Exploring yarigai: The meaning of working as a physician in teaching medical professionalism.

INTRODUCTION: The shift in medical professionalism now considers the well-being of physicians, given the prevalence of burnout and the importance of work-life balance. To reconsider the question 'Why do doctors work for the patient?' and explore the meaning of working as a physician, this study adopts the concept of 'yarigai,' which represents fulfillment and motivation in meaningful work. The authors' research questions are: How do doctors recount experiences of yarigai in caring for patients? What kind of values are embodied in their stories about yarigai? METHOD: They adopted narrative inquiry as the methodology for this study. They interviewed 15 doctors who were recognized by their colleagues for their commitment to patient-centered care or had demonstrated yarigai in caring for patients. The semi-structured interviews were conducted face-to-face with each participant by the Japanese researchers, yielding 51 cases of patient-doctor interactions. After grouping the interview data, they translated the cases into English and identified four representative cases to present based on the set criteria. RESULTS: From the 51 case studies, they constructed four representative narratives about the yarigai as a physician. Each of them spoke of (1) finding positive meaning in difficult situations, (2) receiving gifts embodying ikigai, (3) witnessing strength in a seemingly powerless human being, and (4) cultivating relationships that transcend temporal boundaries, as being rewarding in working as a physician. The main results of the study, which are the narratives, are described in the main body of the paper. CONCLUSION: The stories on yarigai gave intrinsic meanings to their occupational lives, which can be informative for students, residents, and young physicians when contemplating the meaning of their work as doctors. Rather than demanding selfless dedication from physicians towards patients, they believe it more important to foster yarigai, derived from the contribution to the well-being of others through patient care.

Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME).

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

Competency-based medical education: The spark to ignite healthcare's escape fire.

High-value care is what patients deserve and what healthcare professionals should deliver. However, it is not what happens much of the time. Quality improvement master Dr. Don Berwick argued more than two decades ago that American healthcare needs an escape fire, which is a new way of seeing and acting in a crisis situation. While coined in the U.S. context, the analogy applies in other Western healthcare contexts as well. Therefore, in this paper, the authors revisit Berwick's analogy, arguing that medical education can, and should, provide the spark for such an escape fire across the globe. They assert that medical education can achieve this by fully embracing competency-based medical education (CBME) as a way to place medicine's focus on the patient. CBME targets training outcomes that prepare graduates to optimize patient care. The authors use the escape fire analogy to argue that medical educators must drop long-held approaches and tools; treat CBME implementation as an adaptive challenge rather than a technical fix; demand genuine, rich discussions and engagement about the path forward; and, above all, center the patient in all they do.

Inequity is woven into the fabric: a discourse analysis of assessment in pediatric residency training.

Intrinsic inequity in assessment refers to sources of harmful discrimination inherent in the design of assessment tools and systems. This study seeks to understand intrinsic inequity in assessment systems by studying assessment policies and associated procedures in residency training, using general pediatrics as a discourse case study. Foucauldian discourse analysis (FDA) was conducted on assessment policy and procedure documents. Two authors independently prepared structured analytic notes using guiding questions. Documents and respective analytic notes were subsequently reviewed independently by all authors. Each author prepared further unstructured analytic notes on the documents' discourse. The authors then compared notes and constructed truth statements (i.e., interpretations of what the discourse establishes as true about the construct under study) and sub-strands (i.e., themes) that were repeated and legitimized across the documents via iterative discussion. Based on analysis, the authors constructed two truth statements. These truth statements, "good assessment is equitable assessment," and "everyone is responsible for inequity," conceptualized inequity in assessment as an isolated or individual-level aberration in an otherwise effective or neutral system. Closer examination of the truth statements and sub-strands in the discourse presented an alternative view, suggesting that inequity may in fact not be an aberration but rather an inherent feature of assessment systems.

SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Systemic Anti-Blackness and Racism in Healthcare: A European Perspective.

Despite notions of colour-blindness and denials of widespread systemic racism, anti-Black racism remains inherent in the political, economic, educational and healthcare systems in Europe. We use the Netherlands as a case study to explore some of these mechanisms. Here, we discuss how a focus on cultural deficiency and the denial of racism allows the bearers of inequality and inequity to be blamed for their own disenfranchisement. Nonetheless, scholars in the Netherlands continue to show how everyday racism is negatively impacting marginalized people's lives and their access to the social determinants of health and well-being in society.

The impact of an educational intervention on physician leadership competencies among rural and remote primary care doctors in Aceh, Indonesia.

PURPOSE: This study aims to examine how an educational intervention, using the lens of the LEADS framework, can influence the development of primary care doctors' leadership skills in Aceh, Indonesia. In order to persevere in the face of inadequate resources and infrastructure, particularly in rural and remote settings of low- and middle-income countries, physicians require strong leadership skills. However, there is a lack of information on leadership development in these settings. DESIGN/METHODOLOGY/APPROACH: This study applied an educational intervention consisting of a two-day workshop. The authors evaluated the impact of the workshop on participants' knowledge and skill by combining quantitative pre- and post-intervention questionnaires (based on Levels 1 and 2 of Kirkpatrick's model) with qualitative post-intervention in-depth interviews, using a phenomenological approach and thematic analysis. FINDINGS: The workshop yielded positive results, as evidenced by participants' increased confidence to apply and use the information and skills acquired during the workshop. Critical success factors were as follows: participants were curiosity-driven; the use of multiple learning methodologies that attracted participants; and the use of authentic scenarios as a critical feature of the program. ORIGINALITY/VALUE: The intervention may offer a preliminary model for improving physician leadership skills in rural and remote settings by incorporating multiple teaching approaches and considering local cultural norms.

Unpacking the Social Constructs of Discrimination, Othering, and Belonging in Medical Schools.

ISSUE: Triggered by the lived experiences of the authors-one junior career, female, and black; the other senior career, male, and black-we provide a critical, sociological overview of the plight of racial/ethnic minority students in medical education. We analyze the concepts of categorization, othering, and belonging in medical education, which we use to shed light on the psychological and academic consequences of overgeneralizing social categories. EVIDENCE: The ability to categorize people into different social groups is a natural, subconscious phenomenon. Creating social groups is believed to aid people in navigating the world. This permits people to relate to others based on assumed opinions and actions. Race and gender are two primary dimensions of categorization, with race or ethnicity being a particularly salient category. However, over-generalization of social categories can lead the categorizer to think, judge, and treat themselves and members of a perceived group similarly, leading to prejudice and stereotyping. Social categorization also occurs in educational settings across the globe. The consequences of categorization may influence a student's feelings of belonging and academic success. IMPLICATIONS: Our analysis reflects on how to promote equitable opportunities for ethnic minority medical trainees through the lens of those who have experienced and succeeded in an inequitable system. By revisiting the social and psychological constructs that determine and influence the academic progress and success of minority students in medical education, we discovered that more engagement is (still) needed for critical discourse on this topic. We expect such conversations to help generate new insights to improve inclusion and equity in our educational systems.

A Cross-Sectional Study of the Physical and Mental Well-Being of Long COVID Patients in Aruba.

Objective: To investigate the pattern and prevalence of persistent symptoms of Post-COVID-19 Syndrome (PCS) at 3, 6, 9, and 18 months after discharge. Associated risk factors were further examined to potentially explain the persistence of these symptoms.Design and Setting: A cross-sectional cohort study was conducted at the primary health care facility of Aruba, Dr. Horacio E. Oduber Hospital (HOH).Participants: Inclusion criteria were adults hospitalized at HOH for at least one night between March and July 2021 and laboratory-confirmed COVID-19 diagnosis. Exclusion criteria were deceased before the follow-up, not able to mobilize before or after discharge, living outside of Aruba or in nursing homes, and patients with psychosis, dementia, or hospitalized due to unrelated diseases.Methods: Eligible and willing participants completed a 20-question survey: a self-reported symptoms questionnaire about symptoms during and after COVID-19 infection, level of dyspnea measurement (mMRC-scale), quality of life measurement (EQ-5D-5E with EuroQoL VAS), and mental well-being (WHO-5). Hospitalization related data were gathered via retrospective analysis of patient records. Chi-square test, logistic regression, and ANOVA analyses were conducted; P<0.05 was chosen as level of statistical significance for all analyses.Results: In total, 222 (34.5%) patients were eligible, consenting, and completed the survey. Most participants were interviewed a year or more after their initial COVID-19 infection. Fatigue (37.8%), new-onset dyspnea (38.7%), hair loss (20.3%), and muscle pain (18.0%) were the most frequently reported symptoms at any time post COVID-19 infection. Female participants were found more likely to experience fatigue (P<0.05, OR 2.135, 95% CI 1.154-3.949) and new-onset dyspnea (P<0.05, OR 2.026 95% CI 1.093-3.756) after initial infection. Participants with one or more respiratory comorbidity were more likely to experience new-onset dyspnea (P<0.05, OR 2.681, 95% CI 1.223-5.873). None of the predictor variables was associated with cognitive impairment.Conclusion: This study identified female sex and respiratory comorbidity as crucial risk factors for PCS. Females were also found to have significantly lower health scores. Female participants were more likely to experience fatigue and dyspnea after COVID-19 infection.

Stakes of Assessments in Residency: Influence on Previous and Current Self-Regulated Learning and Co-Regulated Learning in Early Career Specialists.

Introduction: Assessments drive learning but the influence of the stakes of the assessments on self-regulated (SRL) during and after residency are unknown. As early career specialists (ECS) must continue learning independently, the answer to this is important as it may inform future assessments with the potential to promote life-long learning after graduation. Methods: We utilized constructivist grounded theory to explore the perspectives of eighteen ECS on the influence of stakes of assessments within residency on their SRL during training and in current practice. We conducted semi-structured interviews. Results: We initially set out to examine the influence of the stakes of assessments on SRL during residency and after graduation. However, it was apparent that learners increasingly engaged with others in co-regulated learning (CRL) as the perceived stakes of the assessments increased. The individual learner's SRL was embedded in CRL in preparation for the various assessments in residency. For low-stakes assessments, the learner engaged in less CRL, taking less cues from others. As stakes increased, the learner engaged in more CRL with peers with similar intellectual level and supervisors to prepare for these assessments. SRL and CRL influenced by assessments in residency had a knock-on effect in clinical practice as ECS in: 1) developing clinical reasoning, 2) improving doctor-patient communication and negotiation skills, and 3) self-reflections and seeking feedback to deal with expectations of self or others. Discussion: Our study supported that the stakes of assessments within residency reinforced SRL and CRL during residency with a continued effect on learning as ECS.

An exploratory university-based cross-sectional study of the prevalence and reporting of mistreatment and student-related factors among Thai medical students.

BACKGROUND: Mistreatment is a behavior that reflects disrespect for the dignity of others. Mistreatment can be intentional or unintentional, and can interfere with the process of learning and perceived well-being. This study explored the prevalence and characteristics of mistreatment, mistreatment reporting, student-related factors, and consequences among medical students in Thai context. METHODS: We first developed a Thai version of the Clinical Workplace Learning Negative Acts Questionnaire-Revised (NAQ-R) using a forward-back translation process with quality analysis. The design was a cross-sectional survey study, using the Thai Clinical Workplace Learning NAQ-R, Thai Maslach Burnout Inventory-Student Survey, Thai Patient Health Questionnaire (to assess depression risk), demographic information, mistreatment characteristics, mistreatment reports, related factors, and consequences. Descriptive and correlational analyses using multivariate analysis of variance were conducted. RESULTS: In total, 681 medical students (52.4% female, 54.6% in the clinical years) completed the surveys (79.1% response rate). The reliability of the Thai Clinical Workplace Learning NAQ-R was high (Cronbach's alpha 0.922), with a high degree of agreement (83.9%). Most participants (n = 510, 74.5%) reported that they had experienced mistreatment. The most common type of mistreatment was workplace learning-related bullying (67.7%), and the most common source was attending staff or teachers (31.6%). People who mistreated preclinical medical students were most often senior students or peers (25.9%). People who mistreated clinical students were most commonly attending staff (57.5%). Only 56 students (8.2%) reported these instances of mistreatment to others. Students' academic year was significantly related to workplace learning-related bullying (r = 0.261, p < 0.001). Depression and burnout risk were significantly associated with person-related bullying (depression: r = 0.20, p < 0.001, burnout: r = 0.20, p = 0.012). Students who experienced person-related bullying were more often the subject of filed unprofessional behavior reports, concerning conflict or arguments with colleagues, being absent from class or work without reasonable cause, and mistreatment of others. CONCLUSIONS: Mistreatment of medical students was evident in medical school and was related to the risk for depression and burnout, as well as the risk of unprofessional behavior. TRIAL REGISTRATION: TCTR20230107006(07/01/2023).

Investigating physician leadership competencies in rural and remote areas of the province of Aceh, Indonesia.

BACKGROUNDS: Globally, the most rural healthcare systems are lagging behind those of urban healthcare systems. Especially in rural and remote areas, the essential resources to provide principal health services are inadequate. It is purported that physicians have an important role in healthcare systems. Unfortunately, there is a paucity of studies on physician leadership development in Asia, especially on how to enhance physician leadership competencies in rural and remote low-resource settings. This study aimed to investigate doctors' perceptions of existing and needed physician leadership competencies based on their experiences in primary care settings in low-resource rural and remote areas are in Indonesia. METHODS: We performed a qualitative study with a phenomenological approach. Eighteen primary care doctors, who worked in rural and remote areas of Aceh, Indonesia, purposively selected, were interviewed. Prior to the interview, participants were asked to select the top-five skills they deemed most essential for their work based on the five domains of the 'Lead Self', 'Engage Others', 'Achieve Results', 'Develop Coalitions' and 'Systems Transformation' (LEADS) framework. We then performed a thematic analysis of the interview transcripts. RESULTS: We identified the following qualities a good physician leader in low-resource rural and remote settings should possess: (1) cultural sensitivity skills; (2) a strong character that includes courage and determination; and (3) creativity and flexibility skills. CONCLUSIONS: Local cultural and infrastructural factors create a need for several different competencies within the LEADS framework. A profound amount of cultural sensitivity was considered the most important in addition to the ability to be resilient, versatile and ready for creative problem-solving.

Primary care doctors' perceived needs for physician leadership development in rural and remote settings of Aceh province, Indonesia.

BACKGROUND: Globally, rural/remote health systems fall short of optimal performance. Lack of infrastructure, resources, health professionals and cultural barriers affect the leadership in these settings. Given those challenges, doctors serving disadvantaged communities must develop their leadership skills. While high-income countries already had learning programmes for rural/remote areas, low-income and middle-income countries (LMICs), such as Indonesia, are lagging behind. Through the lens of the LEADS framework, we examined the skills doctors perceived as most essential to support their performance in rural/remote areas. METHODS: We conducted a quantitative study, including descriptive statistics. Participants were 255 rural/remote primary care doctors. RESULTS: We discovered that communicating effectively, building trust, facilitating collaboration, making connections and creating coalitions among diverse groups were most essential in rural/remote communities. When rural/remote primary care doctors serve in such cultures, may need to prioritise harmony within the community and social order values. CONCLUSIONS: We noted that there is a need for culture-based leadership training in rural or remote settings of Indonesia as LMIC. In our view, if future doctors receive proper leadership training that focuses on being competent rural physicians, they will be better prepared and equipped with the skills that rural practice in a specific culture requires.

The taste of success: how to live and thrive as black scholars in inequitable and racialized professional contexts.

Successful black or nonwhite healthcare scholars represent ideal role models for young, aspiring, and underrepresented healthcare professionals. Unfortunately, their successes are often celebrated by many who do not have a proper understanding of the rough journey they went through, to get to the positions they attained. Most black healthcare professionals, if asked, would share that the secret behind their success is working twice as hard as their white peers. Based on the author's lived experience, a recent academic promotion triggered some personal reflections that resulted in a teachable case story presented in this article. Unlike most conversations that focus on the career challenges of black healthcare physicians and scholars, this discourse uses an empowering context to highlight how scholars can excel within inequitable professional contexts. The author uses this case to describe the 3Rs of resilience, which is a construct that can help black scholars thrive in inequitable and racialized professional contexts.

Awareness of Toxic Stress and Adverse Childhood Experiences among Dutch Pediatric Health Care Providers: A National Survey.

Introduction: Early recognition of adverse childhood experiences (ACEs) and adequate interventions are required to prevent negative effects on the child's mental and physical health later in life caused by toxic stress. This study aimed to assess how familiar the concepts of ACEs and toxic stress are among Dutch pediatric health care providers (PHCPs) and whether screening for ACEs is standard practice in the Netherlands.Methods: From October 2018 until March 2019, a nation-wide questionnaire survey was held.Results: Of 548 participating PHCPs, 29% were familiar with toxic stress, 67% were familiar with ACEs, and 63% knew of the relationship between multiple ACEs and somatic diseases. Routine inquiries about ACEs were done always by 17% of the participants and sometimes by 65%. The ACEs which PHCPs asked about the most included divorce (n=288; 76.8%), bullying (n=265; 70.7%), physical domestic violence (n=184; 49.1%), parental psychiatric diseases (n=205; 54.7%) and sexual abuse (n=164; 43.7%). The ACEs asked about the least included deportation of a family member (n=22; 5.9%), gender discrimination (n=9; 2.4%) and racism (n=17; 4.5%).Conclusion: Even in 2019, there is limited awareness among Dutch PHCPs of ACEs and toxic stress. While most acknowledged to be aware of the role that toxic stress plays in the physical and mental health consequences of ACEs later in life, only 17% of the respondents performed standard ACE screening. Our findings underscore the need for standard ACE screening guidelines to support early recognition and adequate treatment of children suffering with toxic stress.

SPINE20 recommendations 2022: spine care-working together to recover stronger.

PURPOSE: Globally, spine disorders are the leading cause of disability, affecting more than half a billion individuals. However, less than 50% of G20 countries specifically identify spine health within their public policy priorities. Therefore, it is crucial to raise awareness among policy makers of the disabling effect of spine disorders and their impact on the economic welfare of G20 nations. In 2019, SPINE20 was established as the leading advocacy group to bring global attention to spine disorders. METHODS: Recommendations were developed through two Delphi methods with international and multi-professional panels. RESULTS: In 2022, seven recommendations were delivered to the leaders of G20 countries, urging them to: Develop action plans to provide universal access to evidence-based spine care that incorporates the needs of minorities and vulnerable populations. Invest in the development of sustainable human resource capacity, through multisectoral and inter-professional competency-based education and training to promote evidence-based approaches to spine care, and to build an appropriate healthcare working environment that optimizes the delivery of safe health services. Develop policies using the best available evidence to properly manage spine disorders and to prolong functional healthy life expectancy in the era of an aging population. Create a competent workforce and improve the healthcare infrastructure/facilities including equipment to provide evidence-based inter-professional rehabilitation services to patients with spinal cord injury throughout their continuum of care. Build collaborative and innovative translational research capacity within national, regional, and global healthcare systems for state-of-the-art and cost-effective spine care across the healthcare continuum ensuring equality, diversity, and inclusion of all stakeholders. Develop international consensus statements on patient outcomes and how they can be used to define and develop pathways for value-based care. Recognize that intervening on determinants of health including physical activity, nutrition, physical and psychosocial workplace environment, and smoking-free lifestyle can reduce the burden of spine disabilities and improve the health status and wellness of the population. At the third SPINE20 summit 2022 which took place in Bali, Indonesia, in August 2022, 17 associations endorsed its recommendations. CONCLUSION: SPINE20 advocacy efforts focus on developing public policy recommendations to improve the health, welfare, and wellness of all who suffer from spinal pain and disability. We propose that focusing on facilitating access to systems that prioritize value-based care delivered by a competent healthcare workforce will reduce disability and improve the productivity of the G20 nations.

Managing the Mental Health of Healthcare Professionals in Times of Crisis: The Aruban COVID-19 Experience.

Hospital workers in Aruba have been facing an increased demand for healthcare in the unique setting of a Small Island Developing State (SIDS). This study assessed the impact of the first wave of the SARS-CoV-2 pandemic on the mental health of staff at the major hospital in Aruba, examining the differences between employee groups, with the goal of providing recommendations for targeted support and coping strategies in future crises in a small island setting. Patients and methods: In a mixed-method cohort design, Dr. Horacio E. Oduber Hospital staff were asked to complete a 25-item questionnaire about their concerns and worries, organization of work, and general wellbeing; 24% of the hospital staff filled in the questionnaire (mean age 41 ± 11 years, 79% female). Alongside the needs assessment questionnaire, six focus groups were established to explore staff feelings on specific measures taken by hospital management during the COVID-19 crisis. Results: Questionnaire analysis (n = 231) revealed employees' concerns about infecting their relatives and their financial stability. In particular, nurses were significantly more concerned than other staff groups. In the wellbeing section of the questionnaire, items regarding future security scored poorest, alongside increased levels of tiredness and nervousness. Focus groups discussions revealed frustrations of the hospital staff with the foreign staff brought in to help during the crisis and a need for better leadership and communication practices from hospital management. Conclusions: Comprehensive and holistic approaches should be implemented by the hospital management to prevent occupational burnout and demoralized work ethics and further emotional exhaustion.

Promoting a sense of belonging, engagement, and collegiality to reduce burnout: a mixed methods study among undergraduate medical students in a non-Western, Asian context.

BACKGROUND: Burnout is a psychological condition induced by work-related chronic interpersonal stressors. Interventions creating a sense of belonging and collegiality have been proposed as approaches for alleviating burnout. The current study aimed to: (1) explore the relationships between burnout, sense of belonging (relatedness with others), and work engagement; and (2) identify the key elements perceived by undergraduate medical students as positively contributing to collegiality, engagement, and a sense of belonging, in an undergraduate medical training setting. METHODS: An exploratory sequential mixed-methods design using questionnaires and semi-structured individual interviews collected quantitative and qualitative data among undergraduate medical students at Mahidol University, Thailand. The Maslach Burnout Inventory-Student Survey questionnaire was used to measure burnout. The Basic Psychological Need Satisfaction at Work Scale (BPNSS-21) and the Utrecht Work Engagement Scale-Student Version (UWESS-9) measured students' basic psychological needs satisfaction at work and work engagement, respectively. Descriptive statistical analysis and confirmatory factor analysis were performed on BPNSS-21 and UWESS-9 data. Spearman's correlation coefficient was used to identify the correlation between burnout and other factors. Twenty undergraduate medical students participated in the qualitative study. Qualitative analysis was conducted iteratively using constant comparison and the standard principles of primary, secondary, and tertiary coding for thematic analysis. RESULTS: Thai versions of the BPNSS-21 and UWESS-9 showed an acceptable fit for the Thai cultural context. Burnout had significant weak inverse associations with engagement (r = - 0.39, p < 0.005) and basic psychological needs satisfaction (r = - 0.37, p < 0.005). Sense of belonging had a significant weak inverse relationship with burnout (r = - 0.25, p < 0.005). The main themes emerging from qualitative analysis were relevant tasks and learning activities, safety in the learning environment, peer interaction, program design factors, dynamics of collegiality while progressing through medical school, and personal stance and social skills. CONCLUSIONS: Sense of belonging, engagement, and collegiality were related to burnout. The key features for promoting collegiality, the sense of belonging, and engagement were relevant tasks and learning activities, safety in the learning environment, peer interaction, program design factors, dynamics of collegiality while progressing through medical school, and personal stance and social skills.