How Medical Residency Sidesteps Labor Laws
After graduating from medical school, physicians enter a residency—a multi-year training program that blends education with intense, full-time clinical service. Residents are expected to manage patient care, perform procedures, and make life-or-death decisions while working up to 80 hours per week, often in 24- to 28-hour shifts with minimal rest. Despite being fully licensed professionals contributing essential labor to hospitals, residents are paid modest salaries and lack many protections guaranteed to workers in other industries. While the residency process is framed as a rite of passage, its structure routinely sidesteps fundamental labor laws—raising serious ethical and legal questions about how we treat the future of our medical workforce.
The Fair Labor Standards Act (FLSA) is a federal law that establishes minimum wage, overtime pay eligibility, and labor standards for most workers in the United States. Under the FLSA, employees who work more than 40 hours per week are entitled to time-and-a-half pay for overtime. However, resident physicians are technically classified as "exempt professionals," a designation that allows hospitals to avoid paying overtime wages despite residents frequently working 80+ hours per week. This exemption is rooted in the argument that residency is primarily educational rather than employment-based—a claim that becomes increasingly questionable given the level of service residents provide. In practice, residents function as essential medical staff, performing billable work and generating revenue for hospitals, all while earning a fixed salary that often equates to less than minimum wage when adjusted for hours worked. This structure circumvents the fundamental protections the FLSA was designed to guarantee, creating a labor system that would be illegal in nearly any other industry.
The Occupational Safety and Health Act (OSHA) was enacted to ensure that every worker in the United States has the right to a safe and healthy workplace. This includes protection from physical hazards, excessive fatigue, psychological stress, and unsafe working conditions. Yet the structure of medical residency routinely violates these principles. This is not an isolated incident, but a systemic issue. Residents are regularly scheduled for 24- to 28-hour shifts, often without adequate time for rest or recovery, despite overwhelming evidence that sleep deprivation impairs cognitive function, increases the risk of medical errors, and endangers both patients and providers. OSHA regulations also emphasize the importance of mental well-being and the employer's responsibility to prevent workplace stress and burnout. However, residency culture normalizes chronic overwork, emotional abuse, and a fear-driven environment where reporting safety concerns can lead to retaliation. In any other industry, such conditions would be subject to investigation and penalties. In medicine, they are regarded as traditions.
The culture of excessive work hours in residency has disturbing origins. The modern model of grueling, around-the-clock training is often traced back to Dr. William Halsted, a pioneering surgeon at Johns Hopkins—and a known cocaine addict. Halsted's personal habits, which included periods of hyperfocus and sleeplessness fueled by drug use, shaped the early norms of residency training. Rather than being re-evaluated with advances in sleep science and labor protections, his model was institutionalized and romanticized as a test of dedication. As a result, today's residency system still reflects the values of a bygone era—prioritizing endurance over safety and tradition over evidence.
The Family and Medical Leave Act (FMLA) entitles eligible employees to up to 12 weeks of unpaid, job-protected leave for medical conditions, childbirth, or caregiving needs. It wasn't until 2021 that the ACGME mandated that all residency programs provide a minimum of six weeks of paid parental leave, a move partially in response to growing scrutiny and lawsuits. Even now, many programs subtly discourage residents from taking leave—implying it will delay graduation, burden co-residents, or damage their reputation. Residents who become pregnant, fall ill or need mental health leave are often made to feel guilty or inadequate, reinforcing a culture of self-neglect that runs counter to both labor law and basic human dignity. Though policy has evolved, the stigma remains deeply embedded.
Residency programs are also frequently at odds with federal anti-discrimination laws, including Title VII of the Civil Rights Act and the Americans with Disabilities Act (ADA). Title VII prohibits discrimination based on race, gender, religion, and pregnancy, while the ADA mandates reasonable accommodations for individuals with physical or mental disabilities. In practice, many residency programs fail to uphold these standards. Pregnant residents are often discouraged from taking time off or are subjected to biased assumptions about their work ethic or career commitment. Residents with disabilities—including chronic illnesses, mental health conditions, or neurodivergence—regularly face opaque accommodation processes, institutional resistance, or outright retaliation for disclosure. Some are advised to "push through" rather than seek help, while others are penalized through poor evaluations or contract non-renewal. The very institutions that train physicians to advocate for vulnerable patients often neglect to protect their own trainees from discrimination and exclusion.
Even seeking mental health treatment—a right protected under the ADA—is fraught with risk for residents. Many fear that disclosing a psychiatric diagnosis or pursuing therapy could jeopardize their future board certification, medical licensure, or job opportunities. Some state medical boards and credentialing bodies still ask invasive questions about mental health history, reinforcing stigma. As a result, residents are often forced to choose between their well-being and their careers.
Perhaps most dangerously, residency programs often violate whistleblower protection laws by punishing residents who speak up about unsafe conditions, discrimination, or mistreatment. In many institutions, formal complaint filing can lead to subtle but devastating retaliation—poor evaluations, exclusion from opportunities, or even contract non-renewal. The hierarchy of medical training, combined with the power imbalance between residents and attendings, creates a high personal risk for any residents who report any wrongdoing. This ensures that systemic problems remain unsolved. This kind of retaliatory environment would be a legal violation in any other workplace. In medicine, it's simply called training.
Fixing these systemic violations will require more than surface-level policy changes—it demands a fundamental shift in how we value the labor and humanity of resident physicians. Enforcing existing labor protections—such as FLSA standards, OSHA safeguards, FMLA rights, and anti-discrimination laws—should be the baseline, not the exception. Accrediting bodies must hold programs accountable for educational benchmarks, workplace safety, and legal compliance. Medical boards must eliminate punitive questions about mental health, and residency leadership must cultivate environments where seeking help or speaking out doesn't come at a personal cost. Residents are not merely trainees but employees, caregivers, and human beings. To build a sustainable and ethical healthcare system, we must start by honoring their rights.
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