Social psychologist Christina Maslach, PhD, of the University of California, Berkeley, defines 6 factors that lead to physician burnout. She posits that a breakdown in workload, control, rewards, community, fairness, and/or values conflicts contribute to the epidemic. I posit that all of these factors breakdown throughout residency, and the crushing blow occurs when graduation does not ameliorate, or worse, exacerbates certain of them. Burnout doesn’t begin because these factors break down. It begins with the realization that they may not get better.
While residency is wrought with inequity, one of the most egregious issues, albeit controversial, is the question of compensation. Though salary has increased steadily with time, it has been outpaced by increases in cost-of-living, mounting debts, inflation, and is further complicated by decreases in overall job satisfaction.
Let’s take a semi-objective look, from the admittedly biased perspective of an interested party, at some of the elements surrounding resident pay…
Too Many Hours
Framing the debate on resident pay in terms of hourly compensation seems mandatory given the laughable number of hours residents can work. The deliberation concerning resident work hours versus wellbeing and capacity to provide safe patient care at extremes of exhaustion is out of the scope of this article. Still, for some context, I pieced together a quick comparison of resident duty hours to those of an airline pilot; two professionals you do not want tired while taking care of you. The differences speak for themselves, but here is the surprise ending in case you wish to skip the table:
Overall, resident guidelines sanction significantly less rest before a shift, obviate time off, and permit far more on-duty hours (2.74x more in a calendar year).
Keep in mind that, per the ACGME, things like “reading done in preparation for the following day’s cases, studying, and research done from home do not count toward the 80 hours [per week].” As work hours have been decreased (with the old guard regularly putting in 120-hour-weeks), the expectation is that hospital time be spent performing hospital duties, leaving little time to read, study, or do research on the job. In turn, time spent at home is dedicated to these undertakings rather than sleep, voiding any wellness benefit the restrictions may have intended. Other professions, such as lawyers (who do one year less of graduate school and no required residency), might consider these billable hours. This unpaid effort contributes to a feeling of inequitable pay-per-unit-time, and piles on to the resentment harbored by performing duty hours in excess of comparable peers, again, at relatively low per-hour-wages.
Too Little Pay
Nurses, when referencing an unpleasant resident duty or mistakenly paging at 2 a.m., often excuse themselves with, “Well, that’s why you make the big bucks, Doc.” Let’s be clear; I do not make the big bucks. I am a resident, and have been for more than half a decade. I do not drive a Ferrari; I drive an eleven-year-old Jeep with 130K miles, a cracked windshield, and a perennially glowing check engine light. I do not live in a mansion; I live in a modest house with a rented room to defray cost, furnished as if I can only afford secondhand Craigslist furniture largely because I can only afford secondhand Craigslist furniture. And I don’t travel first class to exotic lands; when I have time to visit my family or friends, I mostly fly Spirit Airlines (if that doesn’t say enough, then you haven’t flown Spirit Airlines; #BareFares).
According to the Residents Salary and Debt Report 2017, the average resident salary is $57,200. While ostensibly reasonable and well-above the poverty line, when you consider that many residents work the maximum allowance of 80 hours per week (or secretly more) that figure falls short of impressive. The average work week is 40 hours. That makes a resident one person doing two people’s full-time jobs every week, in my case, for 6 years. Assuming 48 weeks worked per year, at 80 hours/week, this comes to an average of approximately $14.60 per hour.
As an intern (first year resident), I calculated my hourly salary to be about $10.70 per hour. For reference, in Nevada, that is more than a current McDonald’s cashier ($8.40) and crew member ($8.59) but less than an assistant manager ($11.31). While I have nothing against McDonald’s workers, my understanding is that most have not completed 8+ years of higher education, and certainly have not incurred the debt that accompanies such an endeavor.
In summary, a resident can work 274% more hours-per-year than an airline pilot, while making an hourly salary that is only 27.4% more than a fast food cashier.
(Did this sentence blow your mind? If not, re-read it.)
Which of the 6 Maslach factors for burnout (workload, control, rewards, community, fairness, and/or values conflicts) do you think conditions like this might affect? I think hours and pay alone negatively impact all of these wellness factors, and we haven’t even gotten to other financial aspects like debt, residents as hospital earners, or wage suppression. Stay tuned…
In Part II, I discuss “Too Much Debt, Too Few Options”.
Joshua J. Goldman, MD is a PGY-6 Plastic and Reconstructive Surgery Resident at the University of Nevada, Las Vegas School of Medicine and is Microsurgery Fellowship-bound. His professional interests outside PRS include healthcare advocacy, device innovation, digital marketing, ethics, medical education, and physician wellness. You can follow him on instagram at @GoldStandardPlasticSurgery. Thanks for reading!
The above represent my experience and viewpoints alone. They are not representative of my institution, program, or hospital. I have no conflicts of interest to disclose.