$11.25 per hour. For
three to seven years. Working 60- to
80-hour work weeks. With a little raise
every year to keep up with inflation.
Would you take that job?
That’s the average hourly rate for a physician-in-training
in this country. Surprised? Disgusted? Worried about where the rest of the money is
going?
That physician-in-training had to put in four years at an
undergraduate university earning a bachelor’s degree, followed by four years of
a rigorous curriculum at an accredited medical school. He was swallowed whole for countless nights by
the depths of the campus library, studying for organic chemistry exams, medical
school admission tests, and preparing his competitive application for medical
school. He had to give up the “yuppy”
lifestyle that all of his friends enjoyed after graduating from college and
getting their first jobs, just so that he could now be swallowed whole by the medical school library, studying for
even tougher anatomy and physiology exams, medical board exams, and once again
preparing his competitive application for a residency training program. And what was it all for? To get into a residency program where he could
continue to climb the endless ladder to
become a physician.
Residency is an exciting time for physicians-in-training. It’s a time for them to finally put to use all
of the classroom skills and knowledge they have learned over the years. It’s also a time to bond with other fellow
trainees who are confined within the same trenches. But it’s no piece of cake. As recently as the turn of the century,
residents would work sometimes 100-120 hours per week on average. These hours became more strictly regulated by
a few of the agencies that oversee medical education, and are currently limited
to 80 hours per week. But the pay hasn’t
improved much over this time. Residents
are generally underpaid for the amount and quality of work that they produce.
That’s what I just don’t understand. Why is there a delay in proper reimbursement
for the hard work put in by physicians-in-training? There are multiple factors and interests
involved here, so let’s take a look at some of them.
Residencies were formalized after William Osler created the
first residency program for specialty training of Internal Medicine physicians
at The Johns Hopkins Hospital in the early 1900’s. At that time, the residency program he created
was one where residents led a restricted and confined life within the walls of
the hospital itself (that’s where the term “residency” originated – these physicians
resided in the hospital where they were
trained). They were “on call” frequently
– sometimes every other night. There
were no pre-specified years required in training; instead, the programs were
open-ended, and graduation into the real world of practice was based on your
performance and evaluations by those more senior. A residency that currently would take three
years may have taken up to seven or eight years back then. And pay was minimal beyond room, board, and
laundry. It was expected that you
dedicated your life to the study and practice of medicine, and that there was
not much outside of this that should detract from such a lifestyle.
Twenty years after President Truman first proposed the
concept of health insurance, President Lyndon B. Johnson signed the Social
Security Act, establishing both Medicare and Medicaid on July 30, 1965. In
1977, a new department called the Health Care Financing Administration (HCFA)
was created to administer the two programs. The HCFA would later go on to be what is
currently known as the Center for Medicare and Medicaid Services, or CMS. The head of the CMS is a presidential
appointee requiring Senate approval. Currently,
Marilyn Tavenner is the acting administrator and chief operating officer. And
amongst all of the scrutiny that her organization has come under for increased
healthcare costs and sicker patient populations, one of the less talked about
roles of the CMS is how they provide the salaries for residents.
Hospitals are paid a yearly “lump-sum” of money from the CMS for
each physician-in-training they have on premise. Current estimates show that they are paid
approximately $100,000 per year for each resident, although this information is
kept out-of-reach of the public for the most part. Agencies like the Accreditation Council for
Graduate Medical Education (ACGME) ensure that hospitals are able to provide an
appropriate training environment for each of the residents, and work with CMS
to accredit hospitals as a training-hospital.
Hospitals are then able to use this money at their own discretion, but
resident salaries are governed by the National Institute of Health (NIH) and
are simply based upon the number of years it has been since the resident has
graduated from medical school. Some
hospitals will give an additional stipend to supplement this salary if they are
located in regions of the country, like San Francisco, where cost of living is
notably higher. In 2013, an average
salary for the first year of residency was approximately $49,000. If you had already completed five years of training
by 2013, you might make approximately $59,000.
This means that a resident who has been training for six years after he graduated from medical school,
has celebrated 31 birthdays, and has already begun to pay back the
approximately $200,000 in loans is not even breaking $60,000 before taxes from his day job that
arguably keeps him busy for at least 50-60 hours per week.
You can imagine that this situation creates a lot of unhappy employees. In 2002, a class-action lawsuit was filed in Washington
against the matching program by which medical students are “matched” into
residency programs. Sherman Marek, a
Chicago-based lawyer representing three young physician plaintiffs, challenged
the program on antitrust grounds, stating the program is used to keep
residents’ wages low and hours long[1]. They were also frustrated that this mandatory
“match” program takes away the ability to compare job offers between hospitals –
a basic, free market-driven process that exists for other professions like law,
consulting, engineering and business. In
April 2004, with help from lobbyists and by attaching her efforts to a pension
act, Mona Signer (Director of the National Resident Matching Program) was able
to make her program exempt from the accusations through a bill signed into law
by President Bush. She defended that the
Match is intended to help students and provides a valuable service. The case was, thus, dismissed. To add salt to the wounds and, more importantly, to recuperate the $3.5 million in
legal fees it took for her to go to court, Ms. Signer raised the enrollment fees
for subsequent Match years[2].
The financial duress that faces the medical field has
multiple other facets. What about the
lack of ability for physicians-in-training to make long-term investments in
their retirement accounts or other sources? Any basic wealth management and investment course
will teach that compound interest is the most valuable investment tool. Having to wait until your early 30’s to properly
invest your money makes for significant amounts of lost time and money
(projected to be in the tens to hundred thousands of dollars over a ten-year
period). Doing it any earlier is almost
impossible given the low salaries paired with the high debt from school.
Then there is the moral dilemma of being financially
compensated for caring for the sick and the poor. Is it right to make money off of our
patients? That sort of incentive placed
in the wrong hands could lead to an abuse of the “expensive” tests. On the other hand, adequate money attracts
people who work hard. And wouldn’t you
want someone who is going to be fully dedicated to his profession, without
having to work a second job or concentrate on a start-up company on the side to
make ends meet? We all have one life to
live – staying healthy and having a worthy set of doctors who are willing and
able to help you achieve that goal should be priceless, shouldn’t it?
The reality is that none of this has dissuaded students from
applying and entering medical school.
Total medical school applications increased 6.1% to more than 48,000 in
2013, according to the Association of American Medical Colleges. The number of medical students enrolled in
medical schools in 2013 also increased by 2.8% to just over 20,000[3]. But something happens to these medical
students after they are exposed to the numbers and are kept poor for longer
than their friends who went into the business or finance world. They may have arrived in medical school with
dreams of solving the world’s primary care problems, but eventually less of
them are entering fields like pediatrics and family medicine which are
notoriously underpaid and instead end up choosing specialties like dermatology
and ophthalmology which reap high financial reward along with 9-to-5
lifestyles.
If medical schools weren’t so costly, and physicians-in-training
saw a competitive salary immediately after completing medical school, one has
to wonder if we’d be facing the same primary care physician shortage which is currently
being projected given the aging baby boomer population. But until things change, please take a number and your doctor will see you...eventually.
Doc Veritas
[1] Liptak, Adam. “Medical Students Sue Over
Residency System.” The New York
Times. May 7, 2002.
[2] Robinson, Sara. “Antitrust Lawsuit Over
Medical Residency System Is Dismissed.”
The New York Times. Aug 14, 2004.
[3] Lopatto, Elizabeth. “Medical School
Applications, Enrollment Rise to Records.”
Bloomberg News. Oct 24, 2013.
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