Residencies: doctors have it figured out

[Amistad]

After chatting with a fourth year med student today at clinical, it occurred to me how vastly different the physician career-path is from our own. Fourth year medical students are undergoing the process of being matched to a residency in the specialty of their choosing. They apply to prospective hospitals and hope to be matched to their top choice, awaiting the chance to learn from their experienced superiors. Then, after gaining some experience, they apply for a fellowship or are recruited to a hospital.

Meanwhile, new graduate nurses face roadblock after roadblock to becoming an experienced nurse. As nursing students approach graduation, they frantically begin the Job Search, only to encounter "__ years experience required" on almost every job posting. If nursing school is not adequate preparation to be recruited to a nursing position, is our education failing us? How are we to become experienced professionals if hospitals are unwilling to let us grow to this capacity?

I believe the answer to this problem is nurse residency programs. Like medical residencies, these programs assume and even require that the applicant be a relatively-inexperienced new graduate. I feel that like medical residencies, nurse residencies should become a traditional and required portion of nursing training. I envision this to be far off in the future, but maybe someday every teaching hospital will have "nurse residents" and every nursing student will go through a residency as part of their training, not just the lucky few who are accepted to these programs today.

[Esme12, ASN, BSN, RN]

OK. Here is something not all of you probably know.

First, the process of applying for physician's residency costs A WHOLE LOT of money. There is an organization, popularly known as "The Match" which takes from about $50 for each application prospective candidate sends to a particular hospital. Counting that for most competitive specialties even the cream of US grads have to apply for every single program in the country, and that no program will put the candidate in its "list" without a formal interview, the total lump can easily go over a few thousands. And that's not paying for the residency - just for a mere chance to get into it. There is absolutely no chance to avoid this money sucker.

Second, the "match" is, basically, all about math and stats. Whatever "they" are saying (and they LOVE to say about inherent beneficence of the process, blah, blah...) it really cares only, and ONLY about programs' interests. Only one way for an applicant not to end in some God-forsaken place in the middle of nowhere is not to apply in this place, or not to put it into "his" Match List. If, as it quite commonly happens, applicant still put one or two not-so-good places there, then.... well, nobody cares. You're bound for "X" years to be a resident there, and nobody cares that you may have, for example, something named "family". Also, nobody cares if after slaving out years in there everything you can get is local family medicine practice (all residency programs are known for training and connections they provide; usually applicants know exactly from the very beginning where they can get jobs and fellowships and where they can not).

Third, as it was mentioned here already, residency training programs bring money in hospitals. The money are paid by All Mighty Medicare in amount approximately $200000/year/resident's head. The hospital has absolute freedom in how to spend these money. They not only pay less than $10/hour (counting the real time worked), they also charge residents for things like parking, meals and sometimes library using. Recently there appeared a trend to increase training time for family practice residents from 3 years to 4, with presumption that the time can be used for learning "management skills"... got the idea??

Fourth and the worst of it. The problem is, the resident is, like a slave, personally bound with the program for the time of his or her training while the program is not. Not only resident cannot immediately leave program and just join another, in some specialties he has to stay in the place for "X" years just in order to be, with time, eligible for Boards and license. After that condition, the absolutely, bloody worst kind of "nurses eating their young" looks like innocent babies' play comparing with what is considered to be a norm in medical residencies, including things like sabotage, diversions and physical aggression for those unfortunate ones who didn't figure out immediately that 75% of residency is about politicking and not about medicine.

The attending's who know that their behavior will one day or another bring them loss of their licenses tend to gather in residency programs because there they can do whatever they like and be happy with their reputation of "strong guys" and because, once canned out (for whatever reason, legal or not), a resident has close to 0 chance to get into another program. And that's the main difference. A newly graduated nurse can switch floors, hospitals, specialties and states as often as he/she wishes, and unless there were VERY dubious circumstances, his/her license looks nice and blemish-free. A resident who switched programs within the same specialty just in order to be able to visit his dying mother once every week can be legally denied licensing simply because of it, or can be "sentenced" to repeating couple of years of training... again, because of it, alone.

I'd known a guy who managed to go through surgical residency (5 years) trauma fellowship (2 years) and thoracic surgery (3 more years) and broke his spine while skiing during his second year of practice, ending with his both legs paralyzed. Everybody though that, after reading thousands upon thousands of X-rays of every kind, he would do just fine as radiologist. But in order to do so he must complete another full residency (4 years, if not more) in order to become qualified to, basically, read chest X-rays and the like. The doctor carefully collected his pain and sleeping pills for a while, went home and took them there all at once. He left a note mentioning, among other things, that he was dying happy knowing that his widow and three small kids won't carry his $$$$$ educational debts.

Nursing has a whole lot of problems of its own, and to copy blindly a system widely recognized as arcane, wasteful, deceptive and inherently prone to supporting the worst features of human nature would be the worst mistake possible.

Well said.

[Esme12, ASN, BSN, RN]

You didn't complete a nurse residency? I did. Nurse residency in Critical Care. Nurse residencies already exist. Obviously not wide spread and what some organizations call "residency" can be something pathetic like meeting for 4 hours a week or some brief four month orientation.

Nurse "residency" programs are the exception and not the rule and I have found they are "offered" by the larger academic type facilities almost exclusively.

They don't offer new grads positions because they are too cheap to train them. They staff poorly on purpose and complain about a nursing shortage that doesn't exist.

A simple orientation to new grads isn't an unfair expectation and if they are so afraid to train them and loose them I do think it is reasonable to have them sign a contract that put a time limit on how long they must stay top "pay for" the education.

[dirtyhippiegirl, BSN, RN]

Why not revert back to a more diploma-based education where nurses actually trained in hospitals and not in skills labs?

[BostonFNP, APRN]

Why not revert back to a more diploma-based education where nurses actually trained in hospitals and not in skills labs?

Nursing needs more education not less.

[klone, MSN, RN]

Meanwhile, new graduate nurses face roadblock after roadblock to becoming an experienced nurse. As nursing students approach graduation, they frantically begin the job search, only to encounter "__ years experience required" on almost every job posting.

One of the main differences is there are federal (?) regulations on how many new docs are made each year, in order to ensure that there are enough residency spots for all of them.

No such regulations exist for new nurses or nursing schools. As a result, you see lots of for-profit and fly-by-night "schools" churning out new grad nurses by the thousands, and not enough new grad programs or residencies to accommodate them all.

[klone, MSN, RN]

I think part of the problem is that medical schools limit the numbers and nursing schools are constantly trying to flood the market with as many nurses as they can.

Are new nurses willing to work for dirt cheap wages and be on call for lengthy periods of time and submit to the hierarchical nature of medical residencies? It doesn't seem so.

Or I could have just kept reading and saved a lot of typing.

[klone, MSN, RN]

Not all doctors work their residencies for "dirt cheap wages." The resident doctors at my university teaching hospital are paid more than I make now, plus they only work 4 days per week. They have generous amounts of time off, and they can work in emergency rooms for extra money if they want to.

They are definitely in the minority. Most residents work about 80 hours a week (it used to be more, but laws now prevent that due to patient safety issues) - I believe the national average has the typical resident making about $12-15/hour, when you consider how many hours they work.

[klone, MSN, RN]

On any given day on this forum you'll find nurses "eating their young" to be a hot topic. The pecking order in a typical 3 or 4 year residency structure would have those people beside themselves. Interns know they have to earn their respect as they plug through the hell of their first year. I don't think nursing has accepted the same, and is more focussed on being treated almost as equal to their elders in the nursing world from day one.

GREAT post! I totally agree with this, especially.

[KatieMI, BSN, MSN, RN]

One of the main differences is there are federal (?) regulations on how many new docs are made each year, in order to ensure that there are enough residency spots for all of them.

No such regulations exist for new nurses or nursing schools. As a result, you see lots of for-profit and fly-by-night "schools" churning out new grad nurses by the thousands, and not enough new grad programs or residencies to accommodate them all.

There are no fed regulations regarding number of med schools' graduates. There are money Medicare pays for training of the residents. There is only that much of the money, and there are accreditations' rules. If hospital has "X" beds and does "Y" surgeries every year, it can only have certain number of residents. Hospital has to have "X" number of high-risk L&D cases every year in order to train obstetricians, etc. But these rules are pretty flexible and "outside rotations" are not prohibited, so that's usually not a problem.

Actually, Medicare pays for more residency positions then number of all Americn grads every year. That's why so-called "foreign medical graduates" can get into residency training. At the same time, Medicare (and anybody else, as a matter of fact) doesn't care if newly graduated and licensed doctors can find jobs or not. Right now there is a dead glut of pathologists but pathology residencies continue to churn out grads just like before because they got the money to spend on doing just this. As I mentioned, it is not impossible but extremely difficult for a doctor to change specialty after he/she was initially "matched", and specialties in medicine are prone for the same "fashions" and "waves" of popularuity as everything else.

Of course, getting $200000 every year for training of one resident who is paid $50000 over the same time, the hospital sure could hire one more resident for the same money. But, you see, it will decrease what attendings can legally pocket for their indespensible "teaching functions". They suffer so much inconviniences calling those friends of them, aka drug reps, to come and tell their residents about those new miracles from the pharmacy and feed them stale pretzels, or mouthing their old war stories by hours while rounding... it would be unacceptable to deny them some miserable financial gratification!

[KatieMI, BSN, MSN, RN]

BTW, doctors as a community vehemently deny the very fact of existence of violence in residency programs.

In nursing, I cannot imagine situation where a preceptor would have absolute power over a new grad nurse, limited only for things like gang rape, and where the new nurse would knowingly forfeit his/her legal rights in order to remain in training and not to kill chances of being a nurse in the future. But that's how it looks like in some residency programs. If you take a textbook for doctors, chances are you'll find a list of "experts" or "referrees" in there, many of whom will be listed as "residents". These people were "honored" to do a job of writing down whole chapters for the author without any pay, any royalties from the money which came from selling the book and such, all that done in their sparce free time. It is so specified in legal paperwork they have to sign to be so "honored". For some of them, the "honor" would be an opportunity (not a guarantee!) to get a reference letter from the author. For some, it would be a single option to just stay where they are. And the opportunity to become such sort of intellectual slave is considered to be a hallmark of a good, benigh residency program. The worse ones can be only compared to a cross between gestapo, ghetto and Moscow in 1937.

[PMFB-RN, RN]

Nursing needs more education not less.

*** Maybe if nurses were not graduating so well educated, but useless at the bedside, there would be more interest in hiring new grads.

[PMFB-RN, RN]

Nurse "residency" programs are the exception and not the rule and I have found they are "offered" by the larger academic type facilities almost exclusively.

*** Yes I understand that. However a few health systems use a universal nurse residency program for all new nurses wether the grad working in the big flagship hospital or one of the smaller feeder hospitals in the system.

They don't offer new grads positions because they are too cheap to train them. They staff poorly on purpose and complain about a nursing shortage that doesn't exist.

*** Yes well said and 100% correct. However it is my observation that new grads are graduating from nursing school helpless at the bedside and not having learned simple and basic nursing tasks and skills. Rather than the well trained new nurse concentrating on learning time managment, advanced skills and critical thinking when she is first hired, she must be trained in fundamental nurse tasks and skills by her employer. This dramaticaly increases the cost of training new grads.

A simple orientation to new grads isn't an unfair expectation and if they are so afraid to train them and loose them I do think it is reasonable to have them sign a contract that put a time limit on how long they must stay top "pay for" the education

*** I agree but a simple orientation isn't going to be enough for new grads going into specialiety units. Any new grad should be able to function on a med-surg floor with a few week orientation. They can't though cause nursing schools are letting them down.