A handful of notable free tuition experiments aside, the combination of rising medical school costs, vocational pressures, life-quality issues, and reimbursement battles has clearly had a chilling effect on many lower-paying specialties and continues to funnel medical students into procedural fields and surgical subspecialties.

An individual student’s personal calculus aside, the broader question is still worth answering, particularly as doctor’s compensation is once again in the news:

Taking into account the whole picture including student loans, a delayed start in the workforce, and high hours—is medicine worth it?

Well, we’re not going to answer that question today.

But we are going to briefly discuss one of the financial downsides of becoming a practicing physician: residency. This is perhaps compounded even more now with the blurring “provider” divide, where midlevels like NPs are increasingly able to create a similar if not substantially broader practice to resident physicians while also being able to make adult financial progress (paying off loans, meaningfully saving for retirement) immediately after school (and can even change specialties with little friction!).

All of that is a massive, thorny issue. But for this short post, I’d just like to quickly share two interesting data points that vindicate all you residents out there frustrated with watching your loan balances balloon.

Funding is nice, but cheap labor is cheap labor

The first is from a (not new) paper by UC Berkeley’s Nicholas Roth titled “The Costs and Returns to Medical Education.” The paper looks at medical school and training as a combination of financial and opportunity costs and calculates the relative return for different fields (I discussed it at length here if you’re curious), but it has an interesting statistic toward the beginning.

After Congress passed the 1997 Balanced Budget Act, which capped government payments to hospitals for residents, hospitals added over 4,000 more residents than the government would support. This suggests that market forces are at work as hospitals try to hire residents until the marginal value of an additional resident is zero. It also suggests that hospitals profit from additional residents long after the point when our government stops funding resident education.

That’s fascinating because it dovetails perfectly with the narrative all residents believe that hospitals benefit from their cheap labor despite the ludicrous claims that it “costs more” to educate a trainee. (Right, because if that were the case, why ever hire a midlevel fresh out of school?)

The Residency Fire Sale

And if there was any further doubt, look no further than the recent Hahnemann bankruptcy fire sale for corroboration. When the hospital went under, they tried to sell their 570 residents slots as a tidy parcel to the highest bidder as if their residents were a commodity like office furniture. The winning bid was $55 million, meaning that even in an absurd market situation with a desperate seller, each resident was worth about $100k, not too far from what Medicare provides for each residency slot (again under the pretense that it costs about as much money extra to the institution to train a resident as they actually earn in salary).

Details Matter, But It’s Not Pretty

Of course, not all residents are created equal from a finance perspective. There are both intra-speciality and inter-specialty differences. While attending compensation is generally tied to the generated revenue, all residents of a given training level at an institution are paid the same amount. For an easy example, a radiology resident at a program that has 24/7 attending coverage provides much less bankable value than a resident who takes independent night call.

Of course, I see zero chance of this changing meaningfully in the near (or any?) future, but given the renewed political discussion of physician compensation and the growing role of non-physician providers, it’s worth pointing out that the reality on the ground (low trainee salaries, huge opportunity cost for additional training time) is a system construct that stakeholders should address when considering the future of medical training.

Parting Question

In the “non-profit” world of academic medicine, why do institutions need to profit from training doctors?

Over four years of medical school, a one-year internship, a four-year radiology residency, a one-year neuroradiology fellowship, and now some time as an attending, one of my consistent takeaways has been how well (and thus how badly) the traditional academic hierarchy conforms to The Peter Principle.

The Peter Principle, formulated by Laurence J Peter in 1969, postulates that an individual’s promotion within an organizational hierarchy is predicated on their performance in their current role rather than their skills/abilities in their intended role. In other words, people are promoted until they are no longer qualified for the position they currently hold, and “managers rise to the level of their incompetence.”

In academic medicine, this is particularly compounded by the conflation of research prowess and administrative skill. Writing papers and even getting grants doesn’t necessarily correlate with the skills necessary to successfully manage humans in a clinical division or department. I don’t think it would be an overstatement to suggest that they may even be inversely correlated. But this is precisely what happens when research is a fiat currency for meaningful academic advancement.

The business world, and particularly the tech giants of Silicon Valley, have widely promoted (and perhaps oversold) their organizational agility, which in many cases has been at least partially attributed to their relatively flat organizational structure: the more hurdles and mid-level managers any idea has to go through, the less likely it is for anything important to get done. A strict hierarchy promotes stability primarily through inertia but consequently strangles change and holds back individual productivity and creativity. The primary function of managers is to preserve their position within management. As Upton Sinclair wrote in The Jungle: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.” (which incidentally is a perfect summary of everything that is wrong in healthcare and politics).

The Three-legged Stool

Academic medicine is sometimes described as a three-legged stool, where the department/institution is balanced on the three pillars of clinical care, research, and education. There is a pervasive myth that academic physicians can do it all: be an outstanding clinician, an excellent teacher, and a prodigious researcher. The reality is that most people don’t have all three skills in sufficient measure, and even those that do are not given the requisite time to perform meaningfully in all three categories.

While polymaths exist, the idea of the physician-scientist is increasingly intractable in modern medicine. The demands of clinical work have increased substantially with increasingly advanced medicine, increased productivity/RVU expectations, often overwhelming documentation burdens, and greater trainee oversight. Meanwhile, research has gotten more complex at the same time that the grant money has dried up. More and more of the funding pie goes to fewer and fewer people. And, lastly, education is typically taken for granted as something that should just take care of itself, something we expect “clinician-educators” to do without faculty development, dedicated time, or even credit.

It’s very easy to have an unbalanced stool. Departments tend to lean in one direction or another precisely because they are aligned to do so and are staffed accordingly. As Arthur Jones of Proctor & Gamble famously remarked, “All organizations are perfectly designed to get the results they get.”

Putting pressure on individuals to do everything—deliver excellent clinical care, teach/mentor students/trainees, and contribute to high-impact research—fails to acknowledge the reality on the ground that doing high-end work in any of these dimensions is hard. Without dedicated time and sufficient support, doing anything successfully for very long is a challenge. Trying to work toward impossible expectations (even self-imposed ones) is a big contributor to burnout. At least a veneer of control, self-determination, and respect are prerequisites—not luxuries—for a successful “knowledge worker”-type career. We could more reasonably expect people in every role to excel at one role, be competent at another, and largely ignore the third.

Hospitals and large academic institutions are not filled by flat teams of equals working on a common mission, they are occupied by layers of committees and bureaucracy. Rising stars often contribute more to their superior’s careers than their own. Progress, change, and new initiatives are choked by a spinning-wheels-grind of proposals, SOPs, committees (and subcommittees), amassing nebulous “stakeholders,” and every other trick in the large organization toolbox that isn’t bad in theory but should never be implemented universally and thoughtlessly. It’s all leadership in the I-attended-a-leadership-conference sense without any true leadership.

Physicians who focus on producing excellent care are derided as “worker bees” while those who believe in education are labeled “doesn’t like research.” And the managers rise to the level of their incompetence and perpetuate the hierarchy.

Meanwhile, the consultants and nonphysician leadership consolidate power outside of the traditional hierarchy. And how can we stop them, when we do such a bad job ourselves?

In March of this year, there was the InCUS: Invitational Conference on USMLE Scoring. The results page is here, and the summary report is here.

Invitational? That means that the only people invited were stakeholders who are deeply entrenched in the status quo and/or directly profit from the USMLE system. Namely, the Association of American Medical Colleges (AAMC), American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates (ECFMG), the Federation of State Medical Boards (FSMB) and the National Board of Medical Examiners (NBME).

Absent? Regular humans like students, residents, or even much in the way of program directors, educators, etc. No big surprise. When a growing body of students and educators advocated for removing Step 2 CS because it was an easy superfluous reduplicative and expensive waste of time, the NBME just made that harder to pass. They’d much rather just change the paper you get at the end of the other tests than introspect or make a structural change.

So, the NBME has always said they didn’t like people using the score to evaluate medical students (but have spent an awfully long time letting people do just that):

Said another way, the exams were developed as medical licensure examinations and not as academic achievement exams.

The outcome of this big convening of masterminds? Well, the recommendations are extremely vague but give the impression that eventually removing the three-digit USMLE score is a likely component.

Recommendations specific to USMLE:
1) Reduce the adverse impact of the current overemphasis on USMLE performance in residency screening and selection through consideration of changes such as pass/fail scoring.
2) Accelerate research on the correlation of USMLE performance to measures of residency performance and clinical practice.
3) Minimize racial demographic differences that exist in USMLE performance.

Recommendations to the UME-GME transition system:
1) Convene a cross-organizational panel to create solutions for the assessment and transition challenges from UME to GME, targeting an approved proposal, including scope/timelines by end of calendar year 2019.

Indeed.

One of the unintended consequences of more medical schools moving to pass/fail amidst increasing medical school enrollment and flat residency spot numbers has been the increasing importance of the USMLE and the shadow curriculum it has created.

If Step 1 matters but your coursework does not, then you’d be better off in a correspondence course that let you spend all your time preparing for Step 1 and ignoring anything your school actually wants you to do. On the flip side, if the USMLE were to suddenly be pass/fail, then residency programs may be evaluating applicants with literally no comparative data from which to judge candidates.

Point #2 from the blockquote is fascinating in its awkward tardiness because everyone knows the correlation with most clinical performance is negligible, and no meaningful research would likely ever state otherwise. USMLE scores correlate with written boards’ pass rates, which themselves also do not correlate with clinical performance. It’s turtles all the way down. None of these tests actually test what they purport to. The whole system is in shambles from the SAT on up. They all measure a degree of general intelligence and preparation, but…who cares.

Despite the mea culpas about mental health, failing students, blah blah blah, not discussed at all—of course—is whether or not the USMLE sequence should even be maintained as is. There’s a painful failure of vision in a conference solely focused on…scoring.

For example, is CS something the NBME should be doing in the first place or isn’t that what an accredited medical school is for? Or, are Step 1, 2, and 3 testing sufficiently different things to do justify three different exams, and if they are, do all three really play a distinct role in the licensing process? One could easily argue that Step 2 CK is much more meaningful to clinical practice and residency performance than Step 1, which mainly has the benefit of a) being hard and b) having scores universally available during the residency application process because it’s taken earlier.

Feel free to submit your comments on these meaninglessly vague preliminary recommendations here.

Pretty damning results about the impact of perceived attractiveness on residency application success. Suffice to say, what came up didn’t exactly make it into the NRMP Program Director’s Survey.

There’s a new paper in Academic Medicine titled “Bias in Radiology Resident Selection: Do We Discriminate Against the Obese and Unattractive?” coming out of Duke. Hint: the rhetorical question posted in an academic paper title is always answered with a yes. But while the study used their own radiology program, I have zero doubt that this is universal and probably substantially worse in other fields.

The idea was to grade mock applications and see who you’d invite:

Reviewers evaluated 5,447 applications (mean: 74 applications per reviewer). United States Medical Licensing Examination Step 1 scores were the strongest predictor of reviewer rating (B = 0.35 [standard error (SE) = 0.029]). Applicant facial attractiveness strongly predicted rating (attractive versus unattractive, B = 0.30 [SE = 0.056]; neutral versus unattractive, B = 0.13 [SE = 0.028]). Less influential but still significant predictors included race/ethnicity (B = 0.25 [SE = 0.059]), preclinical class rank (B = 0.25 [SE = 0.040]), clinical clerkship grades (B = 0.23 [SE = 0.034]), Alpha Omega Alpha membership (B = 0.21 [SE = 0.032]), and obesity (versus not obese) (B = -0.14 [SE = 0.024]).

The breakdown:

• Facially attractive and nonobese applicants had a 24% chance of getting an interview
• Less attractive, nonobese applicants had a 12% chance
• Obese and unattractive had a 10% chance

At the end of the day, the top three factors for selecting candidates were Step 1 > Race > Facial attractiveness. And being both skinny and attractive literally doubled your chances.

Awkward.

While programs will always eventually meet their applicants and may always “like” applicants who are easy on the eyes, I don’t think any residency (except derm kidding not kidding) actively wants to screen their applicants by appearance.

Is there really any legitimate justification for having access to an ERAS photo in the first place prior to selecting interview candidates? I don’t need to know what you look like.

In the meantime, this study just further confirms the advice I’ve given before: you want your ERAS photo to be good.

Mednax, Inc.’s CEO Roger Medel on their Q1 2019 Earnings Call:

Looking across our service lines. Volumes increased modestly in most of our women and children specialties. In neonatology, the underlying trend of births at the hospitals where we provide services remained negative, but our volumes increased based on rate of admission into the neonatal intensive car unit and length of stay.

Thankfully, despite birth rate decreases at our hospital, either the babies were coincidentally sicker or we managed to squeeze more kids into unnecessary NICU admissions and longer stays, so we were still able to grow our profits.