Trainee Overload

Right around the turn of the millennium, provincial governments across Canada realized that we had been training too few doctors. Way too few. So they opened up a ton of new medical school spots, including a new medical school itself (NOSM), to fill the gap. Residency spots also expanded, with extra ones specifically for international medical graduates. The whole result was a rather massive and (by medical training standards) rapid increase in the number of trainees in medicine. In Ontario alone, 380 medical student spots were added between 2000 and 2010, up to 950 from a mere 570.

The overall merits of such a rapid expansion are complex and worth saving for a separate discussion, but for now I'd like to focus on one clear downside - trainee overload.

Despite all perceptions to the contrary, medicine isn't that tough. Each individual piece of knowledge or skill doesn't require super-human ability to accomplish. The challenge comes more from the volume of skills and knowledge required and the complexity of putting it all together in unanticipated or uncommon situations.

Acquiring this large volume of knowledge and skills requires an equally large volume of experiences. This is the major rationale behind long and intense training times. However, these factors are being undone by a greater increase in trainee volume. In medicine, patients are a resource, arguably the most important resource. If you're the only learner on a busy service, it's easy to maximize your experiences - you get first dibs on any interesting patients or on any procedures. You can perform to the maximum of your skill set and learn any appropriate new skills whenever an opportunity arises.

When there are more learners at your same level, you have to share. That means fewer procedures, fewer patients, fewer experiences. If the service you're on is particularly busy and there's more than enough to go around, that may not be as big a problem, but even then learning opportunities are not often maximized.

More consequentially, when there are more learners above your level, you get second billing. Rather than perform to the maximum of your skill set, you perform to the maximum of whatever's left over after your seniors have their experiences covered. That's a necessary set-up in these situations - we want senior trainees to be closer to competence than juniors, especially with respect to medical students who aren't necessarily set on a career course. Still, it does slow everything down, delaying trainee development and reducing volume or quality of important experiences. Something previously done by a senior resident is now done by a fellow; something previously done by a junior resident is now done by a senior resident; something previously done by a medical student is now done by a junior resident. Everyone can get set back a peg.

We haven't even hit the worst of it. Current PGY-5s and fellows came from classes that were, in total, 150 students smaller than today's class sizes in Ontario alone. As the PGY-1s and PGY-2s that came from larger classes move up, the competition for learning opportunities will only increase. International students, mostly Canadians studying abroad, are increasingly trying to do electives in Canada in the hopes of matching back.

Unfortunately, when we had the expansion of medical trainees, we didn't have an equal expansion in medical training sites. Most programs simply got bigger. Some efforts were made - NOSM opened up and satellite campuses opened up at many existing medical schools. These take advantage of larger (formerly) community hospitals to open up additional learning opportunities for medical students. Unfortunately, residency spots have not adjusted as quickly - with the exception of NOSM and many family medicine programs, there are only a handful of residency spots in these satellite campuses.

The optimistic side is that this situation should stabilize soon. No one is considering a further expansion of medical spots and there's rumblings that a decrease may be in order (no plans as of yet, to my knowledge). Residency spots have slightly declined and there's been a slow redistribution of spots to peripheral centers. There are only so many elective spots to go around, even if there are more and more interested international students, while schools are generally pretty careful about not giving those out frivolously.

It's a lesson in properly planning medical training - with such a complex system, all aspects need to be considered. Our current decision-making process is fairly fractured, with different actors responsible for different parts of the training process. Strong communication between these groups is vital moving forward.