The Case for Better Resident Physician Pay
Not unlike professional collegial athletes, resident doctors are being taken for a ride. Is it time to place the brakes and reconsider the pay structure?
COViD has highlighted a host of societal inadequacies and one that floods the mind of many is the state of our healthcare system. One welcome shift is the newfound appreciation for healthcare professionals that COViD has ushered in.
Despite front line workers, family doctors, and mental healthcare professionals receiving attention in some form or another, governments still find themselves unable to organize effective reforms. When it comes to appreciation and reform, one prominent but invisible example involves the work of resident doctors in this country and around the world.
Let us begin by focusing on the numbers, because they matter, and because they are concrete and objective metrics in need of consideration.
After a ~$90,000 tuition fee for medical school, in addition to four years of living costs, unmitigated by a salary pay, and compounded by debt and interest, graduates enter residency training and begin to be compensated.
Residents work somewhere around 60 hours a week in addition to many other responsibilities. These numbers are likely conservative, and estimates will vary based on factors like specialty.
Resident physicians do a large part of the leg work in medicine in nearly every urban hospital in Canada and the United States. Sleep deprivation, anxiety, mistakes, and the shame that comes with mistakes, are commonplace. At specific periods of transition when responsibilities increase, predominantly in the first and third years of residency, these stressors increase as well.
In addition to working during the day in clinics, and operating rooms, and on busy inpatient floors, residents are required to complete regular overnight on-call shifts. The on-call environment can be incredibly taxing and stressful. Residents are supported by consultants but are also tasked with considerable parts of decision-making processes and the heavy lifting associated with chart reviews, patient assessments, and family interactions. This work is often completed while plagued by hunger, sleep deprivation (20-30 hours without sleep is not uncommon) and doubt.
On-call duties vary based on specialty. In my own specialty of psychiatry, being on call means living in the emergency department. We field consults and assess patients who may have just tried to end their life by swallowing a bottle of medication or wrapping a cord around their neck. We’re responsible for assessing pediatric patients in similar circumstances.
It is under these harsh conditions that decisions related to admitting or discharging patients is made. Shortages and resource limitations fan the fire. Compared to safety protocols in other industries like air travel, for example, the standard set in medical culture is an alarming one.
The demands of on-call duties provide some room for insight. During one of my own call shifts early on in residency, I received a patient from a peripheral hospital being transferred to the neurology service at my center. I assessed the patient after they arrived and nearly immediately consulted our airway and intensive care step down unit. I called my consultant, who came into the hospital from home to assess the patient himself, given the gravity of the situation and given how sick our patient was.
After we transferred the patient to the intensive care unit and things settled down, we had a few moments to chat. The consultant was a very senior doctor and a wise and deliberate clinician, unshaded by the chaotic and dangerous situation we had just passed through together. I must have been visibly anxious as he took time to reflect on the case and debrief with me.
He told me that he was still recovering from his own residency call shifts and their impacts more than thirty years on. He told me that there was no easy way to learn medicine and that jumping in was necessary for learning. Similar arguments are made by those advocating for a continuation of the medical training system as it exists today, sleep deprivation and burnout be damned.
It was a passing comment he made about residents that stuck out to me more than the meaningful and thoughtful debriefing session though. He told me that without residents, hospital systems would collapse. I knew more about the admitting protocols than did he and I had been working in the hospital for 2 or 3 weeks at the time. His comment struck a tone I won’t forget in part because other consultants have since signed on to his opinion.
We hear a lot in medicine about wellness. More and more, we are appreciating that resident and staff physicians are at high risk of burnout, mental and physical health issues, and suicide. We attend lectures and get advice on how to avoid the road to burnout that can lead to those tragic end points. That is a positive change, but when it comes to actual wellness, much is left to be desired.
Throughout my own experiences, in the clinic, on the floor, and in the depths of the emergency room in the early morning hours, I sometimes think about my neurology consultant’s comments about the hospital crumbling. I sometimes think that if these hospital systems, and universities, and public funders were serious about wellness, and fairness, they might opt to put their money where their mouth is and more forcefully advocate for a fair compensation structure.
Resident physicians are not alone when it comes to unfair pay. Collegial sports serves as another prominent example of compensatory abuse. College athletes make little, mainly compensated with the promise of a ticket to the big leagues. But unlike in medicine where a future of fair compensation down the road is achievable for most, few in college sports will make it to the big leagues. After considering what sporting leagues profit in these scenarios, that is to say, eye-watering amounts of money, the abuse becomes much clearer to understand. While the specifics in medicine are different than those in college athletics, the main point still holds.
The easy charge laid at my feet on this issue will be that I’m a resident and so it should be no surprise that I take this hard stance on resident pay. But my views on pay are not so simple. After Prime Minister Trudeau announced an aggressive crack down on small business loopholes in 2017, I took the opinion that insofar as the crackdown impacted the wealthiest physicians, and insofar as it didn’t hamstring access to primary care, I was in favor of it.
This was an unpopular opinion. I suspect I was alone in my medical school class at the time, most of my classmates being offended by the impending changes and the impact it would have on them down the road. Some posted passionately on social media and attended raucous townhalls in favor of keeping the loopholes in place. There was and is something about that stance that doesn’t sit well with me.
Keeping on with the numbers, let us shift to compensation for this lifestyle. Junior resident doctors in Nova Scotia gross approximately $68,000. In Ontario, they make roughly $62,000 and in British Columbia they make $58,000. These numbers are representative and have changed little over time.
What about on-call stipends? For a 16 hour overnight call shift (after a 10 hour day), residents make approximately $130 dollars, working out to around $8 an hour. Given the tremendous stress and exhaustion at play, resident physicians assisting in emergent operating room procedures, or managing COViD patients, or assessing suicidal teens deserve better.
Aside from these unsavory numbers, there are other flagrant examples of the mismanagement of public funding in medicine that should give us pause. Take ophthalmologists for instance, who make an average of $809,000 a year with an overhead percentage rate of ~40%. Over the course of the last 20 years, technological advances have curtailed procedure time for cataract surgery, for example. Despite this, billing has not adjusted in a sensible way. Discuss this with the eye doctors and they will tell you about the liability risks they burden. Not only is that logically and professionally inconsistent, its wrong. Our use of limited resources can and should be optimized better than that.
I’m also now at risk of being charged with a problem in tone, in messaging, and perhaps with having a lack of perspective. What about patient care some may ask?
Patients, it should go without saying, should always retain the highest priority, but acknowledging issues of fairness and the realities of human behavior and motivation deserve a seat at the table as well.
We live in a world of constraints with respect to resources and how much the society can give to medical practitioners, but that does not mean that the balance between resident pay and consultant physician pay is optimized or fair. Acknowledging unethical norms and trying to rectify at least some of the egregious compensation architecture in medicine is simply long overdue.
If I sound ungrateful, please know that I’m confident when I say that I’m not. I voluntarily entered this profession and enjoy the work, helping patients, and the awesome privilege of serving the populations and people that surround me. Still, at some level, pay architecture is backward and receives too little attention. I can hold these sentiments together at once, and so should other physicians.
The literature linking both compensation and job satisfaction to performance is growing. Its hard to imagine that fair compensation would not have tangible impacts on rates of burnout. The logic here is that fair pay serves as an investment not just for clinicians but for the patients they care for now and down the road. That matters for us all.
If the system itself is resistant to change as it relates to norms and working conditions, perhaps it is not too much to ask that the pay scales shift toward a fair and ethical distribution, given the nature of the work we do.
In the end, movement on this issue will only follow if decision makers start to take notice or are forced to. The nature of residency advocacy on the question of pay is going to need to intensify. Professional resident associations have been largely asleep at the wheel on the issue. This is doubly frustrating given the great influence they wield.
Perhaps its time we started putting that influence to work. Until that happens, change, however justified, will be impossible.