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> Are you sure it's not just a case of Hollywood style accounting? Yes, for the reason I said: > An easy way to reason about this is to remember that nothing

> Are you sure it's not just a case of Hollywood style accounting? Yes, for the reason I said: > An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money. Even if you don't trust the accounting numbers, you have to trust the overall (lack of) incentive for hospitals to create self-funded programs.

jacobrobbins 9y ago
I agree with this logic about "if residency programs predictably broke even" but I don't see any concrete support for that in the article. They don't have an accounting of revenue per doctor or at least the article has not shown one. Saying the benefit is social benefit doesn't help here, obviously it is it's a hospital, there needs to be revenue numbers in the mix to talk about breaking even.
jacobrobbins 9y ago
re-reading your comment "This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital." I think perhaps you do not understand what residents do. Residents handle a portion of the patient workload. They provide direct economic benefit to the hospital by handling patient workload at a lower salary than more senior doctors. There is a hierarchical system by which work is reviewed by more senior doctors but this is used in all hospitals regardless of whether there are residents. The economic benefit to the hospital is that residents do the work for lower salary than doctors. Putting that into dollar terms is what this article has failed to do, likely because the data to do so is not there.
- chimeracoder 9y ago
  > I think perhaps you do not understand what residents do. Given my background, I understand exactly what residents do. My point still stands. Even if you don't trust the accounting numbers, you have to look at the end result. Let's assume that residency programs are, at the margin, profitable for hospitals. Let's also assume that hospitals like profit. - The statement "residency programs are profitable (at the margin) for the hospital" is logically equivalent to "increasing the number of residency slots (or programs) would be profitable for the hospital". - If increasing the number of residency slots (or programs) would be profitable for the hospital, there would be more of them. - However, there aren't - the number of self-funded residency programs has been (essentially) zero for decades. Therefore, one of our two assumptions must be wrong. Either residency programs are not, at the margin, profitable hospitals, or hospitals just like turning down profit.
  - sanderjd 9y ago
    You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question.
    - chimeracoder 9y ago
      > You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question. Because they... don't make money if they do? I don't know how to make it any clearer. The costs of providing additional residency slots (paying resident salaries, paying additional attending salaries, paying taxes, paying insurance, etc.) don't bring in enough additional revenue or offset enough other costs to be worthwhile. It's not particularly complicated math - it's the same arithmetic a McDonald's franchise owner has to do to decide whether to hire another person to flip patties, just with bigger numbers attached to it.
      - pas 9y ago
        Are residents that much less effective? Do they require so much supervision? If residents are just cheaper doctors, then hospitals would optimize for a high resident:attending ratio. So what is it? As far as I know, in hospitals residents are really cost effective doctors. Yes, sure, they don't do the big fancy operations, but they are very capable. It might be that hospitals have other parameters to factor in. Maybe if there would be too many residents compared to regular doctors, people would flock to other hospitals. And so on.
        chimeracoder 9y ago
        > Are residents that much less effective? Yes, because they aren't yet trained to practice medicine. Residency is where they are trained to practice medicine. > Do they require so much supervision? Yes, both by practicality and by law. > If residents are just cheaper doctors They're not "just" cheaper doctors > then hospitals would optimize for a high resident:attending ratio. They tried. Patients died. Now we cap both the number of hours they can work per week (80 hours/week) and the resident:attending ration.
- dragonwriter 9y ago
  > They provide direct economic benefit to the hospital by handling patient workload at a lower salary than more senior doctors But do they do so at lower total cost including both their direct costs and the additional cost of supervision by a more senior doctor?

jacobrobbins 9y ago

I agree with this logic about "if residency programs predictably broke even" but I don't see any concrete support for that in the article. They don't have an accounting of revenue per doctor or at least the article has not shown one. Saying the benefit is social benefit doesn't help here, obviously it is it's a hospital, there needs to be revenue numbers in the mix to talk about breaking even.

jacobrobbins 9y ago

re-reading your comment "This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital." I think perhaps you do not understand what residents do. Residents handle a portion of the patient workload. They provide direct economic benefit to the hospital by handling patient workload at a lower salary than more senior doctors. There is a hierarchical system by which work is reviewed by more senior doctors but this is used in all hospitals regardless of whether there are residents. The economic benefit to the hospital is that residents do the work for lower salary than doctors. Putting that into dollar terms is what this article has failed to do, likely because the data to do so is not there.

chimeracoder 9y ago
> I think perhaps you do not understand what residents do. Given my background, I understand exactly what residents do. My point still stands. Even if you don't trust the accounting numbers, you have to look at the end result. Let's assume that residency programs are, at the margin, profitable for hospitals. Let's also assume that hospitals like profit. - The statement "residency programs are profitable (at the margin) for the hospital" is logically equivalent to "increasing the number of residency slots (or programs) would be profitable for the hospital". - If increasing the number of residency slots (or programs) would be profitable for the hospital, there would be more of them. - However, there aren't - the number of self-funded residency programs has been (essentially) zero for decades. Therefore, one of our two assumptions must be wrong. Either residency programs are not, at the margin, profitable hospitals, or hospitals just like turning down profit.
- sanderjd 9y ago
  You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question.
  - chimeracoder 9y ago
    > You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question. Because they... don't make money if they do? I don't know how to make it any clearer. The costs of providing additional residency slots (paying resident salaries, paying additional attending salaries, paying taxes, paying insurance, etc.) don't bring in enough additional revenue or offset enough other costs to be worthwhile. It's not particularly complicated math - it's the same arithmetic a McDonald's franchise owner has to do to decide whether to hire another person to flip patties, just with bigger numbers attached to it.
    - pas 9y ago
      Are residents that much less effective? Do they require so much supervision? If residents are just cheaper doctors, then hospitals would optimize for a high resident:attending ratio. So what is it? As far as I know, in hospitals residents are really cost effective doctors. Yes, sure, they don't do the big fancy operations, but they are very capable. It might be that hospitals have other parameters to factor in. Maybe if there would be too many residents compared to regular doctors, people would flock to other hospitals. And so on.
      - chimeracoder 9y ago
        > Are residents that much less effective? Yes, because they aren't yet trained to practice medicine. Residency is where they are trained to practice medicine. > Do they require so much supervision? Yes, both by practicality and by law. > If residents are just cheaper doctors They're not "just" cheaper doctors > then hospitals would optimize for a high resident:attending ratio. They tried. Patients died. Now we cap both the number of hours they can work per week (80 hours/week) and the resident:attending ration.
dragonwriter 9y ago
> They provide direct economic benefit to the hospital by handling patient workload at a lower salary than more senior doctors But do they do so at lower total cost including both their direct costs and the additional cost of supervision by a more senior doctor?