Match day — the fateful day when medical students all over the country learn where they “match” for internship and residency — is only less than 2 weeks away. Most of my fellow classmates look forward to the day with anticipation.
Not me. I am dreading it. Match day means that I am an indentured servant for the length of the program. (Most people are bound for at least 3 years.)
Residency isn’t so bad if you enjoy hospital medicine, working 80 hours a week for almost minimum wage, and being a subordinate. But if you’re like me and hate inpatient medicine, working most of my waking hours for peanuts, and being controlled, then it’s hell.
If I dislike it so much, why sign up for the match? Fair question. Well, doing at least 1 year of post-graduate training is the requirement for getting a medical license. Some states need at least 2 years or even at least 3 years. So if I want to practice medicine at all, I am forced to do this.
If I opt out, all the time, money and effort I spent in medical school is meaningless.
I curse the day that doctors agreed to such a crappy deal.
Comparing Doctors to Other Healthcare Providers
Look at other health providers: nurses, physician assistants, optometrists, pharmacists, and dentists. They don’t have to do residency before practicing.
As doctors, our closest competition are physician assistants (PAs). When you compare a new PA to a new doctor, our assistants beat us financially …
- PAs have less schooling (3 years vs. 4 years)
- PAs make more money right out of school ($70,000 vs. $50,000)
- PAs work less hours a week (40 hours vs. 80 hours)
Based on the above values, a PA who works 50 weeks a year makes $35 / hour … while a doctor makes $12.50 / hour. Is a new PA worth almost 3x more than a new doctor? Most definitely not.
Heck, even more advanced healthcare providers — optometrists, pharmacists, and dentists — can get a cushy job and make six-figures right out of school. So why can’t doctors?
How Residencies Breach Antitrust Laws
Any intelligent person sees that doctors get shafted financially with residency. I’m not saying that we should do away with residency. But make it optional.
But doctors are reluctant to change. They’re under the influence of Stockholm syndrome — a psychological phenomenon in which hostages express empathy and sympathy and have positive feelings toward their captors, sometimes to the point of defending them.
They defend a system that takes advantage of them. Did you know that the whole residency system was slapped with an antitrust lawsuit? The defendants had to
buy lobby Congress and President Bush to get an exemption from antitrust laws.
According to Jake Seliger …
You apply to residencies in the first half of your fourth year, interview at various places, and then list the residencies you’re interested in. Residency program directors then rank you, and the National Residency Match Program “matches” you to each other. You’re then obligated to attend that residency program. You can’t privately negotiate with other programs, as you can for, say, undergrad admissions, or med school admissions, or almost any other normal employment situation. You can’t say, “How about another 5 grand?” or “Can I modify my contract to give me fewer days?” If you refuse to accept your “match,” then you’re blackballed from re-entering for the next three years.
Once I realized how nasty the residency match process is and how fundamentally unfair the labor market for residents is, I was shocked: residency programs have formed a cartel designed to control cost and reduce employee autonomy, and hence salaries. I only went to law school for a year, by accident, but even I know enough law and history to recognize a very clear situation of the sort that anti-trust laws are supposed to address in order to protect workers. When my friend entered the match process like a mouse into a snake’s mouth, I became curious, because the system’s cruelty, exploitation, and unfairness to residents is an obvious example of employers banding together to harm employees. Lawyers often get a bad rap in our society, and sometimes for good reasons, but a case like this looked ripe to me.
It turns out that I’m not a legal genius and that lawyers have noticed this anti-trust violation. So an anti-trust lawsuit was filed. You can read about it in the NYTimes, including a grimly hilarious line about how “The defendants say the Match is intended to help students and performs a valuable service.” Ha! A valuable service to employers, since employees effectively can’t quit or negotiate with individual employers. Yes, indeed, curtailing employee power by distorting markets is a valuable service. The article also noted this bit of regulatory capture:
Meanwhile, the medical establishment, growing increasingly concerned about the legal fees and the potential liability for hundreds of millions of dollars in damages, turned to Congress for help. They hired lobbyists to request legislation that would exempt the residency program from the accusations. A rider, sponsored by Senators Edward M. Kennedy, Democrat of Massachusetts, and Judd Gregg, Republican of New Hampshire, was attached to a pension act, which President Bush signed into law in April.
In other words, employers bought Congress and President Bush in order to screw residents. If you attend med school, you’re agreeing to be screwed for three to eight years after you’ve incurred hundreds of thousands of dollars of debt, and you have few if any legal rights to attack the exploitive system you’ve entered.
When I tell my peers and practicing doctors about my desire to shorten or even make residency optional, they recoil in horror. They ask, “How will you know what to do? I know I won’t feel ready to practice by myself.”
Their premise is that after 4 years of medical school, you still don’t know enough to treat patients. Never mind that almost all other healthcare providers practice right out of school. Never mind that doctors in other countries can practice primary care without going to residency. (And never mind that their World Health Organization ranking way surpasses ours.)
If you cannot provide basic care after graduating from medical school, there is something seriously wrong with the education.
When Extra Training Is the Wrong Answer
On the same note, extra training always sounds good. Who can argue against that? Our WHO ranking is down. Therefore, we need more training. Extend residency another year!
But the cry for more training is a lot like the cry for more education when dealing with obesity. It sounds good. But when you look at the facts, our country’s population is better education now than 50 years ago. And yet, our country’s population is fatter now than 50 years ago.
According to the The Culture Code:
Years ago, Tufts University invited me to lecture during a symposium on obesity …
Lecturer after lecturer offered solutions for America’s obesity problem, all of which revolved around education. Americans would be thinner if only they knew about good nutrition and the benefits of exercise, they told us. Slimming down the entire country was possible through an aggressive public awareness campaign …
When it was my turn to speak, I couldn’t help beginning with an observation. “I think it is fascinating that the other speakers today have suggested that education is the answer to our country’s obesity problem,” I said. I slowly gestured around the room. “If education is the answer, then why hasn’t it helped more of you?”
There were audible gasps in the auditorium when I said this, quite a few snickers, and five times as many sneers. Unsurprisingly, Tufts never invited me to lecture again.
Doctors have more education and more training than nurse practitioners (NPs). But researches demonstrate that the quality of primary care given by doctors and NPs are similar. According to Health Policy Briefs …
A systematic review of 26 studies published since 2000 found that health status, treatment practices, and prescribing behavior were consistent between nurse practitioners and physicians.
This proves that learning on a job is just as effective as a formal training program (i.e. residency).
At some point, more education and more training is not the answer to providing quality healthcare.
(On a side note … Is there really a shortage of doctors? Then shorten the education and shorten the training. You’ll have more doctors practicing medicine. Whatever the doctor doesn’t know, he’ll learn while on the job. If the shortage gets bad enough, the NPs and PAs will take over the role of doctors. That is what the DOs did when there was not enough MDs to treat the country.)
Why Are Doctors So Dumb?
As you dig deeper into the medical profession, you will see that much of what doctors do is based on lemming behavior. Old doctors had to go through residency. So new doctors have to go through it as well.
Because other doctors do it, he will do it.
Because employers demand it, he will do it.
Because insurance companies want it, he will do it.
Will things change? I doubt it, unless the survival of doctors as a group is in jeopardy. Allopathic medicine could not prevent the rise of chiropractic medicine. Allopathic medicine could not prevent the rise of osteopathic medicine. Allopathic medicine could not prevent the rise of alternative medicine. Based on history, allopathic (and osteopathic) doctors cannot prevent the rise of nurse practitioners and physician assistants.
Doctors are so book-smart and can out-memorize the average person. Most of them can out-memorize me. And yet, they are so street-dumb. If they don’t adapt to the currently harsh environment, they will have a bleak future. It’s already happening.
For thoughts about medicine and its future, visit the About Alex section and look for “Musings (My Philosophy on Medicine).”