Opposing Thoughts on the Residents' Strike in NYC

John M. Mandrola, MD

June 01, 2023

News that resident doctors in New York went on strike induced opposing thoughts in my brain.

One side thinks that doctors need to stick together. I have always believed that, but the current employed-doctor model has strengthened this belief.

When I started private practice in the late 1990s, I joined a group of about 20 cardiologists. It was a strong group because we stuck together. Our size gave us the ability to cover all of the hospitals in our city. We had leverage. We had input to hospital functions. When a cath or echo lab needed more staff, we had a say.

Sticking together was not easy. There were fights. I came home from group meetings charged with emotion, unable to sleep. Yet, our leaders kept us together.

Then came the employed model. Reimbursement models changed around 2010. Cardiologists, along with many doctors, signed on to be employees of hospital systems. The first few years were the honeymoon period, wherein there was an illusion of control.

That is now gone. Large hospital systems have all the control. Employed doctors have little input. This is not a complaint; it is a fact. Complaining about the lack of control in employed models is akin to complaining about the weather.

The best way to understand the employed model is to contrast it with groups of doctors who resisted the urge. For example, in our area, nephrologists, urologists, and vascular and orthopedic surgeons remained independent.

I have no hard data, but they seem happier than most. To be sure, some of the ability to stay independent relates to the complexities of payment models. But a lot of it is due to the desire to remain in control. Many primary care clinicians have taken risks and now thrive in the direct primary care model — outside of employment.

Again, I am not an expert in burnout, but it strikes me as possible that loss of professional control may contribute to the rise in doctor burnout.

Pay and Past Performance

The opposing idea is that the residents make naive arguments for their strike. In The New York Times report, they cite their main grievances as less pay than their peers and insufficient acknowledgement of past performance.

The difference in pay is nominal, at about $7000. Another story from my early days of private practice. All partners received a spreadsheet detailing our productivity and pay. My senior partner took me aside very early in my career and said, "Mandrola, everyone here is happy about their income; what makes them mad is seeing what others make."

This observation stands the test of time because at its core, it describes human nature. I have learned (slowly) to focus on gratitude for what I earn. It is toxic to health to dwell on what others make. If these residents pursue a career in clinical medicine, striking over $7000 will seem foolish in hindsight.

Salary is only one factor in the many tradeoffs a doctor makes in choosing a place to work. For instance, doctors can (generally) earn more in rural areas, but the tradeoff is no city amenities. Drip coffee from quickie marts vs espresso from an upscale café. Salaries in medicine will never be fair.

Yet, even more naive than debating nominal differences in salaries is complaining about insufficient credit for past duties.

I have no doubt that many doctors at Elmhurst worked incredibly hard during the pandemic, especially because this hospital was hit hard during the early (and scary) part of COVID-19. But in our current system, reward for past work well done is between you and the patients you helped. You did your job under trying circumstances. You know that. Your patients know it. That is all there is. There are no trophies in the employed business model of healthcare.

I repeat: This is not a complaint; it is a fact. Your value to a hospital system is not what you did last year or in the past 10 years; it is what you are doing now and what you are projected to do in the future.

In days of old, a doctor might have known their hospital president. Administrators were often present in the hospital. A more likely scenario now is that hospital administrators are off site, managing the system far from the points of care. Personal relationships are less common. What's more, administrators often change hospital systems. So it's possible that the current set of bosses were at a different hospital while you were establishing status as a good doctor.

Credit for past performance and a nominally higher salaries are not the right reasons to organize.

Yet, the residents did in fact succeed. The strike has ended, and they achieved an increase in salary. It is a small win in the short-term.

Perhaps, though, the larger win could come in demonstrating that it is possible to get 150 doctors organized for common goals. The residents have exposed an obvious but totally ignored truth: That is, without clinicians caring for patients, there are no hospitals and clinics.

I hope the next generation of clinicians can find a way to organize and advocate for things more relevant than nominal differences in salary or credit for past performance.

This won't be easy. Doctors become doctors largely because of selfish devotion to reaching individual milestones. The sacrificing of personal goals for the good of a group is a different skill.

We shall see if this strike is a one-off or a start of a trend.

John Mandrola practices cardiac electrophysiology in Louisville Kentucky and is a writer and podcaster for Medscape. He espouses a conservative approach to medical practice. He participates in clinical research and writes often about the state of medical evidence.

Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.

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