WHEN HIERARCHY SILENCES LEARNING: POWER ASYMMETRY IN FEEDBACK, PSYCHOLOGICAL SAFETY, AND TRAINEE BURNOUT IN FCPS INTERNAL MEDICINE – A MODERATED MEDIATION ANALYSIS

Abstract

Background:

Burnout among postgraduate medical trainees in South Asia is rarely examined as the systemic outcome it is.

In the FCPS Internal Medicine training environment in Khyber Pakhtunkhwa (KPK), Pakistan, steeply hierarchical supervisory relationships govern every dimension of feedback exchange – who initiates it, who may challenge it, and who is permitted to reveal uncertainty. This hierarchical conditioning of feedback may erode trainees` psychological safety, and through it, accelerate burnout and reduce professional engagement. Whether perceived supervisory support moderates this pathway has not been tested in any South Asian postgraduates training context. 

Objective:

To test a moderated  mediation model in which hierarchical feedback structure (HFS) predicts trainee burnout and work engagement, with psychological safety (PS) as mediator and perceived supervisory support (PSS) as moderator, among FCPS Internal Medicine trainees in KPK public-sector teaching hospitals.

Methods:

Cross-sectional survey study with 180 FCPS Internal Medicine training across KPK public-sector hospitals (February – March 2026). Five constructs were assessed using validated Likert instruments (Cronbach’s α = 0.94 – 0.97): HFS, PS, PSS, burnout, and engagement. Path analysis with bootstrapped indirect effects (5,000 resamples, 95% bias-corrected CIs) tested mediation; a product-term interaction tested moderated mediation. Age, gender, and weekly working hours served as covariates.

Results:

Higher HFS predicted greater burnout (β = 0.48, p < 0.001) and lower engagement (β =-0.41, p <.001).PS partially mediated both pathways (indirect burnout effect: B =0.29, 95% CI [0.17, 0.43]; indirect engagement effect: B= -0.31, p= 0.003); simple slopes confirmed that the suppressive effect of HFS on PS was substantially stronger when PSS was low (β = -0.62) than high (β = -0.29). Weekly working hours independently predicted burnout (β = 0.22, p = .008).

Conclusion:

Power asymmetry in feedback is a structural driver of trainee burnout, operating through its suppression of psychological safety. Supervisory support attenuates this effect, identifying how supervisors communicate – not how hierarchy is structured – as the most tractable intervention target. FCPS programme leaders should treat supervisory communication as a modifiable institutional lever, not a personality variable.