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> 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 i

> 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?
  - walshemj 9y ago
    There a black joke amongst doctors in the UK where all the junior doctors start in the same week each year the mortality rates go up :-)
    - paviva 9y ago
      Indeed, and it's not even a joke, but a real phenomenon. Sources : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896592/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896592/ https://www.ncbi.nlm.nih.gov/pubmed/21747093 https://www.ncbi.nlm.nih.gov/pubmed/21747093
      - pas 9y ago
        Then ... that means the supervision of residents is not working. That basically means, it's useless. (Since it'd make sense to apply the maximum amount of supervision when a resident is new and as the resident gains trust, decrease it.) Or of course it means, that attending doctors do a constant amount of (insufficient) supervision, or they ramp up supervision after someone screws up... :|
- dragonwriter 9y ago
  > If residents are just cheaper doctors Residents are cheaper doctors, but they are cheaper because they are less trained, less experienced doctors. They aren't equally-capable doctors with lower salary demands.
  - pas 9y ago
    Sure, but the 90% of problems don't require brain surgery and a consult from a team of specialists.
    - dragonwriter 9y ago
      Sure, but lots of real problems require more than the skill level expected of residents, if nothing else to have reasonably justified confidence that the problem isn't one which requires more specialized attention.
      - pas 9y ago
        At that point someone with WebMD and a scriptbook of a random House MD season is more efficient anyway. But maybe the problem is that if we would have more generalists that'd just shovel more load on the specialists.
    - walshemj 9y ago
      probably not 90% once your actually admitted to hospital especially if the hospital is a centre for the trickier problems.
sjg007 9y ago
Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem.
- chimeracoder 9y ago
  > Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem. Once again, "non-profit" or "government agency" doesn't mean "no profit motive". The profit motive affects all players. Someone has to pay for it, at the end of the day.
sanderjd 9y ago
The way to make it clearer would be to discuss specifically why the services rendered by residents are not valuable enough to cover their costs. A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to. Did the hospital lose money on that checkup? If so, wouldn't they have lost more money if the fully trained doctor would have done it? If they make money on that sort of thing, what kinds of things are the opposite? I don't know how it works, I've only ever been a patient. It seems like you might know, so I'm asking you how it works. Do you see how "they don't make money" is really not an answer?
- chimeracoder 9y ago
  > A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to. You're assuming that, in the absence of the resident, they'd be hiring an additional attending physician. In reality, they'd just have a smaller staff, and you'd have to wait longer, the doctor would have to work longer/harder/faster, etc to cover the same patient load. Hiring a resident doesn't bring in additional revenue. Insurers don't reimburse more per patient just because an additional physician was involved. Hiring a resident doesn't bring more patients in the door, because that's not the bottleneck for hospitals anyway. It does increase costs, because it's an additional person on staff - they have to pay them an extra $51,000/year, plus 25% of the cost of an additional attending physician to supervise them (and three other residents), plus taxes, plus health insurance, plus insurance to practice medicine, plus licensing fees, and so on. > Did the hospital lose money on that checkup? Probably not, unless you're on Medicare or Medicaid - in which case, yes, they do lose money on you on a per-patient, per-service basis.
  - sanderjd 9y ago
    Great point about how it isn't a question of the same service at a different price but of avoiding poor service which would otherwise have to be accepted because of the distorted market for health care that makes it hard to effectively punish poor service.

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?
- walshemj 9y ago
  There a black joke amongst doctors in the UK where all the junior doctors start in the same week each year the mortality rates go up :-)
  - paviva 9y ago
    Indeed, and it's not even a joke, but a real phenomenon. Sources : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896592/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2896592/ https://www.ncbi.nlm.nih.gov/pubmed/21747093 https://www.ncbi.nlm.nih.gov/pubmed/21747093
    - pas 9y ago
      Then ... that means the supervision of residents is not working. That basically means, it's useless. (Since it'd make sense to apply the maximum amount of supervision when a resident is new and as the resident gains trust, decrease it.) Or of course it means, that attending doctors do a constant amount of (insufficient) supervision, or they ramp up supervision after someone screws up... :|
dragonwriter 9y ago
> If residents are just cheaper doctors Residents are cheaper doctors, but they are cheaper because they are less trained, less experienced doctors. They aren't equally-capable doctors with lower salary demands.
- pas 9y ago
  Sure, but the 90% of problems don't require brain surgery and a consult from a team of specialists.
  - dragonwriter 9y ago
    Sure, but lots of real problems require more than the skill level expected of residents, if nothing else to have reasonably justified confidence that the problem isn't one which requires more specialized attention.
    - pas 9y ago
      At that point someone with WebMD and a scriptbook of a random House MD season is more efficient anyway. But maybe the problem is that if we would have more generalists that'd just shovel more load on the specialists.
  - walshemj 9y ago
    probably not 90% once your actually admitted to hospital especially if the hospital is a centre for the trickier problems.

sjg007 9y ago

Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem.

chimeracoder 9y ago
> Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem. Once again, "non-profit" or "government agency" doesn't mean "no profit motive". The profit motive affects all players. Someone has to pay for it, at the end of the day.

sanderjd 9y ago

The way to make it clearer would be to discuss specifically why the services rendered by residents are not valuable enough to cover their costs. A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to. Did the hospital lose money on that checkup? If so, wouldn't they have lost more money if the fully trained doctor would have done it? If they make money on that sort of thing, what kinds of things are the opposite? I don't know how it works, I've only ever been a patient. It seems like you might know, so I'm asking you how it works. Do you see how "they don't make money" is really not an answer?

chimeracoder 9y ago
> A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to. You're assuming that, in the absence of the resident, they'd be hiring an additional attending physician. In reality, they'd just have a smaller staff, and you'd have to wait longer, the doctor would have to work longer/harder/faster, etc to cover the same patient load. Hiring a resident doesn't bring in additional revenue. Insurers don't reimburse more per patient just because an additional physician was involved. Hiring a resident doesn't bring more patients in the door, because that's not the bottleneck for hospitals anyway. It does increase costs, because it's an additional person on staff - they have to pay them an extra $51,000/year, plus 25% of the cost of an additional attending physician to supervise them (and three other residents), plus taxes, plus health insurance, plus insurance to practice medicine, plus licensing fees, and so on. > Did the hospital lose money on that checkup? Probably not, unless you're on Medicare or Medicaid - in which case, yes, they do lose money on you on a per-patient, per-service basis.
- sanderjd 9y ago
  Great point about how it isn't a question of the same service at a different price but of avoiding poor service which would otherwise have to be accepted because of the distorted market for health care that makes it hard to effectively punish poor service.