In the United States, work hours are traditionally recorded on a weekly basis, and salaries are paid every two weeks. However, full-time employees (FTEs) work for a full year and receive a W-2 annually. FTEs are usually hired based on an annual wage divided into 26 bi-weekly paychecks. Tracking weekly work hours can lead to inconsistencies in time recording, so it might be better for both employers and FTEs to agree to track annual work hours. This practice could also be applied to residents and fellows in graduate medical education (GME) programs.
FTEs typically work 2,080 hours per year, based on an average of 40 hours per week for 52 weeks. GME programs could limit residents and fellows to no more than 4,160 hours per year, based on the 80-hour weekly limit set by the Accreditation Council for Graduate Medical Education (ACGME). In recognition of burnout among residents, ACGME allows for a minimum of 6 paid weeks off, and the American Board of Anesthesiology allows for up to 12 weeks off for medical, parental, or caregiver leave, in addition to a 12-week vacation during a 3-year residency program. However, since residents may use medical, parental, and caregiver leave differently, this can lead to inconsistencies in the total work hours spent by residents in GME programs.
To standardize the training work hours in graduate medical education (GME) programs, it would be best to design the curriculum based on a weekly expectation of 80 hours rather than just a limit. Suppose all 3-year residency programs provide a total of 24 paid weeks off for all residents. In that case, regardless of whether they need or want time off, it can be assumed that all residents should complete 132 work weeks over three years, with eight paid weeks off per year for smoother and more efficient work logistics. In this case, the total residency hours would be 10,560, or 3,520 hours per year. If the Accreditation Council for Graduate Medical Education (ACGME) allows some GME programs to increase the weekly limit to 88 hours to meet their needs, then the total residency hours would be 11,616, or 3,872 hours per year.
In this scenario, residents would work an average of 68 to 74 hours per week over the course of their 3-year residency, which is well below the threshold to be considered double-time employees (DTEs). It may be necessary to equalize the residency hours for all residents so that healthy, child-free, and single individuals are not penalized because of these traits. This is particularly important as these attributes are becoming more common, and equalizing residency hours may ironically further accentuate this trend.
The annual wages of residents could also be equalized by paying them based on their annual work hours. For example, an annual wage of $70,400 for 3,520 hours of work would effectively be $20 per hour, which is well above the current federal and state minimum wage. For a residency with 3,872 hours of work, the annual wage would need to be adjusted to $77,440 to maintain a rate of $20 per hour. The annual wage could be increased each year of residency while keeping the annual work hours fixed for residents.
Suppose it is determined through systematic investigation that residents do not experience worsening burnout and patients do not suffer poor outcomes when residents work more than 3,872 hours annually. Residents could be paid a premium rate for those extra hours in that case. This would ensure that GME programs would rarely, if ever, expect residents to exceed their weekly hour limit, even if residents choose to do so to increase their total wage.
With the increasing use of remote work and telemedicine in residency, time recording applications can be used to ensure that residents are paid for their full annual work hours, minus any deductions for non-worked hours at the end of their residency. These applications can help balance time recording and time tracking, allowing residents to avoid being underpaid, and GME programs to avoid overpaying residents.
To make scheduling easier for GME programs, the residency curriculum may need to shift from a month-by-month to a week-by-week schedule, preferably bi-weekly. This way, if a resident cannot complete 132 work weeks over the three-year period due to unexpected emergencies, they would need to stay and work beyond the three-year period to make up those missed weeks before graduating from their GME program.
It may be time to consider residents and fellows as full-time employees, almost double-time employees, as long as their curriculums can be standardized in terms of total work weeks and they are paid based on their total residency hours.
Deepak Gupta is an anesthesiologist. Sarwan Kumar is an internal medicine physician.
