Saturday, March 24, 2007

The Economics of Residency Part I: The Basics of Residency

One of the first things that you hear about in medical school is the match. This life altering event, which the majority of incoming medical students have never even heard of, is the catalyst for thousands of newly minted physicians relocating to various corners of the country in order to train in their respective specialties. For those of you who are unfamiliar with the modern medical training system, candidates will interview at a number of different training programs across the country. After hearing about this process constantly for the first three years of medical school, every student will actively participate in the fourth and final year of school. After all of the interviews, the programs and interviews rank each other by order of overall preferance and the information is fed into a computer. The computer then determines who goes where. These training programs are called residencies, and the new physicians, soon to be called residents, will find themselves obligated to work with an annual contract.

Before I continue this post, I am going to add a disclaimer. I am not a resident. I probably will be one day, but I am currently just a medical student. After speaking to many people who are in various stages of training, I feel that I have gotten a pretty significant grasp on the whole process. I have friends who are going through the different stages as we speak. However, I am fully willing to accept any criticisms over my perception. This first post is primarily for background, and we will get to money in part II.

Residency training can be a vastly different experience for the different specialties. The internship year can mean anything from a 40-45 hour week with most weekends off to brutal weeks of 80+ hours with persistent sleep deprivation and 30+ hour shifts. Surgical specialties tend to have the worst hours of all. Currently, residencies are restricted from working their residents for than 80 hours a week, though some programs have managed to attain an exemption that carries this out to 88. Everyone doesn't play by the rules, and different programs have different degrees of compliance with this requirement. There is also a 30 hour shift time limit, that is also followed to varying degrees. Depending on specialty, residency training can also vary from 3-7 years in length.

The concept of residency originally came from an academic program at John Hopkins University. A few bright and single medical students would upon graduation, with academic ambition, actually live in the hospital in exchange for room and board. They were then exposed to highly varied pathology, and they covered the floors of the hospital as physicians. This old world hospital was essentially a boarding house for the sick who had no family to take care of them. The hours were long, but the pace was slow. The residents were give a half day off each week, and they still managed to, with a 156 hour work week, get enough sleep to be compatable with life. They had no family to speak of, due to the requirement of being single, and the length of training was only 1-2 years. Residency had NOTHING to do with medical licensing, there were no board certifications, and this relatively short sacrifice was almost a sure ticket to a prestigious career.

In time, an internship became required in order to even qualify for a state medical license. This was 1-2 years, which was no longer sufficient to qualify as a residency. In many states, this is still all that this required for licensure, though some states now require a full three years, consistent with the shortest of modern residency programs. That being said, just doing an internship and then practicing is almost unheard of these days. Most of these physicians are relegated to low level positions, with minimal chances for better pay, promotions, status positions, or partnerships.

Of course, this whole process is strange. What other occupation requires years of formal training after the schooling process in order to procure a license? Even in professions in which such training is possible, it is certainly not required for even the highest levels of private practice achievement. Lawyers finish three years of law school and learn on the job or engage in a trial by fire by striking out on their own. There is a similar process for engineers, architects, journalists, and everyone else. Sometimes a one year internship is built into the actual schooling process, but there is certainly nothing even remotely close to what exists in medicine. Why is medicine different? Stay tuned to find out.


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