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.”) Read the whole article here.