Under the Covert Norm: A Qualitative Study on the Role of Residency Culture on Burnout

Under the Covert Norm: A Qualitative Study on the Role of Residency Culture on Burnout | 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 Under the Covert Norm: A Qualitative Study on the Role of Residency Culture on Burnout Mónica Armas-Neira, Ithandehui Jaimes-Jiménez, Bernardo Turnbull, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4584423/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Apr, 2025 Read the published version in Social Psychiatry and Psychiatric Epidemiology → Version 1 posted 14 You are reading this latest preprint version Abstract Purpose: Burnout has become a major concern within healthcare. Medical residents comprise a notorious at-risk population with around half of its population affected. While previous work highlights the role of organizational risk factors as the main contributors to occupational burden, research on culture in medicine as a potential organizational risk factor is limited. The main objective of this qualitative study was to explore the expressions of the cultural norm from the medical residents’ perspective to set the stage for future high-impact interventions. Methods: Data were gathered from 87 semi-structured interviews with residents in Mexico City and analyzed through a grounded theory lens. Results: The analysis uncovered harmful customary practices within medical residency culture. A distorted hierarchical system was responsible for promoting abusive power dynamics that fed into a ‘covert norm’ that continually infringed on formal regulations. This system is partly sustainable due to poor reporting mechanisms and self-perpetuating behaviors through normalization and violent enforcement. Conclusion: The findings suggest that burnout was independently associated with and occurred in the context of covert conventions that defy guidelines. Further studies are needed to assess proper organizational interventions that reject covert sociocultural normative conformity for a more humanistic side of medical culture. burnout medical residency risk factors sociocultural norms workplace violence Figures Figure 1 1. Introduction Burnout is characterized by a combination of emotional exhaustion, unhealthy detachment, and reduced professional efficacy following extended work-related stress [ 1 ]. Healthcare professionals carry a burdensome degree of burnout that directly interferes with their quality of life and capacity to deliver optimal patient care [ 2 ]. Medical residents are particularly at risk due to the inherently demanding nature of their training. The escalating prevalence of this occupational disorder during residency is alarming, present in at least fifty percent of US medical residents [ 3 , 4 ] and at similar rates internationally [ 5 – 8 ]. Traditionally, burnout risk factors are classified into organizational aspects that pertain to the environment and individual elements that relate to inherent traits [ 9 ]. Structural risk factors include a perceived lack of meaning at work, fatigue, and exhaustion, cultural norms in medicine, the steep learning curve from medical school to residency, and social relationships in and outside the field [ 9 ]. The research to date highlights the role of organizational risk factors as the main contributors to occupational burden [ 10 ]. However, fewer studies have explored the cultural norm in medicine as an organizational factor playing a role in burnout, resulting in scarce viable interventions on that front [ 11 ]. Certain phenomena concerning the culture of residency have been studied in the past in association with occupational distress, representing an opportunity to understand the influence of sociocultural norms [ 1 ]. Moral injury, for instance, ensues when we commit, witness, or fail to stop an action that violates our core ethical values [ 11 ]. Failing to deliver proper patient care due to external factors beyond control undermines the value of the caregiver’s role and the patient’s needs. The concept of moral injury goes hand in hand with the hidden curriculum. Initially developed as a classroom concept, the hidden curriculum has expanded to an unofficial influence on the ethical culture, norms, and rules inside any educational setting through role modeling [ 12 ]. In the healthcare context, it represents a set of unwritten, and mostly unintended, lessons from senior physicians that shape expected values, beliefs, and behaviors, usually resulting in behavior that contradicts bioethical principles [ 1 ]. The transmission of these covert practices is mostly guaranteed by the pressure of power dynamics between learners and senior physicians [ 13 ]. Evidence points to further sociocultural norms that deviate from established guidelines, impeding ideal professional development and contributing to burn-out—particularly those pertaining to interpersonal relationships between residents. In a study on workplace bullying, 29% of residents mentioned hierarchy as the main contributing factor to mobbing in medical residency, followed by “customs and habits in the medical field” with 28% [ 14 ]. The relational context in the medical field operates under strict hierarchical control [ 15 ]. Traditional medical hierarchies are typically an inflexible omnipresent feature of clinical settings to which medical learners, like residents, are subjected with little to no chance of retort [ 16 ]. Conferred ranks are determined by continually demonstrating worthiness, with academic and clinical trajectories as the most valued assets [ 17 ]. In a Mexican study on violence in clinical environments, the prevalence of inappropriate behaviors reached 52.3% in medical residencies, with psychological violence as the most frequent manifestation [ 18 ]. The attendings were recognized as the most frequent perpetrators of abuse (24%), followed by higher-ranking residents (21.5%) and female medical staff (13.7%). The learning environment encountered was described as unpleasant, competitive, and tense among medical residents, particularly perceived by first-year residents, suggesting abuses in power relations. Ideally, guidelines and regulations should set precedents for appropriate behavior and ensure the well-being and fair treatment of all. Nonetheless, the current clinical learning environment suggests a systematic failure to enforce proper norms with dysfunctional dynamics that stray from legal standards [ 18 ]. National law places residents under an already vulnerable hybrid category, not fully employee or student [ 19 ]. It also stipulates that internal program guidelines will expand on the obligations, duties, and benefits, subjecting residents to comply with the medical facility's needs. Some of these protocols have been longstanding, such as the eligibility requirements, clinical responsibilities, curriculum requirements, and duties delegated according to seniority. In contrast, other standards have been ambiguous in their enforcement or implemented relatively recently, including formal work-hour limitations and resident mistreatment monitoring. While the literature on burnout in medical residents is expanding, it is largely limited to the incidence analysis, risk factors of an individual nature, and their corresponding interventions. The studies that delve into organizational factors mention the interplay of cultural norms specific to the clinical settings of medical residency [ 17 ]. Despite these findings, much remains unknown about the dynamics of sociocultural norms in medical residency. Previous work on the population of interest measured the psychological well-being of medical residents by uncovering burnout prevalence, allowing a framework from which to elaborate [ 20 ]. In this study, we intend to explore the role of the cultural norm in medicine as a structural risk factor for burnout through the resident's perspective. This research could be a crucial step toward improving the safety and well-being of medical residents in Mexico and similar settings. 2. Materials and Methods 2.1 The Setting, Participants, and Study Design The current qualitative study followed an inductive approach for data gathering from a medical resident population within a public hospital network. The characteristics that define qualitative research – such as flexibility, openness, and responsivity to context – were ideal for confronting the increasing demands for research on the conditions of medical residency training. A grounded theory design was appropriate for further exploration of each participant's experience and to facilitate a detailed analysis of risk factors, expressions, and social interactions within a population with high burnout prevalence [ 21 ]. The team strove to create a theoretical model capable of comprehending the resulting phenomena from medical residents' personal and occupational experiences amidst training. Potential participants were identified from 9 public hospitals affiliated with the Mexico City Health Ministry (Secretaría de Salud) and data collection was achieved via snowballing and convenience sampling. Trainees were voluntarily recruited through e-mail and text messages until meaning saturation was achieved. The study was organized in four phases: 1) Instrument validation, 2) Initial observations, 3) Semi-structured in-depth interviews, and 4) Focus groups to validate results. We aimed for a purposive sample that allowed data saturation while anticipating some attrition between the focus groups and interviews. All reporting was crafted in accordance with the COREQ (Consolidated for Reporting Qualitative Research) guideline [ 22 ]. 2.2 Data Collection We designed two instruments, one for direct observations and one for semi-structured interviews. The interview covered topics including personal experience sections, such as their relationship with the residency program environment, professional fulfillment and motivation, presence of workplace violence, thoughts on quitting, and key moments related to physical and emotional symptoms of burnout. After pilot testing, both instruments were re-evaluated and modified during group sessions to be implemented in phases two and three, which were conducted simultaneously. Interviews were conducted in Spanish and audio recorded with an average duration of 60 minutes [ 23 ]. Transcriptions were verbatim, only excluding filler words for improved visualization during analysis. All identifying characteristics were carefully removed from the interview transcripts to reduce threats to confidentiality. Phase four implemented focus groups to validate findings with residents who had previously participated in individual interviews. 2.3 Ethical Considerations Prior to fieldwork, the research protocol was approved by the internal ethical review board at the Mexico City Health Ministry (CONBIOETICA-09-CEI-004-20180213). This study adhered to ethical standards and regulations, including informed consent, confidentiality, and the freedom to withdraw from the study at any point [ 24 ]. Participants were not compensated for their contribution to the study, and participation was voluntary. Consent forms containing identifiable information were securely stored in an office under lock and key to impede any breach of confidentiality. 2.4 Data Analysis Initial analysis was conducted in parallel with data gathering from interviews and observations. We acquired the data analysis software Atlas.ti to facilitate the coding processes accomplished by the same investigators who conducted and transcribed the interviews. Following grounded theory core steps [ 25 ], researchers exercised open coding around themes that described risk factors, protective factors, coping mechanisms, re-percussions, external factors, and expressions of burnout, identifying 136 initially. We then reviewed and redefined each concept during weekly meetings through axial coding to establish standard relationships. For this study, only codes associated with burnout risk factors that dealt with medical culture were strung together via selective coding to integrate them coherently under four core categories: Dysfunctional hierarchy, power abuse, lack of overt norm enforcement, and perpetuation. Selected quotes were translated into English by the lead author involved in the data collection phase. Lastly, we gained insight into our theoretical framework by tying our themes to a central concept denominated the ‘covert norm’ as an all-encompassing organizational risk factor for burnout. 3. Results Eighty-seven participants from 12 medical specialties, including surgical and non-surgical specialties, took part in this study. More than half (72%, n = 63) were female with pediatrics (26%, n = 23) and OBGYN (17%, n = 15) as the most represented specialties. The sample was diverse in terms of seniority with mostly first-year residents (39%, n = 34), followed by second-year (26%, n = 23), third-year (21%, n = 18), and senior residents from the 4th year and upwards at last (14%, n = n). Our analysis centered on risk factors identified 20 main themes with poor academia and hierarchy as the most mentioned topics, followed by work hours and punishments. Medical residents shared experiences of psychosocial challenges through the enforcement of covert sociocultural conventions among colleagues. Such conventions included behaviors under a dysfunctional hierarchical system, that evolved into abusive power dynamics, feeding into a covert norm that continually infringes on formal regulations. This system is sustainable under a lack of overt norm enforcement with poor reporting mechanisms that allow a climate of impunity and, ultimately, a self-perpetuating cycle of normalization and enforcement through violence (Fig. 1 ). 3.1. Dysfunctional hierarchy Regarding hierarchy, participants acknowledged the intrinsic positive value in the fair distribution of tasks depending on rank. Ideally, this would allocate patients based on complexity to properly handle the bulk of work. "We couldn't have the same amount of work because the intern doesn't possess the intellectual capabilities acquired by a senior resident with over two years of experience. It's preferable to instruct the intern to handle sample transportation while assigning the critical patient to the senior." (Third-year, male, ER). However, they also recognized a common divergence from a proper top-down structure in clinical settings, reflecting an uneven distribution of work with an increasing sense of powerlessness at the bottom ranks. "...I know that the second-year residents already went through their first year and don't want to do intern things anymore, but many times, they are not doing anything, and you are overwhelmed with work, and they don't lift a finger. So well, I can't say anything to them because they've already gone through it, they've suffered, so now it's your turn." (First-year, male, surgery). These cultural norm practices culminate in a poor teamwork dynamic and overtime work with little to no recognition or appraisal from superiors. The uneven distribution of work appears to be the standard [ 26 ]. "There are times when… there are no residents because it's an academic day or something. The attendings are in a bad mood and upset because they must do all the work. The attending does supervise, check, and see things, but the actual work, the JOB, is done by the resident." (Second-year, female, pediatrics). Additionally, junior residents described an inability to act or speak out against problematic behavior from higher-ranking positions, resulting in a lack of bottom-up accountability. Some even described it as a constant feeling of hopelessness. "We've noticed that he [referring to attending] does enact a bit of violence against women. So, there's also this sense of helplessness, not being able to do anything. Because you're a junior, right? In this case, you're like the weakest link, so to speak. So, you can't contradict him. So, many times, he has blamed us […] He still performs Kristeller. Many times you don't even see the head, and the patient is already tired of pushing, and he just goes ahead and does it. So, he dilates them. I mean, literally with his hand, and the patients scream." (First-year, female, OBGYN). When asked to clarify, the participant mentioned witnessing violence carried out against patients in labor in the form of outdated and unethical practices. The resulting moral injury from this experience accompanies a sense of futility and powerlessness to exert change. 3.2. The fall into power abuse and covert power dynamics Residents who reported the presence of an imbalanced hierarchy were also prone to experiences of abuse under corrupt power dynamics, including hazing, punishments, extortion, and the use of dehumanizing covert language that accompanies customary practices with their respective internal denominations ("eventeo" and "encargo"). 3.2.1. Hazing We encountered harassment in the form of hazing, consisting of belittling and threatening behaviors directed at individuals (Sawant et al., 2019). Such mistreatment was mainly directed at first-year residents, marking transitional periods within the hierarchy through perceived customary practices [ 14 ]. "To prove that you were a good PGY2 [...] you had to make an intern resign. So, when I started, I was like the weakest link, so everyone treated me awful to make me resign, and the senior residents made a bet to see how many days I would last." (Fourth-year, female, surgery). The unfair distribution of work went beyond formal clinical duty, superiors would assign menial tasks to humiliate the individual. "Something that was particularly humiliating, but it had to be done because you are the intern, you are the "little one," was washing dishes and cleaning the kitchenette of the hospital [...] In other words, apart from everything you do, you had to clean and wash dishes, and they have to be nice and tidy." (Third-year, Female, anesthesiology). 3.2.2. Punishments Enforcement of negative feedback secondary to medical errors is promoted and incentivized by authorities. The consequences are frequently excessive and out of proportion, threatening physical and psychological violence at times. "In this type of environment, I was PGY2, and they [senior residents] would say, 'Why don't you keep them [assign them extra hours]? Why don't you hit them? I support you if you want to keep them. Yes, let them stay." (fourth-year, female, surgery). 3.2.3. Extortion A particularly violent customary practice was the extortion of peers. Several participants mentioned the pressure to pay tribute through financial or material means to avoid punishment or gain the right to basic clinical knowledge and practice. “I remember that to keep the attendings happy, when I started my residency, we had to buy them things, buy them food, and even alcohol that they wanted to consume inside the hospital. If we didn't comply with that, we didn't get to operate.” (Second-year, male, surgery). Several residents were asked to infiltrate alcohol inside the workplace for their superiors, feeling forced to transgress formal regulations and ethical considerations. "They told me, 'You have to step up, you have to get us some beer.' it was then that I had to decide between starting a revolution myself and dealing with the paperwork because they asked me to sneak in beers or continue, right? And I thought, what do I do? I'm a first year. No one will listen to me, no one will support me, I'm scared." (Third-year, female, anesthesiology). 3.2.4. Covert language A particular vernacular accompanies the covert norm, describing and normalizing unlawful practices with day-to-day terminology. Participants described dehumanizing speech patterns that preceded other harmful behavior. "They don't address you by your name. They call you a dog, and they use, well, even more offensive words […] They don't let you speak; you have no voice. If something goes wrong and you know you didn't do it, you still must take the blame for it. You can't know more than your senior resident. That's also wrong." (Second-year, male, surgery). Residency culture also engages in the fabrication of neologisms to refer to unique events inside the clinical setting. Residents define "Eventeo" as the tradition of partying within hospital property, typically involving heavy alcohol use and other recreational substances. "We've heard about other hospitals, where imagine this... they say, 'today's an Evento,' then they give a list to the interns and say 'go buy everything.' You spend 4 or 5 thousand pesos on drinks so the attendings and senior residents can lock themselves in the residence." (first-year, male, surgery). Participants described being targeted by superiors, including a type of blacklisting practice called "Encargo", a sardonic expression given that the direct translation is "to take responsibility for something/someone". "So, as you go through different rotations every six months, it's like, 'you caused trouble here, you snitched, and you cried [...] When you go to your other hospital, everyone there is our friend, fellow residents, and so on. I'm going to "encargarte" to them, so they treat you badly, and you won't be admitted to the operating room." (Second-year, male, surgery). 3.3. The fall into power abuse and covert power dynamics Furthermore, overt norm transgression meets no resistance due to scarce, bordering on nonexistent, monitoring structures for correspondent disciplinary action for offenders. Duty hours pertain a common target, as a formal 80-hour weekly limit for work shifts was just established in 2022 [ 28 ]. "Yes, they gave us guidelines, well, documentation where the departure schedule is clearly established, but it's not something that is followed as such."( First-year, male, pediatrics). The lack of anonymity in reporting mechanisms plays an important role in developing burnout in medical residents, with a counterproductive outcome at best and retaliation at worst. "He said, 'Well, what are you going to do? If you want, you are free to submit a document at the central level, and the corresponding procedure will be carried out,' he said, 'but what will happen is that they will also expose you and everything you have done wrong.' So, it's like a threat, isn't it? 'if you do it, there will be consequences for you too." (First-year, female, pediatrics). A common threat pertains to deliberately obstructing their training, targeting the intrinsic purpose of a specialty program. This is a predominant trend, particularly in surgical specialties where hands-on practice becomes invaluable in developing operative experience. Under these threats, residents are left vulnerable to exploitation by the system they work for. "Just recently, the residents complained about mistreatment, long shifts, punishments, blah, blah, blah, and they were transferred to another hospital. They spent three weeks at the new hospital, and they were told, 'you know what? Return to your original location.' Now they are treated like outcasts, 'you were the ones who complained, the ones who cried. None of you will enter the operating room for the remainder of your time here. You'll be handling other tasks, but you won't step into the OR. ' And your surgical training ends up compromised.” (Fourth-year, female, surgery). 3.3. The fall into power abuse and covert power dynamics Testimonies from senior residents pose a dichotomy. On the one hand, normalizing behaviors associated with the covert norm by resorting to downplay complaints from lower-ranking members. Others resented these behaviors and avoided perpetuating them, even to their detriment. "Perhaps in younger generations, things have changed a bit. With those who are called "the crystal generation," it's very noticeable. They complain about things they shouldn't, like, 'Oh no, they're so mean to me and stuff. 'It's like they enjoy playing the victim card. So maybe that makes it more challenging because it is challenging. (…) And then they say, 'No, they spoke badly of me, they mistreat me and all that.' We're all adults here, and you know what you have to do." (Fourth-year, male, surgery). Higher rank residents and attendings would commonly equate abusive treatment to ideal hierarchy management. Stern behavior towards subordinates was praised. "A doctor used to tell me: 'They are your dogs, you kick them, you punish them, you keep them overnight,' and I also had problems because of that, because I didn't mistreat others, and they said that it was a lack of character." (Fourth-year, female, surgery). 4. Discussion The present study reflects the perceptions of medical residents under the scope of informal practices that further increase their risk for burnout syndrome. Participants described formal residency guidelines being reduced to little more than recommendations regarding their rights. Open-ended wording regarding work conditions, such as the maximum length of a continuous shift and number of hours per week, can ultimately allow the existence of loopholes. Individual health institutions can then misuse them to compensate for the lack of personnel and resources in times of high demand. All this while the covert norm, a work culture not dissimilar to institutionalized hazing, seizes control of the narrative in the resident's day-to-day life. Standard training is characterized by conditions of stress, long hours of work, and poor pay. On top of that, residents must navigate strict hierarchy dynamics that heavily target lower-ranking interns through intimidation, belittling, harassment, and moral injury-inducing practices [ 1 ]. Scales of power determine who remains silent regarding the portrayal of out-of-norm behaviors [ 15 ]. In this study, junior residents resigned their right to report malpractice and norm violation out of fear of punishment and workplace ostracism. A study at UCLA found that fear of reprisal is a major barrier to reporting mistreatment, even in anonymity [ 29 ]. On the other hand, the few residents who gain the courage to initiate the process are met up with inefficient reporting mechanisms that cannot guarantee their protection. Eventually, the presence of abusive practices becomes as ordinary as witnessing clinical formation inside the hospital. This feeds into the perception that medical culture must include mistreatment [ 29 ]. Moreover, there appears to be a sense of pride linked to the amount of abuse withstood, creating a customary practice meant to be passed down to younger generations. During interviews, some senior residents mentioned being pressured by attendings to perpetuate violent practices against interns, while others ended up developing unfavorable views towards their lower-ranking colleagues. Ultimately, the culture strives to force residents to abide by the unspoken rules, whether by the threat of systematic violence or by the persuasion of reaping its benefits down the line. In a systematic review, nearly all studies identified the organizational aspects of work as the focal risk factors for burnout [ 10 ]. Heavy workloads and lack of time remained the top common complaints, while relational factors such as problems in the chain of command and experiences of discrimination were close seconds. According to an extensive review, the perception of injustice and the lack of social support due to internal conflicts with peers are critical organizational triggers for this syndrome [ 30 ]. Covert practices also raised ethical concerns for participants. Testimonies varied from witnessing questionable management to downright violence against patients, surpassing the boundaries of their moral beliefs. Over time, these events culminate in a moral injury that adds to the distress for the medical professional in training [ 11 ]. Similarly, enforcing a dysfunctional hierarchy results in a hostile workplace environment. Colleagues are frequently pitted against each other for the approval of high-ranking clinicians. Impression management is common in the medical field and can be optimal when it promotes a positive impression through competent patient care [ 31 ]. However, if residents mold their behavior according to standards based on situational norms, it can lead to the distortion of professional behavior by perceiving these behaviors as acceptable [ 32 ]. The individual impact of burnout includes difficulty in making decisions, poor memory, reduced coping capacity, depression, dissatisfaction with life, drug consumption, and even suicide [ 30 ]. A burnt-out state has also been linked to dishonest clinical behavior, namely cheating, and diminished altruistic values [ 33 ]. These effects eventually translate to low performance at the structural level. Burnout and loss of empathy are associated with an increased risk of self-perceived major medical errors in residents, undermining patient safety [ 34 ]. Supplementary exposure to covert norm practices only accelerates the development of cynicism in physicians in training, impacting their professional empathy development from early on [ 1 ]. The constant feeling of distress ultimately leads to further self-doubt in a vicious cycle of patient care deficit. 5. Conclusions The results of this qualitative study acknowledge that burnout was independently associated with and occurs in the context of institutionalized violence. While it does not establish a causal relationship, we argue that its dynamics hurt future attendings' overall clinical learning environment. Therefore, workplace environment improvement is crucial for the reduction of occupational burnout. In contrast to isolated individual interventions, long-term solutions demand changes in the entire framework of residency culture [ 35 ]. A top-down approach should be more effective regarding the mistreatment based on hierarchy. To improve team dynamics, senior residents and attendings must be trained to promote compassion and respect among colleagues. Support and adequate leadership have been demonstrated to reduce burnout and should be encouraged in the clinical setting [ 30 ]. When correctly implemented, hierarchies can be positive by promoting better social order, effective delegation of tasks, and role expectations. An internal vertical stratification inside the hospital should aspire to assign levels of responsibility accordingly to improve patient safety and personnel accountability. Furthermore, appointing mentors and role models of higher hierarchy should inspire junior medical residents to strive for excellence [ 15 ]. On the other hand, stakeholders in leadership positions, like program directors, must enforce a zero-tolerance policy on occupational violence and harassment. Similarly, bottom-up mechanisms are essential for accountability. Ensuring anonymity might not be enough [ 29 ]. Instead, we propose mechanisms of mandatory bi-directional feedback that allow residents to feel more comfortable speaking out against unlawful practices. Periodic evaluation could also enable careful monitoring of burnout symptomatology. Likewise, reinforcing the formal normative must go hand in hand with these changes, placing monitoring systems that ensure its fulfillment. Further studies are needed to assess proper organizational interventions that reject covert socio-cultural normative conformity for a more humanistic side of medical culture. Declarations Statements and declarations : The authors declare no conflicts of interest. Ethical approval The study was approved by the Ethics Committee of the Mexico City Health Ministry (CONBIOETICA-09-CEI-004-20180213). Consent to participate Informed written consent was obtained from all subjects involved in the study. Funding This research received no external funding. Author Contribution Conceptualization, L.M.-R., B.T.-P., S.O.-M.; methodology, I.J.-J, M.A.-N., A.V.-L., A.L.-C., J.N.-M.; formal analysis, I.J.-J., M.A.-N., B.T.-P.; investigation, I.J.-J., M.A.-N., A.V.-L., A.L.-C., J.N.-M., B.T.-P.; resources, L.M.-R.; data curation, I.J.-J, M.A.-N., A.V.-L., B.T.-P., M.M.-M.; writing—original draft preparation, M.A.-N.; writing—review and editing, M.A.-N., B.T.-P. and I.J.-J.; visualization, L.M.-R., B.T.-P.; supervision, I.J.-J., B.T.-P.; project administration, L.M.-R., S.O.-M. All authors have read and agreed to the published version of the manuscript. 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SAGE Open Med 7:205031211882292. https://doi.org/10.1177/2050312118822927 Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 19:349–357. https://doi.org/10.1093/intqhc/mzm042 Hennink MM, Kaiser BN, Marconi VC (2017) Code Saturation Versus Meaning Saturation: How Many Interviews Are Enough? Qual Health Res 27:591–608 Karnieli-Miller O, Strier R, Pessach L (2009) Power Relations in Qualitative Research. Qual Health Res 19:279–289. https://doi.org/10.1177/1049732308329306 Charmaz K (2006) Constructing Grounded Theory: A Practical Guide through Qualitative Analysis. Sage, London Villanueva M, Castro R (2020) Hierarchy systems of the medical field in Mexico: a sociological analysis. Cien Saude Colet 25:2377–2386. https://doi.org/10.1590/1413-81232020256.28142019 Sawant S, Karki U, Bhandari A (2019) Hazing victimization and its psychological consequences on undergraduate newcomer medical students. J Psychiatrists’ Association Nepal 8:22–27. https://doi.org/10.3126/jpan.v8i1.26332 Gobierno de México (2022) NORMA Oficial Mexicana de Emergencia NOM-EM-001-SSA3-2022, Educación en salud. Para la organización y funcionamiento de residencias médicas en establecimientos para la atención médica. Diario Oficial de la Federación, Mexico City Chung MP, Thang CK, Vermillion M et al (2018) Exploring medical students’ barriers to reporting mistreatment during clerkships: a qualitative study. Med Educ Online 23:1478170. https://doi.org/10.1080/10872981.2018.1478170 Edú-Valsania S, Laguía A, Moriano JA (2022) Burnout: A Review of Theory and Measurement. Int J Environ Res Public Health 19:1780. https://doi.org/10.3390/ijerph19031780 Huffman BM, Hafferty FW, Bhagra A et al (2021) Resident impression management within feedback conversations: A qualitative study. Med Educ 55:266–274. https://doi.org/10.1111/medu.14360 Reddy ST, Farnan JM, Yoon JD et al (2007) Third-Year Medical Students’ Participation in and Perceptions of Unprofessional Behaviors. Acad Med 82:S35–S39. https://doi.org/10.1097/ACM.0b013e3181405e1c Dyrbye LN, Massie FS, Eacker A et al (2010) Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students. JAMA 304:1173. https://doi.org/10.1001/jama.2010.1318 West CP, Huschka MM, Novotny PJ et al (2006) Association of Perceived Medical Errors With Resident Distress and Empathy. JAMA 296:1071. https://doi.org/10.1001/jama.296.9.1071 Montgomery A, Panagopoulou E, Esmail A et al (2019) Burnout in healthcare: the case for organisational change. https://doi.org/10.1136/bmj.l4774 . BMJ l4774 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Apr, 2025 Read the published version in Social Psychiatry and Psychiatric Epidemiology → Version 1 posted Editorial decision: Revision requested 24 Jan, 2025 Reviews received at journal 08 Jan, 2025 Reviews received at journal 07 Jan, 2025 Reviewers agreed at journal 07 Jan, 2025 Reviewers agreed at journal 04 Jan, 2025 Reviews received at journal 03 Jan, 2025 Reviewers agreed at journal 02 Jan, 2025 Reviewers agreed at journal 02 Jan, 2025 Reviewers agreed at journal 04 Aug, 2024 Reviewers agreed at journal 02 Jul, 2024 Reviewers invited by journal 01 Jul, 2024 Editor assigned by journal 24 Jun, 2024 Submission checks completed at journal 18 Jun, 2024 First submitted to journal 14 Jun, 2024 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. 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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-4584423","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":322430831,"identity":"e22ea290-9c97-47dd-bd2a-3074acd5a224","order_by":0,"name":"Mónica Armas-Neira","email":"data:image/png;base64,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","orcid":"","institution":"Universidad de la Salud (UNISA)","correspondingAuthor":true,"prefix":"","firstName":"Mónica","middleName":"","lastName":"Armas-Neira","suffix":""},{"id":322430832,"identity":"41d2e9f7-840a-4057-8f63-698f27a4a66a","order_by":1,"name":"Ithandehui Jaimes-Jiménez","email":"","orcid":"","institution":"Universidad de la Salud (UNISA)","correspondingAuthor":false,"prefix":"","firstName":"Ithandehui","middleName":"","lastName":"Jaimes-Jiménez","suffix":""},{"id":322430833,"identity":"e7328fb6-29d8-4820-bd2c-cf3381c3496c","order_by":2,"name":"Bernardo Turnbull","email":"","orcid":"","institution":"Ibero American University","correspondingAuthor":false,"prefix":"","firstName":"Bernardo","middleName":"","lastName":"Turnbull","suffix":""},{"id":322430834,"identity":"9be929b2-388f-44aa-989a-af137ad30f24","order_by":3,"name":"Alma Vargas-Lara","email":"","orcid":"","institution":"Instituto Nacional de Psiquiatría","correspondingAuthor":false,"prefix":"","firstName":"Alma","middleName":"","lastName":"Vargas-Lara","suffix":""},{"id":322430835,"identity":"97c266e8-73e9-4cd0-8012-819becd2a547","order_by":4,"name":"Adara López-Covarrubias","email":"","orcid":"","institution":"Universidad de la Salud (UNISA)","correspondingAuthor":false,"prefix":"","firstName":"Adara","middleName":"","lastName":"López-Covarrubias","suffix":""},{"id":322430836,"identity":"e2916ee6-e589-44ca-921a-a21adaad946f","order_by":5,"name":"Jatsiri Negrete-Meléndez","email":"","orcid":"","institution":"Universidad de la Salud (UNISA)","correspondingAuthor":false,"prefix":"","firstName":"Jatsiri","middleName":"","lastName":"Negrete-Meléndez","suffix":""},{"id":322430837,"identity":"63a15fc7-8436-466a-b941-5a46aa475f0b","order_by":6,"name":"Manuel Mimiaga-Morales","email":"","orcid":"","institution":"Universidad de la Salud (UNISA)","correspondingAuthor":false,"prefix":"","firstName":"Manuel","middleName":"","lastName":"Mimiaga-Morales","suffix":""},{"id":322430838,"identity":"e09688fc-68fb-4ae4-892c-717bb45ec185","order_by":7,"name":"Sandra Montes Oca-Mayagoitia","email":"","orcid":"","institution":"Ibero American University","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"Montes","lastName":"Oca-Mayagoitia","suffix":""},{"id":322430839,"identity":"878f6236-a938-474a-a233-7cc278ef3d16","order_by":8,"name":"Lilia Monroy-Ramírez","email":"","orcid":"","institution":"Universidad de la Salud (UNISA)","correspondingAuthor":false,"prefix":"","firstName":"Lilia","middleName":"","lastName":"Monroy-Ramírez","suffix":""}],"badges":[],"createdAt":"2024-06-15 01:24:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4584423/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4584423/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00127-025-02856-w","type":"published","date":"2025-04-09T16:04:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60170102,"identity":"8f6deb0b-965c-406c-a61a-73eb5525f37b","added_by":"auto","created_at":"2024-07-12 15:04:40","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":375124,"visible":true,"origin":"","legend":"\u003cp\u003eThe theoretical framework\u003cstrong\u003e \u003c/strong\u003eof the covert norm.\u003c/p\u003e","description":"","filename":"Figure1.theoreticalframeworkcovertnorm.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4584423/v1/00735fa00401d1f6023c364c.jpeg"},{"id":80558887,"identity":"b19c8ac3-6367-4190-aba6-c7f42c4a4dd5","added_by":"auto","created_at":"2025-04-14 16:16:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1040723,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4584423/v1/191b833d-cebc-477a-ac4c-593eed3fe0ee.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Under the Covert Norm: A Qualitative Study on the Role of Residency Culture on Burnout","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBurnout is characterized by a combination of emotional exhaustion, unhealthy detachment, and reduced professional efficacy following extended work-related stress [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Healthcare professionals carry a burdensome degree of burnout that directly interferes with their quality of life and capacity to deliver optimal patient care [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Medical residents are particularly at risk due to the inherently demanding nature of their training. The escalating prevalence of this occupational disorder during residency is alarming, present in at least fifty percent of US medical residents [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and at similar rates internationally [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Traditionally, burnout risk factors are classified into organizational aspects that pertain to the environment and individual elements that relate to inherent traits [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStructural risk factors include a perceived lack of meaning at work, fatigue, and exhaustion, cultural norms in medicine, the steep learning curve from medical school to residency, and social relationships in and outside the field [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The research to date highlights the role of organizational risk factors as the main contributors to occupational burden [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, fewer studies have explored the cultural norm in medicine as an organizational factor playing a role in burnout, resulting in scarce viable interventions on that front [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCertain phenomena concerning the culture of residency have been studied in the past in association with occupational distress, representing an opportunity to understand the influence of sociocultural norms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Moral injury, for instance, ensues when we commit, witness, or fail to stop an action that violates our core ethical values [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Failing to deliver proper patient care due to external factors beyond control undermines the value of the caregiver\u0026rsquo;s role and the patient\u0026rsquo;s needs. The concept of moral injury goes hand in hand with the hidden curriculum. Initially developed as a classroom concept, the hidden curriculum has expanded to an unofficial influence on the ethical culture, norms, and rules inside any educational setting through role modeling [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In the healthcare context, it represents a set of unwritten, and mostly unintended, lessons from senior physicians that shape expected values, beliefs, and behaviors, usually resulting in behavior that contradicts bioethical principles [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The transmission of these covert practices is mostly guaranteed by the pressure of power dynamics between learners and senior physicians [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Evidence points to further sociocultural norms that deviate from established guidelines, impeding ideal professional development and contributing to burn-out\u0026mdash;particularly those pertaining to interpersonal relationships between residents. In a study on workplace bullying, 29% of residents mentioned hierarchy as the main contributing factor to mobbing in medical residency, followed by \u0026ldquo;customs and habits in the medical field\u0026rdquo; with 28% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe relational context in the medical field operates under strict hierarchical control [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Traditional medical hierarchies are typically an inflexible omnipresent feature of clinical settings to which medical learners, like residents, are subjected with little to no chance of retort [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Conferred ranks are determined by continually demonstrating worthiness, with academic and clinical trajectories as the most valued assets [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In a Mexican study on violence in clinical environments, the prevalence of inappropriate behaviors reached 52.3% in medical residencies, with psychological violence as the most frequent manifestation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The attendings were recognized as the most frequent perpetrators of abuse (24%), followed by higher-ranking residents (21.5%) and female medical staff (13.7%). The learning environment encountered was described as unpleasant, competitive, and tense among medical residents, particularly perceived by first-year residents, suggesting abuses in power relations.\u003c/p\u003e \u003cp\u003e Ideally, guidelines and regulations should set precedents for appropriate behavior and ensure the well-being and fair treatment of all. Nonetheless, the current clinical learning environment suggests a systematic failure to enforce proper norms with dysfunctional dynamics that stray from legal standards [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. National law places residents under an already vulnerable hybrid category, not fully employee or student [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It also stipulates that internal program guidelines will expand on the obligations, duties, and benefits, subjecting residents to comply with the medical facility's needs. Some of these protocols have been longstanding, such as the eligibility requirements, clinical responsibilities, curriculum requirements, and duties delegated according to seniority. In contrast, other standards have been ambiguous in their enforcement or implemented relatively recently, including formal work-hour limitations and resident mistreatment monitoring.\u003c/p\u003e \u003cp\u003eWhile the literature on burnout in medical residents is expanding, it is largely limited to the incidence analysis, risk factors of an individual nature, and their corresponding interventions. The studies that delve into organizational factors mention the interplay of cultural norms specific to the clinical settings of medical residency [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Despite these findings, much remains unknown about the dynamics of sociocultural norms in medical residency. Previous work on the population of interest measured the psychological well-being of medical residents by uncovering burnout prevalence, allowing a framework from which to elaborate [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In this study, we intend to explore the role of the cultural norm in medicine as a structural risk factor for burnout through the resident's perspective. This research could be a crucial step toward improving the safety and well-being of medical residents in Mexico and similar settings.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 The Setting, Participants, and Study Design\u003c/h2\u003e \u003cp\u003e The current qualitative study followed an inductive approach for data gathering from a medical resident population within a public hospital network. The characteristics that define qualitative research \u0026ndash; such as flexibility, openness, and responsivity to context \u0026ndash; were ideal for confronting the increasing demands for research on the conditions of medical residency training. A grounded theory design was appropriate for further exploration of each participant's experience and to facilitate a detailed analysis of risk factors, expressions, and social interactions within a population with high burnout prevalence [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The team strove to create a theoretical model capable of comprehending the resulting phenomena from medical residents' personal and occupational experiences amidst training. Potential participants were identified from 9 public hospitals affiliated with the Mexico City Health Ministry (Secretar\u0026iacute;a de Salud) and data collection was achieved via snowballing and convenience sampling. Trainees were voluntarily recruited through e-mail and text messages until meaning saturation was achieved.\u003c/p\u003e \u003cp\u003eThe study was organized in four phases: 1) Instrument validation, 2) Initial observations, 3) Semi-structured in-depth interviews, and 4) Focus groups to validate results. We aimed for a purposive sample that allowed data saturation while anticipating some attrition between the focus groups and interviews. All reporting was crafted in accordance with the COREQ (Consolidated for Reporting Qualitative Research) guideline [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data Collection\u003c/h2\u003e \u003cp\u003eWe designed two instruments, one for direct observations and one for semi-structured interviews. The interview covered topics including personal experience sections, such as their relationship with the residency program environment, professional fulfillment and motivation, presence of workplace violence, thoughts on quitting, and key moments related to physical and emotional symptoms of burnout. After pilot testing, both instruments were re-evaluated and modified during group sessions to be implemented in phases two and three, which were conducted simultaneously. Interviews were conducted in Spanish and audio recorded with an average duration of 60 minutes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Transcriptions were verbatim, only excluding filler words for improved visualization during analysis. All identifying characteristics were carefully removed from the interview transcripts to reduce threats to confidentiality. Phase four implemented focus groups to validate findings with residents who had previously participated in individual interviews.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Ethical Considerations\u003c/h2\u003e \u003cp\u003e Prior to fieldwork, the research protocol was approved by the internal ethical review board at the Mexico City Health Ministry (CONBIOETICA-09-CEI-004-20180213). This study adhered to ethical standards and regulations, including informed consent, confidentiality, and the freedom to withdraw from the study at any point [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Participants were not compensated for their contribution to the study, and participation was voluntary. Consent forms containing identifiable information were securely stored in an office under lock and key to impede any breach of confidentiality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Analysis\u003c/h2\u003e \u003cp\u003eInitial analysis was conducted in parallel with data gathering from interviews and observations. We acquired the data analysis software Atlas.ti to facilitate the coding processes accomplished by the same investigators who conducted and transcribed the interviews. Following grounded theory core steps [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], researchers exercised open coding around themes that described risk factors, protective factors, coping mechanisms, re-percussions, external factors, and expressions of burnout, identifying 136 initially. We then reviewed and redefined each concept during weekly meetings through axial coding to establish standard relationships. For this study, only codes associated with burnout risk factors that dealt with medical culture were strung together via selective coding to integrate them coherently under four core categories: Dysfunctional hierarchy, power abuse, lack of overt norm enforcement, and perpetuation. Selected quotes were translated into English by the lead author involved in the data collection phase. Lastly, we gained insight into our theoretical framework by tying our themes to a central concept denominated the \u0026lsquo;covert norm\u0026rsquo; as an all-encompassing organizational risk factor for burnout.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eEighty-seven participants from 12 medical specialties, including surgical and non-surgical specialties, took part in this study. More than half (72%, n\u0026thinsp;=\u0026thinsp;63) were female with pediatrics (26%, n\u0026thinsp;=\u0026thinsp;23) and OBGYN (17%, n\u0026thinsp;=\u0026thinsp;15) as the most represented specialties. The sample was diverse in terms of seniority with mostly first-year residents (39%, n\u0026thinsp;=\u0026thinsp;34), followed by second-year (26%, n\u0026thinsp;=\u0026thinsp;23), third-year (21%, n\u0026thinsp;=\u0026thinsp;18), and senior residents from the 4th year and upwards at last (14%, n\u0026thinsp;=\u0026thinsp;n). Our analysis centered on risk factors identified 20 main themes with poor academia and hierarchy as the most mentioned topics, followed by work hours and punishments. Medical residents shared experiences of psychosocial challenges through the enforcement of covert sociocultural conventions among colleagues. Such conventions included behaviors under a dysfunctional hierarchical system, that evolved into abusive power dynamics, feeding into a covert norm that continually infringes on formal regulations. This system is sustainable under a lack of overt norm enforcement with poor reporting mechanisms that allow a climate of impunity and, ultimately, a self-perpetuating cycle of normalization and enforcement through violence (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Dysfunctional hierarchy\u003c/h2\u003e \u003cp\u003eRegarding hierarchy, participants acknowledged the intrinsic positive value in the fair distribution of tasks depending on rank. Ideally, this would allocate patients based on complexity to properly handle the bulk of work.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We couldn't have the same amount of work because the intern doesn't possess the intellectual capabilities acquired by a senior resident with over two years of experience. It's preferable to instruct the intern to handle sample transportation while assigning the critical patient to the senior.\"\u003c/em\u003e (Third-year, male, ER).\u003c/p\u003e \u003cp\u003eHowever, they also recognized a common divergence from a proper top-down structure in clinical settings, reflecting an uneven distribution of work with an increasing sense of powerlessness at the bottom ranks.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"...I know that the second-year residents already went through their first year and don't want to do intern things anymore, but many times, they are not doing anything, and you are overwhelmed with work, and they don't lift a finger. So well, I can't say anything to them because they've already gone through it, they've suffered, so now it's your turn.\"\u003c/em\u003e (First-year, male, surgery).\u003c/p\u003e \u003cp\u003eThese cultural norm practices culminate in a poor teamwork dynamic and overtime work with little to no recognition or appraisal from superiors. The uneven distribution of work appears to be the standard [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"There are times when\u0026hellip; there are no residents because it's an academic day or something. The attendings are in a bad mood and upset because they must do all the work. The attending does supervise, check, and see things, but the actual work, the JOB, is done by the resident.\"\u003c/em\u003e (Second-year, female, pediatrics).\u003c/p\u003e \u003cp\u003eAdditionally, junior residents described an inability to act or speak out against problematic behavior from higher-ranking positions, resulting in a lack of bottom-up accountability. Some even described it as a constant feeling of hopelessness.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We've noticed that he [referring to attending] does enact a bit of violence against women. So, there's also this sense of helplessness, not being able to do anything. Because you're a junior, right? In this case, you're like the weakest link, so to speak. So, you can't contradict him. So, many times, he has blamed us [\u0026hellip;] He still performs Kristeller. Many times you don't even see the head, and the patient is already tired of pushing, and he just goes ahead and does it. So, he dilates them. I mean, literally with his hand, and the patients scream.\"\u003c/em\u003e(First-year, female, OBGYN).\u003c/p\u003e \u003cp\u003eWhen asked to clarify, the participant mentioned witnessing violence carried out against patients in labor in the form of outdated and unethical practices. The resulting moral injury from this experience accompanies a sense of futility and powerlessness to exert change.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2. The fall into power abuse and covert power dynamics\u003c/h2\u003e \u003cp\u003eResidents who reported the presence of an imbalanced hierarchy were also prone to experiences of abuse under corrupt power dynamics, including hazing, punishments, extortion, and the use of dehumanizing covert language that accompanies customary practices with their respective internal denominations (\"eventeo\" and \"encargo\").\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1. Hazing\u003c/h2\u003e \u003cp\u003eWe encountered harassment in the form of hazing, consisting of belittling and threatening behaviors directed at individuals (Sawant et al., 2019). Such mistreatment was mainly directed at first-year residents, marking transitional periods within the hierarchy through perceived customary practices [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"To prove that you were a good PGY2 [...] you had to make an intern resign. So, when I started, I was like the weakest link, so everyone treated me awful to make me resign, and the senior residents made a bet to see how many days I would last.\"\u003c/em\u003e (Fourth-year, female, surgery).\u003c/p\u003e \u003cp\u003eThe unfair distribution of work went beyond formal clinical duty, superiors would assign menial tasks to humiliate the individual.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Something that was particularly humiliating, but it had to be done because you are the intern, you are the \"little one,\" was washing dishes and cleaning the kitchenette of the hospital [...] In other words, apart from everything you do, you had to clean and wash dishes, and they have to be nice and tidy.\"\u003c/em\u003e (Third-year, Female, anesthesiology).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2. Punishments\u003c/h2\u003e \u003cp\u003eEnforcement of negative feedback secondary to medical errors is promoted and incentivized by authorities. The consequences are frequently excessive and out of proportion, threatening physical and psychological violence at times.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"In this type of environment, I was PGY2, and they [senior residents] would say, 'Why don't you keep them [assign them extra hours]? Why don't you hit them? I support you if you want to keep them. Yes, let them stay.\"\u003c/em\u003e (fourth-year, female, surgery).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3. Extortion\u003c/h2\u003e \u003cp\u003eA particularly violent customary practice was the extortion of peers. Several participants mentioned the pressure to pay tribute through financial or material means to avoid punishment or gain the right to basic clinical knowledge and practice.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I remember that to keep the attendings happy, when I started my residency, we had to buy them things, buy them food, and even alcohol that they wanted to consume inside the hospital. If we didn't comply with that, we didn't get to operate.\u0026rdquo;\u003c/em\u003e (Second-year, male, surgery).\u003c/p\u003e \u003cp\u003eSeveral residents were asked to infiltrate alcohol inside the workplace for their superiors, feeling forced to transgress formal regulations and ethical considerations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"They told me, 'You have to step up, you have to get us some beer.' it was then that I had to decide between starting a revolution myself and dealing with the paperwork because they asked me to sneak in beers or continue, right? And I thought, what do I do? I'm a first year. No one will listen to me, no one will support me, I'm scared.\"\u003c/em\u003e (Third-year, female, anesthesiology).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e3.2.4. Covert language\u003c/h2\u003e \u003cp\u003eA particular vernacular accompanies the covert norm, describing and normalizing unlawful practices with day-to-day terminology. Participants described dehumanizing speech patterns that preceded other harmful behavior.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"They don't address you by your name. They call you a dog, and they use, well, even more offensive words [\u0026hellip;] They don't let you speak; you have no voice. If something goes wrong and you know you didn't do it, you still must take the blame for it. You can't know more than your senior resident. That's also wrong.\"\u003c/em\u003e (Second-year, male, surgery).\u003c/p\u003e \u003cp\u003eResidency culture also engages in the fabrication of neologisms to refer to unique events inside the clinical setting. Residents define \"Eventeo\" as the tradition of partying within hospital property, typically involving heavy alcohol use and other recreational substances.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"We've heard about other hospitals, where imagine this... they say, 'today's an Evento,' then they give a list to the interns and say 'go buy everything.' You spend 4 or 5 thousand pesos on drinks so the attendings and senior residents can lock themselves in the residence.\"\u003c/em\u003e (first-year, male, surgery).\u003c/p\u003e \u003cp\u003e Participants described being targeted by superiors, including a type of blacklisting practice called \"Encargo\", a sardonic expression given that the direct translation is \"to take responsibility for something/someone\".\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"So, as you go through different rotations every six months, it's like, 'you caused trouble here, you snitched, and you cried [...] When you go to your other hospital, everyone there is our friend, fellow residents, and so on. I'm going to \"encargarte\" to them, so they treat you badly, and you won't be admitted to the operating room.\"\u003c/em\u003e (Second-year, male, surgery).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3. The fall into power abuse and covert power dynamics\u003c/h2\u003e \u003cp\u003eFurthermore, overt norm transgression meets no resistance due to scarce, bordering on nonexistent, monitoring structures for correspondent disciplinary action for offenders. Duty hours pertain a common target, as a formal 80-hour weekly limit for work shifts was just established in 2022 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u003cem\u003e \"Yes, they gave us guidelines, well, documentation where the departure schedule is clearly established, but it's not something that is followed as such.\"(\u003c/em\u003eFirst-year, male, pediatrics).\u003c/p\u003e \u003cp\u003eThe lack of anonymity in reporting mechanisms plays an important role in developing burnout in medical residents, with a counterproductive outcome at best and retaliation at worst.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"He said, 'Well, what are you going to do? If you want, you are free to submit a document at the central level, and the corresponding procedure will be carried out,' he said, 'but what will happen is that they will also expose you and everything you have done wrong.' So, it's like a threat, isn't it? 'if you do it, there will be consequences for you too.\"\u003c/em\u003e (First-year, female, pediatrics).\u003c/p\u003e \u003cp\u003eA common threat pertains to deliberately obstructing their training, targeting the intrinsic purpose of a specialty program. This is a predominant trend, particularly in surgical specialties where hands-on practice becomes invaluable in developing operative experience. Under these threats, residents are left vulnerable to exploitation by the system they work for.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Just recently, the residents complained about mistreatment, long shifts, punishments, blah, blah, blah, and they were transferred to another hospital. They spent three weeks at the new hospital, and they were told, 'you know what? Return to your original location.' Now they are treated like outcasts, 'you were the ones who complained, the ones who cried. None of you will enter the operating room for the remainder of your time here. You'll be handling other tasks, but you won't step into the OR. ' And your surgical training ends up compromised.\u0026rdquo;\u003c/em\u003e (Fourth-year, female, surgery).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.3. The fall into power abuse and covert power dynamics\u003c/h2\u003e \u003cp\u003eTestimonies from senior residents pose a dichotomy. On the one hand, normalizing behaviors associated with the covert norm by resorting to downplay complaints from lower-ranking members. Others resented these behaviors and avoided perpetuating them, even to their detriment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"Perhaps in younger generations, things have changed a bit. With those who are called \"the crystal generation,\" it's very noticeable. They complain about things they shouldn't, like, 'Oh no, they're so mean to me and stuff. 'It's like they enjoy playing the victim card. So maybe that makes it more challenging because it is challenging. (\u0026hellip;) And then they say, 'No, they spoke badly of me, they mistreat me and all that.' We're all adults here, and you know what you have to do.\"\u003c/em\u003e (Fourth-year, male, surgery).\u003c/p\u003e \u003cp\u003eHigher rank residents and attendings would commonly equate abusive treatment to ideal hierarchy management. Stern behavior towards subordinates was praised.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"A doctor used to tell me: 'They are your dogs, you kick them, you punish them, you keep them overnight,' and I also had problems because of that, because I didn't mistreat others, and they said that it was a lack of character.\"\u003c/em\u003e (Fourth-year, female, surgery).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe present study reflects the perceptions of medical residents under the scope of informal practices that further increase their risk for burnout syndrome. Participants described formal residency guidelines being reduced to little more than recommendations regarding their rights. Open-ended wording regarding work conditions, such as the maximum length of a continuous shift and number of hours per week, can ultimately allow the existence of loopholes. Individual health institutions can then misuse them to compensate for the lack of personnel and resources in times of high demand. All this while the covert norm, a work culture not dissimilar to institutionalized hazing, seizes control of the narrative in the resident's day-to-day life. Standard training is characterized by conditions of stress, long hours of work, and poor pay. On top of that, residents must navigate strict hierarchy dynamics that heavily target lower-ranking interns through intimidation, belittling, harassment, and moral injury-inducing practices [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eScales of power determine who remains silent regarding the portrayal of out-of-norm behaviors [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this study, junior residents resigned their right to report malpractice and norm violation out of fear of punishment and workplace ostracism. A study at UCLA found that fear of reprisal is a major barrier to reporting mistreatment, even in anonymity [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. On the other hand, the few residents who gain the courage to initiate the process are met up with inefficient reporting mechanisms that cannot guarantee their protection.\u003c/p\u003e \u003cp\u003eEventually, the presence of abusive practices becomes as ordinary as witnessing clinical formation inside the hospital. This feeds into the perception that medical culture must include mistreatment [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Moreover, there appears to be a sense of pride linked to the amount of abuse withstood, creating a customary practice meant to be passed down to younger generations. During interviews, some senior residents mentioned being pressured by attendings to perpetuate violent practices against interns, while others ended up developing unfavorable views towards their lower-ranking colleagues. Ultimately, the culture strives to force residents to abide by the unspoken rules, whether by the threat of systematic violence or by the persuasion of reaping its benefits down the line.\u003c/p\u003e \u003cp\u003eIn a systematic review, nearly all studies identified the organizational aspects of work as the focal risk factors for burnout [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Heavy workloads and lack of time remained the top common complaints, while relational factors such as problems in the chain of command and experiences of discrimination were close seconds. According to an extensive review, the perception of injustice and the lack of social support due to internal conflicts with peers are critical organizational triggers for this syndrome [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Covert practices also raised ethical concerns for participants. Testimonies varied from witnessing questionable management to downright violence against patients, surpassing the boundaries of their moral beliefs. Over time, these events culminate in a moral injury that adds to the distress for the medical professional in training [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, enforcing a dysfunctional hierarchy results in a hostile workplace environment. Colleagues are frequently pitted against each other for the approval of high-ranking clinicians. Impression management is common in the medical field and can be optimal when it promotes a positive impression through competent patient care [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. However, if residents mold their behavior according to standards based on situational norms, it can lead to the distortion of professional behavior by perceiving these behaviors as acceptable [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe individual impact of burnout includes difficulty in making decisions, poor memory, reduced coping capacity, depression, dissatisfaction with life, drug consumption, and even suicide [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A burnt-out state has also been linked to dishonest clinical behavior, namely cheating, and diminished altruistic values [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These effects eventually translate to low performance at the structural level. Burnout and loss of empathy are associated with an increased risk of self-perceived major medical errors in residents, undermining patient safety [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Supplementary exposure to covert norm practices only accelerates the development of cynicism in physicians in training, impacting their professional empathy development from early on [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The constant feeling of distress ultimately leads to further self-doubt in a vicious cycle of patient care deficit.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThe results of this qualitative study acknowledge that burnout was independently associated with and occurs in the context of institutionalized violence. While it does not establish a causal relationship, we argue that its dynamics hurt future attendings' overall clinical learning environment. Therefore, workplace environment improvement is crucial for the reduction of occupational burnout.\u003c/p\u003e \u003cp\u003eIn contrast to isolated individual interventions, long-term solutions demand changes in the entire framework of residency culture [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. A top-down approach should be more effective regarding the mistreatment based on hierarchy. To improve team dynamics, senior residents and attendings must be trained to promote compassion and respect among colleagues. Support and adequate leadership have been demonstrated to reduce burnout and should be encouraged in the clinical setting [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. When correctly implemented, hierarchies can be positive by promoting better social order, effective delegation of tasks, and role expectations. An internal vertical stratification inside the hospital should aspire to assign levels of responsibility accordingly to improve patient safety and personnel accountability. Furthermore, appointing mentors and role models of higher hierarchy should inspire junior medical residents to strive for excellence [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. On the other hand, stakeholders in leadership positions, like program directors, must enforce a zero-tolerance policy on occupational violence and harassment.\u003c/p\u003e \u003cp\u003eSimilarly, bottom-up mechanisms are essential for accountability. Ensuring anonymity might not be enough [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Instead, we propose mechanisms of mandatory bi-directional feedback that allow residents to feel more comfortable speaking out against unlawful practices. Periodic evaluation could also enable careful monitoring of burnout symptomatology. Likewise, reinforcing the formal normative must go hand in hand with these changes, placing monitoring systems that ensure its fulfillment. Further studies are needed to assess proper organizational interventions that reject covert socio-cultural normative conformity for a more humanistic side of medical culture.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatements and declarations\u003c/strong\u003e: The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e \u003ch2\u003eEthical approval\u003c/h2\u003e \u003cp\u003e The study was approved by the Ethics Committee of the Mexico City Health Ministry (CONBIOETICA-09-CEI-004-20180213).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent to participate\u003c/strong\u003e \u003cp\u003e Informed written consent was obtained from all subjects involved in the study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization, L.M.-R., B.T.-P., S.O.-M.; methodology, I.J.-J, M.A.-N., A.V.-L., A.L.-C., J.N.-M.; formal analysis, I.J.-J., M.A.-N., B.T.-P.; investigation, I.J.-J., M.A.-N., A.V.-L., A.L.-C., J.N.-M., B.T.-P.; resources, L.M.-R.; data curation, I.J.-J, M.A.-N., A.V.-L., B.T.-P., M.M.-M.; writing\u0026mdash;original draft preparation, M.A.-N.; writing\u0026mdash;review and editing, M.A.-N., B.T.-P. and I.J.-J.; visualization, L.M.-R., B.T.-P.; supervision, I.J.-J., B.T.-P.; project administration, L.M.-R., S.O.-M. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors sincerely thank the medical residents who volunteered to share impactful details of their experience in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data presented in this study is available on request from the corresponding author due to ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBillings ME, Lazarus ME, Wenrich M et al (2011) The Effect of the Hidden Curriculum on Resident Burnout and Cynicism. 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JAMA 296:1071. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.296.9.1071\u003c/span\u003e\u003cspan address=\"10.1001/jama.296.9.1071\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMontgomery A, Panagopoulou E, Esmail A et al (2019) Burnout in healthcare: the case for organisational change. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.l4774\u003c/span\u003e\u003cspan address=\"10.1136/bmj.l4774\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. BMJ l4774\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"social-psychiatry-and-psychiatric-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sppe","sideBox":"Learn more about [Social Psychiatry and Psychiatric Epidemiology](http://link.springer.com/journal/127)","snPcode":"127","submissionUrl":"https://submission.nature.com/new-submission/127/3","title":"Social Psychiatry and Psychiatric Epidemiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"burnout, medical residency, risk factors, sociocultural norms, workplace violence","lastPublishedDoi":"10.21203/rs.3.rs-4584423/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4584423/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Burnout has become a major concern within healthcare. Medical residents comprise a notorious at-risk population with around half of its population affected. While previous work highlights the role of organizational risk factors as the main contributors to occupational burden, research on culture in medicine as a potential organizational risk factor is limited. The main objective of this qualitative study was to explore the expressions of the cultural norm from the medical residents’ perspective to set the stage for future high-impact interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eData were gathered from 87 semi-structured interviews with residents in Mexico City and analyzed through a grounded theory lens.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The analysis uncovered harmful customary practices within medical residency culture. A distorted hierarchical system was responsible for promoting abusive power dynamics that fed into a ‘covert norm’ that continually infringed on formal regulations. This system is partly sustainable due to poor reporting mechanisms and self-perpetuating behaviors through normalization and violent enforcement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e The findings suggest that burnout was independently associated with and occurred in the context of covert conventions that defy guidelines. Further studies are needed to assess proper organizational interventions that reject covert sociocultural normative conformity for a more humanistic side of medical culture.\u003c/p\u003e","manuscriptTitle":"Under the Covert Norm: A Qualitative Study on the Role of Residency Culture on Burnout","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 15:04:35","doi":"10.21203/rs.3.rs-4584423/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-24T12:32:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-08T14:02:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-07T15:07:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59028135059207669817243963613756299576","date":"2025-01-07T14:16:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"157332432866009227422032400143193257265","date":"2025-01-04T06:15:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-03T15:13:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309813858213923839326087730564789289856","date":"2025-01-03T01:21:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143738358999648850012990772804028794101","date":"2025-01-02T22:49:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178527647229298272764158415746953968268","date":"2024-08-04T06:27:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"323180988056337261795243524533272118558","date":"2024-07-02T06:34:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-01T22:52:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T12:58:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T01:46:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Social Psychiatry and Psychiatric Epidemiology","date":"2024-06-15T01:22:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"social-psychiatry-and-psychiatric-epidemiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sppe","sideBox":"Learn more about [Social Psychiatry and Psychiatric Epidemiology](http://link.springer.com/journal/127)","snPcode":"127","submissionUrl":"https://submission.nature.com/new-submission/127/3","title":"Social Psychiatry and Psychiatric Epidemiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3e34498a-9d78-4435-962e-02547e841824","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-04-14T16:12:53+00:00","versionOfRecord":{"articleIdentity":"rs-4584423","link":"https://doi.org/10.1007/s00127-025-02856-w","journal":{"identity":"social-psychiatry-and-psychiatric-epidemiology","isVorOnly":false,"title":"Social Psychiatry and Psychiatric Epidemiology"},"publishedOn":"2025-04-09 16:04:57","publishedOnDateReadable":"April 9th, 2025"},"versionCreatedAt":"2024-07-12 15:04:35","video":"","vorDoi":"10.1007/s00127-025-02856-w","vorDoiUrl":"https://doi.org/10.1007/s00127-025-02856-w","workflowStages":[]},"version":"v1","identity":"rs-4584423","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4584423","identity":"rs-4584423","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}