Balancing act—ethnic minority trainees' coping strategies in Dutch GP-specialty training—a qualitative study

Abstract

Background

Dutch GP-specialty training, like many Western European and U.S. postgraduate medical programs, emphasizes learning from role models and peers through reflection and openness to feedback. However, these methods depend on safe learning environments, which studies have indicated are often undermined for ethnic minority trainees due to microaggressions and exclusion experiences. Understanding their coping strategies and how they impact learning processes is crucial for promoting educational equity.

Research question

What coping strategies do ethnic minority GP trainees employ to balance the challenges of their educational environment with their personal backgrounds, and how could these strategies affect their ability to comply with learning processes required in GP-specialty training?

With the following sub questions: What coping strategies do ethnic minority GP-trainees employ given the interplay between their learning environment and personal backgrounds? A How could utilizing these strategies affect these trainees' these learning processes?

Method

We conducted fourteen semi-structured, in-depth interviews with minority GP trainees, using purposive convenience sampling to ensure diversity across various dimensions. Through thematic analysis, we identified participants’ coping strategies and learning processes with which they struggled.

Results

While strongly motivated to complete their GP-specialty training, participants faced prejudice and bias, leading them to adopt coping strategies—ranging from emotion-focused (religious support, compliance, detachment) to problem-focused (peer support, adaptation, identity balancing)—which notably shaped their abilities to adhere to learning processes required in their GP-specialty training (Table 3).

Conclusion

Ethnic minority GP trainees in the Netherlands face challenges that lead to coping mechanisms. While these strategies offer temporary relief, they can undermine connectedness and reflective thinking—both required in GP-specialty training. Consequently, these trainees often feel inclined to balance educational success with maintaining their well-being. We recommend further research into the challenges that drive these coping strategies among ethnic minority trainees to inform the development of inclusive learning environments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-03069-5.

Introduction

Like many Western countries, the Netherlands has experienced successive immigration waves [1, 2], resulting in an ethnically diverse population. While recognizing the benefits of physician ethnic diversity for quality of care in diverse populations [3–6], international studies indicate persistent ethnic disparities in medical education outcomes for minority students and trainees [7–12]. These disparities persist even after adjusting for pre-university performance, socioeconomic status, language proficiency, motivation, study habits, living situation, and personality [12–15]. Biased organizational policies, microaggressions, and stereotyping can contribute to these disparities and may negatively impact minorities’ well-being, potentially leading to lower academic performance and increased dropout rates [16–20]. Additionally, cumulative discrimination experiences can cause internalized stigma, identity concealment, and vulnerability to mental illness [21–26].

In the Dutch context, the concepts of migrancy and ethnic minority are often used interchangeably, as the Netherlands has no indigenous ethnic minority populations. Its ethnic minority population has historically been shaped by immigration from former colonies, labor migration (e.g., from Turkey and Morocco), and more recent EU and refugee movements [27, 28]. Between 2016 and 2020, approximately 20–25% of the Dutch population had at least one parent born abroad, indicating that ethnic minorities are predominantly first- or second-generation migrants [1, 29, 30]. While we acknowledge that, from a global perspective, ethnicity and migration are distinct—such as in the United States, where many ethnic minorities have resided for multiple generations without a recent migration history—in our study setting, using the terms ethnicity and migration background interchangeably is justified [31].

These patterns may also affect ethnic minority trainees in Dutch GP-specialty training, as our previous study found that discrimination and microaggressions recur consistently across their educational and life experiences [32].

This study adopted a lens of creating inclusive educational spaces, while also integrating a decolonizing aspects as these perspectives are closely interconnected [33, 34]. It highlights how dominant Western learning styles and knowledge systems can perpetuate inequities, thereby limiting the extent to which minority trainees may feel included and supported [32].

Studies on discrimination, microaggressions, and exclusion generally focus on describing, monitoring, and analyzing these occurrences and their repercussions [35, 36], emphasizing the need for inclusive learning environments [37]. However, creating such environments requires a deeper understanding of how students and trainees navigate these encounters throughout their education [38] and how their (un)consciously adopted coping strategies may affect learning processes. With this study, we aim to address this knowledge gap.

The educational approach of Dutch GP-specialty training demands specific attitudes and skills from trainees, aligning with the standards of medical education across Western Europe, Canada and the USA. Reflectiveness and openness to learning from feedback are critical among these qualities [39, 40], enabling trainees to benefit from in-clinic and faculty role models, learn from failure [41, 42], grow professionally through peer-based small group learning [43], and actively direct their thoughts, emotions, and behaviors toward personal goals through self-oriented feedback loops [44–46].

Such attitudes require safe and inclusive learning environments that support students and trainees to their full potential. However, fostering inclusiveness in educational settings is complex [47–49]. Ethnic minority trainees frequently report facing misunderstandings, microaggressions, and discriminatory incidents, which heighten their vigilance towards less safe learning environments [50, 51]. This sense of precariousness can prompt coping strategies—thoughts and behaviors used to handle internal and external stress [52]—which may develop into coping styles, reflecting consistent tendencies [53]. Studies show that personalities and social settings influence preferred coping strategies. While apprehensive individuals tend to adopt defensive and polarizing approaches, confident people favor strategies that foster connection [53–56]. Additionally, workplaces and educational settings often encourage conforming strategies, as structured roles, predictable norms, and readily available support allow individuals to manage experiences with some degree of control. In contrast, public spaces—where personal agency is limited due to interactions with strangers, less predictable norms, and minimal institutional support—may provoke stronger, oppositional responses such as anger, assertiveness, or withdrawal [57]. Moreover, explicit discrimination often prompts confrontational coping, such as directly challenging the perpetrator, whereas subtler microaggressions tend to elicit uncertainty and more measured, adaptive responses, adjusting one’s behavior to navigate the situation [58]. These coping strategies often prove useful in seeking empowerment, stress relief, and social inclusion [55, 59]. However, they may also carry paradoxical risks, including heightened stress, isolation, and increased sensitivity to exclusion [55, 59].

Many studies on coping build on Folkman's theory, which categorizes coping strategies into two major types [52, 56, 60]:

1. Emotion-focused coping (regulating emotional responses to stressful situations);

2. Problem-focused coping (addressing the encountered obstacles)

Both strategies are crucial to our defensive system and focus on security, prompting us to avoid or neutralize threats and protect self-esteem, beliefs, and goals [61].

Starting with open coding to identify recurring themes in participants’ coping strategies, we found that our results aligned well with Folkman’s categorization of emotion-focused and problem-focused coping, which we then used as a framework to structure our analysis further and connect it to learning processes within the GP-specialty program (Tables 2 and 3). Integrating this framework as the theoretical basis for understanding participants’ coping strategies strengthened the conceptual grounding of our study. To our knowledge, no previous studies have examined how ethnic minority GP-trainees balance their personal backgrounds with pressures from their educational environments or how these coping strategies may affect their learning.

Table 2.

Coping strategy themes emerging from participants' responses, categorized by Folkman’s emotion-focused and problem-focused framework [56]

Emotion-focused	Problem-focused	Uncategorized
Seeking Support in Religion Drawing support from religious beliefs or practices to find solace and comfort during difficult times.	Functional adaption Flexibly adjusting strategies and approaches to navigate challenges effectively and achieve successful outcomes.	Seeking and Providing Peer Support Utilizing peer support networks for emotional encouragement and practical guidance in tackling challenges.
Compliance Adjusting without genuine involvement to avoid stress.	Creating Personal Space for Growth Allocating resources to focus on learning and personal development.
Detachment Withdrawing from stressful environments and making oneself less visible to reduce emotional strain.	Addressing Discriminatory Incidents and Microaggressions Responding to discriminatory statements by mirroring them and initiating discussions to address bias.
Ignoring Discrimination and Microaggressions Choosing to ignore or divert attention away from stressors or negative emotions.	Seeking Clarification and Transparency Seeking clarity and transparency on educational requirements to find effective solutions.
	Introspection Reflecting internally to gain insight in one's professional identity, opinions, and aspirations.
	Demonstrating Competence and Challenging Stereotypes Disproving negative stereotypes or prejudices through hard working and proactively demonstrating one's qualities.

Table 3.

Challenging learning processes, required in Dutch GP-specialty training, along with reported experiences [32], aligned with literature on their requirements and threats

Learning Process	Requirements	Threats	Participants’ experiences
In-clinic learning from role models	Mutual trust between trainees and supervisors [62]; Identifiable role models [63]; Constructive feedback [63]	Threats Participants’ experiences [64] Fear of bias in one-on-one clinic settings Reluctance to genuinely engage	Participants often felt hesitant to engage due to fear of biased assessments. This reluctance hindered their ability to fully benefit from learning opportunities provided by role models.
Peer-based Learning from Exchange of Experiences	Active participation [65, 66]; ReflectivenessSkilled facilitators to promote safe group dynamics [65, 66]	Past discriminatory experiences Hesitancy to voice opinions and ideas	Participants struggled to fully benefit from peers’ perspectives due to misunderstandings and prejudice. ccasionally, meaningful exchanges occurred, helping identify professional strengths.
Learning from failure	Blame-free learning from inevitable mistakes [67]; Vulnerability and openness as learning tools [67]	Biased assessments Hesitancy to openly discuss failures	Participants often felt unsafe sharing failures due to fear of biased assessments. They were unfamiliar with openly discussing failures, which impeded learning from these experiences.
Appreciation for Work-Life Balance	Supportive environments [68]; Strong supervisor-trainee relationships [68]	Heavy workload combined with intensive training requirements High work ethics to prove competency	Participants felt pressured to work twice as hard for equal recognition. They feared that their fatigue might be misinterpreted as a lack of motivation.
Self-directed learning	Familiarity with the approach of self-directed learning [69, 70]; Openness to identify knowledge and skill gaps [69, 70]; Clear guidance from supervisors, with an emphasis on learning processes over innate abilities [69, 70]	Lack of support for autonomy Prejudice and inadequate feedback	Participants felt the need to better understand their learning processes. They were unfamiliar with taking ownership of their educational goals.

In this context, personal background refers to the constellation of individual attributes and life experiences—such as ethnicity, generational or migration status, socioeconomic origins, prior education, language proficiency, and cultural practices and beliefs—that shape how participants perceive and engage with their learning environments [71]. In this study, we used Ngozi Adichie-inspired identity cards to invite participants to identify the aspects of their background they regarded as influential in shaping their educational experiences [72].

To address this knowledge gap, we examined how ethnic minority trainees navigate challenges, such as (but not limited to) discrimination, microaggressions, and exclusion, within Dutch GP-specialty training, and how they perceive these strategies to impact learning processes, required in the Dutch GP-Specialty Educational plan (Table 3). This exploration led to the following research question:

What coping strategies do ethnic minority GP-trainees employ to balance the challenges of their educational environment with their personal backgrounds, and how could these strategies affect their ability to comply with learning processes required in Dutch GP-specialty training? We divided this question into the following sub-questions:

• 3.What coping strategies do ethnic minority GP-trainees employ given the interplay between their learning environment and personal backgrounds?
• 4.How could utilizing these strategies affect these trainees' these learning processes?

Methods

Design

In this qualitative study, we conducted a thematic analysis of semi-structured, in-depth interviews with ethnic minority GP trainees.

Setting

We conducted this study within the eight GP-specialty training institutes of the GP-specialty training Netherlands network (HN). Despite 28% of the Dutch population under 25 belonging to ethnic minority groups, they are underrepresented among GP-trainees, comprising about 15%, many of whom completed pre-training at Dutch medical schools [9]. Dutch GP-specialty training aims to provide a supportive learning environment with a helpful social network.

The 2017–2023 Dutch GP-specialty educational plan, used during our participants' training, employed competency-based learning based on the CanMeds model [73]. It included in-clinic and in-faculty activities and was grounded in five educational principles:

• 5.The trainee primarily learns through practical in-clinic experience;
• 6.In-faculty instruction complements practical in-clinic learning;
• 7.Critical reflection, observation, feedback, assessment, and evaluation support the trainee's learning process;
• 8.The program aligns with the professional development and ambitions of each trainee;
• 9.Competent teachers and supervisors in didactics and content ensure a high-quality education.

The program includes protocolled assessments such as knowledge tests, consultation observations with reflective reports, systematic competence assessments, and reviews of learning objectives. Nationally centralized entry assessments evaluate applicants' medical knowledge, motivation, and Dutch language proficiency. All these learning activities and assessments are rooted in Western educational principles, emphasizing self-directed learning, critical reflection, analytical reasoning, and verbal assertiveness. Consequently, the Dutch GP-specialty training may pose challenges for those from more collective, hierarchical, or practice-based educational backgrounds [74].

Participants

We included GP-(ex)trainees who self-identified as ethnic minorities and were currently enrolled at one of the eight Dutch GP-specialty training institutes or had graduated as a GP within the last five years. After informing the teachers at these institutes about our study, they asked trainees in their classes if they were interested in participating and, with their consent, provided us with contact details of those who wished to schedule an interview. We combined convenience and purposive sampling to strike a balance between feasibility and diversity [75, 76]. Trainees who expressed interest comprised the convenience component, while purposive sampling ensured inclusion of participants with varied characteristics such as gender, age, ethnicity, social background, migration generation, educational stage, success, and GP-training institute. Additionally, we employed snowball sampling to expand the participant pool, thereby capturing a more diverse range of experiences relevant to our research questions. Recruitment continued until redundancy of themes was reached. Eligible participants received additional information via email and scheduled interview appointments upon providing informed consent for anonymized demographic and interview data collection and publication without financial compensation.

Data collection and analysis

Data collection and analysis occurred iteratively from April 2019 to October 2023. Five trained interviewers (MN, NM, AJ, SZ, and SG) conducted 49–86-min in-depth interviews, with the latter two supervised by the three primary interviewers (MN, NM, and AJ).

The interviews were conducted at a location of the participant’s choice or online if required by COVID-19 restrictions. The interviewers introduced the study's context, ensuring confidentiality. They then initiated the interviews with broad, open questions, allowing ample space for participants' experiences and emotions, in line with a reflexive thematic analytical approach [77, 78]. To deepen understanding, we used a topic list (Appendix) informed by existing literature and expert opinion with flexibility for spontaneous additions. This topic list was originally developed for our prior study exploring the experiences of ethnic minority trainees throughout their educational journey in GP-specialty training [32]. While the topic list did not explicitly mention the concept of coping, it did include attention to how participants navigated challenges within the educational setting. Additionally, we employed identity cards [79], inspired by Ngozi Ardichie’s 2009 TED talk on multifaceted identities [72]. These cards represented eighteen unique identity and background aspects, such as gender, life stage, migration history, previously encountered discrimination or microaggressions, along with one blank card for personal interpretation. Participants selected three cards representing key aspects of their identities that had influenced their coping styles with specific challenges in the context of GP-specialty training. The interviewer then asked them to reflect on the impact of these aspects.

Following each interview, the interviewers reflected on the atmosphere and conduct. Audio recordings were transcribed verbatim and anonymized.

Four researchers (MN, MV, NM, and AJ) conducted the analysis, following Braun & Clarke's six-phase framework for thematic analysis and using MAXQDA version 12 [80]. After familiarizing ourselves with the data, we linked interviewees' comments to initial codes and discussed these codes until reaching a consensus. MN, MV, and AJ then continued coding in pairs and searched for themes, which they discussed with NM until a consensus. This iterative process of coding, reviewing, and defining themes continued until redundancy of themes was achieved [77]. Initially, we refrained from using an analytical framework, allowing us to identify recurring themes and patterns in participants' perspectives on the origins and impacts of their coping strategies [77, 81]. Subsequently, we adopted Folkman's as an analytic lens [81] for categorization of coping strategies into emotion-focused and problem-focused types [56]. We subdivided these categories based on the themes emerging from participants' responses (Table 2). Additionally, we identified learning processes within the GP-specialty educational program that participants reported struggling with (Table 3).

Reflexivity and ethics

This qualitative study is a follow-up to our quantitative study indicating an increased risk of underperformance assessments among minority GP trainees compared to their majority peers [9]. The research team included four GPs: a PhD candidate (NM), the head of the GP department (JB), the head of GP-specialty training (JE), and a professor in health disparities (MM)), along with a cognitive psychologist (MV), a research assistant (MN), and a GP trainee (AJ), all affiliated with Dutch GP-research and training institutes and experienced in medical education research. None of the researchers or interviewers had direct teaching or assessment roles with the participants.

Two researchers (NM and MN) identify as minority females, which may enhance sensitivity to issues affecting minority participants, but also carries the risk of resonance bias. Equally important is the positionality of non-minority researchers on the team, as they may overlook subtle nuances or participants may share less with them. To address these potential biases, the research team held reflective sessions to examine diverse perspectives within the team and underscore the role of researchers as instruments in data collection and analysis. These sessions involved critically discussing each other’s experiences, expectations, and potential perspective gaps, aiming to mitigate bias and foster a more nuanced interpretation of participants’ experiences.

Results

Fourteen ethnic minority GP-(ex)trainees from all eight Dutch GP-specialty training institutes participated. Table 1 shows their characteristics, such as diversity in gender, age, training stage, and migration generation. Their educational outcomes varied, including successful graduates, honors program participants, and those in mandatory coaching or involuntarily dropout situations. First-generation migrant trainees immigrated 8–26 years ago, completed pre-training in the Netherlands, and were fluent in Dutch.

Table 1.

Participants characteristics

Participant	Gender		Trainee/Alum			Migration background
1	M		Trainee			First-generation
2	F		Trainee			First-generation
3	F		Trainee			Second-generation
4	F		Alum			Second-generation
5	M		Alum			First-generation
6	F		Trainee			First-generation
7	F		Trainee			Second-generation
8	M		Trainee			Second-generation
9	F		Alum			First-generation
10	F		Alum			First-generation
11	M		Dropped out			Second-generation
12	F		Trainee			Second-generation
13	F		Alum			Second-generation
14	M		Trainee			Second-generation
TOTAL %	M	F	Trainee	Alum	Dropped out	1st generation	2nd generation
	N=536%	N=964%	N=857%	N=536%	N=17%	N=643%	N=857%

Participants reflected on how aspects of their backgrounds and personal experiences—illustrated through discussions about their choices of Ngozi-inspired identity cards—may have shaped their preferences for particular coping approaches. Additionally, they reflected on how these approaches influenced their learning processes, considering whether their strategies primarily addressed emotional relief or problem-solving (Table 2). In the following paragraphs, we explore these coping styles, background aspects, learning processes, and potential interconnections in detail.

Coping strategies during GP-specialty training

Participants noted that while they usually followed their behavioral preferences, circumstances notably influenced their coping responses. For instance, repeated stigmatization ultimately left naturally assertive individuals intimidated and silenced.

‘During introductions, this GP-supervisor said it again; a doctor with hijab wouldn’t fit in his clinic... at some point it even didn’t bother me anymore, and that's actually not like me... not finding words...’ (participant 10, female, first-generation alum)

Depending on the situation, some participants described periods of self-doubt and a sense of giving up alternated with moments of strength, allowing them to exhibit their personality and competencies confidently.

‘My supervisor's repeated criticism makes me feel like a failure, keeping a low profile. Talking with peers after work made me feel understood and confident in my skills.’ (participant 6, female, first-generation trainee)

When asked to reflect on their preferred methods for navigating challenges, participants generally reported not relying on a single approach. The majority indicated that they alternated between several strategies, including those focused on emotional relief and problem-solving. Within these categories, they described shifting between different approaches (Table 2). While these approaches encompassed elements of both emotional relief and practical problem-solving, most tended to emphasize one aspect over the other. However, participants who employed 'seeking and providing peer support' as a coping strategy described it as a balanced blend of emotional relief and problem-solving, simultaneously alleviating feelings of isolation and providing practical guidance for addressing challenges. Consequently, we discuss this coping strategy separately, without categorizing it within Folkman’s framework of emotion-focused and problem-focused coping styles [56].

Seeking and providing peer support

Participants reported finding resilience and empowerment through mutual support among ethnic minority peers. Most viewed this peer support as a transformative strategy that could offer advice, emotional relief, and support in collective action.

‘When things get tough, we're there for each another. Yet, though empowering, it can be tricky, just because I handled something a certain way doesn't mean it would work for others.’ (participant 7, female, second-generation trainee)

Additionally, most participants observed that colleagues from the majority group, who lacked a full understanding of the issue, often defaulted to sympathetic remarks instead of offering meaningful support.

‘When I shared my pain after my in-clinic supervisor made this remark about foreigners, they said they felt bad for me and understood my despair. Yet, I sensed they didn’t, feeling even more isolated.’ (participant 2, female, first-generation trainee)

Emotion-focused coping strategies

Analysis revealed that participants’ responses to stressors often involved emotion-focused strategies, which served to manage the immediate emotional impact of discriminatory experiences while also, in their specific ways, influencing their engagement in learning processes.

Seeking support in religion

Some participants noted that seeking support through faith or religion empowered them internally, helping them navigate stress and adversity while enabling them to thrive despite these challenges.

´I believe that my religious faith helps me overcome challenges. The idea that there is a reason behind every event helps me to see positive aspects of seemingly adverse experiences.´ (participant 10, female, first-generation alum)

Compliance

Participants who used compliance as a coping strategy appeared to be "model trainees" but reported lacking inner drive. They explained how past experiences with prejudice had taught them to avoid negative attention by exhibiting the expected behavior, even when it conflicted with their personal values.

‘I felt pushed to be someone I'm not, just jumped through their hoops, not asking any further explanations...’ (participant 5, male, first-generation alum)

Detachment

Participants who used detachment as a coping mechanism often reported reacting defensively. They acknowledged that this behavior made them appear defiant, arrogant, and resistant to learning. Still, they mentioned that negative experiences had made them feel disconnected from the training program and less motivated to engage or benefit from it. They noted that they carefully chose their words and actions during both in-clinic and in-faculty educational sessions to avoid vulnerability. Although aware that disengagement could hinder their professional growth, they preferred to stay under the radar.

‘My brown eyes always make me the odd one out; even my successes can be labelled negatively. So, I keep distance, not revealing too much of myself.’ (participant 3, female, second-generation trainee)

Ignoring discrimination and microaggressions

Some participants stressed the need to develop a shield, deflecting remarks others might dismiss as mere humor. They deliberately ignored hurtful instances, chose their battles wisely, and avoided the pain and isolation these moments could cause.

‘You’d hear in-clinic supervisors say, 'That one with the foreign name won't make it into my clinic.' I pretended not to hear. As migrant trainees, we had a code: SMGD—Shut your Mouth, Get your Diploma. It was how we supported each other when we heard such remarks.’ (participant 8, male, second-generation trainee)

Problem-focused coping strategies

Problem-focused strategies were more oriented toward practical solutions and adapting behaviors, illustrating how participants actively navigated program requirements and sought to maintain progress in their training.

Functional adaptation

Most participants were motivated to enter GP-specialty and embrace its values. However, they emphasized the importance of preserving their identity within that framework.

‘Well, different, I am just different... and that is who I am. Yet, I feel drawn to adopt certain ways - so to speak - to fit in as a professional GP.’ (participant 11, male, second-generation, dropped out)

Creating personal space for growth

In the training program that did not always fully meet their expectations for learning needs, some participants viewed proactively choosing their direction as a path to personal growth. They also reported supporting peers who struggled to navigate the program's rigid structure.

‘When we were chatting informally about our experiences, I said, 'Look at it like swimming across a river—don't just drift and stay afloat, keep yourself on course and that’s how you’ll reach where you want to be.’ (participant 1, male, first-generation trainee)

Addressing discriminatory incidents and microaggressions

Despite initially feeling silenced by some incidents or microinsults, participants subsequently recovered and addressed the exclusionary nature of such remarks, rather than letting themselves be inhibited from responding. They demonstrated an active coping strategy to reassert their voices within the interaction and address discriminatory incidents and microaggressions.

‘... over my head, my supervisor commented, 'Wow, he speaks Dutch.'...My jaw dropped open for a moment or two, grasping for words. Then I responded, 'Yes, with a southern Dutch accent, where I grew up.’ (participant 8, male, second-generation trainee)

They tended to mirror the incidents and openly express their feelings in various ways, from filing official complaints to the program head to using humor or publicly confronting teachers and supervisors.

‘When the teacher said, 'We all know them, these rotten Moroccan kids'. I jokingly interjected, 'Did I mishear you? You can't have said that, right?' My peers laughed, but I hope the teacher understood that serious undertone.’ (participant 10, female, first-generation alum)

Seeking clarity and transparency

Almost all participants requested explanations for unclear feedback and discussed mutual expectations with their supervisors.

‘However simple their feedback seemed to them, it wasn’t straightforward for me. I learned to ask... that has indeed been a learning point.’ (participant 6, female, first-generation trainee)

‘When my supervisor expressed concerns about my religious background, I took the opportunity to discuss our expectations on that matter.’ (participant 7, female, second-generation trainee)

Introspection

Several participants engaged in introspection often without sharing or exchanging their reasoning with peers, supervisors, or teachers. They contemplated how internalized values, interests, strengths, and weaknesses would align with their career perspectives, weighing strategies for advancement.

‘I get that wearing a hijab might make some patients feel I’m less neutral, but for me, staying true to who I am is just as important as being an approachable doctor. I’ve been thinking a lot about these issues, and it helps me discover the kind of GP I truly want to be.’ (participant 5, male, first-generation alum)

Most of them reflected on how they wished to gain optimal growth from educational opportunities within the program, even when teacher’s demands did not align with their natural inclinations.

‘My teacher urged me to be more assertive, saying that opening up would create more learning opportunities. His feedback left me pondering how to align my communications - a core part of who I am, probably rooted in my background – with the program’s demands.’ (participant 12, female, second-generation trainee)

Demonstrating competence and challenging stereotypes

Eager to challenge stereotypes and driven to succeed, participants often tended to present their best selves, with some reporting working twice as hard as their majority peers or participating in honors programs.

‘I’ve always felt that drive to outperform—it's not a new story. Feeling like an outsider, you strive to excel in education, work, life; it's a relentless pursuit.’ (participant 14, male, second-generation trainee)

Background aspects and experiences that may influence coping styles

Participants noted that their coping strategies were closely intertwined with aspects of their personal and cultural backgrounds. They elaborated on how these aspects may have influenced their strategies to navigate experienced stressors, and how these affected their engagement with learning processes fostering professional growth in the GP-specialty program.

Cultural background and family upbringing

Out of nineteen options, participants selected identity cards representing their upbringing, family history, ethnicity, and learning style, emphasizing how these influenced their coping strategies within their GP-specialty educational context. They highlighted the challenges of coping with norms and habits different from those of their Dutch-origin peers and misunderstandings stemming from these differences.

‘At home, I learned not to value my perspective over the community's views. But in school, my teachers ask, 'What do you think?' I am working now on expressing my opinions.’ (participant 8, male, second-generation trainee)

Participants’ family values and cultural norms shaped how they responded to challenges, influencing strategies such as compliance, introspection, or seeking peer support.

They reported dealing with teacher misunderstandings due to friction between their biculturalism and the program's expectations.

‘I approach certain situations differently... teachers may think I lack reflectiveness or don't make myself visible. Talking with other minority peers, we realized we all experienced this. Some adapted, but I found it difficult.’ (participant 11, male, second-generation, dropped out)

Several participants reported being raised with strong family values, which often led them to take on informal caregiving roles alongside their vocational training.

‘As the oldest of six, I had tons of responsibilities, draining my energy for school. I never voiced these concerns—it was just how things were. Not many Dutch-born colleagues would understand.’ (participant 3, female, second-generation trainee)

These family values, less common in Dutch families, often required participants to balance their GP-specialty training’s demands (e.g., continuity of attendance beyond regular hours) with their families’ expectations. While these conflicting responsibilities also nurtured qualities central to general practice—such as responsibility, empathy, and cross-cultural sensitivity —in most cases, their supervisors did not recognize these competencies. These experiences often caused stressors that led to coping strategies that either offered emotional relief or supported problem-solving.

Participants described how this upbringing fostered a deep sense of respect toward their parents, which extended to an ingrained respect for teachers and influenced the way they communicated with them.

‘My in-clinic supervisor kept encouraging me to challenge him on professional matters, but how could I ever openly argue with him? He is my teacher!’ (participant 2, female, first-generation trainee)

While experiencing these challenges, participants also viewed their multicultural backgrounds as an asset for understanding patients from diverse backgrounds.

‘Coming from a migrant background, I could really connect with that woman’s concerns. I used her case to present a workshop in class on cross-cultural competencies.’ (participant 4, female, second-generation alum; discussing a migrant patient who visited her consultation hour suffering from burn-out due to a cultural clash at work)

Cumulative experiences of discrimination, microaggressions or exclusion

Even after decades in the Netherlands, most participants noted the tension of being seen as outsiders.

'It's hard to explain if you are not in my shoes. People always ask where I am from or tell me I speak Dutch so well. Subtle understatements, making me feel like I don’t belong here... I learned that ignoring them works best for me' (participant 2, female, first-generation trainee)

The majority of participants reported having experienced biases throughout their school careers, with such prejudices continuing into their GP-specialty training. Additionally, they conveyed a perceived lack of support from peers in the majority group.

‘Shamelessly, she called the patient a 'stupid fat Turkish diabetic.' I was shocked to see such blatant disrespect accepted, even in academia, and felt a strong urge to speak up, but it would have been easier if more of my colleagues had joined... unfortunately, there aren't many like that.’ (participant 8, male, second-generation trainee)

Repeated exposure to bias and exclusion prompted participants to adopt coping strategies ranging from seeking peer support to addressing incidents directly, illustrating the interplay between identity, backgrounds and coping.

Those who had reported these experiences emphasized the lasting impact of discriminatory experiences on their self-esteem.

‘As a foreigner of color, I've faced constant slights, overt and covert. Even excelling worked against me. It left me wary, always on edge, and eventually exhausted.’ (participant 7, female, second-generation trainee)

Overall, participants’ background aspects provided a lens through which they interpreted stressors and selected coping mechanisms to manage challenges. By linking background factors such as migration background and prior experiences with the coping strategies employed, we can better understand how these strategies may influence engagement with learning processes in the GP-specialty program.

Challenging learning processes

The coping strategies and background aspects described above intersected with participants’ experiences of learning processes in the GP-specialty program (Table 3), highlighting how identity, backgrounds, prior experiences, and institutional expectations collectively shaped their educational engagement, particularly in challenging learning processes.

Participants frequently reported challenges in meeting the requirements of learning processes integral to the program's educational principles. They also discussed how their strategies for balancing these challenges with personal preferences alleviated or intensified these difficulties.

In-clinic learning from role models

Participants who had noted a lack of identifiable role models described their coping strategies ranging from avoidance to confrontation, which left them feeling resentful and disengaged in response to their supervisor's stigmatizing remarks.

‘He was knowledgeable but made stereotyping comments about patients and even about me. I wouldn’t consider him a role model.’ (participant 8, male, second-generation trainee)

‘She always saw me as 'the other.' It is what it is... Standing up and getting dragged into it takes energy. Eventually, I chose my battles.’ (participant 12, female, second-generation trainee)

Peer-based learning from exchange of experiences

Several participants highlighted that navigating perceived unsafe environments sometimes hindered them from openly reflecting on professional issues or sharing their in-clinic experiences for mutual learning. They stressed that, in some cases, teachers' misunderstandings would create a vicious cycle of discomfort and further withdrawal.

‘During these exchange-sessions, I feel all eyes on me, all curious for my ‘exotic ideas,’ making me even more cautious to share my ideas... you must be careful what you say in those group sessions.’ (participant 11: male, second-generation, dropped out)

Some participants felt that teachers did not fully understand their backgrounds or the attitudes shaped by those backgrounds. Others gradually came to value exchanging perspectives and found discussions on differing ideas enriching.

‘Some teachers had a fixed idea of who I am, having no clue of my cultural upbringing. I found myself constantly asserting my identity, feeling pressured and held back from truly engaging.’ (participant 13, female, second-generation alum)

‘You learn from others' problems; hearing their doubts and questions made me think, 'I have that too' or 'I'd handle it differently,' prompting me to reflect on my own tendencies.’ (participant 6, female, first-generation trainee)

Learning from failure

Participants who reported feeling uncomfortable sharing their failures to learn from them cited unfamiliarity with openness about failure and feeling unsafe with their teachers and supervisors to do so.

‘Where I come from, teachers were so harsh in judging mistakes that I learned to think twice before sharing anything, especially in formal classroom setting.’ (participant 9, female, first-generation alum)

‘It was tough—I struggled to connect with my supervisor. When observing my consultations, he’d focus on what I could have done better, making me fear he'd find more mistakes. I started hiding them, even though it meant missing the chance to learn.’ (participant 4: female, second-generation, alum)

Self-directed learning

Some participants emphasized reluctance to take the initiative to pursue their individual learning goals, feeling unequipped to take ownership and accustomed to relying on teacher authority.

‘My teacher wanted me to create my individual PDP (Personal Development Plan). How could I know what I should be learning at which stage? I'd expect that to be clearly laid out in the official curriculum!’ (participant 14, male, second-generation trainee)

Additionally, others perceived limitations in following their goals, particularly when these did not align with their supervisors' views or were not explicitly supported by the program.

‘After years in clinical practice, I was excited to explore GP-entrepreneurship. But despite the program’s promise of flexibility, it feels rigid, leaving little space for such individual goals.’ (participant 3, female, second-generation trainee)

Appreciation for work-life balance

Those participants who had emphasized their tendency to work hard to counteract stereotypes and prejudice reported difficulty balancing the program's emphasis on work-life balance with the performance pressure they felt. They noted their fear of supervisors potentially perceiving them as lacking motivation.

‘... and then, the training tells you to set boundaries, but I find myself working until everything is done, even if it means coming home late and missing out on family time.... there's always this nagging feeling that I have to keep pushing.’ (participant 6, female, first-generation trainee)

Discussion

Summary of findings

Commonly reported emotion-focused strategies included seeking support through religion, compliance, detachment, and ignoring discrimination and microaggressions. Crucial problem-focused strategies were peer support, demonstrating competence, and addressing discriminatory incidents. Background aspects and previous experiences, including differing norms and habits from their Dutch peers, sometimes conflicted with the program's expectations for self-expression and reflective skills, influencing participants’ strategies to cope with challenges in Dutch GP-specialty training. Participants encountered difficulties with learning processes, such as peer-based learning, learning from role models, maintaining a work-life balance, and self-directed learning. Though beneficial in some situations, disengagement often exacerbated these struggles while engaging strategies proved more helpful. Although participants eventually mastered GP-specialty competencies and came to value some of the program’s learning methods, their journeys required notably more coping efforts to overcome additional barriers than those of their majority peers.

Comparison to existing literature

In line with Folkman and Lazarus’ categorization [60], we identified participants’ strategies as either emotion-focused [82, 83] or problem-focused [82], with one exception: the strategy of seeking and providing peer support, which incorporated elements of both. Consistent with the literature, participants reported that each coping category offered distinct advantages and disadvantages, shaped by their purpose, implementation, and context [64, 84]. Emotion-focused strategies reduce psychological burdens but risk distraction and long-term issues like vigilance for discrimination, impaired reflective thinking, and burnout [54, 59, 85, 86]. In contrast, problem-focused strategies enhance connectedness in professional and social spheres but risk alienation from personal identities if misaligned with the individual's natural tendencies [57, 64, 85, 87].

Studies have found that cumulative experiences of rejection and exclusion [88] lead individuals to develop coping strategies to counter stigma-based exclusion [85]. These strategies vary based on personal preferences, social contexts, and past experiences with discrimination [87]. In accordance with these findings, our participants who faced discrimination throughout their school years adopted coping strategies tailored to their personal styles and contexts. They noted that these strategies remained relevant during their GP-specialty training, where most of them encountered similar exclusionary experiences. Consistent with the literature, ongoing encounters with exclusion and microaggressions prompted them to adopt coping strategies for emotional relief and maintaining self-esteem [61].

While these strategies are vital for immediate protection in stressful environments, they can create tension between defensiveness and longer-term needs for engagement, relatedness and reflectiveness [61], required for learning and professional growth [89]. Consistent with this literature, our participants’ coping strategies often involved balancing the protection of their identities with the need to connect to their educational contexts. This balancing act risked conflicting with learning processes required in GP-specialty training, such as learning from feedback in faculty and clinic settings and engaging in reflective group sessions. Participants’ strategies ranged from being centered on distraction and compliance—such as building emotional shields, outward conformity, or finding solace in religion—to fostering connectedness through discussing expectations or sharing cross-cultural expertise. In some instances, participants courageously confronted microaggressions directly, risking polarization and potential repercussions, including setbacks in their academic progress.

Our findings should be viewed in the context of the broader literature on postgraduate clinical learning climates. Challenges such as hesitations to be candid with supervisors or difficulties navigating trainer–trainee relationships are documented among the broader population of medical trainees and linked to hierarchy, power dynamics, and concerns about psychological safety [90–92]. What distinguishes our study is that our participants explicitly reported feeling vulnerable in excluding learning environments, with supervisors often interpreting their coping strategies through the lens of their backgrounds, placing them at risk of stereotyping. Many of them connected these experiences to prior encounters with bias or microaggressions, intensifying the challenges they faced in GP-specialty training. These findings are in line with our previous studies which demonstrated that these trainees are notably more at risk of being assessed as underperforming compared to their peers from the majority group. This pattern could not be explained by motivation or starting qualifications [9, 32, 51]. Therefore, while some struggles may be common across trainees, this study’s findings underscore how feeling minoritized shapes the meaning and impact of these experiences, highlighting the importance of equity and inclusion in clinical learning environments. In Dutch GP-specialty training, trainees learn through observation, consultation, and reflection on feedback from supervisors and peers [49, 93]. Studies emphasize the necessity of safe environments and equitable assessments for trainees’ reflective learning processes, integral to the program´s educational principles [51, 94, 95]. Insensitive feedback can undermine receptiveness to feedback [59, 85, 87], hinder independent thinking [89, 96], and trigger detachment coping strategies that may lead to biased assessments [89, 96]. Consequently, several participants reported feeling misjudged, which hindered their openness to reflective learning. They expressed the need for a more secure environment to help them stay connected and engage fully in reflective processes. Additionally, they reported avoiding stigmatization by staying inconspicuous as a coping strategy, which created a vicious cycle that further impeded their ability to reflect on feedback and their personal roles, adding another layer of complexity to their learning experiences.

As outlined in Table 3 and consistent with the literature, participants found it challenging to fully engage in learning processes that relied on reflective processes, openness, and engagement, which required safe learning environments [62–68]. Despite experiencing these obstacles, most participants eventually embraced the core values of GP-specialty training. They learned to request transparency, discuss expectations, and balance opportunities that aligned with their identities with their learning needs as reflective practitioners.

Strengths and limitations

To our knowledge, this is the first study to explore ethnic minority GP trainees' coping strategies for navigating challenges within their educational environment related to balancing their self-determined background aspects and learning processes. We acknowledge that focusing on experiences of discrimination, microaggressions, and exclusion could risk oversimplifying participants' narratives since these experiences represent only one aspect of their broader, nuanced journey, as described in our previous study [32]. However, the present study specifically aimed to examine the coping strategies of minority trainees within learning environments known to be prone to exclusion or lacking openness to diversity. Within this context, our analysis also considered the multidimensionality of their experiences, including navigation of family responsibilities, professional expectations, and personal development. Thereby, it complements previous research on inclusiveness for ethnic minority medical students and trainees.

Due to COVID-19 restrictions, this study employed both in-person and online interviews. These different methods may have led to varying outcomes, as they offered different opportunities for genuine connection and non-verbal communication between participants and the interviewer. In-person interviews likely fostered a stronger sense of trust, potentially leading to more candid responses, whereas online interviews may have been affected by distractions, technical issues, or a sense of physical distance, which could have influenced the depth and authenticity of participants' responses. However, we also found that online interviews allowed participants to feel more comfortable in their familiar environments, leading to openness comparable to that of in-person interviews. To address potential outcome differences, we maintained consistency in our approach, creating an environment that encouraged openness in both settings and reflecting on the atmosphere after each interview to evaluate the quality of interactions.

Using Folkman's framework for coping styles in this study provided a structured approach to identify, categorize, and understand the coping strategies employed by ethnic minority GP trainees in balancing their identities with the challenges of their educational environment. It also allowed for an exploration of how these strategies influenced key learning processes, offering insights into the potential advantages and limitations of each. Folkman's distinction between emotion-focused and problem-focused coping facilitated a nuanced analysis of how participants managed stress and adversity—either by addressing emotional responses or by actively seeking solutions to their challenges. Furthermore, this framework offered a comparative lens, facilitating the alignment of our findings with existing literature on coping mechanisms. It promoted consistency in interpretation while maintaining our focus on the complexity of the trainees' experiences.

Despite the potential for resonance bias, the involvement of two ethnic minority researchers was instrumental in establishing trust and rapport with the participants. This approach yielded rich data on intricate, potentially sensitive interactions. Our open-ended, trainee-centered approach [97] elicited detailed responses, often accompanied by numerous examples, providing valuable insights into participants' coping strategies and their impact on the educational demands of GP-specialty training. To counteract resonance bias, we conducted reflective sessions to explore diverse perspectives on the researchers' roles in data collection and analysis. These sessions thoroughly examined of the influences of each other's experiences, expectations, and opinions.

While most postgraduate medical education settings share similarities, variations in context may limit the transferability of our findings. However, the challenges faced by ethnic minority trainees—such as integrating in-clinic and faculty learning, developing reflective skills, peer-based learning, and learning from feedback—may be comparable across settings. To address transferability, we accurately detailed our context and ensured diversity in age, gender, educational stages, training institutes, progress, and represented regions, including urban and rural areas. Nonetheless, respondents may have had specific interests in diversity and inclusion or experiences with discrimination, which may not fully represent the broader minority GP trainee population.

Implications for future research and practice

Future research should focus on developing and testing interventions that foster inclusive learning in postgraduate medical education, including GP-specialty training. These interventions should create environments where trainees feel safe sharing and reflecting on their unique perspectives without resorting to adverse coping strategies.

Research on inclusive learning must first acknowledge the complexities within educational settings [47–49]. Studies should engage all stakeholders to address these challenges effectively, ensuring broad support to implement and evaluate their findings. The content of this research should prioritize reducing bias, exclusion, stigmatization, and microaggressions at all organizational levels while promoting identifiable role models [63, 98]. By doing so, these studies would strengthen connections among peers, supervisors, and teachers and empower trainees to take active roles in their development.

Moreover, research should explore reflectiveness as a learning tool rather than an ultimate goal. Particularly in GP-specialty training, this shift in perspective is crucial for identifying alternative learning tools that could benefit all trainees, specifically those from minority groups.

To achieve these goals, employing mixed methods—including quantitative studies to assess the impact of participant-reported factors, participatory action research on inclusive interventions, and qualitative evaluations—would support developing and continuously adjusting inclusive strategies within organizations.

Educational practices in many contemporary medical training programs are predominantly grounded in Western learning paradigms. These paradigms often emphasize individual achievement, standardized assessment, and a hierarchical structure in the teacher-learner relationship [99, 100]. While such approaches have been effective in certain contexts, they may not fully accommodate the diverse cultural backgrounds and learning styles of all trainees [100]. Several studies have critiqued the Eurocentric knowledge system's dominance in medical education for marginalizing alternative perspectives, reinforcing systemic inequities [100, 101]. Therefore, a more inclusive approach that recognizes and values the diverse experiences and contributions of all learners is required. Postgraduate medical training programs, including GP-specialty programs, should focus on reducing barriers to equity by encouraging open dialogue between trainees and supervisors about their experiences and coping strategies during challenging learning processes. Cultural competence training, inclusive assessment designs for reflective skills, tailored mentorship, and visible role models can help facilitate these conversations.

Conclusion

Participants frequently encountered prejudice and biased judgments within a predominantly white system that consciously or unconsciously favors the majority. As a result, they were not only a numeric minority but also at risk of being institutionally minoritized [102]. These experiences prompted the use of coping strategies, which provided temporary emotional relief but also risked diminishing trainees' connectedness and reflective thinking—both crucial for success in GP-specialty training. This disconnect ultimately hindered their professional development during training, which relies on engaging in those learning activities grounded in connectedness and mutual trust, reflecting on feedback, learning from failure, openness to peers and role models, and self-directed learning through identification of knowledge and skill gaps (Table 3).

Future research should explore interventions that promote genuine inclusiveness in GP-specialty educational settings, reducing the need for ethnic minority trainees to rely on potentially maladaptive coping strategies. Supervisor training in cultural competence, open dialogue, and tailored mentorship can foster such an equitable learning environment.

Authors’ contributions

All authors have substantially contributed to this work. Each author participated in drafting the manuscript and/or critically revising it for intellectual content. Furthermore, all authors have reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work, ensuring its accuracy and integrity. NvM developed the design of this study, led data collection and analysis, and wrote the manuscript; MN contributed to the data collection, analysis, and manuscript review; AJ contributed to the data collection, analysis, and manuscript review; JvE contributed to the manuscript review; JB contributed to the manuscript review; MvdM supervised the entire process of development, data collection, analysis and manuscript preparation; MV supervised the entire process of development, data collection, analysis and manuscript preparation.

Funding

The authors have no external funding to report.

Data availability

The datasets generated and analyzed during the current study are not publicly available for individual privacy reasons but are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

In accordance with the Declaration of Helsinki, participation in the study was voluntary, with informed consent for participation obtained from all participants.

The Dutch Association for Medical Training's Ethical Review Board (NVMO ERB) approved the study (file number 2018.7.14). Data handling followed the General Data Protection Regulation (GDPR) and Amsterdam UMC Clinical Research Unit procedures and we shared the study results with all participants.

Consent for publication

By the Declaration of Helsinki, all participants in this study provided informed consent for publication prior to their involvement. Participants were fully briefed on the purpose and scope of the study, including how their data and contributions would be used in published materials. Confidentiality was ensured, and identifying information was excluded. Participants were allowed to review and approve any directly attributed statements or identifiable content before publication. Furthermore, participants were informed of their right to withdraw consent for publication at any stage before the finalization of materials for public release.

Competing interests

The authors declare no competing interests.