Students Forever? No Longer!

I am an avid reader of the Health Policy and Reform blog of the NEJM and believe that they should enable the commenting system on the site to allow bidirectional interaction, much like BMJ and its Rapid Responses.

So, this week’s NEJM came with an article which piqued me greatly: Residents: Workers or Students in the eyes of Law?

The critical point in understanding this article is appreciating what a medical resident is, what his responsibilities are and how he is answerable to the authorities. Now, if you read the article (its free) you will realize that there are several great arguments on both fronts. Let us just take a look:

As Workers:

• In any hospital, in any part of the world, the residents make up a significant amount of the workforce serving the hospital and the patients. Consequently, they fulfill the responsibilities of being an employee. In most cases, patient care gets precedence over the educational pursuits. In fact in the case which brought this debate to the forefront, this was one of the central points for the argument to brand residents as employees.
• In case of malpractice litigations, the residents are held in equal standing as senior physicians who are, undeniably, employees of the hospital.
• The residents enjoy “compensations and standard employment-related benefits”. Although the latter half may not be true in all cases: for example, in my hospital, residents are unlikely to enjoy and employment related benefits besides the stipend.
• The “resident differs in notable ways from a “student” who is ‘enrolled in and regularly attending classes.’” (1) Unlike the medical student, who have no real service obligations, the residents serve as taskforce, hence, they should be accorded the status of an employee.

As Students:

• It has been argued that the resident is admitted based on academic excellence, much like the medical student. His execution of patient care and other responsibilities in the hospital is considered to be a part of the overall training. The Mayo and Minnesota hospitals, which were fighting the case for labeling residents as students contended that they “permit their residents to care for patients purely for educational purposes . . . residents do not provide a net economic benefit.” (2)
  • • Now this is just plain unbelievable. The residents form a significant portion of the workforce, and hence they must impact the hospital in a financial capacity. Even if the residents are to be supervised by licensed practitioners, their contribution is undeniable in the dispensation of proper healthcare services. Anyways, the cost implications of following the ACGME guidelines is immense in hospitals that find replacing lost resident-work-time an expensive affair. (3)
• The resident is not a fully licensed free-to-practice physician: hence, he is a student.

Now, coming to the scene in India, unlike the US or UK, there are no ceilings for maximum or minimum weekly work hours. In many hospitals, the residents (and interns) are responsible for actually executing the various acts of providing healthcare services. In any cases, they should be viewed at par with the employees.

The major repercussion of this issue is the payment of taxes and the consideration whether that expense may be better served in enriching the medical education system or healthcare infrastructure. In India, depending on where one is a resident, the stipend can be as high as Rs. 600,o00/ (in New Delhi hospitals like AIIMS). That brings into play a large amount of exchequer in taxes. And obviously, this issue is of greater relevance in the US or UK where compensations are considerably higher. Another thing which is to be kept in mind is the fact that the average Indian medical student, passing out of a Government hospital and/or medical college bears almost no financial burden that is attributable to the medical education expenses. Though the scenario is vastly different in the private sector, keeping in view the minimum number of seats in post graduate medical education in the private sector, as compared to the government set up, we can set this side of the topic aside. However, the medical student who passes out of a US/UK medical school has a considerable financial debt to worry about (right now I cannot find the citation, but studies indicate that medical student debts may be, on an average, in the range of 140,000 to 200,000 US $ – that is some serious money we are talking of here!). So, an added tax burden is obviously a major turn off.

However, all said and done, in this financial environment, where stability still seems some distance away, it may be actually a good thing to be labeled as employees in the eyes of the law. In fact, it would not be too bad a deal to be able to start enjoying (albeit after paying for it) the employee benefits from an earlier age. And given the length of the medical curriculum, that is not altogether a bad thing.

However, I must say, much of the advantages that would accrue to a developed world resident being labeled as an employee would not be applicable to those in India. In fact, considering the fact that in India social security and other employee benefits are minimum anyways in most government set up for the junior-most employees, it maybe a good thing to still be labeled as students! I admit my understanding of the social security and employee benefits that residents would receive in the UK/US are sketchy, at best, but still, I think it would be better for the Indian Medical Resident if he still was considered to be a student.

What do you think?

References:

1. Kesselheim, A., & Austad, K. (2011) Residents: Workers or Students in the Eyes of the Law?. New England Journal of Medicine, 41-49. DOI: 10.1056/NEJMp1100414

2. Brief for the Petitioners, Mayo Foundation for Medical Education and Research, et al. v. U.S., No. 09-837 (Aug. 2010).

3. Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med 2009;360:-2215 Full Text | Medline