The Cost of Learning: When Wellness, Equity, and Rigorous Practice Collide
- Dr. Washington
- 5 days ago
- 11 min read
The Tension Between Professional Rigor and Emotional Well-Being in Residency Programs
18 May,2025 Dr Sharon Washington
Table of Contents
Opening Message
Over the past decade—and especially since 2020—I’ve had the privilege of working closely with over 20 residency programs, medical schools, nursing schools, and physician assistant programs across the country. As a DEIA and organizational wellness consultant, I’ve been invited into vulnerable spaces where learners, faculty, and leadership are navigating profound change, tension, and transformation. Through interviews, retreats, focus groups, and coaching conversations, I’ve witnessed how culture, trauma, and shifting expectations are playing out across the healthcare training landscape.
This reflection is offered with care, humility, and a deep desire to support the continued evolution of medical education. It is not meant to center blame on learners or to absolve faculty and leadership of the very real ways in which they have contributed to toxic, harmful, or disjointed workplace cultures. Both dynamics are true—and both must be addressed in parallel. This thought piece is focused on learners not to scapegoat them, but because we often lack shared language to name the newer cultural forces shaping how residents and trainees engage, struggle, resist, or grow. Much of what I have observed and share here can be said about particular faculty and others in the workforce, and for this piece, I am focusing on the experiences of learners that I've witnessed.
Too often, in the absence of reflection and support, faculty—confused, overwhelmed, and navigating uncharted challenges in medical education—land on harmful assumptions: that learners are lazy, that the implementation of holistic review or increased diversity in admissions has led to an erosion of rigor, or that DEI efforts have derailed the mission of teaching medicine. These narratives are troubling and must be challenged. This perspective is offered to balance those assumptions and mitigate their impact by naming the deeper cultural and systemic forces at play.
I know how tender and difficult this conversation is. I’ve seen firsthand how hard it is for programs to balance compassion and accountability, to support healing while holding high standards, and to rebuild trust in environments marked by isolation, conflict, and fatigue. Yet these challenges are not unique—they are widely shared. My hope is to offer a perspective that invites deeper reflection, contextual understanding, and concrete direction as we work to create learning communities that are rigorous, inclusive, and well.
Let this serve as an offering to move the conversation forward—with clarity, complexity, and care.
Introduction
The shifts in higher education over the past three decades have significantly reshaped how learners approach schooling, learning, feedback, and professional growth. These dynamics, compounded by the trauma of the COVID-19 pandemic, mental health advocacy, social justice movements, and digital culture, are now manifesting with increasing intensity in graduate medical education. Below is a synthesis that outlines these trends and connects them directly to the residency experience.
Shifts in Higher Education (Last 30 Years)
1. Economic and Political Shifts
Rising Costs & Student Debt: Since the 1990s, the cost of college has skyrocketed, outpacing inflation and wage growth. State disinvestment in public universities, privatization, and an increased reliance on tuition have shifted the burden to students.
Justifications for Cost Increases: Institutions have defended rising costs by citing the need for upgraded facilities, technology, administrative support, and global competitiveness, but little of this has translated into better classroom instruction or learner support.
2. Commodification of Education & the Consumer Mentality
Students as Customers: With high tuition, students increasingly expect a return on investment. Education is treated like a purchased product. If satisfaction is low—whether in a course, a grade, or feedback—it is viewed as a customer service failure.
Transactional Mindset: Students often believe they are entitled to a degree because they paid for it. This erodes curiosity, critical inquiry, and engagement in challenging discourse or growth processes. Many learners expect degrees, honors, or support accommodations without reciprocal effort. The idea of earning success has eroded into a belief in deserving it due to enrollment.
Cultural Shifts & Mental Health Awareness
3. Wellness, Boundaries & Mental Health
Mental Health Normalization: A long-overdue shift has reduced stigma and expanded access to accommodations. But it has also, in some cases, conflated discomfort with danger or “unsafety.”
Boundary-Setting as Opting Out: “Protecting my peace” or “prioritizing rest” are often appropriate. Yet overused, these phrases can justify avoidance of discomfort that is part of adult learning and professional development.
Professional Expectations vs. Burnout Culture: The struggle is real—residents are tired and anxious. But residency is designed to grow tolerance for complexity, not shield from it.
4. Academic Shortcuts & Online Culture
Rise of Shortcut Culture: AI tools, online summaries, and shared notes have replaced deep reading. Learners increasingly rely on pre-digested knowledge without developing reasoning skills.
Cheating, Circumvention, and the Internet: Technology has made it easier to avoid grappling with content. This undermines critical thinking and clinical decision-making in medicine.
Devaluation of Reading & Reflection: Many learners report little time or desire to engage with foundational texts or literature. Instead, they seek direct, fast answers with minimal effort.
The EHR as Cognitive Overload: The burden of documentation has grown with the expansion of the electronic health record. The EHR demands high levels of time and attention, often outside work hours, and is frequently experienced as dehumanizing—especially by underrepresented learners. This contributes to feelings of burnout and disengagement.
Rise of Social Justice Consciousness
5. Performative Activism & Righteous Indignation
Online Advocacy vs. Real-World Organizing: Learners today are often well-versed in social justice language and demand for institutional change. However, advocacy is frequently conducted in digital echo chambers—comment sections and callouts—rather than community-based coalition building.
Impatience with Institutional Timelines: Institutions that have only engaged in equity work for the last 5–8 years are being judged against decades of systemic harm. While frustration is valid, the demand for instant transformation lacks practical grounding.
Personal Trauma & Dysregulation in Learner Advocacy: Some learners advocate for equity with urgency but little vision or capacity to navigate conflict. Emotional reactivity and personal pain replace strategy, curiosity, or collaboration. This can produce friction when institutions do not keep pace with evolving social justice narratives.
“You Should Have Fixed It Already” Mentality: Learners—especially learners of color and their allies—increasingly say, “It’s not my job to fix this.” While that can be a fair stance, particularly on an individual level or at specific times in one's life, change without shared effort is impossible. We still exist in a racist society, and many institutions only in the past two decades, have experienced significant increase in diversity and representation. Junior professionals today are first-generation desegregationists, yet increasingly, are unwilling to carry the legacy of creating the equity we need. Equity requires participation, not just expectation.
The Lasting Impact of the COVID-19 Pandemic
6. Disruption of Learning and Human Connection
Interrupted Clinical Training: Medical students and pre-health learners lost essential hands-on learning and in-person mentorship, which has created long-term knowledge and skill gaps as they enter residency.
Global Trauma & Fear: Residents today were premeds or early trainees during the height of the pandemic. The trauma of mass illness and death, fear of exposure, and being tasked with heroic care during crisis deeply shaped their worldview and sense of safety.
Social Isolation & Stigma of Connection: The normalization of distancing led to eroded peer bonding. In residency, many still feel socially disconnected, making collaboration and mutual accountability more difficult. In high-stress contexts and demanding institutional and patient needs, this distance and isolation increased the ability for dehumanizing others and lacking the social fibers and relational foundation to work through conflict or disagreement. In-person interactions began carrying more of the essence of black zoom boxes on a screen or the comment section of the internet.
Low Social Bandwidth: Chronic stress, reduced social energy, and eroded relational capacity contribute to emotional avoidance, burnout, and difficulty receiving feedback or engaging in repair.
Reduced Exposure to Feedback & Structure: Learners missed early opportunities to build tolerance for feedback and professional responsibility due to the fractured learning environments of the pandemic. I increasingly witness learners resisting feedback, opting out of socialization and relationship building as a part of training, and preferring didactics via zoom with limited engagement and cameras off, or skipping these aspects of their training altogether.
How These Trends Show Up in Residency
Residency programs now sit at the intersection of these educational and cultural transformations, with growing misalignment between what is required for medical professionalism and what some residents are prepared to give.
A. Professionalism, Independence & Feedback Avoidance
The term professionalism has long been contested—rightfully so. Historically, it has often served as coded language to enforce white supremacy culture and dominant norms around behavior, dress, communication, and emotional expression. Expectations tied to professionalism have disproportionately penalized those who express cultural, linguistic, or personality differences, reinforcing exclusion rather than cultivating excellence.
Over the last 5–8 years, I’ve witnessed many forward-thinking residency programs begin to interrogate these norms. Faculty and leaders are shifting away from using the term “professionalism” as a vague catch-all and instead focusing on more precise, equitable language like accountability, integrity, or interpersonal effectiveness. This evolution reflects a growing awareness of how systemic bias shows up in performance assessment—and it’s a necessary shift.
However, in some cases, this critical lens on professionalism has inadvertently led to a broader rejection of professional accountability altogether. Some learners, in their rightful skepticism of bias, now resist all feedback that references their behavior, communication, or clinical follow-through.
Example: A resident receives feedback about being consistently late with notes, slow to respond to nursing concerns, or disengaged during interdisciplinary team huddles. Rather than reflecting on the impact of these patterns, the feedback is dismissed as “subjective” or “biased,” with no further inquiry or effort toward repair.
B. Under-Developed Resilience Skills & Internal Tools
Rather than viewing challenge as an opportunity for development, some interpret struggle as evidence of unworthiness or harm. Without structured support or internal tools to process these moments, residents may disengage, withdraw, or resist growth opportunities. This shows up as emotional avoidance, passivity in the face of challenge, and a lack of initiative in repairing mistakes or taking ownership for improvement.
Example: A resident delays taking Step 3 multiple times due to test anxiety, which is understandable. But instead of seeking support, engaging a study plan, or tapping into available resources, they remain stalled—trapped in avoidance that ultimately delays progression and places additional stress on peers and program leadership. What’s missing isn’t ability—it’s the resilience and internal scaffolding needed to move through fear toward growth.
C. Resistance to Authority & Institutional Norms
Over the past decade, medical learners—particularly those from marginalized backgrounds—have played a vital role in advancing equity and inclusion in academic medicine. Many of the most impactful DEIA reforms have come not from leadership, but from student and resident advocacy: pushing for inclusive curriculum, culturally responsive care, and institutional accountability. Similarly, younger generations of physicians often bring fluency in emerging technologies and digital tools, challenging legacy practices and prompting important updates in clinical education. This inversion of power—where learners introduce progressive frameworks and advocate for institutional change—has been instrumental in transforming healthcare education. But when this advocacy morphs into broad rejection of feedback or institutional norms, it becomes counterproductive.
Some residents now position themselves as more socially or clinically “up-to-date” than faculty, using perceived generational or ideological gaps to dismiss supervision, critique, or systems-based responsibilities. The narrative may sound like: “I’m not intimidated by medical hierarchy,” or “My attendings aren’t ready for how medicine is evolving.” But this framing, while grounded in real cultural shifts, can be used to avoid responsibility, interpersonal repair, or necessary learning.
Example: A resident resists participation in team debriefs, disregards feedback on communication style, or bypasses supervision by citing outdated institutional culture—while failing to consider how their choices impact patient care or team dynamics.
D. Entrustability & Delayed Readiness
Faculty across many programs report a growing need to remain more hands-on, even in clinical situations where residents would typically be expected to take greater initiative or lead. While residency is inherently a space for learning and supervision, some learners are exhibiting delayed readiness when it comes to independent clinical judgment, team leadership, and accountability.
Increased reliance on faculty input appears not only in clinical decision-making but also in areas such as documentation, communication, and follow-through. Feedback that addresses these gaps—such as missing notes, inconsistent follow-up, or reluctance to engage in reflection—is sometimes dismissed as biased or oppressive, rather than taken as a developmental opportunity.
Example: One program developed an entrustability framework to clarify expectations across levels of training. At the foundational level, faculty must consistently step in and direct care. At the highest level, residents demonstrate leadership by teaching others, anticipating needs, and managing complexity with minimal supervision. A concerning number of residents are stalling in the early phases of this progression longer than expected—not necessarily due to lack of skill, but due to reluctance to take ownership or navigate discomfort.
The Tension in Residency Culture
Cultural Shift | Impact in Residency |
Wellness culture & boundary language | Residents increasingly frame disengagement from learning, teamwork, or reflection as “self-care” or “protecting my peace,” even when discomfort is essential for growth. |
Consumer mentality & educational transactionalism | Some residents interpret feedback, coaching, or accountability as “bad service.” The mindset of “I paid, so I deserve” undermines humility and commitment to professional rigor. |
Mental health advocacy & fragility | Rightful emphasis on wellness sometimes conflates discomfort with harm. Accommodations are requested, but reflection and follow-up are often lacking. |
Shortcut culture | Overuse of AI and pre-digested resources reduces clinical reasoning and deep engagement. Foundational reading and documentation are often viewed as optional. |
Social justice fluency & institutional disillusionment | Learners advocate for systemic change but may resist institutional structure or dismiss feedback. Activism is strong, but relational trust and shared responsibility are weak. |
COVID-era isolation & low-relational bandwidth | Learners struggle with interpersonal repair, group dynamics, and feedback after years of disconnected training. In-person conflict is approached like a comment section on the internet. |
The Autonomy Paradox in Adult Learning
Residency embraces adult learning theory—more autonomy, self-direction, and internal motivation. But many junior physicians are using this autonomy to opt out of:
Unpreferred curriculum content
Wellness or behavioral trainings
Feedback that challenges their worldview or self-perspective
We must recalibrate: Autonomy is not the right to disengage—it is the responsibility to co-create one’s growth.
Balancing Cultural Progress with Professional Accountability
These cultural shifts matter: we need trauma-informed learning spaces, robust mental health support, and DEI advocacy. But when taken to an extreme without balance, these can erode critical aspects of professional formation, that must be re-centered in residency:
Rigor: Internalizing deep knowledge and practice
Resilience: Tolerating ambiguity, criticism, and complexity
Responsibility: Taking ownership for growth and repair
Respect: Understanding one’s role in the larger healthcare ecosystem
Conclusion & Recommendations
Residency programs must now:
Clarify Expectations and Entrustability
Define behaviors for professionalism, feedback reception, and leadership.
Normalize early feedback and developmental interventions.
Operationalize milestones and behavioral expectations for each phase of training, and make this information transparent to learners
Coach residents in receiving feedback and building professional resilience without framing every challenge as harm.
Foster Reflective Dialogue
Integrate spaces to explore: What am I resisting? Why? What is the cost of opting out?
Develop reflective tools for residents to examine their stance toward learning, authority, and community.
Address trauma without avoiding truth.
Have incoming cohorts reflect on their medical, educational, and social traumas that may impact their residency experience. Name the trauma so it is not conflated with institutional oppression.
Reclaim Professionalism
Frame professionalism/professional accountability not as a tool of oppression, but as a liberatory practice in service to others.
Use language that acknowledges mental health needs and names professionalism gaps.
Support Resident Leaders Differently
Coach them on how to lead, not just why equity matters.
Provide infrastructure so equity doesn’t fall only on residents of color.
Rebuild the Social Contract of Medical Training
Commit to the promise: You get out what you put in.
Teach residents that leadership in equity means moving from critique to contribution.
Take the first step towards creating a culture of equity and excellence in your medical training institution. Book a free consultation with us today to discuss how we can help you lead and transform your organization.
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