The path to becoming a doctor is notoriously difficult. Following pre-med studies and four years of medical school, freshly minted M.D.s must spend anywhere from three to seven years (depending on their chosen specialty) training as “residents” at an established teaching hospital. Medical residencies are institutional apprenticeships—and are therefore structured to serve the dual, often dueling, aims of training the profession’s next generation and minding the hospital’s labor needs.
How to manage this tension between “education and service” is a perennial question of residency training, according to Janis Orlowski, the chief health-care officer of the Association of American Medical Colleges (AAMC). Orlowski says that the amount of menial labor residents are required to perform, known in the profession as “scut work,” has decreased "tremendously" since she was a resident in the 1980s. But she acknowledges that even "institutions that are committed to education … constantly struggle with this,” trying to stay on the right side of the boundary between training and taking advantage of residents.
Despite improvements brought about by the good-faith efforts of the AAMC and other organizations, the physical and emotional demands on residents remain without parallel in the modern American economy. Some of these pressures are inherent in the nature of the profession: Most people cannot imagine a workday mental lapse or error in judgment depriving another of their hearing, brain functioning, or even life. But those in the medical profession are expected to swallow hard, cry it out, and be back the next morning for their 6 a.m. shift.
Other demands are less easily explicable. Residents in America are expected to spend up to 80 hours a week in the hospital and endure single shifts that routinely last up to 28 hours—with such workdays required about four times a month, on average. (Some licensed physicians continue to work similar schedules even after residency but, importantly, only because they choose to do so. The vast majority of doctors work fewer than 60 hours a week after they complete their training.) Overall, residents typically work more than twice as many hours annually as their peers in other white-collar professions, such as attorneys in corporate law firms—a grueling schedule that potentially puts both caregivers and patients at risk. In Europe, by contrast, residents are subject to a maximum workweek of 48 hours, without apparent harm to patient care or the educational component of residencies.
Part of the reason medical training is so demanding in the United States is that hospitals control the labor market for residents by assigning spots based on a centralized matching system rather than an ordinary, competitive market. While such collusive arrangements are generally prohibited by the nation’s antitrust laws, employer-controlled labor markets are not uncommon. Just as an enterprising entrepreneur cannot form an independent baseball team and challenge the Yankees for a spot in the A.L. East, an aspiring doctor has no legal right or ability to negotiate the terms of his or her entrée into the medical profession. Instead, the sole avenue to being a fully licensed medical doctor in the United States is by submitting to what is known as “the match.”
Considered on its own terms, the match seems fair. It gives principal consideration to medical students’ stated preferences, and is governed by a mathematical algorithm so efficient that its designers won a Nobel Prize in Economics. Moreover, the original purpose of the system was to improve the bargaining power of medical students vis-a-vis residency programs. “The match was created in 1952 to eliminate the pressure that was being placed on medical students to accept offers earlier and earlier during medical school, and typically before the students knew what other offers might be available,” explains Mona Signer, the president and CEO of the National Resident Matching Program (NRMP), which administers the match. Signer therefore dismisses the notion that the match harms residents. Instead, she says, it “creates order out of chaos,” to the benefit of both institutions and the residents they employ. (She further notes that the NRMP itself “does not take any position on the salaries and benefits received by residents in training.”)
But creating order out of the chaos of a free labor market also contributes to industry norms of punishing hours and low pay, by restricting competition among employers that could result in better wages and working conditions. For this reason, a group of residents brought a lawsuit in 2002 challenging the match as an illegal “contract ... or conspiracy, in restraint of trade or commerce” in violation of the federal antitrust laws. Legal niceties aside, it is hard to argue with this general characterization of the match. If, say, fast-food workers or stock-market analysts were subject to a similar arrangement, most would view it as a clear affront to free enterprise and workers’ rights. Under lobbying from the AAMC, among others, Congress disagreed. After a federal district court initially ruled that the match might be an illegal restraint on trade, Congress immediately enacted legislation immunizing medical training programs from antitrust liability.
While residency-program administrators no doubt take their educational obligations seriously, residents are also a cheap source of skilled labor that can fill gaps in coverage. They are paid a fixed, modest salary that, on an hourly basis, is on par with that paid to hospital cleaning staff—and even, on an absolute basis, about half of what nurse practitioners typically earn, while working more than twice as many hours.* After adjusting for inflation, residents’ salaries have remained essentially unchanged for the last 40 years.
However, the evidence is mixed as to whether the match is responsible for depressing residents’ salaries. In ranking programs, as Signer of the NRMP points out, most medical students are mainly concerned with prestige and the quality of training, not money. One 2015 study showed, for example, that even without the match, residents would still earn far less than their true market value—which is estimated to be about double what they presently earn—because they, in effect, accept a pay cut for high-quality medical training and a prestigious residency placement. Similar preferences are observed in other labor markets for professional training—for example, law clerks working under judges—in which the long-term career benefits outweigh any temporary earnings hit. Accordingly, it is not clear whether the free market would necessarily yield better resident pay.
Working conditions, though, are another matter. Residents work exceptionally long hours and are subject to unrivaled physical and psychological demands. And it used to be worse. In 2003, the Accreditation Council for Graduate Medical Education (ACGME), the governing body for medical-training programs, introduced “duty hour” restrictions that, among other things, capped the average number of hospital hours per week at 80 (meaning one week can be 100 hours if the next is 60) and limited single shifts to 30 hours. The ACGME established further restrictions in 2011 which, among other things, reduced the maximum shift lengths to 16 hours for first-year residents (otherwise known as interns) and 28 hours for more experienced residents. These reforms appeared to substantially relax the extreme nature of medical training. Before, it was routine for residents to spend 100 or even 120 hours a week in the hospital (and, yes, there are only 168 hours in a week), with single shifts stretching to 48 hours and beyond. Grumbling by the old guard aside, most in the profession agreed this system was abusive, outdated, and in need of replacement.
But looking closely at the effects of the new rules, it is unclear how much residents’ working lives have really changed. Averaging 80-hour workweeks and regularly putting in 28-hour shifts is still brutal by any measure. In fact, the evidence is mixed as to whether duty-hour reform did much of anything to reduce the number of hours residents actually work. As an ACGME spokesperson told me, ACGME-sponsored research indicates that the 2003 reforms led to large reported decreases in the average number of hours worked by residents—for example, reducing average workweeks for first-year OB/GYN residents from 90.5 hours to 78 hours. However, other surveys found that the 2003 reforms led to no change in overall work or sleep hours, and that the 2011 reforms actually made residents less satisfied with their work schedules.
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.
In addition, it seems inconceivable that residents would engage in a sustained work stoppage to force the issue. Most doctors are in medicine for the right reason—to help people. The prevailing ethos was well illustrated to me during a major blizzard on the East Coast last winter. While commerce, government, and education ground to a halt, some residents in my wife’s pediatrics program dutifully strapped on their boots and trudged for miles through two feet of snow, determined to serve their shifts, while others arrived at the hospital the night before the blizzard with pillows and toothbrushes, ready to ride out the storm. This is not a group that would compromise patient care in a labor dispute.
So this leaves government action. In response to the innumerable studies confirming that sleep-deprivation erodes virtually every aspect of people’s work performance—including judgment, motor skills, and basic reasoning—the federal government has established detailed regulations limiting the work hours of professionals entrusted with responsibility for public safety, such as pilots and nuclear-plant operators. Duty-hour restrictions were, in large part, an attempt to stave off federal regulation of this sort for medical residents. Not coincidentally, the ACGME announced the restrictions just a few months after legislation was introduced in Congress to impose strict, federal limits on residents’ hours, to be enforced by the U.S. Department of Health and Human Services. Given the limited impact duty-hour reform has had in reining in the excesses of medical training, perhaps government oversight is in order. Regulation need not be on the federal level. In 1984, in the wake of the high-profile death of an 18-year-old college student in a Manhattan emergency room staffed by overworked residents, New York state instituted the nation’s first mandatory duty-hour restrictions. And even since the 2003 reforms, several states, including Pennsylvania, Massachusetts, and New Jersey, have considered, though not enacted, more stringent rules.
Medicine enjoys the status of being the most prestigious profession in America, yet the rigor of medical training remains unduly excessive. The American public overwhelmingly supports restrictions on residents’ working hours. A recent poll conducted by an independent public-opinion survey firm found that nearly 90 percent of Americans believe residents’ shifts should be 16 hours or less, and over 80 percent of those surveyed said that they would request a new doctor if they knew their physician was on the tail end of a 24-hour shift.
If nothing else, this public consensus indicates just how out-of-step the medical profession is with the ordinary expectations placed on American workers. Much of this gulf can be attributed to a legal structure that facilitates an employer-controlled labor market for residents. But of course that legal structure can be changed. As the medical profession displayed in adopting the initial round of duty-hour restrictions in 2003, the best way to prevent government-imposed reform of an unfair system is to address the problem voluntarily. As it becomes increasingly clear that the ACGME’s reforms have been largely ineffective, the profession would do well to remember this lesson.
* This article originally misstated that residents’ salaries are half that of nurses’. we regret the error.
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