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Much still needs to be done to improve working conditions for medical residents, starting with increasing their salaries and improving access to healthy food and child care, members of the American Medical Association's (AMA) House of Delegates said Sunday.

"The student debt that medical students take carries over then into relatively low salaries that we receive during residency," Luke Selby, MD, a delegate from the Resident and Fellow Section, said during a reference committee hearing at the AMA's annual meeting of the House of Delegates. "The low salaries that we receive are augmented by the fact that residents not only have to support themselves, but they have to support their families and depending on the specialty that they're in, often have to purchase very expensive safety equipment that's completely required for their job. A prime example would be the lead used by interventional radiologists, vascular surgeons, orthopedic surgeons, and several other types of physicians."

"We Need to Do Better"

Selby was discussing a resolution he authored which calls for the AMA to work with stakeholders to define "access to food" to include 24-hour access to fresh food and healthy meal options within all training hospitals, and to ensure that medical trainees have access to on-site and subsidized child care. The resolution also asks that the AMA revise its "Residents and Fellows' Bill of Rights" to say that residency and fellowship programs should provide benefit "including but not limited to on-call meal allowances, transportation support, relocation stipends, and child care services."

David Walsworth, MD, a delegate from Michigan, said his delegation "strongly supports" the resolution. "We all appreciate the effects of compound interest in our 401(k)s, but the same effect works against students and their low salaries during residency and fellowship," he said. "We can do better; we need to do better. We need to treat our young as the valued resources they are."

Several residents spoke about the effect that low salaries and lack of financial support have had on them. "My wife, a pediatrics resident, and I have decided to delay having children, due to insufficient support which makes raising a child during residency and fellowship impossible," said Breyen Coffin, MD, a delegate from the American College of Radiology. "As a two-resident household, it is logistically impossible to provide adequate child care ourselves -- it's financially impossible to pay for the amount of assistance required."

"Our residents who have children are only able to do so because they have one parent who is not a physician in training, or they have their own parents or family nearby to act as full-time child care," Coffin said. "This is a gender disparity issue, a racial disparity issue, and a socioeconomic status issue. These issues have been facing trainees for far too long, and we strongly urge the AMA to pass policy on this now."

Arguments for Referral

Jason Schwalb, MD, an alternate delegate for the American Association of Neurological Surgeons, said he "kind of surprised myself" because he was speaking in favor of referring the resolution for further study. "I can tell you after 9 years of training, my wife and I -- she's a colorectal surgeon -- we owe about $420,000 in educational debt, so we're very sensitive to this," he said. "However, I think that this is probably not the right way to go about this. We need to attack the educational debt and not impose unfunded mandates on our residency programs ... It's just really not feasible without increased GME [graduate medical education] funding, and we think really the better way to go about this is by increasing student aid."

June-Anne Gold, MD, a member of the Academic Physician Section, also favored referral. "As an IMG [international medical graduate], I've trained in two separate countries," said Gold, who was speaking for herself. "I went to medical school with four children and went through the equivalent of residency and fellowship with four children. I didn't have the debt students have here, and I was supported to go through those trainings at 50% time, which is the law in the U.K. I think this is a much bigger problem, and we need to refer it to look at more ways we can solve this to better benefit trainees, to allow them to have a family life and also be good parents."

The delegates also discussed another issue of importance to physicians in training: accommodations for students with disabilities who are taking their United States Medical Licensing Examination (USMLE) or National Board of Medical Examiners (NBME) exams. "As the system functions now, the timeline for receiving a response for an accommodation request can take over a year, and the process is burdensome and unreasonable," said Natasha Hongsermeier-Graves, a student delegate from Nebraska who spoke on behalf of the Medical Student Section, which developed the resolution.

"Many cases do not appear to follow ADA [Americans with Disabilities Act] stipulations," she said. "This deters prospective medical students with disabilities and creates extra hardships for current students trying to make it through medical school with their peers." The medical students' resolution calls on the AMA to collaborate with medical licensing organizations to facilitate a timely accommodations application process, and says that the AMA should work with the NBME to develop a plan to reduce the amount of proof required for approving accommodations to lower the burden of cost and time to medical students with disabilities.

Wealthier Students "Get the Reports They Need"

Frank Dowling, MD, speaking for themselves and the Medical Society of New York in support of the resolution, discussed the difficulties test-takers have in getting the required reports and other documents needed to prove they deserve an accommodation. "As a psychiatrist who specializes in the care of our siblings and emergency responders ... I have seen this over and over again in students I treat, in people who come to me for evaluations -- this is a major inequities issue."

"Those who come from wealthier families, those who have more funding, and more access, get the reports they need and get approved -- whether they have a disability or not -- because the reports say what they say, and they go back and fix them if they need to," Dowling said. "Those who have disabilities, on average, have less ability to spend the money and take the time and the resources to get to the right people, and they end up being denied. The process assumes that people are lying, and that's wrong. We have to start taking care of people with disabilities and help them move forward."

Reference committee members heard testimony from several people who have been personally affected by the process. Danielle Rivera, an alternate delegate from New Mexico who was speaking for herself, said that "as a medical student with a disability, this issue is personal for me. In my class there were four of us who were granted accommodations by our school, but I was the only one granted accommodations by the NBME, and not one of us will graduate on time due to the accommodations process."

"For months, both before and while my classmates were in the dedicated study period, I was compiling a packet on my disability and accommodations history, and reaching out to my doctors and schools for medical documentation and documentation of previous accommodations and transcripts," she continued. "I was working to get into a specialist clinic with one of the top doctors in the country for my condition, and finally, flying to see that doctor. Even then, with the best physician I could find to speak on my behalf, the NBME wanted even more information and wouldn't grant my accommodations at that time."

"It was only after another letter from my doctor and a total of 6 months of work that I was granted the accommodations I needed, and I was lucky," she added. "I was lucky to have the people around me who connected me to the resources that helped me find my doctor, I had family that could afford to send me to a doctor out of pocket, and I was lucky that my doctor decided to accept me as a patient ... Disabled students shouldn't have to be lucky to get accommodations."

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