Two months ago, I celebrated Match Day with my medical school classmates. We learned where we will train as resident physicians after graduation. Upon opening their envelopes, some students leapt with excitement. Our families beamed with pride.
Yet soon after the festivities ended, words of caution began to flood in. Faculty members grinned as they told us to rest up. A colleague quipped, “Enjoy your freedom while it lasts.”
Residency is a difficult time in a new doctor’s life. After graduating from medical school, residents generally train for three to seven years in order to practice in their chosen specialties. The workloads are notoriously grueling. At the nation’s teaching hospitals, residents often provide the bulk of patient care, working up to 80 hours per week.
These years can also be tough financially. The costs of medical school and college have soared, so most residents now face hefty educational debts upon graduation—according to the American Association of Medical Colleges, 81% of physicians graduate with an average educational debt of over $180,000. Meanwhile, resident salaries haven't changed since the 1970s when adjusted for inflation.
And there’s no way around residency. Students in other professions like law, business, dentistry, and veterinary medicine can set up shop right after graduation. But, if medical students wish to ever practice, they have to go through residency programs first.
All of this has led columnists to compare residency training to hazing, working for Walmart, abuses in Chinese factories, and indentured servitude.
But are these fair comparisons?
Residents have the privilege of taking care of patients and enjoy stable professional trajectories, earning comfortable incomes after completing their training. During this period, residents receive many benefits in addition to their salaries, such as health insurance or housing stipends. Residency programs also carry academic privileges, including teaching activities, mentorship, and research opportunities.
In 2002, this question attracted national attention when former residents filed a class-action lawsuit against medical organizations and teaching hospitals, accusing them of colluding to control labor conditions and violating antitrust laws. Amidst widespread media coverage, the debate soon reached policymakers in Washington, D.C. But Congress granted an explicit antitrust exemption to these medical institutions, effectively ending the suit.
This issue of residency work conditions has since regained prominence after several high-profile suicides in recent years. In response, the medical community has sought to improve residents’ lives by developing wellness programs, emphasizing work-life balance, and cracking down on workplace abuse.
Teaching hospitals can do more to alleviate the burdens of residency training. For example, last year, physicians at Columbia University and New York University published a set of guidelines as to how residency programs might promote mental health among new doctors. These recommendations include screening trainees for depression and expanding mental health treatment options.
Further legislative reforms can also help.
We should expand the number of nationwide residency slots. Congress, which helps finance residencies through Medicare, has capped the number of federally funded residency positions since 1997. But this cap doesn’t account for the millions of newly insured individuals under the Affordable Care Act, as well as the steady growth and aging of the country's population. Lifting this cap would decrease resident workloads, address looming physician shortages, and ease the strains on our overburdened healthcare system.
We can reform duty hour reporting. National regulations limit residents to 80-hour workweeks, but that isn’t always the reality. Nearly half of residents admit to falsifying their reported work hours, oftentimes to avoid backlash from superiors. Residents must be able to report duty hours anonymously. This would help gather more accurate data on resident work habits and ensure residency programs adhere to these regulations.
Residents also need help with their growing educational debts. Until 2009, residents meeting specific financial criteria could apply for economic hardship status through the “20/220 pathway”, which allowed them to defer debt payments during training. However, Congress eliminated this option in favor of income-based repayments. Many residents cannot even afford these small payments though. We need to reinstitute the 20/220 pathway and widen the availability of loan deferment opportunities for residents.
Lastly, medical students and residents should be more involved in decision-making surrounding graduate medical education. In 2014, Dr. Jacob Sunshine, then a second-year resident, wrote in Slate, “What we seek, above all, is an ongoing voice in the system.” He’s right. Whether this entails positions on legislative committees or better representation in teaching hospital leadership, physicians-in-training deserve a seat at the table.
Residents are part of the backbone of our healthcare system. They devote their lives to caring for patients and shouldn’t be driven to suicide by their training. By improving working conditions during residency, we can help heal—rather than harm—our next generation of doctors.