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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 perha

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.
        sanderjd 9y ago
        Oh nice! This is what I'm interested in! What kinds of things can they and can't they do without supervision? What is common in practice? Is there a good place to read about how this all works?
- Retric 9y ago
  "residency programs are profitable (at the margin) for the hospital" No, there are many options between 'profit' and 150k costs. The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'. Thus, the cost of a residency slot is not inherently negative 150,000$/year. It's very possible for residency's to break even without hospitals to have any incentive to implement them, further that 150k/year provides profit even with the current mix.
  - chimeracoder 9y ago
    > No, there are many options between 'profit' and 150k costs. Why are you bringing $150,000 into this? That's the median debt load of a resident - it has nothing to do with what a hospital makes. > The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'. I... don't even understand what point you're trying to make here. The point is that hospitals cannot generally provide self-funded residency programs, because they lose money on those programs. Yeas, it's true that not all residency programs cost the same amount - some fields are more expensive than others. But it's not like we're trying to optimize for the total number of residents in the system at any time; the reason we have more expensive programs like neurology is because we need neurologists. Yeah, we could "save money" by training them in EM instead, but then that'd just mean an even greater shortage of neurologists (and even higher market wages for neurologists).
    - Retric 9y ago
      > Why are you bringing $150,000 into this? Because 150k/year is the current subsidy per resident. People may reasonably not want to spend more money on this, but it's hard to argue with spending money more efficiently.
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?

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.
      - sanderjd 9y ago
        Oh nice! This is what I'm interested in! What kinds of things can they and can't they do without supervision? What is common in practice? Is there a good place to read about how this all works?
Retric 9y ago
"residency programs are profitable (at the margin) for the hospital" No, there are many options between 'profit' and 150k costs. The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'. Thus, the cost of a residency slot is not inherently negative 150,000$/year. It's very possible for residency's to break even without hospitals to have any incentive to implement them, further that 150k/year provides profit even with the current mix.
- chimeracoder 9y ago
  > No, there are many options between 'profit' and 150k costs. Why are you bringing $150,000 into this? That's the median debt load of a resident - it has nothing to do with what a hospital makes. > The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'. I... don't even understand what point you're trying to make here. The point is that hospitals cannot generally provide self-funded residency programs, because they lose money on those programs. Yeas, it's true that not all residency programs cost the same amount - some fields are more expensive than others. But it's not like we're trying to optimize for the total number of residents in the system at any time; the reason we have more expensive programs like neurology is because we need neurologists. Yeah, we could "save money" by training them in EM instead, but then that'd just mean an even greater shortage of neurologists (and even higher market wages for neurologists).
  - Retric 9y ago
    > Why are you bringing $150,000 into this? Because 150k/year is the current subsidy per resident. People may reasonably not want to spend more money on this, but it's hard to argue with spending money more efficiently.

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?