When Professional and Educational Feedback Turns into a Cycle of Violence: A Qualitative Study of Educational and Punitive Interactions During Medical Residency

When Professional and Educational Feedback Turns into a Cycle of Violence: A Qualitative Study of Educational and Punitive Interactions During Medical Residency | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article When Professional and Educational Feedback Turns into a Cycle of Violence: A Qualitative Study of Educational and Punitive Interactions During Medical Residency Leila Azizi, Mahboobeh Saber This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8417993/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Medical residents’ education and learning are inherently situated within hierarchical clinical environments shaped by power relations. Professional feedback is a central component of clinical education and plays a critical role in residents’ professional and clinical development. However, evidence shows that feedback is often influenced by power imbalances and, rather than serving a formative and educational role, may become punitive, non-constructive, or even violent. Given frequent reports of burnout, bullying, harassment, and adverse psychological outcomes among medical residents in Iran, a qualitative examination of residents’ lived experiences of feedback, punishment, and violence in clinical education is warranted. Method This qualitative study used conventional qualitative content analysis based on the Graneheim and Lundman approach. Participants were 8 medical residents (currently in training or graduated within the past 3 years) from diverse medical specialties and educational centers across Iran who had experienced feedback and punishment during residency. Data were collected through in-depth semi-structured interviews conducted between January and March 2024 and analyzed inductively. Peer debriefing enhanced the credibility of the findings. Results The analysis yielded 4 main categories, 9 subcategories, and 20 initial codes. Participants described professional feedback as a continuum ranging from “supportive and corrective feedback” to “punishment” and ultimately “violence.” Feedback delivered with respect, clarity, and an explicit educational purpose supported learning, error correction, and professional development. In contrast, feedback provided in humiliating, nontransparent, or rigidly hierarchical contexts often lost its educational value. Punishment—particularly informal practices such as assigning extra on-call shifts—was perceived as a gray zone between feedback and violence. Participants reported multiple forms of violence, including soft and hard, as well as structural and institutional violence. The normalization and repetition of violent behaviors, hierarchical organizational structures, conflicts of interest, and gaps in legal protections facilitated the transformation of feedback into a harmful experience. Conclusion The findings reveal a violence-based pedagogy embedded in medical residency education, linking learning to fear, humiliation, and compliance. Creating a more humane and ethical training environment requires revising disciplinary policies, strengthening supportive and legal frameworks, and equipping clinical educators with skills in power awareness, participatory power, effective communication, and care-cantered ethics. Medical Residents Feedback Punishment Medical Education Clinical Environment Medical Hierarchy Violence Pedagogy of Violence Power Imbalance Background Education and learning of medical residents in clinical departments constitute one of the fundamental processes in medical education [ 1 , 2 ]. During their training period, residents are required to acquire clinical competencies and communication skills appropriate to their specialty. Residents’ learning occurs through work-based learning, case-based learning, problem solving, and hands-on experience, and feedback plays a crucial role in raising awareness about the quality of the learning experience and identifying areas that require improvement. The quality of feedback itself is therefore of considerable importance [ 3 , 4 ]. Competency based medical education proposes a structured framework for feedback that includes a clearly defined learning pathway, repeated workplace-based observation, meaningful feedback, sufficient time and opportunities for the development of new skills, and assessment [ 5 ]. Some residents prefer feedback primarily for confirmation of good performance and tend to avoid feedback that contains criticism [ 6 ]. Discrepancies between faculty members’ and residents’ perceptions of the observed event also represent an important factor influencing the meaningfulness of feedback [ 7 ]. In other words, the feedback process should enable both parties to move toward a shared and interactive understanding. Accordingly, clinical residents should actively participate in discussion, review, and reflection on feedback so that they perceive it as credible and can use it effectively to advance their learning [ 8 , 9 ]. Medical practice and the education of medical residents are inherently contingent upon a clinical environment that is highly interactive and hierarchical [ 10 ]. Research in medical education has demonstrated in various ways that power, as embedded within organizational structures, is closely intertwined with processes of learning and assessment. This hierarchical structure influences feedback exchanges, moral agency, error disclosure, and help-seeking behaviors, and often constrains openness and honesty [ 11 ]. Understanding and adhering to these implicit rules are described by medical students and residents as a crucial means of demonstrating professionalism and fostering successful relationships with peers and supervisors [11, 12 ]. While such structures are necessary to ensure clinical accountability, they may also give rise to unequal and potentially harmful relationships. In light of these factors, feedback may not solely reflect the educational function of interactions but may also represent an expression of the cumulative effects of power relations within the clinical environment [11 , 13 ]. Evidence indicates that violence experienced by medical residents has been perpetrated by a range of individuals, including attending physicians, senior residents, clinical faculty members, nurses, and patients. The forms of violence reported by residents include overwork, isolation, withholding of information that affects performance, assignment of tasks below an individual’s level of professional competence, excessive monitoring, and criticism [ 14 ]. Some of the behaviors identified as experiences of violence occur specifically within educational interactions, suggesting that a substantial portion of the violence experienced by residents arises during training-related encounters. In clinical settings such as operating rooms and hospital wards, where feedback functions as a core component of formative assessment, it may occupy a precarious position, at times bordering on violence and bullying. The phenomenon of violence experienced by medical residents in Iran represents a significant and concerning issue. More than 90% of residents have either directly experienced violence or witnessed violence directed toward their colleagues [ 15 ]. Furthermore, the quality of residents’ professional life declines in association with experiences of bullying, an effect that is further exacerbated by longer weekly working hours [ 16 ]. Despite its importance, only a limited number of studies have examined the phenomenon of violence experienced by medical residents in Iran. Given the substantial prevalence of depression and burnout, as well as the rising trend of suicide among residents in recent years, focused attention to the issue of violence experienced by medical residents is both necessary and urgent. The increasing prevalence and evolving nature of various forms of violence within the structures of clinical practice necessitate a systematic examination of this phenomenon and its less visible dimensions. Accordingly, we adopted a qualitative approach to explore and interpret medical residents’ experiences, perceptions, and narratives related to educational interactions, professional feedback, and incidents of violence. This approach enabled the elucidation of the complexity of the phenomenon and facilitated an in-depth examination of its less frequently recognized aspects, including inter-resident relationships and interactions with faculty members. The present study aims to identify the types and contextual conditions of academic violence occurring in the course of feedback to medical residents, with the intention of generating evidence that may inform policy change, contribute to the improvement of educational culture, and enhance learning conditions within clinical environments. Methodology Study Design The authors selected a qualitative study using a qualitative content analysis approach as described by Graneheim and Lundman. The analysis was conducted inductively (data-driven) , moving from the text toward higher-order understandings while attending to both manifest content (what is explicitly said) and latent content (the underlying meanings or “red thread”). This analysis was conducted within an interpretivist/hermeneutic stance that attends to how sociocultural context and structural conditions shape participants’ experiences [ 17 ]. Study Participants Medical residents from multiple disciplines who had experienced educational feedback and/or punishment during hospital training were recruited using purposive sampling. Participation was voluntary and included residents who were either currently in training or had graduated within the past three years. Participants represented various disciplines and hospitals across Iran, including cardiology, obstetrics and gynecology, neurology, psychiatry, pediatrics, internal medicine, and orthopaedics (Table 1. .(Although residents from orthopaedic and other surgical specialties were invited, none agreed to participate; however, participants’ accounts included observations related to surgical fields, particularly orthopaedics, which are reflected in the results. The sample comprised both male and female participants, with a mean age of 30 years. Table 1. Demographic features of participants Characteristics NO Gender Female Male 6 2 Level of Training Senior Residents Post Graduated (Less than 3 years) 3 5 Disciplines Cardiology OB/GYN Internal Medicine Neurology Paediatrics Psychiatry Orthopaedics Surgery (Second hand narratives) 2 1 1 1 1 1 1 Data Collection Data were collected through semi-structured interviews conducted between January and March 2024. Potential participants were invited through verbal, telephone, or social media contact, and additional participants were recruited using snowball sampling via colleagues or peers. Volunteer medical residents were informed about the study objectives, the use of anonymized quotations, and confidentiality procedures prior to participation. All interviews were conducted by LA, lasted 60–90 minutes, and were preceded by written informed consent. A semi-structured interview guide with open-ended questions was used. Interviews began with the question, “During your residency, how do/did you usually receive feedback from your professors or senior residents?” and subsequently explored participants’ experiences of punishment. Participants were encouraged to describe their experiences and associated feelings in depth. The semi-structured interview guide was specifically developed for the purposes of this study and had not been used or published in any previous research. It is provided as Supplementary File 1. Due to the lack of participation from surgical residents across most specialties—with the exception of obstetrics and gynecology and the availability of repeated secondary narratives from orthopaedics—the scope of qualitative data in this study was inherently limited. The observed thematic repetition reflects saturation within a narrowly defined and indirect data source rather than saturation across the intended population of surgical residents. Consequently, the findings should be interpreted as context-specific and exploratory, and the restricted participation is acknowledged as a significant limitation of the study. Data analysis The interview transcripts were carefully and repeatedly read to grasp the depth and nuances of participants’ experiences. Through this attentive process, meaningful parts of the text were identified, condensed, and given codes that reflected their essence. Similar ideas were brought together into sub-categories and broader categories, which were then interpreted to uncover deeper, underlying categories. Throughout the analysis, we sought to stay true to participants’ voices while maintaining a coherent and balanced relationship between description and interpretation. MAXQDA 2020 software was used to assist with coding and data management. Ethical Considerations The study received full ethical approval from the Shiraz University of Medical Sciences (SUMS) ethics committee (IR.SUMS.MED.REC.1403.040). All participants provided written informed consent. Talking about the punishment experience is not easy at all, so they were informed that they are free to withdraw at any time. They also consented to the interviews being recorded and then transcribed anonymously for analysis. In addition to sustained engagement with participants, this qualitative study employed two common validation techniques to enhance credibility: member checking (to confirm the findings with the interviewees) and peer debriefing (with qualitative research specialists and a research colleague) [ 18 ]. Results Content analysis of interviews with residents The content analysis of interviews with residents revealed that the experience of punishment during medical training is often not only devoid of corrective or pedagogical value, but in many cases constitutes a form of overt or covert violence. The findings were categorized into four primary categories (themes), nine subcategories, and 20 initial codes (Table 2.). Table 2. Typology of Feedback, Punishments and Violence in Medical Education Main Category Subcategory Codes Professional Feedback Corrective feedback Emphasis on correcting educational or clinical performance Continuous feedback across hierarchical levels Supportive feedback Feedback aimed at facilitating shared learning Dialogic reflection and post-event discussions focused on identifying errors or gaps Punishments Framed as Feedback Informal and situational punishment Additional on-call duty exclusion from educational groups or activities Structural and formal punishment Restriction of access to educational opportunities temporary suspension from academic progression and overwork Violence as Punishment Interpersonal (soft and hard) violence Verbal and psychological abuse Stigmatization and Psychiatric labels Sexual and gender-based violence Physical violence Structural and institutional violence Expectation of omnipotence Staffing and welfare shortages as punitive pressure Transformation of Feedback into Violence Normalization of violence Reproduction of the cycle of interpersonal violence among senior and peer residents Persistence of structural violence Hierarchies of power in medical training Conflicts of interest within hierarchy Instruments of power and inclination toward violent behaviour Legal and regulatory gaps - Lack of transparent, contextualized regulations for addressing errors - Absence of legal protections for residents Professional feedback Professional feedback was divided into two subcategories: corrective feedback and supportive feedback. Corrective feedback primarily emphasized rectifying an error or a deficiency in a resident’s performance. Corrective feedback Based on participants’ accounts, corrective feedback emerged as an important educational practice during residency and was embedded in residents’ everyday clinical work. Participants described receiving corrective feedback from senior residents or attending physicians, typically in response to specific errors or situational demands. According to their experiences, such feedback was delivered either individually or in group settings involving multiple team members, including the resident concerned. One participant who had experience as a chief resident described: “I think we more or less observe stepwise feedback within our group. For this reason, I, as chief resident [and intermediary between residents and attendings], both gave feedback to residents and at the same time listened to them.” A psychiatry resident recounted a positive experience: “One night, I was on call and admitted a patient with a history of seizures. I forgot to place a protection order for the patient, and I failed to order one dose of his medication. The patient seized, fell from the bed to the floor, and even sustained a head injury. The way they treated me there was very humane. They said, ‘Let’s talk about this case. What happened? Do you not know these drugs or how to manage seizures, or is there another problem?’ Based on my experience, psychiatric wards generally confront residents more humanely.” Supportive feedback Some residents experienced corrective feedback that was delivered within a supportive, educational framework. In such cases, attendings and senior clinicians attempt to correct residents’ errors in the clinical setting while simultaneously teaching them. These interactions are often pedagogically motivated and conducted in a supportive environment; efforts are made to identify and address not only the resident’s role but also other contributing factors to the error. Dialogic reflection and post-event discussions focused on identifying errors or gaps A participant with chief resident experience in Internal Medicine stated: “Sometimes, when serious scientific errors occur, our group convenes a meeting with the department head, the attending, the chief resident, and the resident who made the error to review the issue. The committee may conclude that the resident lacked knowledge of that subject or, conversely, that the resident knew the material and tried their best, but other factors caused the error. These meetings are very good and genuinely helpful. If a resident has been negligent, they receive extra on-call duty, and in other cases, the problem is resolved through other means.” Punishments Framed as Feedback Some residents perceived punishment—more severe than feedback—as a form of corrective feedback, whereas others experienced such punishment as unsympathetic, unfair, or unrelated to the error or the event that had occurred. Consequently, punishment occupies a position on a spectrum: it may be experienced as corrective or may be experienced as violent. Informal and situational punishment According to the study findings, punishments are not always communicated formally to residents; rather, informal punitive practices exist based on customary, unwritten rules within training groups. One of the most common punishments is additional on-call duty. Notably, training groups use extra on-call shifts as a punitive measure for a wide range of perceived infractions—from arriving late to academic conferences to committing a medical error. Additional on-call duty One participant who had recently completed residency and become an attending clinical physician reported: “Once I was supposed to present the morning report and I arrived late, so they gave me additional on-call duty. This was despite the fact that I had been on call the night before and had slept only one hour; I arrived at 8:10 rather than 8:00. Because the attending arrived before me, they assigned me extra on-call duty. In my view, extra on-call duty is a polite punishment. There is no insult; they simply tell you to repeat the task you failed to perform. When the chief resident told me I had to take extra on-call, I laughed. I myself use extra on-call as a sanction for residents. Being told that you made a certain error and therefore must do extra on-call is not insulting.” Another participant who had also been assigned extra on-call duty considered the transparency of that punishment to be an advantage: “In the defective system we have [where procedures for feedback and punishment are not clearly defined], one prefers a specific punishment such as extra on-call duty so that one’s obligations are clear.” exclusion from educational groups or activities Exclusion from the training group—whether temporary or prolonged—is another unwritten punitive measure that we classified as a form of soft violence based on our data. Exclusion may arise due to an error, a disagreement, or resistance to coercion, which constitutes a severe punishment. “ If you are a resident who does not blindly comply and sometimes chooses to ask questions or speak up instead, you are quickly pushed to the margins by senior residents. Sometimes this shows up as being ignored or treated with indifference; other times, it means being cut off from educational resources and learning opportunities, with little guidance offered to Structural and formal punishment Temporary deprivation of academic promotion and overwork According to our findings, this form of punishment is applied pursuant to some national regulations when a resident’s examination scores do not meet the required threshold. “In the orthopaedics department, every year on the night of the promotion exam, two residents with the lowest departmental scores are prevented from sitting the exam; instead, they are assigned to cover on-call duty so that the other residents can have the night off and then take the promotion exam the following morning. This routine has become institutionalized. In contrast, in other specialties, fellowship trainees and attending physicians cover departmental duties on the night before the promotion exam, allowing all residents to prepare adequately for the examination.” Violence as punishment A substantial portion of the residents’ narratives described punitive acts that lacked educational or corrective value and instead represented personal or systemic violence. Therefore, these experiences transcend the category of ‘punishment’ and are regarded as forms of violence. The study revealed that residents experienced two levels of violence during training: (1) soft and hard interpersonal violence, and (2) structural and institutional violence. Soft and hard interpersonal violence The defining characteristic of soft and hard interpersonal violence, in contrast to structural and institutional violence, is that they occur interpersonally. As some residents mentioned, soft violence (e.g., verbal, psychological abuse, and stigmatization) is less readily identifiable and provable than more overt forms, yet it leaves profound and persistent psychological effects on residents. By contrast, hard violence includes physical and sexual/gender-based violence, whose harms and consequences are more observable. Verbal and psychological violence In this study, verbal violence in the form of sarcasm, irony, and cold speech was classified as soft violence, while verbal abuse that included insults and profanity was categorized as hard violence. One female resident recounted a severe verbal incident in which she was not directly involved but experienced guilt: “Once, when I was a second-year resident, during rounds in the emergency department I realized that a first-year resident had started an antiemetic for a patient in the last weeks of pregnancy. This error was unacceptable for a resident who had been working in the women’s emergency for four months. I told a third-year resident to teach this first-year resident; perhaps she was unaware of the point. The third-year resident immediately picked up the phone and verbally abused the first-year resident! That first-year resident resigned one month later, and I still feel guilty about that.” Another resident reported: “ At a morning report session, an attending asked me whether the patient also had Pitting Edema. When I answered that I had not checked this, he began, in front of 400 people, to swear at me: ‘What are you calves doing? How do you expect to be a doctor tomorrow?’ No one dared respond.” Stigmatization and psychiatric labelling Some second- and third-year residents noted that in the first year they did not fully recognize stigmatization as a form of violence. They accepted those labels for a long period and needed time to perceive the violent nature of such behaviours. “In psychiatry, hidden violence is more common. For example, you are subjected to ‘analysis’ [psychological analysis]. They may speak to you as if you are an abnormal person. They do not assign you extra on-call, but they do things that internally make you feel very bad. Once, I said I had forgotten to go to the ECT ward. They did not give me extra on-call; instead, they said that it seems you have a personality that constantly forgets things. One of the violences in psychiatry is the expectation that you be perfectly normal, standard, and well-adjusted.” A neurology resident, who had witnessed a senior resident’s behaviour in response to a scientific error, stated: “I have seen a senior resident tell a junior resident, ‘You are stupid, you understand nothing, you are confused.’ I have seen how these words destroy the other person.” Sexual and gender-based violence Sexual and gender-based violence emerged as one of the most explicit and frequently reported forms of violence among female residents in this study. One female resident recounted event from the final months of her training: “My spouse and I sometimes worked shifts together. The senior resident, who was male, turned my former husband off at midnight when there were no patients in the emergency department but told me I had to stay. My husband suggested he would stay and relieve me, but the senior resident refused because he had other intentions. My husband said then we would both stay and neither of us would go to the dormitory to rest.” A resident said about the orthopaedics field: “A woman chose orthopaedics in recent years and was, naturally, the only female resident in that specialty. All the male residents of that year united to harass and pressure her so much that she was forced to resign.” Physical violence Residents’ experiences of physical violence varied across departments. According to the study, the highest rates of physical violence were reported in surgical and orthopedic groups, where there seems to be little attempt to conceal violent behaviour; indeed, greater openness and severity of violence are sometimes regarded as a badge of identity in those groups. One resident described observations in the orthopaedics specialty: “Orthopaedics and surgery are notorious for their highly aggressive environments and have a high annual resignation rate. These departments are intensely hierarchical and patriarchal. We encounter overt and visible harsh violence. For example, a third-year resident once broke a first-year resident’s leg with a kick because the junior had brought the radiographs to the operating room two minutes late. When that first-year resident went to the department head, they were told, ‘Don’t come to me until you have been sexually assaulted!’” Structural and institutional violence Structural and institutional violence in medical education occurs when systems and regulations function in ways that, rather than supporting residents, create conditions for pressure, exclusion, or deprivation. Two subcategories were identified. Expectation of omnipotence The expectation that residents must be omnipotent is sometimes institutionalized and functions as structural, systemic violence. This expectation extends beyond mastery of diagnosis and treatment and the flawless recall of inpatients’ signs and tests; it targets even fundamental human needs such as eating, sleeping, and toileting, which are deemed impermissible except in exceptional emergency circumstances. This norm is imposed as an immutable principle of daily practice and can render a resident punishable even when no medical error has occurred. Some residents internalize and accept this expectation. A resident recounted a first-month experience: “In the first month of residency I had to perform an LP on a patient. Despite repeated attempts I could not succeed. The patient’s companion stood at the bedside watching me. I called a senior resident to assist; on the first try he succeeded. Afterwards he did not even stop to collect the CSF and angrily threw off his gloves, saying, ‘When will you learn?’ That day I thought I was very stupid—I had injured the patient—and the companion complained about me to hospital administration.” Another resident, describing emergency paediatrics’ on-call experiences, said: “Sometimes there were 300–400 patients overnight and we had to present all of them at morning report the next day. Several problems arise: you cannot retain all the information on every patient; you cannot take a complete history or perform a full examination on everyone; and, most importantly, you are extremely exhausted. I was running the entire on-call. Medicine expects omnipotence of one person, and in my view this is the greatest violence; it creates enormous anxiety and stress.” A further account regarding suppression of basic needs: “During my residency I went to the restroom and one of the attendings called me. I heard the phone ring while inside the restroom and immediately called the attending back after returning. Although only five minutes had passed, the attending asked why I had not answered the phone. What could I do in that situation? The implied solution was to always carry my mobile phone—even into the restroom!” Staffing and welfare shortages used as punitive pressure Although hospitals provide welfare facilities for residents, in this study it was found that these amenities are sometimes employed as mechanisms of control and violence. An orthopedics resident reported: “For first-year orthopedics residents, especially during the first two weeks, no dedicated residents’ rest room is provided in the hospital. If a room exists at all, it may be locked by the chief resident so that no one can use it. If a first-year resident is exhausted and wishes to use the senior residents’ rest room for a few minutes, they may be punished.” Transformation of Feedback into Violence The findings indicate that, although professional feedback is theoretically a tool for learning and correction, in practice it can transform into a form of violence. In such an environment, feedback that ought to be constructive is delivered in a directive, humiliating, or threatening tone such that the corrective and educational content is obscured by the speaker’s harsh tone or positional power. What appears superficially as professional feedback often becomes a distressing and undermining experience for the recipient, one that is not educational and that perpetuates structural patterns of violence within training environments. Identifying legal and regulatory gaps clarifies how this cycle of violence and the reproduction of power persists. Normalization of violence Residents who have been repeatedly exposed to violent environments have, despite the harm they experienced, come to accept such violence as a norm. One resident who had recently become a clinical attending stated: “Until now, I had always thought that since we ourselves went through these hardships during our first and second years of residency, others should be able to go through them as well. I had never seriously considered the need for fundamental reform of the system, because I believed that the system could not be easily changed—only slightly, at best.” Reproduction of the cycle of interpersonal violence among senior and peer residents Residents who were subjected to various forms of violence during the early years of their training sometimes reproduce these same behavioral patterns later on, either as senior residents or even during their own junior years, often motivated by different reasons. “In interactions with senior residents, the more work you do, the lighter their workload becomes. This dynamic leads to frequent and repeated punishment under various pretexts from senior residents.” “If a third-year resident makes a mistake, the chief resident usually refrains from reprimanding them because they are at the same educational level. In contrast, the same chief resident may, in a similar situation, reprimand a first-year resident twice as harshly.” The findings indicated that the heavy responsibilities and workload pressures inherent in residency training often erode empathy, leading individuals to focus solely on self-preservation—even among peers who share similar conditions and collective interests: “A second-year resident (a year that is not particularly demanding) had a broken leg in a cast. He requested medical leave, which was his right. However, his peers opposed it, arguing that if he went on leave, their own workload would increase.” Persistence of structural violence Residents’ experiences revealed that violence is deeply embedded in institutional policies and systemic structures, perpetuating harm, burnout, and even exploitation. One resident described their experience with emergency shifts: “During a sixty-day period, I worked forty-eight emergency shifts. I didn’t see sunlight, and I could no longer tell when it was day or night. What kind of working condition is that? What is left of a person afterward?” Another resident recounted: “One of the chief residents believed that first-year residents are not really human. For a first-year resident, simply staying alive is enough—they should not have any expectations at all. After completing the first year, we are no longer the same people we were before. And no one in this system cares what happens to us; the entire system has accepted this reality.” Hierarchies of power in medical training The vertical and hierarchical structure of medicine was identified as an important facilitator of the transformation of feedback into violence. This hierarchy not only limits an open and egalitarian learning environment but also fosters conditions for soft and hard violences to be exercised without oversight or accountability. “My spouse was an orthopedics resident. In the first year of residency, if his mobile phone rang and the caller was not a second- or third-year resident, he would be assigned extra on-call duty! Even if he was speaking with a second-year resident and a third-year resident joined the line, he had to immediately end the call and respond to the third-year resident. In orthopedics, Leveling is terrifying.” Conflicts of interest within the hierarchy Conflict of interest was identified as a major antecedent of violent behavior. In Iran’s healthcare system, because of economic pressures and dual practice by clinical faculty in both public/university and private sectors, many problems arise. Two illustrative remarks: “Many attendings are absent, attending only the weekly morning report and then leaving for their private clinics. They do the minimum work possible and engage minimally in emotional connections and problem-solving.” “There is an unwritten rule that ‘the senior is always right.’ Attendings wish to maintain a military-like order. They fear that if they do not side with the senior resident, the department’s order will collapse. They want minimal engagement and thus strive to preserve this military governance.” Instruments of power and inclination toward violent behaviour Residents described violence as something the system generates: the structure is arranged such that individuals progressively incline toward violent conduct. “Much of the violence is exerted by senior residents toward juniors. You are not punished by the primary source of authority, but you are repeatedly exposed to violence that, in psychoanalytic terms, is called Sibling violence: senior brothers and sisters gradually become the instruments of the institution’s power.” “The physician’s role is expected to embody omniscience and omnipotence, which gradually elevates one’s position to near-divine status, promoting fallibility denial and the imposition of power over others.” Legal and regulatory gaps Lack of transparent, contextualized regulations for addressing errors Although regulatory frameworks exist in Iran’s educational and therapeutic system describing how to confront professional incompetence in residents, our findings show these regulations are insufficient: they are neither widely known nor, given the system’s disordered and hierarchical structure, endowed with sufficient executive power. A senior resident remarked: “I had junior residents who were entirely irresponsible and there was no mechanism to follow up on my concerns. I tried everything but could not make them understand that patients are not movable money and that you are responsible for them. I was not one to pick fights with juniors, but there really was no mechanism for follow-up.” A female resident said: “There is no routine or order. When a resident repeatedly commits faults, no one asks why. Instead, rumours and gossip start: ‘she is dumb,’ ‘irresponsible,’ ‘a scoundrel who wants to slack off.’ The issue must be clarified, and there should be a proper procedure to investigate problems.” Absence of legal protections for residents Residents repeatedly expressed a sense of helplessness due to the lack of protective regulations. “When people visit their family physician, they immediately receive a message asking whether they were satisfied with the services. During residency, there should be monitoring of residents’ conditions so that residents can provide feedback and the system can ensure that residents’ rights are respected.” “Humans have impulses toward dominance, aggression, and competition; a system that controls these impulses needs a third party between you and me—something beyond the individual that we both commit to, such as the law. I repeatedly encountered this gap in medicine. There was no authority to whom I could appeal and ask whether what I experienced was punishment or violence, and whether I truly deserved punishment.” Discussion In this study, we initially aimed to explore the processes of giving feedback and experiencing punishment within educational and professional environments. However, the trajectory of our inquiry unexpectedly led us to the concept of violence. It became evident that violence, in its very nature, is fundamentally distinct from punishment—not only in terms of its intensity and impact, but also in its lack of corrective or educational intent. From the standpoint of medical ethics, this distinction is profoundly significant, as violence functions neither as a pedagogical tool nor as a means of growth. Rather, it constitutes an experience that undermines human dignity, erodes the sense of security, and weakens trust within interpersonal and professional relationships. In environments where violence prevails, respect for others—one of the core principles of ethics in both medicine and education—is replaced by fear and passivity. This, in turn, reflects a departure from the moral and human values that ought to govern such settings. The findings of this study indicate that the violence is reproduced within a context characterized by the normalization of violence, hierarchical relations, and legal and regulatory voids. A review of prior research shows that most studies have avoided the term violence to describe residents’ experiences, instead employing terms such as Bullying , Mistreatment , Harassment , Discrimination , and Intimidation [14, 19 , 20 ]. Averbuch T et al. conducted a systematic review of 68 studies published between 1999 and 2021 and reported that the most prevalent bullying behaviors included excessive workload, followed by humiliation, isolation, and professional undermining. Among 34,982 resident participants, only 28.9% reported being bullied, and 57.2% of these individuals believed that reporting the incident yielded no positive outcome. The authors identified Normalization of bullying as one of the Facilitators of bullying behaviors, mentioned in ten studies [14]. Similarly, in the systematic review by Leisy and Ahmad, the main perpetrators of mistreatment were colleagues or physicians occupying higher hierarchical positions, reported at 69.8% in the United States and up to 90% in some Asian–African countries [ 21 ]. In the study by Torabi et al. (2022) conducted in Iran, 95% of residents reported experiencing bullying—60% by faculty members and supervisors and 73% by senior residents [15]. Vanstone and a colleague, in their paper on medical education and social power, argue that social power in medicine shapes both behavior and knowledge, functioning as a potentially constructive or destructive force. They identify social power and medical hierarchy as the central mechanisms of their analysis and categorize power in medicine into three dimensions: Interactional , Structural , and Symbolic . A major distinction between their work and the present study lies in the focus: while they emphasize the impact of social power on residents’ learning experiences, our study centers on the lived experience of punishment and violence. They contend that medical education research should explicitly integrate social power into analytical and interpretive models rather than treating it as a peripheral element—since, as they note (and we add, this is also true in medical ethics), researchers often fail to conceptualize power as a Mediation Mechanism . [11] The classification and typology of various forms of violence undoubtedly play a crucial role in achieving a more precise understanding of this social phenomenon and enable its systematic and scientific analysis. However, mere attention to the manifestations and categorizations of violence is insufficient; it is essential to move beyond such classifications and examine the underlying causes and contextual factors that give rise to different levels and intensities of violence. A deeper understanding of the origins and persistence of violent behavior can provide more profound insights into its nature and pave the way for the development of effective strategies aimed at its prevention and reduction. Our findings, analyzed within Rita Segato’s theoretical framework of the Pedagogy of Violence and Counter-Pedagogy of Violence , reveal that medical education in Iran— probably similar to other hierarchical systems in all over the world—reproduces mechanisms of domination, fear, and unconditional obedience, perpetuated in the absence of effective oversight systems. Segato conceptualizes the Pedagogy of Violence as a process in which social learning—in this case, medical residency training—occurs through humiliation, repression, and exclusion. From childhood onward -in this case, beginning of clinical education for medical students-, individuals are taught to perceive domination as natural, violence as legitimate, and subordination as an intrinsic part of social order [ 22 ]. In educational sciences, pedagogy refers to the totality of methods, institutions, and systems through which societies transmit behaviors, values, and emotions. Segato deliberately uses the term pedagogy beyond its conventional academic meaning to emphasize that we are dealing with a much broader educational system that routinely endorses and reproduces violence. Hence, violence is not an isolated event caused by individuals; it is a systemic phenomenon that is learned and perpetuated [ 23 ]. Within the context of residency education, this manifests in non-corrective and humiliating feedback, unwritten punitive practices, structural silence, and the neglect of residents’ psychological harm. The data from this study demonstrate that excessive on-call duties, exclusion from educational groups, stigmatization, verbal, psychological and sexual harassment—all represent expressions of this Pedagogy of Violence that fuses learning with submission. De Vito similarly reports that among medical residents in Latin America, hierarchical power structures and a culture that glorifies overwork and absolute obedience produce a form of symbolic violence (in Bourdieu’s terms)—an internalized, invisible, and self-reinforcing phenomenon [21]. The present study corroborates this trend: residents internalize violence, interpret it as part of “good training” or “rigorous discipline,” and later reproduce the same patterns toward junior residents. This vertical reproduction of violence constitutes what Segato calls the social cycle of violence , wherein yesterday’s victim becomes today’s perpetrator. Rada-Estarita et al. through a qualitative study among surgical faculty, found that dominant narratives of the “good surgeon,” “self-sacrificing physician,” and “committed doctor” serve as tools for normalizing exhaustion, silence, and exclusion of residents—forming part of a departmental culture that asserts: “if you cannot devote yourself completely, you do not belong here.” Our findings reflect the same logic, portraying the ideal resident as “omniscient, ever-present, and immune to basic human needs such as sleep or rest.” This expectation engenders a Sacrificial Ethics in which the “good resident” is one who endures suffering without complaint. Segato terms this the Pedagogy of Cruelty (as a pedagogy of obedience to violence) [ 24 ]. From a medical ethics perspective, this condition has dual consequences: on one hand, it leads to moral desensitization and the erosion of empathy; on the other, it distances clinical education from its primary purpose—the cultivation of morally conscious physicians. As Hafferty argues in his analysis of the “hidden curriculum” in medical education, the true values of an educational system are conveyed not through official curricula but through unwritten behaviors, rewards, and punishments [ 25 ]. According to the findings of this study, the residency education structure in Iran also embodies a hidden curriculum that fosters a form of negative moral formation through mechanisms of silence, humiliation, and fear. A key element in Segato’s theory is the distinction between violence as an instrument of order and violence as the pleasure of domination. She argues that in the Pedagogy of Violence , perpetrators often derive a sense of empowerment from their “capacity to harm,” which is continually reproduced within hierarchical institutions [22]. We conceptualized this dynamic as the “Instruments of power and inclination toward violent behaviour”. In the participants’ experiences, this pleasure of domination occasionally manifests as shouting in the operating room, public humiliation during morning reports, or the denial of residents’ requests for leave. Such acts serve not to “correct errors” but to reinforce power hierarchies. Our qualitative data reveal that many residents interpret these behaviors as “training,” and upon becoming faculty, reproduce the same actions—a process of vicarious learning that De Vito also identifies as one of the driving mechanisms of educational violence [22]. In response to this situation, Segato introduces the concept of the Counter-Pedagogy of Violence —an attempt to restore humanity, empathy, and dialogue to the heart of the educational process [22]. This counter-pedagogy calls for “seeing the Other as human,” rejecting the logic of domination, and emphasizing care as both a political and ethical act [23]. The findings of this study demonstrate that whenever educational interactions were grounded in empathy, participation, and support, learning experiences became more ethical and humane. For example, the resident whose clinical error was discussed in a supportive environment rather than through humiliation exemplifies that the Counter-Pedagogy of Violence is not an unattainable ideal but a tangible possibility for reforming clinical education. Reinterpreting conflicts of interest through Segato’s lens also reframes them not merely as ethical or administrative issues, but as manifestations of structural violence and domination within social systems that encourage individuals to prioritize self-interest over collective well-being. In the healthcare system, a physician who privileges financial gain over patient need is not merely committing a professional infraction; rather, this behaviour reflects a cultural logic that objectifies the patient’s body and commodifies the act of healing. The same applies to interactions with residents: a clinical supervisor who denies educational or human engagement treats the resident as a tool for fulfilling institutional tasks. From Segato’s theoretical perspective, every conflict of interest embodies a form of hidden pedagogy of violence, revealing how cruelty becomes institutionalized. Therefore, addressing conflicts of interest requires more than transparency, regulation, or oversight—it demands a Counter-Pedagogy of Violence , that is, education in empathy, care, relational reconstruction, and participatory power. As a practical intervention model, the A.W.A.R.E. program proposed by Leisy and Ahmad offers a useful framework for understanding, preventing, and correcting mistreatment in residency training. This model begins with Acknowledge (recognition and identification of misconduct), followed by Witness and Act , which encourage individuals to move beyond passive observation. Finally, Reflect and Empower aim to address structural problems at their roots [21]. When integrated with Segato’s theory, the Witness and Act components can be enriched through principles of empathy, care, and participatory power, while Reflect and Empower can promote deeper critical understanding of the underlying crisis. Limitations This study has several important limitations that should be acknowledged. First, the relatively small sample size and the inclusion of residents from a limited number of specialties may restrict the transferability of the findings. Despite considerable efforts to recruit residents from surgical specialties—areas that previous studies have identified as having the highest reports of violence—almost no surgical residents agreed to participate in interviews, with the exception of one resident from obstetrics and gynecology. This lack of participation limited access to first-hand accounts from surgical training environments. At the same time, the reluctance of surgical residents to take part in the study may itself be meaningful, potentially reflecting intense hierarchical pressures, fear of negative consequences, or the normalization of violence within these fields. A second limitation was the lower willingness of male residents to participate in interviews, resulting in a gender imbalance that may have shaped the perspectives captured in the data. This issue becomes particularly salient when considered alongside the absence of surgical residents, as men constitute the majority of trainees in most surgical specialties in Iran, except for obstetrics and gynecology, which is exclusively open to women. Taken together, these overlapping limitations further narrowed insight into surgical residency environments, while also raising important questions for future research about why male residents may be less inclined than female residents to speak openly about their educational and punitive experiences. Conclusion The qualitative analysis of feedback and punishment during medical residency demonstrates that a form of Pedagogy of Violence is structurally embedded within medical education—a system that teaches residents “how to become doctors” through humiliation, exclusion, silence, and fear. Yet this process of becoming often comes at the cost of burnout, alienation, and the erosion of empathy. Educational violence is not an exception but a constitutive logic of the medical training system. In this context, Rita Segato’s concept of the Counter-Pedagogy of Violence offers both an ethical and practical framework for reconstructing medical education. This model emphasizes dialogue, transparency, mutual care, and equality in power relations, envisioning learning as a process rooted in respect and empathy. At the policy level, it is crucial to revise disciplinary regulations and replace punitive mechanisms with reflective and supportive structures. From the standpoint of medical ethics and medical education, transitioning from a Pedagogy of Violence to a Counter-Pedagogy of Violence requires training clinical educators in communication, self-awareness, and power management. Without such a cultural transformation, no structural reform can be sustainable. As Freire reminds us, education is either “an act of freedom” or “an act of domination.” For medical education to reclaim its ethical mission, it must aim not to produce obedient physicians, but reflective, critical, and compassionate ones. Declarations Acknowledgments The authors gratefully acknowledge the medical residents who participated in this study for their time, cooperation, and valuable contributions. The authors also acknowledge the use of artificial intelligence–based tools for language editing and manuscript preparation. Fundings The authors declare that this study was not supported by any funding. Author Information Authors and affiliations Leila Azizi Department of Medical Ethics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Mahboobeh Saber Department of Medical Ethics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Contributions Study Design (LA and MS), Data collection (LA), Transcription (LA), Data Analysis (LA and MS), Manuscript Preparation (LA and MS), Supervision and critical review (MS). Both authors approved the final manuscript. Corresponding Author Mahboobeh Saber Email Address: [email protected] Ethics Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.MED.REC.1403.040) and conducted in accordance with the Declaration of Helsinki and national ethical guidelines. Written informed consent was obtained from all participants, and confidentiality was maintained throughout the study. Consent for Publication Not Applicable Competing Interests The authors declare no competing interests. Data Availability Data supporting the findings of this study are available from the corresponding author upon reasonable request. References AlHaqwi AI, Taha WS. Promoting excellence in teaching and learning in clinical education. Journal of Taibah University Medical Sciences. 2015 Mar 1;10(1):97-101. Steelman LA, Levy PE, Snell AF. The feedback environment scale: Construct definition, measurement, and validation. Educational and psychological measurement. 2004 Feb;64(1):165-84. Rahimi M, Ehsanpour S, Haghani F. The role of feedback in clinical education: Principles, strategies, and models. Ende J. Feedback in clinical medical education. Jama. 1983 Aug 12;250(6):777-81. Royal College of Phsycians and Surgeons of Canada. Competence by Design (CBD): What is Competence by design? http://www.royalcollege.ca/ rcsite/cbd/what-is-cbd-e Accessed 27 Sept 2020. Yarris LM, Linden JA, Gene Hern H, Lefebvre C, Nestler DM, Fu R, Choo E, LaMantia J, Brunett P, Emergency Medicine Education Research Group (EMERGe). Attending and resident satisfaction with feedback in the emergency department. Academic emergency medicine. 2009 Dec;16:S76-81. Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. Surgery residents and attending surgeons have different perceptions of feedback. Medical teacher. 2005 Aug 1;27(5):470-2. Govaerts M. Workplace-based assessment and assessment for learning: threats to validity. Journal of graduate medical education. 2015 Jun 1;7(2):265-7. Watling CJ, Kenyon CF, Zibrowski EM, Schulz V, Goldszmidt MA, Singh I, Maddocks HL, Lingard L. Rules of engagement: residents’ perceptions of the in-training evaluation process. Academic Medicine. 2008 Oct 1;83(10):S97-100. Cantillon P, De Grave W, Dornan T. Uncovering the ecology of clinical education: a dramaturgical study of informal learning in clinical teams. Advances in Health Sciences Education. 2021 May;26(2):417-35. Vanstone M, Grierson L. Thinking about social power and hierarchy in medical education. Medical education. 2022 Jan;56(1):91-7. Vanstone M, Grierson L. Medical student strategies for actively negotiating hierarchy in the clinical environment. Medical education. 2019 Oct;53(10):1013-24. Lerchenfeldt S, Mi M, Eng M. The utilization of peer feedback during collaborative learning in undergraduate medical education: a systematic review. BMC medical education. 2019 Aug 23;19(1):321. Averbuch T, Eliya Y, Van Spall HG. Systematic review of academic bullying in medical settings: dynamics and consequences. BMJ open. 2021 Jul 1;11(7):e043256. Torabi N, Shakiba B, Vaseghi H, Maghsoudi R, Alimoradzadeh R, Irani S, Dini P. Perceived Workplace Bullying and Mental Health Status among Medical Residents in Iran. Journal of Iranian Medical Council. 2022 Oct 1;5(4):557-66. Assadpour, N., Alazmani-noodeh, F., Baniyaghoobi, F. et al. Factors influencing quality of professional life and perceived bullying among medical residents in Iran. BMC Med Educ 25, 217 (2025). https://doi.org/10.1186/s12909-025-06724-8 Graneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse education today. 2017 Sep 1;56:29-34. Stenfors T, Kajamaa A, Bennett D. How to… assess the quality of qualitative research. The clinical teacher. 2020 Dec;17(6):596-9. Lall MD, Bilimoria KY, Lu DW, Zhan T, Barton MA, Hu YY, Beeson MS, Adams JG, Nelson LS, Baren JM. Prevalence of discrimination, abuse, and harassment in emergency medicine residency training in the US. JAMA network open. 2021 Aug 2;4(8):e2121706-. Szafran O, Woloschuk W, Torti JM, Palacios Mackay MF. Intimidation, harassment, and discrimination during family medicine residency training: a mixed methods study. BMC medical education. 2021 Mar 20;21(1):173. Leisy HB, Ahmad M. Altering workplace attitudes for resident education (AWARE): discovering solutions for medical resident bullying through literature review. BMC medical education. 2016 Apr 27;16(1):127. De Vito EL. Towards a counter-pedagogy of cruelty in medical residencies. MEDICINA (Buenos Aires). 2025 Apr;85(1):148-. Segato R. Contra-pedagogías de la crueldad. de De Carvalho RL. La guerra contra las mujeres. Traficantes de sueños; 2020. Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Academic medicine. 1998 Apr 1;73(4):403-7. Additional Declarations No competing interests reported. Supplementary Files File1Interviewguide.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers invited by journal 23 Jan, 2026 Editor assigned by journal 22 Jan, 2026 Editor invited by journal 05 Jan, 2026 Submission checks completed at journal 04 Jan, 2026 First submitted to journal 04 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8417993","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":581272354,"identity":"300d23c2-8490-477b-8931-5d40bda227c2","order_by":0,"name":"Leila Azizi","email":"","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Leila","middleName":"","lastName":"Azizi","suffix":""},{"id":581272355,"identity":"d4c8c6bb-6061-4b86-bb9e-482ad4806dce","order_by":1,"name":"Mahboobeh Saber","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYFACHghlIMHAwMzAcEAOLkK0FmPStSQ2ENIi33724OMKhm3y5tLNBx8XVNxJ33D87MEHHxjs5HQbsGsxOJOXbHiG4bbhzjnHko1nnHmWuwEkMoMh2djsAA4tDDlmkg0Mtxk33Mgxk+ZtO5y74QCQwQN04TYcWuT735j/BGqxh2j5dzjd4Pwb/FoYgCoZgVoSIVoaDicY3CBgi8GNd8kghyVvuAPyy7HDhjNvvDE2nGGA2y/y/bkHPwK12G64DQqxmsPyfOdzDB98qLCTw6UFDBj/IXEUDkCChQQg30CK6lEwCkbBKBgJAABNBmX4v+27YQAAAABJRU5ErkJggg==","orcid":"","institution":"Shiraz University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Mahboobeh","middleName":"","lastName":"Saber","suffix":""}],"badges":[],"createdAt":"2025-12-21 14:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8417993/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8417993/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103503859,"identity":"af8b790e-807c-4c9c-9492-2fb2f01cfbe7","added_by":"auto","created_at":"2026-02-26 13:03:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1128175,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8417993/v1/0b59386d-0b09-4cfe-85b6-39dc1a825ecb.pdf"},{"id":101339704,"identity":"f32d1aa6-42f1-4c39-9198-e129a2b47a21","added_by":"auto","created_at":"2026-01-28 15:58:21","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22464,"visible":true,"origin":"","legend":"","description":"","filename":"File1Interviewguide.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8417993/v1/4852385a4c31900b70c3b331.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"When Professional and Educational Feedback Turns into a Cycle of Violence: A Qualitative Study of Educational and Punitive Interactions During Medical Residency","fulltext":[{"header":"Background","content":"\u003cp\u003eEducation and learning of medical residents in clinical departments constitute one of the fundamental processes in medical education [\u003csup\u003e1\u003c/sup\u003e, \u003csup\u003e2\u003c/sup\u003e]. During their training period, residents are required to acquire clinical competencies and communication skills appropriate to their specialty. Residents\u0026rsquo; learning occurs through work-based learning, case-based learning, problem solving, and hands-on experience, and feedback plays a crucial role in raising awareness about the quality of the learning experience and identifying areas that require improvement. The quality of feedback itself is therefore of considerable importance [\u003csup\u003e3\u003c/sup\u003e, \u003csup\u003e4\u003c/sup\u003e]. Competency based medical education proposes a structured framework for feedback that includes a clearly defined learning pathway, repeated workplace-based observation, meaningful feedback, sufficient time and opportunities for the development of new skills, and assessment [\u003csup\u003e5\u003c/sup\u003e]. Some residents prefer feedback primarily for confirmation of good performance and tend to avoid feedback that contains criticism [\u003csup\u003e6\u003c/sup\u003e]. Discrepancies between faculty members\u0026rsquo; and residents\u0026rsquo; perceptions of the observed event also represent an important factor influencing the meaningfulness of feedback [\u003csup\u003e7\u003c/sup\u003e]. In other words, the feedback process should enable both parties to move toward a shared and interactive understanding. Accordingly, clinical residents should actively participate in discussion, review, and reflection on feedback so that they perceive it as credible and can use it effectively to advance their learning [\u003csup\u003e8\u003c/sup\u003e , \u003csup\u003e9\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eMedical practice and the education of medical residents are inherently contingent upon a clinical environment that is highly interactive and hierarchical [\u003csup\u003e10\u003c/sup\u003e]. Research in medical education has demonstrated in various ways that power, as embedded within organizational structures, is closely intertwined with processes of learning and assessment. This hierarchical structure influences feedback exchanges, moral agency, error disclosure, and help-seeking behaviors, and often constrains openness and honesty [\u003csup\u003e11\u003c/sup\u003e]. Understanding and adhering to these implicit rules are described by medical students and residents as a crucial means of demonstrating professionalism and fostering successful relationships with peers and supervisors [11, \u003csup\u003e12\u003c/sup\u003e]. While such structures are necessary to ensure clinical accountability, they may also give rise to unequal and potentially harmful relationships. In light of these factors, feedback may not solely reflect the educational function of interactions but may also represent an expression of the cumulative effects of power relations within the clinical environment [11 ,\u003csup\u003e13\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eEvidence indicates that violence experienced by medical residents has been perpetrated by a range of individuals, including attending physicians, senior residents, clinical faculty members, nurses, and patients. The forms of violence reported by residents include overwork, isolation, withholding of information that affects performance, assignment of tasks below an individual\u0026rsquo;s level of professional competence, excessive monitoring, and criticism [\u003csup\u003e14\u003c/sup\u003e]. Some of the behaviors identified as experiences of violence occur specifically within educational interactions, suggesting that a substantial portion of the violence experienced by residents arises during training-related encounters. In clinical settings such as operating rooms and hospital wards, where feedback functions as a core component of formative assessment, it may occupy a precarious position, at times bordering on violence and bullying.\u003c/p\u003e\n\u003cp\u003eThe phenomenon of violence experienced by medical residents in Iran represents a significant and concerning issue. More than 90% of residents have either directly experienced violence or witnessed violence directed toward their colleagues [\u003csup\u003e15\u003c/sup\u003e]. Furthermore, the quality of residents\u0026rsquo; professional life declines in association with experiences of bullying, an effect that is further exacerbated by longer weekly working hours [\u003csup\u003e16\u003c/sup\u003e]. Despite its importance, only a limited number of studies have examined the phenomenon of violence experienced by medical residents in Iran. Given the substantial prevalence of depression and burnout, as well as the rising trend of suicide among residents in recent years, focused attention to the issue of violence experienced by medical residents is both necessary and urgent.\u003c/p\u003e\n\u003cp\u003eThe increasing prevalence and evolving nature of various forms of violence within the structures of clinical practice necessitate a systematic examination of this phenomenon and its less visible dimensions. Accordingly, we adopted a qualitative approach to explore and interpret medical residents\u0026rsquo; experiences, perceptions, and narratives related to educational interactions, professional feedback, and incidents of violence. This approach enabled the elucidation of the complexity of the phenomenon and facilitated an in-depth examination of its less frequently recognized aspects, including inter-resident relationships and interactions with faculty members. The present study aims to identify the types and contextual conditions of academic violence occurring in the course of feedback to medical residents, with the intention of generating evidence that may inform policy change, contribute to the improvement of educational culture, and enhance learning conditions within clinical environments.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors selected a qualitative study using a qualitative content analysis approach as described by Graneheim and Lundman. The analysis was conducted\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003einductively (data-driven)\u003cstrong\u003e,\u003c/strong\u003e moving from the text toward higher-order understandings while attending to both manifest content (what is explicitly said) and latent content (the underlying meanings or \u0026ldquo;red thread\u0026rdquo;). This analysis was conducted within an interpretivist/hermeneutic stance that attends to how sociocultural context and structural conditions shape participants\u0026rsquo; experiences [\u003csup\u003e17\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedical residents from multiple disciplines who had experienced educational feedback and/or punishment during hospital training were recruited using purposive sampling. Participation was voluntary and included residents who were either currently in training or had graduated within the past three years. Participants represented various disciplines and hospitals across Iran, including cardiology, obstetrics and gynecology, neurology, psychiatry, pediatrics, internal medicine, and orthopaedics (Table 1. .(Although residents from orthopaedic and other surgical specialties were invited, none agreed to participate; however, participants\u0026rsquo; accounts included observations related to surgical fields, particularly orthopaedics, which are reflected in the results. The sample comprised both male and female participants, with a mean age of 30 years.\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic features of participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Training\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSenior Residents\u003c/p\u003e\n \u003cp\u003ePost Graduated\u003c/p\u003e\n \u003cp\u003e(Less than 3 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisciplines\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCardiology\u003c/p\u003e\n \u003cp\u003eOB/GYN\u003c/p\u003e\n \u003cp\u003eInternal Medicine\u003c/p\u003e\n \u003cp\u003eNeurology\u003c/p\u003e\n \u003cp\u003ePaediatrics\u003c/p\u003e\n \u003cp\u003ePsychiatry\u003c/p\u003e\n \u003cp\u003eOrthopaedics Surgery\u003c/p\u003e\n \u003cp\u003e(Second hand narratives)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected through semi-structured interviews conducted between January and March 2024. Potential participants were invited through verbal, telephone, or social media contact, and additional participants were recruited using snowball sampling via colleagues or peers. Volunteer medical residents were informed about the study objectives, the use of anonymized quotations, and confidentiality procedures prior to participation. All interviews were conducted by LA, lasted 60\u0026ndash;90 minutes, and were preceded by written informed consent. A semi-structured interview guide with open-ended questions was used. Interviews began with the question, \u0026ldquo;During your residency, how do/did you usually receive feedback from your professors or senior residents?\u0026rdquo; and subsequently explored participants\u0026rsquo; experiences of punishment. Participants were encouraged to describe their experiences and associated feelings in depth.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThe semi-structured interview guide was specifically developed for the purposes of this study and had not been used or published in any previous research. It is provided as Supplementary File 1.\u003c/p\u003e\n\u003cp\u003eDue to the lack of participation from surgical residents across most specialties\u0026mdash;with the exception of obstetrics and gynecology and the availability of repeated secondary narratives from orthopaedics\u0026mdash;the scope of qualitative data in this study was inherently limited. The observed thematic repetition reflects saturation within a narrowly defined and indirect data source rather than saturation across the intended population of surgical residents. Consequently, the findings should be interpreted as context-specific and exploratory, and the restricted participation is acknowledged as a significant limitation of the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interview transcripts were carefully and repeatedly read to grasp the depth and nuances of participants\u0026rsquo; experiences. Through this attentive process, meaningful parts of the text were identified, condensed, and given codes that reflected their essence. Similar ideas were brought together into sub-categories and broader categories, which were then interpreted to uncover deeper, underlying categories. Throughout the analysis, we sought to stay true to participants\u0026rsquo; voices while maintaining a coherent and balanced relationship between description and interpretation. MAXQDA 2020 software was used to assist with coding and data management.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study received full ethical approval from the Shiraz University of Medical Sciences (SUMS) ethics committee (IR.SUMS.MED.REC.1403.040).\u0026nbsp;All participants provided written informed consent. Talking about the punishment experience is not easy at all, so they were informed that they are free to withdraw at any time. They also consented to the interviews being recorded and then transcribed anonymously for analysis. In addition to sustained engagement with participants, this qualitative study employed two common validation techniques to enhance credibility: member checking (to confirm the findings with the interviewees) and peer debriefing (with qualitative research specialists and a research colleague) [\u003csup\u003e18\u003c/sup\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eContent analysis of interviews with residents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe content analysis of interviews with residents revealed that the experience of punishment during medical training is often not only devoid of corrective or pedagogical value, but in many cases constitutes a form of overt or covert violence. The findings were categorized into four primary categories (themes), nine subcategories, and 20 initial codes\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e(Table 2.).\u003c/p\u003e\n\u003cp\u003eTable 2.\u0026nbsp;Typology of Feedback, Punishments and Violence in Medical Education\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubcategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional Feedback\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCorrective feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eEmphasis on correcting educational or clinical performance\u003c/li\u003e\n \u003cli\u003eContinuous feedback across hierarchical levels\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSupportive feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eFeedback aimed at facilitating shared learning\u003c/li\u003e\n \u003cli\u003eDialogic reflection and post-event discussions focused on identifying errors or gaps\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePunishments Framed as Feedback\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInformal and situational punishment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eAdditional on-call duty\u003c/li\u003e\n \u003cli\u003eexclusion from educational groups or activities\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructural and formal punishment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eRestriction of access to educational opportunities\u003c/li\u003e\n \u003cli\u003etemporary suspension from academic progression and overwork\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eViolence as Punishment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInterpersonal (soft and hard) violence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eVerbal and psychological abuse\u003c/li\u003e\n \u003cli\u003eStigmatization and Psychiatric labels\u003c/li\u003e\n \u003cli\u003eSexual and gender-based violence\u003c/li\u003e\n \u003cli\u003ePhysical violence\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStructural and institutional violence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eExpectation of omnipotence\u003c/li\u003e\n \u003cli\u003eStaffing and welfare shortages as punitive pressure\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTransformation of Feedback into Violence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNormalization of violence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eReproduction of the cycle of interpersonal violence among senior and peer residents\u003c/li\u003e\n \u003cli\u003ePersistence of structural violence\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHierarchies of power in medical training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003eConflicts of interest within hierarchy\u003c/li\u003e\n \u003cli\u003eInstruments of power and inclination toward violent behaviour\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLegal and regulatory gaps\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- Lack of transparent, contextualized regulations for addressing errors\u003c/p\u003e\n \u003cp\u003e- Absence of legal protections\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efor residents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eProfessional feedback\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProfessional feedback was divided into two subcategories: corrective feedback and supportive feedback. Corrective feedback primarily emphasized rectifying an error or a deficiency in a resident\u0026rsquo;s performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrective feedback\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on participants\u0026rsquo; accounts, corrective feedback emerged as an important educational practice during residency and was embedded in residents\u0026rsquo; everyday clinical work. Participants described receiving corrective feedback from senior residents or attending physicians, typically in response to specific errors or situational demands. According to their experiences, such feedback was delivered either individually or in group settings involving multiple team members, including the resident concerned.\u003c/p\u003e\n\u003cp\u003eOne participant who had experience as a chief resident described:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think we more or less observe stepwise feedback within our group. For this reason, I, as chief resident [and intermediary between residents and attendings], both gave feedback to residents and at the same time listened to them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA psychiatry resident recounted a positive experience:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One night, I was on call and admitted a patient with a history of seizures. I forgot to place a protection order for the patient, and I failed to order one dose of his medication. The patient seized, fell from the bed to the floor, and even sustained a head injury. The way they treated me there was very humane. They said, \u0026lsquo;Let\u0026rsquo;s talk about this case. What happened? Do you not know these drugs or how to manage seizures, or is there another problem?\u0026rsquo; Based on my experience, psychiatric wards generally confront residents more humanely.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupportive feedback\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome residents experienced corrective feedback that was delivered within a supportive, educational framework. In such cases, attendings and senior clinicians attempt to correct residents\u0026rsquo; errors in the clinical setting while simultaneously teaching them. These interactions are often pedagogically motivated and conducted in a supportive environment; efforts are made to identify and address not only the resident\u0026rsquo;s role but also other contributing factors to the error.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDialogic reflection and post-event discussions focused on identifying errors or gaps\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA participant with chief resident experience in Internal Medicine stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes, when serious scientific errors occur, our group convenes a meeting with the department head, the attending, the chief resident, and the resident who made the error to review the issue. The committee may conclude that the resident lacked knowledge of that subject or, conversely, that the resident knew the material and tried their best, but other factors caused the error. These meetings are very good and genuinely helpful. If a resident has been negligent, they receive extra on-call duty, and in other cases, the problem is resolved through other means.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePunishments Framed as Feedback\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome residents perceived punishment\u0026mdash;more severe than feedback\u0026mdash;as a form of corrective feedback, whereas others experienced such punishment as unsympathetic, unfair, or unrelated to the error or the event that had occurred. Consequently, punishment occupies a position on a spectrum: it may be experienced as corrective or may be experienced as violent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformal and situational punishment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the study findings, punishments are not always communicated formally to residents; rather, informal punitive practices exist based on customary, unwritten rules within training groups. One of the most common punishments is additional on-call duty. Notably, training groups use extra on-call shifts as a punitive measure for a wide range of perceived infractions\u0026mdash;from arriving late to academic conferences to committing a medical error.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional on-call duty\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne participant who had recently completed residency and become an attending clinical physician reported:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Once I was supposed to present the morning report and I arrived late, so they gave me additional on-call duty. This was despite the fact that I had been on call the night before and had slept only one hour; I arrived at 8:10 rather than 8:00. Because the attending arrived before me, they assigned me extra on-call duty. In my view, extra on-call duty is a polite punishment. There is no insult; they simply tell you to repeat the task you failed to perform. When the chief resident told me I had to take extra on-call, I laughed. I myself use extra on-call as a sanction for residents. Being told that you made a certain error and therefore must do extra on-call is not insulting.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother participant who had also been assigned extra on-call duty considered the transparency of that punishment to be an advantage:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the defective system we have [where procedures for feedback and punishment are not clearly defined], one prefers a specific punishment such as extra on-call duty so that one\u0026rsquo;s obligations are clear.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eexclusion from educational groups or activities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExclusion from the training group\u0026mdash;whether temporary or prolonged\u0026mdash;is another unwritten punitive measure that we classified as a form of soft violence based on our data. Exclusion may arise due to an error, a disagreement, or resistance to coercion, which constitutes a severe punishment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eIf you are a resident who does not blindly comply and sometimes chooses to ask questions or speak up instead, you are quickly pushed to the margins by senior residents. Sometimes this shows up as being ignored or treated with indifference; other times, it means being cut off from educational resources and learning opportunities, with little guidance offered to\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural and formal punishment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTemporary deprivation of academic promotion and overwork\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to our findings, this form of punishment is applied pursuant to\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003esome national regulations when a resident\u0026rsquo;s examination scores do not meet the required threshold.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the orthopaedics department, every year on the night of the promotion exam, two residents with the lowest departmental scores are prevented from sitting the exam; instead, they are assigned to cover on-call duty so that the other residents can have the night off and then take the promotion exam the following morning. This routine has become institutionalized. In contrast, in other specialties, fellowship trainees and attending physicians cover departmental duties on the night before the promotion exam, allowing all residents to prepare adequately for the examination.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eViolence as punishment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA substantial portion of the residents\u0026rsquo; narratives described punitive acts that lacked educational or corrective value and instead represented personal or systemic violence. Therefore, these experiences transcend the category of \u0026lsquo;punishment\u0026rsquo; and are regarded as forms of violence. The study revealed that residents experienced two levels of violence during training: (1) soft and hard interpersonal violence, and (2) structural and institutional violence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSoft and hard interpersonal violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe defining characteristic of soft and hard interpersonal violence, in contrast to structural and institutional violence, is that they occur interpersonally. As some residents mentioned, soft violence (e.g., verbal, psychological abuse, and stigmatization) is less readily identifiable and provable than more overt forms, yet it leaves profound and persistent psychological effects on residents. By contrast, hard violence includes physical and sexual/gender-based violence, whose harms and consequences are more observable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVerbal and psychological violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, verbal violence in the form of sarcasm, irony, and cold speech was classified as soft violence, while verbal abuse that included insults and profanity was categorized as hard violence.\u003c/p\u003e\n\u003cp\u003eOne female resident recounted a severe verbal incident in which she was not directly involved but experienced guilt:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Once, when I was a second-year resident, during rounds in the emergency department I realized that a first-year resident had started an antiemetic for a patient in the last weeks of pregnancy. This error was unacceptable for a resident who had been working in the women\u0026rsquo;s emergency for four months. I told a third-year resident to teach this first-year resident; perhaps she was unaware of the point. The third-year resident immediately picked up the phone and verbally abused the first-year resident! That first-year resident resigned one month later, and I still feel guilty about that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother resident reported:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eAt a morning report session, an attending asked me whether the patient also had Pitting Edema. When I answered that I had not checked this, he began, in front of 400 people, to swear at me: \u0026lsquo;What are you calves doing? How do you expect to be a doctor tomorrow?\u0026rsquo; No one dared respond.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStigmatization and psychiatric labelling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome second- and third-year residents noted that in the first year they did not fully recognize stigmatization as a form of violence. They accepted those labels for a long period and needed time to perceive the violent nature of such behaviours.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In psychiatry, hidden violence is more common. For example, you are subjected to \u0026lsquo;analysis\u0026rsquo; [psychological analysis]. They may speak to you as if you are an abnormal person. They do not assign you extra on-call, but they do things that internally make you feel very bad. Once, I said I had forgotten to go to the ECT ward. They did not give me extra on-call; instead, they said that it seems you have a personality that constantly forgets things. One of the violences in psychiatry is the expectation that you be perfectly normal, standard, and well-adjusted.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA neurology resident, who had witnessed a senior resident\u0026rsquo;s behaviour in response to a scientific error, stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have seen a senior resident tell a junior resident, \u0026lsquo;You are stupid, you understand nothing, you are confused.\u0026rsquo; I have seen how these words destroy the other person.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSexual and gender-based violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSexual and gender-based violence emerged as one of the most explicit and frequently reported forms of violence among female residents in this study.\u003c/p\u003e\n\u003cp\u003eOne female resident recounted event from the final months of her training:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My spouse and I sometimes worked shifts together. The senior resident, who was male, turned my former husband off at midnight when there were no patients in the emergency department but told me I had to stay. My husband suggested he would stay and relieve me, but the senior resident refused because he had other intentions. My husband said then we would both stay and neither of us would go to the dormitory to rest.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA resident said about the orthopaedics field:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A woman chose orthopaedics in recent years and was, naturally, the only female resident in that specialty. All the male residents of that year united to harass and pressure her so much that she was forced to resign.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysical violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents\u0026rsquo; experiences of physical violence varied across departments. According to the study, the highest rates of physical violence were reported in surgical and orthopedic groups, where there seems to be little attempt to conceal violent behaviour; indeed, greater openness and severity of violence are sometimes regarded as a badge of identity in those groups.\u003c/p\u003e\n\u003cp\u003eOne resident described observations in the orthopaedics specialty:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Orthopaedics and surgery are notorious for their highly aggressive environments and have a high annual resignation rate. These departments are intensely hierarchical and patriarchal. We encounter overt and visible harsh violence. For example, a third-year resident once broke a first-year resident\u0026rsquo;s leg with a kick because the junior had brought the radiographs to the operating room two minutes late. When that first-year resident went to the department head, they were told, \u0026lsquo;Don\u0026rsquo;t come to me until you have been sexually assaulted!\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStructural and institutional violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStructural and institutional violence in medical education occurs when systems and regulations function in ways that, rather than supporting residents, create conditions for pressure, exclusion, or deprivation. Two subcategories were identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExpectation of omnipotence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe expectation that residents must be omnipotent is sometimes institutionalized and functions as structural, systemic violence. This expectation extends beyond mastery of diagnosis and treatment and the flawless recall of inpatients\u0026rsquo; signs and tests; it targets even fundamental human needs such as eating, sleeping, and toileting, which are deemed impermissible except in exceptional emergency circumstances. This norm is imposed as an immutable principle of daily practice and can render a resident punishable even when no medical error has occurred. Some residents internalize and accept this expectation.\u003c/p\u003e\n\u003cp\u003eA resident recounted a first-month experience:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the first month of residency I had to perform an LP on a patient. Despite repeated attempts I could not succeed. The patient\u0026rsquo;s companion stood at the bedside watching me. I called a senior resident to assist; on the first try he succeeded. Afterwards he did not even stop to collect the CSF and angrily threw off his gloves, saying, \u0026lsquo;When will you learn?\u0026rsquo; That day I thought I was very stupid\u0026mdash;I had injured the patient\u0026mdash;and the companion complained about me to hospital administration.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother resident, describing emergency paediatrics\u0026rsquo; on-call experiences, said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes there were 300\u0026ndash;400 patients overnight and we had to present all of them at morning report the next day. Several problems arise: you cannot retain all the information on every patient; you cannot take a complete history or perform a full examination on everyone; and, most importantly, you are extremely exhausted. I was running the entire on-call. Medicine expects omnipotence of one person, and in my view this is the greatest violence; it creates enormous anxiety and stress.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA further account regarding suppression of basic needs:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;During my residency I went to the restroom and one of the attendings called me. I heard the phone ring while inside the restroom and immediately called the attending back after returning. Although only five minutes had passed, the attending asked why I had not answered the phone. What could I do in that situation? The implied solution was to always carry my mobile phone\u0026mdash;even into the restroom!\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaffing and welfare shortages used as punitive pressure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough hospitals provide welfare facilities for residents, in this study it was found that these amenities are sometimes employed as mechanisms of control and violence. An orthopedics resident reported:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;For first-year orthopedics residents, especially during the first two weeks, no dedicated residents\u0026rsquo; rest room is provided in the hospital. If a room exists at all, it may be locked by the chief resident so that no one can use it. If a first-year resident is exhausted and wishes to use the senior residents\u0026rsquo; rest room for a few minutes, they may be punished.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransformation of Feedback into Violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings indicate that, although professional feedback is theoretically a tool for learning and correction, in practice it can transform into a form of violence. In such an environment, feedback that ought to be constructive is delivered in a directive, humiliating, or threatening tone such that the corrective and educational content is obscured by the speaker\u0026rsquo;s harsh tone or positional power. What appears superficially as professional feedback often becomes a distressing and undermining experience for the recipient, one that is not educational and that perpetuates structural patterns of violence within training environments. Identifying legal and regulatory gaps clarifies how this cycle of violence and the reproduction of power persists.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNormalization of violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents who have been repeatedly exposed to violent environments have, despite the harm they experienced, come to accept such violence as a norm. One resident who had recently become a clinical attending stated:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Until now, I had always thought that since we ourselves went through these hardships during our first and second years of residency, others should be able to go through them as well. I had never seriously considered the need for fundamental reform of the system, because I believed that the system could not be easily changed\u0026mdash;only slightly, at best.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReproduction of the cycle of interpersonal violence among senior and peer residents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents who were subjected to various forms of violence during the early years of their training sometimes reproduce these same behavioral patterns later on, either as senior residents or even during their own junior years, often motivated by different reasons.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In interactions with senior residents, the more work you do, the lighter their workload becomes. This dynamic leads to frequent and repeated punishment under various pretexts from senior residents.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If a third-year resident makes a mistake, the chief resident usually refrains from reprimanding them because they are at the same educational level. In contrast, the same chief resident may, in a similar situation, reprimand a first-year resident twice as harshly.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe findings indicated that the heavy responsibilities and workload pressures inherent in residency training often erode empathy, leading individuals to focus solely on self-preservation\u0026mdash;even among peers who share similar conditions and collective interests:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A second-year resident (a year that is not particularly demanding) had a broken leg in a cast. He requested medical leave, which was his right. However, his peers opposed it, arguing that if he went on leave, their own workload would increase.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePersistence of structural violence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents\u0026rsquo; experiences revealed that violence is deeply embedded in institutional policies and systemic structures, perpetuating harm, burnout, and even exploitation.\u003c/p\u003e\n\u003cp\u003eOne resident described their experience with emergency shifts:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;During a sixty-day period, I worked forty-eight emergency shifts. I didn\u0026rsquo;t see sunlight, and I could no longer tell when it was day or night. What kind of working condition is that? What is left of a person afterward?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother resident recounted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One of the chief residents believed that first-year residents are not really human. For a first-year resident, simply staying alive is enough\u0026mdash;they should not have any expectations at all. After completing the first year, we are no longer the same people we were before. And no one in this system cares what happens to us; the entire system has accepted this reality.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHierarchies of power in medical training\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe vertical and hierarchical structure of medicine was identified as an important facilitator of the transformation of feedback into violence. This hierarchy not only limits an open and egalitarian learning environment but also fosters conditions for soft and hard violences to be exercised without oversight or accountability.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My spouse was an orthopedics resident. In the first year of residency, if his mobile phone rang and the caller was not a second- or third-year resident, he would be assigned extra on-call duty! Even if he was speaking with a second-year resident and a third-year resident joined the line, he had to immediately end the call and respond to the third-year resident. In orthopedics, Leveling is terrifying.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest within the hierarchy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConflict of interest was identified as a major antecedent of violent behavior. In Iran\u0026rsquo;s healthcare system, because of economic pressures and dual practice by clinical faculty in both public/university and private sectors, many problems arise. Two illustrative remarks:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Many attendings are absent, attending only the weekly morning report and then leaving for their private clinics. They do the minimum work possible and engage minimally in emotional connections and problem-solving.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is an unwritten rule that \u0026lsquo;the senior is always right.\u0026rsquo; Attendings wish to maintain a military-like order. They fear that if they do not side with the senior resident, the department\u0026rsquo;s order will collapse. They want minimal engagement and thus strive to preserve this military governance.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstruments of power and inclination toward violent behaviour\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents described violence as something the system generates: the structure is arranged such that individuals progressively incline toward violent conduct.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Much of the violence is exerted by senior residents toward juniors. You are not punished by the primary source of authority, but you are repeatedly exposed to violence that, in psychoanalytic terms, is called Sibling violence: senior brothers and sisters gradually become the instruments of the institution\u0026rsquo;s power.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The physician\u0026rsquo;s role is expected to embody omniscience and omnipotence, which gradually elevates one\u0026rsquo;s position to near-divine status, promoting fallibility denial and the imposition of power over others.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLegal and regulatory gaps\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of transparent, contextualized regulations for addressing errors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlthough regulatory frameworks exist in Iran\u0026rsquo;s educational and therapeutic system describing how to confront professional incompetence in residents, our findings show these regulations are insufficient: they are neither widely known nor, given the system\u0026rsquo;s disordered and hierarchical structure, endowed with sufficient executive power.\u003c/p\u003e\n\u003cp\u003eA senior resident remarked:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I had junior residents who were entirely irresponsible and there was no mechanism to follow up on my concerns. I tried everything but could not make them understand that patients are not movable money and that you are responsible for them. I was not one to pick fights with juniors, but there really was no mechanism for follow-up.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA female resident said:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There is no routine or order. When a resident repeatedly commits faults, no one asks why. Instead, rumours and gossip start: \u0026lsquo;she is dumb,\u0026rsquo; \u0026lsquo;irresponsible,\u0026rsquo; \u0026lsquo;a scoundrel who wants to slack off.\u0026rsquo; The issue must be clarified, and there should be a proper procedure to investigate problems.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbsence of legal protections for residents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResidents repeatedly expressed a sense of helplessness due to the lack of protective regulations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When people visit their family physician, they immediately receive a message asking whether they were satisfied with the services. During residency, there should be monitoring of residents\u0026rsquo; conditions so that residents can provide feedback and the system can ensure that residents\u0026rsquo; rights are respected.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Humans have impulses toward dominance, aggression, and competition; a system that controls these impulses needs a third party between you and me\u0026mdash;something beyond the individual that we both commit to, such as the law. I repeatedly encountered this gap in medicine. There was no authority to whom I could appeal and ask whether what I experienced was punishment or violence, and whether I truly deserved punishment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we initially aimed to explore the processes of giving feedback and experiencing punishment within educational and professional environments. However, the trajectory of our inquiry unexpectedly led us to the concept of violence. It became evident that violence, in its very nature, is fundamentally distinct from punishment\u0026mdash;not only in terms of its intensity and impact, but also in its lack of corrective or educational intent. From the standpoint of medical ethics, this distinction is profoundly significant, as violence functions neither as a pedagogical tool nor as a means of growth. Rather, it constitutes an experience that undermines human dignity, erodes the sense of security, and weakens trust within interpersonal and professional relationships. In environments where violence prevails, respect for others\u0026mdash;one of the core principles of ethics in both medicine and education\u0026mdash;is replaced by fear and passivity. This, in turn, reflects a departure from the moral and human values that ought to govern such settings.\u003cspan dir=\"RTL\"\u003e\u003cbr\u003e\u0026nbsp;\u003c/span\u003eThe findings of this study indicate that the violence\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eis reproduced within a context characterized by the normalization of violence, hierarchical relations, and legal and regulatory voids. A review of prior research shows that most studies have avoided the term \u003cem\u003eviolence\u003c/em\u003e to describe residents\u0026rsquo; experiences, instead employing terms such as \u003cem\u003eBullying\u003c/em\u003e, \u003cem\u003eMistreatment\u003c/em\u003e, \u003cem\u003eHarassment\u003c/em\u003e, \u003cem\u003eDiscrimination\u003c/em\u003e, and \u003cem\u003eIntimidation\u003c/em\u003e [14,\u003csup\u003e19\u003c/sup\u003e,\u003csup\u003e20\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eAverbuch T et al. conducted a systematic review of 68 studies published between 1999 and 2021 and reported that the most prevalent bullying behaviors included excessive workload, followed by humiliation, isolation, and professional undermining. Among 34,982 resident participants, only 28.9% reported being bullied, and 57.2% of these individuals believed that reporting the incident yielded no positive outcome. The authors identified \u003cem\u003eNormalization of bullying\u003c/em\u003e as one of the \u003cem\u003eFacilitators\u003c/em\u003e of bullying behaviors, mentioned in ten studies [14]. Similarly, in the systematic review by Leisy and Ahmad, the main perpetrators of mistreatment were colleagues or physicians occupying higher hierarchical positions, reported at 69.8% in the United States and up to 90% in some Asian\u0026ndash;African countries [\u003csup\u003e21\u003c/sup\u003e]. In the study by Torabi et al. (2022) conducted in Iran, 95% of residents reported experiencing bullying\u0026mdash;60% by faculty members and supervisors and 73% by senior residents [15].\u003c/p\u003e\n\u003cp\u003eVanstone and a colleague, in their paper on medical education and social power, argue that social power in medicine shapes both behavior and knowledge, functioning as a potentially constructive or destructive force. They identify social power and medical hierarchy as the central mechanisms of their analysis and categorize power in medicine into three dimensions: \u003cem\u003eInteractional\u003c/em\u003e, \u003cem\u003eStructural\u003c/em\u003e, and \u003cem\u003eSymbolic\u003c/em\u003e. A major distinction between their work and the present study lies in the focus: while they emphasize the impact of social power on residents\u0026rsquo; learning experiences, our study centers on the lived experience of punishment and violence. They contend that medical education research should explicitly integrate social power into analytical and interpretive models rather than treating it as a peripheral element\u0026mdash;since, as they note (and we add, this is also true in medical ethics), researchers often fail to conceptualize power as a \u003cem\u003eMediation Mechanism\u003c/em\u003e. [11]\u003c/p\u003e\n\u003cp\u003eThe classification and typology of various forms of violence undoubtedly play a crucial role in achieving a more precise understanding of this social phenomenon and enable its systematic and scientific analysis. However, mere attention to the manifestations and categorizations of violence is insufficient; it is essential to move beyond such classifications and examine the underlying causes and contextual factors that give rise to different levels and intensities of violence. A deeper understanding of the origins and persistence of violent behavior can provide more profound insights into its nature and pave the way for the development of effective strategies aimed at its prevention and reduction.\u003c/p\u003e\n\u003cp\u003eOur findings, analyzed within Rita Segato\u0026rsquo;s theoretical framework of the \u003cem\u003ePedagogy of Violence\u003c/em\u003e and \u003cem\u003eCounter-Pedagogy of Violence\u003c/em\u003e, reveal that medical education in Iran\u0026mdash;\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e probably similar to other hierarchical systems in all over the world\u0026mdash;reproduces mechanisms of domination, fear, and unconditional obedience, perpetuated in the absence of effective oversight systems. Segato conceptualizes the \u003cem\u003ePedagogy of Violence\u003c/em\u003e as a process in which social learning\u0026mdash;in this case, medical residency training\u0026mdash;occurs through humiliation, repression, and exclusion. From childhood onward -in this case, beginning of clinical education for medical students-, individuals are taught to perceive domination as natural, violence as legitimate, and subordination as an intrinsic part of social order\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e [\u003csup\u003e22\u003c/sup\u003e].\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eIn educational sciences, \u003cem\u003epedagogy\u003c/em\u003e refers to the totality of methods, institutions, and systems through which societies transmit behaviors, values, and emotions. Segato deliberately uses the term \u003cem\u003epedagogy\u003c/em\u003e beyond its conventional academic meaning to emphasize that we are dealing with a much broader educational system that routinely endorses and reproduces violence. Hence, violence is not an isolated event caused by individuals; it is a systemic phenomenon that is learned and perpetuated [\u003csup\u003e23\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eWithin the context of residency education, this manifests in non-corrective and humiliating feedback, unwritten punitive practices, structural silence, and the neglect of residents\u0026rsquo; psychological harm. The data from this study demonstrate that excessive on-call duties, exclusion from educational groups, stigmatization, verbal, psychological and sexual harassment\u0026mdash;all represent expressions of this \u003cem\u003ePedagogy of Violence\u003c/em\u003e that fuses learning with submission.\u003c/p\u003e\n\u003cp\u003eDe Vito similarly reports that among medical residents in Latin America, hierarchical power structures and a culture that glorifies overwork and absolute obedience produce a form of \u003cem\u003esymbolic violence\u003c/em\u003e (in Bourdieu\u0026rsquo;s terms)\u0026mdash;an internalized, invisible, and self-reinforcing phenomenon [21]. The present study corroborates this trend: residents internalize violence, interpret it as part of \u0026ldquo;good training\u0026rdquo; or \u0026ldquo;rigorous discipline,\u0026rdquo; and later reproduce the same patterns toward junior residents. This vertical reproduction of violence constitutes what Segato calls the \u003cem\u003esocial cycle of violence\u003c/em\u003e, wherein yesterday\u0026rsquo;s victim becomes today\u0026rsquo;s perpetrator.\u003c/p\u003e\n\u003cp\u003eRada-Estarita et al. through a qualitative study among surgical faculty, found that dominant narratives of the \u0026ldquo;good surgeon,\u0026rdquo; \u0026ldquo;self-sacrificing physician,\u0026rdquo; and \u0026ldquo;committed doctor\u0026rdquo; serve as tools for normalizing exhaustion, silence, and exclusion of residents\u0026mdash;forming part of a departmental culture that asserts: \u0026ldquo;if you cannot devote yourself completely, you do not belong here.\u0026rdquo; Our findings reflect the same logic, portraying the ideal resident as \u0026ldquo;omniscient, ever-present, and immune to basic human needs such as sleep or rest.\u0026rdquo; This expectation engenders a \u003cem\u003eSacrificial Ethics\u003c/em\u003e in which the \u0026ldquo;good resident\u0026rdquo; is one who endures suffering without complaint. Segato terms this the \u003cem\u003ePedagogy of Cruelty\u003c/em\u003e (as a pedagogy of obedience to violence) [\u003csup\u003e24\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eFrom a medical ethics perspective, this condition has dual consequences: on one hand, it leads to \u003cem\u003emoral desensitization\u003c/em\u003e and the erosion of empathy; on the other, it distances clinical education from its primary purpose\u0026mdash;the cultivation of morally conscious physicians. As Hafferty argues in his analysis of the \u0026ldquo;hidden curriculum\u0026rdquo; in medical education, the true values of an educational system are conveyed not through official curricula but through unwritten behaviors, rewards, and punishments\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e[\u003csup\u003e25\u003c/sup\u003e]. According to the findings of this study, the residency education structure in Iran also embodies a hidden curriculum that fosters a form of \u003cem\u003enegative moral formation\u003c/em\u003e through mechanisms of silence, humiliation, and fear.\u003c/p\u003e\n\u003cp\u003eA key element in Segato\u0026rsquo;s theory is the distinction between violence as an instrument of order and violence as the pleasure of domination. She argues that in the \u003cem\u003ePedagogy of Violence\u003c/em\u003e, perpetrators often derive a sense of empowerment from their \u0026ldquo;capacity to harm,\u0026rdquo; which is continually reproduced within hierarchical institutions [22]. We conceptualized this dynamic as the \u0026ldquo;Instruments of power and inclination toward violent behaviour\u0026rdquo;. In the participants\u0026rsquo; experiences, this pleasure of domination occasionally manifests as shouting in the operating room, public humiliation during morning reports, or the denial of residents\u0026rsquo; requests for leave. Such acts serve not to \u0026ldquo;correct errors\u0026rdquo; but to reinforce power hierarchies. Our qualitative data reveal that many residents interpret these behaviors as \u0026ldquo;training,\u0026rdquo; and upon becoming faculty, reproduce the same actions\u0026mdash;a process of \u003cem\u003evicarious learning\u003c/em\u003e that De Vito also identifies as one of the driving mechanisms of educational violence [22].\u003c/p\u003e\n\u003cp\u003eIn response to this situation, Segato introduces the concept of the \u003cem\u003eCounter-Pedagogy of Violence\u003c/em\u003e\u0026mdash;an attempt to restore humanity, empathy, and dialogue to the heart of the educational process [22]. This counter-pedagogy calls for \u0026ldquo;seeing the Other as human,\u0026rdquo; rejecting the logic of domination, and emphasizing care as both a political and ethical act [23]. The findings of this study demonstrate that whenever educational interactions were grounded in empathy, participation, and support, learning experiences became more ethical and humane. For example, the resident whose clinical error was discussed in a supportive environment rather than through humiliation exemplifies that the \u003cem\u003eCounter-Pedagogy of Violence\u003c/em\u003e is not an unattainable ideal but a tangible possibility for reforming clinical education.\u003c/p\u003e\n\u003cp\u003eReinterpreting \u003cem\u003econflicts of interest\u003c/em\u003e through Segato\u0026rsquo;s lens also reframes them not merely as ethical or administrative issues, but as manifestations of structural violence and domination within social systems that encourage individuals to prioritize self-interest over collective well-being. In the healthcare system, a physician who privileges financial gain over patient need is not merely committing a professional infraction; rather, this behaviour reflects a cultural logic that objectifies the patient\u0026rsquo;s body and commodifies the act of healing. The same applies to interactions with residents: a clinical supervisor who denies educational or human engagement treats the resident as a tool for fulfilling institutional tasks. From Segato\u0026rsquo;s theoretical perspective, every conflict of interest embodies a form of hidden pedagogy of violence, revealing how cruelty becomes institutionalized. Therefore, addressing conflicts of interest requires more than transparency, regulation, or oversight\u0026mdash;it demands a \u003cem\u003eCounter-Pedagogy of Violence\u003c/em\u003e, that is, education in empathy, care, relational reconstruction, and participatory power.\u003c/p\u003e\n\u003cp\u003eAs a practical intervention model, the \u003cem\u003eA.W.A.R.E.\u003c/em\u003e program proposed by Leisy and Ahmad offers a useful framework for understanding, preventing, and correcting mistreatment in residency training. This model begins with \u003cem\u003eAcknowledge\u003c/em\u003e (recognition and identification of misconduct), followed by \u003cem\u003eWitness\u003c/em\u003e and \u003cem\u003eAct\u003c/em\u003e, which encourage individuals to move beyond passive observation. Finally, \u003cem\u003eReflect\u003c/em\u003e and \u003cem\u003eEmpower\u003c/em\u003e aim to address structural problems at their roots [21]. When integrated with Segato\u0026rsquo;s theory, the \u003cem\u003eWitness\u003c/em\u003e and \u003cem\u003eAct\u003c/em\u003e components can be enriched through principles of empathy, care, and participatory power, while \u003cem\u003eReflect\u003c/em\u003e and \u003cem\u003eEmpower\u003c/em\u003e can promote deeper critical understanding of the underlying crisis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several important limitations that should be acknowledged. First, the relatively small sample size and the inclusion of residents from a limited number of specialties may restrict the transferability of the findings. Despite considerable efforts to recruit residents from surgical specialties\u0026mdash;areas that previous studies have identified as having the highest reports of violence\u0026mdash;almost no surgical residents agreed to participate in interviews, with the exception of one resident from obstetrics and gynecology. This lack of participation limited access to first-hand accounts from surgical training environments. At the same time, the reluctance of surgical residents to take part in the study may itself be meaningful, potentially reflecting intense hierarchical pressures, fear of negative consequences, or the normalization of violence within these fields. A second limitation was the lower willingness of male residents to participate in interviews, resulting in a gender imbalance that may have shaped the perspectives captured in the data. This issue becomes particularly salient when considered alongside the absence of surgical residents, as men constitute the majority of trainees in most surgical specialties in Iran, except for obstetrics and gynecology, which is exclusively open to women. Taken together, these overlapping limitations further narrowed insight into surgical residency environments, while also raising important questions for future research about why male residents may be less inclined than female residents to speak openly about their educational and punitive experiences.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe qualitative analysis of feedback and punishment during medical residency demonstrates that a form of \u003cem\u003ePedagogy of Violence\u003c/em\u003e is structurally embedded within medical education\u0026mdash;a system that teaches residents \u0026ldquo;how to become doctors\u0026rdquo; through humiliation, exclusion, silence, and fear. Yet this process of becoming often comes at the cost of burnout, alienation, and the erosion of empathy. Educational violence is not an exception but a constitutive logic of the medical training system.\u003c/p\u003e \u003cp\u003eIn this context, Rita Segato\u0026rsquo;s concept of the \u003cem\u003eCounter-Pedagogy of Violence\u003c/em\u003e offers both an ethical and practical framework for reconstructing medical education. This model emphasizes dialogue, transparency, mutual care, and equality in power relations, envisioning learning as a process rooted in respect and empathy. At the policy level, it is crucial to revise disciplinary regulations and replace punitive mechanisms with reflective and supportive structures.\u003c/p\u003e \u003cp\u003eFrom the standpoint of medical ethics and medical education, transitioning from a \u003cem\u003ePedagogy of Violence\u003c/em\u003e to a \u003cem\u003eCounter-Pedagogy of Violence\u003c/em\u003e requires training clinical educators in communication, self-awareness, and power management. Without such a cultural transformation, no structural reform can be sustainable. As Freire reminds us, education is either \u0026ldquo;an act of freedom\u0026rdquo; or \u0026ldquo;an act of domination.\u0026rdquo; For medical education to reclaim its ethical mission, it must aim not to produce obedient physicians, but reflective, critical, and compassionate ones.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgments\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge the medical residents who participated in this study for their time, cooperation, and valuable contributions. The authors also acknowledge the use of artificial intelligence\u0026ndash;based tools for language editing and manuscript preparation.\u003c/p\u003e\n\u003cp\u003eFundings\u003c/p\u003e\n\u003cp\u003eThe authors declare that this study was not supported by any funding.\u003c/p\u003e\n\u003cp\u003eAuthor Information\u003c/p\u003e\n\u003cp\u003eAuthors and affiliations\u003c/p\u003e\n\u003cp\u003eLeila Azizi\u003c/p\u003e\n\u003cp\u003eDepartment of Medical Ethics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran\u003c/p\u003e\n\u003cp\u003eMahboobeh Saber\u003c/p\u003e\n\u003cp\u003eDepartment of Medical Ethics, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran\u003c/p\u003e\n\u003cp\u003eContributions\u003c/p\u003e\n\u003cp\u003eStudy Design (LA and MS), Data collection (LA), Transcription (LA), Data Analysis (LA and MS), Manuscript Preparation (LA and MS), Supervision and critical review (MS). Both authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCorresponding Author\u003c/p\u003e\n\u003cp\u003eMahboobeh Saber\u003c/p\u003e\n\u003cp\u003eEmail Address: [email protected]\u003c/p\u003e\n\u003cp\u003eEthics Declarations\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.MED.REC.1403.040) and conducted in accordance with the Declaration of Helsinki and national ethical guidelines. Written informed consent was obtained from all participants, and confidentiality was maintained throughout the study.\u003c/p\u003e\n\u003cp\u003eConsent for Publication\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eData supporting the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlHaqwi AI, Taha WS. Promoting excellence in teaching and learning in clinical education. Journal of Taibah University Medical Sciences. 2015 Mar 1;10(1):97-101.\u003c/li\u003e\n\u003cli\u003eSteelman LA, Levy PE, Snell AF. The feedback environment scale: Construct definition, measurement, and validation. Educational and psychological measurement. 2004 Feb;64(1):165-84.\u003c/li\u003e\n\u003cli\u003eRahimi M, Ehsanpour S, Haghani F. The role of feedback in clinical education: Principles, strategies, and models.\u003c/li\u003e\n\u003cli\u003eEnde J. Feedback in clinical medical education. Jama. 1983 Aug 12;250(6):777-81.\u003c/li\u003e\n\u003cli\u003eRoyal College of Phsycians and Surgeons of Canada. Competence by Design (CBD): What is Competence by design? http://www.royalcollege.ca/ rcsite/cbd/what-is-cbd-e Accessed 27 Sept 2020.\u003c/li\u003e\n\u003cli\u003eYarris LM, Linden JA, Gene Hern H, Lefebvre C, Nestler DM, Fu R, Choo E, LaMantia J, Brunett P, Emergency Medicine Education Research Group (EMERGe). Attending and resident satisfaction with feedback in the emergency department. Academic emergency medicine. 2009 Dec;16:S76-81.\u003c/li\u003e\n\u003cli\u003eSender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. Surgery residents and attending surgeons have different perceptions of feedback. Medical teacher. 2005 Aug 1;27(5):470-2.\u003c/li\u003e\n\u003cli\u003eGovaerts M. Workplace-based assessment and assessment for learning: threats to validity. Journal of graduate medical education. 2015 Jun 1;7(2):265-7.\u003c/li\u003e\n\u003cli\u003eWatling CJ, Kenyon CF, Zibrowski EM, Schulz V, Goldszmidt MA, Singh I, Maddocks HL, Lingard L. Rules of engagement: residents\u0026rsquo; perceptions of the in-training evaluation process. Academic Medicine. 2008 Oct 1;83(10):S97-100.\u003c/li\u003e\n\u003cli\u003eCantillon P, De Grave W, Dornan T. Uncovering the ecology of clinical education: a dramaturgical study of informal learning in clinical teams. Advances in Health Sciences Education. 2021 May;26(2):417-35.\u003c/li\u003e\n\u003cli\u003eVanstone M, Grierson L. Thinking about social power and hierarchy in medical education. Medical education. 2022 Jan;56(1):91-7.\u003c/li\u003e\n\u003cli\u003eVanstone M, Grierson L. Medical student strategies for actively negotiating hierarchy in the clinical environment. Medical education. 2019 Oct;53(10):1013-24.\u003c/li\u003e\n\u003cli\u003eLerchenfeldt S, Mi M, Eng M. The utilization of peer feedback during collaborative learning in undergraduate medical education: a systematic review. BMC medical education. 2019 Aug 23;19(1):321.\u003c/li\u003e\n\u003cli\u003eAverbuch T, Eliya Y, Van Spall HG. Systematic review of academic bullying in medical settings: dynamics and consequences. BMJ open. 2021 Jul 1;11(7):e043256.\u003c/li\u003e\n\u003cli\u003eTorabi N, Shakiba B, Vaseghi H, Maghsoudi R, Alimoradzadeh R, Irani S, Dini P. Perceived Workplace Bullying and Mental Health Status among Medical Residents in Iran. Journal of Iranian Medical Council. 2022 Oct 1;5(4):557-66.\u003c/li\u003e\n\u003cli\u003eAssadpour, N., Alazmani-noodeh, F., Baniyaghoobi, F. et al. Factors influencing quality of professional life and perceived bullying among medical residents in Iran. BMC Med Educ 25, 217 (2025). https://doi.org/10.1186/s12909-025-06724-8\u003c/li\u003e\n\u003cli\u003eGraneheim UH, Lindgren BM, Lundman B. Methodological challenges in qualitative content analysis: A discussion paper. Nurse education today. 2017 Sep 1;56:29-34.\u003c/li\u003e\n\u003cli\u003eStenfors T, Kajamaa A, Bennett D. How to\u0026hellip; assess the quality of qualitative research. The clinical teacher. 2020 Dec;17(6):596-9.\u003c/li\u003e\n\u003cli\u003eLall MD, Bilimoria KY, Lu DW, Zhan T, Barton MA, Hu YY, Beeson MS, Adams JG, Nelson LS, Baren JM. Prevalence of discrimination, abuse, and harassment in emergency medicine residency training in the US. JAMA network open. 2021 Aug 2;4(8):e2121706-.\u003c/li\u003e\n\u003cli\u003eSzafran O, Woloschuk W, Torti JM, Palacios Mackay MF. Intimidation, harassment, and discrimination during family medicine residency training: a mixed methods study. BMC medical education. 2021 Mar 20;21(1):173.\u003c/li\u003e\n\u003cli\u003eLeisy HB, Ahmad M. Altering workplace attitudes for resident education (AWARE): discovering solutions for medical resident bullying through literature review. BMC medical education. 2016 Apr 27;16(1):127.\u003c/li\u003e\n\u003cli\u003eDe Vito EL. Towards a counter-pedagogy of cruelty in medical residencies. MEDICINA (Buenos Aires). 2025 Apr;85(1):148-.\u003c/li\u003e\n\u003cli\u003eSegato R. Contra-pedagog\u0026iacute;as de la crueldad.\u003c/li\u003e\n\u003cli\u003ede De Carvalho RL. La guerra contra las mujeres. Traficantes de sue\u0026ntilde;os; 2020.\u003c/li\u003e\n\u003cli\u003eHafferty FW. Beyond curriculum reform: confronting medicine\u0026apos;s hidden curriculum. Academic medicine. 1998 Apr 1;73(4):403-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Medical Residents, Feedback, Punishment, Medical Education, Clinical Environment, Medical Hierarchy, Violence, Pedagogy of Violence, Power Imbalance","lastPublishedDoi":"10.21203/rs.3.rs-8417993/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8417993/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMedical residents\u0026rsquo; education and learning are inherently situated within hierarchical clinical environments shaped by power relations. Professional feedback is a central component of clinical education and plays a critical role in residents\u0026rsquo; professional and clinical development. However, evidence shows that feedback is often influenced by power imbalances and, rather than serving a formative and educational role, may become punitive, non-constructive, or even violent. Given frequent reports of burnout, bullying, harassment, and adverse psychological outcomes among medical residents in Iran, a qualitative examination of residents\u0026rsquo; lived experiences of feedback, punishment, and violence in clinical education is warranted.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThis qualitative study used conventional qualitative content analysis based on the Graneheim and Lundman approach. Participants were 8 medical residents (currently in training or graduated within the past 3 years) from diverse medical specialties and educational centers across Iran who had experienced feedback and punishment during residency. Data were collected through in-depth semi-structured interviews conducted between January and March 2024 and analyzed inductively. Peer debriefing enhanced the credibility of the findings.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe analysis yielded 4 main categories, 9 subcategories, and 20 initial codes. Participants described professional feedback as a continuum ranging from \u0026ldquo;supportive and corrective feedback\u0026rdquo; to \u0026ldquo;punishment\u0026rdquo; and ultimately \u0026ldquo;violence.\u0026rdquo; Feedback delivered with respect, clarity, and an explicit educational purpose supported learning, error correction, and professional development. In contrast, feedback provided in humiliating, nontransparent, or rigidly hierarchical contexts often lost its educational value. Punishment\u0026mdash;particularly informal practices such as assigning extra on-call shifts\u0026mdash;was perceived as a gray zone between feedback and violence. Participants reported multiple forms of violence, including soft and hard, as well as structural and institutional violence. The normalization and repetition of violent behaviors, hierarchical organizational structures, conflicts of interest, and gaps in legal protections facilitated the transformation of feedback into a harmful experience.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings reveal a violence-based pedagogy embedded in medical residency education, linking learning to fear, humiliation, and compliance. Creating a more humane and ethical training environment requires revising disciplinary policies, strengthening supportive and legal frameworks, and equipping clinical educators with skills in power awareness, participatory power, effective communication, and care-cantered ethics.\u003c/p\u003e","manuscriptTitle":"When Professional and Educational Feedback Turns into a Cycle of Violence: A Qualitative Study of Educational and Punitive Interactions During Medical Residency","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-28 15:57:40","doi":"10.21203/rs.3.rs-8417993/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-16T07:57:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"284501870279537010120743971108874433192","date":"2026-02-02T13:55:36+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-23T08:07:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-22T10:58:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-05T19:37:55+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-05T00:29:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-05T00:23:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"890e1ca8-96fc-4c0e-9ce7-e7b744971964","owner":[],"postedDate":"January 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T15:57:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-28 15:57:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8417993","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8417993","identity":"rs-8417993","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}