How could it be possible for limits on work hours to not lead to less work? Most fundamentally, duty-hour restrictions did nothing to reduce the overall workload of residents, meaning the reforms simply require residents to do the same amount of work in less time. Or as the ACGME spokesperson put it, “ACGME requirements … outline the local institutions’ [minimum] responsibilities” to residents, but ultimately “resident pay, benefits, and working conditions are the responsibility of the local institution.” (It should be noted, moreover, that the ACGME is not involved in the design or implementation of the match.)
This problem of “work compression” arose independent of the ACGME’s reforms, as medical staffing has generally not kept pace with the rising burden on the nation’s health-care system. For example, the number of patients admitted at teaching hospitals rose 46 percent from 1990 to 2010, a period during which the number of residency spots increased only 13 percent. Accordingly, as the doctors and researchers Lara Goitein and Kenneth Ludmerer have noted, “by the time ACGME restrictions were implemented, residents were already doing much more, in less time and for more and sicker patients, than were previous generations” of doctors.
It is therefore no wonder that duty-hour restrictions are often honored in the breach. Residents are regularly expected to (and frequently do) work beyond their allotted shifts, with up to 83 percent of them saying that they are either unable or unwilling to comply fully with the rules. Non-compliance is so widespread that medical experts openly fret that duty-hour restrictions may be “promoting a culture of dishonesty” among doctors, given that large majorities of surveyed residents admit they falsely under-report their hours to their programs and the ACGME.
Less obvious is that the hourly caps only pertain to time spent physically in the hospital or clinic—meaning they do not account for the many responsibilities residents must now often complete on their own time. These tasks, which can add up to several hours a day or more, include taking notes on patient visits, filing reports on patient deaths and other adverse events, conducting independent research to aid in diagnosis and treatment, preparing for patient visits and unfamiliar clinical rotations, complying with training and academic-research obligations, and assisting remotely with patient-specific issues that arise after one’s shift. Combined with technological advances that have facilitated working from home, it seems the new rules merely transferred much of a resident’s work from the hospital to the living room.
If industry self-regulation has thus far proved less than fully successful in moderating the excesses of medical training, could unions help? A 1999 ruling from the National Labor Relations Board determined that residents are “employees,” not students, under federal law and therefore may unionize. Nevertheless, union membership among residents remains low—hovering between 10 and 15 percent since the 1999 ruling. And while some resident unions have succeeded in winning small, appreciable improvements in pay, benefits, and working conditions, structural barriers prevent them from having a major impact on reform: Residents are physicians in training, at the conclusion of which they are freed from the strictures of this controlled labor market. The only way to become a fully-fledged medical doctor is to set aside complaints, sign the contract, and move on. There is little incentive to invest time, money, and energy in organizing when the end is near.