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.
Hoover,
Well put. I agree wholeheartedly with every point. Of course, the establishment will argue that we are still in “training” and, as such, should not have the basic rights that the average American has in the private sector.
Moreover, as Panda likes to say, they will throw the phrase “Patient Care Comes First” around b/c they know we are suckers for it.
The question is, how do we go about unionizing and fighting for these rights??
That’s a very good question RKN, and one that I don’t have an answer for. The trick would be convincing the “goody goody” residents who don’t like to stir things up to participate.
The “goody goodies” may be swayed by the argument that a well compensated (ie not pissed at their employer) resident will provide better patient care.
I knew from previous posts here that Hoover was an intellectual powerhouse, but I didn’t know that he was also qualified to be the Czar of residency programs, and the Protector of residents.
ALL HAIL HOOVER!
PS: where do I sign up for that union thing??? ;-
PPS: seriously!?!?
Has such a thing as a union even been discussed? Do physicians “do” unions in the style of AFL-CIO?
Your ideas are literally life saving, I’d be glad to hear your thoughts on how to get the ball rolling.
There will never be a resident’s union for a few reasons.
1. Everybody loves to sh*t on people below them. I.e. – PGY2 on PGY1 – “stop whining, everybody had to do that” and older doctors on everybody – “when I was training I had call for 36 hours a day”
2. Nobody is a resident long enough to really get anything done. Most people are residents for 3-4 years, the last 30-40% of which is spent trying to secure the next job, fellowship, etc.
3. Acceptance of “professionalism” by medical students. Med students are trained to understand that a “professional” medical underling will accept their beating.
good concept..
will be good if this turn out in reality..
good post hoover.
Residents and doctors cannot unionize because the are contractors, and as such can’t negotiate en masse-at least that was my understanding
Justin – nicely put, that argument would most likely hold water.
Bob – If it were only that easy. I wish I could tell you guys where to sign up, but unfortunately this doesn’t exist.
Yan – I don’t think there is a union even for practicing physicians. I think the idea has been tossed around over at SDN, but that’s about it.
phil – Your first point is something that I’ve seen personally during medical school. This school of thought is disappearing as more of these old schools die out or retire.
Only being a resident for 3-5 years does have its drawbacks to a union scenario, but I do think it’s long enough to become active and strike if necessary.
Your third point is something that medical students need to work on themselves. It’s part of the “conditioning” that takes place during medical school. I think students need to start staying away from buying what the man is selling, and think more long-term for what’s going to benefit them more as a resident.
vijay – It would indeed be awesome if this turned into a reality. However, I think this is more of a dream than anything else. The need for reform is real, but it will take drastic measures to get them in place.
beebfalls – I think there are some ethical concerns to unionizing as well. For example if all residents strike, what will that do to patient care? The same can be said for public safety. If all of the police in a particular city strike, what does that do to the safety of the public or city? Either way, I think this is what it’s going to take so that training programs get the well-deserved slap in the face. If what you stated is indeed the case, then the reform movement needs to start by making sure they can negotiate as one unit.
I don’t think the rules that keep practicing physicians from unionizing apply to residents. Practicing physicians are independant contractors so there are antitrust issues. Residents are employees and allowed to unionize and strike.
Striking would have ethical issues. Residents in emergency medicine would probably still have to show up (except the ones on off service rotations.)
Imagine a nationwide resident strike though. It would probably not work out well. I can see the headlines already. “Selfish residents want more money/time off and don’t care who has to suffer… hospitals doing everything they can to help the patients.” These hospitals are huge multimillion dollar companies. They have good PR resources. You need to poke small holes in them first like having the mainstream know the conditions. Do you think the average person knows that residents are working ~80 hours a week (if the program is compliant)?
You make very valid points. I read Panda bear’s post as well. I am not sure where you all are training, but many residencies are not like what you describe. I will address a couple of things that are extremely hare to change.
There are certain requirements to be board certified. If you jump from residency to residency, it will be hard to make sure everyone gets the requirements because every program is different.
I prefer to have a PA than a resident. I can work faster, I can see more patients, I don’t need to see all of the patients if there is no problem, and my OR runs smoother.
another thing is that in the competitive specialties would have the ability of really squeezing the residents to sign early. if there is no contract, PD would have a much easier to get rid of residents that they do not want (no contractual obligation).
the resident that left early from his prelim spot, that is just wrong. I am not sure if I totally agree with what the PD did, I do think the resident is at fault for not completing his contract (this may be a breech of contract) and it screws his fellow residents. Not nice.
Currently, being in practice, I think residency was easier. The hours are about the same for me and there is more work that has nothing to do with medicine.
keep posting,
I enjoyed it.
Hoover-
One of the best posts yet. I’ve never seen so many potential solutions to what seems an insurmountable problem in one location before.
I’d like to add one more thing. When you’re applying for a job at a company, they give you a contract with hours, pay, overtime, and vacation policy set. If they violate your contract, you can sue or leave. With residency programs, the only way to find out what the *real* hours are is to surreptitiously ask a current resident how long they work–and could this bite you in the ass, if they snitch that you asked? I think this third party advisory board should keep an eye on the working situation and should help provide this information to incoming residents. I know HoursWatch and scutwork.com attempt to do so, but a more coordinated effort by a third party would go a long way toward helping residents choose wisely, thereby contributing to a freer market.
Oh, I forgot to address the union issue. There are resident unions. We had one when I was in michigan.
Puryear is mistaken. Quiting a residency program is not a breach of contract. No contract may be written which subjects one of the parties to indentured servitude which is what such a clause in a contract would amount to.
In other words, you cannot be forced to work at a job if you don’t want to. You can’t even be forced to give a two-weeks notice except that your contract may specify some damages if you don’t give two weeks (loss of accumulated vacation, etc.) but I’m very sure this would be easily nullified in any lawsut and I have never, in my 25-year working life (I’m 43) heard of such a thing.
This is the problem of people going straight through from high school to residency. They internalize the completely atypical and abusive customs of medical training and think this kind of behavior is normal. I agree that residency training is a special case and requires continuity. But in the case we are discussing, the resident quit to start a completely new program and specialty that did not require the intern year she was currently struggling through.
Puryear has read my blog but has not understood it. It is the program which screws over the remaining residents. Period. End of story. The prisoners are not responible for the capriciousness of their captors. that some residents believe their absent colleague is to blame is probably some kind of Residency Stockholm Syndrome.
Tiny Surgeon is exactly right. I have never, at any other job, been intimidated to not ask about the pay, the benefits, or the hours for fear of looking weak and selfish. “How many hours will I work in a week?” is a perfectly reasonable question and deserves an honest and immediate answer.
The fact that some programs lie about this, coerce their residents to lie about their hours, and don’t think twice about it shows you the value of integrity in much of the medical training establishment.
I.e, I ‘m only going to obey laws and rules with which I agree.
i would like to point out it “may be” a breech of contract, not sure what the prelim or residency contracts say. i know my contracts make specific statements in terms of non renewal for both parties, like amount of notice needed before leaving without cause, reason you may shorten this period with cause, reasons they may not renew my contract, etc.. there is usually some type of no compete clause as well. there is a lot of legal terms that i needed a contract attorney to explain to me.
if i sign a year contract, i am obligated to follow the requirements of my contract. like my military contract, i can just up an quite without consequences.
this is just a side note. A problem we see for many students of go into my specialty and do not match is the prelim year. it cuts into the resident funding, so if the go into a specialty that is 5 years, they do a prelim and then match into a program the second time around (not into a R-2 position), they are only funded for 4 of those years. the department has to pick up the extra year and some programs are not willing to incur that cost. just a note, random.
Residency is not the military. With the exception of the military, you cannot sign away your civil rights and any contract that requires terms that have been made unfair or illegal by legislation (“Unfair Terms”)is void ab initio (“from the start,” as the lawywers say).
Also, as residency programs sometimes demonstratably misrepresent the conditions of employment, there may be no consensus ad idem and the contract is also probably void.
Restrictive covenants, when they are challenged in court, rarely stand as most courts view them as unfair restrictions on trade.
You sign a contract for a year but either party can dissolve the contractual relationship for various reasons that are spelled out clearly. I just signed my contract for next year and there was no penalty for my quitting at any time.
You may indeed quit a residency contract without consequences, just like your program can terminate you for any number of reasons including downsizing and disbandment (like what happened at King Drew in LA.
Heh heh heh.
“The most important thing in medicine is INTEGRITY! Physicians have to be HONEST! You need to make SACRIFICES!
But be sure to lie about your hours worked so we don’t get in trouble. Oh, and Sue broke her leg, so you all have to do her work with no extra pay. Don’t look at US, it’s HER fault for slipping and falling. After renovating the office, and the staff trip to Cancun, we just don’t have the money for a moonlighter. Besides, admitting gomers for dehydration at 3am is how you learn. PatientcarePatientcarePatientcarePatientcarePatientcare
PatientcarePatientcarePatientcarePatientcarePatientcare!
Four legs good, two legs better!”