The Transition to Independence: A Longitudinal Qualitative Study on Drivers of Burnout and Resilience in Japanese Medical Residents

The Transition to Independence: A Longitudinal Qualitative Study on Drivers of Burnout and Resilience in Japanese Medical Residents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Transition to Independence: A Longitudinal Qualitative Study on Drivers of Burnout and Resilience in Japanese Medical Residents Mitsuru Watanabe, Kosuke Nakano, Yui Amari, Yukina Yokoyama, Mizuki Kato, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9074021/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background/Objective The transition from postgraduate residency to independent practice is a critical period in medical education, often accompanied by heightened clinical responsibilities. While adequate workload and stress are essential for professional growth, excessive demands can precipitate burnout. This study explores the underlying drivers of burnout and the development of resilience among resident physicians in Japan during this transitional phase. Methods A longitudinal qualitative study was conducted at an urban hospital in Japan. Eight resident physicians participated in semi-structured, in-depth interviews at the end of their two-year training in 2022, followed by a subsequent interview in 2024 after transitioning to their specialties. Additionally, senior attending physicians and support center staff were surveyed to triangulate the findings. Audio data was transcribed and analyzed using a grounded theory approach via NVivo 14. Results Typical burnout was rarely observed during the initial two-year residency, as residents perceived their training environment as highly protected, often citing a lack of autonomy and primary responsibility. However, the follow-up interviews revealed that the abrupt transition to independent practice exposed them to heavy responsibilities and complex patient management, triggering delayed burnout episodes. Crucially, residents who experienced burnout reported that overcoming these challenges ultimately enhanced their professional resilience. Peer communication and appropriate mentoring were identified as vital mitigating factors, whereas simple reductions in working hours were insufficient to prevent emotional exhaustion. Conclusion Burnout among early-career physicians is strongly associated with the abrupt shift in clinical responsibility during the transition to independent practice, rather than the absolute volume of workload during initial training. While appropriate stress is a necessary catalyst for professional development, stakeholders must design transition programs that provide graduated autonomy, robust peer support, and ongoing mentoring to foster resilience and prevent burnout in the post-residency period. Introduction The term "burnout" was first described by Freudenberger in 1974 [ 1 ] and later theoretically framed by Maslach, who conceptualized it as a syndrome characterized by emotional exhaustion, depersonalization, and reduced personal achievement [ 2 ]. Today, burnout is recognized globally as a critical, work-related condition that disproportionately affects healthcare professionals [ 1 , 2 ]. It is not merely an individual psychological burden but a systemic threat that leads to increased medical errors, decreased patient satisfaction, and potential disruptions to healthcare delivery systems. A comprehensive systematic review revealed that a significant majority of physicians experience burnout symptoms at some point in their careers [ 3 ]. Early-career physicians and residents are particularly susceptible to profound stress as they navigate the demanding early stages of their professional development. Systematic reviews focusing on postgraduate medical trainees indicate high global prevalence rates of burnout [ 4 ]. Factors such as overwork, poor work environment, heavy job demands, and conflicts regarding work-life balance have been consistently identified as significant risks for emotional exhaustion during residency training [ 4 , 5 ]. However, training systems differ significantly across countries, suggesting that the drivers and manifestations of burnout may vary depending on the specific educational context and structural environment. The postgraduate residency training system in Japan provides a unique context for this issue. It mandates a two-year clinical training program where residents rotate through multiple specialties before selecting a definitive career path, exposing them to fast-paced environmental changes and continuous relationship-building with various medical staff. Previous quantitative studies in Japan have reported varying burnout prevalence rates among residents, ranging from 18% to 33% [ 6 , 7 , 8 ]. While these studies have identified factors such as long working hours and low autonomy [ 8 ], the majority of this existing research is highly heterogeneous, cross-sectional, and lacks the capacity to extract causal relationships. Crucially, they overlook the longitudinal dynamics during the most vulnerable phase of a young physician's career: the abrupt transition from the highly protected, general rotational residency to assuming primary, independent responsibility in a specific clinical specialty. To address this gap, this qualitative study aimed to investigate the underlying drivers of burnout and the mechanisms of resilience among early-career physicians in Japan through a longitudinal approach. By conducting in-depth interviews with a cohort of residents at the end of their protected two-year training and following up as they transitioned into specialty practice, we hypothesized that the shifting balance of clinical responsibility, autonomy, and environmental support critically influences their mental well-being and professional maturation. Methods Research Setting This qualitative study examined the mental health of residents at a city hospital in Japan (Hospital A). Included participants were limited to second-year post-graduate residents who had completed their clinical training at the urban hospital with more than 400 rooms for inpatients. There are 8 residents per year. First-year post-graduate residents and medical students were not included. There were no selection/exclusion criteria based on age, known past medical history such as mental illness, or monthly working hours. To ensure balance of the characteristics of the residency environment, residents who had experienced COVID-19 during same academic year were identified as the primary target group. Snowball sampling was employed to expand and enrich the context. We also investigated residents who had completed clinical training at the same hospital and senior physicians responsible for resident education in our hospital to speculate this theme from different perspectives. Recruitment of participants continued until data saturation was achieved and no new themes identified. Data Collection Semi-structured in-depth interviews were conducted in Japanese. Interviews were recorded but participants could decline the recording. Data was not collected when the possible participant declined. The interview consisted of 10 questions on six topics. It covered background and professional views, training systems, stress experiences, burnout concepts, mentoring, and COVID19. A semi-structured interview guide was originally developed for this study by the authors (see Supplementary File 1). Interviews were conducted by the principal researcher between March 2022 and March 2024. Each interview was intended to last 30–45 minutes. Clinical residents who participated in the interviews were not compensated; however, refreshments were provided at the principal investigator’s expense. Data Analysis Interviews were transcribed in Japanese by using NVivo14 and cleaned to correct for language and grammatical errors. Based on prior studies on clinician burnout and interview questions, a preliminary code set was developed. Coding of the completed transcripts was performed using NVivo14. A grounded theory approach was implemented to facilitate multiple cycles of coding and analysis. We iteratively applied codes deductively derived from a pre-created conceptual model and codes inductively derived from a detailed reading of the interview transcripts. The research team reviewed key themes and corresponding quotes to assess the evidence to support the themes, and we developed final concepts with insights from the clinical training support center in our hospital. Consensus was made through discussion. Reflexivity and Positionality The principal investigator is a male physician specializing in rheumatology. Given that a significant proportion of the senior physician participants (8 out of 12) responsible for resident education belonged to the same specialty, an 'insider' relationship existed. This positionality facilitated a deep understanding of the specific clinical context, jargon, and implicit workplace culture, allowing for the establishment of strong rapport during interviews. To mitigate potential biases arising from shared professional backgrounds and existing hierarchical relationships, the interviewer consciously maintained a neutral stance, encouraging participants to elaborate on their experiences rather than assuming shared understanding. Data analysis was iteratively reviewed to ensure that the themes were grounded directly in the participants' narratives rather than the researcher's preconceived notions. Results Our study enrolled 8 residents and 10 other senior physicians and was conducted between 2020 and 2022. One participant consented to the study but declined recording. Residents consisted of four males and four females, average age of 27 years, all participants were Asian ethnicity, most of the senior specialty was rheumatology, and all were in charge of resident education; other details are shown in Table 1. Residents were requested to provide a follow-up interview in 2024. One female resident reported experiencing a burnout episode between the first and second interview. Four thematic areas—reflections on residency, the concept of burnout, professionalism and mentoring, well-being and resilience—were identified. Informative excerpt from the transcription was summarized in Table 2. 1.Reflections on residency In the target hospital, residents felt that the workload in the emergency room (ER) was hard, especially in the first year. The main source of stress was the night shift, the insufficient ER staff number, the fear of misdiagnosis, and the responsibility for tasks. Regarding ER tasks, they said that their role has changed throughout time, and they were required to manage the night shift. Rotating through each specialty, they were aware that they could not gain the opportunity to learn without presenting motivation. However, it is difficult to show initiative in decision-making. Their conflicts were expressed in the word "guest". ("Residents are somewhat treated as 'guests' here; we tend to lack initiative because we aren't given real authority.") Although the attending physicians try to show resident’s work consideration, residents are not delegated authority and just follow physicians as the result. Once their training was over, some said that the senior medical staff load was more significant than that of resident. One commented that the main impact of the COVID19 pandemic was the absolute reduction of communication with other medical staff in the hospital, which disrupted smooth practices. ("If we had more opportunities to interact repeatedly within the same ward, we could build better relationships... Having social gatherings or joint training sessions would make it easier to ask for help, which would significantly alleviate interpersonal stress.") There was little awareness that they were experiencing exhaustion leading to burnout, and there was a common perception that they were protected from excessive work. 2.The Concept of Burnout While most resident participants did not report experience of burnout during their residency from 2020 to 2022, most also were not familiar with the definition of burnout, which they described as "too much effort and exhaustion" without noting aspects of depersonalization and loss of personal achievement. On the other hand, in follow-up interviews described several burnout-like episodes such as entire exhaustion or lost drive and motivation after 2022. These were due to complaints from patients, increased responsibility and conflicts in the new environment. While each stressor was successfully overcome, many physicians and residents believed that they were unable to keep track of their peer's stress. Notably, one female resident reported an episode of burn out in the year following her residency and experienced a temporary leave from work. When caring for a critically ill patient, his gradually worsening condition made her feel helpless and caused her lose confidence. Managing and interacting with patient’s family required a considerable expenditure of time. ("The initial trigger was a severe case that didn't go well while I was managing the patient as the primary attending... Being cornered by that heavy responsibility meant my own self-study stalled, and I completely lost my mental bandwidth and sense of time. It became a vicious cycle.") She reflected that excessive contribution to the profession and the heavy responsibility associated with her decision-making have been primary causes of her burnout. She could return to her job after adequate rest and perceived improved resilience.("I actually feel that I've become stronger after experiencing it... Now, I even use my burnout as an icebreaker, telling junior residents, 'I've burned out before, so feel free to talk to me about anything.'") In the follow-up interviews, many of the participants described that their duties had changed drastically since their residency. They experienced excessive working hours including explanation to patients or on-call duty. Constant personal emotional conflicts resulted in the depletion of self-confidence and developed a vicious cycle. 3.Professionalism and Mentoring Many residents possessed eagerness for personal growth and motivation toward future professionalism. During post graduate clinical training, they showed passive attitude of acquiring knowledge rather than making their own choices and decisions, suggesting the Japanese tendency to "read the line" and "adjust oneself to others" as virtue. Experiencing the life event or sudden change of a patient status and negative feedback on one's medical decisions were typical stress events but were recognized as necessary for professionalism and likely to promote growth. In relation to the COVID-19 pandemic, the relative changes in clinical cases were shared. Common colds were decreased due to the magnitude of COVID19 patients and lessened the opportunity to diagnose other febrile disease. Also, the lower number of scheduled operations decreased the chance for them to be involve in surgery proactively. At the same time, there was an awareness of stigma of residents affected by COVID19. ("It was highly stressful dealing with the stigma and the judgmental looks from others, as if I had caused the outbreak, even though it wasn't at all clear that I was the source.") Almost all residents had found a mentor and set milestones for themselves. At Hospital A, each resident was assigned a mentor by resident support center from experience, and this system generally worked well. On the other hand, COVID19 contributed to a lack of absolute quantity and quality of communication, suggesting some residents may not have received adequate mentoring. Residents regarded the most appropriate mentor as a doctor who was neither too close nor too far in age, and who can share empathy and consult easily. 4.Well-being and Resilience Residents indicated that promotion of personal wellbeing included not only stress reduction methods such as sleep and rest in daily life, but also awareness of the individual’s general wellbeing and understanding of oneself, as well as the ability to communicate and interact socially with peers and family. Many of them mentioned that taking regular breaks and talking about silly things among their peers contributed to stress reduction.("It's about providing breaks systematically. Not just suddenly telling someone to take a few days off because they look exhausted, but ensuring that regular rest periods are built into the schedule.") Interestingly, experiences were also shared with communities outside of the same workplace. The COVID-19 pandemic possibly limited rest and communication, but there was little perception of a major impact on clinical training. We assumed that it was seen as standard practice setting for them. Some suggested that the restriction of excessive communication inversely provided time for rest. Residents who took the "COVID-19 associated restraint" at face value likely suffered from the loss of wellbeing.("Perhaps finding a balance by allowing for some imperfection is the key...") In general, they were consistent in their assertions regarding the importance of adequate rest and mentoring. On the other hand, they described that residents with low interactive skills and a poor grasp of self-capacities were likely not to call for help. Conversely, positive feelings toward colleagues were considered an important factor in improving their wellbeing. Discussion This qualitative study addresses a significant gap in understanding physician burnout in Japan, particularly focusing on the critical transition from early residency to specialty practice. Previous quantitative studies in Japan have reported burnout prevalence ranging from 18% to 33% among residents. However, these cross-sectional metrics often fail to capture the longitudinal dynamics of emotional exhaustion.[ 7 ] Contrary to the high incidence suggested by prior literature, our findings indicate that typical burnout was notably absent during the initial two-year residency program at the study institution. This phenomenon can be largely attributed to the highly protected nature of the training environment. Residents perceived themselves as "guests" lacking primary clinical authority, consistently shielded by senior staff. While this supportive structure successfully prevented emotional exhaustion in the short term, participants themselves noted a lack of the "fire" of ultimate responsibility, which is typically required to test and build professional capacities. To understand this dynamic, it is crucial to consider the sociocultural context of the Japanese postgraduate residency system. During the mandatory two-year rotation, residents carry the constant burden of being "the one to be evaluated." As a social factor, they are strongly expected to maintain harmonious relationships with peers and multiple professions, often prioritizing being a "good student" over taking proactive clinical risks. This cultural pressure further reinforces their passive, "guest-like" behavior. Our longitudinal follow-up revealed a stark contrast once these physicians completed this general rotation and transitioned to independent practice. The abrupt shift from a highly protected, rotational environment to assuming primary, solitary responsibility for complex patient care acted as a severe stressor. This sudden exposure to the "cliff of independence" triggered delayed episodes of emotional exhaustion, suggesting that a heavily shielded residency leaves young physicians underprepared for the harsh realities of full autonomy. Crucially, this study highlights that burnout and professional stress exist on a spectrum and can paradoxically serve as a catalyst for developing professional resilience. Participants who navigated through periods of profound exhaustion and loss of confidence reported emerging with enhanced coping mechanisms and a stronger professional identity. This underscores the vital role of "eustress"—where an appropriate clinical load combined with genuine decision-making authority is essential for professional maturation. While previous reports have explored the association between long working hours and burnout[ 8 ], our findings imply that limiting hours without concurrently providing graduated autonomy may hinder long-term development. True resilience is not forged in the complete absence of stress, but through successfully overcoming manageable clinical challenges. These findings have direct and practical implications for postgraduate medical education. Rather than merely protecting residents from workload, training programs must implement structured "graduated autonomy" to safely bridge the gap between initial residency and independent practice. Furthermore, longitudinal mentoring and peer support systems must be intentionally extended beyond the early training period to target this highly vulnerable transition phase. This study has limitations, including its single-center design and potential selection bias. Notably, a highly supportive and non-overburdening environment in an urban hospital might be "counter-selected" by candidates who are implicitly aware of their own mental vulnerability. This dynamic may have artificially reduced the pool of vulnerable residents in our studied cohort. Future mixed-methods research should further explore these transitional dynamics. Ultimately, to foster sustainable physician well-being, educational stakeholders must balance necessary clinical exposure with robust, phase-appropriate support systems. Conclusion This longitudinal qualitative study revealed that typical burnout is rare during the highly protected two-year initial residency in Japan. However, the abrupt transition to independent specialty practice acts as a severe stressor, triggering delayed burnout episodes. Because intrinsic resilience and the capacity to handle "eustress" vary significantly among individuals, uniform administrative interventions, such as strictly capping working hours, are insufficient and may inadvertently hinder professional growth. To effectively prevent burnout during this critical transition, healthcare institutions must implement highly individualized support systems. First, training programs should design structured "graduated autonomy" to optimize clinical workload, shifting the focus from merely limiting hours to managing the quality and responsibility of the work. Second, continuous, longitudinal mentoring must be established, extending intentionally beyond the initial training period to support physicians during their most vulnerable transition. Finally, institutions should implement regular subjective and objective evaluations of both the physician's well-being and clinical load to detect early signs of emotional exhaustion. Educational stakeholders must shift their strategy from simply shielding young physicians to actively equipping them with the resources and manageable challenges necessary to forge long-term professional resilience. Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the ethical review board of Daido Hospital (ECD2022-017, March 2022). Written informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. No identifying images or personal details are included in this manuscript. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the need to protect participant confidentiality and privacy, but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors declare that no specific funding was received for this study. Authors' contributions MW conceptualized and designed the study, conducted the interviews, performed the qualitative data analysis, and drafted the main manuscript. KN contributed to the interpretation of the qualitative data from the perspective of the target demographic and critically reviewed the manuscript. YA, YY, and MK contributed significantly to the acquisition of data, the validation of thematic saturation based on clinical experiences, and the interpretation of the findings. YH supervised the overall project, provided critical academic insights for the conclusion, and comprehensively reviewed and edited the final manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Freudenberger H, et al. Staff Burnout. Journal of Social Issues 1974, 30, 159-165. Maslach C. & Jackson S. The measurement of experienced burnout. Journal of Occupational Behavior, 2, 99-113. Rotenstein LS, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018 Sep 18;320(11):1131-1150. doi: 10.1001/jama.2018.12777. Naji L, et al. Global prevalence of burnout among postgraduate medical trainees: a systematic review and meta-regression. CMAJ Open . 2021 Mar 8;9(1):E189-E200. doi: 10.9778/cmajo.20200068. Print 2021 Jan-Mar. Zhou AY, et al. Factors Associated With Burnout and Stress in Trainee Physicians: A Systematic Review and Meta-analysis. JAMA Netw Open . 2020 Aug 3;3(8):e2013761. doi: 10.1001/jamanetworkopen.2020.13761. Miyoshi R, et al. Burnout in Japanese residents and its associations with temperament and character.sian J Psychiatr . 2016 Dec:24:5-9. doi: 10.1016/j.ajp.2016.08.009. Nishimura Y, et al.Factors related to burnout in resident physicians in Japan. Int J Med Educ. 2019;10: 129-135. doi: 10.5116/ijme.5caf.53ad Matsuo T, et al. Resident Burnout and Work Environment.Intern Med. 2021 May 1; 60(9): 1369-1376. doi: 10.2169/internalmedicine.5872-20 Tables Tables 1 and 2 are available in the supplementary files section Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.docx Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 May, 2026 Reviews received at journal 03 May, 2026 Reviewers agreed at journal 21 Apr, 2026 Reviewers invited by journal 03 Apr, 2026 Editor invited by journal 30 Mar, 2026 Editor assigned by journal 16 Mar, 2026 Submission checks completed at journal 14 Mar, 2026 First submitted to journal 14 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Today, burnout is recognized globally as a critical, work-related condition that disproportionately affects healthcare professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is not merely an individual psychological burden but a systemic threat that leads to increased medical errors, decreased patient satisfaction, and potential disruptions to healthcare delivery systems. A comprehensive systematic review revealed that a significant majority of physicians experience burnout symptoms at some point in their careers [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEarly-career physicians and residents are particularly susceptible to profound stress as they navigate the demanding early stages of their professional development. Systematic reviews focusing on postgraduate medical trainees indicate high global prevalence rates of burnout [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Factors such as overwork, poor work environment, heavy job demands, and conflicts regarding work-life balance have been consistently identified as significant risks for emotional exhaustion during residency training [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, training systems differ significantly across countries, suggesting that the drivers and manifestations of burnout may vary depending on the specific educational context and structural environment.\u003c/p\u003e \u003cp\u003eThe postgraduate residency training system in Japan provides a unique context for this issue. It mandates a two-year clinical training program where residents rotate through multiple specialties before selecting a definitive career path, exposing them to fast-paced environmental changes and continuous relationship-building with various medical staff. Previous quantitative studies in Japan have reported varying burnout prevalence rates among residents, ranging from 18% to 33% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While these studies have identified factors such as long working hours and low autonomy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], the majority of this existing research is highly heterogeneous, cross-sectional, and lacks the capacity to extract causal relationships. Crucially, they overlook the longitudinal dynamics during the most vulnerable phase of a young physician's career: the abrupt transition from the highly protected, general rotational residency to assuming primary, independent responsibility in a specific clinical specialty.\u003c/p\u003e \u003cp\u003eTo address this gap, this qualitative study aimed to investigate the underlying drivers of burnout and the mechanisms of resilience among early-career physicians in Japan through a longitudinal approach. By conducting in-depth interviews with a cohort of residents at the end of their protected two-year training and following up as they transitioned into specialty practice, we hypothesized that the shifting balance of clinical responsibility, autonomy, and environmental support critically influences their mental well-being and professional maturation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch Setting\u003c/h2\u003e \u003cp\u003eThis qualitative study examined the mental health of residents at a city hospital in Japan (Hospital A). Included participants were limited to second-year post-graduate residents who had completed their clinical training at the urban hospital with more than 400 rooms for inpatients. There are 8 residents per year. First-year post-graduate residents and medical students were not included. There were no selection/exclusion criteria based on age, known past medical history such as mental illness, or monthly working hours. To ensure balance of the characteristics of the residency environment, residents who had experienced COVID-19 during same academic year were identified as the primary target group. Snowball sampling was employed to expand and enrich the context. We also investigated residents who had completed clinical training at the same hospital and senior physicians responsible for resident education in our hospital to speculate this theme from different perspectives. Recruitment of participants continued until data saturation was achieved and no new themes identified.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eSemi-structured in-depth interviews were conducted in Japanese. Interviews were recorded but participants could decline the recording. Data was not collected when the possible participant declined. The interview consisted of 10 questions on six topics. It covered background and professional views, training systems, stress experiences, burnout concepts, mentoring, and COVID19. A semi-structured interview guide was originally developed for this study by the authors (see Supplementary File 1). Interviews were conducted by the principal researcher between March 2022 and March 2024. Each interview was intended to last 30\u0026ndash;45 minutes. Clinical residents who participated in the interviews were not compensated; however, refreshments were provided at the principal investigator\u0026rsquo;s expense.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eInterviews were transcribed in Japanese by using NVivo14 and cleaned to correct for language and grammatical errors. Based on prior studies on clinician burnout and interview questions, a preliminary code set was developed. Coding of the completed transcripts was performed using NVivo14. A grounded theory approach was implemented to facilitate multiple cycles of coding and analysis. We iteratively applied codes deductively derived from a pre-created conceptual model and codes inductively derived from a detailed reading of the interview transcripts. The research team reviewed key themes and corresponding quotes to assess the evidence to support the themes, and we developed final concepts with insights from the clinical training support center in our hospital. Consensus was made through discussion.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eReflexivity and Positionality\u003c/h3\u003e\n\u003cp\u003eThe principal investigator is a male physician specializing in rheumatology. Given that a significant proportion of the senior physician participants (8 out of 12) responsible for resident education belonged to the same specialty, an 'insider' relationship existed. This positionality facilitated a deep understanding of the specific clinical context, jargon, and implicit workplace culture, allowing for the establishment of strong rapport during interviews. To mitigate potential biases arising from shared professional backgrounds and existing hierarchical relationships, the interviewer consciously maintained a neutral stance, encouraging participants to elaborate on their experiences rather than assuming shared understanding. Data analysis was iteratively reviewed to ensure that the themes were grounded directly in the participants' narratives rather than the researcher's preconceived notions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur study enrolled 8 residents and 10 other senior physicians and was conducted between 2020 and 2022. One participant consented to the study but declined recording. Residents consisted of four males and four females, average age of 27 years, all participants were Asian ethnicity, most of the senior specialty was rheumatology, and all were in charge of resident education; other details are shown in Table 1. \u0026nbsp;Residents were requested to provide a follow-up interview in 2024. One female resident reported experiencing a burnout episode between the first and second interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFour thematic areas—reflections on residency, the concept of burnout, professionalism and mentoring, well-being and resilience—were identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformative excerpt from the transcription was summarized in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e1.Reflections on residency\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIn the target hospital, residents felt that the workload in the emergency room (ER) was hard, especially in the first year. The main source of stress was the night shift, the insufficient ER staff number, the fear of misdiagnosis, and the responsibility for tasks. Regarding ER tasks, they said that their role has changed throughout time, and they were required to manage the night shift. Rotating through each specialty, they were aware that they could not gain the opportunity to learn without presenting motivation. However, it is difficult to show initiative in decision-making. Their conflicts were expressed in the word \"guest\". (\"Residents are somewhat treated as 'guests' here; we tend to lack initiative because we aren't given real authority.\") Although the attending physicians try to show resident’s work consideration, residents are not delegated authority and just follow physicians as the result. Once their training was over, some said that the senior medical staff load was more significant than that of resident. One commented that the main impact of the COVID19 pandemic was the absolute reduction of communication with other medical staff in the hospital, which disrupted smooth practices. (\"If we had more opportunities to interact repeatedly within the same ward, we could build better relationships... Having social gatherings or joint training sessions would make it easier to ask for help, which would significantly alleviate interpersonal stress.\") There was little awareness that they were experiencing exhaustion leading to burnout, and there was a common perception that they were protected from excessive work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e2.The Concept of Burnout\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWhile most resident participants did not report experience of burnout during their residency from 2020 to 2022, most also were not familiar with the definition of burnout, which they described as \"too much effort and exhaustion\" without noting aspects of depersonalization and loss of personal achievement. On the other hand, in follow-up interviews described several burnout-like episodes such as entire exhaustion or lost drive and motivation after 2022. These were due to complaints from patients, increased responsibility and conflicts in the new environment. While each stressor was successfully overcome, many physicians and residents believed that they were unable to keep track of their peer's stress. Notably, one female resident reported an episode of burn out in the year following her residency and experienced a temporary leave from work. When caring for a critically ill patient, his gradually worsening condition made her feel helpless and caused her lose confidence. Managing and interacting with patient’s family required a considerable expenditure of time. (\"The initial trigger was a severe case that didn't go well while I was managing the patient as the primary attending... Being cornered by that heavy responsibility meant my own self-study stalled, and I completely lost my mental bandwidth and sense of time. It became a vicious cycle.\") She reflected that excessive contribution to the profession and the heavy responsibility associated with her decision-making have been primary causes of her burnout. She could return to her job after adequate rest and perceived improved resilience.(\"I actually feel that I've become stronger after experiencing it... Now, I even use my burnout as an icebreaker, telling junior residents, 'I've burned out before, so feel free to talk to me about anything.'\") In the follow-up interviews, many of the participants described that their duties had changed drastically since their residency. They experienced excessive working hours including explanation to patients or on-call duty. Constant personal emotional conflicts resulted in the depletion of self-confidence and developed a vicious cycle.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e3.Professionalism and Mentoring\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eMany residents possessed eagerness for personal growth and motivation toward future professionalism. During post graduate clinical training, they showed passive attitude of acquiring knowledge rather than making their own choices and decisions, suggesting the Japanese tendency to \"read the line\" and \"adjust oneself to others\" as virtue. Experiencing the life event or sudden change of a patient status and negative feedback on one's medical decisions were typical stress events but were recognized as necessary for professionalism and likely to promote growth. In relation to the COVID-19 pandemic, the relative changes in clinical cases were shared. Common colds were decreased due to the magnitude of COVID19 patients and lessened the opportunity to diagnose other febrile disease. Also, the lower number of scheduled operations decreased the chance for them to be involve in surgery proactively. At the same time, there was an awareness of stigma of residents affected by COVID19. (\"It was highly stressful dealing with the stigma and the judgmental looks from others, as if I had caused the outbreak, even though it wasn't at all clear that I was the source.\") Almost all residents had found a mentor and set milestones for themselves. At Hospital A, each resident was assigned a mentor by resident support center from experience, and this system generally worked well. On the other hand, COVID19 contributed to a lack of absolute quantity and quality of communication, suggesting some residents may not have received adequate mentoring. Residents regarded the most appropriate mentor as a doctor who was neither too close nor too far in age, and who can share empathy and consult easily.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e4.Well-being and Resilience\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eResidents indicated that promotion of personal wellbeing included not only stress reduction methods such as sleep and rest in daily life, but also awareness of the individual’s general wellbeing and understanding of oneself, as well as the ability to communicate and interact socially with peers and family. Many of them mentioned that taking regular breaks and talking about silly things among their peers contributed to stress reduction.(\"It's about providing breaks systematically. Not just suddenly telling someone to take a few days off because they look exhausted, but ensuring that regular rest periods are built into the schedule.\") Interestingly, experiences were also shared with communities outside of the same workplace. The COVID-19 pandemic possibly limited rest and communication, but there was little perception of a major impact on clinical training. We assumed that it was seen as standard practice setting for them. Some suggested that the restriction of excessive communication inversely provided time for rest. Residents who took the \"COVID-19 associated restraint\" at face value likely suffered from the loss of wellbeing.(\"Perhaps finding a balance by allowing for some imperfection is the key...\") In general, they were consistent in their assertions regarding the importance of adequate rest and mentoring. On the other hand, they described that residents with low interactive skills and a poor grasp of self-capacities were likely not to call for help. Conversely, positive feelings toward colleagues were considered an important factor in improving their wellbeing.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative study addresses a significant gap in understanding physician burnout in Japan, particularly focusing on the critical transition from early residency to specialty practice. Previous quantitative studies in Japan have reported burnout prevalence ranging from 18% to 33% among residents. However, these cross-sectional metrics often fail to capture the longitudinal dynamics of emotional exhaustion.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Contrary to the high incidence suggested by prior literature, our findings indicate that typical burnout was notably absent during the initial two-year residency program at the study institution. This phenomenon can be largely attributed to the highly protected nature of the training environment. Residents perceived themselves as \"guests\" lacking primary clinical authority, consistently shielded by senior staff. While this supportive structure successfully prevented emotional exhaustion in the short term, participants themselves noted a lack of the \"fire\" of ultimate responsibility, which is typically required to test and build professional capacities.\u003c/p\u003e \u003cp\u003eTo understand this dynamic, it is crucial to consider the sociocultural context of the Japanese postgraduate residency system. During the mandatory two-year rotation, residents carry the constant burden of being \"the one to be evaluated.\" As a social factor, they are strongly expected to maintain harmonious relationships with peers and multiple professions, often prioritizing being a \"good student\" over taking proactive clinical risks. This cultural pressure further reinforces their passive, \"guest-like\" behavior. Our longitudinal follow-up revealed a stark contrast once these physicians completed this general rotation and transitioned to independent practice. The abrupt shift from a highly protected, rotational environment to assuming primary, solitary responsibility for complex patient care acted as a severe stressor. This sudden exposure to the \"cliff of independence\" triggered delayed episodes of emotional exhaustion, suggesting that a heavily shielded residency leaves young physicians underprepared for the harsh realities of full autonomy.\u003c/p\u003e \u003cp\u003eCrucially, this study highlights that burnout and professional stress exist on a spectrum and can paradoxically serve as a catalyst for developing professional resilience. Participants who navigated through periods of profound exhaustion and loss of confidence reported emerging with enhanced coping mechanisms and a stronger professional identity. This underscores the vital role of \"eustress\"\u0026mdash;where an appropriate clinical load combined with genuine decision-making authority is essential for professional maturation. While previous reports have explored the association between long working hours and burnout[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], our findings imply that limiting hours without concurrently providing graduated autonomy may hinder long-term development. True resilience is not forged in the complete absence of stress, but through successfully overcoming manageable clinical challenges.\u003c/p\u003e \u003cp\u003eThese findings have direct and practical implications for postgraduate medical education. Rather than merely protecting residents from workload, training programs must implement structured \"graduated autonomy\" to safely bridge the gap between initial residency and independent practice. Furthermore, longitudinal mentoring and peer support systems must be intentionally extended beyond the early training period to target this highly vulnerable transition phase. This study has limitations, including its single-center design and potential selection bias. Notably, a highly supportive and non-overburdening environment in an urban hospital might be \"counter-selected\" by candidates who are implicitly aware of their own mental vulnerability. This dynamic may have artificially reduced the pool of vulnerable residents in our studied cohort. Future mixed-methods research should further explore these transitional dynamics. Ultimately, to foster sustainable physician well-being, educational stakeholders must balance necessary clinical exposure with robust, phase-appropriate support systems.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis longitudinal qualitative study revealed that typical burnout is rare during the highly protected two-year initial residency in Japan. However, the abrupt transition to independent specialty practice acts as a severe stressor, triggering delayed burnout episodes. Because intrinsic resilience and the capacity to handle \"eustress\" vary significantly among individuals, uniform administrative interventions, such as strictly capping working hours, are insufficient and may inadvertently hinder professional growth.\u003c/p\u003e \u003cp\u003eTo effectively prevent burnout during this critical transition, healthcare institutions must implement highly individualized support systems. First, training programs should design structured \"graduated autonomy\" to optimize clinical workload, shifting the focus from merely limiting hours to managing the quality and responsibility of the work. Second, continuous, longitudinal mentoring must be established, extending intentionally beyond the initial training period to support physicians during their most vulnerable transition. Finally, institutions should implement regular subjective and objective evaluations of both the physician's well-being and clinical load to detect early signs of emotional exhaustion. Educational stakeholders must shift their strategy from simply shielding young physicians to actively equipping them with the resources and manageable challenges necessary to forge long-term professional resilience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The study was conducted in accordance with the Declaration of Helsinki. The study protocol was approved by the ethical review board of Daido Hospital (ECD2022-017, March 2022). Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Not applicable. No identifying images or personal details are included in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are not publicly available due to the need to protect participant confidentiality and privacy, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The authors declare that no specific funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;MW conceptualized and designed the study, conducted the interviews, performed the qualitative data analysis, and drafted the main manuscript. KN contributed to the interpretation of the qualitative data from the perspective of the target demographic and critically reviewed the manuscript. YA, YY, and MK contributed significantly to the acquisition of data, the validation of thematic saturation based on clinical experiences, and the interpretation of the findings. YH supervised the overall project, provided critical academic insights for the conclusion, and comprehensively reviewed and edited the final manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFreudenberger H, et al. Staff Burnout. Journal of Social Issues 1974, 30, 159-165.\u003c/li\u003e\n \u003cli\u003eMaslach C. \u0026amp; Jackson S. The measurement of experienced burnout. Journal of Occupational Behavior, 2, 99-113.\u003c/li\u003e\n \u003cli\u003eRotenstein LS, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018 Sep 18;320(11):1131-1150. doi: 10.1001/jama.2018.12777.\u003c/li\u003e\n \u003cli\u003eNaji L, et al. Global prevalence of burnout among postgraduate medical trainees: a systematic review and meta-regression. CMAJ Open . 2021 Mar 8;9(1):E189-E200. doi: 10.9778/cmajo.20200068. Print 2021 Jan-Mar.\u003c/li\u003e\n \u003cli\u003eZhou AY, et al. Factors Associated With Burnout and Stress in Trainee Physicians: A Systematic Review and Meta-analysis. JAMA Netw Open . 2020 Aug 3;3(8):e2013761. doi: 10.1001/jamanetworkopen.2020.13761.\u003c/li\u003e\n \u003cli\u003eMiyoshi R, et al. Burnout in Japanese residents and its associations with temperament and character.sian J Psychiatr . 2016 Dec:24:5-9. doi: 10.1016/j.ajp.2016.08.009.\u003c/li\u003e\n \u003cli\u003eNishimura Y, et al.Factors related to burnout in resident physicians in Japan. Int J Med Educ. 2019;10: 129-135. doi: 10.5116/ijme.5caf.53ad\u003c/li\u003e\n \u003cli\u003eMatsuo T, et al. Resident Burnout and Work Environment.Intern Med. 2021 May 1; 60(9): 1369-1376. doi: 10.2169/internalmedicine.5872-20\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9074021/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9074021/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe transition from postgraduate residency to independent practice is a critical period in medical education, often accompanied by heightened clinical responsibilities. While adequate workload and stress are essential for professional growth, excessive demands can precipitate burnout. This study explores the underlying drivers of burnout and the development of resilience among resident physicians in Japan during this transitional phase.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA longitudinal qualitative study was conducted at an urban hospital in Japan. Eight resident physicians participated in semi-structured, in-depth interviews at the end of their two-year training in 2022, followed by a subsequent interview in 2024 after transitioning to their specialties. Additionally, senior attending physicians and support center staff were surveyed to triangulate the findings. Audio data was transcribed and analyzed using a grounded theory approach via NVivo 14.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTypical burnout was rarely observed during the initial two-year residency, as residents perceived their training environment as highly protected, often citing a lack of autonomy and primary responsibility. However, the follow-up interviews revealed that the abrupt transition to independent practice exposed them to heavy responsibilities and complex patient management, triggering delayed burnout episodes. Crucially, residents who experienced burnout reported that overcoming these challenges ultimately enhanced their professional resilience. Peer communication and appropriate mentoring were identified as vital mitigating factors, whereas simple reductions in working hours were insufficient to prevent emotional exhaustion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBurnout among early-career physicians is strongly associated with the abrupt shift in clinical responsibility during the transition to independent practice, rather than the absolute volume of workload during initial training. While appropriate stress is a necessary catalyst for professional development, stakeholders must design transition programs that provide graduated autonomy, robust peer support, and ongoing mentoring to foster resilience and prevent burnout in the post-residency period.\u003c/p\u003e","manuscriptTitle":"The Transition to Independence: A Longitudinal Qualitative Study on Drivers of Burnout and Resilience in Japanese Medical Residents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 04:46:17","doi":"10.21203/rs.3.rs-9074021/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"45554652198667434705845548609765410726","date":"2026-05-14T12:06:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T11:14:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168039068396203447942627631544325839044","date":"2026-04-21T06:52:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T10:09:09+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-30T06:28:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-16T17:38:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-15T01:07:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-03-15T01:02:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8af9cbc1-23e3-4b5d-adb4-4b1275ae041f","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"45554652198667434705845548609765410726","date":"2026-05-14T12:06:35+00:00","index":78,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-03T11:14:23+00:00","index":69,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T04:46:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 04:46:17","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9074021","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9074021","identity":"rs-9074021","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}