This loses sight of the lack of incentive missing from hospitals and even residency programs from funding their own positions. There’s literally no regulation preventing a program from funding their own without Medicare dollars. They just need ACGME to sign off on it.

Turns out if you hand out free money for minimum wage employees that rely on your training to not kill people, there’s very little incentive to pay out of pocket. Especially so when programs realize that their trainees will just work harder/longer for the same pay without much complaining.

I also think there’s a method to the madness of training program length and number of spots (namely, ensuring you have enough exposure to the common things/uncommon things you will encounter on your own to be competent), but I agree more scrutiny would weed out inefficiencies in the training process. But like, there’s an obvious reason neurosurgery residencies don’t take that many trainees every year, not just to create artificial scarcity.