BTK_CoSEF_beyond the match Ep10 pt3_ working conditions_final
===

[00:00:00] Hello, hello everyone, and welcome back to Behind the Knife. I'm Mackenzie Roebuck, a general surgery resident at Inova Fairfax, and this is episode three of our COSF series, Beyond the Match, where we're using the recent congressional report on the match as a starting point to talk about what is actually driving some of the biggest problems in residency.

Today, we're focusing on working conditions, accountability, and the potential for resident mobility. I'm joined by fellow COSF members Carl, Michael, and Omer. Carl, can you start us off by quickly reintroducing COSF for anyone who missed episodes one and two?

Hello, and thanks for having me. My name is Carl Engelke, and I am currently a general surgery resident at the Ohio State University.

COSF is the Collaboration of Surgical Education Fellows, a multi-institutional group of surgery residents and fellows working together on surgical education, scholarship, and peer mentorship. If you are a surgical education fellow or a surgery resident interested in [00:01:00] education and want to learn more, fill out our new member form at cosf.org.

I'm Michael Brinton. I'm a fourth year general surgery resident at the Medical College of Wisconsin.

I'm Omer Hassan, and I'm a pediatric surgery fellow at University of Calgary, Alberta Children's Hospital, Canada.

Amazing. So in episode one, we talked about pay, benefits, and bargaining power. In episode two, we moved upstream to the application process itself, over-application, signaling, transparency, and why applicants and programs both feel like they're guessing.

Today, we're moving downstream and asking what happens after you match, and are these problems actually caused by the match itself?

Because matching into a program is not the end of the story. It's the beginning of years of training inside a system where residents may have little control over their schedule, workload, supervision, leave, or ability to leave.

So let's get into it. Beyond the Match, episode three. Whatever concerns we may have about the committee report, and there are several, [00:02:00] it does point to real problems affecting residents.

Agreed. What are some of the things you all noticed?

Long hours and chronic under-reporting.

Mistreatment, discrimination, fear of retaliation.

Limited ability to transfer and rising

unionization

Exactly. Our argument isn't that these problems are exaggerated or fake. They're real.

Right. But the report treats the match as if it explains nearly everything. However, I think most of us know that these problems are shaped by many things: staffing models, institutional culture, accreditation, funding, hierarchy, and whether residents actually have a meaningful voice.

Exactly. So let's start with working conditions. Carl, what do you think the report gets right here?

I think it correctly identifies that residents can work under conditions that would be hard to justify in almost any other profession. Surgery has historically lionized pushing through fatigue, staying late, not complaining, while sometimes framing [00:03:00] the consequences as problems with a resident's efficiency, resilience, or attitude rather than a structural problem in the system.

So the question becomes: how can we separate what is desirable difficulty from what is unnecessary cruelty?

All right there, Carl. I mean, with this being a three-part series, unfortunately I don't think we have time to fix all of residency. But that piece does feel familiar. Residents know what it feels like to work beyond what is sustainable and then be told the problem is their fault.

Our listeners love data, though. Does anything support these claims?

Yeah. A systematic review from 2022 found that 71% of residents chose not to report events of mistreatment, and over half of those who do report have a negative experience doing so.

QTR reporting as another example. Multiple studies have shown concerning rates of reporting falsification, the worst among surgical specialties.

I think we all know the rules exist, but knowing the rules exist and feeling safe [00:04:00] reporting violations are two different things.

These issues extend into mental health as well. This is an environment where depressive symptoms are over three times more prevalent in residents than the general population at 29%, and suicidal ideation is reported by roughly one in six interns.

Yet the culture around seeking help can still be complicated, especially when people worry about stigma, licensing, or being seen as less capable.

Really? One in six? Wow.

Yeah. A recent episode of BTK with fellow COSF member Steven Thornton and others took an excellent dive into mental health and surgery, and I highly recommend listening if you haven't already.

I think we're getting to the core of this episode already. Policies on paper are not the same thing as protections people trust. I don't know about you all, but without some concrete examples, my attention just turns off. What does this actually look like day to day?

Well, it might look like the resident who accurately reports that they went over hours post call and is told that they are inefficient rather than acknowledging service [00:05:00] issues that contributed.

Or the resident who technically has a way to report mistreatment but knows the same hierarchy they're reporting into also controls evaluations, autonomy, recommendation letters, remediation decisions, and future career opportunities.

And then there are the issues around family and leave Carl, as the token dad of the group, how does that show up around parenthood?

#girldad. You know, I'm really fortunate in my program to be supported for paternity leave and needs by my leadership and co-residents. But I've heard horror stories elsewhere of residents who were ostracized by peers for how parental leave shifted coverage burden, especially in specialties and programs with smaller class sizes.

Not to mention the just make it work attitude toward childcare and breastfeeding or pumping.

And that's such a good point because the problem is not only whether a policy exists, it's whether the system has enough coverage and support for people to actually use it without guilt or backlash.

These residents aren't completely wrong to be frustrated with the [00:06:00] extra burden placed on them during a co-resident's family leave, but it's misdirected.

It's really a symptom of a larger problem. The system doesn't have any redundancy, and the residents are there to absorb the shock.

One example that stuck with me from intern year was being told our role on the trauma team was to take on the most patients and make sure the APPs got out at a reasonable time.

To be clear, this is not about APPs versus residents. The problem is that resident time was treated as the flexible backup plan to pretty much any problem that would come up. I think all of us have heard some version of that.

And when that becomes normalized, residents may stop seeing the workload as a systems problem.

They may start seeing it as personal failure. I'm not fast enough. I'm not tough enough. I'm not efficient enough.

I'm sure that doesn't help with our mental health issues in residency and in surgery.

Which is exactly why culture matters.

I think all of these problems really drive home how the problems listed in the report shouldn't be attributed to any single cause.

And therefore are unlikely to be solved by a single intervention.

Exactly. We talked in [00:07:00] episode one about why residency is not a normal job market. Residents don't have much individual bargaining power, and the Match is only one piece of that. But working conditions are even less directly connected to the Match.

The NRMP does not set duty hour policies. It does not write staffing models. It does not decide whether a program has enough backup coverage or whether reporting feels safe.

And I think we have to discuss the dual role of residents as learner and worker. A major tension in residency is that institutions can frame residents as learners when discussing pay and protections but rely on them as indispensable workers when s- the service needs to run.

Which is not to say that some, if not many, places balance these appropriately, but we're reliant on professional norms rather than tangible guardrails to ensure that our unique position is not taken advantage of. That's where things like laws, accreditation standards, or systems that automatically record, track, and report issues can matter because they don't rely entirely on residents to identify the problem [00:08:00] and take on the risk of reporting it.

Meanwhile, there are a whole host of governmental licensing and accreditation bodies with the ability to enforce working conditions reforms, yet this doesn't happen.

Not to mention that surgery also has a strong professional culture. Some of that culture is good: commitment, accountability, ownership. But the same values can be distorted into silence, endurance, and self-blame.

Yikes. Yeah, we've all probably contributed to that culture without meaning to, like praising the intern who stayed late every day this week to make sure things were tied up, or the medical student who stayed for a case long after they needed to be there.

I see somebody's been watching Season 2 of The Pit.

But you're right, the formal curriculum says, "Ask for help, report unsafe conditions, protect your mental health, and speak up." But the hidden curriculum can say something very different sometimes: "Endure it. Don't complain. Don't burden your co-residents. Don't make the program look bad."

But I do [00:09:00] think it's important to say clearly, we all believe surgical training should be hard.

It should push us. There are going to be long days, sick patients, hard cases, and moments where you stay late because that is what the patient or the team needs. That's part of becoming a surgeon.

Exactly. The issue is not that training is difficult. The issue is when preventable dysfunction gets treated like education.

Staying late for an unstable patient or a meaningful learning opportunity is very different from staying late every day because the system has no redundancy, and then being told the problem is your efficiency or resilience.

That distinction feels really important. The goal is not easier training. The goal is better training, where the hard parts are purposeful, not just inherited dysfunction.

And that is also where residents have some day-to-day power. Policy matters, staffing models matter, funding matters, but culture is also built into the small moments on service.

Senior residents especially set the tone. [00:10:00] Junior residents learn a great deal of how they're expected to respond to fatigue, illness, excessive workload, and mistreatment by watching their senior residents.

So when we normalize residents asking for help, support the appropriate use of backup coverage, and respond constructively when someone raises a concern, we establish a different model of professionalism. We show that suffering in silence is not the same as dedication.

And that can be very practical. If an intern is drowning, the answer does not always have to be they need to get faster Sometimes the answer is, "Let's have them prioritize," or, "I can write two of these notes," or, "I can call that consult," or, "Let's figure out what actually has to get done before they leave."

Or when someone has something come up, a sick kid, a medical appointment, a family emergency, the culture we create is whether people feel punished for being human or whether the team says, "We've got you."

Right. Residents cannot fix a broken staffing model by being nice to each other. But [00:11:00] we should also not underestimate the power of residents to make the day-to-day environment more humane.

Helping each other does not mean lowering standards.

I think one thing to point out is that commitment to patients and commitment to safe working conditions are not opposing values. Unsafe workloads, sleep deprivation, burnout, and depression all affect patient care and increase the risk of medical errors.

That feels like an important reframing. Asking for safer working conditions is not selfish. It's part of taking good care of patients.

So how do we move the needle on this issue?

Culture can be one of the most difficult things to change in any organization. The good news is that although residents may contribute to perpetuating harmful norms, they're also in a powerful position to change them.

But culture change cannot depend upon residents alone.

Exactly. Senior residents, faculty, and program leaders must consistently reinforce the same expectations. Identifying unsafe conditions is responsible, requesting [00:12:00] help reflects sound judgment, and staffing problems belong to the organization rather than to an individual resident.

And people need to see that when legitimate concerns are raised, action is actually taken.

Over time, this cycle of actions can replace a culture of concealment and self-sacrifice with one grounded in psychological safety, fairness, shared responsibility, and mutual support.

And that idea of shared responsibility is important because improving working conditions cannot rest entirely on individual residents learning to cope better.

That's where wellness efforts can become complicated. Retreats, pizza, yoga, and lectures about sleep may all have value, but only when they complement meaningful changes to the conditions causing distress rather than being offered as substitutes for those changes.

Changes like safe staffing, adequate leave coverage, freedom from mistreatment, and reporting systems that, uh, residents can actually trust.

Exactly. Individual support matters, but it cannot compensate [00:13:00] for harmful working conditions. When an institution creates distress and then responds by telling residents to be more resilient, responsibility subtly shifts from the system to the individual.

So maybe the line is, "Wellness cannot substitute for accountability."

There we go. That's the one.

So team, you've described why difficult working conditions can persist even when we have duty hour rules, institutional policies, and wellness initiatives. One response I've heard is if a resident's unhappy being mistreated or realizes the program is no longer a fit, why can't they just leave?

Omair, how realistic is that?

For most residents, not very realistic, and this is where I think the report identifies a real problem but attributes too much of it to the Match itself.

Because the Match mostly just decides where you start, right?

Right. The binding commitment is limited to the beginning of residency, the initial forty-five days.

After that, residents are technically permitted to change programs, [00:14:00] but being technically permitted to transfer is very different from having a realistic pathway to do so.

And programs are not really built for constant movement. They're built around annual training cycles, call schedules, rotations, and graduated responsibilities.

Losing even one resident can significantly affect the workload for everyone else.

So the system is designed for residents to enter together, progress together, and graduate together. It's not really designed for regular movement between programs.

Exactly. As a result, an appropriate position may simply not exist when a resident needs to move.

In a separate conversation we had with Dr. Carmody, he compared this to a very tight housing market. You may want to leave your house, but there is nowhere available for you to move, and because nobody can move, the entire market stays frozen. That is a useful way to understand resident mobility.

But general surgery has a fairly high attrition rate.

Wouldn't residents leaving create transfer openings?

Sometimes, but [00:15:00] attrition does not automatically create a compatible spot. For example, if a PGY one leaves a program, that does not necessarily help a PGY three who needs to change programs. The opening has to match the resident's specialty, PGY level, timing, and prior training, and board requirements can further limit flexibility, especially in the senior years.

So a resident who has already completed preliminary or accredited training at multiple institutions or who needs to transfer during the senior years may have much less flexibility than the phrase, "You can just transfer if you don't like it," might suggest.

A more accurate version is you can transfer if there's a spot at the right level, in the right specialty, at the right time, with a program willing to take you, and with your prior training accepted.

That's quite a few ifs. And I imagine it's even more complicated for residents on visas.

Absolutely. For residents on J-1 visas, which is more than 17,000 physicians, their ability [00:16:00] to remain in the country and continue training is tied to a specific program and set of dates. It does not automatically follow them to another program.

So for a visa-dependent physician, leaving an unsafe or harmful program can immediately become an immigration status issue.

And then there is the funding question for all residents. When people say that funding does not follow the resident, what does that actually mean?

And please explain this without making me understand the entire Medicare reimbursement system.

A noble goal. Omair, can you give us the short version?

A short version is that Medicare does not give each resident a portable five-year funding source. Instead, GMA payments go to teaching hospitals. Those payments are based partly on the number of eligible residents each hospital trains and are subject to hospital-specific formulas and historical institutional caps.

Imagine a PGY3 resident leaves hospital A and wants to transfer to hospital B. Hospital A may eventually refill that position, but hospital B does not [00:17:00] automatically receive a funded slot for that resident, especially if hospital B is already at, at its cap.

So when you combine scarce vacancies, board requirements, major student debt, professional stigma, family and geographic constraints, and for some residents, visa restrictions-

You create a system where a trainee in a harmful environment may not be legally required to stay but may still have no safe or viable place to go.

And limited mobility probably affects accountability too.

It does. In most workplaces, the ability to leave creates at least some pressure on employers to improve, but that pressure is much weaker in residency because leaving can cost a resident time and training, financial stability, professional relationships, and potentially their future career.

If a program knows that transferring may force a resident to repeat a year, destabilize their family, damage their reputation, or jeopardize their ability to complete training, then the institution holds far more leverage.

So the [00:18:00] inability to leave is not separate from working conditions. It is one of the reasons harmful conditions can persist.

So what could make mobility more real?

There is no single fix, but there are several practical steps. First, residents considering a transfer should also have access to independent advising outside their direct program hierarchy. They need somewhere to ask confidential questions about eligibility, creating credit, board requirements, visa implications, and the risks of approaching their current program.

Second, transfer policies should be clearer and more standardized across institutions. Completed training should be preserved whenever accreditation and board requirements allow it.

There also needs to be stronger protections against retaliation. Exploring a transfer should not threaten a resident's evaluations, mentorship, recommendations, or standing within the profession.

And that is especially important for residents who may already have less institutional power. International medical graduates, visa-dependent [00:19:00] trainees, underrepresented residents, and residents without powerful mentors or advocates.

And we also need to reduce the stigma around transfer itself.

Absolutely.

Transfer should not automatically be treated as evidence that the resident failed. Sometimes there's a genuine mismatch. Sometimes family or personal circumstances change, and sometimes leaving is the safest and most professional decision available.

None of this means transfers should become casual.

Programs need stable teams and continuity matters. But that stability should not depend on residents feeling that they must choose between preserving their careers and protecting themselves. A functioning training system should provide residents with both a voice and exit, a safe way to raise concerns and a realistic pathway to leave when serious problems are not corrected.

And if leaving is not a realistic option or when residents want to try and solve the problem first, residents might wanna report the problem. But [00:20:00] having a reporting pathway is not necessarily the same as having one that residents trust or feel safe using. Michael, what reporting options do residents actually have, and why might they still hesitate to use them?

Great question. There are multiple pathways to potentially address issues in residency, but none of them are perfect. Let's start local. Every program should have some form of reporting mechanism specific to the program. Obviously, the most direct path is just bringing issues up with the program director, but end-of-rotation evaluations and faculty evaluations can also be a functional reporting mechanism.

But residents may still hesitate because they feel identifiable, especially in small programs, small specialties, or specific rotations where everyone knows who was there.

Exactly. Some programs do have additional anonymous reporting mechanisms, but that requires trust that anonymous actually means anonymous.

Some residents may also feel that reporting directly to the program is ineffective because of a [00:21:00] history of the program not responding to prior reports.

This is true. We all know residents who have gotten frustrated at a perceived lack of movement on important issues. This may be real or it may be a function of the slow pace of change at some institutions.

Either way, it can make residents feel that reporting issues is futile. Beyond the program but still at the institution level, there are generally other pathways for accountability as well. The team spoke in the first episode about the GMEC or the Graduate Medical Education Committee. This is a committee made up of trainees from across an institution that provides oversight of the institution's training programs, among other roles.

Bigger issues, especially those affecting multiple training programs, may be able to be addressed through

the GMEC. But as our colleagues mentioned, the GMEC only acts in an advisory capacity. Their decisions or recommendations don't really have any teeth.

That's true, which takes us beyond the institution.

As we all know, the ACGME is the accreditation body [00:22:00] for all residencies and many fellowships. The ACGME has three main reporting mechanisms. The first is the ACGME survey, which is administered yearly.

The results of which are part of what determine ACGME citations.

Correct. Programs can get citations from the ACGME, which indicate specific deficiencies that must be addressed.

If a program fails to improve on its citations, it can receive a warning or be put on probation and eventually lose accreditation entirely.

And if that happens, all the residents lose their jobs, their training, and either have to relocate to a different program or lose their path towards specialty certification.

Yikes.

Which is a big reason why residents might not report real problems on the ACGME survey.

Yeah. And if you talk to enough residents, it won't take long to find one whose program used that fact as a scare tactic to coerce residents into not reporting. It's unfortunate, but it's happening.

It's a real [00:23:00] fear, but programs don't just go from good standing to losing accreditation immediately.

I think that's a common misconception.

So it's a reasonable fear among residents and likely contributes to under-reporting of issues, but it might not be as credible a fear as some residents are led to believe.

I do wanna clarify, though, that the ACGME can only intervene on issues regulated by ACGME accreditation or recognition requirements.

Many issues that residents face fall within this purview, like working hours, for example. But some do not, so the ACGME isn't the answer to everything.

You said earlier that there are three reporting mechanisms for ACGME. What are the others?

So the next is the Office of the Ombudsperson for the ACGME. I didn't actually know about this until recently, but this mechanism allows anonymous reporting of issues about residency programs without affecting the program's accreditation status.

According to the ACGME, this office functions as an independent, impartial [00:24:00] party which will work with the institution to request an internal inquiry to further explore the issues raised and to create an action plan to address any valid concerns.

Oh, so potentially improvement not directly tied to accreditation.

Yes. The ACGME also has an Office of Complaints. Anyone who has evidence of non-compliance with ACGME r- requirements can report the issue by submitting a formal complaint. A formal complaint may affect accreditation status and therefore cannot be made anonymously.

That seems like a nuclear option.

It definitely is.

Not only are you risking putting your program's accreditation at risk, you are also doing so without the anonymity provided by the ACGME survey. I can understand why a resident would be hesitant to do so.

ACGME enforcement in general is difficult because there's very little middle ground between nothing happening and putting accreditation at risk, which becomes an even bigger problem for the resident.

So how can we fix [00:25:00] it?

Well, I think there are several opportunities. I would first call upon our program directors to be the leaders in this space. I know there are some phenomenal PDs out there who are doing their best to advocate for their residents. To them, I say thank you One good example of this, I think, is collecting accurate data regarding work hours and using it to affect change on how services are staffed and run.

There are automatic work hour reporting apps that can be implemented. For example, my program uses the Rescue app, which automatically logs my hours when I enter and leave the hospital.

Aren't you worried about privacy with that?

That's a fair point. Rescue uses your location to determine when you enter and leave the hospital, but it does not save or store any of that data on its servers, per the company's website.

I know that requires us to trust a company, but I look at it this way. There are plenty of companies that track my location most of the time anyway, so I might as well use some of that data to make my life easier. I understand the privacy concerns, and I [00:26:00] know that Rescue implementation has failed at some programs for that exact reason, but it's worked in my program, and personally, I love it.

Since you told me about this app, I've actually started the conversation for it in my program. I will say another resident I brought this up to mentioned a, a fair point. She talked about a time when an attending noticed that she was working really late, and that attending told the chief the next day to help make sure she got out sooner.

Then the chief, though, got mad at her because she thought she'd tattled, um, and then the whole classic, you know, she needed to be more efficient situation. So this also requires programs to accept that data without blaming the resident.

Agreed. But without accurate data, programs can't necessarily identify the root of the hours issue.

Regardless, is there anything that could be done beyond the individual problem or institution level?

Sure. As we discussed, the ACGME only has so many options for enforcement, and they pretty much all affect accreditation. One thing that could help is improve transparency regarding accreditation status and [00:27:00] citations.

Yes. If applicants knew all the citations that programs currently held or probation status during the application process, applicants could make more informed decisions when it comes to ranking. This could make program citations more influential. So I'm not sure how much of an effect it would have

That's fair.

Otherwise, the ACGME's enforcement power is a bit of a blunt tool and can't reach all of the issues that residents might face. That's where a discussion about policy comes in. Anonymous reporting requirements and anti-retaliation re- protections could help. Also, a stronger middle ground for enforcement could allay residents' fear that their complaints could lead to a loss of accreditation.

Perhaps policy aimed at funding ramifications in response to issues could be a strong motivator for institutions, though that could get messy quickly, so thoughtful development and implementation would be needed.

Yeah, that would definitely be tough to do.

Lastly, I think [00:28:00] more residents should be aware of the ACGME Ombudsperson as a reporting mechanism.

They are not the only solution. We could definitely use an independent ombuds beyond the ACGME, and that's where I think we should talk about unions.

Yes. We discussed in the first episode how unions can be useful, though not perfect, regarding pay and benefits. How does it fit in here?

Unions aren't only about salary.

They also represent the residents as a stronger way to hold institutions accountable to their commitments.

So after the union helps to negotiate a contract between residents and their training institution, they also provide representation to help resolve any conflicts that arise.

Residents can file grievances if hospitals don't honor their commitments.

If the grievances aren't resolved, they can also force an arbitration process to resolve the issues.

In that way, a union could fill the gap when it comes to reporting to help hold institutions accountable.

In the end, though, they don't replace the [00:29:00] ACGME and are not a substitute for other reforms.

And we need to be transparent.

Unions aren't a perfect solution, and there are reasonable critiques. Some of these were outlined in a 2024 paper where one of the major themes was that unions change the educational environment.

Residents and faculty expressed that unionization transformed the relationship into an adversarial one and it interfered with the building of mentoring relationships.

It goes back to our prior conversation that residents are stuck between the roles of learner and laborer, and a union may not be able to reconcile that position well

That being said, this data is only from two programs and was a secondary analysis of interview and focus group data from a larger study not specifically focused on unionization.

It's important to consider, but it might not tell the whole story.

It's a nuanced conversation that could be an entire episode on its own, um, and the data is also actively evolving. All right, so [00:30:00] before we close out this episode in the series, I wanna give each of you a chance to leave listeners with your biggest takeaway.

The horrors persist, but so do I. But seriously, the problem is multifaceted and residents have a real voice in how we can shape the solution, not only as agents of culture change, but also through advocacy and involvement.

There's no easy solution, but residents need reporting mechanisms that are respected and lead to meaningful change without fear of retaliation or loss of accreditation.

Residents should not have to choose between protecting their training and protecting themselves. If speaking up can threaten your career and leaving can end it, neither voice nor mobility is truly meaningful.

Now, stepping back to the whole series, thank you for following along with us this whole time.

In episode one, we talked about pay, benefits, and bargaining power, and how compensation is not just about money, it is also about value. When residents are essential to patient [00:31:00] care but have limited say over salary, benefits, leave, childcare, parking, meals, or basic protections, that sends a message about how resident labor is valued.

In episode two, we moved upstream to the application process, over-application, signaling, transparency, and the application arms race. Applicants apply broadly because they are afraid of going unmatched, while programs are trying to review hundreds or thousands of applications and still somehow do meaningful holistic review.

That is not a failure of individual applicants or programs. It's a system responding to uncertainty.

And today in episode three, we move downstream to what happens after the match when residents are actually living and working inside these training environments.

So our final takeaway is this: meaningful reform cannot be only about keeping or abolishing the match.

That framing is too narrow. The congressional report brought attention to real concerns. We agree those concerns deserve attention, but if we want reform that [00:32:00] actually helps residents, patients, and programs, we need to focus on the structures underneath the match because residents are not just future physicians, they are physicians now.

They are learners, yes, but they are also workers, teachers, caregivers, colleagues, and essential members of the healthcare system. A better system should recognize all of that. Thank you to Carl, Michael, and Omair for joining today and all of the other COSF members who helped make this series possible.

Thank you for listening to Behind the Knife, and as always, go forth and dominate the day