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

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.