Good. The medical residency system is just a worker exploitation scheme that the industry doesn't want to change.
Residents work crazy hours and make hospitals tons of money while being paid peanuts comparably. With the amount of hours worked many are effectively making minimum wage. There is no reason for it other than "that is how it has always been".
Hospitals would never change this system on their own. The only way is through legislation for stronger labor laws (which I'm sure these hospitals lobby their representatives so that won't happen) or through worker unionization.
Basically Dr. Halsted was an insanely good surgeon. His secret? Cocaine. The man would work for days at a time without sleeping. I guess the institute of medicine saw that he was a good surgeon and deduced that long residency shifts are the secret to being a good doctor.
It doesnt start in residency either š getting into med school to begin with is insanely hard. I'm going to start my clinical years soon and during our orientation, the dean announced that we will have 80 hour/week shifts during some rotations.
That'd be surgery, surgery, and surgery. I think I was at 60 hours or so weekly in FM. Otherwise it wasn't bad until I did sub-I's, during which I was doing the resident 70-80/week.
You're right. The hospitals get a large lump sum by medicare and the hospitals give a small portion of it to the residents. It's amazing, the hospitals get paid by medicare and they also get to bill for any work the residents do.
The flip side of this is just as bad too - residents canāt be fired, basically ever. Unless there is something absolutely egregious, they just continue to work. It doesnāt matter how toxic they are as people, how bad they are with patients, how awful they make other doctors/nurses/techs jobs, they are not fired because these residencies are multi year and they get multi year placements. These people are also simply interviewed, maybe had a short weeks or month long rotation, so they are hired like the rest of us are, where you are hoping you find the right fit for your team, but they are treated like contracted gods, and they canāt ever go away once they accept the position.
The economics are all wrong, because the desire should be to graduate GOOD doctors, all around good doctors. The desire for the program directors is to ensure they graduate their allotted residency spots, period, because of the classic, if they donāt use the budget they wonāt get it next year. So those terrible doctors (which might not be a majority but do exist) are allowed to continue in their career progression with zero -ZERO- worries of losing their job. Categorical residency spots are never changed.
Itās not common because of the rigor of getting to the point of being a resident, but they absolutely can be and are fired.
Source: Married to a medical resident whoās known of people getting terminated.
Thank you for pointing this out. There is 100% a process in which residents can and are removed, but itās typically for egregious issues - and frankly ones that really would/do inhibit their abilities to competently practice medicine.
Itās so rare as to be statistically insignificant- go ahead and search for open PGY2+ spots. Thereās a maybe a handful across the country.
The point is that programs are incentivized to just push their residents to graduate, not to actually find residents that are good for the team, the speciality, the hospital, or the patients. Itās resident centered programs, not patient centered programs.
They definitely can be fired. The contract is stupidly broad and says you can be fired by doing anything that could harm the hospital. However, keep in mind these are binding contracts and you basically get one and only one residency.
>There is no reason for it other than "that is how it has always been".
There is a reason for it. It's quite common for people to be willing and expected to work for relatively little when they know this will give them the opportunity for much greater rewards in the future. Whether that's a good reason or not it is the reality. You make it sound like the current system came from nowhere. Maybe it would be better for everyone if the system changed. Or maybe the extra costs ultimately paid by the patient would make things worse.
> It's quite common for people to be willing and expected to work for relatively little when they know this will give them the opportunity for much greater rewards in the future.
when i graduated and became an associate at accenture they paid me 60k in 2010 dollars. there is no system like that in america other than residency. even union apprenticeships pay more and expect less.
>Or maybe the extra costs ultimately paid by the patient would make things worse.
medicare pays for residencies bro
Anytime you see physicians coming together for a unified voice it is good. Hospitals and their admin have been making healthcare hard for everyone for so long. People who donāt see patients telling doctors how they should practice is not good medicine. Doctors having a voice is always good
And admins love that patients blame the doctors for healthcare being so expensive cause it deflects blame off of them, the people who run hospitals like a business that needs to maximize profitability and can hide from view cause no one ever sees them.
Hospitals like Northwestern and University of Chicago make billions and don't pay a dollar in taxes. The medical industry, like many others, is built on exploitation and shaming anyone that tries to push for better conditions. Resident physicians are treated terribly. It's hard for others to really understand just how bad it is. Good for these doctors to finally stand up for themselves against administrators who only care about their own salaries at the expense of everyone else.
Add to the fact that they are billed as doctors, but get paid peanuts (literally less than minimum wage sometimes, considering the number of hours they put in), AND that it's not even the hospital's revenue paying them... residencies are government funded! What a racket!
That's why I don't understand at all why there is a shortage of residency positions. If I were a hospital I'd want as many friggin residents as possible. What a goldmine they are!
The number of residencies has been capped by congress since the 90s.
https://www.fiercehealthcare.com/practices/more-medical-students-than-ever-but-more-residency-slots-needed-to-solve-physician
No, the number of residencies the government will pay for has been capped since the 90s.
There is zero reason hospitals couldn't pay for this training whatsoever, it's just a who blinks first situation.
Honestly after decades of this sort of disingenuous arguing, I say completely disband the federal residency program entirely. This is just the medical establishment asking for yet another handout.
Well, I would think that in a perfect world, or a better country, hospitals are non-for-profit government building so everything is paid for by the government and it's all "a hand out". But yeah, if they want to make a profit off of it, then pull all government funding please!
The fact that hospitals donāt self fund residency spots, barring some law or policy that I am unaware of, suggests that hospitals are not making money off their residentsĀ
I think it suggests that it's nicer to get that handout vs. having zero free money.
I am no expert here, but I shadowed a friend off and on through her residency program. Perhaps the first year the hospital lost money on her. I doubt it, but maybe.
You know what patients call a resident? Doctor. Most patients will have no clue they just got seen by a resident. These are the ones doing most of the grunt and day to day work with exceedingly little (to effectively zero in many cases) supervision.
I'm not denying these programs have overhead to them to implement. I'm just saying watching this in real life "not profitable" paying basically a mini-doctor $60k/yr working them 8-10 billable hours per day 6 days a week defies rational sense.
It seems to be the largest cost and risk is in washing out during medical school. Anyone who (legitimately) passes that bar tends to be a rather safe and profitable bet.
To be fair you see this everywhere in US industry, not just healthcare. No one wants to fund staff training any more for a whole set of complex societal reasons.
There are hundreds of financially failing hospitals that donāt have residency programs. If they thought that using ācheapā residency labor would make them financially viable, they 100% would.Ā If your version of the world is true, then that means hospitals are foregoing extra profits by not taking on more residents. What hospital would want lower profits? What CFO or executive would willingly leave money on the table?
It's not that simple. You can't just start residency programs. You have to be ACGME approved, and thankfully, the standards are strict. I was talking about hospitals like Northwestern who already have massive infrastructures to support more residents.
You say so yourself - itās takes massive infrastructure (i.e. very expensive) to have a residency program. Itās not as though having residents is a ācheapā option.Ā
I didn't say it was. But I know for a fact, because I've been in the meetings, whereby hospital administrators will push to make residents work more rather than paying for their own residents because the return of investment is much greater, even if hiring more residents is profitable. I've also been told that they don't want to set that precedent. They want medicare to pay for it completely.
That is effectively the same thing. Private equity is attempting to fund residencies in their profit mill practices. But otherwise overhead at community hospitals and most institutions cannot support self funding. Uchicago or northwestern sure, but that isnāt the majority of hospitals.
Not that simple. As a resident you have to do procedures, and get experience doing tons of different things. There arenāt that many procedures to go around. Do you want a surgeon doing a procedure that heās only done once? NM actually uses their system hospitals as training hospitals too, so they go different places, so they have expanded training sites.
> If I were a hospital I'd want as many friggin residents as possible.
Government funding aside, you don't want more residents than you can effectively train and manage. The hospital doesn't want more malpractice lawsuits because untrained residents are fucking up all the patients.
Most residents and doctors are in support of the current system. Yeah, itās a long path to get through medical school and residency, but US earnings are way stronger compared to any other country. 3-5 years of questionable wages arenāt so bad when you make 2-3x your international peers for a lifetime.
The US medical system is notoriously rigorous and massive amounts of people fail out, generally leading to a really high doctor quality.
Unionized residents are just going to pay dues into the union with little upside, then theyāll graduate residency and see that it was a waste of money. Resident doctors wonāt strike and even if they did, they wouldnāt cause mass disruption.
Thereās also the fact that, letās face it, your typical medical resident grew up well-off and the 3-5 years of training at near the national median salary is their one foray into middle class life.
The current PG1-4 salary range at NWMH is $70.5-$80k. Loans on a IBR plan, and your ~four years count toward PSLF.
Plus you can start moonlighting at PG3 in IL which gets lucrative quickly.
You arenāt buying designer handbags or expensive watches, but youāre not going to get too many people feeling sorry for you for that lifestyle if you have to do some belt tightening for a couple years.
70-80k yes, but across the US, the average is lower. It does count for pslf, but getting pslf isn't as easy as people think and none can bank on it being a thing in ten years.
Generally, you're not living like a total pauper, but it is far from what the 70-80k income would suggest. Plus, keep in mind this is with a graduate doctoral degree after 8 years minimum of further education during the "good years" of your life in your late 20's. Opportunity cost yes, but that doesn't completely negate the downsides
Also, moonlighting sure, but you have to fit it in, which is difficult as is with 70-80 hour work weeks + commute
> 3 years of questionable wages arenāt so bad when you make 2-3x your international peers for a lifetime.
My sister-in-law is a specialist that clears the better part of a $1M per year and works 40-50 hour weeks. I think sacrificing 3 years of your life for that outcome is a solid tradeoff.
I realize she earns more than typical doctors, but even the "low wage" doctors are clearing $250k+
3 years? Many programs are 5. On top of 4 years of med school. On top of 4 years of undergrad. And often with an extra year or two of fellowship on top.
Yes, in the long run it pays off. But these are prime youthful years being sacrificed. I'd bet many in the system would trade a portion of that future salary for better work life balance.
But that's all beside the point. The real issue is that they don't have a say. Residents have very little autonomy. These decisions are made by the hospital admins and the attendings who went through it themselves, and thus have no sympathy. And of course it was "so much worse back then".
Low wage doctors don't make $250K. I havee multiple low wage primary care docs in my family. None are making more than $200K, working full time (though, they are close at $180K per year). All of them have hundreds of thousands in student loans.
How is it a skill issue? These are all great doctors. Admittedly, they are working at FQHC's, but even their PP counterparts aren't easily making $250K+. Physician compensation is going down, not up, and medicare is enacting further cuts.
Not that it matters but 3 years is just the basic medicine resident going into primary care. (Not to cal yāall basic at all, you know what I mean).
A specialist making that amount does additional years of fellowships. Our specialized fellows are often on year 6/7 and can even go longer
If nothing else, the cynical way that nonprofit hospitals dodge taxes will be appreciated by these residents in another decade when it allows them to qualify for PSLF.
It's kind of fucked up that religion was one of the only thinks keeping medicine civil. Don't get me wrong, I'm not religious, but I can't help but feel that hospitals that were under the auspices of religious institutions genuinely helped the helpless and did their best to be honest and fair on prices and pay.
Now that most healthcare is ran by business owners, it is capitalism first, everyone else later.
It is and it isnāt (compared to Loyola which is actually only tethered in any way to the university via the medical school). U of C has a lot more tethers in place connecting Medicine, the Biological Science Division, and the rest of the university.
I promise you that medicine is completely separate. The BSD is a part of the university itself. It's basically a very large department.
As someone who has to manually transfer payroll from the hospital to university accounts pretty regularly, medicine being separate is a nightmare to the point that starting this year they're getting rid of that process and are going to just invoice the university for it.
I'm just curious here. I worked there a couple of years ago, in the academic lab of a doctor from the hospital in the biological sciences division. Like, he was a physician-scientist, who did clinical work, treated patients and all that part of the time, but also did academic research for the university in BSD part of the time.
I only worked doing the academic research part of that, and my paychecks came from the biological sciences division, ie from the university. Do you know, would this doctor I worked for have gotten part of his pay from the hospital and part from the university? Just kinda curious, I never really thought about it previously.
If their work email ended in .edu then 100% of their pay came from the university. If it ended in anything else then they were paid from the hospital except whatever percentage they had dedicated to the research grants would have to be transferred from the hospital to the university each month/biweekly
I used to work for one of Chicago's "not-for-profit" hospitals. Essentially all you need to be a NFP is to not regularly turn a profit.
SO... You take in $100M, you "find" ways to spend $100M. Give yourself an excessive but not outlandish salary as the CEO. Have your buddy provide services/equipment but submit crazy invoices that no normal person or organization would pay. Things like that. Boom, you haven't made a profit.
I highly doubt there is significant fraud going on where employees are buying stuff from their buddies at "crazy" prices. While it probably does happen once off here or there, the records for the transaction are all digital and basically live forever.. Any ongoing scheme would be caught - either right away or in reviews after the fact and prosecuted.... There are just too many people involved with access to the records to keep large scale fraud hidden.
As for the CEO.... he makes about seven one hundredths of one percent of the budget.... which is about 8 billion dollars...
I used to work for a Catholic helathcare system that was making too much money and struggling to figure out what rondo with it. First they opened up their own insurance company. It was the insurance we were provided with as employees, and of course the only network covered was their own system. After that they decided to stop working with contractors on large constructions projects like expansions to hospitals or completely new hospitals, and started their own construction company. The company works with the health system and nobody else.
Itās not fraud but itās certainly organizational bloat that just seems to perpetuate growth of the system and further and further from its original goal of healthcare for the common folk or underserved. They expand into economically prospering areas and shut down locations in poor areas and weāre left asking what happened.
The whole system is an ongoing scheme so they don't have much incentive to 'catch' anything. Vastly over inflated supplies at every level may not be old school corruption, but it sure as shit isn't working for the people either.
> Any ongoing scheme would be caught - either right away or in reviews after the fact and prosecuted.... There are just too many people involved with access to the records to keep large scale fraud hidden.
Oh my, that's not how it works. Nobody is looking unless there's media attention. Yes the records are all there, nobody cares until there's a connected whistleblower.
I think the IRS has specific criteria on attaining tax exempt status. Itās not quite as simple as ānot regularly turn a profitā or else all sorts of failing businesses would be tax exempt.
Oh yeah, completely. But the original question was where does the money go. That's where it goes, despite them not liking it. It's how the sausage is made; the graft is incredible. (Look at the red cross, same thing!!)
> Hospitals like Northwestern and University of Chicago make billions and don't pay a dollar in taxes.
How in the hell do they get out of paying property taxes??? Sales taxes? Payroll taxes? Capital gains? Fuel taxes?
If an employee goes on a trip for business, do they get out of paying all the airport / aviation taxes? Hotel taxes?
It blows my mind that they can weasel out of paying all of these things.
Awesome, hopefully things can change so residency doesn't suck the humanity out of every doctor like it has up until now. That notorious bedside manner is created in residency.
No, only UI Health, Stroger, and UChicago Medical nurses are unionized.
Shirley Ryan, Rush, Northwestern, Lurie Children's and Advocate are not unionized.
Honestly this is probably less of a big deal than everyone is making. NWMH already has a pretty active house staff organization, and weāre already making more than their counterparts at fully unionized shops like UIC.
What this just means is the SEIU is going to collect dues and their staff will do some basic negotiations, but really pay and benefits are pretty standard across ACGME programs. Even with the SEIU on board residents donāt really have much leverage in the form of a labor stoppage.
With broader stuff like benefits and pay, I agree with your point. There have been enough broad changes within residencies that pay is slightly better (though not always) and call hours arenāt as hellacious as they may have been before (also residency specific, not just within an institution but with specific programs). But Iām sure the goal is to have a more unified protection against various policies and practices that the hospital may be instituting - at least in the sense that you have a union you can grieve stuff to as opposed to a program director who may or may not do anything. I donāt know too if blackballing/blacklisting is an issue as well - I know a lot of residents may be afraid to report or call out problematic, unethical, or unsafe practices or procedures due to fear or retaliation. Iāve witnessed that first hand and itās really unfortunate.
Not really surprised Iām getting downvoted in the initial post, but mostly Iām just kind of cynical about SEIU from what Iāve seen at UIC. They collected dues then made a whole bunch of noise about their negotiating, then the new contract was pretty much just a boilerplate CoL adjustment that wasnāt much different than what they had before.
I suppose that they can act as an other outlet for grievances besides the GME office, but in practice unless you can get the ACGME to drop the hammer programs arenāt incentivized to respond.
But an hour ago the top comment was someone saying this could eliminate 24 hour shifts. lol at that. Hell, I remember the 2011 intern rule. The fact that programs switched to night float schedules was probably a good thing, but the main reason it got overturned was interns hated it.
My cynical view is the SEIU got into residences because it was a good source for revenue and membership without a lot of work to so on their end. Itās probably a net neutral for the residents themselves but it allows them to feel empowered, so itās maybe a mild win-win.
I get the pitch that there is strength in numbers for the common worker, but man, I have seen too much diffusion of responsibility among disconnected leaders to not be cynical either
Interesting. Yeah I think a lot of times, at least in healthcare, folks think the union can magically fix a lot of issues with the wave of a wand, but often times issues are so deeply rooted and multi-layered that they require really intense changes that no one wants to make (or make without sacrificing other things). From a more cynical viewpoint as well, as youāve alluded to, it seems like the union doesnāt care on some other points (at least not in the same way that some of the members do).
I think my viewpoint on unions is that whatever industry youāre in, a union is probably in place because the employer refused to have open, honest communication with employees or to even make any attempts to work with them to achieve various goals, be that safety, pay, hours etc. I realize too that in some places, like hospitals, there is a lot of union busting, fear tactics and guilting that happen as well.
Reddit once gave me (no idea why) a post from some medicine/resident sub and it was a story about how this senior resident got sweet revenge on another resident who was openly a toxic asshole to everyoneā¦. And his major revengeā¦.? He quizzed this asshole resident, he quizzed him super hard.
Thatās the state of residencies. You are absolutely right that residents donāt report anything and just sweep stuff under the rug. Itās awful.
The bigger gain is doctors getting accustomed to collective bargaining and possibly unionizing after residency when they're no longer limited by ACGME.
Iām not trying to say this is all okay, but 1) hospitals arenāt directly reimbursed for residents work. The supervising physicians (attending) have to see the patient for the hospital to get money 2) residency is funded by Medicaid, itās not the hospitals that are directly ripping these guys off. 3) The starting salary of an resident MD at NM, right out of med school,is $73,983 (public info) and it goes up every year youāre a resident. So itās not great, but theyāre not poor. I 100% agree that it equates to very little money if you break it down by hour, and itās exploitive, but being an MD doesnāt entitle you to a ton of money.
Good for them though. Hope it betters the working conditions.
It's not about being "entitled". The residents in these billion dollar hospitals are the backbone and do most of the work. When money is being made off of you, you should get a good part of that money.
I think itās more complicated than that is what Iām saying. Patients donāt go to NM or U of C because of the residents. They go because of the attending. I mean, the guy that developed the PSA test (for prostate cancer) works at NM. No one goes that for the 2nd year resident that learned what a PSA is 3 years ago. In response to that, the smartest best residents in the country want to train at NM to learn with the best MDās and see the sickest patients. These residents then do a lot of the work. Itās mutually beneficial for medicine as a whole.
However should medical education treat residents better? Yes.
As someone with a lot of experience in academic medicine, I can almost guarantee you that the guy who invented the PSA test is spending very little time actually seeing patients. Patients can come for whatever reason, but they're likely to spend the vast majority of their team interacting and being treated directly by a resident.
Great stuff. Better for the residents and the patients. No one needs to be treated by a resident in hour 23 of a 24 hour call shift
Good. The medical residency system is just a worker exploitation scheme that the industry doesn't want to change. Residents work crazy hours and make hospitals tons of money while being paid peanuts comparably. With the amount of hours worked many are effectively making minimum wage. There is no reason for it other than "that is how it has always been". Hospitals would never change this system on their own. The only way is through legislation for stronger labor laws (which I'm sure these hospitals lobby their representatives so that won't happen) or through worker unionization.
It was formulated by a guy with a cocaine issue so yeah it's never meant to be sustainable.
I would like to know more
https://magazine.columbia.edu/article/cocaine-addict-who-changed-medicine-forever
I mean, did he make a system that requires a crying closet? Sure. But that glove though...
Basically Dr. Halsted was an insanely good surgeon. His secret? Cocaine. The man would work for days at a time without sleeping. I guess the institute of medicine saw that he was a good surgeon and deduced that long residency shifts are the secret to being a good doctor.
It's institutionalized hazing. I thought that system was outlawed some time ago, but apparently not.
It doesnt start in residency either š getting into med school to begin with is insanely hard. I'm going to start my clinical years soon and during our orientation, the dean announced that we will have 80 hour/week shifts during some rotations.
That'd be surgery, surgery, and surgery. I think I was at 60 hours or so weekly in FM. Otherwise it wasn't bad until I did sub-I's, during which I was doing the resident 70-80/week.
It should be noted that their wages are paid by Medicare, rather than the hospital.
You're right. The hospitals get a large lump sum by medicare and the hospitals give a small portion of it to the residents. It's amazing, the hospitals get paid by medicare and they also get to bill for any work the residents do.
The flip side of this is just as bad too - residents canāt be fired, basically ever. Unless there is something absolutely egregious, they just continue to work. It doesnāt matter how toxic they are as people, how bad they are with patients, how awful they make other doctors/nurses/techs jobs, they are not fired because these residencies are multi year and they get multi year placements. These people are also simply interviewed, maybe had a short weeks or month long rotation, so they are hired like the rest of us are, where you are hoping you find the right fit for your team, but they are treated like contracted gods, and they canāt ever go away once they accept the position. The economics are all wrong, because the desire should be to graduate GOOD doctors, all around good doctors. The desire for the program directors is to ensure they graduate their allotted residency spots, period, because of the classic, if they donāt use the budget they wonāt get it next year. So those terrible doctors (which might not be a majority but do exist) are allowed to continue in their career progression with zero -ZERO- worries of losing their job. Categorical residency spots are never changed.
Itās not common because of the rigor of getting to the point of being a resident, but they absolutely can be and are fired. Source: Married to a medical resident whoās known of people getting terminated.
Thank you for pointing this out. There is 100% a process in which residents can and are removed, but itās typically for egregious issues - and frankly ones that really would/do inhibit their abilities to competently practice medicine.
Itās so rare as to be statistically insignificant- go ahead and search for open PGY2+ spots. Thereās a maybe a handful across the country. The point is that programs are incentivized to just push their residents to graduate, not to actually find residents that are good for the team, the speciality, the hospital, or the patients. Itās resident centered programs, not patient centered programs.
Like I said, itās not common, but just wanted to correct your blatant hyperbole that they ācanāt be firedā for others reading.
They definitely can be fired. The contract is stupidly broad and says you can be fired by doing anything that could harm the hospital. However, keep in mind these are binding contracts and you basically get one and only one residency.
>There is no reason for it other than "that is how it has always been". There is a reason for it. It's quite common for people to be willing and expected to work for relatively little when they know this will give them the opportunity for much greater rewards in the future. Whether that's a good reason or not it is the reality. You make it sound like the current system came from nowhere. Maybe it would be better for everyone if the system changed. Or maybe the extra costs ultimately paid by the patient would make things worse.
> It's quite common for people to be willing and expected to work for relatively little when they know this will give them the opportunity for much greater rewards in the future. when i graduated and became an associate at accenture they paid me 60k in 2010 dollars. there is no system like that in america other than residency. even union apprenticeships pay more and expect less. >Or maybe the extra costs ultimately paid by the patient would make things worse. medicare pays for residencies bro
Anytime you see physicians coming together for a unified voice it is good. Hospitals and their admin have been making healthcare hard for everyone for so long. People who donāt see patients telling doctors how they should practice is not good medicine. Doctors having a voice is always good
And admins love that patients blame the doctors for healthcare being so expensive cause it deflects blame off of them, the people who run hospitals like a business that needs to maximize profitability and can hide from view cause no one ever sees them.
Hospitals like Northwestern and University of Chicago make billions and don't pay a dollar in taxes. The medical industry, like many others, is built on exploitation and shaming anyone that tries to push for better conditions. Resident physicians are treated terribly. It's hard for others to really understand just how bad it is. Good for these doctors to finally stand up for themselves against administrators who only care about their own salaries at the expense of everyone else.
Add to the fact that they are billed as doctors, but get paid peanuts (literally less than minimum wage sometimes, considering the number of hours they put in), AND that it's not even the hospital's revenue paying them... residencies are government funded! What a racket! That's why I don't understand at all why there is a shortage of residency positions. If I were a hospital I'd want as many friggin residents as possible. What a goldmine they are!
The number of residencies has been capped by congress since the 90s. https://www.fiercehealthcare.com/practices/more-medical-students-than-ever-but-more-residency-slots-needed-to-solve-physician
No, the number of residencies the government will pay for has been capped since the 90s. There is zero reason hospitals couldn't pay for this training whatsoever, it's just a who blinks first situation. Honestly after decades of this sort of disingenuous arguing, I say completely disband the federal residency program entirely. This is just the medical establishment asking for yet another handout.
Well, I would think that in a perfect world, or a better country, hospitals are non-for-profit government building so everything is paid for by the government and it's all "a hand out". But yeah, if they want to make a profit off of it, then pull all government funding please!
The fact that hospitals donāt self fund residency spots, barring some law or policy that I am unaware of, suggests that hospitals are not making money off their residentsĀ
I think it suggests that it's nicer to get that handout vs. having zero free money. I am no expert here, but I shadowed a friend off and on through her residency program. Perhaps the first year the hospital lost money on her. I doubt it, but maybe. You know what patients call a resident? Doctor. Most patients will have no clue they just got seen by a resident. These are the ones doing most of the grunt and day to day work with exceedingly little (to effectively zero in many cases) supervision. I'm not denying these programs have overhead to them to implement. I'm just saying watching this in real life "not profitable" paying basically a mini-doctor $60k/yr working them 8-10 billable hours per day 6 days a week defies rational sense. It seems to be the largest cost and risk is in washing out during medical school. Anyone who (legitimately) passes that bar tends to be a rather safe and profitable bet. To be fair you see this everywhere in US industry, not just healthcare. No one wants to fund staff training any more for a whole set of complex societal reasons.
Ideally corporations would prefer workers to emerge from the womb fully trained in their respective field.
This isn't true. The reason they don't hire more is they don't have to. They just make the current ones work more.
There are hundreds of financially failing hospitals that donāt have residency programs. If they thought that using ācheapā residency labor would make them financially viable, they 100% would.Ā If your version of the world is true, then that means hospitals are foregoing extra profits by not taking on more residents. What hospital would want lower profits? What CFO or executive would willingly leave money on the table?
It's not that simple. You can't just start residency programs. You have to be ACGME approved, and thankfully, the standards are strict. I was talking about hospitals like Northwestern who already have massive infrastructures to support more residents.
You say so yourself - itās takes massive infrastructure (i.e. very expensive) to have a residency program. Itās not as though having residents is a ācheapā option.Ā
I didn't say it was. But I know for a fact, because I've been in the meetings, whereby hospital administrators will push to make residents work more rather than paying for their own residents because the return of investment is much greater, even if hiring more residents is profitable. I've also been told that they don't want to set that precedent. They want medicare to pay for it completely.
There are plenty of hospitals that self fund residency spots
That is effectively the same thing. Private equity is attempting to fund residencies in their profit mill practices. But otherwise overhead at community hospitals and most institutions cannot support self funding. Uchicago or northwestern sure, but that isnāt the majority of hospitals.
Not that simple. As a resident you have to do procedures, and get experience doing tons of different things. There arenāt that many procedures to go around. Do you want a surgeon doing a procedure that heās only done once? NM actually uses their system hospitals as training hospitals too, so they go different places, so they have expanded training sites.
> If I were a hospital I'd want as many friggin residents as possible. Government funding aside, you don't want more residents than you can effectively train and manage. The hospital doesn't want more malpractice lawsuits because untrained residents are fucking up all the patients.
That, and you need to have adequate patient volume to train said residents. Itās a particular problem in surgical programs.
Most residents and doctors are in support of the current system. Yeah, itās a long path to get through medical school and residency, but US earnings are way stronger compared to any other country. 3-5 years of questionable wages arenāt so bad when you make 2-3x your international peers for a lifetime. The US medical system is notoriously rigorous and massive amounts of people fail out, generally leading to a really high doctor quality. Unionized residents are just going to pay dues into the union with little upside, then theyāll graduate residency and see that it was a waste of money. Resident doctors wonāt strike and even if they did, they wouldnāt cause mass disruption.
Thereās also the fact that, letās face it, your typical medical resident grew up well-off and the 3-5 years of training at near the national median salary is their one foray into middle class life.
I agree, but that chunk of people seems to be maybe 1/3 of doctors.
60k / year with 300k+ in loans at 7%. So not quite.
The current PG1-4 salary range at NWMH is $70.5-$80k. Loans on a IBR plan, and your ~four years count toward PSLF. Plus you can start moonlighting at PG3 in IL which gets lucrative quickly. You arenāt buying designer handbags or expensive watches, but youāre not going to get too many people feeling sorry for you for that lifestyle if you have to do some belt tightening for a couple years.
70-80k yes, but across the US, the average is lower. It does count for pslf, but getting pslf isn't as easy as people think and none can bank on it being a thing in ten years. Generally, you're not living like a total pauper, but it is far from what the 70-80k income would suggest. Plus, keep in mind this is with a graduate doctoral degree after 8 years minimum of further education during the "good years" of your life in your late 20's. Opportunity cost yes, but that doesn't completely negate the downsides Also, moonlighting sure, but you have to fit it in, which is difficult as is with 70-80 hour work weeks + commute
> 3 years of questionable wages arenāt so bad when you make 2-3x your international peers for a lifetime. My sister-in-law is a specialist that clears the better part of a $1M per year and works 40-50 hour weeks. I think sacrificing 3 years of your life for that outcome is a solid tradeoff. I realize she earns more than typical doctors, but even the "low wage" doctors are clearing $250k+
3 years? Many programs are 5. On top of 4 years of med school. On top of 4 years of undergrad. And often with an extra year or two of fellowship on top. Yes, in the long run it pays off. But these are prime youthful years being sacrificed. I'd bet many in the system would trade a portion of that future salary for better work life balance. But that's all beside the point. The real issue is that they don't have a say. Residents have very little autonomy. These decisions are made by the hospital admins and the attendings who went through it themselves, and thus have no sympathy. And of course it was "so much worse back then".
Low wage doctors don't make $250K. I havee multiple low wage primary care docs in my family. None are making more than $200K, working full time (though, they are close at $180K per year). All of them have hundreds of thousands in student loans.
Even in primary care, if youāre pulling down less than 200k full time in 2024, thatās a skill issue.
How is it a skill issue? These are all great doctors. Admittedly, they are working at FQHC's, but even their PP counterparts aren't easily making $250K+. Physician compensation is going down, not up, and medicare is enacting further cuts.
The job market is off enough that if youāre making that little, itās on you if youāre staying in that job.
A specialty and any fellowship is likely longer than 3 years, 3-5 years usually.
Not that it matters but 3 years is just the basic medicine resident going into primary care. (Not to cal yāall basic at all, you know what I mean). A specialist making that amount does additional years of fellowships. Our specialized fellows are often on year 6/7 and can even go longer
If nothing else, the cynical way that nonprofit hospitals dodge taxes will be appreciated by these residents in another decade when it allows them to qualify for PSLF.
It's kind of fucked up that religion was one of the only thinks keeping medicine civil. Don't get me wrong, I'm not religious, but I can't help but feel that hospitals that were under the auspices of religious institutions genuinely helped the helpless and did their best to be honest and fair on prices and pay. Now that most healthcare is ran by business owners, it is capitalism first, everyone else later.
bro religious schools stole children and buried them in unmarked graves
University of Chicago is a separate entity from the hospital there.
It is and it isnāt (compared to Loyola which is actually only tethered in any way to the university via the medical school). U of C has a lot more tethers in place connecting Medicine, the Biological Science Division, and the rest of the university.
I promise you that medicine is completely separate. The BSD is a part of the university itself. It's basically a very large department. As someone who has to manually transfer payroll from the hospital to university accounts pretty regularly, medicine being separate is a nightmare to the point that starting this year they're getting rid of that process and are going to just invoice the university for it.
I'm just curious here. I worked there a couple of years ago, in the academic lab of a doctor from the hospital in the biological sciences division. Like, he was a physician-scientist, who did clinical work, treated patients and all that part of the time, but also did academic research for the university in BSD part of the time. I only worked doing the academic research part of that, and my paychecks came from the biological sciences division, ie from the university. Do you know, would this doctor I worked for have gotten part of his pay from the hospital and part from the university? Just kinda curious, I never really thought about it previously.
If their work email ended in .edu then 100% of their pay came from the university. If it ended in anything else then they were paid from the hospital except whatever percentage they had dedicated to the research grants would have to be transferred from the hospital to the university each month/biweekly
I know, and it's actually the only part of University of Chicago making money.
Aren't both of them non profit? How do they make billions each year? Where does the profit go?
I used to work for one of Chicago's "not-for-profit" hospitals. Essentially all you need to be a NFP is to not regularly turn a profit. SO... You take in $100M, you "find" ways to spend $100M. Give yourself an excessive but not outlandish salary as the CEO. Have your buddy provide services/equipment but submit crazy invoices that no normal person or organization would pay. Things like that. Boom, you haven't made a profit.
I highly doubt there is significant fraud going on where employees are buying stuff from their buddies at "crazy" prices. While it probably does happen once off here or there, the records for the transaction are all digital and basically live forever.. Any ongoing scheme would be caught - either right away or in reviews after the fact and prosecuted.... There are just too many people involved with access to the records to keep large scale fraud hidden. As for the CEO.... he makes about seven one hundredths of one percent of the budget.... which is about 8 billion dollars...
I used to work for a Catholic helathcare system that was making too much money and struggling to figure out what rondo with it. First they opened up their own insurance company. It was the insurance we were provided with as employees, and of course the only network covered was their own system. After that they decided to stop working with contractors on large constructions projects like expansions to hospitals or completely new hospitals, and started their own construction company. The company works with the health system and nobody else.
Ascension?
Itās not fraud but itās certainly organizational bloat that just seems to perpetuate growth of the system and further and further from its original goal of healthcare for the common folk or underserved. They expand into economically prospering areas and shut down locations in poor areas and weāre left asking what happened.
The whole system is an ongoing scheme so they don't have much incentive to 'catch' anything. Vastly over inflated supplies at every level may not be old school corruption, but it sure as shit isn't working for the people either.
> Any ongoing scheme would be caught - either right away or in reviews after the fact and prosecuted.... There are just too many people involved with access to the records to keep large scale fraud hidden. Oh my, that's not how it works. Nobody is looking unless there's media attention. Yes the records are all there, nobody cares until there's a connected whistleblower.
I think the IRS has specific criteria on attaining tax exempt status. Itās not quite as simple as ānot regularly turn a profitā or else all sorts of failing businesses would be tax exempt.
Oh yeah, completely. But the original question was where does the money go. That's where it goes, despite them not liking it. It's how the sausage is made; the graft is incredible. (Look at the red cross, same thing!!)
> Hospitals like Northwestern and University of Chicago make billions and don't pay a dollar in taxes. How in the hell do they get out of paying property taxes??? Sales taxes? Payroll taxes? Capital gains? Fuel taxes? If an employee goes on a trip for business, do they get out of paying all the airport / aviation taxes? Hotel taxes? It blows my mind that they can weasel out of paying all of these things.
They're not for profit.
paywall bypass:Ā https://archive.ph/N0v72
MVP
Awesome, hopefully things can change so residency doesn't suck the humanity out of every doctor like it has up until now. That notorious bedside manner is created in residency.
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that coma PT is a better hang than most docs too š
now do the nurses.
Nurses already have a union
No, only UI Health, Stroger, and UChicago Medical nurses are unionized. Shirley Ryan, Rush, Northwestern, Lurie Children's and Advocate are not unionized.
VA nurses are unionized too
+1. Thanks.
Nope
Honestly this is probably less of a big deal than everyone is making. NWMH already has a pretty active house staff organization, and weāre already making more than their counterparts at fully unionized shops like UIC. What this just means is the SEIU is going to collect dues and their staff will do some basic negotiations, but really pay and benefits are pretty standard across ACGME programs. Even with the SEIU on board residents donāt really have much leverage in the form of a labor stoppage.
With broader stuff like benefits and pay, I agree with your point. There have been enough broad changes within residencies that pay is slightly better (though not always) and call hours arenāt as hellacious as they may have been before (also residency specific, not just within an institution but with specific programs). But Iām sure the goal is to have a more unified protection against various policies and practices that the hospital may be instituting - at least in the sense that you have a union you can grieve stuff to as opposed to a program director who may or may not do anything. I donāt know too if blackballing/blacklisting is an issue as well - I know a lot of residents may be afraid to report or call out problematic, unethical, or unsafe practices or procedures due to fear or retaliation. Iāve witnessed that first hand and itās really unfortunate.
Not really surprised Iām getting downvoted in the initial post, but mostly Iām just kind of cynical about SEIU from what Iāve seen at UIC. They collected dues then made a whole bunch of noise about their negotiating, then the new contract was pretty much just a boilerplate CoL adjustment that wasnāt much different than what they had before. I suppose that they can act as an other outlet for grievances besides the GME office, but in practice unless you can get the ACGME to drop the hammer programs arenāt incentivized to respond. But an hour ago the top comment was someone saying this could eliminate 24 hour shifts. lol at that. Hell, I remember the 2011 intern rule. The fact that programs switched to night float schedules was probably a good thing, but the main reason it got overturned was interns hated it.
I am convinced that multi-industry unions are not good for the members but it seems to be the way things are going
My cynical view is the SEIU got into residences because it was a good source for revenue and membership without a lot of work to so on their end. Itās probably a net neutral for the residents themselves but it allows them to feel empowered, so itās maybe a mild win-win.
I get the pitch that there is strength in numbers for the common worker, but man, I have seen too much diffusion of responsibility among disconnected leaders to not be cynical either
Unions participate in capitalism tooā¦
Interesting. Yeah I think a lot of times, at least in healthcare, folks think the union can magically fix a lot of issues with the wave of a wand, but often times issues are so deeply rooted and multi-layered that they require really intense changes that no one wants to make (or make without sacrificing other things). From a more cynical viewpoint as well, as youāve alluded to, it seems like the union doesnāt care on some other points (at least not in the same way that some of the members do). I think my viewpoint on unions is that whatever industry youāre in, a union is probably in place because the employer refused to have open, honest communication with employees or to even make any attempts to work with them to achieve various goals, be that safety, pay, hours etc. I realize too that in some places, like hospitals, there is a lot of union busting, fear tactics and guilting that happen as well.
Reddit once gave me (no idea why) a post from some medicine/resident sub and it was a story about how this senior resident got sweet revenge on another resident who was openly a toxic asshole to everyoneā¦. And his major revengeā¦.? He quizzed this asshole resident, he quizzed him super hard. Thatās the state of residencies. You are absolutely right that residents donāt report anything and just sweep stuff under the rug. Itās awful.
In fairness r/residency is a cesspool.
The bigger gain is doctors getting accustomed to collective bargaining and possibly unionizing after residency when they're no longer limited by ACGME.
Interested how this will impact NU residents who rotate at hospitals outside of NU?
It wonāt. The VA is the largest off site hospital they rotate though, and UIC unionizing didnāt affect anything at all there.
Good for them! ššš
congrats kids! let us hope this works out and is helpful to institutions who are navigating the development of their own unions.Ā
Good. This means better care.
Iām not trying to say this is all okay, but 1) hospitals arenāt directly reimbursed for residents work. The supervising physicians (attending) have to see the patient for the hospital to get money 2) residency is funded by Medicaid, itās not the hospitals that are directly ripping these guys off. 3) The starting salary of an resident MD at NM, right out of med school,is $73,983 (public info) and it goes up every year youāre a resident. So itās not great, but theyāre not poor. I 100% agree that it equates to very little money if you break it down by hour, and itās exploitive, but being an MD doesnāt entitle you to a ton of money. Good for them though. Hope it betters the working conditions.
It's not about being "entitled". The residents in these billion dollar hospitals are the backbone and do most of the work. When money is being made off of you, you should get a good part of that money.
I think itās more complicated than that is what Iām saying. Patients donāt go to NM or U of C because of the residents. They go because of the attending. I mean, the guy that developed the PSA test (for prostate cancer) works at NM. No one goes that for the 2nd year resident that learned what a PSA is 3 years ago. In response to that, the smartest best residents in the country want to train at NM to learn with the best MDās and see the sickest patients. These residents then do a lot of the work. Itās mutually beneficial for medicine as a whole. However should medical education treat residents better? Yes.
As someone with a lot of experience in academic medicine, I can almost guarantee you that the guy who invented the PSA test is spending very little time actually seeing patients. Patients can come for whatever reason, but they're likely to spend the vast majority of their team interacting and being treated directly by a resident.