Institutional masking: a qualitative study of inaccurate reporting in psychological screening among medical postgraduates under graduation pressure

Abstract Background Psychological screening is widely used in medical education to identify distressed students. However, medical postgraduates, defined in the Chinese context as currently enrolled Master ‘s and Doctoral students in clinical or academic medical programs (equivalent to “graduate students” in the U.S. system, not post-graduation trainees), often give inaccurate responses to avoid perceived consequences. The mechanisms behind this phenomenon remain unclear. Purpose To understand how and why medical postgraduates report inaccurately in psychological screening, and to explore their interactions with institutional support systems during the high-pressure graduation phase. Methods A qualitative design with a thematic analysis approach was used. Semi-structured interviews were conducted with 25 final-year medical postgraduates purposively sampled from three Chinese medical schools and 6 (administrators, program coordinators, and counselors) recruited to provide complementary perspectives on screening policies and practices. Sampling continued until data saturation. Results Three main themes emerged: (1) Formalized experience of screening, students knew the “correct” answers, viewed screening as institutional compliance rather than support, and feared truthful responses; (2) Structural gaps in the support system, contradictory roles of advisors, perceived inaccessibility of counseling services, and limited peer support; and(3) a core dynamic we term "institutional masking", institutions fulfilled administrative duties through screening, students protected themselves by performing “normality,” while genuine distress stayed hidden. Conclusions The findings suggest that inaccurate reporting in psychological screening may be understood not simply as “non-cooperation” but as a rational response to institutional distrust, stigma, and lack of meaningful feedback. This dynamic, which we term institutional masking, requires shifting from surveillance-based screening to trust-based support.