The scale of the problem in such settings is stark. The authors cite a study of healthcare workers at Kenya’s largest government referral hospital that reported a burnout prevalence of 95.4 percent, a figure that approaches universality. A separate study of residents at a Kenyan tertiary academic teaching center found that 47.3 percent were at high risk for burnout. The drivers identified in both studies were systemic rather than individual: conflict between departments, relentless patient volumes, chronic workforce shortages, difficulty balancing professional and personal responsibilities, and maladaptive coping mechanisms including substance use. These conditions matter beyond the individual, the authors note, because burned-out physicians make more errors, communicate more poorly with patients, and generate lower patient satisfaction, turning a workforce crisis into a quality-of-care crisis.

RESIST takes its name from an acronym covering six domains: Rest and workload hygiene, Emotional and peer support, Skill training for residents, Institutional culture and psychological safety, Supportive faculty and role modeling, and Tracking and continuous improvement. The framework was introduced at Aga Khan University Hospital, which in 2020 became the first institution in Africa to earn accreditation from the Accreditation Council for Graduate Medical Education International, a milestone that gave the program an established accreditation foundation on which to build. The authors drew on global literature from higher-resource settings, including evidence for mindfulness training, structured mentorship, workload regulation, and organizational interventions targeting culture, and adapted those insights to their own constraints and lived experience.

The most consequential intervention, and the most expensive, was staffing. The program hired four part-time locum junior providers to cover additional shifts, academic half-days, and weekends, reducing resident fatigue while preserving protected educational time. Since implementation, tracked metrics have shown lower resident attrition and reduced self-reported burnout. The authors argue that this upfront investment may prove cost-effective relative to the downstream costs of burnout-related attrition, medical errors, and turnover, expenses they say are chronically underrecognized in training budgets across low- and middle-income countries. For programs that cannot afford locum hires, the paper proposes tiered alternatives such as rotating elective coverage or task-shifting. In parallel, the hospital adopted a lower-cost electronic health record, a change not originally part of the resiliency initiative, which further reduced the documentation burden on trainees.

Emotional support was addressed by leveraging resources the institution already had. Where access to professional counseling was limited, the program strengthened peer-support groups, faculty mentorship, and partnerships with community mental health services, alongside structured debriefing after critical clinical events. These mechanisms, the authors write, helped residents process emotionally difficult experiences, normalized help-seeking behavior, and acknowledged the emotional dimensions of patient care, an aspect of medicine that is often left unspoken in hierarchical training environments.

Skills training focused on practical, teachable defenses against stress. The program ran quarterly workshops on sleep science and fatigue management, optimized on-call rooms, and created structured opportunities for short restorative naps during overnight shifts, with facilitated discussions woven into monthly academic half-days. Substance use, which the authors describe as frequently underaddressed in training programs, was tackled through targeted educational sessions, peer-led discussions, and confidential referral pathways built on existing institutional and community resources. The authors note that formal outcome data for these measures are not yet available, though informal feedback from residents and faculty has been favorable.

Perhaps the most culturally ambitious component targets psychological safety, the shared belief that individuals can speak openly without fear of retribution. The program created quarterly town halls, small-group debriefs, and monthly wellness check-ins as protected forums for residents to raise concerns and propose solutions. To counter the barriers posed by steep hierarchies and fear of retaliation, the institution implemented an anonymous reporting system alongside a university Safe Disclosure Program. Residents were empowered to choose their own faculty mentors, and faculty were encouraged to model vulnerability by openly sharing their own professional struggles during teaching sessions, a deliberate strategy to destigmatize imperfection and encourage early help-seeking. Initial surveys and structured discussions already point to stronger one-on-one engagement between faculty and residents, and the team is extending this into a formal longitudinal evaluation.

Faculty development was embedded in the institution’s mandatory continuing education program, which trained designated wellness champions and promoted dialogue around fatigue and burnout. Biannual faculty workshops were introduced to help senior physicians recognize early signs of resident distress, complemented by informal coaching. The authors emphasize that role modeling mattered as much as formal training: faculty consistently demonstrated healthy behaviors, including respecting time off and protecting academic time, reinforcing the message that well-being is a core professional value rather than a private individual responsibility.

Crucially, the framework treats data collection as an active feedback loop rather than a bureaucratic exercise. The program monitors duty hour violations, sick leave utilization, burnout survey scores, and resident satisfaction, and uses those metrics to guide interventions. Increases in duty hour violations prompted targeted schedule adjustments, while adverse trends in burnout survey results triggered the introduction of additional peer support sessions. This iterative approach, the authors argue, kept resiliency efforts dynamic and embedded within the training environment rather than functioning as isolated, one-off interventions that fade once initial enthusiasm wanes.

The authors are candid that implementation was not without obstacles, including difficulty recruiting junior providers, building faculty capacity to address burnout, and encouraging uptake of anonymous reporting. Those barriers were managed through phased implementation, faculty development, and sustained leadership engagement. Formal outcome and cost-effectiveness data are not yet available, and the team acknowledges that early signals, such as improved faculty-resident engagement, are encouraging but not conclusive. Longitudinal evaluation, including resident-level outcomes and cost analysis, is now a priority, aimed at rigorously testing whether RESIST produces resilient and compassionate physicians, sustains a constrained workforce, and can be adapted across similar low-resource settings. If those evaluations bear out the early trends, the Nairobi experience could offer a template for training programs worldwide that have assumed, until now, that physician well-being is something only wealthy health systems can afford to protect.

Subject of Research: Resilience training and burnout prevention among medical residents in low-resource settings

Article Title: RESIST: Addressing Resident Resiliency in Low-Resource Settings

Article References: Ali, S. K., Chandani, A. K., Sayed, F., & Talib, Z. (2026). RESIST: Addressing Resident Resiliency in Low-Resource Settings. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10896-4

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10896-4

Keywords: physician burnout, medical residency, resilience training, low-resource settings, graduate medical education, Kenya, psychological safety, resident wellness, peer support, workforce sustainability, Aga Khan University Hospital, global health

The Gonzalez review, which the editorial frames as a timely analysis of a wicked problem, examined the published literature on structures and interventions aimed at mitigating mistreatment within graduate medical education, the training phase that begins after medical school graduation. The authors identified 71 articles and 30 abstracts published between January 2015 and July 2025, describing 71 distinct structures. Of these, 56 were educational or training interventions and 15 were programs or policies. The policy-level approaches included instruments to measure mistreatment and institutional or programmatic strategies to address or prevent it, some of which targeted efforts at specific groups such as minoritized trainees. On the surface, that volume of activity might suggest a field taking the problem seriously. The details tell a different story.

The most striking finding is how thin most of the effort has been. The majority of the training interventions cataloged in the review were single sessions, 44 of them, and most targeted residents as participants, 34 in total. In other words, the dominant model for combating a deeply entrenched cultural problem has been a brief lecture or workshop delivered to one layer of the hierarchy. Miller and Logio argue that this approach exposes a critical structural limitation: mistreatment is treated as a learner issue, something to be managed through trainee education, when it is in fact a workforce, quality, safety, retention, and equity issue that implicates everyone who shapes the clinical environment.

The data on prevalence help explain why the editorial’s authors are impatient. Mistreatment in undergraduate medical education has been tracked annually since 1999 through the American Association of Medical Colleges Graduation Questionnaire, and the most recent data show that 38 to 40 percent of medical students report experiencing at least one incident of mistreatment during medical school. Mistreatment is defined by the AAMC as any behavior that shows disrespect for the dignity of others and unreasonably interferes with the learning process. Nearly four in ten students encountering such behavior suggests that disrespect is not an aberration in clinical training but a routine feature of it.

The picture in graduate medical education looks different, and the difference matters for how interventions should be designed. Since 2020, the Accreditation Council for Graduate Medical Education has included professionalism items on its annual resident survey, asking whether residents personally experienced or witnessed abuse, harassment, mistreatment, discrimination, or coercion. National rates of personally experienced mistreatment have ranged from 5 to 7 percent, and witnessed mistreatment from 6 to 8 percent. Those percentages translate into an average of nearly 9,500 trainees who personally experience mistreatment and more than 10,700 who witness it each year. The editorial argues that these figures reveal the persistence of an unsafe culture in which bad behavior is written off as a professional rite of passage.

Why do medical students report mistreatment at rates several times higher than residents? The editorial points to structural differences between the two populations. Medical students are novice learners who receive grades during short-term clinical rotations, making them uniquely vulnerable to the power dynamics of the wards. Residents, by contrast, are embedded in a specialty as employed junior colleagues who often work with the same faculty over years, and they are joining a discipline-specific guild in which success depends heavily on a strong network of mentors. Graduate medical education programs are also housed within hospitals where institutional factors may shape the culture of reporting. All of this makes the true scope of mistreatment difficult to measure, let alone eliminate, and it means that findings from one level of training cannot simply be transferred to the other.

Perhaps the most consequential evidence cited in the editorial comes from a study by Leitman and colleagues at the Icahn School of Medicine, which used an online reporting system to track unprofessional behavior. Of 173 reported incidents, 104 were attributed to faculty. Just twenty faculty members, 0.7 percent of the faculty, accounted for 52 of the reports, a full half of the total, while 97 percent of faculty members had no reports at all. Miller and Logio endorse the study’s conclusion that longitudinal skills programs focused on the small fraction of repeat offenders, roughly 3 percent, are more likely to move the needle than broad-based training aimed at everyone. The concentration of harm in so few hands suggests that targeting resources at the source, rather than diffusing them across entire trainee populations, could be the single highest-yield intervention available.

The editorial also insists that any reboot of the clinical learning environment must center the marginalized populations who bear a disproportionate burden of mistreatment, bias, and harassment. A 2026 AAMC report on sexual harassment among medical school faculty found overall rates of 11.3 percent among men and 29.3 percent among women. Among LGB+ men the rate was 17.2 percent, and among LGB+ women it reached 40.9 percent. Critically, metrics around engagement were significantly lower among those who had been harassed compared with their peers. That erosion of engagement, the authors argue, undermines both learning and patient care, and it demonstrates that rigorous standards of competence and a genuine sense of belonging are not in tension. Psychological safety, they suggest, is the foundation on which both rest.

So what would a systems approach look like? The editorial draws on the literature on healthy clinical learning environments, citing Stuart Slavin, the ACGME Vice President of Well-Being, who advocates for organizational design, strong leadership, and balancing workplace demands with available resources. Eliminating mistreatment, on this view, requires every member of the clinical learning environment to focus on workplace well-being, backed by leaders who buy into necessary changes and reinforce the message clearly and frequently. The authors also point to relationship-centered care, an approach that fosters a strong web of interpersonal connections among care team members in addition to strong clinician-patient relationships. They raise an uncomfortable possibility: the large health systems created through hospital mergers, acquisitions, and private equity buyouts may have eroded something foundational to the learning environment itself.

The destination the editorial describes comes from organizational psychologist Amy Edmondson, whose work identifies high psychological safety combined with high accountability as the hallmark of optimal conditions for learning and performance. Institutions, the authors write, need robust reporting systems that practice transparency and accountability, with particular attention to repeat offenders, and clinical learning environments should embrace frameworks that allow strong interpersonal relationships to form and grow. Future research should follow the gaps the review exposes: longitudinal, multi-level programs that perhaps track trainees from medical school into residency, interventions that measure whether behavior actually changes rather than merely whether awareness increases, and comparative studies across undergraduate and graduate settings where reporting cultures and power dynamics differ substantially. The editorial’s closing argument is blunt. A clinical learning environment shaped by fear, silence, and preventable disrespect cannot produce the belonging, trust, and accountability that learning and patient care require, and rebooting it will require leaders to redesign systems, relationships, and norms so that mistreatment is prevented at its source and no longer mistaken for part of becoming a physician.

Subject of Research: Mistreatment and interventions in the medical education clinical learning environment

Article Title: Reboot the Clinical Learning Environment

Article References: Miller, K. E., & Logio, L. S. (2026). Reboot the Clinical Learning Environment. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10884-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10884-8

Keywords: medical education, graduate medical education, mistreatment, clinical learning environment, resident wellness, psychological safety, sexual harassment, ACGME, AAMC, scoping review, physician burnout, unprofessional behavior

The research team, led by Alfredo Verastegui of Mayo Clinic Florida and Tecnológico de Monterrey, together with Mauricio Gonzalez-Urquijo, Diego Maldonado, Adolfo Leyva-Alvizo and Mario Rodarte-Shade, set out to answer a deceptively simple question: how do the different dimensions of burnout actually change as residents move from their first to their fifth postgraduate year? Most previous studies have offered only snapshots, measuring burnout at a single point in time or comparing different cohorts of residents. What has been missing, particularly in Latin American contexts where surgical training conditions can differ substantially from those in the United States and Europe, is a complete picture of an entire residency program at every stage of training simultaneously.

To build that picture, the researchers surveyed all 37 general surgery residents at a Mexican academic institution in October 2025, spanning the full range from PGY1 to PGY5. The response rate was a perfect 100 percent, a methodological strength that eliminates the selection bias that plagues most burnout surveys, where the most distressed or the most disengaged residents are often the ones who decline to participate. The residents, whose mean age was 28.9 years, were 54.1 percent female, and 62.2 percent had relocated from other regions to train at the institution, a detail that allowed the team to test whether leaving home for residency shapes psychological outcomes.

Burnout was measured with the Maslach Burnout Inventory, the most widely used instrument in the field, which assesses three distinct domains: emotional exhaustion, the feeling of being drained and depleted by work; depersonalization, the development of cynical, detached attitudes toward patients; and personal accomplishment, the sense of competence and meaningful achievement in one’s work. Because these three dimensions can move in different directions, the researchers treated them separately rather than collapsing them into a single burnout score. They then applied a battery of statistical tests suited to the task: Kruskal-Wallis tests to compare the domains across training years, Jonckheere-Terpstra tests to detect monotonic trends, meaning steady increases or decreases from one year to the next, and linear regression models that examined the relationship between training year and burnout while adjusting for demographic factors and whether a resident was local or non-local.

The results were striking. Personal accomplishment was the only domain that differed significantly across training years in the between-group comparison, with a p-value of 0.023, and the scores climbed steadily from the first year to the fifth. The trend analyses reinforced the pattern with remarkable consistency. Emotional exhaustion showed a significant monotonic decrease across training years, with a correlation coefficient of -0.415 and a p-value of 0.011, while personal accomplishment showed an even stronger monotonic increase, with a coefficient of 0.530 and a p-value below 0.001. In plain terms, the longer residents stayed in the program, the less emotionally drained they felt and the more capable and fulfilled they became.

The prevalence figures tell the story in even more vivid terms. Among first-year residents, 37.5 percent reported high emotional exhaustion, 50 percent reported high depersonalization, and a staggering 75 percent reported low personal accomplishment. By the fifth and final year, those numbers had collapsed to 11.1 percent for emotional exhaustion, 22.2 percent for depersonalization, and exactly zero percent for low personal accomplishment. Not a single senior resident in the cohort reported a diminished sense of professional achievement. For a specialty in which burnout prevalence has been reported as persistently high across institutions and countries, the near-total disappearance of one burnout domain by the end of training is a finding that demands attention.

Equally notable is what the researchers did not find. Resident origin, whether a trainee had come from the local area or relocated from elsewhere, showed no significant association with any burnout domain or with the trajectories across training years. In a country where surgical residency often requires young doctors to move far from their families and support networks, the absence of an origin effect suggests that the program itself, rather than geographic circumstance, is the dominant influence on how residents weather the psychological demands of training.

The authors’ conclusion is deliberately provocative: burnout improves progressively during surgical residency, junior residents are the most vulnerable group, and senior residents demonstrate substantial recovery. This directly challenges the widespread assumption that residency is an unrelenting descent into exhaustion, an assumption embedded in much of the wellness literature and in the design of many burnout interventions. If burnout is not a uniformly worsening trajectory, then one-size-fits-all programs spread evenly across five years of training may be misallocating their resources. The data point instead toward targeted early support, concentrating mental health resources, mentorship and workload adjustments on the first years of training, when distress is at its peak.

The study also raises a subtler question about the nature of surgical training itself. The authors emphasize the importance of preserving the transformative aspects of residency, the demanding process through which medical graduates are forged into autonomous surgeons. Some degree of struggle may be intrinsic to that transformation, and the steady rise in personal accomplishment suggests that residents derive a growing sense of mastery from exactly the challenges that make training so hard. The goal, on this reading, is not to eliminate difficulty but to ensure that junior residents, who are simultaneously absorbing the steepest learning curve and the heaviest emotional load, have the scaffolding they need to get through the most vulnerable phase.

Context matters here. The study is cross-sectional, capturing all five training years at a single moment in October 2025 rather than following the same individuals over time, and it comes from one institution with 37 residents. Those limitations mean the trajectories should be interpreted as strong hypotheses rather than universal laws, and the authors themselves frame the work as a complete cohort analysis of a single Latin American program. Yet the 100 percent participation rate, the use of validated trend statistics, and the adjustment for demographics and resident origin give the findings unusual credibility for a study of this size. As residency programs expand across Mexico and Latin America, and as the global conversation about physician well-being intensifies, this complete snapshot from Monterrey offers something the field has lacked: evidence that the arc of surgical training may bend toward recovery, not ruin, and that the most effective interventions may be the ones aimed at the residents who need them most, in their earliest and hardest years.

Subject of Research: Burnout trajectories across the five years of general surgery residency in a Latin American training program

Article Title: Burnout trajectories across general surgery residency: a complete cohort analysis from a Latin American Institution

Article References: Verastegui, A., Gonzalez-Urquijo, M., Maldonado, D., Leyva-Alvizo, A., & Rodarte-Shade, M. (2026). Burnout trajectories across general surgery residency: a complete cohort analysis from a Latin American Institution. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 150. https://doi.org/10.1007/s44186-026-00557-9

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00557-9

Keywords: burnout, surgical residency, general surgery, medical education, resident wellness, Maslach Burnout Inventory, emotional exhaustion, depersonalization, personal accomplishment, Latin America, Mexico, physician well-being