Tuesday, June 21, 2011

Charging for residency

In light of the infamously controversial New York Times Op Ed piece, an attending colleague of mine in practice for many years prophecized that in twenty years or so, in order to deal with the physician shortage, the training process will have changed in the following way:

1) Medical school will be free

2) Residents will pay for their training, instead of vice versa. Residencies where doctors earn less will cost less or be free.

She said that it would cost the same but you'd pay money later rather than sooner. Making residents pay for their training would help fund more residency spots, which would deal with the physician shortage. And charging less for primary care spots would deal with the primary care physician shortage.

I argued that there is NO WAY this would ever happen.

In large cities like New York, residents earn upwards of $70K per year. How could you possibly take that money away and tell them that they now have to pay for training? Residency unions would never allow it. Furthermore, at the point that people are in residency, they are now in their late twenties or thirties... they are married, have kids, mortgages, etc. You can't expect all of these people to exist for 3+ years on no income and even having to PAY money. Paying for education is much easier to swallow when you're young and unattached.

And there's no way that the cost would be equivalent either:

Current model: Pay $40K/year for 4 years of med school + earn $50K/year for 4 years of residency = +$40K

New model: $0/year for med school, then pay $X/year for 4 years of residency = -$4X

Looking at it this way, under the current model, you at least come out ahead financially (although barely) at the end of your training. (Although obviously you're not ahead due to cost of living.)

This colleague of mine insisted, however, that this was a valid model and that it was likely to be implemented in the near future. I'm thinking not so much.


  1. That's the perfect example of an idea that's flawless right until you add in "human psychology" as a variable.

    You're right, there's just no way people in their late 20s and early 30s are going to go that much into the red to pay for a job...

    Maybe that's what makes it brilliant, though. Primary care, here we come!

  2. This is what a Pharm D program is. Granted it is 3 years of graduate classes (at most schools that are just a graduate program) at 25k per year and 1 year of clinical rotations at 35-30 k.

    I was lucky to get into a program straight out of high school(five years of class and 1 year of clinical rotations), so I was relatively young while paying $18-20 an hour to work. Most colleges of pharmacy prefer a bachelors degree so some collegues are in their mid to later 20's.

    This program basically makes you sign your soul for a few years to a major pharmacy chain so you can just live. If you want to be able to get paid for work, you basically can't sleep. You are still an intern at this point and make $15 an hour, which doesn't help much.

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  4. I don't think you can compare a PharmD, even though it was kind of a running joke during our clinical rotations that we were basically paying our preceptors to be there, so we should get to call the shots.

    The residents have far more training years than we have, even if we do a pharmacy residency (don't get me started on how useless that is, but I know some markets require it).

    Also, ime, our training hours are more likely to be 9 to 5ish. I had no problems, with the exception of one month when I had a particularly taxing rotation, working a few hours here or there. I would think the residents I've known would have had more of a problem. There hours are generally longer and less predictable.

    To be honest, 9 times out 10 pharmacy students are "in the way" (at least in my state) and somewhat of a hindrance. Residents may be too, but they do have a "place" in a hospital moreso than pharmacy students (jobs to do, most hospitals would miss residents...ime, not many would miss pharmacy students).

    Maybe your area is different, and I don't mean that as a slight to my profession at all.

  5. In my province, we have a different system for trying to address the physician shortage. Medical students and residents can receive training grants ($15-20 K each) in exchange for committing to a year of work in the province in the future. It's a great way to avoid some of the crippling medical school debt while the province ensures it has physicians in the future.

    It's been really interesting to read the responses to Dr. Sibert's article and to see how passionately opposed to her ideas many people are. It makes me realize that physicians would resist any government initiatives to regulate how much physicians work, making it essential that governments come up with novel solutions to address the physician shortage. Now we just need to figure out what those solutions are...

  6. What would keep people from going to school for free and then go on to do something else with their sweet MD degree? Would you stick people with a bill if they refused to pay for and attend a residency? What if they were kicked out of their residency, either for actual or faked incompetence? Would they then get a 200,000 bill for med school on top of the 40g they just paid for residency?

  7. I see both sides. There are professions that do it that way now. Some hospitals in SF are telling new grad nurses that if they want a job they have to do their 6 months of training and orientation for free.

    Health care is big business and when bean counters and people who don't touch patients make decisions it's not a good thing.