Residents & The Match: Overworked, Underpaid

The Atlantic has a nice brief history of the NRMP Match and an argument for it as a causal factor as to why being a resident is generally terrible. And, in case you didn’t know, the public also wishes you weren’t working so hard:

Medicine enjoys the status of being the most prestigious profession in America, yet the rigor of medical training remains unduly excessive. The American public overwhelmingly supports restrictions on residents’ working hours. A recent poll conducted by an independent public-opinion survey firm found that nearly 90 percent of Americans believe residents’ shifts should be 16 hours or less, and over 80 percent of those surveyed said that they would request a new doctor if they knew their physician was on the tail end of a 24-hour shift.

The Atlantic has been posting a lot of doctor stories recently with the current Republican-ACA collision. One thing Ryan Park’s argument is missing, though, is the fact that the hospitals only sort’ve determine the salaries of their residents. The more than $100k cost of a resident’s salary plus their “training” comes from CMS. Yes, the government, which also sets the number of spots they’re willing to fund. If a hospital were to suddenly improve salaries and benefits, they would lose the “free-ness” of the labor. If they hire more people than are funded (i.e. over the cap) to get the work done, they’re even more in the red. The government subsidizes the cost of training doctors, but as a practical matter, the government is largely subsidizing academic medicine, as well as teaching and county hospitals nationwide. The vast majority of these hospitals aren’t really footing the bill, and their budgets rely on having residents on hand for predictable periods of time churning through the night.

Park includes a reference about how resident training preferences may be a contributing factor to suppressing salaries:

In ranking programs, as Signer of the NRMP points out, most medical students are mainly concerned with prestige and the quality of training, not money. One 2015 study showed, for example, that even without the match, residents would still earn far less than their true market value—which is estimated to be about double what they presently earn—because they, in effect, accept a pay cut for high-quality medical training and a prestigious residency placement.

But of course! The salaries are all terrible. That reference does make that conclusion, but we know better because resident pay is so homogenous (again, paid by CMS with regional COLA). If a terrible program pays a few thousand more per year than a great program, of course no is going to care. Educational factors clearly trump trivial salary differences. If cost were the only factor in all people’s choices, no one would choose to attend private schools. But if a decent nonmalignant program paid twice as much (i.e. a PA salary) as a prestigious misery-factory? It wouldn’t sway everyone, but I have no doubt it would absolutely have a big impact, just like how a lot of very talented people only consider attending their state medical school.

The US has an abundance of patient care to carry out and a growing shortage of doctors, but we’ve both resisted real increases in resident numbers and prevented substantial changes in the training paradigm. In a world where the same Medicare coffers will pay for drugs that cost more than a resident salary while advance practice nurses have lobbied for greater and greater autonomy, the ACGME’s focus on “milestones” and the length of training has serious unintended consequences.

Imagine for a moment that internal medicine, family medicine, and pediatrics were two-year residencies. Without massive budget changes, suddenly we’d be training 50% more generalists per year AND the return on the time/money investment of becoming an internist would improve substantially (likely luring higher performing students). Would there be major negative consequences in the quality of those graduating residents? How long would they last? If so, could they be mitigated by changes in medical school or residency training? Have we even tried? Have we even considered it in the past 40 years?




hdo 02.26.17 Reply

If we did that, attending PCP supply would increase by 50% more than it already is and therefore attending compensation would fall even lower than what it already is. We who have played by the rules and won have a financial incentive to keep physician supply limited.

Ben 02.28.17 Reply

I’d love to see some data that supports that theory for PCPs. It would appear instead that there is an undersupply of generalists to meet current and projected patient care needs. Thus, physicians are leaving money on the table, because salaries are tied more firmly to reimbursement rates. It’s not as though there is a massive glut of endocrinologists or ID docs to explain why their salaries are low.

There are of course some saturated markets, and the reasoning may hold better for some fields (particularly ones that can break into cash payments like dermatology), but I don’t think that view of the configuration jives with reality and the current climate. Instead, we’ve resorted to importing foreign trained doctors in order to try to meet demand, and a greater and greater fraction of patients are seeing mid-level providers, including in an increasing number of states which have no physician oversight. The current trend is not one of maintaining “high” salaries for internists; it’s one where primary care is no longer performed by doctors at all. The status quo, at best, seems shortsighted.

AH.Dx 03.02.17 Reply

Great post, Ben!

The length of training for a family medicine residency in Canada is 2 years. A large proportion of any graduation class in CA will go into family medicine. It’s a 1-year difference between the US system and Canadian system, but it’s enough of a difference to incentivize Canadian trainees to pursue the field. If physicians don’t fix the primary care training structure, we will lose primary care to NPs/PAs completely sooner than later.

Ben 03.08.17 Reply

I actually didn’t know that. That is fascinating! Thanks for sharing.

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