Beyond mistreatment: Learner neglect in the clinical teaching environment

Alienation in the Teaching Hospital: How Physician Non-Greeting Behaviour Impacts Medical Students' Learning and Professional Identity Formation

Introduction

Clinical workplaces offer unrivalled learning opportunities if students get pedagogic and affective support that enables them to confidently participate and learn from clinical activities. If physicians do not greet new students, the learners are deprived of signals of social respect and inclusion. This study explored how physicians' non-greeting behaviour may impact medical students' participation, learning, and professional identity formation in clinical placements.

Methods

We analysed 16 senior Norwegian medical students' accounts of non-greeting behaviours among their physician supervisors in a reflexive thematic analysis of focus group interview data.

Results

The main themes were: A) Descriptions of non-greeting. Not being met with conduct signalling rapport, such as eye contact, saying hello, using names, or introducing students at the workplace, was perceived as non-greeting, and occurred across clinical learning contexts. B) Effects on workplace integration. Non-greeting was experienced as a rejection that hurt students' social confidence, created distance from the physician group, and could cause avoidance of certain workplace activities or specific medical specialties. C) Impact on learning. Non-greeting triggered avoidance and passivity, reluctance to ask questions or seek help or feedback, and doubts about their suitability for a medical career.

Conclusion

Medical students' accounts of being ignored or treated with disdain by physician superiors upon entering the workplace suggest that unintended depersonalising behaviour is ingrained in medical culture. Interaction rituals like brief eye contact, a nod, a "hello", or use of the student's name, can provide essential affective support that helps medical students thrive and learn in the clinic.

Neglect as an undefined and overlooked aspect of medical student mistreatment: A systematic review of the literature

PURPOSE

Although the mistreatment of medical students is a well-researched topic, the scope of mistreatment often leaves out neglect, a subtype for which there is no accepted definition based in the published literature. This review sought to summarize the existing data on the prevalence and descriptors of neglect, identify strategies seen in the literature designed to improve it, and offer a synthesized definition of this phenomenon to guide future research.

METHODS

Following PRISMA guidelines, a relevant systematic literature search from 2000 to April 2021 was performed to identify literature on neglect in clinical settings within American medical schools.

RESULTS

Neglect, a poorly defined phenomenon in medical education related to the suboptimal learning environment, is often excluded from research on medical student mistreatment. Neglect is a barrier to a successful learning environment, yet a paucity of data and the heterogeneous nature of the present literature render it difficult to estimate its true prevalence. Studies that include neglect frequently assess it solely as the result of identity discrimination or stated career interests. Recent interventions include promoting longitudinal relationships between students and clinical faculty and establishing teaching expectations.

CONCLUSIONS

Neglect is the mistreatment of medical students by the medical care team via a lack of meaningful inclusion in the clinical environment such that it has a notable negative impact on learning and student well-being, regardless of intentionality. An established definition that is grounded in the literature is required to create a common point of reference and understand its true prevalence, its associated variables, and the best mitigation strategies, as well as to guide future research, which should examine neglect independently and as a consequence of personal and professional identities.

A national perspective on exposure to essential surgical procedures among medical trainees in Nigeria: a cross-sectional survey and recommendations

BACKGROUND

In sub-Saharan Africa, recent graduates from medical school provide more direct surgical and procedural care to patients than their counterparts from the Global North. Nigeria has no nationally representative data on the procedures performed by trainees before graduation from medical school and their confidence in performing these procedures upon graduation has also not been evaluated.

METHODS

We performed an internet-based, cross-sectional survey of recent medical school graduates from 15 accredited Federal, State, and private Nigerian medical schools spanning six geopolitical zones. Essential surgical procedures, bedside interventions and three Bellwether procedures were incorporated into the survey. Self-reported confidence immediately after graduation was calculated and compared using cumulative confidence scores with subgroup analysis of results by type and location of institution. Qualitative analysis of free text recommendations by participants was performed using the constant comparative method in grounded theory.

RESULTS

Four hundred ninety-nine recent graduates from 6 geopolitical zones participated, representing 15 out of a total of 44 medical schools in Nigeria. Male to female ratio was 2:1, and most respondents (59%) graduated from Federal institutions. Students had greatest practical mean exposure to bedside procedures like intravenous access and passing urethral foley catheters and were most confident performing these. Less than 23% had performed over 10 of any of the assessed procedures. They had least exposures to chest tube insertion (0.24/person), caesarean Sect. (0.12/person), and laparotomy (0.09/person). Recent graduates from Federal institutions had less procedural exposure in urethral catheterization (p < 0.001), reduction (p = 0.035), and debridement (p < 0.035). Respondents that studied in the underserved North-East and North-West performed the highest median number of procedures prior to graduation. Cumulative confidence scores were low across all graduates (maximum 25/60), but highest in graduates from Northern Nigeria and private institutions. Graduates recommended prioritizing medical students over senior trainees, using simulation-based training and constructive individualized non-toxic feedback from faculty.

CONCLUSION

Nigerian medical students have poor exposure to procedures and low confidence in performing basic procedures after graduation. More attention should be placed on training for essential surgeries and procedures in medical schools.

How medical learners and educators decide what counts as mistreatment: A qualitative study

INTRODUCTION

The mistreatment or abuse (maltreatment) of medical learners by their peers and supervisors has been documented globally for decades, and there is significant research about the prevalence, sequelae and strategies for intervention. However, there is evidence that learners experience maltreatment as being less clear cut than do researchers, educators and administrators. This definitional ambiguity creates problems for understanding and addressing this issue. The objective of this study was to understand how medical learners and educators make sense of less-than-ideal interactions in the clinical learning environment, and to describe which factors influenced their perception that the encounter constituted maltreatment.

METHODS

Using constructivist grounded theory, we interviewed 16 medical students, 15 residents or fellows, and 18 educators associated with a single medical school (n = 49). Data collection began with the most junior learners, iterating with analysis as we progressed through the project. Constant comparative analysis was used to gather and compare stories of 'definitely', 'maybe' and 'definitely not' maltreatment across a variety of axes including experience level, clinical setting and type of interaction.

RESULTS

Our data show that learners and educators have difficulty classifying their experiences of negative interpersonal interaction, except in the most severe and concrete cases. While there was tremendous variation in the way they categorised similar experiences, there was consistency in the elements drawn upon to make sense of those experiences. Participants interpreted negative interpersonal interactions on an individual basis by considering factors related to the interaction, initiator and recipient.

CONCLUSIONS

Only the most negative behaviour is consistently understood as maltreatment; a complex process of individual sense-making is required to determine the acceptability of each interaction. The differences between how individuals judge these interactions highlight an opportunity for administrative, research and faculty development intervention.

Impact of faculty well-being on medical student education

Purpose

The prevalence of physician burnout has risen and negatively impacts patient care, healthcare costs, and physician health. Medical students are heavily influenced by the medical teams they rotate with on the wards. We postulate that faculty well-being influences student perception of clerkships.

Methods

Medical student evaluations core clerkships at one academic institution were compared with results of faculty well-being scores over 2 years (2018-2020). Linear mixed models were used to model each outcome adjusting for year, mean faculty distress score, and the standard deviation (SD) of WBI mean distress scores. Clerkships and students were treated as random effects.

Results

Two hundred and eighty Well-Being Index evaluations by faculty in 7 departments (5 with reportable means and standard deviations), and clerkship evaluations by 223 students were completed. Higher faculty distress scores were associated with lower student evaluation scores of the clerkship (- 0.18 per unit increase in distress, std. err = 0.05, p < 0.01). Increased SD (variability) of faculty distress was associated with higher student overall ratings (0.49 points per unit increase in variability, std. err = 0.11, p < 0.01), as was year with 2019-2020 having lower overall ratings (- 0.17, std. err = 0.06, p < 0.01). Findings were similar for ratings of faculty teaching: mean faculty distress (- 0.15, std. err = 0.25), SD faculty distress (0.33, std. err = 0.12), 2019-2020 vs. 2018-2019 (- 0.19, std. err = 0.06) (all p < 0.01).

Conclusions

Physician well-being is not only associated with quality of patient care and physician health, but also with medical student perceptions of clinical education. These findings provide yet another indirect benefit to improved physician well-being: enhanced undergraduate medical educational experience.

Clinician Teacher as Leader: Creating Psychological Safety in the Clinical Learning Environment for Medical Students

PURPOSE

Psychological safety is the perception that a group environment is safe for interpersonal risk taking, exposing vulnerability, and contributing perspectives without fear of negative consequences. The presence of psychological safety has been tied to wellness, retention, and inclusiveness. National data demonstrate that many of the fundamental components of psychological safety are lacking in clinical learning environments. There is evidence that leadership behaviors can create psychological safety in traditional work environments. The authors sought to understand how clinical teachers' leadership behaviors can create, destroy, and rescue psychological safety in the clinical learning environment.

METHOD

This was a multicenter, cross-sectional, qualitative study of fourth-year medical students from 2 institutions using semistructured interviews. Verbatim transcripts underwent constant comparison and iterative data reduction and analysis, continuing beyond thematic sufficiency.

RESULTS

Eighteen students participated in interviews. Participants described key themes of relationships, an emphasis on learning, clear expectations, autonomy, and frequent feedback as promoting psychological safety. Safe environments lead to a sense of belonging and agency. They reported educator disinterest in students, dismissal of questions, lack of autonomy, and unclear expectations as destructive of psychological safety. Unsafe environments lead to withdrawal and a high extraneous cognitive load. Most students were unable to describe a time psychological safety was restored if lost.

CONCLUSIONS

Clinical teachers' leadership behaviors can directly impact students' perception of psychological safety in the clinical learning environment. Psychological safety increases students' sense of belonging, self-efficacy, and engagement. The findings demonstrate that while it is difficult to repair an atmosphere that is psychologically unsafe, there are several actions that can be put into motion early on to ensure the learning environment is safe and remains so. Future research should investigate whether psychologically safe environments lead to meaningful differences in assessments of student learning and effective cultural change.

Quality Assurance of Undergraduate Medical Education in Israel by Continuous Monitoring and Prioritization of the Accreditation Standards

External accreditation reviews of undergraduate medical curricula play an important role in their quality assurance. However, these reviews occur only at 4-10-year intervals and are not optimal for the immediate identification of problems related to teaching. Therefore, the Standards of Medical Education in Israel require medical schools to engage in continuous, ongoing monitoring of their teaching programs for compliance with accreditation standards. In this paper, we propose the following: (1) this monitoring be assigned to independent medical education units (MEUs), rather than to an infrastructure of the dean's office, and such MEUs to be part of the school governance and draw their authority from university institutions; and (2) the differences in the importance of the accreditation standards be addressed by discerning between the "most important" standards that have been shown to improve student well-being and/or patient health outcomes; "important" standards associated with student learning and/or performance; "possibly important" standards with face validity or conflicting evidence for validity; and "least important" standards that may lead to undesirable consequences. According to this proposal, MEUs will evolve into entities dedicated to ongoing monitoring of the education program for compliance with accreditation standards, with an authority to implement interventions. Hopefully, this will provide MEUs and faculty with the common purpose of meeting accreditation requirements, and an agreed-upon prioritization of accreditation standards will improve their communication and recommendations to faculty.

Improving the Obstetrics and Gynecology Learning Environment Through Faculty Development

INTRODUCTION

The learning environment is shaped by both formal and hidden curricula. Faculty play a critical role in the learning environment but may not be prepared to address the hidden curriculum. This workshop teaches faculty how to manage the hidden curriculum's challenges.

METHODS

Medical students' end-of-clerkship evaluations revealed low ratings in the domains of feedback, respectful interactions, professional language use, and empathy. We created a virtual 60-minute case-based faculty development workshop to highlight the role of faculty in improving the learning environment. A preworkshop survey was emailed to participants. At the workshop, following a brief introduction, participants were divided into groups to discuss the cases and develop strategies to improve the learning environment. A postworkshop survey was used to assess the workshop.

RESULTS

Sixty faculty members attended the seminar. Fifty-seven percent completed a preworkshop survey, and 33% completed the postworkshop survey. After the workshop, more faculty felt well prepared to engage students and residents. The majority of participants (85%) reported being more aware of issues around the learning environment. Most (85%) felt that their interactions with medical students would change in a positive way after the workshop. Ninety percent agreed the workshop was relevant to their needs, 70% agreed they learned a new skill in the workshop, and 80% committed to creating an inclusive learning environment after the workshop.

DISCUSSION

This workshop was well received by participants and was associated with an improvement in learning environment ratings. Faculty development seminars are an efficient tool to improve the learning environment.

Creating a win-win for the health system and health Profession's education: a direct observation clinical experience with feedback iN real-time (DOCENT) for low acuity patients in the emergency department

BACKGROUND

Clinical education across the professions is challenged by a lack of recognition for faculty and pressure for patient throughput and revenue generation. These pressures may reduce direct observation of patient care provided by students, a requirement for both billing student-involved services and assessing competence. These same pressures may also limit opportunities for interprofessional education and collaboration.

METHODS

An interprofessional group of faculty collaborated in a sequential quality improvement project to identify the best patients and physical location for a student teaching clinic. Patient chief complaint, use of resources, length of stay, estimated severity of illness and student participation and evaluation of the clinic was tracked.

RESULTS

Clinic Optimization and Patient Care: Five hundred and thirty-two emergency department (ED) patients were seen in the first 19 months of the clinic. A clinic located near the ED allowed for patients with higher emergency severity index and greater utilization of imaging. Patients had similar or lower lengths of stay and higher satisfaction than patients who remained in the ED (p < 0.0001). In the second clinic location, from October 2016-June 2019, 644 patients were seen with a total of 667 concerns; the most common concern was musculoskeletal (50.1%). Student Interprofessional Experience: A total of 991 students participated in the clinic: 68.3% (n = 677) medical students, 10.1% (n = 100) physician assistant students, 9.7% (n = 96) undergraduate nursing students, 9.1% (n = 90) physical therapy students, and 2.8% (n = 28) nurse practitioner students. The majority (74.5%, n = 738) of student participants worked with students from other professions. More than 90% of students reported that faculty set a positive learning environment respectful of students. However, 20% of students reported that faculty could improve provision of constructive feedback. Direct Observation: Direct observation of core entrustable professional activities for medical students was possible. Senior medical students were more likely to be observed generating a differential diagnosis or management plan than first year medical students.

CONCLUSIONS

Creation of a DOCENT clinic in the emergency department provided opportunities for interprofessional education and observation of student clinical skills, enriching student experience without compromising patient care.

Trust and risk pitfalls in medical education: A qualitative study of clinical teachers

PURPOSE

Learning opportunities in teaching hospitals are gated by clinical teachers. One way to unpack their decision-making is to employ a 'trust and risk' model. This study aimed to uncover clinical teachers' experience of trust, risk and vulnerability as they participate in medical education.

METHODS

Hospital-based clinical teachers were interviewed about trust, risk and vulnerability in medical education. Data analysis was undertaken using a constructivist, qualitative framework.

RESULTS

Twenty demographically diverse clinical teachers participated. Trust and risk were regarded as fundamental workplace and teaching concepts. Their concerns fell into three domains of risk: clinical, teaching and personal. Being trusted unlocked clinical learning opportunities, whereas trust failure limited future participation. Feeling trusted or not affected wellbeing and self-efficacy. Trust and risk pitfalls in education included bias, asymmetry and sidelining.

CONCLUSIONS

This study adds to the literature by voicing clinical teachers' personal risks and vulnerabilities. Attention was drawn to the benefits of being perceived as trustworthy, and to the clinical, teaching and personal vulnerabilities of trust failure.If expert judgement of trustworthiness is to be legitimised as meaningful assessment, clinical teachers must be aware not only of how trust is built, but also the pitfalls of trust failure.

Medical student learner neglect in the clinical learning environment: Applying Glaser's theoretical model

INTRODUCTION

Learner neglect is a relatively new concept in education, and no suitable framework for its exploration has been devised. The aim of this study was to determine whether an existing framework, Glaser's framework of child neglect, could be applied to learner neglect in clinical learning environments. This was a retrospective analysis of data obtained as part of a related study.

METHOD

Six focus groups were conducted with medical students in their early clinical years to explore their views of what experiences in medical education were challenging and why they presented a challenge. The transcript data were analysed using inductive content analysis, within an interpretivist approach in the development of categories. The identified categories were cross referenced with Glaser's framework categories replacing the carer with the teacher and the child with the learner.

RESULTS

Glaser's classifications of teacher (parent) behaviours were all identified in the negative aspects of medical learner clinical education including emotional unavailability/unresponsiveness, acting in a hostile manner, inappropriate inconsistent developmental interaction, failure to recognise individuality and failure to promote social adaption. Physical unavailability was identified as an additional category and is included in our proposed framework of learner neglect.

DISCUSSION

Adapting Glaser's framework was useful in considering learner neglect. Medical schools have a role in ensuring learning experiences are positive across contexts and to make explicit to teachers any behaviours that may appear as learner neglect. Applying this framework has the potential to make more explicit any subtle undermining teacher behaviours. Once explicit, there is a greater likelihood that behaviours may be reappraised both by the teacher and learner and modified to promote a more effective clinical learning experience.

Medical educators' beliefs about teaching, learning, and knowledge: development of a new framework

BACKGROUND

The educational beliefs of medical educators influence their teaching practices. Insight into these beliefs is important for medical schools to improve the quality of education they provide students and to guide faculty development. Several studies in the field of higher education have explored the educational beliefs of educators, resulting in classifications that provide a structural basis for diverse beliefs. However, few classification studies have been conducted in the field of medical education. We propose a framework that describes faculty beliefs about teaching, learning, and knowledge which is specifically adapted to the medical education context. The proposed framework describes a matrix in which educational beliefs are organised two dimensionally into belief orientations and belief dimensions. The belief orientations range from teaching-centred to learning-centred; the belief dimensions represent qualitatively distinct aspects of beliefs, such as 'desired learning outcomes' and 'students' motivation'.

METHODS

We conducted in-depth semi-structured interviews with 26 faculty members, all of whom were deeply involved in teaching, from two prominent medical schools. We used the original framework of Samuelowicz and Bain as a starting point for context-specific adaptation. The qualitative analysis consisted of relating relevant interview fragments to the Samuelowicz and Bain framework, while remaining open to potentially new beliefs identified during the interviews. A range of strategies were employed to ensure the quality of the results.

RESULTS

We identified a new belief dimension and adapted or refined other dimensions to apply in the context of medical education. The belief orientations that have counterparts in the original Samuelowicz and Bain framework are described more precisely in the new framework. The new framework sharpens the boundary between teaching-centred and learning-centred belief orientations.

CONCLUSIONS

Our findings confirm the relevance of the structure of the original Samuelowicz and Bain beliefs framework. However, multiple adaptations and refinements were necessary to align the framework to the context of medical education. The refined belief dimensions and belief orientations enable a comprehensive description of the educational beliefs of medical educators. With these adaptations, the new framework provides a contemporary instrument to improve medical education and potentially assist in faculty development of medical educators.

Incidence of resident mistreatment in the learning environment across three institutions

INTRODUCTION

Mistreatment in the learning environment is associated with negative outcomes for trainees. While the Association of American Medical Colleges (AAMC) annual Graduation Questionnaire (GQ) has collected medical student reports of mistreatment for a decade, there is not a similar nationally benchmarked survey for residents. The objective of this study is to explore the prevalence of resident experiences with mistreatment.

METHODS

Residents at three academic institutions were surveyed using questions similar to the GQ in 2018. Quantitative data were analyzed based on frequency and Mann-Whitney U tests to detect gender differences.

RESULTS

Nine hundred ninety-six of 2682 residents (37.1%) responded to the survey. Thirty-nine percent of residents reported experiencing at least one incident of mistreatment. The highest reported incidents were public humiliation (23.7%) and subject to offensive sexist remarks/comments (16.0%). Female residents indicated experiencing significantly more incidents of public embarrassment, public humiliation, offensive sexist remarks, lower evaluations based on gender, denied opportunities for training or rewards, and unwanted sexual advances. Faculty were the most frequent instigators of mistreatment (66.4%). Of trainees who reported experiencing mistreatment, less than one-quarter reported the behavior.

CONCLUSION

Mistreatment in the academic learning environment is a concern in residency programs. There is increased frequency among female residents.