Why do residents make so little?

[Chickenandwaffles]

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Can anyone explain this? My understanding is that Medicare pays around 120k or so per resident. If we are making an average of 50k or so per year, where does the rest go? Especially for those of us who don't get benefits from our hospital because they are crap, why is so much being taken from us? Many places don't give free food, we have to pay for parking!!, etc.

Anyone care to chime in? I think it's kind of abusive. Secretaries make more than us!

 

[styphon]

The rest is split among the hospital and the program itself.

 

[Shikima]

Because residents aren't allowed to collectively bargain.

 

[BlondeDocteur]

Residents cost the hospital money. It's not a net plus. If you count in the inefficiency trainees bring to the system, the high level of supervision they require, and their indemnification, paying us ~50,000/yr costs the hospital and your clinical department money.

 

[killerleaf]

malpractice insurance, benefits (such as medical, disability, those kinds of things). The cost of a program director, because they are not generating money while doing all the paperwork that is required. The cost of a program coordinator, because somebody has to do all the other paperwork, and for most programs, there is more work than one person can do. Office supplies, books for the library, what book money you may get, money for travel for residents to meetings. Lights, water, air conditioning, heat.

And at least around here, the residents are paid a lot more than secretaries!!!

 

[killerleaf]

And to add to what I said above, of course, this is at this institution, but:
I have been in this position for 10 years. I make about 1/3 more than a medical secretary. I make 1/3 LESS than a PGY1 resident.
In canvassing most other instituitons in my area, this is the norm.

 

[Law2Doc]

Residents cost the hospital money. It's not a net plus...

This. It's extremely naive to suggest that $120k comes in and $45k goes to the resident so somebody is making bank. In actuality, it's a net loss to most academic institutions for the "privilege" of being a Teaching hospital. The government money is an enticement to make this more palatable, because frankly the outlay of med mal insurance costs, GME staff, and the slowing down of attending who are now spending some of their very valuable time teaching rather than billing, is not insignificant. even with this government outlay, many places opt to forego having residents because it's such a money drain.

 

[Chickenandwaffles]

This. It's extremely naive to suggest that $120k comes in and $45k goes to the resident so somebody is making bank. In actuality, it's a net loss to most academic institutions for the "privilege" of being a Teaching hospital. The government money is an enticement to make this more palatable, because frankly the outlay of med mal insurance costs, GME staff, and the slowing down of attending who are now spending some of their very valuable time teaching rather than billing, is not insignificant. even with this government outlay, many places opt to forego having residents because it's such a money drain.

I disagree significantly. Most hospitals cannot run without residents. Most attendings are able to have much better/lighter schedules because of residents. In my residency for example, much is saved by not hiring attending staff to work nights/weekends/holidays because they are staffed by residents. All that would cost a ton if they had to hire an attending. Most attendings do much less work clinically than they would if they did not have residents. It is naive to think that attendings do more vs. less work with residents!

 

[SouthernSurgeon]

This. It's extremely naive to suggest that $120k comes in and $45k goes to the resident so somebody is making bank. In actuality, it's a net loss to most academic institutions for the "privilege" of being a Teaching hospital. The government money is an enticement to make this more palatable, because frankly the outlay of med mal insurance costs, GME staff, and the slowing down of attending who are now spending some of their very valuable time teaching rather than billing, is not insignificant. even with this government outlay, many places opt to forego having residents because it's such a money drain.

I always hear this...but I don't really buy it. At least not at the big AMCs.

Similar to the above poster, if you took away the residents our hospital would grind to a halt in a day.

Now certainly there is a cost they are putting into our training as well - support staff like program coordinators, time spent teaching, etc, etc, etc.

But simply in terms of manpower - We work twice as long for half as much as a mid-level provider. Now obviously you couldn't replace a seasoned PA with a July intern...but I'd take a PGY2 or 3 over most of our PAs...and again we are working twice the hours for half the PA.

If they tried to replace us with mid-level providers they'd go broke doing so - not to mention that there simply wouldn't be a talented enough pool of mid-level providers to replace us all.

Academic medical centers, with all their inefficiencies, are built around the subsidized labor of the 1000+ residents they employ.

 

[faw20]

I disagree significantly. Most hospitals cannot run without residents. Most attendings are able to have much better/lighter schedules because of residents. In my residency for example, much is saved by not hiring attending staff to work nights/weekends/holidays because they are staffed by residents. All that would cost a ton if they had to hire an attending. Most attendings do much less work clinically than they would if they did not have residents. It is naive to think that attendings do more vs. less work with residents!

Spoken like a naive junior resident. Once you progress to supervisory roles, you will realize how much more work it is to oversee the more junior residents, making sure they are not accidentally killing someone without knowing it. (It is much easier to do the work myself. But that teaches you nothing.) Add on teaching responsibilities (lectures/presentations don't make themselves), research responsibilities, administrative duties within the hospital/department/medical school, plus the patients you see in the office that do not involve residents, faculty have plenty of work despite a lower patient load than what someone in private practice might see.

ACGME requires supervision by attending faculty. Your program wold not be accredited if there were no supervision, even on the weekends. Having supervision by direct or indirect supervision is specialty dependent. Part of the faculty's salary is to provide backup and call coverage. Just because as a junior resident you don't see it doesn't mean it doesn't exist.

 

[shan564]

Any individual hospital may grind to a halt without residents because it'd require a lot of systematic changes, but if you look at a hospital that has both a teaching service and a hospitalist service, I think it's pretty clear that the hospitalists are more efficient. At my hospital, it takes three residents and a supervising attending to take care of the same number of patients that could be managed by a single hospitalist in the same system.

But in the end, salaries are determined by supply and demand. The healthcare system can recruit good residents at the current market rate, so why would they pay more? Medicare doesn't give us $120k just because they want to, they give us that much because that's how much it takes to subsidize the expenses.

 

[rokshana]

At my hospital, it takes three residents and a supervising attending to take care of the same number of patients that could be managed by a single hospitalist in the same system.

this...

 

[colbgw02]

Any individual hospital may grind to a halt without residents because it'd require a lot of systematic changes, but if you look at a hospital that has both a teaching service and a hospitalist service, I think it's pretty clear that the hospitalists are more efficient. At my hospital, it takes three residents and a supervising attending to take care of the same number of patients that could be managed by a single hospitalist in the same system.

I don't really have a dog in this fight, but I'm glad someone made this point. Residents seem to love pointing out how invaluable they are to healthcare delivery by citing how messed up things would be if they just up and disappeared - as if that's a realistic scenario. Without residents, university hospitals would run just like non-teaching hospitals, with a similar degree of efficiency that makes a teaching hospital look like the DMV.

 

[mvenus929]

I disagree significantly. Most hospitals cannot run without residents. Most attendings are able to have much better/lighter schedules because of residents. In my residency for example, much is saved by not hiring attending staff to work nights/weekends/holidays because they are staffed by residents. All that would cost a ton if they had to hire an attending. Most attendings do much less work clinically than they would if they did not have residents. It is naive to think that attendings do more vs. less work with residents!

I probably would've agreed with you... until I worked in the PICU. The attendings could run the unit on their own, including writing notes and orders, without the 4 residents that were there on a day-to-day basis. Most hospitals function the way they do because they have residents, and yes, if the residents up and disappeared, they would struggle. Until they made changes. There are lots of programs that have days (however frequently) where all the residents leave for one reason or another (usually something academic), and the hospital doesn't grind to a halt when they do.

Also, the attendings don't get paid anything for the time they take away from clinical practice to teach the residents. So by working less clinically in exchange for teaching, they're bringing in less money.

 

[dantt]

Residents cost the hospital money. It's not a net plus. If you count in the inefficiency trainees bring to the system, the high level of supervision they require, and their indemnification, paying us ~50,000/yr costs the hospital and your clinical department money.

Depends on the specialty...I bill thousands in clinic visits daily. The seniors bill 10's of thousands in procedures daily.

Edit: Yet, we're still payed the same as all the other residents.

 

[Law2Doc]

... Add on teaching responsibilities (lectures/presentations don't make themselves), research responsibilities, administrative duties within the hospital/department/medical school, plus the patients you see in the office that do not involve residents, faculty have plenty of work despite a lower patient load than what someone in private practice might see...

I think this is the biggie. I know my attendings literally see only about half the patients that the private practices across the street see, but work relatively similar hours. (obviously this varies by specialty somewhat, but its probably true at the overall organizational level at most places when you average all the specialties). The big difference is the teaching and supervisory obligations. Half the patients means these most valuable members of the organization are generating half the revenue they otherwise could. It's easier to stomach when the residents they are supervising come with their own subsidization, but programs are still leaving money on the table for the privilege and cache of being an academic institution.

Residents don't like hearing that for all their hard work they are more of a drain than a boon, but it's not an accident that a certain level of subsidy was required to make these employees palatable, and that for many years institutions dragged their feet on even increasing resident salaries above the 20k-30k mark out if concern that they would lose too much money on them. To be fair, later year residents probably start being valuable -- they require less supervision and actually take on some of the supervisory and teaching roles that free up attendings. But they really don't offset the drain of the early year residents, who are purely a cost center. And just as the senior residents start becoming really valuable, they graduate and leave.

 

[rokshana]

and the subsidies have not kept pace with the increase in salaries…programs got 125 then, they get 125 now, but the cost of salary and benefits have gone up…the math is not all that difficult on that.

 

[SouthernSurgeon]

Add on teaching responsibilities (lectures/presentations don't make themselves), research responsibilities, administrative duties within the hospital/department/medical school, plus the patients you see in the office that do not involve residents, faculty have plenty of work despite a lower patient load than what someone in private practice might see.

But that's kind of the point...

AMCs aren't private hospitals. No private hospital would survive if their surgeons did one half day of clinic and one day of OR per week. Or if their medicine attendings spent six weeks on service the entire year. AMCs are massive machines that are, at least when it comes to patient care, pretty darn inefficient. Residents are a big part of that inefficiency to be sure. But in the context of the giant machine that is a big AMC - residents are a vital, if inefficient, cog. And there would be no way to replace them in the context of AMCs as they are now. The departments would have to abandon their research missions and attendings would have to start doing all the work currently done by residents.

So yes, a private practice attending could do the work of several residents - that's no surprise. A hospitalist can take care of three times as many patients as a resident - that's no surprise. But without blowing up the whole system, these big centers can't survive without a thousand subsidized laborers.

But that's not to say they can afford to pay us more...

 

[colbgw02]

I feel like you're arguing against a point that no one is making. No one (reasonably) thinks that teaching/research hospitals would survive in their current form without residents.

 

[rokshana]

But that's kind of the point...

AMCs aren't private hospitals. No private hospital would survive if their surgeons did one half day of clinic and one day of OR per week. Or if their medicine attendings spent six weeks on service the entire year. AMCs are massive machines that are, at least when it comes to patient care, pretty darn inefficient. Residents are a big part of that inefficiency to be sure. But in the context of the giant machine that is a big AMC - residents are a vital, if inefficient, cog. And there would be no way to replace them in the context of AMCs as they are now. The departments would have to abandon their research missions and attendings would have to start doing all the work currently done by residents.

So yes, a private practice attending could do the work of several residents - that's no surprise. A hospitalist can take care of three times as many patients as a resident - that's no surprise. But without blowing up the whole system, these big centers can't survive without a thousand subsidized laborers.

But that's not to say they can afford to pay us more...

i think you overestimate how hard it would be to make that shift…many programs have put in place hospitalist non teaching services (mostly because of the restrictions that the ACGME is continually adding to programs) so increasing the number of hospitals wouldn't be difficult and credentialling could be expedited to get them working…heck the change could probably be made in a 1 year.

 

[BlondeDocteur]

Every year at my surgery residency there are 3 days where no residents work. One day/overnight is the ABSITE, and the other is a ski holiday which all residents are allowed to partake in. Amazingly-- amazingly!!-- at our huge academic medical center the attendings are able to field patient calls, admit, see ER consults, and operate. They spend 30s per patient on AM rounds sans discussion, teaching, and cross-checking a care plan. They write terse two line notes. They don't have to double-see each patient in clinic. They manage the Units from afar. Their operations go twice as fast with the scrub doing the assisting and no one clumsily attempting the dissection, anastomosis, etc. Obviously this only goes so far since as SouthernIM noted there are many other functions of an academic med center which will be neglected (principally research) if the attendings shouldered all of the clinical load. But it is laughable to assume that we trainees are completely indispensable.

 

[robberbaronista]

That works really well until there is nobody to replace you when you want to retire/vacation/sleep because you were so busy gloating about how much more efficient you are than a trainee to actually participate in a meaningful way in the training system- a system that others were willing to participate in to train you. You must recognize that no only do they do the bulk of the busy work every day, but they add a future value to the system that you operate within.
People who argue against the value of the resident workforce based on lower efficiency at their current level of training are akin to people who argue that we waste too much time and effort on basic medical research and say that instead we ought spend our time/money/effort on treating the results of a disease rather than understanding/preventing/curing a disease. You share the same self-aggrandizing, narrow minded, ninny-headed limitation of mind power that reproduces the same set of problems over and over and never allows any critical evaluation of our failures as a system.

 

[mvenus929]

That works really well until there is nobody to replace you when you want to retire/vacation/sleep because you were so busy gloating about how much more efficient you are than a trainee to actually participate in a meaningful way in the training system- a system that others were willing to participate in to train you. You must recognize that no only do they do the bulk of the busy work every day, but they add a future value to the system that you operate within.

I don't think anyone was arguing that residents aren't 'necessary' to the system, principally because, as you said, they are the future workforce. But when you ask why residents are paid little--that's why. They are a money sink because without them, hospitals can actually make more money. Under our current system, though, everyone who eventually practices in the US goes through some sort of residency training, so it is a very important part of our health system as a whole.

 

[colbgw02]

That works really well until there is nobody to replace you when you want to retire/vacation/sleep because you were so busy gloating about how much more efficient you are than a trainee to actually participate in a meaningful way in the training system- a system that others were willing to participate in to train you. You must recognize that no only do they do the bulk of the busy work every day, but they add a future value to the system that you operate within.
People who argue against the value of the resident workforce based on lower efficiency at their current level of training are akin to people who argue that we waste too much time and effort on basic medical research and say that instead we ought spend our time/money/effort on treating the results of a disease rather than understanding/preventing/curing a disease. You share the same self-aggrandizing, narrow minded, ninny-headed limitation of mind power that reproduces the same set of problems over and over and never allows any critical evaluation of our failures as a system.

 

[rongeur]

Every year at my surgery residency there are 3 days where no residents work. One day/overnight is the ABSITE, and the other is a ski holiday which all residents are allowed to partake in. Amazingly-- amazingly!!-- at our huge academic medical center the attendings are able to field patient calls, admit, see ER consults, and operate. They spend 30s per patient on AM rounds sans discussion, teaching, and cross-checking a care plan. They write terse two line notes. They don't have to double-see each patient in clinic. They manage the Units from afar. Their operations go twice as fast with the scrub doing the assisting and no one clumsily attempting the dissection, anastomosis, etc. Obviously this only goes so far since as SouthernIM noted there are many other functions of an academic med center which will be neglected (principally research) if the attendings shouldered all of the clinical load. But it is laughable to assume that we trainees are completely indispensable.

And are they coming in every night to lay hands on every painful belly and broken metacarpal? Are they rounding on their ginormous services because they do 10 whipples a week on the service? How many days in a row do you think they're going to do that at an academic salary? People seem to have an inability to realize that academic medical centers could not just magically become community hospitals. Their "business model" is built on taking care of complex -- and often uninsured or poorly reimbursing -- problems that require a high degree of manpower. Cheap resident labor is essential to this.

I just don't know how anyone can look at 23 year old surgical PAs with no past clinical experience and 26 months of schooling getting paid 85k for 38 hours of clocked weekday time per week and argue with a straight face that that's the true market value compared to a PGY2 resident getting paid 45k for 80 hours a week, including nights and holidays. If you want to argue that having a locked salary system is fine and doctors make it up as attendings, ok. But the idea that the free market value of residents is truly ~50k when compared to what midlevels make is prima facie absurd. If you really need more evidence, look at what resident-level moonlighting pays - somewhere between 5 and 10x the hourly rate of a resident salary. That would be the real "market rate".

 

[rokshana]

why would you think they would still be paid an "academic" salary…if they don't have to do teaching, they see more pts and make more money…there would no longer be a difference in attending salaries…

the reason you have these attending who are willing to get paid less and teach residents is because they ARE interested in teaching and training the future of medicine…

its like teaching a toddler to do things for themselves…YOU can dress them yourself way faster than they can do it themselves…but you (hopefully patiently) teach your child how to put on there clothes, pick up their toys and feed themselves because they need these skills as adults.

 

[Substance]

the reason you have these attending who are willing to get paid less and teach residents is because they ARE interested in teaching and training the future of medicine…

Or they are so absolutely weird, weak-skilled, or strangely enamored with pointless research that an academic institution is the only place that'll have them.

If they had better options, they'd take them.

 

[colbgw02]

And are they coming in every night to lay hands on every painful belly and broken metacarpal? Are they rounding on their ginormous services because they do 10 whipples a week on the service? How many days in a row do you think they're going to do that at an academic salary? People seem to have an inability to realize that academic medical centers could not just magically become community hospitals. Their "business model" is built on taking care of complex -- and often uninsured or poorly reimbursing -- problems that require a high degree of manpower. Cheap resident labor is essential to this.

I just don't know how anyone can look at 23 year old surgical PAs with no past clinical experience and 26 months of schooling getting paid 85k for 38 hours of clocked weekday time per week and argue with a straight face that that's the true market value compared to a PGY2 resident getting paid 45k for 80 hours a week, including nights and holidays. If you want to argue that having a locked salary system is fine and doctors make it up as attendings, ok. But the idea that the free market value of residents is truly ~50k when compared to what midlevels make is prima facie absurd. If you really need more evidence, look at what resident-level moonlighting pays - somewhere between 5 and 10x the hourly rate of a resident salary. That would be the real "market rate".

 

[Law2Doc]

And are they coming in every night to lay hands on every painful belly and broken metacarpal? Are they rounding on their ginormous services because they do 10 whipples a week on the service? How many days in a row do you think they're going to do that at an academic salary? People seem to have an inability to realize that academic medical centers could not just magically become community hospitals. Their "business model" is built on taking care of complex -- and often uninsured or poorly reimbursing -- problems that require a high degree of manpower. Cheap resident labor is essential to this.

I just don't know how anyone can look at 23 year old surgical PAs with no past clinical experience and 26 months of schooling getting paid 85k for 38 hours of clocked weekday time per week and argue with a straight face that that's the true market value compared to a PGY2 resident getting paid 45k for 80 hours a week, including nights and holidays. If you want to argue that having a locked salary system is fine and doctors make it up as attendings, ok. But the idea that the free market value of residents is truly ~50k when compared to what midlevels make is prima facie absurd. If you really need more evidence, look at what resident-level moonlighting pays - somewhere between 5 and 10x the hourly rate of a resident salary. That would be the real "market rate".

It's telling that you didny use pgy1 as your example --- the pgy2 is less useless than the pgy1, so some of your cost from the prior year is being offset by the value in subsequent years. By the time you are a pgy3 you might actually be valuable, but lot of (nonsurgical) residency programs end there, and you leave. Will you have made money by then or merely averaged out? Probably the latter. By contrast the PA might still be there at around the same salary a decade later. Second, you ignore the fact that attendings are doing less work by virtue of training you. As mentioned some academic centers see half the patients they might if they weren't teaching hospitals, that not a Money maker. So you can be really good at your job, now, but the fact that during your pgy1 year you slowed the most lucrative members if the organization down is big money.

The truth if the matter is that the fair market value of residents could really be negative. If not for the cache of wanting to be a teaching hospital, programs might reasonably decide that training people who stay on for just three years once they get licensed and trained unpalatable and bad business. In the banking world a lot of the intern/training program jobs used to be unpaid and those that were good got offered "jobs" at the end of the year. There are more than a few IMGs who would be happy to pay cash for a US residency spot if that were an option. So you have a lot less fair market value as a guy who slows down attending for while and as soon as you get productive you leave. It bad business, and so the government had to sweeten the pot to make it sustainable.

 

[Law2Doc]

Or they are so absolutely weird, weak-skilled, or strangely enamored with pointless research that an academic institution is the only place that'll have them.

If they had better options, they'd take them.

Oh please. Many very talented people choose academics for a whole host of reasons. Once you are older than twenty, if you still see success as maximizing income rather than doing what actually interests you it's really a bit sad. "Better options" is in the eye of the beholder and in many cases people choose academic options over the much LESS competitive private practice jobs in this industry. The goal is to enjoy life and frankly "pointless research" you are jazzed about beats going to a job you hate for a nice paycheck any day. You don't go through decades of school and training to not do what you enjoy.

 

[rokshana]

Or they are so absolutely weird, weak-skilled, or strangely enamored with pointless research that an academic institution is the only place that'll have them.

If they had better options, they'd take them.

that's sad if that has been your experience…many(if not most) of the attendings that have trained me along the ways have been some of the smartest people i have met, who have a passion for both caring for patients and teaching residents.

 

[keifernny2]

It has been my experience in multiple AMCs, though this may be specialty specific, that residents tend to get the more challenging cases for *teaching purposes* I suspect that the efficiency of the hospitalist service at the AMC would decrease somewhat if they were caring for the same patients. Also, when people discuss the successful attending care during half-days when residents are off service , they do sometimes neglect how much work is deferred until residents get back .

If programs were losing that much money on residents then it would make little financial sense for them to self-fund additional GME fellowship/residency spots, yet we know that they do this.

 

[KnuxNole]

That works really well until there is nobody to replace you when you want to retire/vacation/sleep because you were so busy gloating about how much more efficient you are than a trainee to actually participate in a meaningful way in the training system- a system that others were willing to participate in to train you. You must recognize that no only do they do the bulk of the busy work every day, but they add a future value to the system that you operate within.
People who argue against the value of the resident workforce based on lower efficiency at their current level of training are akin to people who argue that we waste too much time and effort on basic medical research and say that instead we ought spend our time/money/effort on treating the results of a disease rather than understanding/preventing/curing a disease. You share the same self-aggrandizing, narrow minded, ninny-headed limitation of mind power that reproduces the same set of problems over and over and never allows any critical evaluation of our failures as a system.

That's why I simply just don't want to work in a hospital with mainly residents as an attending. Since, that would personally be ideal compared to being miserable at a teaching hospital.

 

[SouthernSurgeon]

By contrast the PA might still be there at around the same salary a decade later.

Actually the average retention time for PAs in academic jobs is less than two years. Turns out even at half the hours and double the work, being treated like a resident takes its toll on them too...

 

[rongeur]

It's telling that you didny use pgy1 as your example --- the pgy2 is less useless than the pgy1, so some of your cost from the prior year is being offset by the value in subsequent years. By the time you are a pgy3 you might actually be valuable, but lot of (nonsurgical) residency programs end there, and you leave. Will you have made money by then or merely averaged out? Probably the latter. By contrast the PA might still be there at around the same salary a decade later. Second, you ignore the fact that attendings are doing less work by virtue of training you. As mentioned some academic centers see half the patients they might if they weren't teaching hospitals, that not a Money maker. So you can be really good at your job, now, but the fact that during your pgy1 year you slowed the most lucrative members if the organization down is big money.

Actually I chose to give you the benefit of the doubt and use PGY2 instead of a real senior resident. If you think the PGY7 surgery chief found at most academic surgical programs isn't worth several PAs to the hospital/department you're nuts. He HAS been there for most of a decade saving them money over the junior PA (who, as pointed out, will on average leave before an intern even graduates an internal medicine program).

Upon further consideration it may be somewhat true for internal medicine residency that the residents are not cost effective because of the ridiculous amounts of educational rounding, etc they incur. But to argue that surgery residents aren't a steal for programs is crazy. And, again, I have yet to hear why resident-level moonlighting work is worth $80-120/hr if these terrible residents are so inefficient that they cost hospitals money.

 

[joeDO2]

So $48,000 / 80hrswk x 50 weeks a year =$9.60 / hr.

*MAYBE* the hospital loses a little on the PGY-1s to train them. After this, you can bet any resident in any specialty is going to bill more than $9.60/hr for the hospital, even considering the overhead of having a few coordinators, etc. This is combined with the fact that they can pay the attendings considerably less than the going community rate.

Money rules all. They are making money.

 

[Winged Scapula]

So $48,000 / 80hrswk x 50 weeks a year =$9.60 /

3-4 weeks vacation per year is more common in ACGME programs, so;

$48,000/80 hrs x 49 weeks = $12.25/hr.

Now back in the day....

 

[anonperson]

What I would like to see is a detailed breakdown of what a hospital gets per trainee and where the money goes (malpractice coverage, etc). I don't feel there is a lot of transparency in this regard wherever you train.

I think the other thing that gets missed out is that having a residency program is a decent way to recruit attendings with minimal work/effort. At most hospitals with residency programs, the majority of the time residents will stay in the area and either be employed by the hospital or admit to/operate out of the hospital on a regular basis. The hospital/local group benefits from getting a known commodity that they already have a sense of. That familiarity is hard to beat and for certain fields, like hospitalist medicine where I feel the turnover is higher than average, they have a fresh pool of graduate each year. There has to be some sort of cost savings associated with this benefit that other hospitals with no residents have to deal with.

But hospitals do get a fair amount of monetary benefit. On the OB side of things, the hospital owned private OB GYN office will not hesitate to "fire" patients and have them follow up with the resident service for either lack of compliance/no shows or losing insurance coverage. They funnel their non profitable patients, usually medical train wrecks, to the resident service who also either are un/under insured while they can fill up their schedules with compliant patients with excellent insurance plans. I see this thing with other specialties/hospital systems and assume the hospital makes some type of financial benefit from this situation.

 

[ratherbefishing]

The NYTimes covered this topic recently. Hospitals do not lose money on residents, quite the opposite actually. They pay low wages because they can. The finances are hidden and residents are too disorganized/busy/powerless to change things. Residents are legally prevented from unionizing. It boils down to cheap labor and a steady stream of people willing to sign up to do it.

 

[BlondeDocteur]

Again, the point is not that residents provide 0 value. The point is that they aren't walking dollar signs-- it's not like CMS shells out $120,000 per resident, the salary is subtracted, and each department walks away with the rest in their pocket. There is a pernicious canard out there that hospitals view residency programs as cash cows, and it's simply not true.

What is the FMV of a resident? Hard to say. Let's compare to the 'other profession'- law. Lawyers do not undertake any kind of formal training once they graduate. If they're in the lucky small percentage who went to a good enough law school to be considered for a top-paying job, you start as a BigLaw associate in a big city making $165,000/yr.

Sounds great... especially given that they don't receive much in the way of formal, practical training in law school and are quasi-useless (their training is paid for by the firm's corporate clients). However, only a small fraction of graduating students make that salary-- let's say 10% (generous). And of those, only 10% eventually make partner at their firm. They live in constant anxiety that if they don't bill enough or perform highly enough, they're out. For a substantial number of lawyers-- even those who win the lottery and get that BigLaw job-- the highest salary they will ever make in their life is in those couple of years as a junior associate before they're fired.

Now, us. Arguably the 3rd and 4th years of med school provide enough hands-on training so that a new grad can hit the wards running and actually provide meaningful service. Not as meaningful as he thinks-- trust those of us who have supervised green interns-- but still meaningful. Arguably we could merit more pay. However, we exist in a system where a) our indemnification and supervision are provided by others, nicely covering our mistakes and b) where 99% of us march in lockstep on through the system, after which we more than triple (or quintuple, or more) our resident salaries. For life.

Can you seriously claim we're getting a bum deal?

 

[Chickenandwaffles]

The NYTimes covered this topic recently. Hospitals do not lose money on residents, quite the opposite actually. They pay low wages because they can. The finances are hidden and residents are too disorganized/busy/powerless to change things. Residents are legally prevented from unionizing. It boils down to cheap labor and a steady stream of people willing to sign up to do it.

I think this is exactly it. Hospitals don't lose any money on residents. Who do you think would take call, work weekends, evenings, etc? Previous program told me, this hospital could not run without residents. You think it's cheap and magical hiring hospitalists? You think that after about 6 months, a PGY1 is not doing far more than a basic, PA is doing? Why are we paying PA's with minimal medical knowledge 75k or whatever while interns 50k? It's because hospitals can, not because it costs them to "train us." Hospitals make far more money with us on board than they don't. Schedules and time off would be far more generous if hospitals ran so efficiently without residents. It is naive to think otherwise.

One of my previous programs was run by a private practice. Group could absolutely not run without us. When one of us was sick, there was madness to cover procedures, studies, etc. Attendings covered twice the level of reads than they would without us. I would bill thousands in studies and procedures a day. They would not hire nighthawk because they had residents.

Let's not be naive.

 

[NotAProgDirector]

There is nothing stopping residents from forming a union. Take a look here: http://www.cirseiu.org/

Note that ALL residents can't unionize. Each union needs to be specific to the employer. That's no different from anyone else. McDonald's employees could form a union, as could Burger King. But McD and BK employees can't get together and form a fast food union.

Whether unions would make things better is an open issue

 

[colbgw02]

One of my previous programs was run by a private practice. Group could absolutely not run without us. When one of us was sick, there was madness to cover procedures, studies, etc. Attendings covered twice the level of reads than they would without us. I would bill thousands in studies and procedures a day. They would not hire nighthawk because they had residents.

People on both sides need to stop citing these examples of a half day here or an evening shift there about how either the hospital would fall apart or go on running seamlessly without residents. It's not a realistic construct. In particular, it's important for both sides to remember that there's a lot of fat to be trimmed in academia. I think residents should remember that those inefficient attendings that can't function without the residents would be fired, so they're not exactly emblematic of how the department would run sans trainees. Frankly, the same goes for the support staff. Nurses in private practice don't both attendings with inane middle-of-the-night pages the same way they do with residents.

As someone on staff at a residency program, I don't know if you were being hyperbolic for effect, but there's zero chance that a radiology resident makes an attending twice as effective. High functioning residents read about a quarter of what a busy private practice attending reads in a year and about half of the production expectations for an academic radiologist (with teaching/research often on top of that).

You're absolutely right about call. Residents allow radiologists to sleep through the night (right up until the point that the hospital demands 24-hour staff interpretations, which is my understanding of why that group jettisoned its radiology residency a year ago), but how important is that outside of radiology? I'm honestly asking, because I'm not sure. My recollection is that very few physicians in private practice stay in-house overnight the way that residents do, so how many "extra" hours really need to be replaced without residents?

 

[Perrotfish]

There is nothing stopping residents from forming a union. Take a look here: http://www.cirseiu.org/

Note that ALL residents can't unionize. Each union needs to be specific to the employer. That's no different from anyone else. McDonald's employees could form a union, as could Burger King. But McD and BK employees can't get together and form a fast food union.

Whether unions would make things better is an open issue

The point of a union is to provide strength through collective bargaining that is absent in individual bargaining. They're useful for skilled employees whom employers might otherwise view as interchangeable. However a union still requires bargaining chips to be effective. If you can't play one employer off another, or threaten the employer when they refuse to negotiate, then there's no point in unionizing. More succinctly: if you can't strike there's no union.

Residencies collaborate with one another in a way that would be termed a trust in any other industry. Actually its considered a trust in this industry, its just that medical training, like Major League Baseball, holds an exemption to anti trust laws. Anti trust laws, as well as labor laws (which we are also mostly exempt from) are what prevent corporations from stoping the threat of unionization by colluding to destroy employees who threaten to unionize. When employers are allowed to collude to blackball any employee who participates in any kind of meaningful protest (like striking, or refusing to bill for services) then the 'union' is basically nothing other than a house staff council that you need to pay dues to. You elect your representatives, they bring your complaints to the administration, and the administration does whatever they want to do.

 

[Lavan]

For those that mentioned the efficiency of the hospitalist teams. The hospitalist at the three institutions I've worked in generally take the most straightforward patients. A many have teams of midlevels. It's relatively straightforward to manage CP rule outs and the like en masse. Continual readmits for COPD/CHF/ESRD volume overload, straightforward PNA etc are also relatively quick. Anecdotally, I've noticed the teaching teams actually did a significantly better job than the hospitalists, especially the ones who utilize midlevels. The midlevel teams order tons more consults and imaging studies etc. There is value added by having residents beyond the cost. You might think it would be the opposite because residents are in training, but overall the extra diligence goes a long way.

It would not necessarily be cost prohibitive for most hospitals to replace the work residents do with attending physicians. However, the quality of life of the attending jobs overall would decrease, and subsequently more physicians would need to be hired or pay raised to counteract. In that setting, it might not be feasible in the long run. And midlevels, the other option, cost more than residents.

 

[NotAProgDirector]

The point of a union is to provide strength through collective bargaining that is absent in individual bargaining. They're useful for skilled employees whom employers might otherwise view as interchangeable. However a union still requires bargaining chips to be effective. If you can't play one employer off another, or threaten the employer when they refuse to negotiate, then there's no point in unionizing. More succinctly: if you can't strike there's no union.

Residencies collaborate with one another in a way that would be termed a trust in any other industry. Actually its considered a trust in this industry, its just that medical training, like Major League Baseball, holds an exemption to anti trust laws. Anti trust laws, as well as labor laws (which we are also mostly exempt from) are what prevent corporations from stoping the threat of unionization by colluding to destroy employees who threaten to unionize. When employers are allowed to collude to blackball any employee who participates in any kind of meaningful protest (like striking, or refusing to bill for services) then the 'union' is basically nothing other than a house staff council that you need to pay dues to. You elect your representatives, they bring your complaints to the administration, and the administration does whatever they want to do.

I am not certain what point you are trying to make here. CIR represents residents at multiple institutions. You can look at their website and see what they have done. The program I am most familiar with is BMC (it is not my program). Although salaries are probably similar to other programs, their benefits are (perhaps) somewhat better. They get paid if called in for an extra call (i.e on backup), and apparently have a discounted program for providing emergency day care if needed. Any institution could choose to be represented by CIR. The anti-trust exemption is only for the match -- programs are not exempted from anti-trust or labor laws.

In general, physicians do not strike. Ultimately patients might be injured, and that's unacceptable in (almost) everyone's playbook. I have heard of the idea of residents "striking" by refusing to write discharge summaries, or even refusing to discharge patients, but I do not know the legality of that. There's a nice balanced summary here: http://www.acpinternist.org/archives/2000/03/newruling.htm

One of the key protections that a resident union could bring to a program is an added layer of protection for resident who are terminated.

 

[Substance]

Oh please. Many very talented people choose academics for a whole host of reasons. Once you are older than twenty, if you still see success as maximizing income rather than doing what actually interests you it's really a bit sad. "Better options" is in the eye of the beholder and in many cases people choose academic options over the much LESS competitive private practice jobs in this industry. The goal is to enjoy life and frankly "pointless research" you are jazzed about beats going to a job you hate for a nice paycheck any day. You don't go through decades of school and training to not do what you enjoy.

..and I like pooping. Doesn't mean I should spend my life doing it to the detriment of better things.

As for your last comment, sure you do. Work cannot always be enjoyable. For most people, doctors included, its not. It's a means to an end. It provides context and meaning in life for most of us, but it would be a stretch to say that it is an enjoyable job (except dermatologists. They're a pretty happy lot)

 

[Chickenandwaffles]

People on both sides need to stop citing these examples of a half day here or an evening shift there about how either the hospital would fall apart or go on running seamlessly without residents. It's not a realistic construct. In particular, it's important for both sides to remember that there's a lot of fat to be trimmed in academia. I think residents should remember that those inefficient attendings that can't function without the residents would be fired, so they're not exactly emblematic of how the department would run sans trainees. Frankly, the same goes for the support staff. Nurses in private practice don't both attendings with inane middle-of-the-night pages the same way they do with residents.

As someone on staff at a residency program, I don't know if you were being hyperbolic for effect, but there's zero chance that a radiology resident makes an attending twice as effective. High functioning residents read about a quarter of what a busy private practice attending reads in a year and about half of the production expectations for an academic radiologist (with teaching/research often on top of that).

You're absolutely right about call. Residents allow radiologists to sleep through the night (right up until the point that the hospital demands 24-hour staff interpretations, which is my understanding of why that group jettisoned its radiology residency a year ago), but how important is that outside of radiology? I'm honestly asking, because I'm not sure. My recollection is that very few physicians in private practice stay in-house overnight the way that residents do, so how many "extra" hours really need to be replaced without residents?

If you think that residents don't increase a private group's productivity, then you are mistaken. Even when it comes to procedures, our attendings do ZERO procedures, we do ALL procedures. Many of our attendings don't even know how to do them, so if we did not do them they could not bill for them. As you were mentioning with call, residents are the ones who take weekend and overnight call, so attendings and the private group save a ton of money (a good 500k +) by having a residency. Otherwise they would have to pay nighthawk. It doesn't matter what *may* happen in the future, our current hospital does not require attending reads overnight or on weekends, which are still being done by residents. If the residents did not do all the work they do, how do you think they would do it? Oh right, by having to hire more radiologists and paying them an attending salary, which would reduce in turn the group's profits. I don't know what you are talking about other private groups, I'm talking about the very real example of my rads program for example that's a private group that uses the residency program to get the best of both worlds, and saves a ton of $$ and makes far more $$ than they would did they not have a residency.

 

[colbgw02]

If you think that residents don't increase a private group's productivity, then you are mistaken. Even when it comes to procedures, our attendings do ZERO procedures, we do ALL procedures. Many of our attendings don't even know how to do them, so if we did not do them they could not bill for them. As you were mentioning with call, residents are the ones who take weekend and overnight call, so attendings and the private group save a ton of money (a good 500k +) by having a residency. Otherwise they would have to pay nighthawk. It doesn't matter what *may* happen in the future, our current hospital does not require attending reads overnight or on weekends, which are still being done by residents. If the residents did not do all the work they do, how do you think they would do it? Oh right, by having to hire more radiologists and paying them an attending salary, which would reduce in turn the group's profits. I don't know what you are talking about other private groups, I'm talking about the very real example of my rads program for example that's a private group that uses the residency program to get the best of both worlds, and saves a ton of $$ and makes far more $$ than they would did they not have a residency.

No, they would only have to hire more radiologists if the same efficiency were maintained, but that's just a continuation of the status quo argument that a bunch of other people have tried to make on this thread. The argument is not that practices with a residency could be maintained as is without trainees; the argument is that the practices would adapt to be more efficient. Radiologists that can't adapt would be let go, as a I mentioned earlier when I said:

I think residents should remember that those inefficient attendings that can't function without the residents would be fired, so they're not exactly emblematic of how the department would run sans trainees.

And, once again, I concede the point about call vis-a-vis radiology residency. I just don't know how applicable that is to other fields.

 

[Chickenandwaffles]

No, they would only have to hire more radiologists if the same efficiency were maintained, but that's just a continuation of the status quo argument that a bunch of other people have tried to make on this thread. The argument is not that practices with a residency could be maintained as is without trainees; the argument is that the practices would adapt to be more efficient. Radiologists that can't adapt would be let go, as a I mentioned earlier when I said:



And, once again, I concede the point about call vis-a-vis radiology residency. I just don't know how applicable that is to other fields.

And who wins financially? It's a very basic point here. By having residents, who do a ton of the work, at 50k or so a head, vs. 400k for a regular radiologist or more for a nighthawk, do you think the program is benefitting? Clearly the answer is *yes*.

This idea that all programs are this ivory tower gleaming with knowledge and hours of teaching is absurd. Most of the money is simply pocketed, and "teaching" happens in pockets here and there.