What if the NRMP didn't exist?

[LostTommyGuns]

Having had this discussion multiple times with diff people I'm wondering what your take on it is. What if there were no NRMP ? How about for Anesthesia?

You have to wonder if salaries would go up to attract more qualified residents? I don't think so and my justification is any program could do that now...

Would people get screwed by programs giving them openings that have to be accepted or declined immediately (over a 24hr period say?).

I'm interested in any thoughts...

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[2ndyear]

I'm pretty sure they (you) would get screwed. There's no match for fellowships. One of my friends had this scenario for fellowship:

Program A is his top pick, well known and respected, the best in the country.
Program B is OK

Program A interviews him, says decision is made in November.
Program B interviews, offers a spot 1 week later, in September. Must make the decision now or forfeit the spot.

Call program A, no go. They had plenty of applicants and will wait for Nov.
Call program B, no go on holding the spot open until November. Take it or leave it.

Pretty much the same thing would happen. You'd be offered a ton of spots as take it or leave it now.

Residents salaries would absolutely not go up. They're fixed by the government in a very complex formula. Most academic departments don't do that well financially thanks to the teaching rule, there's no incentive to pay residents more. Ultimately the programs have much more demand than spots, at least from FMG's. The US grad number is relatively constant and will only decline from here as to anesthesia interest (it peaked in the class that started CA1 this week). But there are literally thousands of foreign physicians more than happy to retrain in the US. Whatever they make here is more than they make there. I've seen some of these people in 'fellowships' as perma-fellows. They can never get a full license but can somehow get a limited if they're a 'fellow'. Essentially they function as PA's. Weird.

 

[johankriek]

I'm pretty sure they (you) would get screwed. There's no match for fellowships. One of my friends had this scenario for fellowship:

Program A is his top pick, well known and respected, the best in the country.
Program B is OK

Program A interviews him, says decision is made in November.
Program B interviews, offers a spot 1 week later, in September. Must make the decision now or forfeit the spot.

Call program A, no go. They had plenty of applicants and will wait for Nov.
Call program B, no go on holding the spot open until November. Take it or leave it.

Pretty much the same thing would happen. You'd be offered a ton of spots as take it or leave it now.

Residents salaries would absolutely not go up. They're fixed by the government in a very complex formula. Most academic departments don't do that well financially thanks to the teaching rule, there's no incentive to pay residents more. Ultimately the programs have much more demand than spots, at least from FMG's. The US grad number is relatively constant and will only decline from here as to anesthesia interest (it peaked in the class that started CA1 this week). But there are literally thousands of foreign physicians more than happy to retrain in the US. Whatever they make here is more than they make there. I've seen some of these people in 'fellowships' as perma-fellows. They can never get a full license but can somehow get a limited if they're a 'fellow'. Essentially they function as PA's. Weird.

absolutely the salaries of residents would go up.. the market forces at work would dictate the salary of incoming residents.. the programs that wanted the better applicants would pay more..with the exception of the top top programs where the applicants erroneously believe they will get better training..

 

[TIVA]

absolutely the salaries of residents would go up.. the market forces at work would dictate the salary of incoming residents.. the programs that wanted the better applicants would pay more..with the exception of the top top programs where the applicants erroneously believe they will get better training..

Johan, I respect you, but WRONG!!

If a residency program wanted to pay nothing to their residents, they could. Cuz without a residency and just an MD, you're worthless. And if the residency were going to charge you money to do a residency (yeah, you read that right, if you HAD TO PAY TO DO RESIDENCY), you would. Sad, but true.

 

[johankriek]

Johan, I respect you, but WRONG!!

If a residency program wanted to pay nothing to their residents, they could. Cuz without a residency and just an MD, you're worthless. And if the residency were going to charge you money to do a residency (yeah, you read that right, if you HAD TO PAY TO DO RESIDENCY), you would. Sad, but true.

umm not really. If there were only a few training programs i would agree with you but there are just too many.. the laws of nature allows competition and they would compete with each other for the best candidates and they would offer some stipend... to attract candidates.. so the nothing pay wouldnt last too long

 

[TIVA]

umm not really. If there were only a few training programs i would agree with you but there are just too many.. the laws of nature allows competition and they would compete with each other for the best candidates and they would offer some stipend... to attract candidates.. so the nothing pay wouldnt last too long

You may be right, but check out the following scenario.

Pretend for an instance that all the residents get together and go on strike demanding better pay, better working hours, etc. And pretend for a moment that they even bring a lawsuit against the NRMP or Medicare or the federal government or whatever, claiming that it constitutes an unfair monopoly on residency positions and that price-fixing is going on.

In return, I could see the residency programs saying, "you know what? You're not just a doctor. You're a doctor in training and you are doing an apprenticeship. If you are interested in acquiring the skills you need to allow you to become proficient and independent, then you will pay us $40K per year to pay for that opportunity. So if you want to become a general surgeon, it's gonna cost you $200K, if you wanna become an anesthesiologist, it's gonna cost you $160K, if you wanna be a cardiologist, it's gonna cost you $280K."

It might seem farfetched, right? But is it, Johan? Is it really that farfetched for somebody with $100-200K in debt from med school getting themselves ready to borrow another couple hundred K in order to achieve their dreams?

Because that's exactly what happened a few years ago when some medical students who felt shafted by the match did. They brought a lawsuit against NRMP and the American Hospital Association and the NRMP/AHA basically said, "hey, if we wanted to, we could pay you nothing and you would work for free. And if we wanted to, we could charge you to do a residency, and you would pay, because that's what you would have to do in order to complete your formal medical training." And just as quickly, the lawsuit went away.

Johan, you are assuming that market forces will work in favor of residents since there are more jobs than residents. However, that's not entirely true since this year there were a number of graduating medical students who were unable to get any PGY-1 positions this year, granted they're mostly FMG's, but still.

 

[LostTommyGuns]

Tiva - I think you make good points. The problem I have is if that is true then why don't they tell us now that we should pay them 160K a year or $200K a year? I'm guessing they don't pay us $40K a year out of the goodness of their hearts right?

The problem I have is no one can explain why all the salaries are essentially equal - there is nothing to stop UCSF from saying we're going to give you $20K a year because you get such great training here. There is nothing to stop Random-hospital-in-the-middle-of-nowhere from offering $65K+ because they really want residents...

 

[TIVA]

Tiva - I think you make good points. The problem I have is if that is true then why don't they tell us now that we should pay them 160K a year or $200K a year? I'm guessing they don't pay us $40K a year out of the goodness of their hearts right?

The problem I have is no one can explain why all the salaries are essentially equal - there is nothing to stop UCSF from saying we're going to give you $20K a year because you get such great training here. There is nothing to stop Random-hospital-in-the-middle-of-nowhere from offering $65K+ because they really want residents...

There is some element of price-fixing. Resident/fellow salaries are determined by Medicare and approved by the ACGME, which essentially pays teaching hospitals a set stipend for each resident. This figure varies from region to region, but not by much because it's supposed to figure in the cost of living. So, in Pittsburgh, PGY-1 salaries are around $37 including health care, in the Midwest they're around $41 not including health care, and in SF they're around $60 including health care. Whatever differences there are, are usually small and due to either extra stipends to make up for higher cost of living, or the differences in benefit plans (e.g. healthcare) or perks (e.g. free parking).

I'm not sure why hospitals don't charge you to do an apprenticeship. Maybe it's because residents make up such an integral part of the workforce, that if you were a resident paying to do a residency or fellowship, you could choose what tasks you would or would not do (e.g. refuse to do scut work). In which case the hospital would have to pay twice or thrice your salary to a nurse practitioner to do it. In addition, the patients would refuse to let anyone less than a fully qualified, fully certified, and fully trained medical doctor touch them. Afterall, as far as the patient is concerned, he's PAYING for medical care, NOT PAYING to be PRACTICED on by someone who's PAYING in order to practice on them (sorry, crappy sentence, but I couldn't say it clearer).

Third, I think very few people would opt to go into medicine if they knew they had to mortgage their financial futures in order to become a doctor. To some extent, we've already done this in the form of whoppingly huge student loans. But if you were to add residency and fellowship tuition fees, fuggeddabout it. Only the insanely rich or the insanely stupid would go into medicine.

Of course, I could be wrong about all this and somebody from the federal government or the hospital board reading this might think, "really, we can employ residents and not pay them ... or even charge them ... hmmm ... maybe I'll bring it up at the next fiscal meeting." In which case, I'll shut up now.

 

[Gern Blansten]

Bottom line is this:
Sure, the NRMP doesn't always work the best for everyone. But it does most of the time. If the NRMP went away, a lot more people would get a hose job than are currently. Currently, competitive students(basically everyone in the 1st or 2nd quartile of their class and all of those with competitive step I scores) are in the driver's seat. Without the NRMP, the programs would be in the driver's seat almost all of the time.

 

[TIVA]

Bottom line is this:
Sure, the NRMP doesn't always work the best for everyone. But it does most of the time. If the NRMP went away, a lot more people would get a hose job than are currently. Currently, competitive students(basically everyone in the 1st or 2nd quartile of their class and all of those with competitive step I scores) are in the driver's seat. Without the NRMP, the programs would be in the driver's seat almost all of the time.

I agree, but it's a bit off topic. The NRMP is awesome as far as matching up applicants to jobs is concerned. What we were debating was what would happen to salaries if the NRMP werent' around. Some folks say it'll go up, some say it'll go down. At this point, just put your head down and finish the residency ASAP so you can get out and get some return on this investment.

 

[Gern Blansten]

I agree, but it's a bit off topic. The NRMP is awesome as far as matching up applicants to is concerned. What we were debating was what would happen to salaries if the NRMP werent' around. Some folks say it'll go up, some say it'll go down. At this point, just put your head down and finish the residency ASAP so you can get out and get some return on this investment.

The title of the thread is "what if the NRMP did not exist." The salary issue is related but not the only issue. I don't think my response was off topic.

With regards to salary, the cost of living issue is so huge that salaries are already vastly different as far as what you can buy with your money you earn. Living in Cali or Boston, you will be broke and living in a small place (or going further into debt), whereas in other areas, most residents own homes on a one income resident salary (with a little extra moonlighting money).
So, I think people are already paying extra to go to the "name" programs even though the higher salary gives the false impression that the salaries compensate for that.