Other demands are less easily explicable. Residents in America are expected to spend up to 80 hours a week in the hospital and endure single shifts that routinely last up to 28 hours—with such workdays required about four times a month, on average. (Some licensed physicians continue to work similar schedules even after residency but, importantly, only because they choose to do so. The vast majority of doctors work fewer than 60 hours a week after they complete their training.) Overall, residents typically work more than twice as many hours annually as their peers in other white-collar professions, such as attorneys in corporate law firms—a grueling schedule that potentially puts both caregivers and patients at risk. In Europe, by contrast, residents are subject to a maximum workweek of 48 hours, without apparent harm to patient care or the educational component of residencies.

Part of the reason medical training is so demanding in the United States is that hospitals control the labor market for residents by assigning spots based on a centralized matching system rather than an ordinary, competitive market. While such collusive arrangements are generally prohibited by the nation’s antitrust laws, employer-controlled labor markets are not uncommon. Just as an enterprising entrepreneur cannot form an independent baseball team and challenge the Yankees for a spot in the A.L. East, an aspiring doctor has no legal right or ability to negotiate the terms of his or her entrée into the medical profession. Instead, the sole avenue to being a fully licensed medical doctor in the United States is by submitting to what is known as “the match.”

Considered on its own terms, the match seems fair. It gives principal consideration to medical students’ stated preferences, and is governed by a mathematical algorithm so efficient that its designers won a Nobel Prize in Economics. Moreover, the original purpose of the system was to improve the bargaining power of medical students vis-a-vis residency programs. “The match was created in 1952 to eliminate the pressure that was being placed on medical students to accept offers earlier and earlier during medical school, and typically before the students knew what other offers might be available,” explains Mona Signer, the president and CEO of the National Resident Matching Program (NRMP), which administers the match. Signer therefore dismisses the notion that the match harms residents. Instead, she says, it “creates order out of chaos,” to the benefit of both institutions and the residents they employ. (She further notes that the NRMP itself “does not take any position on the salaries and benefits received by residents in training.”)

But creating order out of the chaos of a free labor market also contributes to industry norms of punishing hours and low pay, by restricting competition among employers that could result in better wages and working conditions. For this reason, a group of residents brought a lawsuit in 2002 challenging the match as an illegal “contract ... or conspiracy, in restraint of trade or commerce” in violation of the federal antitrust laws. Legal niceties aside, it is hard to argue with this general characterization of the match. If, say, fast-food workers or stock-market analysts were subject to a similar arrangement, most would view it as a clear affront to free enterprise and workers’ rights. Under lobbying from the AAMC, among others, Congress disagreed. After a federal district court initially ruled that the match might be an illegal restraint on trade, Congress immediately enacted legislation immunizing medical training programs from antitrust liability.