About those Letters of Recommendation

This study was from 2014 and titled, “What Aspects of Letters of Recommendation Predict Performance in Medical School? Findings From One Institution.”

Do you have a guess?

Being rated as “the best” among peers and having an employer or supervisor as the LOR author were associated with induction into AOA, whereas having nonpositive comments was associated with bottom of the class students.

Best = good
Nonpositive comments = nice way of saying you don’t really know someone or think they were lame = bad

Now, this was in reference to medical student performance based on college LORs, but some parallels exist in any situation where the current evaluation and the future task are not substantially similar, and—most importantly—bias knows no bounds.

Almost all LORs are positive, even if most people will, by definition, end up somewhere closer to average.

And because most LORs are based on classroom performance, they’re useless. We have more objective measures of classroom performance. They’re called grades (and—blech—the MCAT), and even those aren’t very good at predicting outcomes. At least your boss, whether in the lab or at a paying job, actually knows if you can show up to work and get stuff done.

I’d almost completely forgotten about the LOR process in applying to medical school. I remember I had one from my lab PI/thesis advisor. And then…I honestly have no clue.

Match Fever, AAMC Apply Smart, and Oodles of Bias

Brian Carmody is a pediatric nephrologist, associate program director, and man after my heart. He’s been publishing an impressive series of excellent, well-researched, and well-argued articles about basically everything wrong with the current medical school-industrial complex and the biases of its major players that have resulted in the general crapifying of medical education.

And here is a great investigative video/podcast to boot.

It’s an excellent video that illustrates one way in which the people who should know better (the AAMC, who own ERAS) subtly encourage students to overapply to residency programs, wasting valuable time, money, and stress in the process (and under the guise of trying to fight against the growing cluster of application shotgunning that has proliferated in recent years no less!)

If you haven’t seen any of his articles, check out his site. It’s excellent and is a must-read for anyone involved in medical education or residency training.

The Resident to Midlevel Ratio

As a great bookend to my recent brief article about resident pay, here’s an interesting little data point from this article about the shutdown of UNM’s neurosurgery residency for ACGME violations:

In the immediate future, UNM plans to double the number of neurosurgeons on staff by March. They have also hired 23 advanced practice providers to the staff to handle the workload of the departing residents.

23! There are 10 residents total. Even ignoring the attending coverage (which could in part be needed to provide adequate supervision), 23:10 is an amazing ratio.

To be sure, neurosurgery is one of if not the most valuable residency fields for a hospital. And highly trained upper-level residents obviously are capable of providing high-level and highly-remunerative largely independent care. And, in this case, the workload was clearly too much for even the ten residents they did have. According to the NRMP match data from the past several years, UNM only offered 1 spot in the match (and has over the past decade offered 2 in some years), so I can imaging the call burden must have been absolutely insane.

But damn.

And, just for fun, here’s a back of the napkin cost analysis:

Here’s a breakdown of UNM resident salaries for 2019-2020:

  • PGY I $53,898
  • PGY II $55,646
  • PGY III $57,671
  • PGY IV $59,800
  • PGY V $62,396
  • PGY VI $64,692
  • PGY VII $67,343

So, on average: $60,206 (we know that two of the residents are graduating this year, so a simple average isn’t quite right, but it works for illustrative purposes).

According to “salary.com”, staring PA/NP salaries in the area average around $92,000.

So, as usual, a new midlevel outearns even an overtrained senior resident.

And, with 23 advanced practice providers to replace 10 residents, UNM can expect to spend around $1.5 million more per year to replace residents with nonphysician providers.

(That doesn’t include the residents’ salaries themselves, which UNM must also continue to pay while the residents continue training elsewhere as part of losing their ACGME accreditation. Assuming 8 residents evenly distributed, adding those back in is would be in the neighborhood of another $2 million (though presumably that money really comes from CMS and represents a loss to the system of that sweet extra dough not eaten up by salary/benefits that helps pay for the “cost” of training a resident, maybe an extra $ 1 million total).

A pretty costly mistake, to be sure. But given the bare-bones staffing UNM was presumably using for years, they probably still end up in the black.

Residents Are Underpaid, But You Knew That

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?

Guesting about PSLF on the Financial Residency Podcast

Listen to me and Ryan Inman of the excellent Financial Residency podcast nerd out about PSLF and why you should 1) be diligent and 2) ignore the clickbait/majority of what you read online.

Check it out.

I would normally give the disclaimer that I had a cold, but I have a four-year-old and now an infant in daycare, so I’m always either sick, recently sick, or about to be sick. Clearly my verbal tick of the day was “at the end of the day,” so mentally subtract that from your listening and it’s a great episode!