The Sex and Money of Time in Medical Education
By: Resident Bolde
Time as Gold
In 1971 Richard Nixon ended the Bretton-Woods gold standard which tied the value of the dollar to the amount of U.S. gold held in Fort Knox. The US still holds the largest amount of gold in the world. Dissolving Bretton-Woods allowed the US Federal Reserve to print more money to inject into global trading without requiring the exchange of gold. Instead of gold being exchanged, it was human time. As economist Richard Duncan pointed out other countries who wanted USD traded with the US in the form of providing the US cheap labor.
This is also true domestically. Today highly trained US citizens earn a fraction of the gold their US ancestors earned for much less time invested. This is another way of looking at inflation. How many USD would you need to by an ounce of gold? More accurately, how much time would you need to invest in labor to get an ounce of gold? The international exchange of cheaper human time for a floated USD as a global index currency has ultimately created reverse colonization where the world comes to the US to provide cheap labor-time.
This is seen in the MATCH and in the human rights abuses endured by residents today that grew out of the Nixon administrations’ economic policies in the 1970s. It is not a coincidence that recent talks in the Trump administration about putting the USD back on the gold standard are taking place as digital currencies are establishing themselves separately from fiat currencies.
Time as Money
Dr. Bryan Carmody summarized statistics collected from NRMP and ERAS. Over approximately 10 years there have been twice the number of IMGs per USGs applying for the same residency spot. The total number of both IMGs and USGs has approximately doubled over 10 years. The ERAS system tripled its profits over 10 years from 30 million to 90 million a year. AAMC reported Medicare funds equaling $15 billion in Direct GME related costs. The more Medicare patients a teaching hospital has, the more funding per PGY position a hospital receives. Residents themselves are paid less than minimum wage for the 70 to 100-hour workweeks they engage in. The amount that residents are paid does not change much for the increase in Medicare patients the hospital has. Hospitals have received money anywhere from 80k to $300k per PGY spot depending on the source of funding and the number of Medicare patients the hospital treats. Not all sources of GME funds are known.
The human rights violations of residents (as well as all doctors) and all their feelings of “burnout” grew out of Nixon’s economic policies. Along with floating the USD, Nixon also created HMOs which were sold to the public as a way to cap the cost of medical services. Today the US boasts the most expensive healthcare with poor outcomes for a developed country and the amount it spends.
According to the Bureau of Labor Statistics, since 1970 the total number of doctors doubled but the total number of administrations went up 30-fold. As reported by Citizen Health, physician costs were 7.3% of the $3.6 Trillion US National Health Expenditure for 2018 in contrast to the 73% of that spending that went to non-clinical activities. While Nixon did achieve a cap on costs of clinical activities, the amount of time and money that goes toward the documentation and billing for these bean counter managed healthcare plans skyrocketed along with the human rights violations of residents. “Burnout” and other macroeconomically induced “mental health” symptoms of residents are in reality the human rights violations stemming from resident devaluation of labor-time being a major economic source of deflation for the floated USD. HMOs are really just a macroeconomic tool to provide deflation to the USD by providing slave labor in the form of residents.
The majority of resident time is not really invested in medical education or surgical training, but in the non-clinical tasks known as “scut work”. Detailed documentation and pre-emptive organization of logistics is done to receive reimbursement and avoid lawsuits from a multitude of regulatory sources. Pre-meds take on jobs as medical scribes to develop time efficiency with documentation so that they can have more time to dedicate to actual learning of medicine once they are in residency. They can also “learn” medicine as a fly on the wall via pattern recognition through what is documented by the attending.
This pressure cooker learning environment created by the high overhead, high-risk business model of medical education reduces the valuable resource of time to such an extent that it amplifies tribalism and discriminatory behavior in a hierarchy with a very steep power gradient. Layer this power dynamic on top of the misogyny women around the world have already endured, internalized and been oppressed by at baseline in society for thousands of years and the result is an even steeper power gradient women residents face.
Time as Sex
As discussed in Kate Manne’s book “Down Girl”, sexism is the bioethical justification of misogyny. Misogyny is the sociopolitical contract of behavior that takes power away from women and gives it to men. Societies that engage in these sociopolitical contracts are patriarchies The reality is that the “sociopolitical contract” of misogyny is actually sadomasochism.
Sexism allows society to have a completely clean conscience, even at a spiritual level, about the subjugation of women to the sadomasochism of misogyny. Sadism is directed to the female sex by both sexes and masochism is expected to be internalized by the female sex. This sadomasochism decimates women’s’ rights to have control over time, control personal resources, control their bodily functions, control their thoughts, control access to money without satisfying a male entitlement, control autonomy to their humanity, their voices, their personalities… the list goes on.
This is the gender normative behavior women are conditioned with all over the world. Gender norms really should be re-termed as “power norms” socially expected and enforced on the sexes to maintain a power gradient that favors men. While women are much more susceptible to abuse in residency, they often are not the best detectors of abuse. This is because gender norms shape women to have porous boundaries whereas men’s boundaries are socio-politically strengthened since birth. Having porous boundaries is one example of female gender normative behavior that enforces the masochism of misogyny. Therefore, when women do begin to detect abuse, it likely means the abuse has gotten really bad. This is particularly true for women raised in more overtly oppressive patriarchal cultures where covert forms of oppression may go initially undetected in supposedly more “progressive” societies. In turn, powerful men in “progressive” patriarchal systems create the illusion of virtue while still continuing their baseline abusive behavior with women conditioned to much more overt and intense sadomasochism.
Women who do not adhere to gender normative behavior get targeted for harassment of different kinds. Men have difficulty empathizing with the boundary violations women experience on a daily basis as men have not been socialized to internalize giving away their power from birth. This is the power of misogyny and sexism. They are so normalized they are invisible to the majority of men and women.
Only just recently, in October 2019, has the NEJM published an article of the obvious that female surgical residents exposed to gender discrimination had higher rates of suicide ideation. Sadly, it is not obvious to most people because most cultures are patriarchies where the power gradient favors the male sex. In order to maintain this power gradient, patriarchies have a variety of methods to ensure the female sex falls in line with the sociopolitical contract of the sadomasochism that is misogyny and the bioethical belief system that is sexism.
Sexual harassment is one such tool as discussed by sociologist Dr. Amy Blackstone where her research showed that is was having access to authority that was the strongest predictor a woman would be targeted for sexual harassment. Sexual harassment is a sociopolitical tool used to prevent women from gaining access to their own economic agency free from having to engage in sexual encounters with men.
Time Vampirism
Resident “depression” or “burnout” are really human rights violations that are symptoms of the continuing global macroeconomic war to maintain the value of the USD as the US Federal Reserve prints more money without requiring gold in exchange. Residents’ human rights are being violated because their time is a major economic source of deflation for the USD.
Before even entering residency, women’s unpaid labor-time is an even stronger economic source of deflation for the USD. According to NYT, if women world-wide were paid minimum wage for their unpaid labor-time just in 2018, they would be owed $10.9 trillion USD. Misogyny, therefore, is the ultimate economic source of deflation for the USD.
Women’s time is sacrificed for Fort Knox’s insufficient gold supply that has a government 1973 “ book value” of $6.2 billion and a current 2020 market value around $236 Billion USD. This value is also not additive by that much each year. Women’s sacrifice is what is keeping the USD alive.
Time has a sex. Money has a sex. Money has a female sex-time value that is taken away from women and given to men.
Our USDs value, made in the land of “freedom”, derives most of its value from misogyny. Women going into the business model of residency training, already built to be a source of USD deflation, subjects women to immense misogyny to extract their time value. Wherever there is an economic source of deflation there will be misogyny. Misogyny is a time vampire that creates money and resources for men.
Time Protection
The ACGME lists what its milestones are but what it does not mention is that all residents will have to achieve these milestones in a high risk, high-overhead business model. The resource that gets restricted the most in such a business model is time because as mentioned earlier residents’ extreme labor-time provides a strong economic source of deflation for the USD. The resulting human rights violations are the basis for the high suicide rates of physicians.
Women residents’ time is an even more potent economic source of deflation because of the devaluation applied to women’s time via gender roles and internalized gender normative behavior even before entering residency. Women pre-meds, medical students, residents, fellows, and attendings need to understand the external economic and misogynistic forces that are creating the lion’s den they are going into medical education. They also need to be armed with the right lexicon, know the lay of the land, have a long-term career strategy including how to choose a residency along with day to day tactical moves to navigate some pretty tough office power politics.
“Overcoming the Fear” is an e-book geared to help women medical students transition into residency training by helping them quickly identify abuses of power early on, set appropriate boundaries, develop a long-term strategy and short-term tactics. The goal of this book is to help women residents keep abuses of power at bay. This prevents further devaluation of women residents’ humanity that had already been systemically devalued without their awareness from the very beginning of their lives. “Overcoming the Fear” is the silver stake that kills the time vampire of misogyny in residency training.
Resident Bolde is a physician who left her training in a surgical subspecialty early because it was clearly not supportive. Since she was the victim of more covert forms of abuse, it took her 5 years to discover that she had experienced the same dynamic as a victim of domestic violence after speaking with DV advocate, author, and former attorney Barry Goldstein Esq. Except this was not happening in an intimate relationship, this was happening in the workplace. Resident Bolde wants to warn future women entering the medical field about the signs of abuse so that appropriate boundaries can be set early on given that so little research has gone into the domestic violence dynamic in the workplace. She gives specialized strategic and tactical advice on how to navigate abuses of power in a hierarchy with a very steep power gradient that has the potential to derail careers.
Where to find Resident Bolde online:
Website: https://residentbolde.org
Twitter: @BoldeResident
Facebook: Facebook profile
Blog: https://residentbolde.org/blogs/
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