# From “Problem Trainees” to Collective Growth: A Self-Ethnographic Analysis of Tension and Change in Medical Education

## TL;DR

This paper explores how 'problem trainees' in medical education are shaped by relational and organizational factors, not just individual shortcomings.

## Contribution

The study introduces a self-ethnographic approach to reveal how emotional and systemic dynamics influence the labeling of trainees as problematic.

## Key findings

- The label 'problem trainee' arises from accumulating relational frictions, not isolated incidents.
- Educators' emotional turbulence signals systemic strain before organizational breakdown.
- Unresolved tensions persist even after apparent stabilization, showing limits of educational interventions.

## Abstract

Introduction

In medical education, trainees labeled as “problematic” are commonly framed as individuals with deficits in professionalism or competence. Such approaches may overlook the relational and organizational processes through which difficulty emerges. This study aimed to explore how “problem trainees” are constructed within training environments and how educators’ emotional experiences reflect broader organizational dynamics.

Methods

A self-ethnographic study was conducted based on longitudinal reflective documentation of seven complex educational encounters in a rural general medicine training program. Data included contemporaneous reflective notes, supervisory records, and team-based observations accumulated over several years. An iterative analytic process was used to identify recurring relational and organizational patterns, with attention to educator emotions, team interactions, and evolving educational practices.

Results

Five interrelated processes were identified. First, the label of “problem trainee” emerged relationally through accumulating frictions rather than isolated incidents. Second, educators experienced emotional turbulence, such as anger, avoidance, exhaustion, and self-doubt, which preceded overt organizational breakdown and signaled systemic strain. Third, psychological safety eroded through collective silence and avoidance, reinforcing deficit-based interpretations. Fourth, teams shifted from individual remediation toward collective holding, renegotiating shared professional norms and responsibilities. Finally, despite apparent stabilization, unresolved tensions persisted, highlighting the limits of educational intervention and the absence of definitive closure.

Conclusion

The emergence of “problem trainees” reflects relational and organizational processes rather than individual deficits. Educators’ emotional experiences serve as early indicators of systemic strain, and unresolved tensions may be an integral component of organizational learning. Recognizing and engaging with these dynamics may support more sustainable and reflective approaches to medical education.