Workforce, Workload and Well-being: A Perspective from Junior Doctors on the Future of Postgraduate Medical Training in Europe
Domingo A. Sanchez¹, Alvaro Cerame², Juan Pablo Carrasco³
¹ Spanish Medical Council & Oncology Department, IMIB-Arrixaca, Murcia, Spain
² Madrid Regional Health Service, Madrid, Spain
³ Psychiatry Department, Consorcio Hospitalario Provincial de Castellon, Castellon, Spain
Abstract
Background
Postgraduate medical training across Europe is increasingly challenged by workforce shortages, rising healthcare demands, excessive workloads, and growing concerns regarding physician well-being. Junior doctors represent a particularly vulnerable group within healthcare systems undergoing demographic and structural transformation.
Methods
This perspective article examines current challenges affecting postgraduate medical education in Europe through the analysis of recent Spanish and European workforce data, including studies on compliance with the European Working Time Directive (EWTD), physician burnout, and medical workforce shortages.
Results
Recent evidence demonstrates widespread non-compliance with European working time regulations among resident physicians. More than 80% of Spanish residents reported exceeding the 48-hour weekly working limit established by the EWTD, while 13% indicated insufficient post-call rest periods. Furthermore, 93.9% of surveyed junior doctors met criteria for at least one dimension of burnout according to the Maslach Burnout Inventory. Workforce shortages and demographic imbalances are increasingly compromising supervision capacity, training quality, and physician retention across several European healthcare systems.
Conclusions
The sustainability of postgraduate medical training in Europe requires coordinated workforce planning, stronger institutional protection of physician well-being, and improved compliance with labour regulations. Competency-based educational frameworks, including Entrustable Professional Activities (EPAs) and European Training Requirements (ETRs), may provide a structured approach to preserving supervision quality, patient safety, and training standards across Europe.
Keywords
Postgraduate medical training; physician burnout; European Working Time Directive; workforce shortages; junior doctors; Entrustable Professional Activities; medical education
Introduction
Postgraduate medical training in Europe is undergoing a period of profound transformation. Healthcare systems are increasingly affected by demographic changes, ageing populations, workforce shortages, and growing clinical complexity. Simultaneously, physicians in training are expected to acquire expanding competencies while maintaining a substantial role in healthcare service delivery.
Three interconnected structural challenges currently threaten the sustainability of postgraduate medical education across Europe. First, the demographic crisis affecting the medical workforce is generating significant shortages in several specialties and regions, reducing supervision capacity and increasing pressure on existing healthcare professionals. Second, persistent non-compliance with the European Working Time Directive (EWTD) continues to expose junior doctors to excessive workloads and prolonged working hours. Third, these structural pressures contribute to increasing levels of burnout and psychological distress among physicians in training.
These issues are not isolated phenomena. Workforce shortages contribute to heavier workloads and reduced supervision, while excessive working hours negatively affect both educational quality and physician well-being. Burnout further threatens workforce retention and the long-term sustainability of healthcare systems.
This perspective article examines the relationship between workforce pressures, workload, and physician well-being in postgraduate medical training, with particular focus on recent evidence from Spain and broader European implications.
Demographic Pressures and Workforce Shortages
European healthcare systems are facing increasing demographic pressure driven by ageing populations and the progressive retirement of senior physicians. These trends have intensified workforce shortages across several medical specialties and geographical regions.
One visible consequence of these shortages is the emergence of “medical deserts,” defined as areas where access to healthcare professionals becomes significantly limited. Rural regions are particularly affected, although workforce deficits are increasingly observed in urban hospitals experiencing recruitment difficulties and high clinical demand.
For junior doctors, these workforce imbalances frequently result in increased clinical responsibilities and reduced access to supervision and structured teaching. When healthcare systems become heavily dependent on resident physicians to maintain service provision, the educational dimension of training may become secondary to operational demands.
The reduction in available supervision time may compromise direct observation, clinical feedback, and competency assessment. Residents may also be required to assume responsibilities exceeding their expected level of autonomy, potentially affecting both patient safety and training quality.
Addressing these demographic challenges requires coordinated workforce planning strategies focused on recruitment, retention, equitable distribution of physicians, and protection of educational supervision within postgraduate training programmes.
Working Time Regulation and the Training-Service Balance
The dual role of resident physicians as both trainees and healthcare providers creates ongoing tension between educational objectives and service provision. The European Working Time Directive established a maximum average working week of 48 hours to protect healthcare professionals and patients from the consequences of fatigue and excessive workload.
However, recent data suggest that compliance with these regulations remains inconsistent across Europe. In Spain, a nationwide survey involving more than 2,000 resident physicians demonstrated that over 80% exceeded the legal 48-hour weekly working limit established by the EWTD. Approximately 13% also reported not receiving the mandatory post-call rest period following 24-hour shifts.
Excessive working hours have important implications for postgraduate medical training. Prolonged fatigue may impair cognitive performance, increase the risk of medical errors, and reduce opportunities for reflection, structured learning, and professional development. Persistent violations of working time regulations may also undermine institutional credibility and contribute to dissatisfaction among junior doctors.
Importantly, regulatory compliance alone is unlikely to resolve these challenges if healthcare systems continue to depend excessively on resident labour to compensate for workforce shortages. Sustainable solutions therefore require broader structural reforms involving workforce planning and resource allocation.
Burnout Among Junior Doctors
Burnout has emerged as one of the most significant challenges affecting the global medical workforce. Characterised by emotional exhaustion, depersonalisation, and reduced professional accomplishment, burnout is increasingly recognised as a systemic rather than exclusively individual phenomenon.
Recent evidence from Spain illustrates the magnitude of this issue among junior physicians. A nationwide survey involving 1,419 doctors who entered postgraduate medical training between 2015 and 2024 found that 93.9% met criteria for at least one dimension of burnout according to the Maslach Burnout Inventory. More than half fulfilled criteria across all three burnout dimensions.
Burnout was strongly associated with several work-related factors, including frequent on-call duties, sleep disturbances, reduced perceived quality of life, and increased use of psychotropic medication. These findings suggest that organisational and structural conditions within training environments play a central role in physician well-being.
The consequences of burnout extend beyond individual psychological health. Physician burnout has been associated with reduced job satisfaction, increased workforce attrition, decreased empathy, and lower quality of patient care. In the long term, burnout may contribute significantly to workforce instability and specialist shortages.
Protecting physician well-being should therefore be considered a central component of healthcare workforce sustainability rather than an isolated occupational health concern.
Competency-Based Training and European Standards
The increasing pressures affecting healthcare systems highlight the importance of maintaining robust educational standards within postgraduate medical training. Structured competency-based educational frameworks may provide an effective mechanism to preserve supervision quality and patient safety despite workforce challenges.
Entrustable Professional Activities (EPAs) and European Training Requirements (ETRs) developed within the framework of the European Union of Medical Specialists (UEMS) represent important tools for modernising specialist training across Europe.
By linking competencies to clearly defined clinical activities and specifying levels of required supervision, EPAs may facilitate safer progressive autonomy for trainees while ensuring accountability and consistency in training standards. Similarly, ETRs contribute to harmonising specialist education across European countries and support minimum quality standards in postgraduate medical education.
In the context of increasing workforce shortages and service pressures, competency-based frameworks may help protect the educational mission of residency programmes while supporting patient safety and physician well-being.
Conclusion
Postgraduate medical training in Europe is currently confronted with multiple interconnected challenges involving workforce shortages, excessive workloads, and physician burnout. Recent evidence from Spain demonstrates how these structural pressures may compromise both physician well-being and training quality.
Addressing these issues requires coordinated action at institutional, national, and European levels. Strengthening workforce planning, ensuring compliance with labour regulations, improving supervision structures, and integrating physician well-being into training policies should become strategic priorities for healthcare systems.
Competency-based educational models such as Entrustable Professional Activities and European Training Requirements may offer a practical framework for safeguarding postgraduate medical training standards while supporting sustainable workforce development across Europe.
Ensuring the future resilience of the European medical workforce will depend not only on increasing the number of trained specialists, but also on protecting the conditions under which future specialists are trained.
Open Access & Copyright
© 2026 The Authors. Published by the European Medical Specialist Review (EMSR) under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0).