A qualitative approach with semi-structured interviews was used to explore experiences and perceptions of abuse and its prevention or report.

A semi-structured questionnaire was developed through a series of team meetings and iterative revisions until a consensus was reached on the initial version. The preliminary draft comprised four sections: demographic data, experiences of abuse, preventive measures and an open-ended section for additional comments.

The interview format and procedures underwent a pilot phase involving two medical students and two medical residents to evaluate feasibility and clarity, and to identify areas for improvement. This phase also facilitated an assessment of the instrument's reliability. Particular attention was given to the practicality of online administration, the adequacy of interviewer notes as a data collection method, respondent comfort, and the wording of the questions. Feedback obtained during this stage culminated in the final version of the interview guide (see online Supplementary data).

Participants were selected using a snowball sampling method based on contacts from the researchers. The first participants were contacted personally trough social media or email in March 2024, date in which the field work began. After that, every participant shared the project with colleagues, who directly contacted the investigation team until September 2024, when the data collection finished. The sample included a total of 10 medical students (4 men and 6 women) and 15 medical residents (7 men and 8 women), all of them studying or working in public institutions. The mean age was 23 (22-26) for the students and 28 (25-33) for the residents. All the medical students were in the 5th or 6th year of the degree. There were at least 3 medical residents for each of the first four residence years. Every student and resident contacted agreed to participate, turning out in 0 rejections. There were no withdrawals.

The study was approved by the Ethics Committee of Miguel Hernández University. Informed consent was obtained from all participants prior to their involvement in the study.

Before the interview, participants were granted with a document with a brief introduction of the reason and objectives of the study and the information gathering methods. In order to ensure participants anonymity and allow a more comfortable situation to share information, any audio nor video of the meetings was recorded. Instead, data were captured in real-time through interviewer notes using a predefined template, complemented by a written report completed immediately after each interview. To avoid potential biases, the fulfilled templates were not handed to the participants and there was not opportunity to repeat the interviews.

During the meetings there were just two people, the participant and the first author. All interviews were online via video call whit an average duration from 45 to 90minutes.

An inductive thematic analysis was conducted. We focused on the content of what was said and we identified, examined, and reported patterns or themes that emerged directly from the data itself, without imposing categories or preconceived theoretical frameworks from the research team. Initial coding was performed by one researcher and subsequently reviewed and discussed with a second researcher. Discrepancies were resolved through internal team consensus. A total of 26 codes were agreed upon which were later grouped into 3 categories, corresponding to the headings presented in the Results section. No qualitative data analysis software was used; coding was conducted manually.

Data saturation began to emerge after the 15th interview; however, data collection continued to ensure maximum sensitivity in detecting both the types of abuse and the preventive interventions perceived as necessary, resulting in a total of 25 interviews.

In response to the general inquiry regarding experiences of power abuse, almost all the interviewees reported feeling invisible or systematically ignored, primarily by the attending specialists within the departments where they were assigned. These experiences were also attributed to residents and, less frequently to nursing staff.

More than half of the interviewees expressed, either explicitly or implicitly, a perception that physicians were disinterested in supervising or engaging with students. Additional concerns were raised regarding early dismissal from clinical duties, a lack of structure and information related to clinical placements, and, in descending order of frequency, instances of discourteous or disrespectful behavior from healthcare professionals.

Regarding medical residents, the most frequently cited issue was the highly hierarchical nature of departmental environments, which appeared to foster systemic mistreatment of individuals in subordinate positions.

Other recurring concerns included inadequate supervision during the first year of residency (particularly in emergency departments), insufficient educational support, excessive workloads that were disproportionate to the residents’ level of training, non-compliance with official working hours, hostile communication from supervisors, and a negative work environment.

In the university context, fewer instances were reported. However, students highlighted recurring inappropriate remarks from certain lecturers, non-compliance with university regulations or the official teaching syllabus, and instances of mocking behaviour.

Slightly more than half of the students reported experiences of arbitrary treatment. These included perceived favoritism towards certain students, exclusion from operating theatres without standardized criteria, and the assignment of clinical tasks or internships based on personal relationships rather than merit.

Residents reported a higher number of arbitrary practices, particularly regarding on-call scheduling. It was noted that the allocation of on-call shifts was often influenced by personal relationships with fellow residents or attending physicians, serving either as a form of reward or punishment with direct implications for financial compensation. One-third of the residents also identified preferential treatment of certain colleagues, while a smaller proportion reported conditional access to procedural training based on their rapport with supervising specialists, sometimes involving coercive or manipulative dynamics.

Verbal or emotional abuse directed toward medical students was frequently reported, particularly in the form of mockery by the supervising specialists. Students described being subjected to teasing and taunting, often related to their perceived lack of knowledge. Several testimonies included instances in which professionals posed compromising or inappropriate questions concerning political opinions or personal information about colleagues within the department.

Most of the residents reported having experienced public verbal abuse, mockery and humiliation being insulted, taunted and ridiculed in public, primarily at the hands of adjuncts physicians, senior residents or professionals from other specialties. In some cases, such behaviours were attributed to patients, especially within emergency departments and operating theatres. Residents further reported being accused of lacking clinical competence or skills.

One of the interviews revealed particularly serious incidents, including shouting, expressions of anger, use of derogatory nicknames, psychological manipulation, and even a case of physical assault by a specialist directed at a resident.

Incidents of racially motivated abuse were less frequently reported by students and typically involved isolated episodes of verbal insults, inappropriate comments, or deliberate exclusion. Among residents, there were a few reports of perceived discrimination against racialized individuals, occasional verbal aggression from patients or specialists, and racist remarks.

Regarding gender-based discrimination among students, many reported situations in which their knowledge or clinical ability was implicitly or explicitly questioned. Reports also included disrespectful treatment toward female students, experiences of sexist comments, personal inquiries about partners, misidentification as nursing staff, and the preferential selection of male students for technical procedures or clinical examinations.

Residents highlighted inappropriate behaviour from patients, including diminished respect for female physicians, refusal to be treated by women despite prior introductions, and repeated confusion between female doctors and nurses. Reports also pointed to sexist remarks by specialists -predominantly male-, including the sexualization of female doctors, preferential allocation of technical procedures to male residents, overall better treatment of men, questioning the competence of female residents, and holding them to higher performance standards.

Regarding sexual harassment, some students reported having received inappropriate sexual comments, suggestive insinuations, and occasional boundary-crossing behaviour. Residents disclosed being subjected to lewd remarks, unsolicited sexual questions, and instances of inappropriate physical contact, including unwanted touching or kissing without consent.

Nearly half of the residents and one student reported exposure to homophobic or transphobic insults or comments, as well as unpleasant behaviour targeting individuals with overweight or disabilities.

Abuses reported by medical students and residents led to formal complaints in 4 medical students and 6 medical residents. The students used teaching quality surveys, the collection of signatures, contact with university entities or public reports. They reported obstacles in the process, mainly from the university or colleagues defending the accused individuals. In contrast, independent university institutions, such as gender and identity observatory, initiated internal investigations more easily. The residents generally reported incidents internally or through hospital committees. Difficulties were reported due to the lack of a clear reference person to report problems involving their tutors. Sometimes the issue was minimized or the person making the report was not believed because he or she was unable to provide evidence of situations that were being concealed.

In some cases, the resolution process was not known or no response was received. In others, interviewees expressed satisfaction with actions such as eliminating a rotation or forcing teachers to take a course. Nonetheless, some participants reported that no action or unsatisfactory action was taken. One person reported a deterioration in their relationship with supervisors.

Students often choose not to report abusive situations for a variety of reasons, most notably being fear of reprisals and lack of knowledge about the tools to use. According to the residents, the two main barriers identified for not reporting were fear of reprisals and the assumption that the report would not be useful.

The normalization of abuse is also widespread. Some respondents prefer not to create a hostile working environment, do not feel able to prove situations or perceive a lack of confidentiality.

Most respondents expressed the need for a mechanism through which to report. Students mainly mentioned the availability of anonymous boxes and surveys. The residents, on the other hand, emphasized the importance of having a reference person to guide them through the reporting process- someone external to their department, hospital, or even outside the trade union structure.

Additional suggestions included the creation of a support group among themselves and assistance in defending against possible reprisals, the development of reporting protocols, disrupting the power relationship and avoiding the normalization of abuse.

Many interviewees emphasized the importance of training in labor rights, medical professionalism and mentoring of students and residents by those professionals who are committed to teaching or, only those who are also teachers should be mentors. Anonymous and public quality surveys were also proposed as a preventive tool, with the recommendation that their results be used to influence the assessment of both hospitals and academic institutions.

The possibility of legislating teaching practice was also considered, introducing rules that reward correct behavior and punish abuse. Some suggested that a portion of the salary of those specialists working in university hospitals should depend on the evaluation of the students.

Several interviewees stressed the need to empower both victims and colleagues to increase the number of reports.

Measures aimed at structural work also stand out, such as encouraging mentorship by younger professionals, breaking the hierarchical chain of abuse, reducing the workload (including 24-hour days on call) and avoiding the delegation of teaching responsibilities for medical students to residents.

Some residents have also suggested the use of specific assessment criteria to reduce subjectivity.

When asked which group was most appropriate to work with, the majority of respondents considered the importance of addressing the adjuncts and chiefs of department, while another group highlighted the need to address residents and medical students as future professionals.