Med School Hell – Residency Training is Dysfunctional

This post is raw and holds nothing back. If you’re uncomfortable with vulgar language, please turn back.

March 22, 2007
By: Hoover


I read through a very interesting post tonight at SDN where the OP asked the question of whether or not he should finish his last few months of prelim year in medicine now that he has matched into a pathology spot for 2007.

Most of the early replies are “stick it out” and “don’t quit.”

Kimberly Cox then posted what happened when a similar situation happened at her program.

We had a Prelim resident who did the same – basically got a position in the scramble and called and said she would not be coming in again. Not only did that upset everyone (adding to their call schedule), it was unprofessional…our PD made sure her new PD knew about what he was getting.

Wow. You know, that PD is an asshole.

Private companies aren’t allowed to release information on why employees left a previous job unless gross misconduct or illegal activity was involved. That’s the problem. Residency programs can do whatever the hell they want to because there is no free market competition. Adam_K sums it up nicely.

If residents could freely transfer over to new training programs that offer better pay and working conditions, this behavior wouldn’t exist. Program directors would be kissing ass instead of overworking and over scheduling to make up for deficiencies in staffing that should have been factored into the system to begin with.

What happens, though? Programs operate with the bare minimum number of residents. If one quits or doesn’t show up, the workload is transferred over to the other residents. They have to pick up more hours, more call, and more patients to make up for a missing body.

Program directors then have more work on their plates, at least for a short amount of time. They know they can get away with blacklisting residents and giving a bad evaluation, and that’s why they do it. There should be legal ramifications such as those that exist in the private sector so crap like this doesn’t happen.

To better understand the dysfunctional state of residency programs today, you have got to check out Panda Bear’s post on the subject within that same thread. In fact, the entire thread is a must read for those that are contemplating medical school and current medical students alike.

Proposed Changes To All Residency Programs

Nothing short of a massive reform is going to put residency programs into their place. The slave labor, pitiful working conditions, low pay, and contractual (i.e. indentured) employment needs to stop. Here are the changes I would propose:

1. Free Market Competition

I think implementing a free market competition into residency training programs is the most important initial step that needs to take place. This would solve several problems at once. If Dr. A could get better pay and working conditions at Program B, he should be able to leave Program A and freely transfer over to Program B, just like with a regular job.

This would shape up residency training programs extremely fast. Programs that treated their residents (i.e. employees) with good working conditions, more competitive pay, more time off, etc. would do much better than those who weren’t as willing to change. This is exactly what we want. Let the shitty programs remain shitty. Once they see they cannot obtain and/or retain residents, they’ll either change their tune or go out of business.

2. Institute Universal Hiring Rules

A universal set of rules needs to be in place to cover for the loss of staff. These rules should be policed by a national committee not associated with the NRMP. It’s already glaringly obvious that residency programs aren’t doing this as evidenced by the strain put on a department when one resident is lost.

These additional physicians (or PA’s) would only be needed during emergent situations. This is to keep the work flow dispersed normally during times of need. They would be used on as as-needed basis, and could be called upon within a day’s time so that other residents within the program would not be forced to work overtime for no additional pay. Once another full-time resident is secured, the “as-needed” physician would no longer be required. These physicians would be paid a premium for their time, and the work would be equivalent to moonlighting.

This would come out of the program’s budget, and the program would need to take measures to incorporate these funds into their budget. Why do I feel the program is responsible? For one, if programs created a good working environment for residents to begin with, the rate of attrition would naturally be low. Thus, programs should be responsible for the funding associated with universal hiring rules.

3. Set Work Hours and Overtime

Residency training still needs more work hour reform. Eighty hours per week maximum is a joke – especially 80 hours per week with no overtime pay.

Instead, the base resident salary should be based on 40 hours weekly. An average hourly wage is then calculated. Anything over 40 hours in a 7 day time frame is paid 1.5 times the hourly wage. Any work done on a Saturday is paid 1.5 times as well. Finally, any work done on Sunday is paid 2 times the hourly wage.

What will this do? It will create a natural work hour reform. Hospitals will learn how to use a resident’s time as efficiently as possible in order to avoid paying overtime. If a resident’s time is wasted, the hospital is responsible for inefficient use of that time and will pay the resident more.

4. Get Rid of Contractual Employment

Along with free market competition, residency programs need to get rid of contractual employment. This is equivalent to indentured servitude. If a free market hiring economy existed within residency training programs, the employment contract would be null and void by default since residents could freely transfer to programs that offered better pay and working conditions.

Signing a contract and being locked into a particular training program for a year at a time is antiquated.

5. Universal Notice Rules

aProgDir suggested that if residents want to quit a program, they should give 2 months notice.

This is the whole purpose of reasonable notice. With 2 months of notice I can usually shrink responsibilities, hire a new intern, moonlight the work, or some combination.

Two months?! That’s ridiculous. There’s no other job out there where employees are required to give 2 months notice. Two weeks is about the maximum that I’ve heard of, and it’s not uncommon for employees to not even give that long.

The problem is that nobody knows how much notice you have to give because it varies from program to program. Instead, universal notice rules again policed by a national committee not associated with the NRMP needs to be in place. However, if universal hirng rules were already in place this would most likely not be an issue.

6. Legal Ramifications For “Blackballing”

What Kimberly Cox’s program director did was blackballing, plain and simple. As stated earlier, if this type of behavior was done in the private sector there would be the potential for a lawsuit.

Residency programs and program directors should be legally held liable for any behavior such as this, and should only be allowed to disclose the date of hire and the date of termination unless gross misconduct, negligence, or illegal activity is involved.

Program directors aren’t God, and they shouldn’t be allowed to act as such.

Salaried Employment Is Not The Solution For Residency

The current state of salaried employment for residents leads to abuse and overworking with no negative consequences on the part of the program. Salaried employment works for the private sector primarily because employees aren’t working anywhere close to the number of hours that residents are used to working.

What is the solution to residency training reform? I honestly believe that residents need to form some type of union scenario and start exercising their rights on a broader scale.

If the mistreatment of residents led to a national strike, I think programs would get the wake-up call that’s needed to get some of these changes rolling.

Are you convinced to leave medicine? If so, you may feel like you are alone. You may feel clueless about what to do next. However, quitting medicine could turn out better than you have ever thought possible. And here is why you should get out …

This article is part of Hoover’s Med School Hell series. Med School Hell reveals the crazy truth about the crappiness of the US medical education and healthcare system … while making you laugh so hard, you’ll crap in your pants.

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