Rites and Mistreatment During Medical Residency: A Qualitative Study

Abstract

Mistreatment is a pervasive and normalized feature of medical culture. In medical residencies, it functions as a structural rite of passage that shapes professional socialization. While the prevalence of mistreatment is documented, there is a lack of qualitative research exploring its role as a mechanism of identity construction. The aim of this study was to understand the experiences of mistreatment among internal medicine residents in Medellín, Colombia, through the lens of ritual theory and symbolic violence. A particularistic ethnographic study was conducted with 12 residents selected via theoretical sampling. Data were collected through semi-structured interviews and a reflexive field journal. Rigor was ensured using investigator triangulation and analytical bracketing to manage researchers’ biases. The training process follows a three-stage rite. (1) Separation: Symbolic violence and social pressure to specialize frame general medicine as “mediocre,” turning admission into a “battlefield” where self-worth is tied to success. (2) Marginalization (Liminality): Residents endure systemic mistreatment, including sleep deprivation (3.5 h rest cycles), public ridicule (“pimping”), and physical/verbal abuse (e.g., being hit with stethoscopes or called “testicles/jerks”). This stage is governed by a “purificatory logic” where suffering is internalized as a meritocratic requirement. This leads to high morbidity, with clinical diagnoses of anxiety and depression. (3) Integration (Postliminality): Professional autonomy and financial stability act as a “redemption” that justifies past suffering. Mistreatment is not an isolated interpersonal issue but a structurally embedded ritual and a core element of the hidden curriculum. It reinforces toxic hierarchies and a “tyranny of merit” that obscures structural barriers. These findings offer analytically transferable insights for global medical education, calling for a deconstruction of ritualized violence to foster more humanistic training environments.

1. Background

A rite is a complex set of behaviors with a profound symbolic dimension that creates discontinuities or critical moments in the everyday life of individuals and societies. Although the study of rites was traditionally circumscribed to religious or “primitive” communities, various authors have reclaimed this analytical category to examine the dynamics of contemporary societies [1]. In these contexts, rites signify transitions across social boundaries, marking the definitive passage from one status to another. They are characterized by being repetitive, learned, and transmitted across generations, reflecting a group’s adherence to values deemed essential for its survival and cohesion [1]. Within contemporary Western societies, medical practice has preserved a wide range of these rituals—including specific dress codes, hierarchical communication patterns, and rigorous behaviors during surgical interventions—all of which serve to stabilize the clinical environment and reinforce professional identity [2,3].

In the specific field of medical education, the most widely recognized rite is the “white coat ceremony,” which symbolizes the formal entry into the profession and the assumption of clinical responsibilities [4]. However, alongside these celebratory ceremonies, medical training—particularly at the postgraduate level—encompasses informal and often coercive initiation rites. These practices frequently involve rules of submission where senior members exert power over newcomers through psychological pressure, humiliation, or physical force [5]. Such behaviors are not merely isolated incidents of misconduct; they have become deeply embedded in the historical “pedagogy” of residency, especially in medical and surgical specialties.

Although there is no universally accepted definition, mistreatment is commonly understood in educational settings as behaviors that violate students’ rights and their physical, moral, or psychological integrity, causing suffering and hindering learning through verbal, psychological, academic, physical, sexual, or even racial abuse [6]. The magnitude of mistreatment in this context is a global concern. Various studies with medical specialty residents have reported verbal, physical, or both types of abuse in 30.3%, racial abuse in 16.6%, and sexual abuse in 10.3% [7]; 48.3% and 62.4% had witnessed mistreatment of other residents [8]; others indicated that 89% had experienced at least one form of mistreatment [9]. The impact of mistreatment has also been evidenced: a meta-analysis of 54 studies found a prevalence of depression or depressive symptoms of 28.8% [10]; another meta-analysis of 26 studies reported a prevalence of burnout of 35.7% [11]; depression and burnout increase the likelihood of medical errors [11], contribute to the dehumanization of medical practice [12], and reduce empathy [13].

In Colombia, the residency system reflects these global tensions but is further complicated by specific institutional and cultural dynamics. Local reports indicate that 35.3% of medical residents face workplace harassment, while alarming figures show that over 20% experience suicidal ideation during their training [14,15]. Even cases of suicide among medical residents have been documented, attributed to the conditions associated with residency training; this situation has, in turn, prompted a series of reports denouncing the mistreatment of trainees in medical and surgical specialties across the country [16]. Despite these statistics, mistreatment remains a persistent and normalized phenomenon, often shielded by a culture of silence and the belief that endurance is a prerequisite for professional excellence. While the prevalence of abuse has been documented, there is a critical need for hermeneutical research that moves beyond numbers to explore the root causes of its persistence as a ritualized practice. Understanding how these experiences are constructed and justified by the actors involved is essential for deconstructing the cycles of violence within the healthcare system.

The objective of this study is to understand the rites and experiences of mistreatment during training in medical specialties among internal medicine residents in Medellín, Colombia, as an exemplary case.

Theoretical Framework: Ritual, Hidden Curriculum, and Socialization

In this study, the training of medical specialists is understood as a process of professional socialization that transcends technical learning to become a profound cultural immersion. This transition is governed by the hidden curriculum, a system of unwritten norms, values, and hierarchies that legitimate power structures and define the identity of the “specialist.” Within this framework, learning occurs not only through the transfer of clinical knowledge but also through the internalization of institutional expectations that shape the resident’s behavior to ensure their belonging and recognition within the medical elite.

To materialize this identity transformation, medical education employs rites of passage that structure the transition between social states through the phases of separation, liminality, and incorporation [1]. Mistreatment emerges as a central element of the liminal phase, where the stripping of the previous identity and the submission to tests of physical or psychological endurance are ritualized. Under this logic, suffering is reframed as a necessary test of merit for the individual’s “consecration”; thus, suffering is assimilated by the system as a pedagogical component that guarantees group cohesion through the overcoming of shared adversity.

From the perspectives of Bourdieu [17] and Foucault [18,19], this dynamic is analyzed as a form of symbolic violence and an exercise of government of conduct over moldable bodies. Institutional power is exercised over the resident’s mind and corporeality, leading them to ultimately accept rigor and hierarchy as natural and legitimate components of their professional advancement. It is essential to clarify that these theoretical frameworks are employed here as sensitizing concepts rather than closed deductive categories; therefore, the analysis remains permanently open to inductive themes emerging from the original narratives, ensuring that the findings respect the particularities and nuances of the specific clinical context in Medellín.

2. Methods

This study was conducted using qualitative methodology, prioritizing the study of the subjective and intersubjective dimensions through an interpretive paradigm, applied to the holistic and systematic search for meanings about the phenomenon in a specific group.

Study Setting and Context: The city of Medellín has four universities offering three-year Internal Medicine programs, admitting approximately 29 students annually through competitive examinations. These programs are governed by Law 1917 of 2018, which established the “Special Contract for Formative Practice,” providing residents with a monthly stipend and social security coverage. Training primarily occurs in hospital settings through two-month rotations in subspecialties such as hematology or oncology, where clinical practice is combined with academic sessions under a vertical hierarchy (R1, R2, and R3).

While Article 5 of the national law limits the workload to 66 h per week and 12 h shifts, institutional dynamics and the traditional culture of medical service suggest that practical requirements may frequently exceed these normative boundaries to fulfill training expectations. Supervision is constant, involving daily patient evaluations and academic questioning by attending specialists. Upon completing all clinical rotations and requirements, residents participate in a graduation ceremony to obtain their specialist title. This structural framework, characterized by high pressure and rigid supervision, constitutes the environment in which the reported experiences are embedded.

Study Type: A particularistic ethnographic study was conducted—sometimes referred to as micro-ethnography or institutional ethnography—which centers on small-scale contexts such as educational or healthcare institutions. Its purpose is to examine the immediate environment to capture social interactions, perspectives, practices, and behaviors. This approach differs from classical ethnography, which focuses on analyzing a group’s broader cultural totality [20].

Participants and Sampling Strategy: The study was conducted with internal medicine residents from two universities in Medellín. A total of 12 residents were included, spanning from first-year trainees to those who had just completed their third year. Of the participants, 66% were male, and the majority had completed their undergraduate studies at private universities. The sampling strategy prioritized diversity among participants based on gender, work experience (4–9 years), duration of residency training (1.5–3 years), and type of university (50% public) attended for undergraduate education (

Table 1. Basic demographic information of participants.

Code	Age	Gender	Work Experience	Residency Duration	Undergraduate University
P1	34	Male	6 years	3 years	Public
P2	30	Male	4 years	3 years	Private
P3	35	Male	9 years	3 years	Private
P4	30	Female	6 years	2 years	Private
P5	32	Male	6 years	3 years	Public
P6	32	Male	4 years	1.5 years	Public
P7	35	Male	7 years	1.5 years	Private
P8	31	Female	4 years	2 years	Private
P9	32	Male	6 years	2 years	Public
P10	32	Female	4 years	1.5 years	Public
P11	31	Male	6 years	2 years	Public
P12	34	Female	5 years	2 years	Private

).

Reflexivity and Researcher Characteristics: All researchers have experience in teaching medical and surgical specialty students, have conducted research on medical education, and have over 10 years of qualitative research experience. All hold postgraduate degrees in social sciences. LFHG designed the data collection instrument, which was validated by other researchers. LFHG contacted participants, conducted interviews, and maintained a reflexive field journal to document their opinions, reflections on their thoughts, and reactions to their presence. This journal was operationalized by recording not only contextual observations but also the researcher’s emotional responses and preliminary assumptions after each interview.

LFHG, JACA, and DAEM performed coding and categorization of transcribed interviews. To ensure the rigor of the analysis, we implemented investigator triangulation: the three researchers coded the first three transcripts independently and then held consensus meetings to resolve discrepancies and refine the coding scheme. All researchers defined codes and categories for the analysis.

Reflexivity was integrated into the analysis through “analytical bracketing,” where journal entries were revisited during the coding phase to identify and set aside personal biases. To prevent the influence of researchers’ backgrounds, ongoing triangulation was further operationalized through: (1) data source comparison, contrasting interview narratives with field notes; (2) member-checking (covalidation), where preliminary findings were shared with participants to confirm interpretive accuracy; and (3) theoretical triangulation comparing emerging categories with theories from medical humanities (philosophy, psychology, and sociology of health). This process made explicit the researchers’ beliefs and theories, allowing for a critical evaluation before final results were selected.

Ethical Considerations: All participants provided informed consent. Anonymity and participant identity protection were guaranteed. The project was approved by the Bioethics Committee of the Universidad Cooperativa de Colombia under Act No. 01, dated 26 January 2023.

Instruments and Data Collection: Initially, a network of personal relationships was established with participants, and three data collection instruments were used: semi-structured interviews, participant observation, and a field diary. Each participant underwent two or three interviews lasting between 45 and 105 min (the first was longer, and the subsequent ones took between 45 and 60 min), totaling 12 h of recorded material. This methodological procedure allowed the data collection process to be progressively approached: the first interview aimed at exploring initial experiences and establishing a climate of trust, while subsequent interviews clarified ambiguities, expanded narratives, and contrast preliminary findings. The repetition of encounters fostered theoretical saturation and the emergence of new analytical categories, thereby increasing the validity and interpretative richness of the results.

The interviews were divided into four sections: (i) sociodemographic, economic, and work experience information; (ii) decision-making process for pursuing specialization and university selection process; (iii) experiences and practices during the residency; we investigated the most common rites in this medical specialization and experiences related to possible mistreatment (psychological, physical, or other types) asking if they or their colleagues have been victims or witnesses of this type of practices; and (iv) experiences and expectations upon obtaining the specialist title to investigate whether participants have normalized mistreatment as an inherent and inevitable experience of this specialization upon graduation or if they generate some personal reflection to transform some behaviors (Supplementary Material S1). These topics were complemented with spontaneous questions that emerged from the conversation flow.

Additionally, a field diary was maintained to document observations of student interactions in their educational environment and capture non-verbal language during interviews, methodological notes, and conceptual notes for data analysis. The observations informed adjustments to the methodological design, particularly in the way mistreatment was explored, ensuring that the interviewees did not limit their accounts to physical abuse alone. During the analysis, these notes also guided the researchers to place greater emphasis on results in which participants conveyed negative or painful emotions through their body language. Finally, the observations served as a strategy to enhance methodological rigor by triangulating and validating specific categories that emerged from the interviews.

Data Analysis: All interviews were recorded, repeatedly listened to by the researchers for familiarization, and transcribed. Coding was then performed by assigning labels to text fragments that shared common ideas. The coding process employed open codes (developed by researchers based on conceptualization) and in vivo codes (direct quotes from participants). In the open coding, we drew on the definitions of rite outlined in the introduction, as well as selected categories from Bourdieu—particularly his work on elite educational institutions (e.g., mechanisms of consecration, the establishment of social boundaries, symbolic efficacy, transformations in self-perception and in the way, individuals are perceived by others, and the shaping of behaviors) and symbolic violence. Additionally, we incorporated insights from Foucauldian studies on medical education, particularly regarding power, the government of conduct, and forms of “violence.”

Although the concept of “rite” was initially introduced as a category, the coding process followed an abductive logic. The subcategories of separation, liminality, and reintegration were not imposed a priori; rather, they emerged through the identification of recurring patterns in the residents’ accounts. Participants consistently emphasized the rupture from their prior role as general practitioners (separation), experiences of hospital-based isolation and physical suffering (liminality), and the attainment of a new “social essence” upon completion of residency training (reintegration).

Coding occurred between interviews, allowing researchers to explore underdeveloped topics in subsequent interviews. After coding, participant data were compared, and a narrative was constructed based on the categories that reflected the participants’ experiences. Finally, the findings were returned to the participants for verification, ensuring that the interpretations of the researchers faithfully represented their testimonies.

Techniques to Enhance Reliability: Prolonged contact was maintained with the study subjects prior to the interviews to enhance trust with the research team and the subsequent credibility of the findings. Methodological and investigator triangulation were performed. Methodological triangulation combines different data collection techniques to enhance result validity and comprehensiveness, validate recurring patterns, capture aspects undetectable by other methods, describe discrepancies (e.g., variations between emic and etic perspectives or inconsistencies between reported and actual behaviors), and expand topic understanding. Investigator triangulation was conducted through the collective interpretation of the three researchers and by returning the findings to the participants for verification.

3. Results

The findings of this study illustrate how mistreatment is not an accidental or isolated occurrence, but a structured and systemic component of the internal medicine residency. By analyzing the narratives through the lens of ritual theory, we identified that the training process operates as a three-stage rite: separation, liminality, and reintegration; where specific forms of symbolic and direct violence serve to mold the professional identity of the resident. The first two phases involve various forms of mistreatment incorporated by a segment of the medical community.

3.1. Preliminary Phase or Separation: A Double-Edged Sword

To address the first dimension of our objective, the results show that the ‘Separation’ phase is characterized by symbolic violence. Mistreatment at this stage is not physical but discursive: the transition begins by devaluing the role of the general practitioner, effectively ‘separating’ the candidate from their previous identity through a narrative of mediocrity that justifies the need for a specialized ‘consecration’.

Pursuing a medical specialization is a goal for many general physicians due to vocational, academic, and economic reasons, as well as the opportunity it represents for improving their quality of life. Society in general, and family in particular, highly value academic credentials and the contributions of these professionals to well-being, exerting implicit or explicit pressure to advance in their education.

Suddenly, we all agree on this—I think we always have some kind of social, family, or peer pressure, from different sources. I mean, I imagine that this is not exclusive to doctors, but I do believe that in medicine it is very… how can I put it… You haven’t even spent 10 days in medical school and people are already asking if you want to specialize. And you’re like, What? What is this? I mean, leave me alone, I don’t know anything yet, I’m just learning about the cell, and you’re already asking me what specialty I want to pursue. And that pressure is always there, it’s always there.

The initial manifestations of psychological mistreatment emerge from family members, friends, and peers. This type of mistreatment is subtle and normalized within the profession, involving behaviors or attitudes aimed at dominating or manipulating general physicians by instilling fear, shame, guilt, or invalidating their interest in general medicine. These attitudes often involve insinuations of mediocrity, devaluing the profession to the extent that practitioners feel being “just a doctor” is undesirable or that general medicine is not a socially respected field.

My father is also an internist, so I kept asking myself, how could I not be able to do this if my father even gave me an easier life than the one he had? Why would I not be capable? Why wouldn’t I be able to take on this new challenge? At some point, my father even made a somewhat uncomfortable comment about it.

However, I think this family aspect—and specifically with my father, given my life story—was something that I truly felt as pressure, as an obligation to live up to that. I felt a lot of social pressure, family pressure, the expectations that people place on you and that keep building over the years. I can even tell you that I had classmates who seemed smarter than me, yet they never got in; they applied a thousand times and never succeeded. The problem is that when we fail to pass, we are usually made to feel inferior or mocked. Society, people, close circles—they keep asking, and it never stops.

In the end, I was desperate. Then, a new residency in critical care came up, and I thought maybe it would be easier to get in, maybe not that many people would be interested in it. So, I applied to two universities for critical care, one for emergency medicine, and the other for internal medicine. I was desperate. I was really desperate. I was happy as a general practitioner for quite some time, but later on, no—I wasn’t doing well, I wasn’t happy, I was completely burned out.

In this context, gaining admission to a specialization program becomes a trial by fire. Universities admit only approximately six students per year, necessitating intense competition among peers to secure a spot.

There’s a statistic that only 10% of general practitioners specialize. So, getting a spot is a fight. Ever since I graduated, I have systematically studied and applied to universities in Bogotá, Cali, and Medellín.

Admission has become a battlefield that requires relentless studying for entrance exams and participation in academic and research activities to impress selection committees. This process affects physical integrity due to long independent study hours and impacts moral and psychological well-being by underestimating structural barriers to entry (e.g., monopolization of admission slots) while overemphasizing individual capacity and responsibility. The resulting distress limits learning and negatively affects the quality of life, reducing daily experiences to mere preparation for an entrance exam. The admission test acts as a double-edged sword, dividing candidates into two groups: those who succeed in this hypercompetitive process and attain resident status and those who fail.

Many of my classmates felt pressured to quickly specialize. Initially, I was happy and pleased with my job, but I began comparing myself to my peers over time. That comparison made me feel like I was falling behind. The pressure started personally and then extended to my family. It affected me so much that I was overwhelmed with anxiety when I began taking entrance exams. It weighed me down so much that my performance suffered—I could not sleep well, and every time I failed an exam, it became a vicious cycle where my self-worth diminished.

3.2. Liminal Phase or Marginalization: Reconfiguration of Social Dynamics

The core of the ritualized experience of mistreatment occurs during the ‘Liminal Phase.’ Our data reveal that at this stage, the institutional culture formalizes suffering through a ‘purificatory logic.’ Mistreatment ranging from sleep deprivation to public ridicule is signaled as a meritocratic requirement, where the resident’s body and psyche are ‘trained’ to accept hierarchy and stress as inherent components of their new social status.

Upon entering residency, individuals undergo a transformation that compels them to conform to the demands of their new social status. Residents feel obligated to adapt to a new lifestyle and meet heightened responsibilities, leading to separation from past practices—especially conventional socialization—while adopting new dynamics such as prolonged hospital confinement, sleep deprivation, and dietary changes.

Let me describe a tough day, although it was not the hardest. During a particular rotation, I would wake up at around 3:30 a.m., arrive at the hospital by 4:30 a.m., and have all my patient rounds prepared for the professor physician by 7 a.m. If everything was not ready, the professor physician would be unpleasant, which had a psychological impact. Even though I tried my best, sometimes I couldn’t meet expectations, leaving me feeling inadequate. After the rounds, we discussed each patient until approximately 10 a.m., followed by a seminar from 10:30 a.m. to noon. If you did not have basic knowledge, you risked ridicule from the professor physician. Around 1 p.m., we moved to another institution for additional patient rounds. By 4 p.m., we presented cases to the professor physician, finishing around 5 p.m., but we were often forced to stay until 6 p.m. doing nothing before going home to prepare for the next day. I would go to bed at 2 a.m. because I had to study to start over at 4:30 a.m.

The inculcation of specific study methods, behaviors, and work ethics, as well as the internalization of the logic of effort and hard work, fosters a competitive environment among residents. Only those who fully commit to these expectations gain institutional approval to be accepted into the new group of specialists. Residents feel pressured to prove themselves to established specialists, even if it means radically altering their social dynamics.

Internal medicine is highly competitive, especially among peers. My colleagues were extremely competitive, making academic meetings tense. There was an absurd level of competition—you had to leave a good impression in every rotation. If my peers scored a perfect grade, I could not afford anything lower. My wife kept telling me, “It’s you against yourself; you don’t need to compete with others.” However, residency is pathological—it’s like pregnancy, you seek it, but it’s an illness.

This phase also involves physical and psychological mistreatment and suffering reminiscent of sacrificial and purificatory logic. For some residents, enduring mistreatment was a rite they had to overcome to complete their training. Perpetrators of mistreatment uphold certain values, often unconsciously, and enforce them to reinforce hierarchy and fix knowledge through humiliation.

It might sound like a joke, but it is not. In my first semester, a professor mistreated me for making a minor mistake—he hit me on the head with a stethoscope and laughed. That shouldn’t happen.

Almost the entire first and second year, psychological mistreatment occurred. They would ask me anything, and if I didn’t know the answer, since I was already in my second year, I was expected to know everything. So, the professor would say something like: “Oh no! Come here,” he’d say to a nearby nurse, “bring me a urologist to get this testicle off my back” [in Spanish “güeva,” similar to “jerk” o “dumbass”, term used in popular folklore to refer to a stupid person with a fearful character]. And “this testicle” was me.

Residents identified the intergenerational transmission of mistreatment as a rite. Mistreatment is learned and perpetuated; although its forms evolve, it remains ingrained in medical training.

More than once, I concluded, ‘This person is an abuser because they were abused”. “I’d ask around and discover that they had endured the same treatment.” Academic meetings were brutal for them, so now they are harsh on their residents.” It is a cycle that repeats itself.

This phase is not without consequences. Sleep deprivation, poor nutrition, lack of socialization, academic pressure, and mistreatment result in significant health issues, including obesity, anxiety, and depression.

By the end of my first year, I was mentally exhausted. I was so stressed that my performance dropped, and I needed a psychiatrist. I was diagnosed with severe anxiety and started taking medication, which helped me improve my condition.

Sometimes professors make derogatory remarks about you in front of other physicians, and such situations made me feel deeply uncomfortable (…). At first, it was difficult—it was a real shock because I was not used to being mistreated. As a result, I developed depression and anxiety, which were diagnosed by a psychiatrist. I realized something was wrong because I was not sleeping well, my hair was falling out, I was not eating, and I was perpetually exhausted. Therefore, I sought medical help and was diagnosed. I began medical treatment, which significantly helped me.

3.3. The Postliminal Phase or Reintegration

Finally, to understand the persistence of these practices, the ‘Reintegration’ phase demonstrates how the completion of the rite functions as a form of ‘redemption.’ The attainment of professional autonomy and financial stability acts as a retrospective justification for the mistreatment endured, thereby closing the cycle.

Graduation marks the reintegration of individuals into the specialist community, reinforcing collective belonging, social cohesion, and dependence on a higher professional order. This process culminates in membership in the national association of the specialty. During this phase, socialization restrictions disappear, normal sleep and eating habits return, and specialists embrace their new professional roles.

I currently work in a great hospital, where I have job security, full autonomy over patient care, and a balanced schedule. I finish work early, have time for myself, and spend quality time with my wife. I have even started losing weight and going to the gym. Financial stability is another plus. I am happy and planning to apply for a subspecialty in three years.

The narratives of the participants reveal a series of social transitions configuring a new professional identity. The preliminary phase is characterized by frustration and demoralization, which justify the hyper-demanding and competitive residency environment, which is often marked by mistreatment. The liminal phase highlights coercive integration into a new community and disciplinary practices similar to those found in schools, factories, and military institutions. Finally, the postliminal phase represents a form of redemption that restores autonomy and social integration.

4. Discussion

This research demonstrates that the internal medicine training process functions as a rite with three stages, separation, marginalization, and integration, with mistreatment incorporated into the first two stages. The inscription of mistreatment as an inherent component of the educational act, the hyper-competitive logic of medical specializations, the consequences on the quality of life and the quality of clinical care of specialists, among other categories emerging from this study, reflect a complex process that has not been previously investigated in medical training in Colombia. The categorization of mistreatment as a rite is also reflected in the absence of similar studies; therefore, the paragraphs in this discussion contrast the evidence from the current study with sociological and philosophical theories and studies that seek to uncover underlying explanations for mistreatment in medical education. Although these explanations have been described in other contexts, their inclusion in this manuscript aims to understand mistreatment, which has been assumed by a segment of the medical community as part of an educational ethos.

In line with the above, the discussion will address the following elements: rites as acts of institution according to Pierre Bourdieu; the overestimation of individual responsibility and the negative effects of excessively meritocratic societies (Michael Sandel’s tyranny of merit); the consequences of mistreatment on quality of life; the risk of mistreated individuals becoming perpetrators; and the benefits of completing the rite.

This study interpreted mistreatment during medical residency education as part of a rite for several reasons. In the preliminary phase, individuals participate in a hyper-competitive process that grants only a few positions, often reserved for an intellectual and/or economic elite (due to the high tuition costs). In this phase, the first manifestations of mistreatment emerge as those who fail to pass the residency entrance exam are harshly judged—either by themselves or external parties. Bourdieu’s concept of “symbolic violence” is particularly useful in explaining this initial mistreatment’s unfolding. According to Michael Burawoy states, “Symbolic violence… is a domination that is not recognized as such, either because it is taken for granted (naturalized) or because it is misrecognized—i.e., recognized as something other than domination” [21]. This form of violence is characterized by the “imposition” of meanings as legitimate while concealing the power relations that underpin them, that is, by enacting subtle forms of violence that may become imperceptible due to their naturalization [22]. In this regard, the first testimony presented by one of the residents in Section 3 is illustrative for describing an immediate environment in which subtle social pressures, expectations, and demands prevail regarding how one should be and where one should aim in aspirational terms.

The general practitioner is vested with the resident identity in the liminal phase, which imposes inherent deprivations in the familial, social, professional, economic, and personal spheres. Simultaneously, physical, psychological, and workplace mistreatment practices emerge, seemingly demonstrating the high cost of entering the specialist community. In the postliminal phase, restrictions on personal freedoms are lifted, and a new subject is instituted—one who has reached adulthood, with autonomy in various aspects of life.

The above illustrates how the educational process of the study group functions as a rite. This interpretation is based on Bourdieu’s analysis of education for certain elites, such as that found in the écoles in France, samurai boarding schools, or sacred Maori colleges [17]. In this institution, students gain admission after passing a rigorous selection process, which is more of a competition than an exam, for which they prepare through multiple and extensive preparatory courses. These examinations serve as an act of separation, creating a social chasm between the last admitted and first rejected student. Bourdieu argues that this type of education not only produces technical outcomes but also imposes a social essence. In this context, the rite is an act that informs the admitted individual of what they are and what they must become, imposing an identity that the student feels compelled to live up to. The social essence of the new status is reinforced through constant encouragement and stimuli that seem to say, “Become what you are.” Inculcating and incorporating this second nature often relies on ascetic practices and physical suffering, based on the assumption that people adhere more strongly to an institution the more it has cost them to enter or belong to it [17].

Furthermore, across the different stages of the rite and their forms of mistreatment, a recurring theme in the qualitative evidence of this study is the overestimation of individual responsibility, which leads to multiple personal and social consequences. This phenomenon has been studied as a distinctive feature of contemporary societies that overvalue effort and individual achievement. The dominant narrative in these societies promotes the idea that individuals are rewarded based on their skills, aptitudes, dedication, work ethic, and personal merits, disregarding the crucial role of social, economic, and political determinants in success. Michael Sandel [23] explored these issues in the context of social justice theories and democratic societies. However, his analyses can also be applied to medical education, where social aspects are often overlooked.

The psychological mistreatment embedded in the rituals described in this study reveals a strong emphasis on personal responsibility and individual merit, resulting in the naturalization of the idea that only those possessing certain talents deserve titles, credentials, and positions of power. Simultaneously, individuals who fail to overcome systemic obstacles are disparaged and harshly judged because their failure is attributed to a lack of individual effort. The emphasis of meritocratic societies on talent, effort, and success fosters competitiveness but also promotes guilt, leading those who fail to believe their outcomes are solely due to their own choices to view themselves as inferior, as illustrated by students’ accounts of not being able to pass the admission exam. At the same time, the most outstanding competitors are revered as the sole architects of their success and superiority. This perspective obscures the social determinants of success, reducing achievements to individual choices without acknowledging the structural barriers that prevent equal access to opportunities or the social arrangements that privilege certain talents or degrees over others [23]. This is not about denying the role of personal merit in the multiple processes involved in medical training, which have produced both individual and institutional benefits such as discipline, academic excellence, and other added values. Rather, the point is to avoid taking this approach to an extreme, where specialists come to believe that their success or failure solely depends on personal attributes. Instead, greater emphasis should be placed on the structural conditions that enable individuals to fully develop their capabilities. In this way, personal success would be accompanied by a sense of solidarity and recognition of collective achievements, while failure could be understood in light of socioeconomic determinants—thus mitigating the risk of mental health problems, such as depression and anxiety, that stem from a naïvely individualistic interpretation of these processes.

While this study foregrounds the harmful and coercive dimensions embedded within these ritualized processes, it is important to acknowledge that rites of passage in medical training may also entail integrative and potentially beneficial functions. These may include the consolidation of professional identity, the development of clinical competence under pressure, and the strengthening of group cohesion. However, the analytical focus of this study is intentionally oriented toward examining how such processes become intertwined with forms of symbolic violence that are frequently normalized within institutional cultures. Recognizing this duality does not dilute the critique but rather situates it within a broader understanding of medical training as a complex and ambivalent process. In this regard, the ritual framework is not intended to be a totalizing explanation; rather, it operates in constant interaction with broader institutional factors—such as hospital management policies and labor regulations—as well as interpersonal dynamics and individual mentorship styles that also modulate the residents’ daily experiences.

Additionally, this logic of hyper-responsibility and merit leads to severe consequences for residents’ quality of life, as described in the findings regarding sleep deprivation, stress, anxiety, obesity, and the inability to socialize outside of medical circles and hospitals. These outcomes align with research showing correlations between poor quality of life, job dissatisfaction, and deterioration associated with depression, anxiety, burnout, and sleep deprivation [24]. Chronic sleep deprivation increases impulsivity, slows cognitive processes, and impairs executive function [25,26]. These conditions negatively impact patient care and increase the rate of medical errors [27]. This underscores the need to deconstruct rites of mistreatment in general and the overestimation of individual responsibility and merit in particular.

In the narratives presented by the participants, one event stands out: the mistreated victim becoming a perpetrator. Various global publications have documented this phenomenon, indicating that it is a universal rather than an isolated phenomenon [28,29]. Humiliation and mistreatment have become deeply ingrained pedagogical mechanisms in medical education, operating within structures that rely on various “technologies of governance”—assemblages of professionals, institutions, infrastructure, knowledge, regulatory frameworks, and educational mechanisms [30], all shaped by hierarchical structures and specific authority styles [31].

From a Foucauldian perspective, this phenomenon can be understood as institutional structures articulated through mechanisms that facilitate mistreatment and harassment rather than as individuals wielding more or less power depending on their hierarchical role. In our findings, for example, participants highlighted how mistreatment operates through long-standing strategies such as “pimping,” a term referring to intense and stressful intellectual confrontations in hospitals and rotations that compel students and residents to remain constantly prepared and to quickly solve problems [32]. This practice is often associated with ridicule following an incorrect response, based on the notion that if instruction alone does not teach, perhaps a little pain or shame will.

These findings contribute to the international literature by offering a nuanced perspective on the hidden curriculum and professional socialization in medical education. The ‘rite of residency’ described here is not merely a local idiosyncrasy but a manifestation of how hierarchical dynamics are globally reproduced. By operationalizing mistreatment as a component of the hidden curriculum, medical institutions implicitly teach that resilience is synonymous with enduring suffering, thereby normalizing symbolic violence as a requisite for professional belonging. Furthermore, our analysis of the ‘victim-to-perpetrator’ cycle aligns with global concerns regarding the persistence of toxic hierarchies, suggesting that professional socialization in medicine often relies on the intergenerational transmission. Thus, this study moves beyond a descriptive account of mistreatment in Colombia to engage with the global challenge of deconstructing the structural barriers that prevent a more humanistic evolution of medical training.

Finally, although the participants in this study did not explicitly approve or validate mistreatment and humiliation, they are perceived as necessary evils that must be endured within the intense training period of residency, even when they clearly transgress a minimal moral threshold. The grueling rite of residency is often considered worthwhile because it grants access to new living conditions characterized by professional autonomy, economic stability, and personal fulfillment. Thought that mistreatment is a necessary evil would mean assuming a kind of defeat of medical humanities, accepting that medical education cannot achieve its goal of training with high human standards, it would mean accepting specialized formation with high costs for the doctor and the patient, as has been documented in previous studies that show a problem of quality of life and worse care for their patients [11,12,13].

The findings in these studies, combined with the evidence from this research, demonstrate the importance of implementing urgent measures, such as providing mental health support and ensuring that counseling and mentoring programs are available for postgraduate students. In the medium term, other teaching strategies should be considered to improve residents’ quality of life. In the long term, adjustments to the education and healthcare systems should be implemented to reduce the workload and educational burden faced by students in medical specialties.

In synthesis, this study provides significant contributions to the field of medical education and sociology at three distinct levels. Empirically, it offers a detailed ethnographic account of how mistreatment is ritualized within the specific context of Internal Medicine residencies in Colombia, documenting that abuse is not a series of isolated incidents but a systemic phenomenon. Conceptually, the manuscript advances the understanding of professional socialization by integrating ritual theory with the concepts of symbolic violence and the hidden curriculum; this allows for a shift in focus from individual misconduct to the institutional ‘purificatory’ logic that sustains these practices as a meritocratic requirement. Practically, our findings highlight the urgent need for medical programs to move beyond formal policies against harassment and address the deep-seated cultural narratives that equate suffering with clinical excellence. By deconstructing these rituals, institutions can begin to foster training environments that prioritize both professional competence and the psychological integrity of the resident.

The scope of this research, while providing an in-depth understanding of the internal medicine residency in Colombia, is bounded by specific parameters that warrant an analytical reflection on its limitations and transferability

This study has the following limitations: (i) It does not include the perspectives of professors or administrative staff who might have a different reading of the experiences described or knowledge of regulatory and structural aspects that would hinder possible transformations. The absence of faculty perspectives constitutes a limitation in fully apprehending the institutional matrix and its organizational dynamics. However, from a Foucauldian perspective, focusing on residents allows for the elucidation of the functioning of the “government of conduct” through its effects on subjects. In this sense, mistreatment is not interpreted as the result of isolated individual decisions, but rather as an institutionalized technology of governance embedded within training practices. Such practices are internalized by residents as part of their professional socialization and may be subsequently reproduced as they transition into positions of greater hierarchical authority. This interpretative lens, while not replacing the need for multi-actor analyses, contributes to understanding how power operates productively within medical training. (ii) First-semester students are not included, as they typically have less time and are in the most challenging stage of adapting to the medical residency’s demands; despite inviting this group, we did not receive a positive response to participate in the study; most claimed they did not have time because starting their postgraduate took up their lives 24/7 (24 h a day, 7 days a week); (iii) some participants described that those who had been mistreated later became perpetrators themselves, thereby perpetuating the rite; however, in this study it was not possible to conduct extended follow-up with participants once they became faculty members, and thus this phenomenon was not directly observed by the researchers. Future studies should explore the perspectives of these groups to broaden the understanding of both phenomena—rites and mistreatment—and their multiple relationships. It is also necessary to continue this line of research to identify disruptive ways to denormalize, denaturalize, and deconstruct—reconstruct a more humanistic specialized formation that improves the health and quality of life of residents and their patients. Such future research would particularly benefit from multi-site and comparative designs that examine how ritualized practices vary across institutional contexts, including those that may preserve formative benefits while minimizing harmful effects.

On the other hand, although the sample included diversity in terms of gender and educational background (public versus private universities), these variables were not established as central axes of comparative analysis. The study was primarily oriented toward identifying the underlying structure of the rite and the forms of symbolic violence shared among internal medicine residents. Consequently, it did not explore in depth how gender or prior cultural capital (as shaped by type of educational background) might differentially modulate the intensity or specific manifestations of perceived mistreatment. This represents an important avenue for future research, particularly in examining how intersecting social positions may shape heterogeneous experiences within medical training.

Regarding the transferability of findings, this study offers a contextually situated interpretation of medical training mistreatment as embedded within ritualized practices. While the findings are derived from a specific group of internal medicine residents within a limited number of institutions, they provide analytically transferable insights into how mistreatment may be structured and legitimized within medical training cultures. The use of a ‘thick description’ of the rite and its stages allows readers and researchers in other settings to evaluate the degree of fit between our findings and their own institutional realities.

Recognizing mistreatment as a ritualized phenomenon is a critical first step toward denaturalizing it. Doing so allows us to move beyond an individualistic explanation—where experiences of suffering are often internalized as personal weakness or lack of resilience—and instead highlight the cultural and symbolic dimensions that sustain these practices. Our study contributes to a broader reflection on how medical institutions reproduce forms of power and hierarchy under the guise of training by unveiling this dimension. Such recognition is not merely descriptive but also transformative, as it calls for academic programs to critically examine which practices genuinely contribute to professional formation and which perpetuate harm under the rhetoric of tradition or discipline.

5. Conclusions

Mistreatment in residency training is not merely an individual or isolated problem but a structurally embedded rite that reinforces hierarchical power dynamics and an exaggerated emphasis on individual merit. Understanding this phenomenon through sociological and philosophical lenses allows for critical reflection on medical education and its impact on professionals and patient care. Addressing these practices requires structural reforms that challenge entrenched traditions and promote more humane and evidence-based pedagogical approaches.