It's a common image in pop culture: the packed ER waiting room, the patient anxiously waiting to be seen, and the overworked resident who hasn't had a full night's rest in days, rushing from patient to patient. Enter the handsome love interest, the ex-boyfriend, his ex-wife, and the hospital-wide crisis to propel the plot forward.
Perhaps the average medical resident isn't dealing with deep romantic tension in their everyday professional life, but the working conditions depicted aren't entirely inaccurate. In fact, in a shocking diversion from the norm, this nameless medical drama is more often than not underdramatizing the environment in which medical residents are expected to work. The popular "teaching" method of overworking residents in the hopes that they'll learn proper patient care is not just harmful to physicians, but patients as well. The archaic tradition is not a necessary evil, but rather a systemic failure of the medical field that can and must be rectified.
Harm to Physicians and Patients
Under current regulations, the conditions imposed on medical residents border on inhumane. Working hours are capped at 80 hours per week, with 28 hour shifts being not only permitted but commonplace. These regulations have been maintained despite research increasingly showing that chronic sleep deprivation is responsible for a host of physical and mental health problems. In fact, healthcare workers are at a higher risk for psychiatric and substance use disorders, a risk which shows no signs of being addressed by healthcare facilities. Even discounting the long-term impacts of sleep deprivation, the immediate effects of an extended period without sleep are similar to that of alcohol intoxication, making these long shifts a liability for hospitals and a risk for patients.
The inevitable result of these conditions– high workloads, long hours, health risks– is burnout, which can lead to consistent exhaustion, a low sense of personal satisfaction, and lower effectiveness in professional life. Typically, burnout leads to much higher turnover rates at hospitals and fewer patients receiving care. . The combination of decreased access to and quality of care poses a large-scale public health risk that the vast majority of the American public deems unnecessary.
Origin and Continuation of American Residency Programs
The clear drawbacks of residency programs begs the question of why they have persisted for so long. To answer this, we must take a look into their origin story and, more specifically, the story of one Dr. William Stewart Halstead.
In the late 19th century, Halstead founded a training program for recently-graduated medical students at Johns Hopkins University, one that emphasized rigor and a pyramidal hierarchy that encouraged intense competition between residents. He expected nothing but the best from his students, and insisted on long hours and a distant teaching style to allow self-driven learning.
While many of his students left the program, those that completed it argued its success in training competent physicians, and the practice eventually became the standard throughout America.
An important note about Dr. Halstead is that, throughout his career, he was functioning with substance use disorder. The long, intense hours he had been able to work as a young physician, which he expected other new doctors to work as well? Fueled by a cocaine habit that had started early in his career. The pyramidal, competitive training hierarchy that he stood by? Conveniently, it also allowed him to step back from active practice while more advanced residents handled much of the education of more recent graduates; this worked to hide the symptoms of the morphine dependency he developed later in life. Despite the praises of the medical community, his system that became the basis for medical education in the U.S. was seemingly not created to best serve future physicians or patients.
Despite this, the structure of residency in the U.S. values the same intense workloads that Halstead did. The continuation of this structure likely also has another motivating factor: money. Medical residency programs in the U.S. are funded by Medicare, which provides a stipend for hospitals to take on a set number of residents. This set number was created in 1999, at a time when the American Medical Association was warning against a potential "oversupply" of physicians (because access to medical care must be a scarce resource in order to be economically beneficial, never mind the human cost), and has only slightly fluctuated in the following years. Since that time, the U.S. population has grown by over 70 million, and the AMA now warns of a severe shortage of doctors, the impacts of which were felt most during the COVID-19 pandemic.
Solutions
Despite the deep-rooted nature of the “hustle culture” in medical residency, the solution to this problem is fairly simple. The two major factors that result in the harsh working conditions of medical residency are a lack of funding and a lack of regulation; substantial efforts to improve both these fields should therefore lead to positive change. By increasing funding to allow for more residency positions for graduating medical students— who currently vastly outnumber program availability— and increasing regulations to limit how many hours physicians may work in a row, significant strides may be made in supporting a safer hospital environment for patients and staff alike. Such strategies have shown promise in countries like the U.K., where shifts are capped at 8 hours, and Australia, where shifts over 10 hours are deemed a source of risk. In both countries, healthcare as a whole— not just residency programs— is fully subsidized by the government. This method of training future physicians has proven to be successful: Australia is reported to have some of the best healthcare in the world, while the United States lists medical errors as the country's third leading cause of death. Despite the relative straightforwardness of this solution, creating change will require significant public outrage and involvement with organizations like the American Medical Association, as well as the federal government.
The expectations of medical residents in America are abhorrent, yet continue to be treated as the standard despite substantial evidence of the harm they cause to patients and doctors. While the U.S. culture has made residency seem like a necessary burden, it is certainly not the only way to train competent physicians. With broader public awareness and outrage at this risk to both doctors and patients, we can enact significant change. The overworked and sleep-deprived heroine of our favorite medical drama can become what she should always have been: a dramatization. Residents beginning their medical careers should be inspired and encouraged to care for others without risking their own health and livelihood in the process.