Recently on Twitter, I found myself in a heated debate. I argued that additional unaccredited years of clinical training in hematology-oncology – an additional year focused on lymphoma, breast cancer, or bone marrow transplant – is a “scam”. Some disagreed, but it’s a conversation we need to have.

The debate, of course, is broader than hematology-oncology. Medical training is growing. Twenty years ago you could get a job after a radiology residency, but nowadays you don’t need one, but two scholarships.

Cardiology rarely ends after 3 years. There are additional years in electrophysiology, interventional, structural, imaging, prevention, etc. You will be lucky to have completed in 8 years (including residency).

My friend completed his neurosurgery residency and fellowship in 7 years, and he considers himself lucky to have found a job. Some of his colleagues took 9 years (additional scholarships). And, a friend from medical school found herself in 11 years of training to do cardiothoracic surgery.

Enough already!

I am a hematologist-oncologist and I spent 10 years there (4 for the faculty of medicine, 3 for the residency and 3 for the scholarship). Since I started working and repaying my loans, I have looked after patients with solid cancers, hematologic malignancies, benign hematology problems and people undergoing bone marrow transplants, that is- ie the whole range of hematology-oncology.

But things have changed recently. A number of scholarships have emerged. Another year to focus on lymphoma, bone marrow transplant or gastrointestinal oncology. I have no doubt that one can spend years learning more about any disease – what I doubt is that these additional scholarships, which are often paid much less than the accompanying salaries , be a good thing.

I think there are eight reasons why, as doctors, we need to reform or boycott those extra years.

1. It won’t stop with 1 more year. One of the fallacies is that “just 1 more year” is all it takes to be prepared for the job of an assistant. But what starts with an extra year to focus on breast cancer will quickly become 2.

Why not add a research section? Soon we’ll be talking about 3 years. As I say below, finances only spur more years. The truth is that you will eventually become an assistant, and there will inevitably be things that you learn on the job.

No training can avoid this. For example, in the documentary “Jiro Dreams of Sushi“, Jiro’s 50-year-old son is apprenticed in his 85-year-old father’s restaurant, eager to one day become a master chef. Too much training exists.

2. Longer training means more money for hospitals and less money for doctors. Recent study calculates that one neurosurgery resident wins $ 345,000 for the hospital. That’s three to four times their annual salary.

When a residency program in New Mexico lost accreditation and 10 residents, the hospital had to hire 29 intermediaries to do their work. When Hahnemann declared bankruptcy and sold the residence at auction, the residence alone was acquired for $ 55 million. It shows how lucrative the residents are.

In short, the more advanced the trainee and the more he works in a clinic, the more money the hospitals earn. If hospitals can justify paying doctors a scholarship’s salary, they will. This incentive means that training will only get longer, not shorter – it is a form of wage exploitation.

3. Longer education makes medicine a profession for the children of the rich. We are already fighting in medicine to train children from poor families. A third of medical students come from families in the richest 5%, and less than 5% come from the bottom 25%. The lengthening of the years it takes to earn a professor’s salary makes it increasingly difficult to pursue medicine for trainees who need to earn money to send to parents, siblings or grandparents. It’s hard enough to earn your first real salary at 32, let alone at 42. If we continue to extend training, we are increasingly making medicine a profession for young aristocrats.

4. Longer training hurts women. Both men and women are victims of longer working hours and more years of training, but women are particularly affected. Research shows that longer working hours meant women were less likely pursue areas such as surgery. Women in medicine face unique challenges balancing career and family and may truncate their training to start a family.

The risk of extending the number of years to become a bone marrow transplanter or lymphoma doctor is that it can make these areas male dominated. It’s bad.

5. Longer training periods mean cruel parental leave policies. At some point, some people can have children. The time available for leave is already insufficient for full faculty members, but interns often have less time. More training means less time for parents to bond with children.

6. If we do not participate in the voluntary scholarships, they will not become compulsory. One response I received is that these scholarships are voluntary and only provide options. The problem is that all training expansions start with voluntary programs that quickly become mandatory. This is why the training has widened. If, on the contrary, doctors refuse to accept these poorly paid scholarships, they will disappear. Moreover, willful does not mean that something cannot also be exploitative. For example, payday loans are voluntary, but they prey on vulnerable people.

7. What is the alternative? Some argue that if they had not pursued those extra years of scholarship these doctors would have a different job or would not have succeeded, but this is not fair. The counterfactual – which would have happened without the fraternity – is usually no different career. More often it is on-the-job training. This means that a hospital hires a junior person to participate in the transplant service and gives them senior counseling or mentoring for a few months before releasing them. This has been the primary method of training for decades.

8. Many support these scholarships and run these scholarships but have not attended these scholarships. A great irony in this space is that many supporters of these extra scholarship years did not educate themselves in these scholarships. In addition, they manage these scholarships. They find themselves in an incredibly confrontational position – advising interns to complete their programs, and not just trying to get a job – rather than encouraging on-the-job training, which is the way they are. themselves entered into their careers.

We are faced with a choice: reform or boycott these stock exchanges.

Option A: Incorporate the program and laudable training aspects of these advanced scholarships into the first year of on-the-job training for beginning teachers. If we really seek justice, we could go one step further and move scholars of all types out of postgraduate year salary scales and into full faculty scales with commensurate benefits for the duration of their scholarship.

After all, fellows are often board-certified internists / surgeons / pediatricians / radiologists. The reorganization of the whole scholarship system and salary scale would avoid the cruel and unusual situation of advanced / supplementary scholarships.

Option B: Until these reforms occur, I will advise all interns – whatever fields they pursue – to complete the few clinical years necessary before starting to participate. It’s simply a way for hospitals to transfer your income to them and, as an alternative, to find another institution – perhaps one with less branding – willing to sponsor on-the-job training.

Vinay Prasad, MD, MPH, is a hematologist-oncologist and associate professor of medicine at the University of California, San Francisco, and author of Smart: How bad policy and bad evidence hurt people with cancer.

Last updated on June 15, 2021