Residency and fellowships are tough. While most trainees come in and expect medicine to be the most challenging thing they have to deal with, what makes a training program challenging to navigate seems to be entirely something else. Having trained in programs in both the U.S. and Canada, there are some trends that I felt had to be addressed. I want to take a deep-dive into some of these trends, explore reasons for these trends, and steps towards an ideal solution:

Supervising physicians are often advertently or inadvertently training interns to be better secretaries and “filling gaps.” Interns are asked to communicate with a busy supervisor in a certain way. This behavior has to be learned, unlearned, and relearned multiple times for different supervisors. While this is a useful skill to have, there seems to be a push to evaluate trainees on this ability formally. It remains questionable whether inter-provider communication should be “secretarial” or whether open dialogue between supervisors and trainees should be encouraged.

New trainees are being pushed to function at a near-physician level early in their training. This “push the trainee” or “resilience-building” form of training is being widely practiced in training programs and perpetuated by hospital systems trying to achieve measurable outcomes. There is no consensus on what that fine line is between reasonable and unreasonable expectations. It is unclear whether this is a useful model of training. There is a lack of understanding of how a lack of empathy during training impacts a young physician as they progress during their career.

There is confusion amongst the trainees about whether they are at goal in their training. The only way a trainee can judge their clinical performance other than in-service training exams is by peer evaluation. This system assumes the objectivity of the reviewer. Humans are not objective by nature, and whether using a subjective evaluation for an objective assessment is effective remains doubtful. It also undermines the effect that a negative review can have on the self-esteem of an otherwise bright trainee.

International medical graduates (IMGs) frequently perceive differential treatment and expectations by their training programs. IMGs form a large part of the medical workforce but feel a general lack of sensitivity to their unique issues. They feel that they are compared to their Western counterparts, and are often expected to overachieve clinically. IMGs include students coming from countries as refugees, victims of abuse, or from war-torn, overburdened, and underserved systems. There is a perceived lack of respect and empathy for the challenges they come with and the insights they bring with them.

Reasons for these trends could be many, some of which I have outlined below:

The main focus is understandably on integration. Most systems are already overburdened, and the immediate focus is on helping the trainee fit into a “functioning” system. While this is seen as altruistic by those trying to accomplish this task, it may inadvertently lead to the perpetuation of racial and country profiling, lack of empathy for natural adaptive mechanisms, the justification for nepotistic behaviors, and the creation of a class of “culturally-appropriate” residents. This disturbing phenomenon is akin to colonialism, where there was often a similar class of people created from the local population who continued to perpetuate perceived altruistic goals. While a certain degree of cultural appropriation could be beneficial, sufficient time for adjustment needs to be allowed. Active cultural appropriation also sets the stage for unreasonable expectations from a young trainee and diverts attention from system-wide issues overburdening the health system. In simpler terms, it clears the responsibility of those running systems and puts the onus on the young trainee. This creates a class divide amongst those who are supposed to be working towards a similar goal – the health of the public. While those in the highest rank order are blind to the problems faced by the vulnerable trainee, the trainee perceives the system they are working in to be almost sociopathic.

There will always be vicious players in society, even amongst physicians. When you place a malevolent player in an overstretched system, the problem can escalate. These will be those willing to do anything to retain their position and power and will use “blind spots” and “loopholes” for their gain. While those working under such a regime will feel that something is “terribly” wrong, they will usually not know how even to begin understanding these issues, much less how to navigate them. It is up to systems to identify these players and take necessary action to protect the vulnerable. A particularly susceptible demographic to such a regime in a training program is female, an IMG, racialized, and perceived as “naïve.” Other compounding factors may be a victim of abuse, type A responsible personalities, etc. 

The solution first lies in understanding and developing a sense of empathy for every trainee demographic. Issues should be explored openly and in a transparent manner. Trainees should not be scrutinized or investigated, but rather should understand that their stories and struggles are part of a broader vision of fostering togetherness and a safe society for patients and providers alike. If open, respectful communication is fostered, most people might be quite open to talking about the issues they have faced in a safe and controlled space. 

Raina Garg and Ria Garg are internal medicine physicians.

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