Imagine two mice that run the same distance on treadmills. One chooses to run. The other is forced. The workload is identical, but the stress response is not.
In fact, mouse experiments show that involuntary treadmill running increases anxiety and stress hormones, while voluntary wheel running does not. Perceived control, not just objective workload, is a core driver of psychological stress. It’s not always what happens to you, but whether you felt you had agency over it that matters.
Residency can feel like that forced treadmill, but it’s also what I signed up for. I remind myself often that residency is temporary. Fellowship is temporary. Attending life will be better.
But recent scrutiny of the physician training pipeline, from the House Judiciary Committee's report on the Match to renewed litigation against the American Board of Internal Medicine (ABIM), makes that light at the end of the tunnel feel less bright. What I have started to feel — and what many physicians are already articulating — is that the system is not merely demanding, but structurally exploitative.
Beginning with the application to medical school, the aspiring physician is funneled into a single application system controlled by the AAMC with no competing alternative. All costs of the process fall entirely on the applicant. The AAMC sets the price because it can. The cycle repeats when medical students apply to residency using ERAS, also operated by the AAMC. As the mandatory portal for residency applications, ERAS generates more than $30 million in annual revenue, which is 20%–25% of the organization’s overall operating budget.
Next is the Match (NRMP), described in the recent House report as a labor monopoly that eliminates negotiation and suppresses wages. During the Match, residents commit to a program without the ability to bargain for salary, benefits, or working conditions. Based on 2024 estimates, a first-year resident will earn an average salary of $66,712. Adjusted for inflation, resident compensation in the early 1970s was higher than it is today. And that is despite the fact that the value of the work each resident performs annually is worth approximately $232,000.
The math only gets more sobering. Resident compensation is not only far below the value of the services we provide to patients, but also far below what Medicare pays the hospital to train us. In 2023, the U.S. government provided $29 billion to residency programs for GME. This is roughly $178,000 per resident, which is more than 2.5 times the average resident salary. Hospitals, however, are not required to spend GME funds the same way or even on residency programs. In fact, most hospitals fund more than 50% of their residency training programs out of patient care revenues, which means GME subsidies can be spent on anything else.
Under ordinary circumstances, a system that restricts labor mobility and wage negotiation would raise antitrust concerns. In turn, a class action lawsuit challenged the Match in 2002. In response, Congress granted it a special antitrust exemption in 2004. Today, applicants who are paired to a program are legally bound to an employment agreement. Violating the Match agreement, either by rejecting the offer, deferring it, or using it to seek other positions, can result in a permanent ban from the NRMP and disciplinary action, including notification to all professional medical societies in the country.
Meanwhile, college graduates entering other fields, such as consulting or technology, may be promoted several times before a physician finishes residency. They negotiate raises and build equity. Their compounding begins early. But physicians spend their 20s and much of their 30s in non-negotiable wage structures.
In the end, we practice delayed gratification so long that we forget to calculate what was delayed. And the institutional control does not stop there. It only continues into retirement.
Board certification must be maintained through recurring exams and continuing education requirements. This process, Maintenance of Certification (MOC), is described as voluntary. In practice, however, many hospitals and insurers require active certification for employment. Failing to pay the fees can jeopardize a physician’s job.
The difference between seeming choice and real compulsion is precisely what has fueled more than a decade of litigation between the Association of American Physicians and Surgeons (AAPS) and The American Board of Medical Specialties (ABMS). In December 2025, the American Osteopathic Association added claims that ABIM’s control over internal medicine certification excludes osteopathic physicians from program directorships, effectively locking DOs out of graduate medical education leadership. And in April 2026, the Restoring Rights of Medical Residents Act was introduced to repeal the 2004 antitrust exemption granted to the Match.
These developments suggest growing discomfort with the structure of the physician training pipeline. Still, physician advocacy for greater autonomy and fair compensation faces a cultural obstacle. Medicine has long been framed as a “noble calling,” which creates an implicit social expectation that physicians should be motivated purely by altruism. The entire ethical foundation of medicine is built around self-sacrifice, "do no harm," put the patient first, and treat regardless of ability to pay. These principles are honorable. But they can also be weaponized to justify undercompensating and overworking physicians.
Nobody questions whether a hedge fund manager or tech CEO "deserves" their compensation in moral terms. But physician pay is perpetually debated and routinely subjected to ethical scrutiny. The implication is that earning a fair income corrupts our professional virtue.
I worry that if every doctor strictly enforced work-life boundaries, refused uncompensated administrative burdens, and negotiated aggressively, the U.S. healthcare system would likely collapse. Often, it relies on physician overextension to survive. Our willingness to absorb hidden costs can keep many clinics staffed and hospitals functional. Our selflessness operates as a hidden subsidy.
A profession, by definition, includes self-regulation and meaningful control over the conditions of work. Advanced education is supposed to increase bargaining power. And in most sectors, it does — just not in medicine. It seems that the pipeline that produces physicians was designed, at every stage, to ensure they arrive at attendinghood already conditioned to comply.
We entered the system willingly. We chose to run. Yet over time — between mandatory application portals, the wage-restricted Match, years of fixed training conditions, and recurring board certification fees — the running stopped feeling voluntary.
A physician who sacrifices freely is not the same as one who has been structurally prevented from doing anything else. One is a vocation. The other is a mechanism. And somewhere along the way, we started mistaking the mechanism for a calling.
