Exhausted. This is the word that comes to mind when asked how I am. Instead, it’s the usual “Good!” with a smile on my face. Not that this is unique per se. Many others work long hours. A friend who is an accountant will work 80-hour weeks in the month up to the tax filing deadline. Another who works in automotive design will sometimes work 60 to 80-hour weeks to meet a project deadline. Heck, even the likes of Bezos and Steve Jobs mentioned working 100-hour weeks while getting their businesses off the ground. I’m sure many of these people have felt exhausted at times. So what makes Residency and physicianhood different? The following are my unfiltered thoughts:

The length of time during which 80-hour work weeks are the norm in such a high-stress environment – name another job where the expectation is 80+ hours per week for 3 to 7 years. Surgical residents regularly pull 100-hour weeks. Not because they want to, but because it is simply not possible to ensure patient safety and meet the education requirements without doing so. Reporting these violations can result in probation and even the program getting shut down. Retaliation may also occur. A major conflict of interest to report exists because if the program shuts down, any time spent working to that point is jeopardized. Not to mention hours worked does not account for time spent researching, reading, and teaching. These are things expected beyond regular clinical duties.

I once was asked, “Why don’t residents find a program that doesn’t do this?” The answer is simple: Residents are cheap labor, and there is no hospital system out there that would purposefully limit the production of residents.

Another shock to most people – Residents are allowed to work up to 30 hours straight. That’s right. Not truckers, not pilots, not sailors, nor any other occupation which deals with hazardous equipment or the safety of others is allowed to work that long. First responders may be assigned to shifts this long; however, they are paid overtime, which represents an increase in value for the additional time spent at their occupation.

Residents make an average of $15 per hour or roughly 55K to 65K per year. Because salary is mostly set by Medicare and Medicaid funding. And because they are employed, there is no overtime or bonus pay for any time spent working over 40 hours/week. This has been challenged several times in court; however, the courts sided with the residency programs, stating that because we are “professional employees,” we are not protected by the Fair Labor Standards Act. There is simply no incentive to pay residents more.

Is unionizing an option? Some residents have been able to unionize, gaining modest improvements in working conditions or compensation. The key here is modest (i.e., not having to do their own lab draws or an increased stipend of several thousand dollars per year). In reality, unionization takes time and energy that most residents already don’t have. In addition, there is fear of retaliation from programs of being fired or smeared as a difficult resident. Finally, residents do not wish to compromise the safety of their patients by walking out on the job and delaying lifesaving care. Some would rather suffer through with the promise of a better life. One that is increasingly hard to attain given decreasing reimbursement rates for physician services.

Respect (or lack thereof) – It is hard to continue slogging when you see the degradation of physicians with the term “provider” and when you have NPs or PAs who have significantly less intense/lengthy schooling making nearly double your salary as a resident. By the time a resident becomes an attending physician, we have missed out on four years of earning potential compared with a college graduate and another 3 to 7 years of potentially increased earnings. Additionally, most residents carry insane amounts of debt (around 250k on average) from undergraduate and medical school education. So by the time they are an attending physician at 31 years of age, making 300K per year, they have not been able to invest or contribute much to savings. And then, of course, the student loan payments which on a salary-based plan can be $2,000 per month or more! And let’s not forget our progressive tax system – “thanks for sacrificing your 20s and early 30s training to learn vital skills to treat, cure, and care for our sick and dying. We will now take more of that income you’ve earned.”

Moral injury and burnout – I figured residency would be a challenge but did not expect the disrespect and even anger towards doctors I witnessed during the pandemic. The perception of doctors sitting in some ivory tower and benefiting from the suffering of others was rampant. I remember one patient’s family refusing a breathing tube based on a blog they read online. Another accused me of pushing certain treatments not proven to work. Yet another said I personally was profiting off the vaccine… After a year of this, I realize now our education system and government has failed. It is evident that people do not understand how our research is different than their “research” or how health systems are designed.

Medical education is not like this elsewhere. In non-western countries, they go through a 5-year combined undergraduate/medical education program. After a one-year internship, they can practice independently and usually without debt. In Europe, they follow a more traditional model totaling six years, and their residency training hours are legally capped at 48 hours per week.

Over half of physicians are employed by corporate medical systems. Physicians are a cog in a machine, dispensable at any time. The bottom line is profit margin. It is demoralizing to see that our mission of improving patients’ health is in direct opposition to profiteering. These systems require that more patients be seen in less time. This requires redundancy to reduce errors, which inherently increases cost and also increases physician burnout.

Solutions? Continued education and awareness. Ideally, change would be through legislation. Unfortunately, lobbying makes this extremely difficult. We talk about conflict of interest and bias as if these lobbying groups don’t have their own. If society cares about access to knowledgeable and skilled physicians, this should be a priority taken upon the government to solve – with input from the average physician, not the 1 percent who sit on boards and do not represent us. It comes down not only to hours worked but also the financial cost required to become a physician and the mediocre resident pay. Perhaps private companies could sponsor medical/GME education, much like private companies sponsor apprenticeships and other educational opportunities.

Bottom line: If you or a loved one suffers an emergency and is admitted to the hospital, please remember that we care and are doing our best but are exhausted.

Jordan Gates is a neurology resident.