Are residents being overprotected?

In the last several years, residency programs across Canada and the United States have instituted measures to reduce burnout and distress among residents—reducing clinical hours, increasing supervision and support, implementing psychological safety interventions and more. But have these initiatives gone too far to shield trainees from discomfort? Are they graduating unprepared to take on the real-life demands of the profession?That was the topic of discussion at a plenary session at this year’s International Conference on Residency Education (ICRE) in Ottawa, with a “courtroom-style” debate, complete with prosecutors, defence counsel, witnesses and a judge.The prosecutionFor the prosecution, internist Dr. Danielle Clark, associate professor of medicine at the University of Cincinnati College of Medicine, delivered the opening remarks, arguing that residents are being overprotected. Dr. Clark said she agreed with the premise that educators should ensure learners are protected from preventable harm (such as mistreatment, humiliation, exploitation or dangerous fatigue), but that too many of the wellness measures “take away the very experiences residents need to become physicians.” “We confused necessary struggle with preventable harm. We sometimes took away opportunities to practice independence, and in the name of kindness, we withheld the feedback residents needed to grow,” said Dr. Clark. “But the question before you isn't whether well-being matters—of course it does. The question is whether our well-being efforts have resulted in a harmful overprotection.”When it comes to residency programs introducing shorter shifts and imposing limits on clinical hours, Dr. Clark argued that these measures come with trade-offs such as increased handovers and lost continuity of care. She cited a systemic review on duty hour limits that found they didn’t improve patient care or resident well-being.“The lesson isn't that longer hours are better; it's that reducing one risk doesn't mean you've eliminated others. Protection has trade-offs. We have to measure them,” said Dr. Clark.Meanwhile, on the topic of supervision, Dr. Clark cited a 2018 randomized trial that measured the impact of increasing supervision of residents. The percentage of residents who reported that their autonomy was “just right” dropped from 97% to 58% after supervision increased, with some reporting they felt like a “scribe” or a “technician” and not a resident at all. In another 2025 study of resident readiness comprising of more than 1,300 pediatric learners, only 31% said they felt ready for unsupervised practice. She also brought up a 2020 survey of surgical fellowship program directors that found more than 42% didn’t believe incoming fellows can independently operate in a major procedure for more than 30 minutes.Dr. Clark also argued that many assessors don’t feel comfortable issuing failing grades, pointing to a survey of family medicine program directors from this spring, in which more than half reported being reluctant to give critical feedback, and over one in five reported graduating residents who still needed remediation.“We've long struggled in med-ed with failure to fail. We hesitate to document concerns, we soften assessments. Sometimes we allow residents to progress without confronting those gaps,” said Dr. Clark. “But here's the uncomfortable truth: avoiding a difficult conversation doesn't make the problem disappear. It just means the resident may face it later with less support.”The defenceDr. Matthew Kelleher, an internal medicine-pediatrics specialist in Cincinnati argued for the defence, saying many of the arguments from the prosecution reek of nostalgialitis imperfecta profunda otherwise known as “back-in-my-day.”“It's been studied for decades and shows that every generation that follows them thinks the next generation is getting worse and is unprepared for real life. Does that sound familiar? What's funny is in 70 years of research, there's never been an actual objective decline. The evidence doesn't support it, and medicine is no exception.”Dr. Kelleher made the argument that if we indeed do have a generation of “coddled residents,” we should see evidence of poorer clinical outcomes. But when he examined the evidence in the literature, he said he found that none existed.“So, I've compiled all of those studies, and here they are! Not one single one! There's not one single link between wellness initiatives and resident protections and a reduction in patient care or clinical outcomes. That's right. No convincing evidence,” he said.On the other hand, Dr. Kelleher said the literature does show a “clear evidence of harm” when resident protections are not instituted, such as an increase in burnout, fatigue, lack of psychological safety and mistreatment.“In one anesthesia multi-centre study, they showed resident performance in an OR simulation dropped by 27% when nothing changed except when the people in the simulation were rude to them. That's all it took,” he said.Dr. Kelleher called it a “false dichotomy” to suggest that protecting residents’ well-being will lead to less competent physicians.“I want you to see this clearly: Don't fall for the illusion of moral decline you just saw. Every single generation thinks the next generation is worse. And don't fall for the prosecution's causal claim that has no causal evidence . . . to support it. And don't fall for the false choice that it has to be either well-being or competence,” he argued.The audience reactsThe court also heard from a series of “witnesses” from the audience who came forward to share their own experiences.One audience member, a Toronto-based general internal medicine physician who is also a resident trainee in the clinician investigator program, said she felt “a lot of moral distress” over the lack of readiness during her first community medicine overnight shift. Another witness, a psychiatric resident in B.C., agreed with the defence’s argument of widespread nostalgialitis imperfecta profunda among attending physicians, and that residents often internalize the toxic culture that believes that they have to “suffer to a certain extent to be able to achieve competence.”The third witness, an orthopedic surgery resident from the U.K., agreed with the prosecution that faculty members do often hesitate to give critical feedback due to a fear of being accused of bullying.At the end of the trial, the audience was invited act as the jury and vote on their phones or computers for which side they agreed with. Ultimately, the jury voted “not guilty,” siding with the defence.

Are residents being overprotected?

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