Creating and Supporting Safe Clinical Learning Environments – What Can I Do?

I was invited to speak at the Dalhousie Postgraduate Medical Education professional day for program directors and program administrators. The title above was one of the talks I was asked to present.

What is the “learning environment?”

The “learning environment” has been defined as “everything that is happening in the classroom or department or faculty or university.”1,2

In our work, where at least two-thirds of our medical education takes place in the clinical setting, our learning environment extends to the entire province. In fact, we have a responsibility to ensure our students have a safe learning environment anywhere—even when taking electives out of province.

So if that is the learning environment, what is a safe learning environment? For me, a safe learning environment is a place you (or your son or daughter) would like to go to medical school. I believe excellent clinical education is dependent on a safe clinical learning environment.

In my talk, I divided the characteristics of a safe learning environment under five headings: Physical, Program, Learning, Clinical, and Behavioral. I provide here my presentation from that day.

Physical includes obvious things like safe house calls by residents, for example. Program includes things like fair and transparent promotion policies. Learning includes things like learning objectives that are attainable. Clinical includes very important principles, like appropriate graduated responsibility and supervision of learners.

The Behavioral heading gets complicated and the discussion at my talk in Halifax developed into a long list. I believe many of us of a certain age were exposed to teaching techniques that are unacceptable today.

I recall an experience in my clerkship with a supervisor who was a fan of scotch and jazz. Tradition was for the house staff to gather in his office late on Friday afternoon, share a “wee dram;” give an assignment to the two clerks to find an obscure piece of trivia about jazz; and share plenty of male jocularity! The irony was that he was an incredible clinical teacher, but the behavior was inappropriate even then. (I am not that old!)

Accreditation is highly dependent on student feedback through the Independent Student Analysis and the Canadian Graduation Questionnaire. Historically, the CGQ documented both locally and nationally that about 30 per cent of students reported mistreatment over the course of four years. The Association of Faculties of Medicine of Canada no longer provides the national comparator on the basis of the fact that zero mistreatment is the only acceptable goal.

Unfortunately, we are not yet down to zero. While the pre-clinical learning environment is not immune, most reports are in the clinical environment. The source is most often clinical faculty but also includes hospital staff, residents and fellow students.

The most common form of mistreatment is public humiliation. This could be shaming over an incorrect diagnosis or public fact-based questioning of increasing difficulty. I include a link to my previous blog on “pimping.” Distressing to me were incidents of racially based comments directed at students.

I know the vast majority of faculty abhor any form of student mistreatment. On the other hand, I am also sure some instances are unintended and that sometimes people are simply unaware of their impact on learners.

We encourage students to come forward with concerns and we guarantee their confidentiality. We can only fix what we know about.

I believe the CoM must be proactive in eliminating mistreatment. I believe it is incumbent on all of us to work every day to ensure our students have the educational experience we would like to have ourselves.

Among my final words at Dalhousie was that we all must be prepared to speak truth to power in addressing these issues.

The CoM has plenty of experienced faculty who can provide faculty development or lead workshops for departments, etc. We have invested more in Faculty Development and welcome the opportunity to assist in making this college a place where zero tolerance for mistreatment is not simply a belief, but also a result.

As always, I look forward to your feedback.

[1] Genn JM. AMEE Medical Education Guide No. 23 (Part 2): Curriculum, environment, climate, quality and change in medical education – a unifying perspective. Med Teach. 2001;23(5):445–54.  [PubMed]
[2] Roff S, McAleer S. What is educational climate? Med Teach. 2001;23(4):333–34.  [PubMed]

2 thoughts on “Creating and Supporting Safe Clinical Learning Environments – What Can I Do?

  1. And this I find equally distressing.
    Thank you for your thoughtful contribution.
    And thank you for what you do for our students and our College.
    I am sure your 50 minutes for some of our students may be the most impactful of the entire curriculum.

  2. Abusive and humiliating comments regarding sexual orientation and gender identity and expression are also still a significant problem. I teach a session to first year med students here and ask them to write a brief reflection on their personal attitudes towards sexual and gender minority identified patients and how these attitudes might affect their ability to provide care to such clients. I teach this session from my personal experience as a queer identified, gender non-conforming person. Every year I get at least 3 reflections that express how afraid the writers are of coming out in medical school because of the homophobia, heterosexism and transphobia they hear from their classmates. The prevalence of homosexuality in Canada is somewhere between 3 and 10%, and it is well recognised that the professions attract higher proportions of sexual and gender minority identified people than are represented in population at large; therefore, it is reasonable to assume that any given class of medical students at the U of S has at least 5 such members. I hope that my 50 minute session provides a very brief respite to these students, and that it prompts the majority of heterosexual and cis-gender students to think about the effect of their words on others. However, it is beyond the scope of this one session to make medical school safe.
    Elliott MN, et al. Sexual minorities in England have poorer health and worse health care experiences: A national survey. Journal of General Internal Medicine. 2014;30(1):9-16
    Conley, TD, et al. Mistakes that heterosexual people make when trying to appear non-prejudiced: A view from LGB people. Journal of Homosexuality. 2001;42(2):21-43
    Mansh, M. et al. From patients to providers: Changing the culture in medicine toward sexual and gender minorities. Academic Medicine, 2015;90(5).
    Mansh, M. et al. Sexual and gender minority identitiy disclosure during undergraduate medical education: “In the closet” in medical school. Academic Medicine, 2015;90(5).

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