The Standardized Resident Training Program (SRTP) in China has been formally established since 2014 as a kind of postgraduate education (1). This program aims to augment the professional competence and overall quality of resident physicians, aligning them with the demands of contemporary medical services (2). These professionals are required to demonstrate comprehensive mastery of medical theory and clinical practice, thereby enabling independent diagnosis and management of common diseases, prevalent conditions, and complex critical illnesses in their respective subspecialties (3). Medical students enrolled in SRTP are officially designated as residency trainees. Eligibility for residency trainee status is contingent upon fulfilling stringent admission criteria at accredited training bases, including successful completion of written examinations and structured interviews.

Trainees are required not only to fulfill rigorous clinical responsibilities but also navigate adverse events inherent to clinical environments on a daily basis. Among these challenges, Adverse Practice Experiences (APEs) are the most common negative events, including but not limited to discrimination, bullying, and harassment. Although these events have been reported internationally, research focusing on residency trainees in China has received limited attention (4–6). Empirical evidence demonstrates that APEs exert detrimental effects on trainees' career trajectory decisions (including specialty selection and residency continuation), professional identity formation, and occupational satisfaction (7–9); furthermore, these experiences may induce enduring psychological sequela.

Meanwhile, sustained exposure to clinical demands, excessive workloads, and effort-reward imbalance have been identified as key determinants of occupational burnout in residency trainees (10). Occupational burnout is defined as a state of physical and mental exhaustion, reduced enthusiasm, and disengagement resulting from prolonged exposure to high work stress and heavy workloads (11). Reports from around the world suggest that approximately one-third to one-half of physicians experience burnout (12). A cross-sectional observational study by Caesar et al. (13) found that general surgeons had the highest total burnout mean score, followed by those in emergency medicine, acute medicine, and orthopedics. In China, the prevalence of occupational burnout among residency trainees have been reported as 71.4% in Beijing, 62.2% in Shanghai, and 47.7% in Yan'an, Shaanxi Province, while the overall physicians' occupational burnout rate ranges from 66.5 to 87.8% (14–17). Additionally, one study indicated that the prevalence of occupational burnout among residents who completed the Standardized Resident Training Program was significantly lower than that of pediatric residents who had not completed the program (18).

It is worth noting that the occupational burnout experienced by residency trainees not only reflects the high-pressure clinical work environment but may also be closely related to the APEs they encounter. APEs can exacerbate occupational burnout through direct emotional distress, cumulative psychological burden, and weakened professional identity. Given that residency trainees are in a critical transitional phase from medical students to independent clinical practitioners, and considering China's unique cultural and healthcare environment, they may be more susceptible to APEs. Therefore, exploring the current situation of APEs and their impact on occupational burnout is of significant practical importance.

This study aims to reveal the current status of APEs experienced among residency trainees in Guangxi, China, and further examine how the frequency of APEs affects the level of occupational burnout among these trainees. The findings will not only provide empirical evidence to improve the quality of residency training and alleviate occupational burnout but also provide information and reference for developing targeted interventions aimed at enhancing trainees' mental health.

To our knowledge, this is the first study to examine the association between varying levels of exposure to adverse practice experiences and occupational burnout among Chinese residency trainees. The findings' main clinical implications may help residency trainees avoid adverse clinical/medical events or errors, patient mortality, and medicolegal complaints/disputes.

The results of this study indicate that the prevalence of occupational burnout among residency trainees is 70.48%, which is higher than the prevalence reported in Shanghai (62.2%) and in Yan'an, Shaanxi (47.7%), but lower than that in Beijing (71.4%) (13–15). Compared to international findings, only 19.0% of resident physicians in France were found to experience occupational burnout (24). The possible reasons for this discrepancy may be that trainees in the study region bear a heavier workload, higher on-call frequency, or are exposed to more complex cases, leading to a higher prevalence of occupational burnout. On the other hand, cultural differences across countries may also play a role. In Western countries, a more open communication culture and work environment that emphasizes personal rights may help alleviate occupational burnout. Even though the same burnout measurement scale was used, there is still no consensus on the standard approach, which could explain the variations across studies. It is important to note that a high rate of occupational burnout not only affects the physical and mental health of trainees but also negatively impacts the development of their professional skills and the sustainability of their careers.

The study found that 68.37% of residency trainees (908 individuals) had experienced at least one APE. Specifically, the most common APE was verbal abuse (such as slander and intimidation), affecting 51.51% of trainees. This finding aligns with Crutche et al.'s (25) study in Canada; however, in Oman, the proportion increased to 88% (26). This highlights the widespread occurrence of verbal abuse during the SRTP period, with significant variation across different countries and regions. Prolonged exposure to verbal abuse was associated with higher levels of anxiety, depression, and occupational burnout, which may relate to changes in trainees' professional identity and future career choices, even suicidal thoughts (27). Additionally, verbal abuse was associated with lower self-confidence, diminish their motivation to learn, and hinder their clinical skills, ultimately compromising the quality of training.

49.25% of trainees reported being required to perform personal services, reflecting the presence of implicit power abuse during the SRTP period. Although being required to perform personal services does not involve direct verbal or physical abuse, it essentially constitutes a misuse of authority. This behavior is rooted in the long-standing hierarchical culture within the medical field, where superiors leverage their authority to demand tasks beyond the trainees' scope of learning. Trainees, being in a subordinate position, are often inclined to comply with such instructions (28). Tasks unrelated to training objectives were associated with less learning time, potentially diminish the quality of training, and are correlated with increased feelings of frustration or being undervalued among trainees. Furthermore, such practices could perpetuate a cycle of power abuse, as today's trainees may emulate these behaviors when they become superiors in the future.

A total of 47.14% of the trainees had experienced gender discrimination. Gender discrimination among medical students during their academic career was experienced significantly more often by women than men (21). In particular, males were long considered more suitable than females for surgical careers, due to traditionally accepted gender norms and stereotypes (29). Moreover, gender discrimination was associated with patterns that may contribute to persistent underrepresentation of women in certain specialties. When fewer women enter certain specialties due to discrimination, the representation of women in these fields further diminishes, reinforcing existing gender stereotypes (30).

The results of this study indicate that residency trainees who have encountered at least one APE have higher occupational burnout score. Looking at the different exposure levels of APEs, higher APEs exposure levels were associated with higher occupational burnout scores (P < 0.001). These findings underscore the association of APEs on the negative psychological wellbeing of residency trainees. The observed positive correlation between APEs exposure and occupational burnout aligns with prior research, which has established hostile learning environments and emotional harm as significant contributors to burnout among healthcare workers (31, 32). Chen et al. (33) find that healthcare workers with workplace violence exposure, particularly to emotional abuse, threats, and verbal sexual harassment, demonstrate higher susceptibility to burnout. This study further suggests that even limited or occasional exposure to APEs may not be benign and could have lasting psychological repercussions for residency trainees.

Due to the cross-sectional design of this study, these findings indicate associations rather than causal relationships; longitudinal studies are needed to examine potential causal mechanisms.

Burnout can lead to many challenges, including a physician's mental health issues such as suicidal tendencies and physical symptoms such as fatigue and headaches, as well as health system troubles such as poor doctor-patient relationships and clinical malpractice (15). The findings of this study have several important clinic implications for clinical education, hospital management, and resident wellbeing. Firstly, based on our findings that verbal, emotional, and physical abuse, as well as pregnancy/childcare-related discrimination, are prevalent among residency trainees, clear anti-verbal abuse policies should be formulated and enforced, establishing accessible, anonymous complaint and reporting mechanisms to enable trainees to seek help safely. Secondly, SRTP should incorporate targeted courses and workshops aimed at reducing burnout, including stress management and resilience training, mindfulness-based interventions, time management courses, and communication skills workshops for both trainees and supervisors. These initiatives are designed to foster respectful mentor-trainee relationships, improve coping strategies, and reduce conflicts and abusive behaviors. Thirdly, considering that residents reported being required to perform personal tasks unrelated to training objectives, systems must be established to clearly define the scope of responsibilities for residents, explicitly prohibiting the assignment of personal tasks unrelated to training objectives; this is crucial to combat power abuse and protect trainees' time and energy for learning. Furthermore, within the medical field, especially in traditionally male-dominated specialties such as surgery, active promotion of gender equality is essential to ensure equal opportunities in education, training, and career advancement for both women and men; increasing the visibility of female role models also helps to break down the constraints of gender stereotypes (34). Additionally, management should implement reasonable distribution of workload and on-call frequency for residents to prevent physical and mental exhaustion from overwork. Finally, it is vital to strengthen and improve accessible psychological support services for residents, ensuring they can obtain timely and effective professional help when facing stress or injustice.

This study has several limitations. First, a retrospective approach was used to assess APEs, relying on self-reports from residency trainees, which may be subject to recall bias. Second, the generalizability of our findings may be limited. While the sampling strategy ensured good representativeness within the western coastal region of China where the study was conducted, the results may not be fully applicable to other Chinese regions with vastly different socioeconomic profiles or to distinct international medical training systems. Lastly, workload-related variables (e.g., working hours, night shifts, and training pressure) were not included as potential confounders, which may have influenced the observed associations between APEs and occupational burnout.

This study revealed a high prevalence of occupational burnout among residency trainees in Guangxi Province, China. A strong positive association was observed between APEs and burnout: trainees experiencing at least one APE reported significantly higher burnout levels, and increasing exposure to APEs was consistently linked to higher burnout scores. The most prevalent APEs contributing to this burden were verbal abuse, demands for personal services, and gender discrimination. It is recommended that training management departments improve relevant regulations and policies to safeguard the legal rights of residency trainees at the institutional level. Training centers should also allocate work intensity more reasonably, reduce excessive workload, and enhance attention to trainees' mental health and provide necessary interventions. At the individual level, trainees should strengthen their psychological adjustment skills, seek support and help, manage expectations appropriately, and maintain both physical and mental wellbeing.