(After two years, I am almost done with call and most of the abusive practices associated with it so you’ll forgive me if I revisit these topics. I have a certain warmth for them and now that I am drawing to the end, I can give you a well-informed opinion. If these topics bothers you or smack of sedition, please skip this article. If not, read on.-PB)

Gulag Archipelago

George Orwell in his classic dystopian novel 1984 invents a nightmarish world where, in the time of Big Brother, the very language was being modified to prevent both the expression of dissent and its conception. In the novel, the Party sought not only to eradicate words that could lead to the discussion of thoughtcrime but to prevent even the possibility of it.

In a similar manner, residents lack the conceptual vocabulary to protest their obvious mistreatment and, because they are unable to frame the debate in any other terms but that of the establishment’s brand of Newspeak, they are reduced to sheepishly shuffling their feet and muttering vague self-centered sounding complaints. Your hospital, for example, may justify depriving you of sleep because some studies show that tired residents don’t jeopardize patient safety. You can cite studies that prove the opposite. But all that can really be proven is that the hypothesis is difficult to prove or disprove and the only result of the debate is that your sleep, a critical component of health, is at the mercy of bureaucrats who are not on your side, would work you (and did, at one time) as much as they possibly could, and will forever justify robbing you of sleep because it is not dangerous for the patients.

The simple and obvious fact that humans need sleep and to deprive them of this is a wrong in of itself (regardless of whether it is safe or not) is never discussed although even convicted felons get their full measure of sleep every night and to deprive them of this is considered a human rights abuse.

The debate is controlled in other ways. Imagine you are an intern in a typical Internal Medicine program pulling your usual every-fourth-day overnight call. Suppose one of your colleagues has his fill of it, successfully scrambles into a less abusive specialty, and decides that since his current intern year counts for nothing at his new program, he will quit a few months early to recover. Your program, following the usual impulses and caring not a whit for their subordinates, assigns his call to the remaining interns and this fellow becomes the enemy, the Emmanuel Goldstein, who is the cause of their suffering.

“We’re sorry,” is the predictable mantra,”But your disloyal colleague left us no choice. There are holes in the call schedule and the rest of you are just going to have to fill them.”

And you hate the disloyal intern and what he did to you. And you are encouraged in this belief. I have heard these sentiments expressed from people who should know better. But think about it. If you were a prisoner in a Soviet Gulag and your entire barracks was punished because one of your tovariches escaped, who is to blame for your punishment and why should his labor quota be divided up among the remaining zeks? Does that make sense, making the prisoners responsible for the injustices committed against them?

Of course it doesn’t. And yet, while most residents could sense this intuitively if they bothered to think about it all, their thinking is cluttered with duckspeak from the medical establishment which not only hides the reality of the situation but sets the conditions of any potential debate to preclude anything but the party orthodoxy.

For the system to change, you need to redefine the terms.

For example, if someone attempts to bludgeon you with “Patient Care” as the debate-stopping, atom bomb of reasons why you are to be routinely over-worked and deprived of sleep, suggest that if patient care were so important, the attendings need to pitch in and pull call and that everyone, from the janitor to the nurses, needs to stay more hours.

The janitors would laugh. They may only have a GED but they’re not stupid and they know when they’re being mistreated.

The fact that your program has bitten off more than it can chew and cannot maintain it’s commitments is not your problem. You are the low guy on the totem pole and are not getting paid to solve the program’s problems. It is actually a leadership problem on the part of the program who are committing the cardinal sin of leadership: Not standing up for their subordinates. The other services clamour for the cheap labor of the program’s residents and instead of protecting you, they say, “Sure, we’ll bravely fill the call schedule with our cannon fodder because, donchaknow‘, we got ’em by the short hairs”

Here is more doublethink from the Party:

Although the hospital receives an average of $110,000 per year for each resident from Medicare and pays you less than half of this, you are a drain to the hospital and the cost of training you far exceeds the Medicare reimbursement. On the other hand if we didn’t have residents the hospital as it is currently configured would grind to a halt for lack of physicians to take care of the huge numbers of patients we are able to run through here because we have so much cheap physician labor to throw around.

Because residents don’t bill for their time, they don’t make the hospital any money and therefore as you are a drag on the system we might as well extract some cheap labor out of you…but please don’t stop performing valuable work for which we will bill, not to mention performing essential duties that we would have to pay two of the lowliest mid-level providers we could find each at least twice your salary to perform…and we wouldn’t get the $110,000 either (which is just gravy).

A physician is ethical in all things and you are expected to be scrupulously honest and never cut corners…but go ahead and lie about your hours because it’s Okay to lie about certain things if we tell you it’s alright.

Black is white if party discipline demands it.

16 thoughts on “Blackwhite

  1. You make good points. The 80 hr work week was point in place to help to protect residents. It is better than it was. I had a total of 4 months of every other night call. That is true sleep deprivation.

    I do feel that residents are a team and some are not team players. That is unfortunate.

    As far as the money that the hospital gets for residents, I use to believe as you that the hospital makes money from the situation. Actually the hospital probable breaks even. The money covers salary, benefits, malpractice,and teaching and incidentals. Remember for in most situations your employers cost for an employee is about 140-150% of their salary (this includes benefits and one of the taxes that they are required to pay half and you pay the other half). All in all, it is about a wash.

    As far as making money, I personally would probably make more money with a PA or nurse practitioner. Both can bill under their own UPIN and once they get use to your quirks, you don’t have to reteach them. Another thing is surgical cases move faster without residents. More cases, more money.

    That’s it. Nice post


  2. Bullshit. I have worked in the private sector and the cost to employ someone is most certainly not 150 percent of their salary. In fact, it is more like 125 percent, (25 percent in excess of actual salary depending on the benefits of which 7.5 percent is the employees contribution to Social Security.) My benefits package adds about 12K a year. I know this because I get a little statement every year from my hospital telling me what it’s worth. But I’d rather have the 12K and buy my own health insurance, for example.

    When I was at Duke, they claimed that my benefits were fantastic but as Duke self-insured for health care and I still payed around $400 per month, I wouldn’t doubt if this was actually a profit center, not a loss.

    I have also had to pay my own liability insurance as a structural engineer (another highly litigious profession) and it did not add to my cost to have junior engineers working under me, the assumption being that I was in overall responsibility.

    A hospital like Duke has about 1000 residents for which they probably receive somewhere in the neighborhood of $100,000,000 from the Feds. After salaries and benefits, they probably clear $50,000,000 or so which is of course sucked down the maw of the bureaucracy for those incidentals that you are so fond of. The entire city budget of my hometown of 30,000 is less than a third of that.

    Man, when I had employees if I could make a forty percent profit off of them for doing nothing at all I’d consider that a coup.

    As for making money, I’ll tell you what, hire a PA or NP to cover and admit patients all night. I guarantee you couldn’t find one who would work for the 10 bucks per hour that we are paid. Money is fungible and a savings is the same as profit for the hospital because its money they don’t have to spend. A PA makes around forty and hour. This is a cost savings of 30 bucks an hour to the hospital every hour we are on call assuming that they would want a PA to handle things which, the more I get trained the more I realize is not that hot an idea all of the time. (I mean, if you want to talk about liability)

    For your field, even if your residents hurt your productivity in the OR, hire a hospitalist to cover the pre-op and post-op care and see how much its going to cost you.

    As far as billing, this is one of the great shell games of the hospital, the assertion that residents don’t make any money for the hospital because they don’t bill I mean.

    Well, no shit. But they do work for which their attending bills. I don’t know how it works in your specialty but the attending does not follow me around supervising every patient encounter. usually we discuss the assesment and plan briefly, he may go chat for a few minutes with the patient to confirm key exam and history findings and that’s it. In this manner, one attending working with three residents can see and bill for many more patients than he could bill for if he was working by himself. He also sees patients himself. The combined salary for all three residents is about 40 bucks an hours. Let’s be conservative and say that counting a first year like me (but I am a PGY-2), we are all combined only the equivalent in productivity of 1.5 attendings. Since EM attendings in private practice (all of ours) usually command a salary of 120 dollars and hour, our work is worth 180 dollars per hout for which the hospital only pays forty.

    In other words, to cover the same number of patients and get the same revenue stream, my hospital would have to pay somebody three times what they currently pay us.

    In no way does the actual cost to hire a resident even come close to the $110,000 the hospital gets for every resident. I would challenge the hospital to open their books. I could not even get my hospital to tell me how much they acutally get per resident. Remember, it may be more than $110,000 (or less, of course) because the actual amount is based off of Medicare billing.

    I’ll give you another thought experiment:  I’ll work for free except when I am on call, in which case the hospital can pay me the going rate for a hospitalist who would otherwise have to admit patients and cover the census.  I was on call eight times last month.  I only want to get paid for work between five PM and eight AM to make it fair because after that your precious PAs can come in and make things run smoothly.  That’s roughly 15 hours per call day or 120 hours of call per month at 80 bucks an hour (for a hospitalist) which works out to…let’s see…$9600 per month which is three times my current salary.

    How about it?

    All of this, of course, has nothing to do with treating residents like chattel slaves.

  3. As for residents being or not being team players, to hell with that and all sports metaphors as they apply to business, warfare, and medicine.

    I have been on sports teams. I have been on military teams (fireteams, squads, sections, and platoons). If the team captain had treated his players like many of our attendings treat us the team would have disbanded. If I had tried to dish out some of the careless treatment of my subordinates which is typical of residency when I was a Marine small unit leader, I would have gotten a reputation for being a poor leader (I would have been a poor leader) and I probably would be reprimanded.

    First rule of leadership: Don’t blame your subordinates for their lack of enthusiasm.

  4. First off, i was not criticizing the team player issue; i was commenting on the resident who left without regards to his/her colleagues. that was a self before team thing. that’s all.

    as for the numbers, i was just quoting some of the figures from when i was in practice. i agrees they may be off. for my practice, when i was in a private practice module. my overhead was about 50% of collections. my secretary and medical assistants cost was about 130 to 140% of their salary with benefits, time off, taxes, yada yada yada. those numbers really add up. i am not a business minded man, so i hated figuring all that crap out.

    as for PA’s, I have 2; and they greatly increase our effectiveness in seeing patients. many hospitals have only pa’s and np’s. i have worked at several hospitals that operate that way. they do preop, postop, and OR as will as er consults. for us, they function as a very good chief resident most of the time. i actually would rather a PA. they work 12 hr shifts and most do pretty good work. and they can bill (we don’t bill for them). they have a separate UPIN, medicare number and everything.

    as for supervision, i can not speak for others services. i can speak for my practice. no bill goes out unless i saw the patient. no clinic patient is discharge with out me laying hands on the patient. no operation is performed without my presence. we are sticklers for the rules. we actually do not bill for most of our inpatient consults unless an operation is generated.

    we push residents out when they are approaching their hour limits. on my service, we are well under the 80 work week. i am not, but that is my fault, i need to learn how to fill out paperwork faster (smiley face).

    remember for patient care, there are separate bills, hospital fee and physician fee. having patients in the hospital makes the hospital money, your services usually generate a physician fee. these are separate bills, unless the hospital employs the physician.

    dude, i am on your side. really.

  5. Let’s do another thought experiment. Suppose the hospital gets $100,000 per year from me from the Feds.

    My current salary is about 40K. I do actually get pretty good health insurance for my family at this program for a very low rate which is probably good for an extra 10K (but I would rather have the 10K and pay 3K for a major medical policy and pay for routine things out of pocket). My employer pays 7.5 percent of my salary for Social Security and if you add Worker’s Comp to this (which I’m not sure they do) it’s about a thousand bucks a year. I get a minimal disability policy which would cost me about 4K a year if I had to pay for it myself and a $50,000 whole life policy which is probably worth 500 bucks per year.

    Let’s see…that’s around $55,000 bucks to employ me. That’s $45,000 left. Malpractice insurance for an attending physician in internal medicine (the kind of rotations where we get abused the most in my program) in Michigan runs from a high of about 45K to a low of 12K per year and I’d wager that, since residents are supervised, the actual cost is more towards the low end. Let’s say $20,000 per year which is ridiculously high as most big hospitals self-insure and residents are rarely sued.

    There’s still $25,000 left in the kitty. I have been on in-house call 50 times this year. Let’s say I’m not the most competant fellow in the world. No matter, I’m being paid for being there, not on quality. Let’s say I work 12 hours a call night where your vaunted PAs are not covering things for you. That’s 600 hours that somebody would have to be paid to cover. At 50 bucks an hour which is the going rate for moonlighting residents to cover “gaps” in the call schedule, that’s $30,000 bucks the hospital “makes” off of me which, not counting any useful work I do during the day is a net profit of $55,000 per year per resident. A place like Duke (which is a good deal bigger than my current program) has a 1000 residents, many of them of a very high skill level who are probably making a lot more money for their hospital than we are assuming for this little experiment. That’s $55,000,000 per year of profit for doing nothing at all but crying poverty which doesn’t even take into account the increased patient throughput and increased revenue stream made possible by access to so much cheap labor.

    I’m sure you’re a fantastic orthopedic surgeon but maybe you don’t understand money and how it makes this bad old world of hours turn. No bureacracy will do anything for free. The demand for residents is high because they are an economic boon to the hospital once they get a little traiining under their belt. Even before that they still serve the function of providing a warm body as required.

  6. And throw all the previous out, if the Federal reimbursement just covered the “cost to employ” a resident, the added patient capacity that residents allow a hospital to process increases revenues and profits. Now, it may be true that an accountant can hold up the books and cry poverty but the money went somewhere as it was diverted from my pocket.

  7. again, i am not in disagreement. the actual cost numbers are not as cute and dry. there are a number of studies that try to compute the overall cost of having a resident. when most conclude is that the cost is around the 80-90,000 dollar mark for the medical subspecialties (there is a study on psychiatrists and one on cardiology fellows from the late 90’s).

    in my department, residents actually cost me money (this is not a complaint). for every deposition i do (usually a criminal case, child abuse or something like that), the money goes to resident education. we have increase our PA and nursing support to shield the residents and allow us to expand our practice without resident support. we use our PA’s to increase our numbers of patients seen. i can do that with a resident, because i do have to see every patient the resident does. so a PA and i can see 45-50 patients in a 1/2 day. with 2 residents, i can only see about 35, because i become the limiting factor.

    i teach residents because i want to. i can tell you life would probably be easier if i didn’t have residents sometimes. but, interacting with the wide eyed residents who slurp up knowledge like they have never learned keeps me from being disheartened by the changes in medicine.

    keep rocking.

  8. Well, your specialty works differently from mine which is only three years and by the beginning of second year we are most certainly expected to “move the meat” and see, on average between 1.5 and 2 patients an hour which is less than a typical attending in private practice but still a pretty good effort. And our attendings don’t have to back us up on everything, either, once we are second years and since I am a PGY-2 “intern” I do a lot of procedures and other patient care activities with minimal supervision. I certainly won’t page my attending next year when I am the ICU senior for his presence every time I intubate or put in a central line.

    You mention teamwork but in the next breath you allow that you’d prefer a PA to even your own chief resident, a guy who is a few months away from being an attending himself. This says nothing about how you feel about your interns and other residents who don’t even rise to this standard.

    Second rule of leadership: You work with what you have and don’t long wistfully for the perfect subordinate. That would be like me opining to my brand new fresh-out-of-infantry-training-school Marines that I’d really rather have Marines with a few years of fleet experience under their belt but “I guess I’ll have to settle for you.”

    Gosh, that’s sure a funny way you have of motivating your team. I hope your residents don’t read my blog.

  9. Besides, we’re talking about the value of residents to the hospital which pays their salary. Your residents still pull call which would otherwise be have to covered by somebody getting paid a whole heck of a lot more.

  10. ah, yes, but the person on call can also bill insurances, while the resident can’t. in the end, a PA or NP can generate funds for the practice or hospital, depending on who employs them.

    so, resident funds, static. midlevel provides funds, dynamic.

  11. I assure you, our attendings bill for every admit and consult that we do while on call. Some on-call attendings don’t necessarily want us to page them at home for every admission or routine consult either and we “square up” in the morning. When the attending reviews my dictated H&P, for example, since it is dictated by me in his name, all he has to do is sign the thing and make a brief statement attesting to his agreement and review of my work and presto bingo, when the patient squares up with the hospital the admission gets billed and collected by his service in whatever manner is customary for that service. (Or not collected but that’s not my problem.)

    We do not, repeat not, work for free at night or at any other time. Every thing that we do that can be billed is billed. I do a lot of minor procedures (central lines, intubations, laceration repairs, arterial lines, lumbar punctures and the like) without direct supervision and these are most certainly coded and billed on whatever service I happen to be on.

    About the only thing we can’t bill for is critical care time but the procedures are usually broken out seperately. In fact, every service I am ever on makes a huge deal over documenting everything in a manner that will let it be coded honestly (of course) but at the highest level possible.

    It is only a bookkeeping slight-of-hand that makes it look as if residents don’t generate any income. A team of on-call residents (intern, second year, and third year) being “supervised” by one attending at home can admit more patients and handle more consults than the attending could possibly do if he were alone at the hospital. On my last rotation, it was not uncommon for the on call team consisting of an intern and a second or third year to admit, between them, almost forty patients in one 24-or-so hour period.

    The proof of this is that the medicine program at one of our hospitals pays moonlighting third year residents 80 dollars an hour to cover gaps in the call schedule which they simply cannot fill with their residents without egregiously violating the work hour rules. Obviously this is the market value for the work that the captive residents ordinarily do for ten bucks an hour.

    I’m harping on this because I think you and some of my readers are missing the point. I’m not saying that a resident is the equivalent of an attending and should be paid as such. I don’t think I’m worth what my attendings make. Hell, I know I’m not worth what they make which is the point of training.

    On the other hand considering that a PA fresh out of his two-and-a-half-year training starts at almost twice my salary (with the same benefits) and works half as many hours(making his hourly pay four times what I make), I don’t think any rational person could conclude other than residents are grossly underpaid for what they do. Heck, the cafeteria lady, if you factor in overtime, makes more than I do. I know because I am friends with the cafeteria ladies.

    If you think that a PA fresh from his training surpasses the medical usefullness of a second year Emergency Medicine resident, a third year medicine resident, or a fourth year orthopaedic surgery resident then I don’t know what to tell you. Maybe we need to shut down the medical schools and teach medicine at the community colleges.

  12. i can say, if your attendings bill for a procedure and are not present for the “key portions of the procedure,” this is a direct violation and is punishable by severe fines to the attending and hospital.

    i can not speak for medicine (not my area), but i can speak for surgery and in particular to my practice. i like residents. they keep me on my toes. my salary is effected none by the residency presents or absence. i do not pay them it comes from the hospital. on days i have no residents in clinic, i can see patient quickly without a much wait on the patients end. as for call, we cover trauma at another hospital in town, er call and floor call is covered by the PA’s. The residents come in for operative cases. i think that is kinda cheating (smiley face).

    as for PA’s vs residents, after a resident has been on the service for more than a month, they begin to get in understand your quirks and pick up on patterns in your practice. problem is that they then leave. if i could keep the same resident for 4 years, it would rock. after your PA is with you for a few months, they get accustom to what is needed to be done. after a while, they function as a upper level resident. and after many years, some are like attendings. i do agree that the salary is probably kinda high at first.

  13. i forgot to address the preferring my PA to my chief resident. you know i am a sub-specialists. my chiefs, if they have no interest, they really done care. my PA always cares, she doesn’t complain, and she nows what i like. Chiefs (PGY-6) are like senior students, just waiting to be done. our PA’s don’t operate by the way.

    as i have said before, i like my residents. they work hard. they don’t whimper when i beat them. if i wanted to work with PA’s and have OR first assists, i would be in private practice and make a lot more money. i prefer my role as educator.

  14. I wish I found this blog when this discussion was on-going.

    1. Attending who do not bill for on-call activities of their residents is by no means a unanimous stance. I learned this early in PGY-1 year when I dictated that films and patient information will be reviewed with the attending in the AM.

    2. There is one important difference between the medical and surgical coding for things like this. That consult or even reduction bill is pennies. Having the resident capture that patient to keep them in the system either to bill for a procedure or fracture care trumps whatever the consult fee would be. So it is not a sign of honesty that thosee consults aren’t billed. Why risk an investigation for fraud over those pennies when it might risk the real dollars to be captured during the definitive care? So the PA can capture (a portion) of those consult fees, etc at night. It means less in the big picture than it would to a non-procedure driven physician.

  15. Wow.

    Bravo on the post and your comments. The indignity that is residency beautiful caught in language. Hopefully we won’t turn into surly old members of The Man’s club – only time will tell.

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