Training climate matters: programmatic openness, individual belonging, and trainee mistreatment in graduate medical education

BACKGROUND: Medical trainee mistreatment remains a widespread challenge in graduate medical education, contributing to burnout, depression, and workforce attrition. Graduate medical education programs have sought to create safer learning environments by fostering programmatic openness-climates perceived as transparent, welcoming, and supportive. Yet it remains unclear how such programmatic conditions interact with individual experiences of belonging to shape wellbeing. Drawing on ecological systems theory, we examine how programmatic openness and trainee belonging interact to mitigate trainee mistreatment during residency. METHODS: We conducted an anonymous online survey (Dec 2023-Jan 2024) at three large US teaching sites with 62 GME programs. Scales with robust validity evidence measured perceived programmatic openness, individual belonging, perceived mistreatment, burnout, and social support. We built a latent moderation model, encompassing both confirmatory factor analysis and latent interaction effects. We examined how programmatic openness moderated trainee perceived mistreatment while controlling for social support and trainee demographics. RESULTS: Of 675 eligible trainees, 266 responded (39.4%). Measurement models demonstrated good fit, supporting construct validity. Both programmatic openness and belonging were protective against perceived mistreatment, which was strongly associated with burnout. Residents' belonging to the training program was significantly associated with low burnout, even after accounting for social support. Moderation analyses revealed that programmatic openness most strongly buffered mistreatment among trainees who experienced low belonging, with diminished effects at higher belonging levels. CONCLUSION: Findings revealed a compensatory effect, suggesting the beneficial effects of programmatic openness were especially crucial among trainees who experienced low individual belonging. This finding aligns with the ecological system theory, which posits that supportive environments may mitigate individual-level vulnerabilities. Both burnout and perceived mistreatment were at its lowest when programmatic openness and individual belonging were both present. This underscores the need for residency programs to foster both openness and belonging as core strategies to support trainee wellbeing.