Is medical training becoming too lax?

Many physicians worry that medical training is becoming too lax. Here’s a representative quote from NEJM’s Not Otherwise Specified podcast (which is insightful and worth listening to):

“10 years ago, students asked to have the day prior to their shelf exam off for clerkships, and they got it. And then, students asked that the day before that be a half day, and they got it. And then students asked, “What’s really the benefit of us having any overnight call on these clerkships?” And so, students went from having overnight calls on OB, internal medicine, surgery, pediatrics, psychiatry to only having one or two overnight calls their entire medical student career in the surgery clerkship… I think it’s that there is an awful lot of creep going on, and if you look at the differences from 10 years ago to now, or 5 years ago to now, they are pretty stark.”
- Dr. Amy Holthouser 
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In this blog post, I’ll aim to characterize and refute the view that medical trainees today aren't willing to work as hard as their predecessors.
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An acute on chronic problem
Medical training has always been grueling, but many physicians believe it has gradually become less so. Historically, the expectation at many residency programs was that physicians would work 100-hour weeks for the duration of their residency training, often going 36 hours without sleeping. In 2003, the Accreditation Council for Graduate Medical Education implemented duty hour restrictions: residents could no longer work more than 80 hours per week or work more than 24 hours consecutively. In addition, residents were newly entitled to one day off per week. (Unfortunately, these changes didn’t clearly improve patient outcomes, and in some cases seemed to undermine them, although the evidence is difficult to parse, as it’s not clear these restrictions greatly reduced residents’ work hours.) 

In the years preceding COVID, more than half of medical students experienced burnout, while medical residents experienced depression at 3.5x the rate of the general population. Medical training programs thus began to take (seemingly effective) steps to improve trainee’s mental health by, for instance, making curricula pass-fail. Then COVID happened, compounding health workers’ rates of burnout, and accelerating many wellness-oriented changes in medical education (e.g., the addition of hybrid lectures and wellness days). Some of these changes were initiated by medical educators, but trainees have also begun to push for them, too; for instance, many residency programs have unionized, with residents seeking benefits like improved parental leave policies and call rooms without roaches.

I think these changes have left many senior physicians with roughly the following perception:
“When I trained, things were a lot harder. We worked constantly, never saw our families, and never slept. Trainees today have it much easier—in medical school, their courses and exams are pass-fail, and during residency, their time is more protected. These changes have also been accompanied by a cultural shift: trainees today feel more entitled to their relatively more comfortable lifestyles, and feel empowered to ask for even more benefits. Importantly, it’s not clear any of this is in the interest of patients, raising questions about whether trainees are forsaking their professional obligations. In addition, it’s not clear these changes are to the benefit of trainees, because part of what makes medicine rewarding and fun is accomplishing things that are harder than you ever thought possible, doing right by your patients, and becoming extremely competent and knowledgeable.”

What this critique gets wrong
Before getting into the substance of this critique, I want to first highlight that fretting about the youth’s declining work ethic is something of a right of passage for adults. That doesn’t make this critique wrong; tropes can be right, and it’s possible that people (and thus medical trainees) increasingly favor relaxation over rigor. But the fact that this narrative about medical trainees fits into a broader pattern of kids-these-days-ism—and is often supported more with vibes than data—means it warrants critical scrutiny. 

That said, I take seriously that a lot of people who have been in medicine longer than I have think two things are true: first, medical trainees today work less hard than their predecessors, and second, that trainees (wrongly) think that “being mentally healthy is equated with feeling good or calm or relaxed,” and thus are unwilling to experience what we might call “marathon joy” (i.e., the joy associated with accomplishing something truly difficult). The problem is that I think both critiques are empirically incorrect: I have yet to see much evidence that, over the course of their training, trainees work fewer hours than they used to, or that they insufficiently appreciate marathon joy. 

Indeed, I think there’s substantial evidence that by the time medical trainees finish their training, they will have worked longer and harder than their predecessors did:

1. High schoolers have to do more than they used to to get into college. Expectations regarding grades, scores, and extracurriculars have increased over the past few decades: the number of students taking AP exams has doubled in the past twenty years, with the average student taking more exams. (The number of high school graduates has only increased by about 10%.) College admissions have also become more competitive; for instance, the acceptance rate for Yale’s class of 1997 was 23%, while in 2023, it was 4%. 
2. College students have to do more to get into medical school. Medical school acceptance rates have fallen from above 50% in the early 1990s to about 42% today. Moreover, the typical applicant today is more qualified than they were just seven years ago: a 56th percentile MCAT score in 2017 (501) is now below the median.  
3. Nearly three quarters of medical school applicants now spend at least one year after college working or studying prior to applying (versus just under 60% in 2015), with nearly half spending this time doing research.
4. Although medical school courses are now often pass-fail, trainees are hardly slacking off: the mean USMLE Step 2 score in 1996 is no longer a passing score, implying that trainees spend a lot of time studying (although they may also be working more efficiently). 
5. And as the canon of medical knowledge expands, doctors are also expected to know more: First Aid—the book summarizing what medical students need to know for Step 1—has nearly doubled over the past two decades, from 481 to 848 pages.
6. In addition to working harder during the four dedicated years of medical school, more students spend more time training. In the 1970s, 90% of students graduated in four years, while in the 1980s, just 83% did. The four-year graduation rate has hovered around there since, but attrition rates have fallen, suggesting that more students take longer to finish because they are taking research years or pursuing additional degrees. (Interestingly—as far as I can tell—the AAMC hasn't released four-year graduation data since 2018. I would not be surprised if the percentage of students graduating in four years has ticked down since then.)
7. Students are spending longer in medical school, in part because residency applications have become more competitive. Among students who take research years, the most widely cited reason for doing so is to increase their competitiveness for residency applications. This is because of the much-maligned research arms race: the average research output for matched medical students applying to residency has tripled since 2009. So, students aren’t taking time off to travel the world; they’re spending time doing (uncompensated) research to bolster their residency applications.
8. Once trainees match into residency, they care for older, more medically complex patients than their predecessors did. Trainees are also providing care against the backdrop of an increasingly strained health care system. For instance, for every day for the past 16 months, Massachusetts General Hospital has been so full that at any given time, there have been patients awaiting care on stretchers in hallways. The average American being older and sicker than they were thirty years ago, coupled with limitations in hospital capacity raising the bar for admission, mean that when trainees are working, they are working extremely hard caring for less stable patients with more medical needs. 
9. Moreover, despite patients having become more complex, the average hospital stay has shortened, meaning the average resident will spend more time admitting and discharging patients than prior generations of residents did. (For readers who aren’t in medicine: at any given time, a resident will have a given number of patients on their list. As you might imagine, it’s easier to care for a patient who has been on your list for a few days, as familiarizing yourself with a new patient involves reviewing their chart, researching the best approaches for treating their ongoing problems, and developing a plan for managing each. Similarly, discharging a patient can involve scheduling follow-up visits with primary care doctors or specialists, arranging transport, coordinating housing, and so on. In short, there is a lot of work associated with higher patient turnover.) 
10. In addition, the dramatic increase in medical documentation has impacted trainees, too, who spend far more time charting in windowless rooms than interacting with patients. 
11. Finally, because medical trainees are spending more total years training (more years before medical school, more years during medical school, more years during residency, and more often fellowship years), they may have more competing obligations (e.g., families to take care of) while training. 
    
    

Why do people think medical training has gotten easier?
In some ways, medical training has become easier than it was thirty years ago; for instance, residents no longer draw labs on their patients and call schedules have become less brutal. But there seems to be very little evidence that medical trainees today spend fewer total hours training, or find the average hour more educational, interesting, relaxing, or rewarding. And I think trainees—most of whom have spent their entire adolescence and adulthood working extremely hard—feel gaslit when they’re told, essentially: “you’re working less hard than your predecessors, so if you’re burnt out, you can’t blame your environment.” 

So where does this narrative come from? My guess is that things like wellness days, duty hour restrictions, and phlebotomists constitute clear, discrete examples of interventions that have made medical trainees’ lives easier. Meanwhile, things like gradually increasing hospital turnover, sicker patients, Step 2 score creep, and longer training paths have impacted trainees’ lives in significant, but subtler, ways, and are correspondingly overlooked.
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It’s not clear to me what we ought to do about this—how can we keep medical education rigorous without making trainees more burned out than they already are? But we need to correctly diagnose the problem in order to treat it, and when we conclude simply that trainees are unwilling to push themselves as hard, we miss an important piece of the puzzle: medical trainees today may not be running as fast, but they’re running a longer, steeper race.