Equalizing the future of medical residencies: standardizing work hours and wages

Residency is where doctors learn to be doctors. It’s also where “work-life balance” becomes a mythical creaturelike a unicorn, but with a pager.
If you’ve ever wondered why two equally talented residents can work similar hours, carry similar responsibility, and still end up with wildly different paychecks
(and wildly different levels of exhaustion), the answer is both simple and annoying: we built a national training system with uneven local rules.

The good news: the U.S. already has a framework for resident work-hour limits, and we have public funding streams that help support training.
The less-good news: enforcement, scheduling realities, and compensation are inconsistent enough that residency can feel like a “zip code lottery.”
Standardizing work hours and wages doesn’t mean turning every program into the same cookie-cutter experience. It means setting fair floors,
predictable guardrails, and transparent expectationsso training quality depends on education, not geography.

Why residency can feel like a “zip code lottery”

Two residents can both be PGY-1s. They can both be trusted with real patients, real decisions, and real consequences. Yet their day-to-day experience can be
dramatically different depending on program culture, hospital staffing, cost of living, union status, and how schedules are built (or rebuilt at 2 a.m.).

Hours are “limited” on paperuneven in practice

National accreditation rules set maximum work-hour standards. But real life is messier than a spreadsheet. A resident’s week might include in-house shifts,
overnight call, night float, and the sneaky hours that happen after leaving the hospitalfinishing notes, handling messages, or reviewing charts.
When programs count and manage these hours differently, fairness and safety get wobbly fast.

Wages vary widely, and cost of living doesn’t politely wait

Resident compensation is typically a salary (a stipend) with benefits, and it increases by training year. The problem is not simply that residents “don’t make
attending money” (that part is expected). It’s that pay can be out of sync with local costs, workload intensity, and even basic needs like housing and childcare.
When a resident’s effective hourly pay can dip into “Is this technically a skilled profession or a very intense volunteer opportunity?” territory, the system is
signaling something it doesn’t mean to signal.

What “standardizing” should actually mean

Standardization is often misunderstood as “every program must do the same thing.” That’s not the goal. Different specialties have different rhythms, and
different hospitals serve different communities. A one-size-fits-all residency would be a disasterlike prescribing the same antibiotic for every infection
because it’s easier to label the shelf.

A smarter definition is: national floors with local flexibility. Floors protect residents (and patients). Flexibility preserves educational
variety and specialty needs. Think of it like guardrails on a mountain road: you can still drive different cars, but you’re less likely to end up in the canyon.

Work hours today: the guardrails we have, and why they still wobble

The basics of duty-hour limits

Accreditation standards limit total clinical and educational work hours per week when averaged over a set period and include in-house work, certain at-home
clinical work, and moonlighting. They also set expectations for time off between shifts, days off, and call frequency. These rules exist for a reason:
fatigue affects performance, handoffs affect continuity, and both affect safety.

But a rule is only as good as its implementation. If a program schedules residents right at the maximum every week, there’s no cushion for the inevitable:
a crashing patient, a complicated family meeting, a delayed transfer, or the time it takes to document care in modern health records.
In practice, that “extra time” is where residents can get squeezed.

The hidden hours problem: “work from home” and documentation creep

Clinical work done from home (like electronic health record tasks and some patient care communications) can count toward weekly hour limits.
That is a big deal, because it acknowledges reality: the hospital workday doesn’t always stay in the hospital.
The catch is that counting those hours depends on residents reporting them and programs building schedules that don’t silently rely on invisible labor.

Standardization opportunity: make compliance measurable, not mythical

If we want work-hour standards to mean the same thing everywhere, we need consistency in how hours are recorded, reviewed, and acted upon. That includes:

• Uniform time-tracking definitions (what counts, what doesn’t, and what “at-home clinical work” looks like in real life).
• Anti-retaliation protections with teeth so residents can report violations without fear of being labeled “not a team player.”
• Schedule design with buffer, so programs don’t plan for perfection in a profession built around emergencies.
• Handoff quality standards, because fewer hours only help if transitions of care are safe and structured.

Wages today: why “stipends” don’t feel standardized (and why that matters)

Resident pay is real pay for real work

Residents are trainees, but they are also frontline clinicians who keep hospitals runningespecially overnight, on weekends, and in high-acuity services.
Compensation should reflect that residents are learning and delivering care. When pay is too low relative to workload and local costs, it creates
predictable downstream problems: financial stress, burnout, moonlighting pressure, and barriers for applicants from less wealthy backgrounds.

Why pay varies so much

Resident salaries are usually set by institutions (often across all programs in a hospital system), influenced by market pressures, regional norms,
andmore recentlycollective bargaining in some locations. Funding streams for training are complicated, and the dollars that support education don’t always
translate neatly into take-home pay.

The cost-of-living mismatch is the loudest unfairness

A resident earning a respectable-sounding salary can still struggle in a high-cost city where rent behaves like it’s trying to win a bodybuilding contest.
Meanwhile, a similar salary in a lower-cost area can stretch further. Without a cost-of-living adjustment (COLA) or housing support, “equal pay” can still be
unequal in practical life.

Where the money comes from (and why transparency matters)

Graduate medical education is supported by a patchwork of funding sources. Medicare plays a major role, providing two major types of payments to teaching
hospitals: direct graduate medical education (DGME) and indirect medical education (IME). In broad terms, DGME is meant to support direct training costs
(like resident salaries and benefits, teaching costs, and overhead tied to training), while IME is an adjustment recognizing that teaching hospitals often have
higher costs due to complexity, services, and training intensity.

But here’s the practical issue for residents: even when public dollars help fund training, the path from “GME payment” to “my paycheck and my schedule” is
not transparent. Residents can be told “there isn’t money” while working inside institutions receiving substantial GME-related funding.
That doesn’t prove bad intentit proves the system is opaque.

Standardization opportunity: a public-facing “GME transparency receipt”

Imagine if every sponsoring institution published a clear annual breakdown:

• Total number of funded resident positions and training sites
• Average resident salary and benefits by PGY
• Major wellness and staffing supports (ancillary staff, scribes, night coverage models)
• Aggregate duty-hour compliance metrics and corrective actions

This isn’t about shaming programs. It’s about making it possible for applicants, residents, and policymakers to compare apples to apples instead of apples
to a mysterious fruit labeled “trust us.”

What union contracts reveal about “possible” standards

Unionization among resident physicians has grown in recent years, and not just as a symbolic gesture. Contracts often spell out specifics that residents care
about: salary scales, benefits, scheduling rules, and grievance processes. In other words, they turn informal “culture” into enforceable expectations.

One striking lesson from union contracts is that some programs set stricter hour limits than national maximums and pair them with pay provisions
(including raises, differentials, or links to peer institutions). Whether you love unions, hate unions, or feel neutral until you need a dental benefit,
these contracts show that standardization isn’t theoreticalit’s already happening in pockets.

A national standardization blueprint that doesn’t wreck training

1) Work-hour floors that prioritize safety and education

The goal shouldn’t be “work fewer hours at all costs.” The goal should be “work hours that match human physiology and safe systems.”
That means pairing hour limits with changes that prevent the classic failure mode: fewer resident hours but more chaotic handoffs, more scut work, and the same
clinical volume shoved into tighter time.

A workable national approach could include:

• Stronger enforcement of existing maximums with independent audits and standardized reporting.
• Protected recovery time after extended in-house shifts that is treated as non-negotiable, not “nice if convenient.”
• Workload measures alongside hours (patient caps or acuity-adjusted load) in high-intensity rotations.
• Handoff training requirements so continuity improves even as shifts change.

2) Wage floors with cost-of-living adjustments

A national wage floor could be set by PGY level and adjusted by region using a transparent index. Think of it like how some large employers use locality pay.
It wouldn’t force identical salaries everywhere; it would guarantee a minimum standard of living and reduce extreme outliers.

A practical model:

• Base national minimum stipend for each PGY year (PGY-1 through PGY-7 or fellowship equivalents).
• Regional COLA multiplier applied to the base (using a publicly defined geography and index).
• Required benefits baseline (health insurance, parental leave minimums, mental health access, and a modest education allowance).
• Optional local enhancements (housing stipends, childcare support, transit benefits) where costs are acute.

3) Tie public funding incentives to resident-facing outcomes

If public dollars help support training, policymakers can encourage resident-facing standards without micromanaging clinical education.
For example, some portions of GME-related funding could be linked to:

• Verified compliance with duty-hour rules
• Transparent salary scales and annual adjustments
• Demonstrated staffing supports that reduce non-educational workload
• Well-being infrastructure that residents can actually access (not just a poster)

4) Protect flexibility where it matters

Standardization should not erase specialty-specific training needs. A surgical service, an ICU month, and an outpatient continuity clinic week will never look
identicaland shouldn’t. The trick is to standardize the boundaries and the supports, not the clinical experience itself.

Common objections (and reasonable answers)

“If you cap hours more, residents will be less prepared.”

Preparation isn’t just about time; it’s about deliberate practice, supervision, feedback, and appropriate autonomy.
Exhausted repetition is not automatically better training. If hours are reduced, programs must redesign learningprotect high-value cases and procedures,
improve teaching efficiency, and reduce low-value clerical load.

“Hospitals can’t afford higher wages.”

Some can, some can’tat least not easily. But “can’t afford” often really means “the current budget is optimized for the current labor model.”
If residents are underpaid relative to workload, the system is balancing its books on the backs of trainees. A phased wage floor, paired with transparency and
targeted funding reforms, would be more honest than pretending the status quo is the only viable option.

“Standardization will be bureaucratic.”

It could beunless we design it like a clinician would: simple definitions, clear metrics, and minimal busywork.
The point is to reduce chaos, not add another mandatory module that residents complete at 11:58 p.m. with one eye open.

What success would look like in 5 years

• Residents know the real rules, and reporting hours is safe and consistent.
• Programs schedule with buffer, so emergencies don’t automatically break compliance.
• Every resident salary scale has a transparent floor and a cost-of-living logic.
• Benefits minimums reduce “survival gaps” (housing, childcare, mental health access).
• Hospitals measure workload and handoff qualitynot just hoursbecause safety is a system property.

Most importantly, standardized work-hour and wage floors would make residency feel less like endurance theater and more like what it’s supposed to be:
rigorous training with humane boundaries. We can keep the intensity that builds excellent physicians without treating sleep, rent, and basic recovery like optional
electives.

Experiences from the front lines (composite stories)

The following experiences are compositesblended from common patterns residents report across programsbecause no single hospital owns the market on fatigue,
and no single intern owns the patent on “I swear I ate dinner… three days ago?”

1) The “80-hour week” that doesn’t count what happens after you leave

A medicine intern finishes a long shift and finally walks to the parking lot feeling like a heroic survivor of modern charting. The official schedule looks
compliant: the week averages under the limit. But the day isn’t actually over. At home, there are unfinished notes, inbox messages, and a couple of lab results
that can’t wait until morning. The intern logs in “just for 20 minutes,” which turns into an hour. Then a senior texts a question, which triggers a quick chart
review, which triggers another note edit, which triggers the existential realization that the laptop has become a second stethoscope.

This is how “compliance” can become an accounting trick rather than a safety tool. Standardization here wouldn’t mean punishing residents for finishing work;
it would mean designing the workflow so residents can finish most clinical tasks while on duty, and defining at-home clinical work consistently so it’s
not treated like invisible volunteer time.

2) Two PGY-1s, two cities, two different lives

In a lower-cost region, a PGY-1 shares an apartment with one roommate, pays bills, and can occasionally do something shocking: save a little money. The same PGY-1
salary in a high-cost metro means roommates plus a long commute, a shrinking grocery list, and the kind of budgeting creativity that deserves CME credit.
The resident isn’t asking to get richjust to live within the same reality as the hospital they work for.

A standardized wage floor with a cost-of-living adjustment would reduce this gap. It wouldn’t make every city equally affordable (nothing can, except maybe a time
machine to 1997). But it would stop the system from pretending that identical dollar amounts represent identical quality of life.

3) When local standards prove national standards are possible

A residency program negotiates clearer rules: a tighter weekly hour limit than the national maximum, a defined process for reviewing violations, and a salary scale
that keeps pace with peer institutions. Suddenly, vague promises turn into enforceable expectations. Residents don’t become less dedicated; they become more
sustainable. The conversation shifts from “Can you tough it out?” to “How do we build a schedule that teaches well and keeps people functional?”

The biggest change isn’t only the paycheck or the hours. It’s psychological safety: residents feel they can raise concerns without being treated like a problem.
Standardization at a national level could create that baseline everywhere, even while leaving room for local innovation in how training is delivered.

4) The moment you realize wellness isn’t yogait’s staffing

A resident sits through a mandatory wellness lecture after a night on call. The lecturer is kind, the slides are calm, and the breathing exercise is fine.
Then the resident returns to a service where ancillary staffing is thin, the pager is relentless, and routine tasks pile up until learning becomes secondary.
The resident isn’t burned out because they forgot mindfulness. They’re burned out because the system needs more hands, smarter workflows, and better boundaries.

This is where standardizing hours and wages connects to patient care. Adequate pay supports retention and fairness. Reasonable hours support cognition and safety.
But neither works if the workload is fundamentally mismatched to staffing. The future of residency needs fewer slogans and more structural fixesbecause no amount of
deep breathing can replace a functioning schedule and a living wage.