Each year, escalating burnout and untreated depression drive more than 400 physicians to die by suicide.[i]  Before 1984, resident physicians often worked 90–100-hour work weeks with 24–36-hour on-call shifts.[ii]  Reform only gained traction after the highly publicized death of Liby Zion in 1984, whose care lied in the hands of sleep-deprived, overworked residents.[iii]  In response, the state of New York proposed caps on resident hours,[iv] but it was not until 2003 that the Accreditation Council for Graduate Medical Education (“ACGME”) instituted national standards limiting residents to an average maximum of 80-hours per week over a four-week period.[v]  Even with this lowered standard, 80-hour work weeks remain excessive and outdated, warranting reform in light of modern employment standards.

The Fair Labor Standards Act (“FLSA”) was designed to protect employees by establishing minimum wage, overtime pay and regulate work hours.[vi]  However, resident physicians remain unprotected and exempt from the FLSA.[vii]  During their “intern” years, residents often work 80-hour weeks for salaries between $50,000–$65,000[viii] which translates to roughly $16.25 an hour before taxes.  This is interestingly low compensation for a profession requiring a doctoral degree and at least nearly a decade of education, all while carrying massive student debt, accounting for today’s cost of living, and shouldering the responsibility of saving lives.[ix]  By comparison, nurses earn an average starting wage of $37 per hour[x] and physician assistants (“PAs”) about $32 per hour,[xi] both protected under the FLSA and neither requiring a doctoral degree or at least 12 years of education and training.  This is not meant to discredit their vital contributions, but rather to underscore the disproportionate compensation residents receive for their work.

Becoming a physician represents one of the most demanding professional journeys.  Acceptance rates at U.S. medical schools often fall below 5%.[xii] Yet even after earning this achievement, residents endure relentless schedules leading to burnout, depression, physical exhaustion, and profound personal sacrifices, all in service to their patients.

In 2011, the ACGME limited first-year residents to shifts no longer than 16-consecutive hours after studies indicated that longer shifts increased medical errors.[xiii]  However, this rule was reversed in 2017, once again permitting 24-hour shifts, undermining any progress.[xiv]  A 2022 Harvard study confirmed the risks associated with working such long hours.  When residents were capped at 16 hours, hospitals saw a 32% reduction in significant medical errors, 34% reduction in preventable adverse events, and 63% reduction in medical errors resulting in patient death.[xv]

A 2023 study expanded on these findings. Residents working 60–70 hours per week faced more than twice the risk of medical errors and nearly three times the risk of preventable and fatal adverse events when compared to those working less than 48-hours per week.[xvi]  Even residents who averaged no more than 80-weekly work hours, but worked one or more extended shifts in a month had an 84% increased risk of medical errors, 51% increased risk of preventable adverse events, and 85% increased risk of fatal preventable adverse events.[xvii]  This study also concluded that “resident physicians [who] worked 80 hours or more per week, . . . saw an 86% increase in the risk of a crash on the commute from work and a 99% increase in [an] incidence of near miss crashes.”[xviii]

While the U.S. is aware of the risks posed not only to their doctors, but also their patients, it should look to Europe in helping establish safe practices.  Since 2009, the European Union (“EU”) has capped average work hours at 48-hours per week for all healthcare personnel including doctors, residents, nurses, and support staff. [xix]  A 2018 Danish cohort study found that employees working 41–48 hours per week exhibited significantly lower all-cause mortality compared to those exceeding the EU limit.[xx]

EU law also guarantees 11 consecutive hours of rest per day, 24 hours of uninterrupted rest per week, breaks during shifts longer than 6 hours, and a maximum of 8 hours for night shifts.[xxi]  European countries also have their own supplementary regulations governing healthcare labor standards and overtime compensation.  For instance, Spain limits overtime to 80-hours annually.[xxii]  France requires overtime pay at +25% for the first 8 hours beyond 35 per week and +50% thereafter.[xxiii]  Furthermore, “[a]s an alternative to monetary compensation, employees can be granted compensatory time off (‘repos compensateur de remplacement’) by agreement.”[xxiv]  Several European countries, including Spain, Sweden, and Romania also allow for overtime to be compensated via additional time off. [xxv]  These protections reflect the recognition that safe patient care undoubtedly requires safe working conditions for physicians.

Notably, these reforms are not merely theoretical; they are real and have been proven successful abroad.  A 2002 study of French cardiology residents concluded that when work hour restrictions (“WHR”) were implemented “83% of residents consider that consequences of WHR are beneficial for the patient.”[xxvi]  Additionally, “75% declare they are less likely to make errors due to fatigue and 58% never cut corners in patient care after their night call.”[xxvii]  Hospitals in the United Kingdom have seen similar results.[xxviii]  When resident work hours were reduced from 56 to 48 hours per week, hospitals reported improved clinical outcomes and a 20% reduction in length of stay, admissions, and readmissions.[xxix]  WHRs have also been associated with enhanced training quality, better work-life balance, and safer patient care overall.[xxx]

In contrast, U.S. residents continue to work double these limits without any guaranteed overtime pay or equivalent rest.  Nurses and PAs, by comparison, are protected under the FLSA and must be paid overtime at 1.5 times their regular rate for hours worked beyond 40 per week.  Residents remain uniquely excluded from these protections, despite carrying responsibilities equal to, or greater than some of their peers.

Therefore, the demands imposed on resident physicians have remained unsustainable for far too long.  It is time for state and federal lawmakers to reevaluate what constitutes “fair labor” in medicine.  Legislation should, at the very least, reduce the maximum weekly hours for residents, require compensation for overtime, or guarantee equal time off.  With Europe setting clear precedent for safe and reasonable labor standards, the U.S. must act, not only to protect the well-being of its physicians, but more importantly, to safeguard the patients who depend on them.

[i] See Sandeep Kishore, et al., Breaking the Culture of Silence on Physician Suicide, Nat’l Acad. of Med. (June 3, 2016), https://nam.edu/wp-content/uploads/2016/06/Breaking-the-Culture-of-Silence-on-Physician-Suicide.pdf  [https://perma.cc/N6FT-8PYV] (discussing physician burnout, depression, substance abuse, and suicide).

[ii] See Duty Hours and Patient Safety, PSNet (Sep. 15, 2024), https://psnet.ahrq.gov/primer/duty-hours-and-patient-safety [https://perma.cc/RR8J-7L8Z]; see also How Medical Residency Sidesteps Labor Laws, Coalition for Residency Reform (May 3, 2025), https://www.coalitionforresidencyreform.org/index/how-medical-residency-sidesteps-labor-laws [https://perma.cc/V7SE-DYCR] (explaining 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).

[iii] See Jacob Bergstein, The Libby Zion Case: A Landmark in Medical Malpractice and Patient Safety, L. Off. of Joseph Lichtenstein (July 22, 2024), https://www.themedicalattorney.com/libby-zion-medical-malpractice/ [https://perma.cc/6B26-Q4AL].

[iv] See id.

[v] See Jeremy Spevick, Debate Over the 80-Hour Work Week, AMA J. of Ethics (Mar. 2003), https://journalofethics.ama-assn.org/article/debate-over-80-hour-work-week/2003-03 [https://perma.cc/JE8R-NUCN].

[vi]  See Wages and the Fair Labor Standards Act, U.S. Dep’t Of Lab., https://www.dol.gov/agencies/whd/flsa [https://perma.cc/B8WE-VBAA] (last visited Oct. 29, 2025). 

[vii] See Fact Sheet #17D: Exemption for Professional Employees Under the Fair Labor Standards Act (FLSA), U.S. Dep’t Of Lab. (Aug. 2024), https://www.dol.gov/agencies/whd/fact-sheets/17d-overtime-professional [https://perma.cc/97QJ-DYKX]

An employee holding a valid license or certificate permitting the practice of law or medicine is exempt if the employee is actually engaged in such a practice. An employee who holds the requisite academic degree for the general practice of medicine is also exempt if he or she is engaged in an internship or resident program for the profession.

[viii] See Dr. Apurva Popat, What is the Salary After USMLE?, USMLEStrike (Sep. 16, 2025), https://usmlestrike.com/what-is-the-salary-after-usmle/ [https://perma.cc/QU6M-DTTH] (explaining “. . . [f]or most residents, the salary begins at around $50,000 to $60,000” while “[b]y the second year, a resident may earn between $55,000 to $65,000”).

[ix] See Melanie Hanson, Average Medical School Debt, Educ. Data Initiative (Sep. 14, 2025), https://educationdata.org/average-medical-school-debt [https://perma.cc/6DK3-XB2L] (explaining among the Class of 2024, 17% of public and 31% of private graduates owed more than $300,000 student loans. Overall, 73% of public graduates borrowed, with an average debt of $203,606, while 67% of private graduates borrowed, averaging $227,839.  Debt repayment however remains a persistent challenge); see also ApartmentAdvisor National Rent Report, Apartment Advisor (Aug. 2025), https://www.apartmentadvisor.com/national-rent-report [https://perma.cc/4YX6-2ES7] (noting that as of 2024, average monthly rent for a one-bedroom apartment was $3,663 in New York City, $3,350 in San Francisco, $2,734 in Boston, $2,495 in Jersey City, $2,337 in Washington, D.C., $2,247 in San Jose, $2,187 in San Diego, $2,152 in Miami, and $2,079 in Los Angeles).

[x] See Entry Level Nurse Salary in Miami, FL, ZipRecruiter, https://www.ziprecruiter.com/Salaries/Entry-Level-Nurse-Salary-in-Miami,FL [https://perma.cc/87W6-EB4T] (last visited Oct. 29, 2025).

[xi] See Physician Assistant Salaries in Florida, Physician Assistant Edu, https://www.physicianassistantedu.org/florida/florida-salary/ [https://perma.cc/J8CK-TRE7] (last visited Oct. 29, 2025).

[xii] See generally Medical School Acceptance Rates (Plus, What to Expect in 2025), MedSchoolCoach, https://www.medschoolcoach.com/medical-school-acceptance-rates/ [https://perma.cc/3K82-SZP7] (last visited Oct. 29, 2025) (demonstrating top schools like Yale, Georgetown, and Johns Hopkins have acceptance rates of 1.58%, 1.40%, and 2.09%, respectively, and that state schools are equally competitive, including Florida International University’s Herbert Wertheim College of Medicine and Florida State University’s College of Medicine with a 1.98% and 1.86% acceptance rate, respectively).

[xiii] See Haley Bridge, Doctors, Sleep, and Patient Safety, Harv. Med. Sch. (May 12, 2022), https://hms.harvard.edu/news/doctors-sleep-patient-safety [https://perma.cc/BC45-D698].

[xiv] See id.

[xv] See id.

[xvi] Laura K Barger, et al., Impact Of Work Schedules of Senior Resident Physicians on Patient and Resident Physician Safety: Nationwide, Prospective Cohort Study, Nat’l Libr. of Med. (Mar. 30, 2023), https://pmc.ncbi.nlm.nih.gov/articles/PMC10254593 [https://perma.cc/2XYQ-LDHS].

[xvii] See id.

[xviii] See id.

[xix] See Directive 2003/88/EC – Working Time, Eur. Agency for Safety & Health at Work (Apr. 28, 2023), https://osha.europa.eu/en/legislation/directives/directive-2003-88-ec [https://perma.cc/Z55X-JBZ5].

[xx] Harald Hannerz & Helle Soll-Johanning, Working Hours and All-Cause Mortality in Relation to the EU Working Time Directive: a Danish Cohort Study,  28 Eur. J. of Pub. Health 810, 810 (Mar. 12, 2018).

[xxi] See id.

[xxii] See Working Hours and Paid Time off in Spanish Jobs – 2025 Guide, Think Spain, https://www.thinkspain.com/information/working-in-spain/working-hours-and-paid-time-off-in-spanish-jobs?utm  [https://perma.cc/KUH4-8254] (last visited Oct. 29, 2025) (“If you work more than an annual weekly average of 40 hours, you must be paid overtime. You cannot work more than 80 hours’ overtime per year.”).

[xxiii] Posted Workers’ Rights, Ministère du Travail, https://travail-emploi.gouv.fr/posted-workers-rights-en?utm [https://perma.cc/KP3L-LUQX] (last visited Oct. 29, 2025) (“Payment for overtime is supplemented as follows . . . [] 25 % for the first 8 hours over the statutory working time (between the 36th and 43 rd hour of work) [and] [] 50 % for hours thereafter (from the 44th hour)”).

[xxiv] Dr. Luise Brunk, Overtime – a Legal Comparison Between France and Germany, Emp. & Lab. Lawyers Int’l https://ellint.net/news/sector/general/overtime-a-legal-comparison-between-france-and-germany/  [https://perma.cc/3E24-BU4E] (last visited Oct. 29, 2025).

[xxv] See Employment Law in Spain, Safeguard Glob., https://www.safeguardglobal.com/country/spain/employment-law/ [https://perma.cc/T6QB-V2GZ] (last visited Oct. 29, 2025) (“Any work beyond the standard working time is considered overtime. Spanish law limits overtime to 80 hours per year, excluding hours compensated with equivalent rest.”); see also Working Hours and Overtime in Sweden, Payroll, https://www.playroll.com/working-hours/sweden [https://perma.cc/5UAQ-WRPQ] (last visited Oct. 29, 2025) (“Some workers may opt for compensatory leave – 1.5 to 2 hours off per hour of overtime – instead of cash payment, depending on their contract or collective agreement.”); see also Working Conditions in Romania, L&E Global https://leglobal.law/countries/romania/employment-law/employment-law-overview-romania/03-working-conditions [https://perma.cc/8BUG-WSV6] (last visited Oct. 29, 2025) (“Overtime shall be compensated by paid off hours during the next 90 days.”).

[xxvi] Ghassan Moubarak & Antoine Leenhardt, Effects of Work Hour Regulations in France as Perceived by Cardiology Residents, Nat’l Libr. of Med. (May 15, 2008), https://pubmed.ncbi.nlm.nih.gov/18672668 [https://perma.cc/8EX7-D5RG].

[xxvii] Id.

[xxviii] See Working Time in the Health Sector in Europe, Eur. Trade Union Confederation 9, https://www.etuc.org/sites/default/files/A_TT_secteur_sante_u_EN_1.pdf?utm [https://perma.cc/PZ9W-9BCA] (last visited Oct. 29, 2025) (“The ‘Hospital at Night’ initiative is a good example of how the Working Time Regulations have been implemented in the UK to reduce working hours from 56 hours a week to 48 hours a week by 2009.”).

[xxix] See id. (“The benefits have been better clinical outcomes and a 20% reduction in length of stay, admissions and readmissions.”).

[xxx] See id. (“The implementation of the system has had positive outcomes on training, work-life balance and safer patient care.”).