Office of Medical Education

Creating a Positive Learning Environment 

 

 

A Faculty Guide

 

Kindness, respect and cultural humility are among the tenets that help inform our University of Vermont Larner College of Medicine Professionalism Statement. As we strive to embody these tenets in our daily interactions, our learning environment inevitably improves. In that spirit, we have compiled a list of strategies, i.e., things to say – and not to say – that we hope can be helpful as we all work together to create and maintain a positive learning environment, free of mistreatment, for all our trainees.   

Six Easy Things We Can Do to Help Create a Positive Learning Environment

1. Be welcoming and inclusive:  Simple suggestions for starting off on the right foot!
   • Welcoming phrases:
     • "Welcome, I look forward to working with you."
     • "I'd like to introduce you to the to the staff members, so you know the team. I’d like you to feel part of the team."
     • Consider setting the stage for students to bring you any concerns in real time by saying something like: “I am here to help you have a great experience in (name of clerkship/rotation). We want to meet the expectations for this rotation and prepare you for your career in medicine, regardless of your specialty choice. If you have concerns about the rotation, student expectations, learning environment or how best to improve, I’d be happy to meet with you or direct you to the appropriate person. The best way to reach me is…”
   • Respectful inclusive phrases:
     • “What would you like to be called?” Remember to learn and use student names!
     • “What do you want to take away from this rotation?” “What are your expectations and goals for the month?”
     • “You look as if you might have something to say. Please share, even if your ideas aren’t fully formed.” 
     • “That’s a really good point.”
2. Demonstrate enthusiasm: Learning is enhanced when learners encounter enthusiastic role models
   • Introduce yourself and describe why you are excited and passionate about learning and patient care “It’s going to be hard work, but we will have fun and see interesting cases.”
   • Embody a positive and optimistic attitude toward the team and learning
3. Be a team player: don’t denigrate other specialties or complain about appropriateness of a consult from a peer
   • Provide appropriate space and trust based on trainees’ level of training and competency
   • Invite learner’s insights, thoughts and opinions
   • Encourage questions and independent thinking; “I want you to feel that you can ask me any questions.”
   • "We can learn from each other as we work together.”
4. Show empathy
   • Put yourself in your learner’s shoes. Be supportive of their uncertainties.
   • If you are concerned about a student who appears to be disengaged or withdrawn, consider reaching out: “You seemed a little quiet/distracted/upset today on rounds. Is everything OK?”
   • Acknowledge personal struggles; “It’s really challenging when a patient…. (receives devastating news, dies…) how are you doing with this?” “I’ve struggled with XYZ as a learner myself.” 
   • Consider communicating to students at the beginning of the rotation not to hesitate to let you know should they ever feel the need to take a moment to reflect after a difficult patient encounter. Students might otherwise find it hard to ask.
   • Consider circling back after rounds; “I know rounds can be an intimidating setting so I wanted to check back with you and see what questions you may have about your patients.”
5. Model humility
   • Admit your own limitations, errors, concerns; “I don’t know all the answers.”
   • Think aloud and invite learners to do the same
   • Acknowledge insecurities, fear of harming patients and desire to know more
   • Be open to learning from your students - They have a heightened awareness and understanding of how social determinants of health impact patient outcomes and, when given the opportunity to participate, can be valuable contributors to the health care team
6. Balance, challenge, AND support*
   • High challenge + high support = progression through a positive environment – trainee is given specific and challenging targets with adequate opportunity to meet them.
   • High challenge + low support = trainees feel discouraged
   • Low challenge + low support = trainee believes they have reached the level required
   • Low challenge + high support = previous misconceptions by the trainee are cemented instead of challenged

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 student4s 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.