Creating a Positive Learning Environment 

 

 

How to Avoid Mistreatment:

First the basics: here are the behaviors the AAMC defines as mistreatment:

• Being publicly humiliated
• Threatened with physical harm or physically harmed
• Required to perform personal services
• Subjected to offensive sexist, racial, ethnic, or sexual orientation remarks
• Based solely on gender, race, ethnicity, or sexual orientation
  • Denied opportunities for training or rewards 
  • Received lower evaluations or grades 
• Subjected to unwanted sexual advances
• Asked to exchange sexual favors for grades or other rewards

Here are some tips for how to avoid behaviors that may not meeting AAMC criteria for Mistreatment, but are nonetheless commonly reported:

 

1. Being ignored or feeling excluded from participating in patient care
   • Consider the following general statement to help introduce students to patients (particularly in the outpatient setting):
     • "A medical student is working with Dr. X as part of the health care team today.  The student will be in shortly to help XYZ (i.e., clarify your history, ask you a few questions, listen to heart and lungs, etc.).”
   • If the clinical situation requires your full attention and you don’t have time to teach, set expectations for the learner:
     • "This patient requires my full attention at this time. I will address teaching points once the patient is stable.”
     • "I have a packed schedule in clinic today and will likely not have time to address questions between patients. Keep track of your questions and let’s plan to regroup at the end of the day.”
     • "I’m sorry I can’t address your questions at this moment. We will get to them later when I have the time to give them the attention they deserve.”
     • If a patient is reluctant to have a medical student involved in their care, consider advocating on behalf of the student. See link below to “Supporting learners when patient declines student involvement in their care.”
2. Not knowing expectations
   • As much as possible, communicate explicit expectations early
     • Discuss goals (yours for the students, the students for themselves, overall clerkship goals)
     • Getting going: When should the students start seeing patients, which patients should they see (or not see)?
     • How much and how long: What should the students do in the room, how much time should they spend alone with the patient, what should they focus on? Try to be specific about what they should do, learn or review.
     • Questions: Make the times students should ask questions predictable. For example, “At the end of rounds, we will go back through the patients with the resident and you can ask your questions.”
     • Help clarify to students where they should physically be during the day (i.e., work room, library, on a laptop on certain floor)
     • Set expectation for how students should spend their “downtime” or time in between rounds or cases (i.e., There’s not much going on right now, why don’t you go to the library and meet up with the team again at x time”)
     • Be clear about when students are dismissed for the day. 
3. Negative comments about other specialties or other broad groups of health professionals
   • At times, the practice patterns of other units, specialties or teams may frustrate us. That said, be especially careful about making any broad negative general statements about others such as, “Why would anyone be an X?” or, “This drives me crazy; the nurses here always do XYZ.”
   • Instead, try to model a collegial approach. For example: “I had thought the team would follow our consult recommendations to do X, but they did Y instead. I’m sure there’s a good reason. Let’s call them to get more information so we’re all on the same page.”
4. Comments or jokes regarding diverse populations such as those concerning race, ethnicity, religion, gender identity, and sexual orientation
   • Many mistreatment complaints concern faculty who thought they were making a joke or an innocent observation, but in reality, they were unwittingly propagating a microaggression. Be especially careful about comments about any aspect of diversity, including race, ethnicity, gender or gender identity, religion or sexual orientation. For your benefit and for the benefit of others, you should avoid making disparaging comments or jokes based on another person’s aspect of diversity.
   • Instead: Inquire. If you think knowing more about a student’s aspects of diversity could help you to improve the learning environment, consider something like: “I know you mentioned that you will not be here Saturday so you can observe the Sabbath. Would it be OK with you if I asked you to tell me a little more about your scheduling needs so that we can work together to develop a schedule that maximizes your learning without interfering with your other obligations?”
5. Comments about student appearance
   • Unless there is a breach of the General Guidelines for Medical Student Appearance Policy, avoid all comments about students’ appearance. Seeming compliments or comments about appearance, attractiveness or other irrelevant characteristics can feel demeaning to learners.
6. Distributing opportunities based on the gender of your medical students
   • Medical students want to participate in real clinical medicine. Try to equally distribute opportunities to your learners. Especially avoid giving males or females different opportunities.
   • For examples, see above: “Being Ignored or Feeling Excluded from Participating in Patient Care”
7. Giving constructive feedback in front of others
   • Giving constructive feedback in front of other people can be challenging, and complaints from students who felt humiliated when given feedback publicly are common.
   • Set the stage for your teaching by saying something like this:
     • "I am going to be asking everyone questions. I am not trying to embarrass you, or anyone. Knowing the edges of your knowledge helps me match my teaching to your knowledge level.”
     • "If I give you a list of specific things to read up on during the clerkship in front of other people, it isn’t to humiliate you, it’s to round out your knowledge of our specialty and I do this commonly. Expect me to give assignments. Sometimes I’ll follow up and ask you to tell me what you learned, and other times I won’t. If I ask you to read on something and tell us about it the next day, don’t wait for me to remember to ask you about it. Sometimes I may get distracted and forget. Feel free to initiate a discussion about the best time to present your topic.”
   • Remember to provide specific, constructive behavior-based feedback 
   • For more information, check out these quick guide:
     • Six Common Pitfalls of Feedback Conversations 
     • Giving and Receiving Feedback
8. Supporting students with disabilities
   • Providing a welcoming, inclusive environment for all students acknowledges the importance of including disability in our diversity and inclusion efforts.
   • Here are some tips for contributing to an inclusive environment for students with disabilities:
     • Consider including a supportive statement in your course syllabus or orientation materials, directing students who require accommodations to the OMSE Office of Academic Achievement. 
     • For examples of statements, see Appendix “A” (p.91) in the AAMC publication: “Accessibility, Inclusion, and Action in Medical Education” 
     • Convey a willingness to collaboratively implement ADA accommodations approved by the UVM Student Accessibility Services 
     • Acknowledge that students with disabilities may experience new challenges when transitioning into the clinical learning environment.
     • Promote an open-door policy for students to reach out to you with any questions or concerns early in the rotation/course.
     • Remain sensitively aware to the reality that some clinical students may have an undiagnosed or hidden disability, or may not have chosen to seek ADA accommodations.
     • Creating an active culture of disability inclusion will remove barriers and encourage students to proactively seek the resources they may need for equal access to educational experiences.
   • For additional resources, including 20 minute educational modules, see Appendix “B” (p. 96) of the AAMC publication: “Accessibility, Inclusion, and Action in Medical Education”

We are all human. If you inadvertently snap at a student, or raise your voice, consider a simple apology:

• "I am sorry I raised my voice. Practicing medicine can be very challenging sometimes. I wasn’t upset with you; I was just worried about xyz.”
• I realize I was harsh when I said xyz. I apologize and I shouldn’t have said it that way.”

If you witness a colleague inadvertently behave in a way that is unprofessional:

• Consider sharing your concern with your colleague. Often, we are simply unaware of how our behaviors are perceived by others and we can depend on one another for assistance.

For more information, check out this quick guide: Is it Mistreatment? Practices for Productive Teacher Learner Interactions. 

 

Thank you for your dedication to and engagement in our educational mission and for all you do to support a positive learning environment for our trainees. 

Acknowledgements:

Mayo Clinic “Resources for Creating a Positive Learning Environment”
Penn State “Faculty Scripts to Help Improve the Learning Environment”
Yale “ERASE” Program
*Gavriel, G, Gavriel, J, Br J Gen Pract. 2011 Oct; 61(591): 630–632.