Burnout in medical education: interventions from a co-creation process | BMC Medical Education

Description of the participants

The co-creation workshops were attended by 78 students and trainees, including 12 first-year bachelor students, 13 first-year master students, 14 first-year GP trainees, and 39 first-year specialist trainees. Among these participants, the majority were female (n = 59, 75.6%). Most participants attended one workshop. Two bachelor students, two master students, two GP trainees and two specialist trainees attended two workshops; and one GP trainee attended all three workshops. Participants who attended multiple workshops were counted as double or triple, accordingly. Additionally, the Delphi session engaged 18 other relevant stakeholders from the included universities (i.e., programme coordinators, staff). Among these, the majority were female (n = 10, 56%). Consequently, the study included a total of 96 participants, comprising 78 medical students and trainees, and 18 other relevant stakeholders. Table 1 shows the characteristics of the participants per workshop or session.

Thematic analysis

This section presents the results of the thematic analysis, categorized in two pre-determined themes: individual-level and organisational-level interventions [10, 59, 65]. On the organisational level, a distinction was made between interventions intended for implementation within universities only, interventions for hospitals and GPs involved in medical training, and interventions that could be beneficial in all contexts (i.e. universities, hospitals and GPs). In addition, some of the interventions listed below are novel and have not yet been implemented, while others are existing interventions that participants consider effective. Figure 1 provides an overview of the thematic analysis.

Overview of the thematic analysis

Individual-level interventions (for universities, hospitals and GPs)

Interventions that focused on the individual-level were cited across all workshops, targeting universities, hospitals and GPs. The first intervention was the ‘provision of tailored personalized coaching and practical advice to address individual needs’. This intervention encompasses psychological support, career coaching, study assistance and practical advice on housing, finances, or other aspects.

It [coaching] can assist you in your study career. Even when facing difficulties, you can always fall back on this support. It can definitely be a valuable resource provided by the university.

– First-year bachelor student 3, workshop 2

A second individual-focused intervention was the ‘implementation of annual health assessments conducted by an occupational physician and psychologist’. The majority of students and trainees supported making these visits mandatory to reduce barriers to attendance. The main advantage would be its focus on prevention of burnout. However, concerns were raised about affordability. In addition, it was suggested to integrate these visits into the curriculum once or twice a year, ideally at the beginning of the academic year or semester.

‘We are healthcare workers who care for others, but it’s also important that care is provided for us.’

– GP trainee 5, workshop 2

A third intervention was the ‘organization of group training sessions focusing on soft skills and stress coping techniques’. Across all workshops, there was consensus on the potential benefits of integrating these sessions into the curriculum, given that physicians will inevitably work in highly stressful environments at some point. However, a GP trainee representative in the Delphi session noted:

‘You can’t fight a toxic work environment with yoga or mindfulness. I think we need to acknowledge that, we can provide soft skills training, but let’s not make students feel responsible for their burnout.’

– Participant 18 (GP trainee representative), Delphi session

Organisational-level interventions

Participants highlighted the need to complement individual-level interventions with organisational interventions. While implementing individual-level interventions may initially seem easier, quicker, and more cost-effective, organisational interventions address systematic factors contributing to burnout. Below, a distinction is made between organisational interventions that can be beneficial in all contexts (i.e. universities, hospitals and GPs), interventions intended for implementation within universities only, and interventions for hospitals and GPs only.

Universities, hospitals and GPs

One intervention that was discussed that could be implemented in all contexts (i.e. universities, hospitals and GPs) was the implementation of onboarding programs. Onboarding programs were considered necessary to acquaint new students and trainees with their student peers or colleagues, while also providing information on customs and facilitating orientation. By stimulating a sense of community and providing clear expectations, onboarding programs might help reduce stress and uncertainty that contribute to burnout.

‘Currently, you’re kind of thrown into the cold water. It would be better to have a metaphorical stepping stone in the cold water, a longer introduction period.’

– Specialist trainee 5, workshop 1

A second intervention involved mentorship programs in group or individually. Ideally, the group sessions should be scheduled in advance and integrated into the curriculum. Each session, moderated by a senior physician, psychologist, or coach, ideally involves a maximum of 10 students or trainees, and occurs once every two months for about two hours. Topics, such as mental health and burnout, can be selected by participants. This type of intervention can contribute to creating a supportive study and work culture, while also increasing support for students and trainees individually. This type of intervention could also address intergenerational conflicts by facilitating improved understanding between new and senior physicians. During the Delphi session, a programme coordinator expressed strong support for mentorship programs:

‘I strongly believe in mentorship programs. We have implemented it in the bachelor training since last year, and I think that with groups of about ten students per mentor, we can really address and mitigate a lot of issues.’

– Participant 10 (programme coordinator), Delphi session

The third intervention comprised a set of interventions aimed at stimulating teamwork and reducing competition. In hospitals and GPs, discussed interventions included regular debriefings, teambuilding activities, and celebrating small successes. In universities, this might involve peer support groups, stimulating studying together (e.g., in libraries), and facilitating group projects. In addition, a bachelor student explained that currently universities stimulate competition through ranking, however, according to these students, this approach results in higher stress levels, creates rivalry among peers, and incites unnecessary competition.

‘Currently our university ranks students on an online study progress dashboard, so that you can see whether you’re doing well relative to your peers.’

– First-year bachelor student 1, workshop 2.

Another intervention comprised a set of awareness raising initiatives to promote cross-generational collaborations and stimulate a culture of change. The above-mentioned mentorship programs could foster cross-generational teamwork. In addition, there is a need to challenge generational stereotypes and remarks from senior physicians such as ‘I had to do this too’ or ‘I used to work 100 hours per week’. These type of interventions might prevent burnout by enhancing mutual understanding and respect across generations, reducing feelings of frustration, and promoting a more supportive work culture.

‘We need a bit more awareness raising and change the culture. Well, yes, this is how it always was, but perhaps it could be different in the future. Just because it’s been this way for so many years doesn’t mean it cannot change.’

– First-year master student 2, workshop 3.

A fifth intervention was the provision of adequate infrastructure and services to promote optimal work conditions and a healthy work-life balance. The direct work and study environment is important, along with the availability of sport facilities, green spaces, childcare services, parking facilities, or amenities such as a small grocery shop, which have the potential to enhance work-life balance and overall well-being in universities, hospitals and GPs.

‘Our campus is located outside the city, and there isn’t much to do besides studying in the library, which is kind of boring and uninspiring.’

– First-year bachelor student 2, workshop 1.

A sixth intervention was the development and implementation of measures to address inappropriate behaviour. Participants in the workshop reported incidents ranging from verbal aggression to sexist or homophobic remarks. A programme coordinator acknowledged the importance of such policies and measures to create a safe and respectful work environment, thereby reducing stress caused by inappropriate behaviour.

‘We’ve actually just recently developed this within the faculty, on a relatively short-term basis, uh, there’s also a new reporting point set up, and there has been extensive communication to the students about it.’

– Participant 9 (programme coordinator), Delphi session.

Universities only

A first intervention mainly for universities encompassed a unified platform or guideline consolidating all deadlines, mandatory classes, and expectations. This intervention aims to improve and align internal communication channels effectively. Additionally, the involvement of year representatives plays an important role in the accurate dissemination of information. A master’s student added an interesting existing intervention in this regard, namely ‘date your doctor’, which encompasses some sort of speed dating with a specialist to gain practical information. These interventions might address burnout by reducing confusion and information overload, making it easier for students to manage their workload, stay organized, and have correct expectations.

‘There is a lot of fake news going around about selection criteria for certain specialisations. And it would have been nice if the university had just informed me clearly on the criteria.’

– First-year master student 3, workshop 1

Another intervention highlighted among students was to reduce the emphasis on detailed theoretical knowledge and increase focus on practical knowledge. First-year master’s students feel ill-prepared for their upcoming internships, as the transition from their theoretical bubble to the work floor feels too abrupt. This type of intervention might ease the transition from theory to practice, helping students feel more prepared and reduce stress about upcoming internships.

‘We learn a lot of theory and see little practice, and have little connection with patients, how they would look. Sometimes I really feel like we’re bookworms focusing on the smallest unnecessary details.’

– First-year master student 4, workshop 1

The final intervention for universities was the implementation of a pass-fail system. During the Delphi session, the president of a student organisation suggested a pass-fail system as an effective intervention to reduce stress. However, concerns about its feasibility across the curriculum and the loss of student differentiation suggest a combination approach might be preferable, with pass-fail for certain courses (e.g., internships) and traditional grading with feedback for others (e.g., theory).

‘I do think it would be feasible for the internship, for example, but then there would of course be less differentiation between students who excel and those who are just on the brink of being good enough.’

– Participant 6 (medical student representative), Delphi session

Hospitals and GPs only

A first intervention for trainees focused on flexible scheduling, including self-scheduling, longer career breaks (e.g., international internships), and part-time residency options. These interventions might give trainees more control over their schedules, allowing for better work-life balance and reducing stress.

‘An option could be to work 3/4 or 4/5 contracts, to promote a healthy work-life balance. Additionally, we recommend considering a flexible work schedule that suits your needs, as we believe having more autonomy in decision-making is beneficial for your health.’

– GP trainee 2, workshop 3

A second intervention focused on regulating and limiting working hours by ensuring accurate tracking through an independent institute, addressing understaffing, and preventing trainees from being a quick fix for staffing shortages. Additionally, there were discussions about Belgium’s ‘opting out system’, which allows specialist trainees to exceed the regulatory maximum 48-hour workweek by up to 12 additional hours for on-call duties. Many specialist trainees report feeling pressured to sign this document, resulting in workweeks often exceeding 60–70h. These interventions might help protect trainees’ well-being, encourage a healthier work-life balance, and prevent burnout.

‘There really needs to be an end to those 60–70 hour weeks; I think that’s the essence if we truly want to reduce burnout.’

– Specialist trainee 10, workshop 2

A third intervention focused on cultivating a feedback culture with regular evaluations (i.e. 360° feedback system: gathering feedback from multiple sources), which might promote professional growth, reduce stress, and boost motivation. Specialist trainees emphasize that they would prefer to establish their learning goals at the start of their residency and regularly discuss them in pre-scheduled evaluations with their supervisors. Although these evaluations are often theoretically planned, they hardly take place, and they often lack preparation and depth. In addition, it is crucial to consider who conducts these evaluations, their hierarchical position towards the trainee, whether they are also responsible for grading the trainee, and whether the relationship between both parties is safe enough to communicate openly.

‘I also find it important that these moments are not only about us and how we perform, but also about how we perceive the work environment, how the team is, how the training is going.’

– Specialist trainee 9, workshop 2

A fourth highlighted intervention among specialist trainees was the allocation of one day per week specifically for study purposes during their residency, which already exists for GP trainees. A specialist trainee emphasized the necessity of this to ensure days off to recharge during the weekend, or have a break in the evening. Sometimes specialist trainees cannot even attend their courses, because of their work schedule. One study day per week could be utilized for (online) courses, scientific work or group work. In terms of frequency, while the ideal situation would be one day per week, even half a day per week or two days per month would be beneficial.

‘Even on Saturdays, there are often (online) lessons or groupwork, which is the one weekend you’re not on call, so you still have to work’.

– Specialist trainee 2, workshop 2

A fifth intervention among GP and specialist trainees was the reduction of administrative tasks. The first step involved distinguishing between essential and nonessential administrative tasks. For instance, a participant recognised the advantages of consultation letters, as it can stimulate reflection on certain cases. Despite recognizing the importance of consultation letters, trainees expressed their concern over the high volume. They also criticized the requirement of writing consultation letters for patients of their supervisors. Strategies to address this issue were discussed, included utilizing templates, minimizing lay-out efforts, and providing support from medical secretaries or others. Furthermore, certain administrative tasks were considered less meaningful, such as short-term sick certificates. An interesting intervention involved the ‘blue crocodile’ project, in which physicians stamped unnecessary sick (or other) certificates with a blue crocodile to raise awareness.

‘We will never eliminate all administrative tasks, and it’s also about what you personally gain from them.[.] This aspect might be something for a soft skill training, namely focusing on optimizing the personal benefits of admin work.’

– Participant 18 (GP trainee representative), Delphi session

The sixth intervention was the establishment of an effective procedure for securing residency positions in hospitals or GPs. A GP trainee suggested to organise speed dates between trainees and supervisors. This intervention might enable both trainees and future supervisors to meet each other more profoundly, reflect on their options, and make well-considered decisions with regard to their internship and residency location.

‘We could organize a speed dating event with senior GPs, which allows to quickly meet a lot of people. […] Additionally, implementing at least one week dedicated to interviews only, with no contracts being signed, would provide the opportunity to visit multiple places.’

– GP trainee 1, workshop 3