In The Netherlands
there is currently a political discussion about the question whether residents should pay for their training. Reasons "pro" and "contra" are exchanged, and both make sense - to some extent. Meanwhile, the two professional associations for Dutch residents are joining forces to prevent this idea to become reality. I will discuss both the "pro" and "contra" side, but my conclusion is clear: contra!
The basic principle behind the idea that you should financially contribute to your education, is that you gain profit from it in the future. You simply invest in yourself, and you have the chance to build a better future for yourself and your family. Compare it to going to college: you pay to your university, and in return you get lectures, group meetings, exams, and support from teachers. And of course the buildings have to be cleaned for you. As modern medicine seems to like the aviation analogy, especially when it comes to safety, people are eager to tell you that becoming a pilot is much more expensive. In The Netherlands, if you want to become an ATPL-licensed
pilot you can count on €100,000 as a minimum. The suggested financial contribution for doing a residency is said to be approximately €10,000 - €20,000 for each training year.
So far the "pro" part... let's continue with the "cons", as they are many!
First and most important: residents are not just "students", but they perform a large part of the production as well. Of course, residents do learn along their way. But managing the ward, seeing patients in the outpatient clinic, preparing patients for surgery and assisting during surgical procedures are often necessary. Suppose all residents decide to go on strike.... staff would have to fill in the gaps: manage the ward, carry the pagers and answer all phone calls, see extra patients, and for some procedures they lack experienced assistance (although the latter will not be relevant for all procedures). So they do earn money for the hospitals. This is also where the pilot training analogy goes wrong: medical residents are not spending whole days in simulators, just to train themselves. They are a part of the workflow!
Then, there is the old issue that children of rich parents are not necessarily the best doctors. Still, it will be more likely that they choose to start a residency. Especially because they are not likely to carry the weight of the loan that may be required for the basic medical education, a requirement to start a residency.
All these reasons would be irrelevant if salary of medical specialists would be very high and considered to remain so. Unfortunately Dutch politicians are debating that medical doctors earn way too much, and that their income should be reduced. As you may guess, the numbers are not really counterbalanced against what actually happens, but against what is thought to happen. The debate is lead by the minister of health, and the media are glad to take over. As Patrick Kelly explains in his editorial
, the "doctor vote" does not add much weight to the debate.
Or does it? There is growing discomfort among Dutch doctors for being depicted as lazy bums who are "just interested in money", a problem that seems not to be restricted
to our country's borders. As one doctor provocatively said: "We doctors have the worst PR-strategy in the world". While we are working, and many of us are working very hard, we still have to fight against this money-grabbers prejudice.
In this light, is it realistic to ask residents to pay for their training? I do not think so. It may be an option in the future, as soon as medical training is purely training without "production distraction" and
'guarantees' an income that makes the investment worthwile for the not-so-rich as well. But if the production part would be eliminated, I doubt whether the training prepares residents for a future career in the real world. And if we actually get cut on our income... well, we can still become soccer players. More money, fans who voluntarily wait in lines that are longer than the ones in your waiting room, and no malpractice suits at all...
Pieter Kubben, MD
Dutch resident in neurosurgery
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