• Residency, salary, and primary care doctors

    Uwe Reinhardt has another must-read column over at Economix. So come back afterwards, but go read it now. Money quote:

    If, by law, teaching hospitals were prohibited from paying residents in some specialties any stipends, these residents might view the need to borrow $50,000 or so annually for living expenses as a sound investment, at least in theory.

    Drs. Bach and Kocher appear to believe that an adequate number of medical-school graduates would see it that way — but also that some now choosing specialty training would opt for primary-care training instead.

    But such forfeiture of their salaries for several years might alter the attitudes these specialists would subsequently bring to medical practice — and the fees they might charge for services and care. In medical parlance, the Bach-Kocher treatment might have unintended and untoward side effects. It behooves policy makers to think of them.

    In the meantime, we may all ponder whether simpler solutions are available to address the shortage of primary-care physicians. I am eager to hear the ideas of others, and I will return to this issue in a while.

    There’s a lot I want to say here. Let’s start with the more emotional reaction, and then transition to data.

    Residency sucks. Really, really sucks. Ask my wife, ask my fellow residents, ask anyone who’s worked with me for some time. I could tell you stories that would make you cry. It’s not because it’s hard work, though it is. It’s not that the pay is bad, though for the work it is. It’s that, as Uwe says, you really, really are an indentured laborer.

    I, like many in medicine, am an over-achiever. I don’t have a hard-luck story to tell, and I have been gifted with some abilities that have allowed me to do very well in school. I went to a great college, then a great medical school, and was accepted into a great residency program. Up until that point, I would have done commercials for the American Dream. But residency changed that.

    It did not matter how hard I worked, because by definition the work never ended. It did not matter how much I achieved, because the system is set up to socialize the wins. But the losses? Those are entirely yours. Moreover, any independence you might show is quickly hammered out of you.

    Residents are overworked and undervalued. They have no voice and little power. They work ridiculous hours, have awesome responsibility, and sometimes little oversight. They are the front line in many medical settings, yet are often not treated as “real” doctors.

    I could spend days telling you tales of horror, but one quick instance springs to mind. I had a bad two months at a county hospital because many of the physicians who worked there demanded that I do things that I felt were not only bad ideas, but also borderline unethical. I refused, and also refused to keep my mouth shut about it. When the end of the rotation came around, I sat with the physician who was to evaluate me. He told me I was going to get a crappy evaluation. He asked me why I couldn’t just keep my head down and conform. This guy had literally made a career out of “sticking it to the man”, and was known as an iconoclast; the irony was lost on him. He ended by telling me he felt compelled to try and sabotage my fellowship application. He said this with a straight face.

    Even today, ten years later, I shake with anger as I write this.

    This kind of thing happened every day. Physicians don’t talk about it, but we all have stories. The system covers up incompetence and punishes independence. We keep a hierarchical structure in place which continually reminds you that someone is on the bottom. And, more than anything else, we fight to defend this system against all encroachment. We all know, deep down inside, that having an underclass of physicians who will do all the crappy work, all night, all weekend, for relatively little money is the only way to hold it all together.

    It’s rotten, it’s wrong, and I loathe it.

    So you can imagine that I think that making life harder in any way for residents is a bad idea. I have no proof, but I think that many of the bad lessons that doctors learn, as physicians and – more importantly – as human beings, are learned in residency. Refusing to pay them will only make things worse.

    I’ll come back to some data on salaries in a subsequent post.

    • really awesome post.

      is there not some community to empower residents? whether online community or a yelp for residents?

    • Wow. Your residency experience was much worse than mine, or at least your response to it. Yours is more like my wife’s. We were residents together and when we finished she said she would never feel guilty about any amount of money she received or any amount she charged. I would note that many people coming out today have similar attitudes even with their working hours limited to 80 hours (or is it 60?) per week.

      I will say that the behavior you describe seemed, just based on my experience, to be more common in internal medicine and peds residencies. The peds residents at CHOP were pretty mean to each other and to students.


    • Wow, Aaron. That experience sounds horrific. Your experience was nothing like mine. I absolutely loved my residency (family practice at U. of WI/St. Mary’s Hosp & Clinics.) I worked hard–but I was learning so much, and the patients and attendings were great. Same goes for my clinical rotations as a medical student (3rd year at U. of Cincinnati, and 4th year at U of WI.) There were extended periods of being on call every third night–so it’s not that the schedule was easy. Just wanted to add my “case report” to yours. I would be interested in seeing what the data shows.

    • I’m not a physician, but my understanding is that one reason that it’s necessary to have an overworked and underpaid population of residents is that amount of indigent care that is provided at public and teaching hospitals.

      If that’s true, will broader health insurance coverage tend to ameliorate or undermine the current system?

    • I remember my medical school surgery experience being terrible. The surgeons used to call us medical students “bitches”, and it was abusive. I actually was failed for rotation, and I remember standing up to the surgeon. This is typical, but they call it standards. Medical school and the perverse socialization that is required to be a physician is worse than the material. Luckily, I moved west for my residency, and the atmosphere was much more benign.

    • The Residency system and indeed the whole medical education system is atavistic. ,