I don't necessarily think the relationship is "worse residency conditions predicts higher board exam scores"? It could be that residents with more time to study

I don't necessarily think the relationship is "worse residency conditions predicts higher board exam scores"? It could be that residents with more time to study or whatever score higher. It could be examinees with scores close to the threshold are accounting for the association. Or maybe it is resiliency. I have no idea. My general impression is that the evidence overall is really not supportive of harsher residencies in terms of patient outcomes. I also think that rigor does not have to mean masochism or hubris; there seems to be this assumption that any change to residencies would mean dumbing it down or making it easier, as opposed to improving things overall. I'm also a little skeptical of minor tweaks to residency that might have happened somewhere now being representative of a more wholesale restructuring. The often unacknowledged factor in the background is that hospitals and residency locations are getting free labor with no chance of repudiation of their situation by workers. Hospitals are getting physicians whose salaries are paid for by the federal government, where those physicians are essentially unfree to move if they're unhappy. So of course there's going to be an attempt to milk them for everything. It gets whitewashed as "selflessness" and physicians are encouraged to boast about it or something, instead of calling it out as exploitation. No physician wants to make that claim, for a whole host of reasons, even if it is true. Imagine what would happen if hospitals had to bear the costs of residency training completely, like just about any other healthcare profession, and residents were able to move freely like most employees. I get despondent about so much in US healthcare. There's so much focus on invoice costs per se, and payment by insurers, and not enough on monopolies in service delivery, and problems with educational structures. Any attempt to address these issues is met with resistance by various groups with conflicts of interest, who aren't called out on these conflicts of interest. Another thing about residencies constantly on my mind from other settings (institutional tracking hours in the moment versus recalled hours later) as well as personal experiences with residency in the past is that people are notoriously bad about reporting past work hours and conditions, and tend to exaggerate. I'm not saying that anyone in particular is necessarily being dishonest in describing their residency experience, but I suspect there has been drift over time in conditions that reflects a kind of biased memory of things on the part of residency directors. "I worked 120 hours a week" when that wasn't actually the case, or is distorted, then becomes residency policy for the next generation. Sometimes I feel like the logical conclusion, given the way these discussions go sometimes, is the only one being legally able to practice is someone with an MD who has completed a residency working 140 hours a week for 6 years, with perfect board exam scores. It just doesn't add up.