All’s Fair in Residency and College Football

Since the college football transfer portal opened this week, my husband has been talking about it at home. 

Normally, football talk sounds like Muppet voices to me. But this one caught my attention, because it made me think about residents and how little freedom of movement they have during training.

Allow me to explain:

Until recently, college football players committed to institutions at eighteen years old, under highly restrictive conditions. They trained, played, and left it all on the field in exchange for scholarships, with limited ability to earn outside income. Transferring schools was possible, but difficult. In many cases, athletes who transferred were required to sit out a full season, effectively delaying their development and visibility. They also had to obtain the permission of their coach or athletic director in order to even begin the transfer process, meaning the coach could simply say no, and their position on the team and scholarship was now in jeopardy.

The structure strongly incentivized staying put.

One mechanism within that system is redshirting: a year in which an athlete does not compete in games, preserving eligibility for later seasons, effectively letting an athlete graduate from college in 4 years but still have a ‘5th’ year to join another team as a grad student. Sometimes this benefited the athlete. Sometimes it benefited the program. Often, it benefitted both. But it also reinforced this system in which institutions controlled the timeline for the individual.

Meanwhile, of course, the leadership and admin did have mobility. Coaches and athletic directors could leave for other programs. Contracts could be renegotiated or broken with no consequences. Cultures could change quickly, with athletes left behind. Imagine if a student had signed for one coach, only to quickly be under the tutelage of another?

Over the past decade, that imbalance has been challenged. A series of antitrust class action lawsuits and policy changes reshaped college athletics, culminating in the recognition that student-athletes could profit from their name, image, and likeness. The idea that their labor had economic value was no longer controversial; it was acknowledged.

Shortly after, the transfer portal became formalized.

Today, athletes can declare their intent to transfer during defined windows of time. Once entered, they may be recruited by other programs without penalty. The process is structured, time-limited, and transparent enough to reduce the career risk of movement. It is not perfect. But it recognizes a basic reality: sometimes the original match no longer makes sense.

Which raises an uncomfortable question for medical education.

Resident physicians also commit early, often with incomplete information. They rank programs based on leadership, training environment, and institutional culture - factors that can change after arrival. Program directors move on. Departments reorganize. A resident thought they could make it work in a city across the country from home, but realize that it’s not the right fit once they’re there. What once felt workable can become untenable.

Transfers do occasionally occur in residency, but they are informal, opaque, and highly variable. There is no standardized window. No centralized system. No clear protections for the trainee navigating that process. Mobility exists largely through personal connections and quiet negotiations, not institutional design.

The comparison to college athletics is not exact. Medicine is not a sport. Patients are not games. But structurally, both systems place young “professionals” into binding arrangements with limited exit options, while allowing leadership far greater freedom of movement.

To underscore how significant the shift has been: the most recent transfer portal window has just opened, and early reporting suggests that roughly 4,500 college football players entered the portal - an estimated one-third of all scholarship players.

That number alone signals something important. When given a structured, time-limited, and sanctioned way to move, a substantial portion of participants used it immediately. Not because everyone was unhappy, but because mobility itself carries value.

Freedom of movement doesn’t create instability by default. Sometimes, it simply reveals how many people were waiting for a door to exist. 

College athletes were long described as amateurs. They were told the scholarship was the payment, the education enough. Meanwhile, their labor filled stadiums, anchored television contracts, and generated billions of dollars for universities, conferences, and the NCAA. The label was never neutral. It functioned as moral cover for denying that work was work.

Residency relies on a strikingly similar story that we’re told. Residents are framed as learners first, compensated in experience and future opportunity. But in practice, they are a primary labor force for hospitals - staffing wards, covering nights, and sustaining the daily operation of the healthcare system. The training they receive is real. But so is the economic value they produce.

College football did not reform because it stopped believing in education (unclear if education was ever really the top priority…). It reformed because the mismatch between responsibility, risk, and autonomy became impossible to defend (and, they kept losing in court).

Medicine still insists that mismatch is character-building.

Will medicine ever be willing to admit that calling resident labor ‘training’ only makes it easier to underpay, overwork and restrict the people doing it? Probably not on its own. But with enough people demanding change, there may be a blueprint for how the power imbalance can shift back towards the residents themselves.

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