Residentured Servitude: Too Many Hours, Too Little Pay, Too Much Debt, Too Few Options
Part II: Debt Hostages
Too much Debt:
The feeling, at least for me, is that hourly compensation does not reflect the job performed, the education required to perform it, or the cost invested in achieving the station, Resident-Physician. With 63% of residents greater than $100K in debt (18% greater than $300K), rising student loans augment concerns regarding compensation. I, myself, am well over $200K in debt, from undergraduate and medical school loans, despite obtaining numerous scholarships. By the time I graduate from my six-year residency program, interest will have me nearer $300K. Many residents even take out loans during residency to keep up with cost-of-living and income-based loan repayments; made worse by the removal of the “20/220 Pathway”. This hardship makes basic things like buying a house difficult. Fortunately for me, when I moved to Las Vegas, the housing market was favorable and the cost-of-living even more so. Buying a house during residency was a rewarding experience, but it clarified two germane issues to which I was previously oblivious:
1. My financial ignorance severely disadvantages my potential for optimizing future economic security.
I spent my entire formative life studying anatomy, physiology, and surgical technique, as well as honing history-taking, physical exam skills, and bedside manner. I, like the majority of my peers, ignored other interests and disregarded the obvious importance of building sources of passive income and alternate revenue streams. Absent any formal pecuniary education, I made mistakes in the handling of loans, savings, and investments. These missteps left me house poor, living mainly paycheck to paycheck, and constantly taking out mortgages on my future for the illusion of disposable income.
2. I have NET NEGATIVE money. Which means I have less than NO money. None. Zero. Nill. Zilch. Nada. Zip. And all the other N and Z words that signify the very real fact that my proverbial pockets are far more than metaphorically empty. I have never missed a rent or mortgage payment, I have an average credit score, and, most importantly, I have job security and the promise of a significant increase in pay in the next five years. What I didn’t know at the time was that none of these factors overcome the metric, Debt-to-Income Ratio. To say my ratio is undesirable, would be to speak in severe euphemism. Without a cosigner, I could never have obtained a reasonable loan (Thanks Mom! Thanks Dad!). I am thankful for the good fortune, and aware of the privilege, in having that support. The metric illuminates the fact that my modest savings and monthly paycheck are dwarfed by my loans. My impulse is to pour money into my debt until the fire is extinguished, or at least to keep the interest at bay so it does not suffocate my future, but the importance of keeping cash-on-hand has been explained and demonstrated to me ad nauseum. Thus, I will likely carry my debt far into my career. This aspect of loan repayment was certainly unclear to the eighteen-year-old freshman undergraduate and twenty-two-year-old medical students who took out most of my loans. Those idiots didn’t have a clue, and I’ve grown to harshly resent their naivety.
Too few options:
To make matters worse, they got me into a sticky debt situation, and they didn’t even know it. Not all debt is created equal, and student loans are subject to rules not applied to other situations. Before 1976, student loans were treated the same as all debt. That year, congress passed a law permitting students to only discharge loans in bankruptcy five years after loan origination. In 1990, this was extended to seven years after origination. Come 1998, in the face of mounting student debts and increasing defaults, bankruptcy of student loans became more strict, with ‘undue hardship’ as the only option for discharge (a very difficult task to accomplish). Students are harassed by creditors, hired by the Department of Education, with impetus (meaning commission) to aggressively extract higher payments from the borrowers. Furthermore, student debt has no statute of limitations on collectors (Let College Students Go Bankrupt).
Elizabeth Warren wrote: “Ultimately the non-dischargeability decisions boils down to two simple policy questions: Why should students who are trying to finance an education be treated more harshly than someone who negligently ran over a child or someone who racked up tens of thousands of dollars gambling? And why a for-profit lender should receive the kind of extraordinary protection that is usually reserved for domestic support recipients or the government?”
This system seizes financial control from high school students, happy to cede it for the opportunity to pursue higher education, and holds them hostage. They can’t drink, they can’t rent a car, but they can certainly take out an unforgivable loan for hundreds of thousands of dollars based on their youthfully optimistic assessment of their lifetime earnings potential.
In essence, once a student loan is taken out, the borrower is without the intrinsic protection afforded to most other debtors. Without an alternate career trajectory viable enough, from an earnings standpoint, to sustain repayment, these loans keep young doctors shackled to a narrow path within medicine. It contributes to a system of residentured servitude perpetuated by new and long-standing institutions and federal-level constraints.
If you’re rolling your eyes, and thinking, “Oooohhh, poooorr doctors.” It’s important to remember that not all doctors become wealthy, and the expectation of impending prosperity is a particularly dangerous one in a system of continuously constricting reimbursement ancillary to consistent expansion of policy and bureaucracy. The discussed issues are real, and barely scratch the surface; a snapshot of only a few elements surrounding resident compensation and downstream consequences. Though these specific issues are confined to a portion of a careers that can be considered education, they contribute to declining physician satisfaction, rising burnout, and the sequelae that follow. Further failure to manage these issues, and continuing to place the onus of healthcare costs on physicians, contributes to an unsustainable healthcare model.
Upcoming articles will discuss wage suppression, changing attitudes with changing generations, residents as hospital income, and midlevel providers in the context of resident wellness and physician burnout.
Coming Soon: “Residentured Servitude: The Emperor Has No Scrubs”
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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.
