Who Bears the Burden? Understanding the Socioeconomic Patterns of Educational Debt in Orthopaedic Surgery Residency Candidates.

BACKGROUND: Educational debt is commonly observed among applicants to orthopaedic surgery residency programs; however, an understanding of the debt burden among minority and nonminority applicants is not well established. Thus, this study aimed to fill these knowledge gaps by examining the extent of and factors shaping educational debt among orthopaedic surgery applicants. QUESTIONS/PURPOSES: (1) What is the educational debt burden among orthopaedic surgery residency applicants? (2) After controlling for relevant confounding variables, what factors are independently associated with increasing levels of educational debt? (3) After controlling for relevant confounding variables, are individuals classified as an underrepresented minority or those with educational debt and socioeconomic disadvantage less likely to match in orthopaedic surgery? METHODS: A retrospective evaluation of orthopaedic surgery residency application data from the American Association of Medical Colleges was analyzed from 2011 to 2021. The American Association of Medical Colleges database was selected because every residency applicant must register and apply through the American Association of Medical Colleges. Therefore, these data exist for every residency applicant, and the sample was comprehensive. Self-reported data including premedical, medical, and total educational debt burden as well as classification as socioeconomically disadvantaged and application fee waiver use were collected. Applicants were dichotomously categorized as an underrepresented minority or a not underrepresented minority based upon self-identified race and ethnicity. Monetary values were reported in USD and inflation-adjusted to 2021 using the Consumer Price Index. We performed t-tests and chi-square tests for continuous and categorical variables, respectively. Significance was considered at p < 0.05. In all, 12,112 applicants were available in the initial cohort, and 67% (8170 of 12,112) of applicants with complete data were included from 2011 to 2021 in the final study cohort. Of these, 18% (1510 of 8170) were women, 14% (1114 of 8170) were classified as underrepresented minorities, and 8% (643 of 8170) were classified as socioeconomically disadvantaged. Sixty-one percent (4969 of 8170) of applicants reported receiving at least one scholarship, 34% (2746 of 8170) had premedical school debt, and 72% (5909 of 8170) had any educational debt including medical school. Among all applicants, the median (IQR) educational debt was USD 197,000 (25,000 to 288,000). Among those with scholarships, the median amount was USD 25,000 (9000 to 86,000). RESULTS: After controlling for the potentially confounding variables of gender and socioeconomic disadvantage, classification as an underrepresented minority applicant was independently associated with higher scholarship amounts than applicants characterized as not underrepresented minorities (ß = USD 20,908 [95% confidence interval (CI) 15,395 to 26,422]; p < 0.001), whereas underrepresented minority classification was not independently associated with a difference in total educational debt (ß = USD 3719 [95% CI -6458 to 13,895]; p = 0.47). After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with higher scholarship amounts (ß = USD 20,341 [95% CI 13,300 to 27,382]; p < 0.001) and higher total educational debt (ß = USD 66,162 [95% CI 53,318 to 79,006]; p < 0.001) than applicants not classified as socioeconomically disadvantaged. After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with decreased match rates (OR 0.62 [95% CI 0.52 to 0.74]; p < 0.001). CONCLUSION: These findings underscore the need for comprehensive scholarship initiatives to ensure equitable financial accessibility for applicants from all backgrounds. CLINICAL RELEVANCE: In the future, orthopaedic surgery may benefit from research comparing the effectiveness of various initiatives aiming to improve fairness in the burden of debt among applicants to orthopaedic surgery residency programs.

Equal pay for equal work: Disparities in compensation in vascular surgery.

Physician compensation varies by specialty, gender, race, years in practice, type of practice, location, and individual productivity. We reviewed the disparities in compensation regarding the variation between medical and surgical specialties, between academic and private practice, between gender, race, and rank, and by practice location. The physician personal debt perspective was also considered to quantify the effect of disparities in compensation. Strategies toward eliminating the pay gap include salary transparency, pay equity audit, paid parental leave, mentoring, sponsorship, leadership, and promotion pathways. Pay parity is important because paying women less than men contributes to the gender pay gap, lowers pension contributions, and results in higher relative poverty in retirement. Pay parity will also affect motivation and relationships at work, ultimately contributing to a diverse workforce and business success. Rewarding all employees fairly is the right thing to do. As surgeons and leaders in medicine, establishing pay equity is a matter of ethical principle and integrity to further elevate our profession.

Perceptions of the Educational and Institutional Impact of the Orthopaedic Fellowship Interview Process.

INTRODUCTION: The time spent applying and interviewing for an orthopaedic fellowship has notable financial, educational, and workflow consequences on both residents and their respective residency programs. The purpose of this study was to assess the perceptions regarding the fellowship interview process to suggest changes that could be implemented. METHODS: Mixed-response questionnaires were sent to orthopaedic surgery residency program directors (PDs) and PGY-4 to PGY-6 residents at the 164 accredited allopathic orthopaedic surgery residency programs in the United States (August 2017). RESULTS: Significantly more PDs believed that time away for fellowship interviews negatively affected resident education compared with residents (68% versus 25%, 48 of 65 versus 28 of 113; P < 0.001). About half of all PDs and residents noted a specific amount of time granted for interviews (range, 3 to 20 days). Seventy-one percent of residents included in this study would favor regionally coordinated interview dates. CONCLUSIONS: Orthopaedic surgery residents and PDs perceive differences in the impact of the fellowship interview process on resident education and means for improvement of the process. Two-tiered or regionally coordinated interviews are favored as changes that could be implemented.

The gender differences in highly paid wage: a case study of Peruvian physicians / Las diferencias de género en los sueldos de mejor remuneración: el estudio de caso de los médicos peruanos / Diferenças de gênero em salários altos: um estudo de caso de médicos peruanos

Abstract: In recent decades, the number of women pursuing careers in health has significantly increased. However, the physician labor market is still characterized by gender differences regarding payment. Using a nationally representative Peruvian sample of health providers (3,219 male and 1,063 female physicians), we estimated the gender gap in the likelihood of earning high wages for physicians and decomposed this gap in a proportion related to differences in individual characteristics (e.g. specialty, labor experience), and a residual proportion related to differences in returns to these characteristics. Our main results reveal that male physicians have on average an 81% higher likelihood of earning high salaries (monthly earning level > 5,000 PEN) relative to their female counterparts. Further, the main proportion of this gap is associated to the unexplained component (among 57% and 77%, according to the model specification), which may be associated to unobservable characteristics and discrimination in the Peruvian labor market.

Resumen: En décadas recientes, el número de mujeres realizando su carrera en el ámbito de salud se ha incrementado significativamente. No obstante, el mercado laboral de los médicos está todavía caracterizado por diferencias de género respecto a los salarios. Utilizando una muestra peruana nacionalmente representativa de proveedores de salud (3.219 hombres y 1.063 mujeres médicos), estimamos la brecha de género en la probabilidad para los médicos de ganar sueldos altos y la desglosamos según los porcentajes vinculados a las diferencias relacionadas con las características individuales (p.ej. especialidad, experiencia laboral) y un porcentaje residual vinculado a las diferencias relacionadas con estas características. Nuestros resultados principales revelaron que los médicos hombres contaban en promedio con un 81% mayor probabilidad de ganar sueldos más altos (nivel mensual de renta > 5.000 PEN) frente a sus compañeras mujeres. Asimismo, gran parte del porcentaje de esta brecha está asociado a un componente inexplicable (entre un 57% y un 77%, según la especificación del modelo), lo que tal vez esté relacionado con las características no observables y la discriminación en el mercado laboral peruano.

Resumo: Nas últimas décadas, o número de mulheres atuando em carreiras da saúde aumentou significativamente. Contudo, o mercado de trabalho médico continua caracterizado por diferenças de gênero nos salários. Usando uma amostra nacional representativa de profissionais da saúde peruanos (3.219 médicos e 1.063 médicas), nós estimamos a diferença de gênero na probabilidade de receber altos salários para médicos e decompomos essa diferença em uma proporção relacionada a diferenças em características individuais (p.ex.: especialidade, experiência profissional) e uma proporção residual relacionada a diferenças de retornos dessas características. Nossos resultados principais revelam que os médicos têm, em média, uma probabilidade 81% maior de receber salários altos (nível de rendimentos mensais > 5.000 PEN) em relação às médicas. Adicionalmente, a principal proporção dessa diferença está associada ao componente não-explicado (entre 57% e 77%, de acordo com a especificação do modelo), o que pode estar associado a características não-observadas e discriminação no mercado de trabalho peruano.

How Much Are We Spending on Resident Selection?

INTRODUCTION: Rigorous selection processes are required to identify applicants who will be the best fit for training programs. This study provides a national snapshot of selection practices used within surgical residency programs and their associated financial costs. METHODS: A 17-item online survey was distributed to General Surgery Program Directors (PDs) via the Association of Program Directors in Surgery listserv. The survey examined program characteristics, applicant pool size, and interview day components of the prior match year. PD/coordinator teams also provided hard costs associated with interview day components, as well as time and effort estimations among program faculty, residents, and staff during the past interview season. Effort estimates were translated to dollar values via national salary data reports of hourly wages for faculty and annual wages for administrative staff and residents. Descriptive statistics and one-way analysis of variance via SPSS 24.0 were used to examine the data. RESULTS: One-hundred and twenty-eight responses were received, reflecting 48% (128/267) of programs in the 2017 match. Average hard costs (±SD) were $8053 ± 6467, covering food ($3753 ± 4042), social sessions ($3175 ± 3749), supplies ($329 ± 866), hotel ($328 ± 1381), room reservations ($120 ± 658), shuttle fees ($84 ± 403), tour guide fees ($50 ± 379), and other ($146 + 824). Costs for personnel effort was $77,601 ± 62,413 for faculty, $12,393 ± 33,518 for residents, $6447 ± 11,107 for coordinators, and $1294 ± 1943 for staff. Total average cost associated with the interview process (hard + effort) was $100,438±87,919, with university-based programs ($128,686 ± 101,565) spending significantly more than independent-university affiliated ($61,162 ± 33,945), independent ($74,793 ± 73,261), and military ($62,495 ± 38,532) programs (p < 0.01). Average cost for each residency program per position being filled was $18,648 ± 13,383, and average cost per interviewee was $1221 ± 894. CONCLUSIONS: In an era of declining resources for medical education, PDs must understand the time and effort associated with resident selection. These data reveal that residency programs are spending significant time and resources on the current selection process. Program leaders can use these data to assess their current selection strategies, review faculty and staff time allocation, and identify opportunities for making the process more efficient.

Analysis of Gender-based Differences in Surgery Faculty Compensation, Promotion, and Retention: Establishing Equity.

OBJECTIVES: The objectives of this study were to evaluate gender-based differences in faculty salaries before and after implementation of a university-wide objective compensation plan, Faculty First (FF), in alignment with Association of American Medical Colleges regional median salary (AAMC-WRMS). Gender-based differences in promotion and retention were also assessed. SUMMARY BACKGROUND DATA: Previous studies demonstrate that female faculty within surgery are compensated less than male counterparts are and have decreased representation in higher academic ranks and leadership positions. METHODS: At a single institution, surgery faculty salaries and work relative value units (wRVUs) were reviewed from 2009 to 2017, and time to promotion and retention were reviewed from 1998 to 2007. In 2015, FF supplanted specialty-specific compensation plans. Salaries and wRVUs relative to AAMC-WRMS, time to promotion, and retention were compared between genders. RESULTS: Female faculty (N = 24) were compensated significantly less than males were (N = 62) before FF (P = 0.004). Female faculty compensation significantly increased after FF (P < 0.001). After FF, female and male faculty compensation was similar (P = 0.32). Average time to promotion for female (N = 29) and male faculty (N = 82) was similar for promotion to associate professor (P = 0.49) and to full professor (P = 0.37). Promotion was associated with significantly higher retention for both genders (P < 0.001). The median time of departure was similar between female and male faculty (P = 0.73). CONCLUSIONS: A university-wide objective compensation plan increased faculty salaries to the AAMC western region median, allowing correction of gender-based salary inequity. Time to promotion and retention was similar between female and male faculty.

The Orthopaedic Surgery Residency Application Process: An Analysis of the Applicant Experience.

INTRODUCTION: Orthopaedic surgery residency positions are highly sought after. The purpose of this survey study was to report the following components of the applicant experience: (1) the number of programs to which applicants applied and interviewed, (2) the performance criteria associated with receiving interviews, (3) the way applicants respond to e-mail interview offers, (4) the pre- and post-interview communication between applicants and programs, (5) the importance of interview day activities and the determinants of the applicant rank order list (ROL), and (6) the financial cost of the application process. METHODS: An online survey was administered and entirely completed by a representative sample of 100 orthopaedic surgery residency applicants for the 2015 to 2016 cycle during the 3-week period between the last interview of the application season and the deadline for ROL certification. The survey included 45 questions: 7 for background, 7 for competitiveness, 15 for the interaction between applicants and programs, 15 for the importance of interview day experience and the determinants of the applicant ROL, and 1 for the cost of attending each interview. RESULTS: Students applied to 83 ± 27 programs, received 17 ± 10 interviews, and attended 12 ± 5 interviews. Interview offers correlated with, in descending order, Alpha Omega Alpha status, Step 2 Clinical Knowledge, and Step 1. The mean time to reply of interview offer was 17 minutes, yet 25% of the applicants lost at least one interview despite having at least one other person monitor the applicant's e-mail account. Applicants and programs frequently contacted each other to express interest. Although evaluating current residents was the most valuable aspect of interview day to applicants, the strongest determinants for applicants' ROLs were location and surgical experience, with research the least important factor. The cost of interview season was >$7,000 per applicant, excluding away externships. CONCLUSION: Applying to orthopaedic surgery residency is a complex, competitive, and costly experience for applicants. The application process may benefit from better expectation management of applicant candidacy and a more prohibitive communication policy between applicants and programs after the interview day.

Current Interview Trail Metrics in the Otolaryngology Match.

Objectives To identify how applicants to otolaryngology residency determine how to apply to, interview with, and rank programs on the interview trail and to determine the extent of the financial burden of the otolaryngology interview trail. Study Design Web-based survey distributed in March and April 2016. Setting Otolaryngology residency applicants throughout the United States. Subjects and Methods Applicants to otolaryngology residency during the 2016 match cycle and current otolaryngology residents were surveyed. Results Median number of applications, interview offers, interviews attended, and programs ranked was not different during the 2016 match and the previous 5 match years. The most important factor affecting the number of applications was the need to apply widely to ensure sufficient interview offers. The most common reason for declining an interview offer was scheduling conflict. Applicants during the 2016 match spent a median of $5400 applying and interviewing for otolaryngology residency. Conclusions Median number of applications, interview offers, interviews attended, and programs ranked has not changed. The most cited reason for applying to many programs was to increase the chances of matching, but this is not statistically likely to increase match success. We advocate for continued attempts to make the otolaryngology match process more transparent for both applicants and resident selection committees, but recognize that applicants are likely to continue to overapply for otolaryngology residency positions.

Digging into Debt: The Financial Burden Associated with the Otolaryngology Match.

Objective To quantify the cost incurred during the match process for otolaryngology applicants, determine sources of expenditures, and highlight potential methods to alleviate financial burden of the match process. Study Design Cross-sectional. Study Setting Online survey. Subjects and Methods An electronic survey was sent via email to those who applied to the otolaryngology residency programs at Dartmouth-Hitchcock Medical Center and MedStar Georgetown University Hospital during the 2016 application cycle. Questions regarding demographics and experiences with the match were multiple choice, and questions regarding cost were open answer. Data were downloaded and analyzed on Excel and Minitab software. Results Twenty-eight percent of the total 370 applicants completed the survey. The mean cost of away rotations was $2500 (95% confidence interval [CI], $2224-$2776). With application fees and the cost of interviewing, the mean total cost of applying for the 2016 otolaryngology match was $6400 (95% CI, $5710-$7090), with a total range of $1200 to $20,000. Twenty-eight percent of students did not have sufficient funds for applying and interviewing despite seeking out additional monetary resources. Conclusion In 2016, otolaryngology applicants spent a mean of $8900 (95% CI, $7935-$9865) on away rotations, applications, and interviewing. Half of the applicants obtained additional funding to cover this cost, while 28% still did not have sufficient funding. Methods of decreasing cost may include instituting a cap on application number, videoconferencing interviews, regionalizing interviews, and adjusting the interview timeline.

Away Rotations and Matching in Integrated Plastic Surgery Residency: Applicant and Program Director Perspectives.

BACKGROUND: Although nearly all medical students pursuing integrated plastic surgery residency participate in elective rotations away from their home medical school, the value and costs of these "away" rotations have not been well studied. METHODS: The authors surveyed all integrated plastic surgery program directors and all applicants in the 2015 National Residency Matching Program. RESULTS: Forty-two program directors and 149 applicants (64 percent and 70 percent response rate, respectively) completed the survey. Applicants reported 13.7 weeks spent on plastic surgery rotations during medical school, including a mean of 9.2 weeks on away rotations. Average reported cost for away rotations was $3591 per applicant. Both applicants and program directors most commonly reported "making a good impression" (44.6 percent and 36.6 percent, respectively) or finding a "good-fit" program (27.7 percent and 48.8 percent, respectively) as the primary goal for away rotations. Almost all applicants (91.1 percent) believed an away rotation made them more competitive for matching to a program at which they rotated. Program directors ranked a strong away rotation performance as the most important residency selection criterion. Twenty-seven percent of postgraduate year-1 positions were filled by an away rotatorm and an additional 17 percent were filled by a home medical student. CONCLUSIONS: Away rotations appear to be mutually beneficial for applicants and programs in helping to establish a good fit between students and training programs through an extended interaction with the students, residents, and faculty. In addition, making a good impression on a senior elective rotation (home or away) may improve an applicant's chance of matching to a residency program.

Health care institutions should not exclude smokers from employment.

Some health care institutions, including academic health centers, have adopted policies excluding smokers from employment. Claims advanced on behalf of these policies include financial savings from reduced health costs and absenteeism as well as advantages consonant with their message of healthy living. The authors suggest that the institutional savings from these policies are speculative and unproven. Also, in settings where large medical schools operate, it is likely to be the poor, including members of minority groups, who, under an employee smoker ban, will lose the opportunity to work for an employer that offers health insurance and other benefits. In response to the incentives created by such bans, some will quit smoking, but most will not. Thus, at the community level, employee smoker bans are more likely to be harmful than beneficial.Although private businesses may rightly choose not to hire smokers in the 19 states where such policies are legal, health care institutions, including academic health centers, should consider hiring choices in light of the values they profess. The traditional values of medicine include service to all persons in need, even when illness results from addiction or unsafe behavior. Secular academic communities require a shared dedication to discovery without requiring strict conformity of private behavior or belief. The authors conclude that for health care institutions, policies of hiring smokers and helping them to quit are both prudent and expressive of the norms of medical care, such as inclusion, compassion, and fellowship, that academic health professionals seek to honor.

Academic plastic surgery: faculty recruitment and retention.

BACKGROUND: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. METHODS: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. RESULTS: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. CONCLUSIONS: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.

Anesthesiology critical care medicine: a fellowship and faculty recruitment program.

STUDY OBJECTIVE: To review national data on anesthesiology critical care medicine (ACCM) fellowship program enrollment and to describe a program that successfully recruited ACCM fellows and faculty at a single academic medical center. DESIGN: An incentive program known as the Mayo Clinic Scholar program, designed to recruit ACCM fellows and faculty, was reviewed. Interviews were conducted to assess the impact of the Mayo Clinic Scholar program. SETTING: Academic health center. MEASUREMENTS: ACCM fellowship program enrollment data were compared with similar data for critical care medicine fellowship programs in internal medicine, pulmonary medicine, pediatrics, and surgery.The results of a program to recruit ACCM fellows and faculty were reviewed. MAIN RESULTS: Only 89 of 147 (60.5%) ACCM fellowship positions available nationally were filled during the 2010-2011 academic year, and only 89 of the 896 (9.9%) critical care medicine fellows anticipated to graduate in 2011 were in ACCM programs. The Mayo Clinic ACCM fellowship enrolled 28 fellows from January 1, 2000 through July 1, 2010 (range 0-6 per yr). Ten of the 28 (35.7%) were United States medical graduates (USMGs) and 6 of the 10 (60.0%) USMGs who were graduates of the Mayo Clinic residency were appointed as Mayo Clinic Scholars. All 6 Mayo Clinic Scholars were retained as ACCM faculty. Only two of the 6 (33.3%) Mayo Clinic Scholars would have completed ACCM training without a Mayo Clinic Scholar appointment. All recommend ACCM training to others and plan to continue to practice ACCM. CONCLUSIONS: The Mayo Clinic Scholar program effectively recruited ACCM fellows and faculty in a single institution. Incentive-based programs should be considered to support the involvement of anesthesiologists in perioperative medicine.

Levantamento do custo do processo admissional de técnico de enfermagem de um hospital de ensino / Survey on the cost of the admission process of nursing technicians in a teaching hospital

Este estudo teve como objetivo contribuir para a gestão de custo do processo admissional de técnicos de enfermagem pelo mapeamento e mensuramento do custo direto das principais atividades desse processo. O estudo exploratório, retrospectivo, documental, na modalidade de estudo de caso foi realizado no Serviço de Apoio Educacional do Hospital Universitário da Universidade de São Paulo. O processo admissional foi dividido em cinco subprocessos: planejamento, recrutamento, seleção, contratação e treinamento admissional. Os resultados mostraram que o custo total direto do processo admissional foi de R$ 6.359,90 e o subprocesso seleção foi o que mais consumiu recurso, com R$ 3.416,40, representando R$ 53,72 por cento do total. Cada candidato contratado custou R$ 635,99.

This study was aimed at contributing to the cost management of the admission process of nursing technicians by mapping and measuring the direct cost of the main activities in this process. The exploratory, retrospective, documental study on the modality of case study was carried out at the Educational Support Service of the University of São Paulo's Hospital Universitário. The admission process was divided into five sub-processes: planning, recruiting, selection, hiring and admission training. Results showed that the direct total cost of the admission process was R$ 6,359.90, and that, within the sub-processes, selection was the one that consumed most resources - R$ 3,416.40, amounting to 53.72 percent of the total. Each hired candidate cost R$ 635.99.

Este estudio tiene como objetivo contribuir para la gestión de costo del proceso ad misional de técnicos de enfermería por el mapa y medición del costo directo de las principales actividades de ese proceso. El estudio exploratorio, retrospectivo, documental, en la modalidad de estudio de caso fue realizado en el Servicio de Apoyo Educacional del hospital Universitario de la Universidad de São Paulo. El proceso ad misional fue dividido en cinco subprocesos: planeamiento, reclutamiento, selección, contratación y entrenamiento ad misional. Los resultados muestran que el costo total directo del proceso ad misional fue de R$ 6.359,90, el sub-proceso de selección fue el que más consumió recurso con R$ 3.416,40 representando R$ 53,72 por ciento del total. Cada candidato contratado costó R$ 635,99.

[The underpaid nursing profession: myth or reality]. / La profession infirmière sous payée: mythe ou réalité.

The originality of this research lies in its object, nurses salaries, a subject that is often discussed amongst professionals, yet rarely broached in writing. The concepts of salaries and salaried workers are examined, then, through literature, a list of salary data from 1845 to 1945 is made. The study of nursing personnel salaries from 1945 to 2001 begins with a reconstruction of salary charts, continuing with an internal analysis of the private and semi-public sector, then alternatively with the teachers. This work provides objective information on the aspect of this profession's salaries and uncovers numerous questions on the origins of wage increases.