid for it out of pocket *ouch* when I've had no insurance.

But back on topic....I can't see them completely getting rid of all paid residency training. Like MT headed said, they'll think of a way to keep residents paid to cover the liability of the training program as well...

 

[princekc]

Not to derail the thread, but as someone who has been on every acid controller under the sun...the only one I don't have to sleep propped up on pillows at night IS Nexium, so for me, that's what I have to take. I've even paid for it out of pocket *ouch* when I've had no insurance.

In clinical practice, Dexilant>Nexium>Prilosec in terms of efficacy.

 

[FrkyBgStok]

GME funding is larger than the resident salary. I've heard that resident salary is ~$50K, but GME funding per position is more like $100K. If GME funding is reduced 50%, then the resident salary could be reduced 100%. The hospital would still keep their cut, to cover the (constant) overhead of training a resident.

this brings up an interesting point. would people do it for free? if it didn't cost any money, but you didn't make any either?

 

[MT Headed]

this brings up an interesting point. would people do it for free? if it didn't cost any money, but you didn't make any either?

Would student loans still be available? Medical students aren't paid either, but they can borrow to meet their Cost of Attendance needs. Otherwise the resident would have to moonlight to pay rent somewhere.

 

[FrkyBgStok]

I suppose it would force you into more debt, but sure, would a large enough number of students still do residency if they could do it by simply getting loans for living? But I suppose that opens up another can of worms.

 

[scarshapedstar]

I really just don't see the political support for this one.

Nobody outside of the Washington Post editorial pages took Simpson-Bowles seriously, and the only way this will happen is if it's tucked inside some horrible Giant Bitter Pill To Swallow austerity package, because even the least informed members of the public understand that residents are "the new doctors who live in the hospital" and I don't think many people feel they should be defunded. Not unless you convinced them that all residents are secretly trained to perform, you know, the procedure that shall not be named. 🙄

 

[gdfernan]

Totally basic question:

Is the work a resident does entirely training or is it work + training (like an apprenticeship)? If the latter, is there value to the hospital in employing a resident (apart from the tax $). Is there a way to leverage the work that a resident does to reimburse the hospital for the training provided?

 

[QofQuimica]

Totally basic question:

Is the work a resident does entirely training or is it work + training (like an apprenticeship)? If the latter, is there value to the hospital in employing a resident (apart from the tax $). Is there a way to leverage the work that a resident does to reimburse the hospital for the training provided?

It's work plus training, and I agree that thinking of it as an apprenticeship is pretty accurate. The thing is, a new resident isn't very useful; it takes time to get people trained to the point where their work is worth more than the costs in time, efficiency, and waste/redundancy that exist during their early training period.

 

[Captain Fantastic]

Around here they are talking about changing the model/shifting the money to support "core" specialties that are needed to keep the hospital doors open and letting the more lucrative specialties fend for themselves. Some talk that this might pull more students into primary care residency (since they'll get that federally supported stipend) and let the money makers (say, ortho?) decide if they want to fund their residents out of (decreasing) clinical revenue. Lots of talk that most fellowships would be de-funded, too.

Of course, they're prepping for worst case scenarios and no one expects the cuts to happen, but it makes you think: how many would still go for, say, pediatric urology if they had to take out another 6 years of loans to live on versus a paid 3-and-out and become an internal medicine hospitalist? How sure are you that, by the time you're done with training, the current reimbursement model will still be around and producing the wages we see now?

 

[Kj615]

Around here they are talking about changing the model/shifting the money to support "core" specialties that are needed to keep the hospital doors open and letting the more lucrative specialties fend for themselves. Some talk that this might pull more students into primary care residency (since they'll get that federally supported stipend) and let the money makers (say, ortho?) decide if they want to fund their residents out of (decreasing) clinical revenue. Lots of talk that most fellowships would be de-funded, too.

Of course, they're prepping for worst case scenarios and no one expects the cuts to happen, but it makes you think: how many would still go for, say, pediatric urology if they had to take out another 6 years of loans to live on versus a paid 3-and-out and become an internal medicine hospitalist? How sure are you that, by the time you're done with training, the current reimbursement model will still be around and producing the wages we see now?

Scary!

 

[Law2Doc]

Totally basic question:

Is the work a resident does entirely training or is it work + training (like an apprenticeship)? If the latter, is there value to the hospital in employing a resident (apart from the tax $). Is there a way to leverage the work that a resident does to reimburse the hospital for the training provided?

It's work plus training but with a huge caveat. The work you do requires attending teaching and oversight, and so basically you are slowing down and decreasing man hours from much much more lucrative employees. So basically if you work one hour and do $100 worth of work, you may slow down an attending by 20 minutes who would otherwise generate $350 per hour. So your value is at a bigger cost. I've heard that a resident, like most young professionals, only starts to become valuable sometime in his third year of practice. Since a lot of residencies are only 3 years, you only become of maximum value as you are on the way out the door.

So yeah, hospitals need the $100k they are paid per resident to make it worth it. Between training costs, administrative costs, salary, medmal and the extent you slow down the attendings, the margins are pretty thin.

 

[scarshapedstar]

The best part is that even if you're paid nothing and prohibited from working anywhere else, your student loans will still be compounding away because you're a "graduate"... 16 tons, anyone?

 

[TriagePreMed]

The best part is that even if you're paid nothing and prohibited from working anywhere else, your student loans will still be compounding away because you're a "graduate"... 16 tons, anyone?

That's the way they destroy you. The companies got a hold of the fact that more and more people were wanting to go to college because it meant getting a better life. They bastardized and destroyed the system. Now you are knee deep in loans and can't file for bankruptcy on them.

 

[artsciencelove]

In 4 years if I can't find a residency that pays at least enough to cover my living expenses (apartment and used car is fine) and the minimum payment on my student loans, I would consider fleeing the country. I pick up languages easily, US-trained doctors are in demand everywhere, and there are lots of places I can be happy. I don't think I would ever intentionally default on a debt, but 3 years of unpaid labor is definitely not part of the "deal" I signed up for when I agreed to attend medical school. The thought of being an unpaid intern with 8 years of post-secondary education is unacceptable to me, and so is a society where we've been conditioned to think of that as normal.

 

[whatbout2morrow]

Chill out, dude(tte); he *is* giving his view on the issue.

OP, we had a discussion thread about this topic in the Gen Res forum a while back. The consensus is that, although some reductions in GME funding are likely, going to the extreme of making residents pay tuition is not realistic. Johns Hopkins already tried that experiment and failed. If residents won't pay to train at Hopkins, they sure as heck won't pay to train at a small, unknown community program. Hospitals may also be able to fund residents by other means, such as via industry sponsoring. I'll leave deciding whether that's a good idea up to you.

I doubt this would be the case if all residency programs started charging tuition.

 

[Law2Doc]

In 4 years if I can't find a residency that pays at least enough to cover my living expenses (apartment and used car is fine) and the minimum payment on my student loans, I would consider fleeing the country. I pick up languages easily, US-trained doctors are in demand everywhere, and there are lots of places I can be happy. I don't think I would ever intentionally default on a debt, but 3 years of unpaid labor is definitely not part of the "deal" I signed up for when I agreed to attend medical school. The thought of being an unpaid intern with 8 years of post-secondary education is unacceptable to me, and so is a society where we've been conditioned to think of that as normal.

You aren't a "US trained doctor" until you complete residency. Med school is pretty meaningless in terms of skills. You really don't know anything useful until after at least intern year, which is why states generally won't allow you to get fully licensed until then. If you want to practice medicine, either here or abroad, you are omitted to completing at least an intern year minimum.