Jason M. Fogler, MA, PhD, Leonor Fernandez, MD, Barbara R. Gottlieb, MD, Elizabeth Harry, MD SFHM, Daniele Ölveczky, MD MS, Clyde Lanford (Lanny) Smith, MD, and Arabella L. Simpkin, MD, MMSc on behalf of The HMS Academy Innovation Groups on the Lived Curriculum, Cross-Cultural Care & Health Justice, & Wellbeing*
* Formerly Interest Groups on the Hidden Curriculum, Cross Cultural Care, and Physician Wellness, respectively.
The learning environment is defined as “the social, psychological, and physical contexts that affect or are affected by academic activities”1. At the November 2018 Summit on the Learning Environment, the HMS Academy and CEO’s of HMS affiliated hospitals identified a high priority: to improve the current clinical learning environment in order to enhance the experience of medical students and trainees and promote high standards for excellence and academic rigor. Student experiences of clinical and teaching interactions in clinic and on inpatient floors shape their sense of well-being and their willingness to approach team members and teachers at all levels with concerns. The Academy’s Innovation Groups ran workshops that explored key “pain points”. Repeatedly, attendees emphasized the critical importance of the deliberate creation of a welcoming learning climate. In this piece, we explore how relationships between students and teachers can impact the learning environment.
Many workshop participants reported feeling “put in the corner,” others felt pushed into high-risk situations without adequate preparation or supervision, and “punished for taking risks.” They described teachers who were too preoccupied and stressed by their own duties to teach. Students also reported experiencing that the learning environment was compromised by lapses in professional conduct among faculty members. These experiences evoke Buery-Joyner and colleagues’ analysis of “learner neglect”2 and Edmondson's concept of psychological safety3.
Learners described positive teaching moments as well, when they felt treated as individuals and found their experiences tailored to their current level of understanding. Examples included: encouragement to research a patient’s presenting condition in advance; huddles before clinic to orient and ground them to what they would soon be experiencing at a rapid pace; manageable tasks that helped them learn and feel integral to the care team; and teachers that conducted “debriefs” to help them synthesize and extract meaning from the experience.
Current wisdom highlights mutual trust, candor, and deep investment of time, emotional support, and social capital, if not tangible financial resources, in the student's success4. Writers underscore a deepening relationship that evolves over time, likened to a “professional parent” (in loco parentis) who takes special pride in the student's growth and accomplishments5. In the current inpatient learning environments, patient care demands often compete and compromise the deep and longitudinal investment of time with the learner. As an educational and healthcare community, we must advocate for clinical educators to have more time to invest in our students’ growth and development so as to sustain the passion, enthusiasm, and competence in our fields.
We must try to build meaningful relationships with our students by treating them as integral members of a clinical team rather than as passive observers or obstacles to be managed. This can be challenging in the context of dynamic teams with rapidly changing membership. Proactively ensuring the learner is introduced and their role, and goals, acknowledged is an important first-step at the start of any shift or rotation.
Intentionally open up time for huddles and individualized needs assessments for learners—where is the learner in their developmental trajectory?
Recognize and teach others how to navigate racism at the bedside, so that residents and attending clinicians can model and scaffold “rising above negativity” for learners.
Promote a culture change where good teaching and mentorship are valued in promotion criteria in the same way that we value clinical or research productivity.
In the context of a rapidly changing environment, with high demands on clinical productivity and limited resources, ensure attention is paid to educator wellbeing as a requisite to be able to focus on trainee/learner wellbeing. Consider longer inpatient service time with appropriate financial protections and other supports.
We welcome the energy of our Innovation Groups and the HMS Academy community as we continue our efforts to understand how to improve the lived curriculum and ensure that teaching and clinical interactions show deep respect and commitment to learners, teachers, and patients alike.
1. Skochelak SE, Stansfield RB, Dunham L, Dekhtyar M, Gruppen LD, Christianson C, Filstead, W, & Quirk M. Medical Student Perceptions of the Learning Environment at the End of the First Year: A 28-Medical School Collaborative. Acad Med. 2016 Sep;91(9):1257-6