A growing concern in the physician workforce over the last decade, burnout rears its ugly head again, this time peppered with a pandemic and racial and political tensions. In this medical education special issue, several authors have identified factors contributing to burnout, and those associated with wellbeing and, indeed, thriving while in training. Unfortunately, many of the actions we implemented as a result of the COVID-19 pandemic may have actually increased burnout and reduced wellbeing in our learners across the continuum of medical education. Recognizing these lessons now may help prevent the same mistakes and even serve to provide evidence-based alternate strategies to enhance wellbeing and mitigate burnout during our next medical crisis.

In response to the COVID-19 pandemic in early 2020, medical students were removed from clinical duties to mitigate exposure to the virus. The article by Alkureishi et al.1 evaluated the consequences of COVID-19 on medical student burnout, stress, and loneliness. Utilizing standard measurement tools, they found, perhaps unsurprisingly, that half of the students reported burnout and loneliness in the early phase of the pandemic. Their findings also highlighted racial inequities, with increased financial strain, experiences of racism and bias, and personal or family experiences with COVID more common in those who identified as a racial minority.

As Hyman and Doolittle2 point out in their examination of thriving in the workplace, little is known of what trainee wellbeing consists of beyond the absence of burnout, and specifically who thrives in training. Through a series of qualitative interviews, they discover thriving trainees attribute their success to themes similar to those found in practicing physicians, namely, supportive leadership, a collaborative learning climate, connectedness personally and professionally, joy and pride in the work done, work-life balance, and intrinsic factors such as faith, optimism and a growth mindset.

Lou et al.3 discuss the role the EHR plays in burnout. They followed the electronic habits of interns as they cared for patients, and correlated them with measures of burnout over a six-month period. Their findings suggest that burnout can be elastic, fluctuating over time, and that higher patient load and time spent on EHR correlate with increased burnout.

McClintock and Fainstad4 discuss ways to improve psychological safety in the clinical learning environment. They reflect that factors to build psychological safety in medical education include team continuity, an absence of social positioning/flattening of the hierarchy, group debriefing, a learner-centered approach to education, and more assessments that are formative with the goal of rewarding learning rather than performance.

As has been highlighted in business literature5 and this special edition, thriving is a result of both extrinsic and intrinsic factors such as optimism, a growth mindset, balance, connectedness, and meaningful work. Our response to the COVID-19 pandemic created a natural experiment of isolating many medical students from the meaningful work of caring for patients, while residents were often left overburdened in the clinical learning environment. That the pandemic resulted in burnout and loneliness in half of the students surveyed is perhaps not a surprise, as a loss of meaning and purpose can have devastating consequences on wellbeing, and may have amplified the underlying belief that medical students are not truly part of the medical team.6 Bolstering this concept, volunteerism served as a mitigating factor against burnout, correlating perhaps with findings on those who thrive in residency, where meaningful work that creates pride leads to joy in medicine.

Lou et al. introduce the concept of burnout as a dynamic and evolving concept, not a static state of being that can’t be remedied without effort. This provides a different lens to assess, monitor, and study burnout in relation to clinical workload. Undoubtedly, as workload increases, threats to wellbeing need to be identified and tempered. As noted, with workload surges, risk for burnout rises considerably, and teachings from these studies can help us plan for adaptations to support trainees (and faculty) in their clinical workspaces and learning environments during these stress points.

Factors to support resilience7,8 should be promoted during training, such as scheduling that allows diastoles in workload, and implementation of wellness interventions. Proactive and tailored support should be considered for trainees at increased risk of loneliness, stress, and burnout, such as women and underrepresented minorities. Building a culture of psychological safety in the workplace via institutional promotion of leadership that fosters this environment, and offering opportunities for learners to reconnect with their purpose through volunteer activities, or opportunities to connect on issues of importance through promotion of reflective practices in narrative medicine should be considered. Creative solutions, such as the use of scribes, may allow increased bedside presence and more connectedness with patients and colleagues, as well as enhance resident wellbeing.9

Some of the factors discussed that contribute to a feeling of psychological safety simply cannot be upheld in our current clinical structures. A co-production model in which the teacher and the learner engage in a partnership each bringing their own experience and expertise into the educational process would promote a culture of psychosocial safety, fostering learners self-regulated learning and agency.10 Team continuity, as an example, may be developed in the outpatient setting by creating a co-production model that involves learners, patients, and staff. The nature of residency training requires learners to rotate through varying specialties and clinical sites, leading to constant disruption of the team. Perhaps team stability can be emphasized through clearly defined roles that value the individual contribution from each team member in the pursuit of high-quality patient care. Finally, although reducing summative assessments may reduce the psychological burden on students, we have a duty to society to ensure competency. A way forward may be to place less emphasis on the performance associated with any single observation. Instead, emphasize and value the growth of learners over time, which arguably requires more observations with feedback for growth as our unit for determining success.

Although the COVID-19 pandemic and prominent social and political events may have contributed to the experiences of trainees in the cohorts studied, these are not the first and won’t be the last challenges our trainees experience. The impact of a constantly evolving learning environment, the complexity and unpredictable nature of the educational system, and the unexpected emergence of social and political tensions outside of the healthcare system should be carefully taken into consideration when we embark upon future research explorations of wellbeing and burnout across the medical education continuum. As educators, our role is to institute best practices that promote wellness, resiliency, and thriving. It will require a deliberate and collaborative effort between the healthcare industry and health professions education complex to move the needle toward habits that lead to sustained joy and excellence in practice.