When the System Blinks First: A Reflection on Breaking Down in Training

There’s a phrase I’ve used often when describing certain moments in medical training when shit just snaps:

“It wasn’t the straw that broke the camel’s back. It was that the camel had been carrying the whole caravan.”

Like many others, I entered higher specialty training with optimism and ambition. I had a good rapport with my department, was already known from previous placements, and was starting to feel like maybe I could belong here. What I hadn’t factored in — and what many trainees never anticipate — was just how fragile the scaffolding can be when life falls apart.

I won’t give you the detailed chronology. That’s already been shared in its appropriate space.

But I want to talk about what happened around the breakdown - my breakdown specifically - because that, in many ways, is the bigger story.

What Happens When Support Isn’t Structured?

At its best, postgraduate training is supposed to be a scaffold: firm, adjustable, supportive.

What I found instead was a network that relied on good will, informal kindness, and implicit resilience — but lacked any meaningful process when things started to unravel.

There was no procedure for watching out for a colleague coming back from bereavement. No structured return-to-work pathway for illness or disruption. Instead, returners are often left to navigate systems that prioritise rota coverage over psychological safety or recovery.

Most of the support I received — and I use that term loosely, but not said that way pejoratively — was verbal, informal, and undocumented. I was repeatedly reminded - officially and unofficially - that my time off had inconvenienced others, but rarely asked what I needed to safely return.

Indeed, returning to work was augmented to be expedient - the onus on “getting back to training” usurping structured Occupational health plans.

This wasn’t cruelty. It was culture.

A culture where time off is tolerated but not understood.

Where wellbeing is encouraged in workshops but questioned at ward handover.

Where professionalism is policed, but never defined with empathy.

“You Just Need to Be More Resilient”

There’s something particularly dangerous about the word “resilience” in medicine.

We use it to describe a quality we admire, but too often we weaponise it against those who are struggling — shifting the burden of failure from systems onto individuals. This is central to the critique of resilience-as-silencing, where emotional suppression is mistaken for fortitude.

When I came back from time off, I wasn’t the same. Grief, exhaustion, and pressure don’t leave you untouched. But rather than asking what support might help, the language shifted to what I was failing to do.

I was labelled as “hard work”, “not a team player,” “a bit of a dick” — sometimes to my face, sometimes in formal forms, more often behind my back. My professionalism was questioned not for anything I had done, but because I had struggled, and it had been visible.

The irony is that I was trying to be resilient. I kept coming back. I kept asking for feedback. I kept doing the work — often far more than was reasonable in the circumstances. But the culture didn’t reward that kind of resilience. It wanted silence. Gratitude. Compliance.

What Feedback Is — And What It Isn’t

The most disorienting part of the breakdown wasn’t the moment I collapsed in the car park. It was the moment I properly realised I had become a “problem trainee.”

Feedback stopped being developmental and became critical. Supervisors didn’t guide — they observed from a distance and judged. Feedback increasingly resembled a tool of control, not growth — a feature of toxic feedback cultures where trainees are monitored, not mentored.

Colleagues stopped engaging and started excluding.

When I later discovered that some consultants didn’t even realise trainees could read their MCRs, it became painfully obvious that much of what was being recorded wasn’t designed to support me. It was to protect the system from me.

That’s not what feedback is supposed to be. And it’s certainly not what training is supposed to feel like.

Lessons, If Anyone’s Listening

If you’re reading this and wondering how to fix it, whether in a genuine or incredulous way, here’s what I’d ask:

• Separate the TPD from the educational supervisor role. Being both structural gatekeeper and pastoral lead creates conflicts of interest.

• Ensure pastoral care isn’t just a box ticked with informal chats. These gaps leave trainees without safe or consistent support, particularly when navigating family illness, bereavement or new parenthood.

• Teach consultants how to give feedback. Not just the format, but the emotional intelligence required to make feedback supportive rather than evaluative.

• Create space for returners to be honest. Lying about being okay is a defensive adaptation — one reinforced by a system that equates openness with risk.

• Understand that professionalism includes vulnerability. Crying at work isn’t unprofessional. Pretending you didn’t see it is. Emotional suppression under stress correlates strongly with long-term burnout and disengagement.

Final Thoughts

I’m okay now — or more okay than I was. I’ve changed careers, rebuilt my life, and I’ve found new meaning in teaching, writing, and mentoring.

But I came close — dangerously close — to not surviving that training environment. I lost colleagues to the same system. I watched others walk away quietly, carrying their own unspoken stories. I’ve known colleagues who aren’t here any more, anywhere, because of it.

So this isn’t a complaint anymore. It’s a reflection.

Of what can go wrong when a system expects people to bend, but never asks how to help them unbreak.

If you’ve been through something similar, you’re not alone.

If you’re in a position to change the system, please do.

And if you’re training in a department that feels more like a gauntlet than a place to grow — trust yourself.

Ask for help.

You don’t have to be the camel or the caravan.

Stay Supportive

—DW