Difficulties Faced by Residents and Clues for Solutions: A Qualitative Study

Abstract

A complex healthcare system often leads to the high variety experiences among medical postgraduate students. This study aims to reveal the difficulties they face during postgraduate education, their consequences, and coping strategies. This is a phenomenological study conducted by using the maximum diversity strategy from purposive sampling methods. Semi-structured interviews were conducted with 10 medical residents from different disciplines, 7 step of thematic analysis was applied. The findings were presented under the headings of challenges, outcomes, and ways of coping in line with the research questions. The sub-themes within the “postgraduate medical education” theme were “learning-teaching processes, educators, educational program, interactions, assessment, and evaluation.” The sub-themes in the “culture/climate” theme were “academic environment, disruptive behaviors, rules and procedures, and hierarchy.” The difficulties experienced by residents in the “health system” theme were examined under the sub-themes of “health care team, health service delivery, payment for service, patients, and their relatives.” The sub-themes in the “specialization” theme were “scope and practices of the specialty area” and “perception of the specialty area.” The difficulties in the “time/period” theme were analyzed under (1) senior and (2) junior sub-themes. The consequences of difficulties were examined under the themes of “deterioration in well-being and perception of incompetence.” Coping with the difficulties was categorized into individual efforts, not expend effort, and getting support themes. Individual efforts were examined under the sub-themes of “sharing difficulties, communication-interaction, being a problem solver, maintaining well-being, and socializing.” Sub-themes of getting support were classified as institutional and psychological. It is necessary to understand the phenomenon of “residents” difficulties’. All parts involved in PGME, should be aware that residents are in early adulthood. They have to recognize internal structural constraints, distinguish between internal and external factors. Solutions should go beyond individual development, systematic design and support mechanisms should be established at both institutional and national levels.

What do we already know about this topic?

During the medical education process, residents face various difficulties. These difficulties are often cited in the literature as factors that impair resident well-being.

How does your research contribute to the field?

Difficulties faced by residents in medical education is multifaceted and multidimensional: postgraduate medical education, culture/climate, health system, specialization area and time/period. Difficulties related to teaching-learning processes, health team dynamics and disruptive behaviors are particularly salient. The consequences of these challenges were observed as perceived incompetence and decline in well-being, in line with burnout indicators. The difficulties faced by residents go beyond internal structural constraints specific to the period to external ones. The need for systemic institutional improvements and support mechanisms is considerable.

What are your research implications toward theory, practice, or policy?

A professional medical education is one that strives for excellence. Addressing the difficulties faced by residents at micro and macro level and supporting the well-being of residents through systematic mechanisms is essential for medical education and all over the community health. A tiny stone can create a huge wave, learning communities are needed for positive change.

Introduction

Postgraduate Medical Education (PGME) represents a pivotal phase in the professional journey of physicians, characterized by specialized training and experiential learning within a clinical environment. ¹ Lasting typically 3 to 7 years, this period, referred to as residency, coincides with critical stages of adult development, as delineated by Levinson’s model. Understanding these developmental milestones is crucial for comprehending the challenges and opportunities encountered by medical residents as they progress through their training. ²

Levinson’s conceptualization of adult development identifies 2 key phases relevant to PGME: the “entry life structure” and the “30-year transition.” The “entry life structure,” spanning from approximately ages 23 to 28, marks a period of exploration and experimentation for individuals, as they focus on personal career goals, values, and aspirations. As residents embark on their training during this phase, they grapple with identity formation and the alignment of professional ambitions with personal values.

The subsequent “30-year transition,” encompassing ages 28 to 33, represents a pivotal shift toward greater stability and clarity in life goals. During this period, residents consolidate their professional identities, embrace societal roles, and make significant life decisions, including career choices and family planning. However, this transition is not devoid of challenges, as internal structural constraints inherent in Levinson’s model may impede residents’ progress and well-being^3,4;

• 1. Identity Uncertainity: Residents often experience ambiguity in defining their professional identities, reconciling career aspirations with real-world experiences, and navigating the complexities of specialization.

• 2. Balancing Autonomy and Dependence: Negotiating the balance between autonomy in clinical decision-making and reliance on supervisory guidance poses a significant challenge for residents as they manage patient care responsibilities.

• 3. Professional and Personal Pressures: Intensive work schedules, clinical duties, academic obligations, and financial strains create a delicate balancing act for residents, impacting their well-being and work-life integration.

• 4. Career and Financial Pressures: Financial burdens, coupled with the pressure to select a specialty and chart a career trajectory, contribute to the stress and uncertainty experienced by residents during their training.^3,4

As medical residents go through these critical stages of adult development described in Levinson’s model, they find themselves in a period of contradictions, stresses, risks, costs and disappointments. It is as if the individual has been dealt a blow when he/she finds that individual ambitions, aspirations and expectations have not been realized. ³ However, this process also offers opportunities for professional growth and personal development. Effectively managing these barriers and capitalizing on the learning environment can promote resilience, self-awareness and clinical competence among medical residents.

When these internal structural constraints are not managed in a positive way and external factors such as inadequate training, communication problems, and disruptive behaviors are added^1,2 we face many consequences such as decreased job satisfaction, burnout, suicidal tendencies, and resignation among medical residents.^{2,5 -10}

Residents are often anxious, hesitant, and fearful about communicating their difficulties. This leads to dissatisfaction and further complexities that residents face due to being ignored. ⁵ A close relationship exists between well-being, empathy, and patient care competencies of residents. As such, failure to adequately identify and address the difficulties faced by residents will adversely affect patient care outcomes and problem-solving efforts. ⁵ Therefore, it is important to classify the challenges faced by resident physicians, differentiate their sources, assess their impact, and identify how each challenge can be overcome.

Understanding the interplay between the intrinsic/intrinsic challenges of medical education at these developmental milestones is essential to support residents’ well-being and promote their success as future physicians. ¹

The concept of difficulty varies depending on individuals’ perceptions and experiences. ¹¹ This may be due to the fact that residents and trainers are in different life cycles (early/mid adulthood) ³ and that residents are still experiencing the internal structural constraints of early adulthood. However, if the educator and the residents are addressing similar external challenges, it may be a sign of where to start to solve the problems. We examined the difficulties experienced by medical residents of PGME and coping strategies from both the resident and educator sides. This article reports the findings from the perspective of medical residents. This study is thought to provide clarity on and the context in which context the problem should be approached. The research questions were planned as follows:

1. What difficulties do medical residents face in PGME?

2. What are the consequences of the difficulties experienced by medical residents in PGME?

3. How do medical residents cope with the difficulties they face in PGME?

Method

Study Type, Sampling Method and Sample

In this phenomenological study, final year residents from three medical faculties (faculties where the researchers were working at the time of the study) in different fields of medicine as basic, surgical and internal sciences were included. As phenomenological study deals with recognizing the meaning of phenomena, concepts, and experiences, aiming to investigate various thoughts, perceptions and reactions ¹² ; we aimed to evaluate the difficulties and coping strategies s experienced by postgraduate medical students. For this purpose, “purposive sampling” method was used. Purposive sampling method is based on the assumption that the researcher wants to explore, understand and gain insight and therefore should choose a sample from which the most can be learned. ¹³ In the study, maximum diversity strategy, one of the strategies of the “purposive sampling” method, was preferred. In order to provide multiple perspectives, the study group consisted of people of different genders, with different specializations in different departments.

In sample selection, support was obtained from the head of basic, internal and surgical science departments, from faculty members and resident representatives. They were asked to recommend the final year residents who could provide the most data for the study and who were thought to be rich in information about the research. The recommended residents were reached and those who volunteered were included in the study. Creswell ¹³ recommend sampling in qualitative studies until a point of saturation or redundancy is reached. In our study, interviews were continued when no new information was received from the participants, when the same answers started to be given, or until there was no difference in opinions. ¹³ Data saturation was achieved with the testimony of 10 residents. Three from Basic Sciences (Physiology, Biochemistry, Microbiology), 3 from Surgical Sciences (Obstetrics and Gynecology, General Surgery, Anesthesiology and Reanimation), and 4 from Internal Sciences (Neurology, Emergency Medicine, Pediatrics, Internal Medicine). Six participants were female and 4 were male.

Study Permission

Approval was obtained from the ethics committee of University and written permission was obtained from the deans of the medical faculties where the study conducted. Following the written permissions, the heads of the departments were contacted by telephone and informed about the purpose and process of the interview. The study was conducted in the 2022 to 2023 academic semester.

Data Collection

Qualitative data consists of “direct quotations of people’s experiences, thoughts, feelings and knowledge” obtained through interviews. ¹³ In this study, semi-structured interviews were preferred in order for the residents to better describe their difficulties and coping strategies. In semi-structured interviews, questions are phrased more flexibly or include less structured questions. This approach allows the researcher to respond to the situation at hand, the participant’s emerging worldview, and new ideas about the topic. ¹³

The questions in the semi-structured interview form were developed by reviewing the literature^{1,2,5 -11} and considering compatibility with the research question/purpose. The questions were open-ended and designed to provide illustrative data. Descriptive information was requested at the beginning of the interview, followed by questions about the difficulties experienced and coping strategies. Four experts from the fields of internal medicine, surgery, basic sciences and medical education were consulted about the content of the questionnaire. Before starting data collection, a pilot interview was conducted with a resident who would not participate in the study. In this interview, which questions were not understood and needed to be rephrased and which questions were not useful was evaluated. The semi-structured questionnaire included experience and behavior questions (eg, what are the difficulties you experienced during your residency training? Can you give examples?), opinion and values questions (eg, what are your suggestions for a support mechanism?), feeling questions (eg, how did the difficulties you experienced make you feel?) and background/demographic questions (self-identification questions—Age, university of study, department/discipline (basic, internal, surgical), marital status, etc.).

Semi-structured interviews were conducted online (synchronous in zoom) and all interviews were recorded. Verbal consent was obtained at the beginning of each interview.

Data Analysis

The interview recordings were transcribed by a professional person other than the researchers, with whom an ethical contract was signed. In order to eliminate any deficiencies or inaccuracies that may arise from the transcriber, the researchers listened the interview recordings and checked the interview texts. The main text was created by bringing the interview datas together.

Thematic analysis was applied in the study by following the steps below ¹³ :

1. The first step of qualitative data analysis is to explore the data. Preliminary exploratory analysis in qualitative research aims to explore the data to get a general idea about the data and to understand the data as a whole. For this purpose, the researchers independently analyzed all interview transcripts read it in its entirety.

2. The second stage is the coding process. This process involves identifying text segments, assigning a code word or phrase that accurately describes the meaning of the text segment. In the study, the researchers coded independently. Different views and alternative explanations were considered.

3. After coding the entire text, the researchers came together and finalized the codes by working on the codes (grouping similar codes, separating unnecessary codes, etc.).

4. The researchers reorganized their coding on the text they worked on with the shared code list and identified possible themes.

5. The researchers reconvened, revised their coding and reached a consensus. The consensus percentage in this round was 91.9%, after which full agreement was reached through negotiation. The researchers created themes and sub-themes from similar codes that were grouped together to form a main idea in the database.

6. Theme definitions were made and quotes were selected to represent the themes. The participant protocol number and department were included in the presentation of the quotes.

7. The findings were interpreted by comparing them with the relevant literature.

Results

The findings are presented in line with the research questions.

1. What difficulties do medical residents face in PGME?

The difficulties experienced by residents were grouped in 5 themes: “postgraduate education,” “system,” “culture/climate,” “specialty,” “time/period” (Figure 1).

Figure 1.

Themes and sub-themes on the difficulties of the medical residents’ face during PGME.

The codes related to education (learning-educator-learner) and the elements of the educational program (content, learning-teaching process, assessment, and evaluation) were evaluated under the theme of “Postgraduate medical education.” The fact that competence development in post-graduate education is predominantly peer-learning (more intensively in surgical disciplines) and based on personal effort poses difficulties. Senior residents may not be knowledgeable/competent and/or willing and interested in teaching. Significant differences in teaching motivation, interest, professional competencies, communication, and accessibility among the trainers involved in PGE are other challenges experienced by the residents.

The general problem of the faculty and even of our country is that we have rules. We have writings. We have a curriculum. Everything is written,. If you look at it, everything is suitable, but it is very insufficient in terms of execution and putting it into practice. When I meet with my firends and other assistants from other faculties, they have nothing. The point where assistant education has come is troubling. You know, it is a little bit from the professors, a little bit from us, from everyone. (9, Emergency)

More in surgery, so you learn from the senior. You learn as much as the senior knows. Then it’s like being thrown out of a nest. It’s like you’re swimming with fluttering.’(2, General Surgery)

It is said No one will teach you anything from now on. You have already come here on purpose, willingly, you will learn with your own efforts’, but need to be guided. If you are a junior in the service, the senior’s is so busy . . . patient admission, discharge, coming, going, asking questions. And it’s like a counseling center. Everyone asks something. The patient of the teaching staff asks. The patient’s relatives ask. Patient discharged from hospital asks. Patient to be hospitalized asks. t. When everyone has two or three services, the day is already divided. You have to do your work. We don’t have a secretary at our internal desk. We do all the admissions and exits. So, the senior doesn’t have time to teach you anything. You are learning alongside him/her. So it is more comfortable to learn from 2 seniority above, not from the service senior. So the degree of seniority is important here. Right now, for example, our specialists have started. This is a great chance for us. They also graduated from here. They know so clearly what we don’t know. They are like a shortcut button. You will work on this right away tomorrow . . . you will work on this tomorrow, We tell each other about it the next day during the visit., What is missing, what have to be known more, what did you miss, what is actually important? The new ones are very lucky in that respect. (1, Neurology)

I don’t think it’s my duty, I’m already at the point of training. I don’t think I need to teach someone else because when I teach someone, my own training is left incomplete. If I am still in this process, my supervisor has to be responsible for my training and the training of our junior colleague. (8, Anesthesia)

I think this is the biggest mistake in Turkey: They confuse being an academic with being an educator. So they can be a very good academic. They can do very good research. They can analyze patients very well, but it is not an easy thing to teach something to a person or to transfer what you know to the other person. I dont not think everyone has such a virtue. Asking questions is education? . . .. It is necessary to transfer what you know to the other person and it is necessary to understand that the other person understand. Now the subjects are told to us. It is being told, but what we understand from it is important. There is no feedback. . . Has it been told? Yes, it has been told. What are we supposed to understand? It’s unclear. To be honest, not many people are interested,. So the quality of education is important. Not everyone has it. (1, Neurology)

Lack of program is a problem. I think leaving all the self-improvement efforts entirely on the assistant is another big problem., After all, the state is investing on us, I am a financial burden on the state. It spends a lot of money here for my development. It will also have expectations from me in the future. I think it is wrong to leave this on an assistant. I think the professors should intervene in this and force the assistants where necessary. I guess it is difficult to deal with us, I guess it takes time or it is laziness (10, Physiology)

'. . .the communication between the resident and the instructor is a relationship based on fear and hesitation. . . .some of our professors have a communication like trying to get over it as soon as possible without getting angry or being badly criticized. . . . . The mentality is that the resident should afraid; if he/she is afraid, he/she will become a good physician. (3, Internal Medicine)

System

The service-based education characteristic of PGE, includes difficulties arising from national health policies and the delivery of health services. Residents experience the challenges of excessive workload caused by excessive demand for care, lack of intra-team and interdepartmental cooperation/coordination, and violence from patients/relatives. They do not receive enough economic compensation for this intense workload, and that there is injustice due to staff/department differences.

‘. . .. We have worked as nurses, personnel, and cleaners. We also worked as doctors. We also worked as professors. We have also been assistants. We did everything here. I mean, we took blood, cleaned under patients, carried patients, and mopped the floor. I did it all. So, were we residents here? . . . I mean, if you withdraw the residents from this faculty, there will be no faculty. (1, Neurology)

“When I was in my first-year residency, I was hit on the shoulder (by patient relatives). . . I underwent surgery afterward. Those were seriously bad days. I got support from psychiatry because I had very serious crying attacks. . . . . I actually got over it by realizing that the violence was not something that was directed against me, that violence is the problem of the world right now, and that it is the problem of Turkiye. I mean, I was thinking, how I am a doctor that I am being beaten.” (9, Emergency)

Culture/Climate

Organizational culture refers to the shared values, beliefs, and practices that shape the behavior and attitudes of employees within an organization. Organizational climate is employees’ perception of an organization’s social, psychological and environmental characteristics. In the study, residents explain the prominent features of the climate/culture as the lack of or unclear rules, job descriptions and boundaries in the working and academic environments, and the lack of punishment for rule violations and bad behavior. Prejudices, discrimination, and disruptive behaviors are frequent and common challenges. It was observed that difficulties in the academic environment differed between institutions and departments. Most of the participants stated that in the academic environment, they made a constant effort to be accountable and prove themselves, and that they felt stress, worthlessness, and loss. Some participants identified tension and perfectionism as the main characteristics of their academic environment.

'. . .who cannot get out of the masculinity or male gender roles. . . not seeing them as colleagues, seeing them as a male surgeon and you as a female doctor. You know, an approach like what do you know, what can you do? . . .. mocking, sometimes we are exposed to sexual jokes and swearing because we work together a lot. . . . . Many instances of learned helplessness exist. Our professors are also women. For example, when a professor in the surgery department makes a sexual joke to me, when I tell my professor about it, my professor says, "He does it to me too. So, there is such a learned helplessness. (8, Anesthesia)

'There is an academic tension. . . I mean, even in the laboratory departments like ours, which should be comfortable, which do not see patients, there is tension between people. Sometimes this can even come out in meetings. Sometimes it happens through us, for example, in article-seminar presentations. You know that a tense environment also affects people negatively. There were times when my psychology really deteriorated.’(4, Microbiology)

Specialization Area

Residents’ perceptions of difficulty arising from their specialty areas vary. Medical residents from basic sciences perceive the underestimation of their specialization as a challenge. Residents of surgical sciences perceive it as very challenging that their specialty training includes intensive shifts and long working hours. Emergency and Gynecology and obstetrics patients require urgency (emergency admissions and urgent intervention requirements) and attention, and their health status fluctuates rapidly. These are seen as important sources of stress.

'. . .I can say that our work (microbiology) is not appreciated very much. You know, this happens because other doctor friends may not know what we do. For example, they think that everything we do is device-based. Moreover, even if it is device-based, for example, biochemistry is more automated than us, there is still a 4-year specialty education at the end of the work. . . but to know whether that result is appropriate or not, you really need to know the patient’s anamnesis and for that you really need to have a medical education beforehand. (4, Microbiology)

'If the outpatient clinic is closed, if the pregnant woman says she is in labor, she goes directly to the 5th floor. So, for example, if you do not have an appointment in other departments, they can say, 'We are not looking. But when a pregnant patient who comes to the obstetrics department says that she is in labor, has a complaint, bleeding, etc., we have to take care of her. (6, Obstetrics and Gynecology)

Time/Period

The difficulties in the time/period theme were analyzed under junior and senior sub-themes. While residents have difficulty in adapting to service delivery, the institution, the team, the hierarchy, and excessive workload (frequent shifts, drudgery) in the first year of their training (junior residents), they experience the stress of increasing responsibilities and approaching specialty life in the last year.

“. . .when you were a junior, you worried about blood, no more dressings, simple things. I mean, I’m going to get that blood on that visit, that’s all you worry about. And the chief assistant will scold you the most. There is no problem. As seniority grows, responsibility increases. The man in charge gets bigger. A chief resident scolding you and a lecturer scolding you are very different things. The chief resident is under much stress. Because he is responsible for everything. He takes the most stress.”(2, General Surgery)

1. What are the consequences of the difficulties experienced by medical residents in PGME?

Themes and sub-themes about the consequences of the difficulties experienced by medical residents during PGME are presented in Figure 2.

Figure 2.

Consequences of the difficulties medical residents experienced in PGME.

Perception of Incompetence

The thought of graduating without competencies relevant to the field of specialization creates anxiety and worry.

Deterioration in Well-Being

Participants exemplified the deterioration of their well-being in physical (fatigue, musculoskeletal complaints, weight gain, sleep disorders), psychological, and social aspects. Psychological impacts were stress, anxiety, depressive mood, burnout, and social disengagement. Other effects included feelings of worthlessness, loss of motivation, and loss of being a good person.

'My mental health was obviously affected. . .While I was more of a calm person, I became more irritable. You can become intolerant. Sometimes you can be unsympathetic. Your character changes. Obviously, you get out of the normal human condition. . . because when you don’t work like a human being, you can’t be a human being. . . There were even people I didn’t even know that I teased because they looked at me the wrong way. There were periods when my psychology went downhill. (2, General Surgery)

1. How do medical residents cope with the difficulties they face in PGME?

Themes and sub-themes about the participants’ coping strategies with the difficulties are presented in Figure 3.

Figure 3.

Participants’ views on their approaches to coping with the difficulties they experienced in PGME.

Individual Efforts

Individual efforts are predominant in coping with difficulties and residents share their difficulties among themselves, with their seniors or in departmental meetings. Socialization and good communication are seen as effective in coping. Some participants stated that they coped with difficulties through a problem-solving and persistent approach. One participant stated that they tried to maintain communication by ignoring the disturbing behaviors/words.

Not Expend Effort

In the study, some participants while experiencing the difficulties of the residency period, perceived them as natural, but temporary and did not attempt to cope with them.

'I think it will end one-day, mean, I think that residency period is temporary. I mean, I think a little bit like military service, to be honest. . . This is a military service, and we say it will end somehow. You know, this is a little bit frankly, this is not only in our department. I hear that it happens in most departments. This department alienates me from academic life, to be honest. (4, Microbiology)

Getting Support

The support that the participants received to cope with the difficulties they experienced included professional psychological support and institutional support (participation in congresses and courses, managerial support).

'. . .the workload, shifts, and sometimes not being able to keep up- I’m comparing now with three years ago. There wasn’t much physical illness, but I feel psychologically worn out. I mean, there were periods when I was very depressed, anxious, or obsessive. There were even periods when I needed the support of a psychiatrist when I needed antidepressants. I also received psychotherapy. (3, Internal Medicine)

Discussion

The findings obtained under the headings of “difficulties,” ‘consequences of difficulties’, and “coping with difficulties” are discussed under the same headings.

Difficulties

Residents encountered difficulties which were categorized as postgraduate medical education, culture/climate, system, specialization area, and time/period themes. According to the medical residents in our study, post graduate medical education process is predominantly conducted through peer learning, and this may cause residents to feel lonely and inadequate. In cases where the senior peer is uninterested, competency acquisition is negatively affected, leading to increased anxiety, especially in surgical branches. Although there have been studies conducted by specialty associations for the structuring of resident education programs in Turkey, these studies are still insufficient, and this problem affects all components of the curriculum. The limited interaction of learners with role models in service-based curricula leads to medical residents’ inability to monitor the cognitive and affective processes of the trainer and benefit from their experience. The difficulties related to the educators are multidimensional, highlighting their insufficiency in terms of quality and quantity, availability, teaching skills, communication, and interaction, as well as interest and motivation.

Another important point identified is that the educators frequently utilize mainly informal mentoring. Mentoring, which has a capacity-building nature and provides a multidimensional support system, is related to the whole development of the person, and requires the use of different types such as formal, diverse, electronic, colloborative, group, and cultural. ¹⁴

PGME faces many difficulties, and there are opinions that it should evolve. ¹⁵ In realizing this evolution, it is recommended to know the characteristics of the new educational paradigm and to design and implement educational processes in accordance with this paradigm empowering both educators and students in the process. ¹⁵ The researchers of this study agree with the idea that the traditional “see one, do one, teach one” approach is inadequate for the complex learning tasks in PGME and that it is instead necessary to opt for a path toward learning communities with the shared responsibility and contribution of all individuals. ¹⁵ However, this requires opportunity, time, and effort to change the learning and service culture. Most medical residency programs have adopted a predominantly resident-led model in which residents play an important role in establishing and maintaining the educational calendar. ¹⁶ While peer learning has many contributions, ¹⁶ the concern of residents’ competence ¹⁷ should not be ignored. Unstructured delegation of teaching responsibility to senior residents is at the core of the problem. Determining effective peer mentoring program designs, ¹⁶ determining who should be included in the curriculum and to what extent, ³ and monitoring and evaluating these processes are considered valuable by researchers.

In this study, in the culture/climate dimension, the presence of disruptive behaviors and a sexist perspective, especially in surgical sciences, were widely expressed, and it was frequently emphasized that this is an institutionally accepted and not much voiced situation. Culture is not easy to change; however, the willingness/motivation/ability to adapt to change is an important trigger. The problem in the organization’s ability to adapt is reflected in the teaching–learning processes. Differences in educators’ interpretation of concepts and approaches to teaching and learning can lead to a situation where the responsibility for learning is left entirely to the resident. Residents’ acquisition of professionalism is often based on the varying expectations of educators or institutions and through the hidden curriculum. This may impact participants’ concerns about the "expectation of excellence from residents. However, it is not easy to recognize excellence and ensure the development of physicians within the framework of this concept. ¹⁸ There is a need for open discussions ¹⁴ at the national and institutional levels. The gaps between the official, perceived, and implemented curricula, the variability of practices according to the person, time, and especially the behaviors of administrators are striking in this study. The blurring of the boundaries between bad and good behaviors may trigger a culture of ignoring. The fact that those who want to talk about the problem in depth and find solutions are labeled as “perpetual complainers” may explain the adoption of a culture of non-complacency and the overlap with the culture of learned helplessness, acceptance, or ignoring the problem. The existence/acceptance of hierarchy and its abuse can be seen as the main factor that feeds this culture. Examining the residents’ statements reveals an environment characterized by tension in the learning, service, and academic climate, where fear prevails, and a heightened sense of worthlessness is evident. Residents still strive to be good doctors, take work home to cover the deficit of the system and the institution, cannot plan their lives, and strive to be strong.

Recent studies reveal that disruptive behaviors in residency training are common, have been steadily increasing over the years, and are consistently associated with burnout, depression, and suicidal thoughts. ¹⁹ It has been observed that women are more exposed to mistreatment, which is more common in surgical departments.^19,20 The most common sources of mistreatment were clinical staff, patients’ families, and faculty members, especially in terms of gender and racial discrimination. ¹⁹ In another study, chief surgeons were the most common sources of sexual harassment and abuse. ²⁰ An important point is that those who are subjected to disruptive behaviors do not report the treatment to their institutions, largely because of the fear of being ostracized or gaslit. Agreeing with recommendations in the literature, addressing the issues with clear and strong protective solutions and implementing zero tolerance policies are advocated.^19,21

In this study, drudgery, excessive patient load, and long working hours were frequently mentioned as difficulties arising from the health system and service delivery. Lack of health personnel or problems in job descriptions are seen as the causes of drudgery, while staff differences and low wages are among the factors that make professional life difficult. Disruption of the balance between service and education is seen as the most important area for improvement in specialty education, according to Sun et al. ²² Despite ongoing efforts to regulate working hours to improve working conditions and quality of life for residents worldwide, they still work longer shifts than many other professions. There is an emphasis on attempts to reduce working hours by adding other health professionals and pooling the talents of the medical team. ²³ Finding the optimal work–education balance for medical residents is a problem found in many countries and is recommended to be solved through a joint international effort, drawing on the experiences of many countries. ²³

Identifying staffing differences and low wages as another potential area for solutions, we believe that addressing these issues could contribute to improving the overall situation. According to data of Turkish Statistical Institute (TUIK), their income is and a bit higher than the poverty line and it continues to decline. ²⁴ However, the numbers are changing rapidly, and the decline is continuing to increase. Another important problem in health service delivery is violence against physicians. In terms of workplace violence types, 71.9% were verbal and 28.1% were physical. In terms of exposure to workplace violence, doctors accounted for 62.3%. ²⁵ According to the statement of the Turkish Medical Association, the number of Code White notifications, which refers to violence in health, was 11 942 in 2020. In 2021, the number of White Codes almost tripled to 29,826. ²⁶ Since 2022, Turkey has faced an unprecedented migration of doctors. Among the three most important factors affecting the tendency to leave Turkey were incidents of violence in the health sector. ²⁷

In our study, the difficulties arising from the practices of the specialty and the value attributed to the specialty were important findings. In particular, surgical residents explained these difficulties with “long and intensive work,” “requiring attention,” “urgency and variability,” while basic sciences residents expressed these difficulties as “being seen as a technician.” The differentiation of difficulties according to the period of residency is another important finding. These findings have made the time/period-specific problems of educational processes more visible.

Consequences of the Difficulties

In our study, the difficulties experienced by the residents were seen as a perception of incompetence and deterioration in well-being (physical, psychological, and social). In the literature, difficulties in postgraduate education are often discussed in terms of factors affecting burnout. Burnout is defined by depersonalization combined with physical and emotional exhaustion and low personal accomplishment, and the findings of our study point to the indicators of burnout. ²⁸ It has been reported that burnout rates are high among medical residents,^{29 -31} that the time to becoming stressed, fatigued, less socially connected, and less resilient occurs within 6 months of starting residency, ³² that burnout rates are similar among physicians in internal and surgical fields, and that the prevalence of burnout has not changed over the past 20 years.^2,6 Factors contributing to burnout include financial stress, work-life imbalance, excessive enrollment, inadequate work resources, poor social support and mistreatment, ²⁹ non-patient problems (such as large administrative tasks), human relations problems, ³⁰ early training year, unmanageable volume of work, inability to attend health care appointments, lack of exercise, lack of program support, lack of support from friends living together, ³¹ clinical supervisor support ³² and hospital resources, ³³ number of patient safety incidents and lack of individuals to provide support in case of distress, ³⁴ total weekly working hours, and female gender. ³⁵ In our study, feelings of worthlessness were expressed as stress anxiety, burnout, depressive affect, detachment from social life, shallowing, distancing from perception of self as a good person, and loss of motivation. Deterioration in well-being leads to burnout, which decreases empathy and leads to unprofessional behaviors. On the other hand, there is evidence that unprofessional behaviors of the residents during their medical education are a good predictor of unprofessional behaviors in his/her professional practice. ³⁶

Coping With Difficulties

Coping strategies are predominantly individual efforts such as improving the work environment, trying to solve the problem, communication, maintaining self-care, and voicing/sharing of difficulties. Not seeking a solution or accepting the situation was reported at a considerable level. Perceiving assistantship as a temporary period, perceiving the difficulties as natural, not sharing the problems with someone else because it is thought that there will be no solution, and efforts to accept/pretending to accept the situation with the thought that I do not have time to deal with it are noteworthy. The presentation of systematic professional support mechanisms is very limited. Institutionalized and planned resident monitoring and support mechanisms are not defined. However, residents point to a change in professional structures and mechanisms at the system level as a solution to the following difficulties: increasing the number of residents, providing non-physician staff support, regulating the number of shifts/after-shift leave, improving the physical environment, using the on-call team more effectively, clarifying job descriptions, introducing shift work, having leaders/managers with problem-solving behavior, providing training appropriate for professional life, improving inter-departmental cooperation and communication, creating a non-intimidating environment, and planning/establishing systematic systemic support mechanisms.

The fact that residency is more of a work environment rather than a learning allows us to see burnout as a disease or occupational stress and to be directed toward institutional/systemic solutions.^29,37 Interventions to address burnout often focus on the individual (eg, well-being classes, mindfulness trainings, and mental health services). However, if these interventions are seen as an additional burden, ignore the need for institutional change, or are perceived as “victim blaming,” they are likely to be met with resistance by residents. ¹⁹ Time away from work, increased training, supportive faculty, participation in social events, the presence of program-based health initiatives, ²⁹ implementation of formal mentoring programs and the provision of protected time during regular working hours, ² autonomy, development of a sense of competence and strong social relationships, sleep and time away from work, perseverance, developing a sense of competence, ² interventions focused on understanding, promoting team cohesion, ³⁸ interventions using peer support and individual meditation, and using educational theories to guide program development^38,39 are among the factors that reduce burnout and should be considered for multidimensional interventions. Systematic interventions increase maltreatment reporting rates because previously unreported problems are typically brought to light. There is a need for multidimensional bottom-up and up-bottom interventions that include education programs, health systems, and cultural structures.^6,19,39

When evaluating the difficulties they experienced and their coping strategies, the developmental period of the residents should also be taken into consideration. Assistants experience internal structural challenges such as identity uncertainty, balancing autonomy-dependence, professional, personal, career and financial pressures that are specific to early adulthood, which is called the period of discovery and experimentation. Along with this, they also experience difficulties regarding post-graduation education. ³ They have to create their professional identity and career goals by coping with all these difficulties. In our study, excessive workload arising from the health care system, difficulties arising from the health care team and patients; tension in the academic environment, hierarchy, exposure to disruptive behaviors; and difficulties during seniority and novice period stand out as factors that challenge residents. The study findings draw attention to external factors such as the health system and its practices, organizational culture, which are complex and not easily overcome by residents. In the study, residents mainly rely on individual efforts to maintain well-being (sharing, socializing) and communication to cope with difficulties. The lack of support mechanisms is a prominent finding. Despite the intensity of the external difficulties, the inadequacy of external supports may be more further challenging for the residents. This may be effective in the behavior of acceptance, non-complaint and lack of effort expressed by some residents.

Conclusions

In conclusion, the comprehensive exploration of difficulties faced by medical residents in postgraduate medical education has revealed multifaceted challenges across various dimensions. Particularly noteworthy were challenges related to the learning-teaching process, healthcare team dynamics, and disruptive behaviors, emphasizing the need for systemic improvements. The consequences of these difficulties were observed as a perceived incompetence and a decline in well-being, aligning with indicators of burnout. Coping strategies primarily centered on individual efforts, revealing a need for more robust institutional support systems and systemic changes to alleviate the burdens on residents.

In order to discuss the solutions of residents’ difficulties, it is first necessary to understand the phenomenon of “residents” difficulties’. Residents should be aware that they are in early adulthood and recognize internal structural constraints. All parties involved in PGME (health teams, health managers at institutional and national level), especially trainers, should have this awareness, distinguish between internal and external factors, and focus on professional and personal development. PGME should be structured around educational theory and practice, and the program should include elements such as mentoring, support programs, reflection sessions and learning communities.

Solutions should go beyond individual development, and systematic design and support mechanisms should be established at both institutional and national levels. Each stakeholder who touches the problems, should take responsibility. Faculties are expected to take more responsibility. They should recognize the difficulties experienced by residents, internal and external factors, and conduct studies and improvements to determine the characteristics and effects of organizational culture and cultural climate. For example, developing clear guidelines and directives to tackle disruptive behaviors. Faculty advocacy for systemic challenges can be effective in reducing excessive patient admissions and care burden through improvements in the health system. Although interventions aimed at the educational program, trainers, and support of residents may allow to see Results in the short and medium term, it should be taken into account that interventions aimed at institutional and systemic improvement can be observed in the long term.

In moving forward, addressing these challenges necessitates a holistic approach, incorporating not only individual coping strategies but also systemic changes in postgraduate medical education, organizational culture, and healthcare system dynamics. Initiatives should focus on enhancing the learning environment, supporting residents’ mental health, and implementing systemic interventions to promote a healthier and more sustainable residency experience.

This part of the study describes the difficulties experienced by residents through their own experiences. Another part of our study exploring the perceptions and experiences of educators will contribute to a deeper understanding.

Limitations

The study provided valuable findings in terms of revealing in depth the difficulties experienced by residents in their specialty training in the Turkish context. The study was conducted with 10 residents from different specialty training areas in 3 medical faculties. Being a qualitative study, while it reveals the difficulties experienced based on experience and context, it has limitations in terms of generalizing the findings.