The case of the reluctant residents
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In the bad old days, medicine was a cozy club whose relatively wealthy members earned their brandy and cigars by serving the rich, assuaged their social conscience by tending to the poor, and ensured continuity by teaching younger physicians for free. These days, the brandy bottles are empty and the cigars extinguished, and students are left to their “personal learning objectives.” The doctors' clubs have been replaced by doctors' unions, a.k.a. professional associations. Health care has become commodified. So has medical education. Physicians teaching clinical medicine in exchange for status appointments now perceive that these tokens are not so valuable after all. Higher costs for teachers and a swing to the political right have forced universities to pass costs on to students, who now have the banks on their heels.1 Medicine threatens to become an exclusive club again.2,3 To make matters worse, the apprenticeships have lengthened to include an obligatory 1-year increase at the beginning and, for most subspecialties, an additional year or more at the end. 

Despite all this, apprenticeship still thrives — if thrives is the word — in the guild of medicine. Every year a new crop of medical graduates await the fateful results of The Match: Will it be dermatology in Winnipeg, or family practice in Vancouver? Whatever card comes up, the terms and conditions are non-negotiable. This is an odd sort of job fair, and it could only survive in a market niche that, like medicine, is steeped in the mystique of privilege and responsibility.

But the mystique is waning, and medical residents are measuring their situation against the standards of the commercialized world. Paul Jung, a fellow at Johns Hopkins, has, with others, launched a class-action suit on behalf of an estimated 200 000 residents in the US, alleging that the National Residency Matching Program violates anti-trust laws4 (see also page 1579).

They have a point. Their salaries and working conditions are — calculatedly, it seems — uniform across the country. In what other professional sector would this lack of competition — along with excessive working hours and substandard pay — be tolerated? The rationale that residency isn't exactly employment, but education, is wearing thin: ongoing professional development is an integral (and obligatory) component of many jobs. 

If the lawsuit is successful, and intern and resident salaries rise to their market value of over US$100 000, health care costs south of the border could increase by US$12 billion.4 But the issues extend beyond questions of money — working conditions and lifestyles, for example, are increasingly important, not least because of the “feminization” (read: humanization) of medicine. 

But what would a free market in medical residency mean? Will competition yield better working terms and conditions, or will it stratify medical residency as well-heeled institutions scoop up the pick of the crop while the quality of learning — and of patient care — languishes elsewhere? What will happen if residency become less vocational and more entrepreneurial? Whatever the judgement of the courts, the modernization of postgraduate medical education will not be easy. — *CMAJ*

## References

1.  1. Wharry S. Banks no longer banking on earning potential of medical students. CMAJ 2001; 164 (12): 1735. Available: [www.cmaj.ca/cgi/content/full/164/12/1735](http://www.cmaj.ca/cgi/content/full/164/12/1735)
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTY0LzEyLzE3MzUiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY2LzEyLzE1MDEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  2. Dhalla IA, Kwong JC, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Characteristics of first-year students in Canadian medical schools. CMAJ 2002; 166(8):1029-35. Available: www .cmaj .ca/cgi/content/full/166/8/1029
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTY2LzgvMTAyOSI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNjYvMTIvMTUwMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  3. Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE, Johnson IL. Effects of rising tuition fees on medical school class composition and financial outlook. CMAJ 2002;166(8):1023-8. Available: [www.cmaj.ca/cgi/content/full/166/8/1023](http://www.cmaj.ca/cgi/content/full/166/8/1023)
    
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4.  4. Liptak A. Medical students sue over residency system. *New York Times* 2002;May 7. Available: [www.nytimes.com/2002/05/07/health/07DOCS.html](http://www.nytimes.com/2002/05/07/health/07DOCS.html) (accessed 2002 May 14).