“Back In My Day:” A Resident’s Retort

What your attending is missing about how residency is different today

We learn to bite our tongues in residency. We have to, if we’re going to make it through. But every time I heard one of my attendings wax poetic about “back in the day,” before duty hours, burnout, and Instagram, it took everything in me not to argue with them. 

So now, officially graduated from the 28th grade, I’m ready to lay out all of my problems with the “back in the day,” speech (with receipts!).

The “back in my day” crowd are right about one thing: residency has changed dramatically since back in the day. But it's not because of duty hours, or laziness, or any version of "kids these days.” The problem is the crushing force of corporatization, driving a wedge through the heart of academic medicine — and specifically between the residents and attendings who should be fighting together to protect it.

Let’s start with what hasn't changed: case numbers. Despite everything — duty hour restrictions, bigger programs, more fellows, more wellness modules — the volume of cases residents report has remained stable (with just a brief, self-limited dip immediately after duty hour restrictions were passed in 2003). (https://pubmed.ncbi.nlm.nih.gov/28398961)

What’s changed are the following three variables: 

• Independence in training, as defined by the level of autonomous clinical experience available to residents
• Faculty hours devoted to the education mission, due to the shift to clinical-volume-based compensation in academic medicine
• Risk tolerance, as defined by residents’ socioeconomic position in public life during and immediately after residency training 

The reason this case is difficult (but not impossible!) to make is that the healthcare system is not designed to collect data about residents’ contributions to patient care (more on that here). Autonomy in particular is a squishy concept. But looking at the literature, you’ll find plenty of alarm bells and coal-mine canaries sounding off on this slow-motion car crash that residency training is in. For example:

• 25-35 percent of graduating general surgery residents report feeling inadequately prepared for independent practice, and are pursuing additional fellowship training at an increasing rate (now over 80 percent in general surgery)
• Program directors across specialties reported a significant decline in teaching time and an increase in time on clinical duties over the decade from 2011 to 2023
• OR teaching time (the difference in case length between teaching and non-teaching cases) fell approximately 36 percent between 2006 and 2013, from around half an hour to just eight minutes per case.
• At the VA, data shows that “attending not scrubbed” (ANS) cases decreased from 15 percent to 5 percent from 2004 to 2019.
•  A study looking at entrustable professional activities (EPAs) found a 61 percent decrease in resident-performed cases and a 52 percent increase in attending performed cases between 2004 and 2020.

So what else, besides duty hours, has changed since the era of flip phones and low-rise jeans, that might be contributing to this devolution of residency training? We just have to follow the money.

Around 2002, academic medical centers started to adopt RVU-based compensation models. Many academic papers at that time flagged this as a serious risk to the academic mission (couched, of course, in that hedged-up academic passive voice).

But nobody stopped the train from barreling down the tracks. By the early 2010s, program directors across specialties were reporting significant declines in teaching time alongside increases in clinical duties. In a 2021 survey, 67 percent of department chairs said financial pressure had affected their ability to educate residents — to “some extent” or “to a great extent.”

And to the corporate overlord’s credit, the shift to RVU-based compensation worked out beautifully. Academic surgeons today generate higher RVUs than their non-academic counterparts, and get paid about 16 percent less for it.

What this means in practice is that the attending who tells you training was better back in the day is the same person whose compensation is tied to volume, whose schedule is built around efficiency, and whose institution has made teaching structurally expensive. They are not taking over the case at the first sign of struggle because they don't want to teach. They're withholding it because they’re trying to get paid what they’re worth.

Money is the most measurable driver of this trend, but it's not the only one. Medicine has also, genuinely and rightly, moved toward the idea that every patient deserves the same standard of care regardless of where they're treated. Oversight requirements have increased at the institutional level. Supervision policies have tightened in the face of ever-increasing liability concerns.

But this creates a tension the system has never honestly resolved: if every case needs to meet the same standard for both quality AND efficiency, where exactly does independent practice get learned? We still need to train surgeons somewhere, somehow. We just haven't figured out how to do that in this new context.

Despite the hierarchy, this is really another example of horizontal hostility, where the frustration your attending is pointing at you belongs somewhere else entirely — and so does yours.

It’s not kids these days, and it’s not the old timers either. It’s the turning of the corporate screw. And if there’s any hope of pushing back, it will mean all of us working together, not screaming up and down the chain.