Residents: Know Your Worth

The best advice I can give you as a chief resident

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Looking back at intern year, I can pinpoint the exact moment when I became radicalized. 

The year was 2020. I’d come to residency to be a plastic surgeon, but like most every resident during that time, I was learning to be a COVID doctor. I was a chronic high-performer with a 0.38 muji pen and a journal article folded hot-dog style in the back pocket of my scrub pants. I was faking it to make it. By the end of that year, I was already fraying at the edges.

And every day, I overheard a version of the same conversation from the nurses and PAs working alongside me.

They were talking about money.

During the pandemic, hospitals across the country were struggling to stay staffed. Pay for nurses and PAs doubled and even tripled, particularly for those willing to travel. The nurse working alongside me in the ICU made $200 an hour that day. I was making about $18.

I knew going in that as a resident, I was going to be underpaid. What the pandemic did was swing a harsh, interrogation-style lamp onto the system that keeps it that way. And once I saw all those ugly pores and wrinkles and unsightly hairs sprouting over the surface of things, I couldn’t unsee it.

You might say I caught a virus and it wasn’t COVID but that’s much too ham-fisted for a sophisticate like me.

Content warning: if you read on, you may become infected too.

The System Doesn’t Work for You

Before medicine, I had a career in health policy. What that gave me—and I think it’s the most useful thing I brought from my prior working life—is the ability to zoom out. If you’re old enough to remember That’s So Raven, it’s kind of like that. Certain moments in residency will just trigger this vision in my head of all of the systems in place that shape what’s happening to me.

What I see when I zoom out is this: there is a HUGE gap between the value of what residents do and how they are compensated, and that gap isn’t accidental, it has been engineered.

It is the result of deliberate choices by non-doctors to suppress our power within our own profession.

The Briefest Possible of Policy Explainers

In 2002, residents tried to sue the medical residency matching system under federal antitrust law,* arguing it functioned as a wage-fixing cartel (spoiler alert: it does). Congress responded by adding a couple of sentences to a random bill about pensions that said the Match was exempt from antitrust law, without any opportunity for hearings or debate.

Boom: monopoly power over residents forever enshrined in law. When we really need nurses, they make more money. Resident wages are shielded from market forces. Average NP/PA salaries are around 130k for 40 hours per week. Average resident salaries are around half that for double the hours.

Different issue, same vibe:

In 2010, the Affordable Care Act banned new physician-owned hospitals and froze the expansion of existing ones, after hospital trade associations lobbied for it as part of the deal. They don’t even want us to be in the room where the big decisions about healthcare are being made.

Lawyers, by comparison, are protected by professional rules that prevent non-lawyers from owning law firms in most of the country. Dentists are also much better at this than us: in some states, they even have laws preventing non-dentists from owning dental practices. Non-toothy medicine has been moving in the opposite direction for decades.

That’s enough policy-wonking for now. There are a lot of details and caveats here, but that’s not the point. The point is the pattern. The system is progressively eroding physicians’ power to care for patients the way they want to, and they start teaching you to just keep your head down and go along with it from the very beginning: in residency.

Residency is an Increasingly Corporatized Job

Residency will ask a great deal of you. You will be told, and it will be true, that you carry enormous responsibility. Patients depend on you. Your liability is real, your stakes are high, and this work is really, really hard. You will give it your all, because you wanted to do something meaningful with your life, and what could be more meaningful than this.

But ask yourself, in the middle of all that sacrifice: how much of what you’re doing is for your patients, and how much of it is for the hospital?

Because residency is first and foremost a workforce. It undergirds much of the daily operations of our healthcare system. The orders you write, the procedures you do, the overnight call you cover: that is the grist for the mill of a massive corporate enterprise, billed for, captured in facility fees, but invisible in the revenue data by design, so it’s hard to pin down just how much they are screwing you.

The best we can do is look to real world examples. Like what happens when a residency program closes and is replaced by an army of NPs and PAs? 

We found out in 2019. The neurosurgery residency program at the University of New Mexico lost its accreditation, leading to a staffing scramble. Replacing 7 residents at $70k per year required hiring 23 NPs and PAs at an average of $115k per year.  

You are doing extraordinary work, and much of the financial benefit flows to an institution structured to ensure you have no leverage over how you are compensated for it.

The system knows this. And so it offers you something else instead: identity. Purpose. The culture of sacrifice and calling that medicine runs on. These things are real. But they are also very useful to the people who benefit financially from your labor.

The truly corrosive part isn’t the low pay. It’s what happens when you internalize the signal the low pay sends. When you start to believe, somewhere under all the exhaustion, that this is what you’re worth. That the hierarchy asking you to defer, to shrink, to be grateful, is reflecting something true about your value.

It isn’t.

If this makes you angry, good. I’m asking you to keep that flame alive. It’s not bitterness, it’s clarity. And even though there’s no easy fix for this mess we’re in, I want you to walk through your training with your eyes open. 

Residents: know your worth. Even when–especially when–everything around you is telling you not to.