Why don't Residents make as much as PAs?
Started by Giovanotto
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I'm calling bull**** on mid-level employees being long-term. A long-term workforce is a thing of the past. If anything, residents (especially in surgical fields) are more long-term than mid-levels. It's like everyone automatically ignores market trends in medicine when lets be honest: it runs like almost any other business.
I'm not trying to argue either side, but I'm just asking for clarification purpose: Isn't IME funding supposed to offset the cost inefficiency associated with residents so that it is at least cost-neutral to have residents? You get an additional payment that is calculated with the resident to bed ratio for each medicare case because it was acknowledged that residents can decrease efficiency.
Does it not end up balancing out such that the hospital maintains its profit level with or without residents?
Edit: And while I still have trouble understanding how a resident's salary is justified by anything other than "they just can do whatever they want," I know @Mad Jack don't mess around when it comes to getting money he feels he deserves. So I trust his knowledge/research on this matter, haha
Does it not end up balancing out such that the hospital maintains its profit level with or without residents?
Edit: And while I still have trouble understanding how a resident's salary is justified by anything other than "they just can do whatever they want," I know @Mad Jack don't mess around when it comes to getting money he feels he deserves. So I trust his knowledge/research on this matter, haha
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This came up recently when a congressional inquiry on GME funding reported that 1/3 of the funding went to resident salaries, 1/3 went to offsetting efficiency costs, and the remaining 1/3 just disappeared. During the attempt to redraw funding schemes, the AMA sent out a mass mailer to all medical students saying that "Congress wants to cut GME funding and you will lose money/training".
Just like anything else, you better believe that these residency programs are making a buck off their residents one way or another.
Yes that is the goal of IME payments, and many argue that hospitals are actually over reimbursed for that aspect.
The main problem does come down to two things: overall budgets/margins and leverage.
Many to most academic centers run on razor thin margins. Individual department budgets more so. The IME payments help offset a lot of general costs - they get distributed at the hospital level not the department level, and if you asked a PD where that money actually goes they have no clue. DME payments help provide for a lot of the necessary support and infrastructure (including things like PCs and paying for the academic time of a PDs salary).
Just asking a hospital l individually to start paying their residents double would make the hospital CEOs have a panic attack - they don't typically have a surplus budget that could accommodate doubling the salaries of 1000 employees.
And residents do have very little leverage. It's not a free market, you are transient (i.e. How much do I really want to fight for this cause when in a year I will be moving on?), and your employer holds the keys to the kingdom.
So as it comes down to in every single iteration of this thread...the premeds and allo money obsessed crowd cries out "but I really really FEEL like I DESERVE more", but can't produce a single argument of either why or how to change it.
This brings up the other problem...if anything, it seems more likely that GME funding will be reduced or restructured dramatically. It's 15 billion a year of low hanging fruit for congress.
Without those offsets to the budget, residency program funding (and our salaries) are gonna get very interesting...
There's also the idiots that argue about "THE FREE MARKET," as if that has any bearing whatsoever on resident salaries.
You know what a free market salary for a derm resident would be? You'd probably end up PAYING tuition for residency, and still have a glut of qualified candidates. Maybe mediocre programs in non competitive specialties might have to increase salaries a bit, but any surgical subspecialty or top program could easily pay the residents nothing without breaking a sweat.
You know what a free market salary for a derm resident would be? You'd probably end up PAYING tuition for residency, and still have a glut of qualified candidates. Maybe mediocre programs in non competitive specialties might have to increase salaries a bit, but any surgical subspecialty or top program could easily pay the residents nothing without breaking a sweat.
PAs (and physicians, for that matter) tend to stay in one job for far longer than their non-medical counterparts. Yearly midlevel turnover was in the single digits where I worked, and we had hundreds of them so it wasn't just some statistical anomaly. In outpatient settings, turnover is higher, but in inpatient academic settings PAs tend to stick around. The reason for this is pretty obvious- a PA's scope is only as broad as their overseeing physician allows it to be, so staying in the same place and getting to know their physician to gain their trust allows them to maximize their autonomy.
So Wharton/Penn Med has been sending around a medical school financial survey to pre-meds at top schools. One of the questions asked how much we would be willing to pay to attend residency per year.... I really want to know where they were going that question and why they would ask it, but I put $0. @SouthernSurgeon probably related to what you were saying about it getting interesting
Paid residencies, coming soon!
What a glorious time to be alive!
...b,b,b,but, free market!
Why is this even a question?
PAs are doing a job.
Residents are learning how to do a job.
PAs are doing a job.
Residents are learning how to do a job.
So glad you chimed in. That's it folks, he solved it. Case closed. Up next:
"Harvard's medical school finest resident has been fired in what is a record first attempt to stop working during residency and only learn"
This sounds great, I'll remember it when I'm in residency: "Excuse me, you want me to check this 65 year old man's anal tone again?"...."But, I did that yesterday, sorry, it would no longer constitute learning since I already know he is putting out Major Es and Cs--no can do mister Attending Physician, I am only here to learn".
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I'm sure it varies per specialty but I can't imagine how surgical residents are not profitable for a hospital. They are paid ~50-60k; now think how much the hospital charges for each procedure/day the patient receives during their stay. For example, as an Ortho resident in a day I'll place numerous splints/casts/I&Ds/soft tissue repairs/etc. (going rate is ~200 per); help in OR cases (attending can now run two rooms and doesn't worry about prepping/closing/etc); manage floor patients (obviously healthy patients who require limited ortho floor mgmt skills or otherwise they'd be in ICU/medicine) and place multiple imaging orders (rake up $$$ for the hospital). If I cared enough to do the math, I'm 100% confident my production/activity in the hospital and the costs it generates (payment received via medicare, medicaid, and private insurance), the hospital is net positive in earnings for the year from having me around
You have to do something more than once to learn...
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Yes because once you do a task one single time, you know every single thing about it forever.
This quote alone proves that you are far too ignorant about medical education to have a real conversation about it at this time. That's okay. You haven't actually had any medical education yet. Come back in a few years.
Before I finished residency, I too thought that the things I did couldn't possibly be done just as if not more efficiently without me around.
I really think you're missing the overall point. It is training. You get good at some things as you train, but that doesn't mean you're still not a trainee- you've still got other things you're learning along the way. If you think you know everything after internship, feel free to take your medical license and run with it. You are under no obligation to complete the residency you claim you'll be learning so little from.
Back in the day you got room and board as a resident, that was it, the reason being that they weren't going to pay you to teach you. Imagine going to a trade school and being like, "oh, I realize that you'll be teaching me all these valuable skills and giving me a certification and everything, but how much will you be paying me to do all this work I have to do to get there?" It'll be extra amusing to me when the day comes that residents start paying tuition (a day which, mark my words, will come), if only so I can see the wailing and gnashing of teeth by people who suddenly realize that they were previously getting paid for something they were lucky to not have been paying for all along (because that's what they would be doing if the free market were left to handle things).
Do you think people will have to pay med school tuition AND residency tuition? That is pretty rough...
It's what some dental fellows have to do. I hope it doesn't come to pass for some time, but if Medicare cuts GME funds, I guarantee it will happen.
Dental residencies already charge tuition. And people line up.
you lauded the UK Jr doctor strike and their system which you know nothing or, at best very little, about. You were "skeptical" about medicine and where private practice was going and are trying to make arguments about the productivity of residents and how apparently you don't believe it is training, before even going to your first medical school lecture. Do you just enjoy arguing about things you really don't understand?
If the coffee shop is willing to sell me a cup of coffee for $2, I don't declare that coffee is actually worth $3 to me and pay them an extra dollar. Same applies to the purchase of labor. The discussion of what value residents provide ignores the supply side of the labor market. Bottom line: when you offer a stipend of ~$50K/yr, you generally end up with a sufficient number of qualified applicants to fill all of your available slots.
Anyway, it isn't like relatively low resident pay is a new thing. You know the deal today, and you are still apparently of the opinion that proceeding with medical education is in your own best interest. I think we're all too educated to feel cheated by a situation we're entering of our own volition with close to full knowledge of costs and compensation.
Anyway, it isn't like relatively low resident pay is a new thing. You know the deal today, and you are still apparently of the opinion that proceeding with medical education is in your own best interest. I think we're all too educated to feel cheated by a situation we're entering of our own volition with close to full knowledge of costs and compensation.
On the DO side of things, there were actually some dermatology residencies that were completely unpaid care of no funding. I don't think any of them exist anymore, and they certainly won't exist post-merger, but that was a thing up until very recently.
Well, not more efficiently than an attending, but considering the cost difference, an attending would have to be what, 5-6x more efficient to make up for the cost difference? Probably more considering how few times attendings come in during the middle of the night and the difference in hours.
I think the "attendings don't come in during the night" thing is a common misconception that it's very easy to make when all you've seen so far is academics/residency. It's not as if patients who are at non-teaching hospitals are just left to die from 6p-6a. Someone is handling that middle of the night stuff (and billing accordingly, trust). It may be a midlevel who is "first call," it may be the physician from home or actually in person. Either way, the stuff gets done, so you can't really say that the presence/absence of residents has a huge effect there.
Do they though (line up)? With loan rates at what they are today, and dental tuition skyrocketing, I highly doubt people will be "lining up" in the near future if education continues to get more expensive in dentistry.
How does change happen then? From within or on the sidelines? Knowing something and running the other way will only assure everyone not much will change.
This debate is entirely dependent on the PGY level and specialty. As a senior radiology resident, I interpret all imaging from 9PM to 7AM for the entire hospital and can count on one hand how many times I've woken up an attending at night. Lumping that together with a fresh medicine intern is dumb. I can also remember the few cases where I missed something significant, with the knowledge that there is almost no academic radiology attending here who could do the same thing as me at night considering most of them are confined to their subspecialty and turn into pumpkins if asked questions outside of that.
Same thing probably goes for any senior resident. Sure, we are "training." We are also allowing attendings to sleep through the night uninterrupted and doing all emergent procedures that we can. If you honestly think that's worth $60k a year I don't know what to tell you.
I will say, however, that residents do have lots of dedicated study or research time as well as off-service time that would no doubt be eliminated if they truly wanted salaries commensurate with what they feel they're "worth."
Same thing probably goes for any senior resident. Sure, we are "training." We are also allowing attendings to sleep through the night uninterrupted and doing all emergent procedures that we can. If you honestly think that's worth $60k a year I don't know what to tell you.
I will say, however, that residents do have lots of dedicated study or research time as well as off-service time that would no doubt be eliminated if they truly wanted salaries commensurate with what they feel they're "worth."
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Which is why I've said from the beginning that paying an intern ~50k a year makes perfect sense. Why that pay doesn't increase (significantly) as he becomes more knowledgeable and productive makes no sense.
Well, it continues apace at all academic centers across the country, so unless hospitals and GME offices ever feel the need to change that it will continue to make sense for them.
You being skeptical of something doesn't make it untrue.
They do. Because they'd rather pay out the nose (tuition is roughly 120k for one year at UPenn, if memory serves) than not be an orthodontist.
Agreed. Do you think it is more likely that resident pay will increase or that it will vanish altogether?
Is this a serious question?
It's most likely that resident salaries will stay the same, adjusted for inflation, unless GME cuts occur, in which case they will decrease.
Easily. In med school the surgery residents would have a lap while book for 2 hours of OR time. In residency, the attendings would knock those out in 10 minutes easy.
That's pretty much what I got from this thread.
Would love to know what the difference between a day 1 Intern is vs. a day 1 PA/NP.
Why is the PA/NP much safer than the day 1 Intern?
Why is the PA/NP worth 2-3x the day 1 Intern?
Why does PA/NP school prepare you much better to be an independent practitioner than medical school?
Please don't tell me PAs/NPs are not independent, because in many specialties and many states, they either are functionally operating independently and at the scope of a board certified physician in their specialty or literally are (owing to lax state laws in this area).
What about the other 75% of the week which is not in the OR
Have fun checking anal tones all day? I think I'm good after trying it once, thank you very much.
I see third year being a real struggle for you.
Come on man, it's like you're trying to justify all of the "Medical Student (Accepted)" jokes that are out there.
What about it?
They do line up as it usually means more income potential, just like specialty and subspecialty training in medicine.
--
Il Destriero
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A day 1 PA/NP isn't just let loose, first off. They usually start with a large amount of oversight that gets pulled back over time. Many new grads are paid substantially less than their experienced counterparts because of this. And neither is as competent as a physician, but that's the thing- as an intern you are being trained to be as competent as a physician. PAs and NPs are in a position of lesser competence in perpetuity. They have less autonomy and more oversight in the vast majority of settings. They also serve a different function than an intern or resident, in that their only purpose is to extend physician or hospital earnings, while residents are being trained and require additional resources care of this that PAs and NPs simply do not. If you want to get paid PA money to do a PA's job, be a PA. If you want to get paid intern money to be trained to do a physician's job, well, be a ****ing resident.
surgery residents in med school and attendings in residency? I'm not sure this statement makes much sense. The limiting factor for efficiency is a combination of the slowest member involved in the case (resident vs. PA/surg assistant) and awful turnover (academic centers are notorious for this). Also academic centers are meant to take on more difficult cases making a case look more efficient in the hands of one performing standard procedures in a healthier population.
Am I the only one that thinks this response still doesn't explain why residents aren't payed as much as a PA/NP? Probably.
There are even times where to me your explanation draws more parallels between residents and mid-levels than differences. Hopefully when I become a resident your explanation will make more sense.
First off, the word is paid. This alone would prompt me to pay you less.
Second, what parallels are you seeing? Almost everyone that is disagreeing with you are, at the very least, medical students with experience in healthcare, residents, or attendings. What are the chances that you've made some sort of paradigm-shifting analysis as a pre-med?
Regarding @Mad Jack's quote, I'm not sure how he could be more clear: a fresh NP/PA is oriented and supervised closely for the first few months and then they hopefully achieved their maximum proficiency for which they were hired. Assuming they never leave that practice environment, their training and mentorship is complete. No one thinks that a fresh NP/PA is more competent than an intern. They are equally incompetent. What MJ and others are saying is that the mid-level ceiling is lower; therefore, they reach that ceiling more quickly. And because they are able to achieve that competence sooner, they are worth their market value sooner.
One thing that has not been mentioned is that the mid-level pathway has traditionally been filled by folks with years of solid experience prior to re-entering school. This was supposed to facilitate mid-level providers getting up to speed more quickly. This is less true now and so perhaps new NP/PA grads also take longer to ripen up, so to speak. In contrast, the traditional physician path had been such that internship and residency were often the first real job these young physicians had. It is my own pet theory that this is part of the reason why physician training is designed the way it is (and perhaps why it is misinterpreted by some as so onerous).
Honestly, I don't know what is so hard to understand about this concept. Physicians take longer to train and the costs of that training are expensive. NP/PAs are not physicians so there isn't even a parallel to uncover. They get paid more sooner because they achieve competence in their more limited scope more quickly. I am not saying that a fresh intern can't also achieve that same level of competence as a mid-level more or less quickly because that is apples to oranges. As an intern, I feel like I could certainly meet the minimum competencies of a good mid-level, but that doesn't make me a good physician.
Yes, in med school I worked with surgical residents. In my FM residency we had no surgical residents, only attending surgeons.
As for case difficulty, it's why I specified lap choles... or tried to before autocorrect got me.
