The emergency department (ED) is a key area to train medical students and residents, and it is one of the only areas that they will see acute undifferentiated patients, resuscitation, toxicology, trauma, and environmental emergencies. But given the uncertainty and challenges of our day to day work, having learners can be stressful for supervisors. There are also concerns from some supervisors regarding the quality of care trainees provide; do trainees in the ED increase risk? Perhaps the most tangible example of this in Canada is what is referred to as the ‘July effect’ [1], when trainees transition from student to resident with a jump in responsibility. The work of Chen et al. [2] in this issue of CJEM adds valuable information to this scholarly conversation.

In their study, they identified 1359 return visits out of the 134,359 visits representing a 1.0% return visit rate. They then compared return visit rate with admission amongst those patients seen by a trainee and those seen solely by a staff physician. Their analysis did not detect an association between the involvement of learners and return visits [2]. They did find a trend towards reduced return visits with clerkship students and senior residents, but this finding was not significant. Return visits are a common occurrence in EDs and are monitored as a performance indicator for quality of clinical care. It should be reassuring for supervisors that this is not an area where having a trainee increases risk for patients.

While not a significant result, the difference between clerkship students/senior residents vs junior residents provides an opportunity for reflection. Most supervisors have a ‘shorter leash’ with clerkship students, engaging in more oversight in the care of their patients. Senior residents are given a ‘longer leash’ and have significant experience and knowledge to back up their decision making. Junior residents will at times be unconsciously incompetent, exhibiting the potential Dunning–Kruger effect and overestimating their own knowledge. Something to take away from this paper would be to consider being a little more intrusive in the patients seen by junior residents.

This adds to the existing evidence that clerkship students have no effect and residents actually increase patients per hour slightly. Length of stay and measures of efficiency have also been studied in this context and have had mixed results ranging from slight decreases to slight increases [1]. The July effect is actually more myth than reality with evidence being mixed and generally neutral in terms of patient safety outcomes [2]. Based on the literature we have, trainees do not appear to affect quality of care. The evidence is not extensive and scholars should continue to study quality of care metrics and the impact of learners so we can adapt our supervision and training practices to ensure patient safety.

The fact that the presence of learners does not impact patient safety is welcome news. With the recent announcement regarding the expansion of undergraduate and postgraduate positions in Ontario [3], the ED is only going to have more and more learners. CAEP has also identified a predicted shortage of Emergency Physicians and has called for increased training positions [4]. Some physicians may choose to work in a smaller regional or rural ED, with one of the potential benefits of not having to supervise learners. As we move forward, working any shift in the ED without a trainee will be the exception and not the norm, regardless of setting. The ED serves as a vital learning ‘lab’ in medical training, and is critical to medical training. We should expect to have learners with us during most of our career.

Much as some of us won’t like to admit it, we cannot work forever and we need capable people to take over for us when we exit the profession. More than a role, supervising learners is a duty to promote and teach our young learners to develop their skills to care for undifferentiated patients, resuscitation, trauma, toxicology and environmental emergencies. The future of emergency care in Canada depends on it.