The impact of hospital overcrowding on postgraduate education: an emergency medicine resident's perspective through the lens of CanMEDS.

According to a position statement by the Canadian Association of Emergency Physicians (CAEP), emergency department (ED) overcrowding is a national problem and the lack of acute care beds has led most Canadian hospitals to frequently operate at unsustainable occupancy levels of greater than 90%. Although more apparent in the ED, overcrowding is a hospital-wide problem, and is particularly prevalent in tertiary centres. Residents are the future of the medical profession. The practices and learning environments to which they are exposed undoubtedly influence the attitudes and knowledge that result. Despite this, there is a notable absence of the perspectives of residents in the overcrowding literature. As a senior resident in the FRCP emergency medicine program at McGill University, I am fortunate to have rotated through many services across 7 different hospitals. I have made a number of observations. First, overcrowding is a bitter reality and not just a statistic. For each increase in rates of bed occupancy or length of stay, there are real patients lying on stretchers in the hallways of EDs, and these patients suffer the consequences of this situation. Second, overcrowding is truly a systemic problem that affects all services inside and outside of the hospital. It has been noted that EDs carry a disproportionate burden of the problem because the ED is the only department that, as a result of a minimal control over patient input and output, is managed as if it had infinite capacity. This said, the reality is that the entire health care system is overwhelmed, and if it weren’t for “in-patient” overcrowding, typically the result of a lack of long-term care availability, EDs would not be so crowded. Failure to fully appreciate this may be a factor in the frequent clashes between emergency physicians and admitting services. Finally, the increased clinical workload and poor care delivery circumstances inherent in overcrowding negatively affect resident education and well-being. The Canadian Medical Education Directions for Specialists (CanMEDS) defines 7 overlapping “Roles” that are needed for medical education and practice (Table 1). CanMEDS has been integrated into The Royal College of Physicians and Surgeons of Canada’s accreditation standards for residency programs and its framework provides a useful lens to discuss the effect of overcrowding on resident education.