This past year, with hundreds of thousands of dollars of debt, I finally started my first real job as an intern at NewYork-Presbyterian Weill Cornell Medical Center. Like most jobs, I was welcomed with a mandatory training session before my official start date. Initially, my 2-week orientation seemed like a standard job training, one that I heard friends outside of the medical field talk about and mock because of boring lectures that overuse words like synergy. However, after speaking with friends attending intern orientations from different specialties across the country, we were shocked when we realized one major difference—some of us weren't being paid to attend.

According to the Association of American Medical Colleges (AAMC), the average age was 24 for students entering US medical schools from 2017 to 2018.1  This gives most first-year medical students 1 to 2 years of real world experience before starting their medical training. Like many interns, I never had a “real job” before medical school; my pre–medical school years were filled with minimum wage employment in clinical and laboratory settings to improve my medical school application. I never negotiated a salary or considered employee benefits and was appreciative of any compensation, as I often felt desperate to build my resume to ensure my dream of becoming a physician.

It is in this spirit that my friends and I had mixed feelings when we discovered that some residency programs pay their interns for orientation while others do not. For years, we worked toward becoming physicians and stressed to family, friends, and most recently, during residency interviews, that we were driven by altruism and not by dollar signs. We tried to convince ourselves that 2 weeks of unpaid training was fair and that we should not speak up because no one wants to be a complainer on day one. The more we thought about this issue, the more it didn't seem right, but once we decided to speak up, no one knew where to direct our concerns. Resident salary is determined by the Graduate Medical Education Committee in collaboration with the designated institutional official and funded primarily by the US government; however, the 2019–2020 AAMC report regarding resident stipends and benefits does not mention resident orientation, and there are no specific Accreditation Council for Graduate Medical Education guidelines that outline payment requirements for residency orientation.24  With little information to guide us, the search for solutions continued.

The not so simple solution to this dilemma dates back to the Fair Labor Standards Act (FLSA) of 1938, which was created to protect workers. Per the US Department of Labor's Wage and Hour Division, the FLSA requires that employees be paid for training unless it is outside the employee's regular work hours, attendance is voluntary, it is not directly related to the employee's job, and the employee does not perform productive work.5  Though the details of orientation may vary, among my peers, we did not find an intern orientation that fits this description. The good news for interns is, when addressing this issue with hospital leadership, some of us were paid. That said, although the resolution to this problem may seem simple, per the AAMC, medical residents are exempt from the FLSA due to the “learned professional exemption,” and therefore not subject to the FLSA requirements regarding overtime pay and minimum wage.6  This exemption was created in September 2019; however, there is no mention of payment for training such as orientation that often occurs before the intern's official residency start date.

I would encourage graduate medical education leaders to evaluate their intern orientation and assess whether their payment structure adheres to the FLSA; however, regardless of the FLSA, I would encourage leaders to pay residents for orientation as it seems like the right thing to do. To interns, congratulations on your first real job and, much like Rod Tidwell in the movie Jerry Maguire, don't be scared to say, “Show me the money!” However, remember to say “please” because, after all, you are still just an intern.

1
Association of American Medical Colleges
.
Age of applicants to US medical schools at anticipated matriculation by sex and race/ethnicity, 2014–2015 through 2017–2018
. ,
2020
.
2
Congressional Research Service
.
Federal Support for Graduate Medical Education: An Overview
.
Updated December 27,
2018
. ,
2020
.
3
Accreditation Council for Graduate Medical Education
.
ACGME Institutional Requirements
.
Effective July 1, 2018
. ,
2020
.
4
Association of American Medical Colleges
.
Survey of Resident/Fellow Stipends and Benefits Report 2019–2020
. ,
2020
.
5
US Department of Labor Wage and Hour Division
.
Fact Sheet #22: Hours Worked Under the Fair Labor Standards Act (FLSA)
. ,
2020
.
6
Association of American Medical Colleges
.
DOL publishes final overtime rule
.
September 27,
2019
. ,
2020
.

Author notes

Katherine Pumphrey, MD, is a Resident, Department of Pediatrics, NewYork-Presbyterian Hospital Weill Cornell Medical Center.