Two sides of the same coin: Elements that can make or break clinical learning encounters

Published 2021/06/03

Abstract

Phenomenon: This project explored how faculty, residents, and students at an academic medical center have experienced meaningful learning moments, what contributed to such moments within the clinical learning environment, and how these moments map on to a previously developed conceptual model of the learning environment. Approach: During AY 2018-19, the authors interviewed faculty (n=8), and residents (n=5) from the Surgery and OBGYN departments at the University of Utah School of Medicine. The authors also conducted interviews (n=4) and focus groups (n=2) with 20 third- and fourth-year students. Authors used an appreciative inquiry approach to conduct interviews and focus groups, which were audio-recorded and transcribed verbatim. Transcriptions were coded using manifest content analysis. Findings: Authors found that three factors determined whether learning encounters were successful or challenging: learner-centeredness, shared understanding, and learner attributes. Situations that were characterized by learner-centeredness and shared understanding led to successful learning, while encounters characterized by a lack of learner-centeredness and shared understanding led to challenges in the clinical learning environment. Likewise, some learner attributes facilitated successful learning moments while other attributes created challenges. These three factors map well onto three of the four elements of the previously developed conceptual model. Insights: The clinical learning environment is characterized by both successful and challenging moments. Paying attention to the factors which promote successful learning may be key to fostering a positive learning environment.  

Introduction

The learning environment encompasses people, social interactions, organizational elements, and material conditions.1 The learning environment is central to the quality of learners’ experiences. Ample evidence exists to suggest that the exceptional learning environment is difficult to create and maintain,1-3 in part because the factors thought to be important in creating an ideal learning environment are not always easy to address or implement.2 Indeed, creating a high quality learning environment is a “wicked problem”4 that is not easily resolved.

Gruppen and colleagues1 explain in detail the various elements that comprise the learning environment. Their conceptual framework includes two dimensions: the psychosocial and material, which when combined, encompass five different elements: personal, social, organizational, physical, and virtual spaces of learning environments. The personal includes factors like prior knowledge, professional identity, and motivation, while the social includes relationships and the interactions included in teaching, learning, and patient care. The organizational refers to the culture, practices, and policies of the organization. Finally, learning spaces can include the physical, such as patient exam rooms and classrooms, and the virtual, including learning management systems and other digital platforms. Gruppen et al.1 aptly point out these dimensions and elements are intersecting and work together within an environment to foster both negative and positive learning encounters. Negative learning environments foster encounters which are often marked by learner mistreatment—a complex, multifactorial issue which has received much attention in the literature.5-13 According to the Association of American Medical Colleges (AAMC), “Mistreatment either intentional or unintentional occurs when behavior shows disrespect for the dignity of others and unreasonably interferes with the learning process.”14 While the AAMC goes on to identify examples of mistreatment, the conditions which lead to mistreatment are often very context-specific and not always well understood especially across all of the interacting elements of the learning environment as captured in the Gruppen et al.1 conceptual framework. As a result, individual institutions must make their own investigations and seek insight about the conditions which prevent or lead to mistreatment behaviors.

Positive learning environments foster encounters which support the well-being of learners. Studies have noted associations between positive learning environments and factors including student demographics and student professional attributes,15 the presence of learning communities,16 and academic performance including United States Medical Licensing Exam (USMLE) Step 1 scores.17 Research has also shown that placing the right amount of trust in students,18 providing clarity around expectations, roles, and communication, and providing feedback can support learning.19

To gain additional insight into what constitutes a positive learning experience within the clinical learning environment within two procedurally-based departments at our institution, we initiated a qualitative investigation designed to elicit perceptions of faculty, residents, and students. We targeted these departments (with reoccurring reports of student mistreatment) to understand the factors influencing the learning experience. We used the following questions to guide our study: (1) “What meaningful moments have individuals experienced in the clinical environment?” and (2) “What factors contributed to these moments?”

Methods

Participants and recruitment

This project was granted exemption by our institution’s Institutional Review Board. We utilized a multi-case study design20 to understand the factors that made learning meaningful and purposefully selected21 faculty, residents, and students to participate. It was important to us to capture perspectives from individuals at multiple levels. Authors LB, BKS, and TW, who hold education leadership positions in their departments, provided names of residents and faculty who were highly involved in educational efforts and CJC chose a subsection of those residents and faculty to participate in the interviews. Residents and faculty were chosen to represent various gender identities, ranks, career tracks, and years of experience. The intention in not interviewing all the suggested individuals was to help participants maintain a degree of anonymity. The Director of Student Affairs provided names of fourth-year students who held current or former leadership positions and who were well-acquainted with their classmates’ experiences. Focus groups with third-year students who were near the end of their clerkship year were conducted while assigned to their surgery clerkship. In total, we spoke with 37 participants: residents (n=3) and faculty (n=4) in the Department of Surgery, residents (n=2) and faculty (n=4) in the Department of Obstetrics and Gynecology, fourth-year medical students (n=4), and 20 third-year medical students. Interviews and focus groups were conducted during AY 2018-19.

Data collection and analysis

Motivated by evidence in the literature about the power of focusing on what was going well in order to generate ideas,22 we chose to employ an appreciative inquiry approach.23 Our intention was not to ignore mistreatment but rather to focus on existing positive conditions upon which to enhance learning outcomes.22 We felt that if we focused singularly on incidences of mistreatment, it would be difficult to move past the problems. Thus, interview and focus group questions (see Appendix24) specifically asked participants to describe a successful learning moment and what they contributed to that moment, to name their values and how well these were reflected by our institution, and to recall an instance in which their values had been challenged. The questions were piloted with two student affairs administrators who were well-acquainted with students’ learning experiences. All interviews were conducted by CJC and/or BFR, who are both PhD-trained educational researchers with qualitative experience. The focus groups were conducted by CJC and CB, who accompanied CJC to some of the interviews to gain qualitative interviewing experience.

We transcribed the interviews and focus groups verbatim using Descript version 3.6.1 (San Francisco, CA). We used Dedoose Version 7.0.23 (Los Angeles, CA: SocioCultural Research Consultants, LLC www.dedoose.com) to engage in manifest content analysis of the data.25 CJC coded the interviews and focus groups. A third of the way through the first round of coding, the coding team (CJC, CB, TC, and BFR) met to discuss, collapse, and reach consensus on the codes in order to establish a codebook. All transcripts were coded based on the agreed upon codebook by CJC, with the understanding that new codes could be added as they were relevant to the data; CB also coded four transcripts to ensure multiple interpretations of the data were explored. Discrepancies were resolved through discussion with the entire coding team. This coding process resulted in code categories that illustrated successes and challenges related to patient care and teaching and learning. To further understand what factors contributed specifically to successful and challenging teaching and learning moments, CJC and TC engaged in a second phase of coding, this time looking for factors that contributed to learning successes and challenges until they reached a saturation of themes.26 Again, we resolved discrepancies through discussion with the coding team. Finally, the codes and categories were further refined as they were organized into themes by CJC and CB.

Ensuring trustworthiness

We recognize that our researcher positionalities matter because of the perspectives we bring to our work. Having multiple coders on the team was essential in exploring multiple interpretations of the findings. Regular peer debriefing27 meetings between those collecting and analyzing the data (CJC, BR, CB, and TC) and those who helped design the study (BKS, LB, TW, and SML) ensured we could make sense of the findings within the context of the departments where the study was conducted. Finally, memo writing28 helped us to keep an audit trail throughout the data collection and analysis process to track the data collection and analysis process. 

Results

We organize our findings into three themes (Figure 1) that help explain why successes and challenges in the learning environment occur: 1) degree of learner-centeredness, 2) extent of shared understanding, and 3) learner attributes. In the following paragraphs, we describe each theme, its positive characteristics (how it’s supportive of the learning environment), its negative characteristics (how it’s distracting to the learning environment), and provide exemplary quotes. We use the terms student or resident when talking specifically about either population and the term learner when referring to both. We use the terms faculty and resident when talking specifically about either group and teacher when talking generally about both. We abbreviate excerpts from surgery and OBGYN interviews with an “S” or “O”, respectively, followed by a number. We abbreviate excerpts from students interviews and focus groups with “St” or “FG, ” respectively, followed by a number.

Figure 1. Factors and attributes that support or distract from a successful learning environment

Figure 1. Factors and attributes that support or distract from a successful learning environment (Click to Enlarge Figure 1)

Learner-centeredness

The theme of learner-centeredness captures how contributions of teachers and learners work together to create an environment where the learners are an important focal point, and where the environment explicitly supports learners’ needs. We organize the contributions to learner-centeredness into three categories 1) teaching is a priority or not, and 2) learning is scaffolded or not, and 3) teaching is differentiated or not. 

  1. Positive: Teaching is a priority. Learners described how gratifying it was when teachers made time for teaching: “when people actually have like two minutes to just like look you in the eye and explain something.” (FG2) Teachers also explained that teaching opportunities were almost always present, and just needed to be utilized: “in my opinion if it’s not a life-threatening situation, there’s always a moment to teach” (S2)
    Negative: Teaching is not a priority. Participants discussed how the urgency of providing patient care could supersede teaching: “We can’t dedicate our undivided attention to… educating students. We have to … take care of the patients.” (S3) Participants also mentioned how “…some [teachers] are not as great about educating students” (O6) or how others do not have the capacity to engage in teaching: “at the beginning of the week, he was…super happy in the operating room and …[say] ‘ hey, like, what do you think this is anatomy wise?’ … towards the end of the week … he like wouldn’t talk” (St2).
  2. Positive: Learning is scaffolded (i.e., chunked, progressively more complex, aligned to context). Teachers discussed how they deliberately expanded opportunities in patient care to scaffold learning: “there was a big incision to suture …I started off and let her kind of watch me do it, …then I watched her do it, and gave her on-the-fly feedback.” (S7). Learners shared that aligning feedback with specific task they were learning to perform enhanced learning: “she’d always give feedback like constantly on how I can improve techniques.” (FG2).
    Negative: Teaching is not scaffolded. Learners and teachers explained that the unpredictability of patient care needs could interfere with carefully scaffolded teaching: “So it is more successful if [skills] can be leveled up in a coherent way, but unfortunately that’s not always how things present themselves …we also are running traumas.” (S3) Learners also shared that it was discouraging and confusing when teachers were dismissive and hostile instead of giving feedback: “When you give your assessment and plan and they don’t even acknowledge it, they say there’s [something wrong] and then they don’t tell you why you were wrong.” (FG1)
  3. Positive: Teaching is differentiated (i.e., tailored to idiosyncratic learner needs). Learners appreciated when the teaching was specific to the context and their individual needs. One mentioned, “They took the time to actually teach me everything in emergency medicine that is related to OBGYN.” (St4) Teachers explained what a difference it made to gear teaching to students’ interests and needs: “…if you try to make an effort the first few days …it goes a long way in terms of buying a little bit of engagement.” (S5)
    Negative. Teaching is undifferentiated. Learners expressed frustration when teaching was not tailored to their level or needs: “…your expectation that you have for a resident is not the same you’re going to have with a… student.” (St4). Teachers expressed frustration at not being able to adequately tailor teaching to individual student needs: “We work with medical students a lot…they’re a very diverse group and they have diverse interests and diverse strengths and weaknesses.” (O4)

Shared understanding

The theme of shared understanding captures the impact of teachers creating an environment where they, their learners, and the rest of the clinical team are on same page. These conditions include 1) explicit expectations or not and 2) communication, teamwork, and camaraderie or not. When these conditions existed, quality learning tended to occur.

  1. Positive: Explicit Expectations. Learners mentioned that knowing what to do to succeed was essential for successful learning encounters: “… it can make a big difference [when] the resident will take 3 or 5 minutes and [say] this is how I want you to structure a note.” (St3) Likewise, teachers explained that managing expectations helps learners know what they can and cannot do: “if you at a beginning of the case say to the students, this is what you should … get out of this case…I think that manages that tension.” (S4) 
    Negative: Lack of consensus on definitions or expectations. Participants discussed how “I think the prior way of teaching accountability and expectations even 10 years ago is different for the learners… so we’re not teaching to them how they learn best” (O3). A lack of consensus also arose when individuals had different definitions for mistreatment: “these reports of mistreatment come from…a different set of expectations on the learner versus the teacher side of things…” (S2).
  2. Positive: Communication, teamwork, and camaraderie. Teachers noted that open communication went a long way in setting learners up for success. One explained, “letting them know, …these are the reasons why you got this feedback and this is how to take it” (O6). Along similar lines, another teacher said, “So what I’ve … done … if I’m sensing things that are getting tense is I’ll pause, … and say look …this is what’s happening.” (S6)
    Negative: Lack of communication and teamwork. Participants spoke about how a breakdown of communication resulted in learning challenges. Both teachers and learners shared that it was challenging to give and receive feedback. A learner reflected on the difficulties of getting feedback: “I try to ask for feedback a lot…I don’t always get it. (FG1) One teacher explained: “I think sometimes … we don’t want to hurt people’s feelings and so we don’t give them the best feedback” (O4).

Learner attributes

The theme of learner attributes captures participants’ perceptions of how learner attributes contribute to the success of a learning encounter. The attributes identified in our study which contributed to successful encounters exemplify interpersonal skills and were 1) resilience and persistence, 2) engagement, and 3) situational awareness.

  1. Positive: Resilience and persistence. Learners discussed the importance of accepting of feedback, “ have a relatively thick skin…keeping that big picture in mind has kind of helped me.” (s7)
    Negative: Lack of resilience/sense of entitlement. Learners who are unable to receive feedback pose challenges to their teachers: “… the response was … not a like, ‘oh, let me learn how to do better,’…but ‘I can’t be anything less than excellent.’” (O2) Similarly, learners who feel like they deserve to be the best can make learning challenging: “What they all want to be is the best team member, not the best member on the whole team…They’re in it for themselves.” (O5)
  2. Positive: Engagement. Learners felt they received more teaching when they showed they were invested. “…my attending my pulled me out of doing other things with the team to come with her to go to this end of life conversation and … I feel like she only would have done that …because I had been engaged” (St1). Teachers also shared that teaching engaged students made for success: “…the ones who really … asked questions or tell me what they have been struggling with … end up being more successful.” (S1)
    Negative: Lack of engagement. Learners who do not display engagement in the learning encounter can discourage teachers from teaching. One attending shared, “…it takes energy for me to take good care of the patient, do the surgery, teach the resident, and teach [a student] at the same time. And if you [the student] don’t put that energy in beforehand, I’m not going to put [in] that energy … it’s disrespectful to the patient.” (S4)
  3. Positive: Situational awareness. Learners and teachers discussed how learners’ situational awareness was important in eliciting teaching: “the best students know how to integrate really well into a team and they understand …this team has a goal of providing the best possible care to the patient” (O2). A learner shared, “…just being able to be aware of the situation and kind of read like, oh now’s a good time to for me to ask a question or I’ll have to wait.” (FG1).
    Negative: Lack of situational awareness. Participants discussed how learners who did not have situational awareness received less teaching: “there are always students who … struggle with …being appropriate or finding the right time to ask questions … Leads them to not get taught as much … and leads to frustration on both sides” (O1).

Discussion

We used appreciative inquiry to explore the learning environment in two of our departments which received reoccurring reports of mistreatment. We conducted focus groups and interviews with faculty, residents, and students to understand what contributed to positive learning encounters in order to generate ideas about how to reproduce these positive situations. Our participants shared meaningful teaching and learning moments in the clinical learning environment. We identified three factors that contributed to these moments: learner-centeredness, shared understanding, and learner attributes. Learner and teacher behaviors represented by these themes contributed, individually and in combination, to the quality of the learning environment which led to learning outcomes. To the degree that these results align with Guppen’s1 recently published model of the learning environment, they help to expand and clarify the literature and support a variety of interventions designed to enhance the learning environment and promote learning.

Alignment to Gruppen model

The three themes identified in our study fit well into the psychosocial domain of the Gruppen model1 Some themes align with multiple elements.29 {Gruppen, 2019 #222}Learner-centeredness falls within the personal, social, and organizational elements of the psychosocial domain. For example, how responsibilities are shared with learners to foster learner-centeredness is largely guided by teachers’ actions (personal), clerkship practices (social), and policies (organization). Shared understanding between students and teachers is highly dependent on the relationships and interactions (social) that take place in the learning environment. Finally, the attributes that learners bring to the learning environment align with the personal element of the model. Interestingly, none of our themes explicitly map onto the material domain, which may be due to the fact that our interview questions may have caused participants to focus on the influences of people, behaviors, and culture rather than on spaces.

Alignment with Literature

Each of our themes reinforce findings from previous studies.  Our participants described how prioritizing teaching contributed to a sense of learner-centeredness and subsequent positive learning outcomes. Likewise, Tien and colleagues30 suggest providing students with opportunities to learn through ownership of patient care is an important part of professional identity formation. It follows then, that being asked to assume ownership also conveys to learners that learning is differentiated and tailored to them. We also found that learners and teachers perceived that scaffolded learning with psychological safety contributed to a sense of learner-centeredness. Similarly, Tsuei and colleagues31 found that students could focus on learning more fully when they did not have to worry about whether they were being judged or how they were performing. Our participants reported that a lack of learner-centeredness was often in conflict with the urgency of providing patient care. Given that exclusion from patient care encounters is associated with mistreatment,7 it is not surprising that feeling excluded leads to challenges in the learning environment. While not new, the findings that faculty and student practices that promote learner-centeredness helps create a positive learning environment which enhances learning the finding is nonetheless reinforcement of the importance of learner centeredness in encouraging learner experiences.

For the theme of shared understanding, our participants identified that having explicit expectations and communication between learners and teachers created situations that fostered positive learning, while not having them led to challenges. These findings heighten the implications of research that found that differences exist among interns, residents, and attendings regarding what should happen on rounds32 and that expectations differ when it comes to time spent on education, skills medical students should have, and the roles students should play.33 This challenges the utility of the traditional approach taken by most academic health centers where students are assigned to teams consisting of interns, senior residents, sometimes fellows, and attendings. Adopting a student-focused clerkship structure such as the one described by Matheny Antommaria et. al 34 more widely could help overcome barriers to achieving student-centeredness, ownership, and autonomy in patient care for learners.  

            In terms of the learner attributes theme, we found that individual learner characteristics strongly influenced the learning and environment and associated outcomes. For example, learners who could navigate new relationships and situations had more positive learning outcomes than did students who lacked situational awareness. Students who engage in a lot of personal impression management during their clinical years, and who are able to convey a positive impression of oneself receive learning opportunities and positive evaluations.35 Similarly, Nguyen & Johnson36 identified ways that students can influence the learning environment to promote positive learning outcomes. 

Implications

These findings have implications for the roles that both learners and teachers play in fostering positive learning encounters. Importantly, our study demonstrates that the relationship between learners and teachers is extremely dependent on the context in which they interact, their individual orientations to the situation, and their engagement with one another.

            Our findings also have implications for how professional learning sessions can be designed to prepare both learners and teachers to engage with each to promote a positive environment and associated learning outcomes. The clinical environment has different demands and expectations from the preclinical setting and students often struggle in making this transition.37 It has been suggested that making these expectations more explicit and teaching them in formal ways could be helpful in preparing students to be successful physicians.38 Changes to the structure of the clinical learning environment, such as creating longitudinal clinical experiences, could also be beneficial.39,40 Similarly, teachers in the clinical environment might need to be taught explicitly about how to support learners during this transition period.39 Likewise, teachers may need instruction on how to incorporate students into learning moments and how to foster psychological safety.41

Limitations

Our appreciative inquiry approach by design did not focus directly on just the factors influencing mistreatment; as such, we could have missed out on learning about factors that contribute more directly to mistreatment and negative learning encounters. In addition, we only interviewed faculty and residents in two clinical departments that were procedurally based at one institution. The factors that positively and negatively impact the learning environment in more medically based disciplines (e.g. internal medicine, pediatrics) may be somewhat different and are an opportunity for future exploration.  Therefore, we acknowledge that surgery and OBGYN have specific cultures and that the findings we report may not fully reflect circumstances in other clinical settings. Furthermore, student perspectives were obtained from individuals who were predominantly speaking to their experiences in the clinical clerkship learning environment. Inquiry into factors influencing the learning environment in the pre-clerkship or predominantly classroom-based setting were not a focus of this study.

            Despite these limitations, our study reinforces that the components proposed in the Gruppen1 model are, in fact, significant contributors to the learning environment. Our study also verifies how intersecting these components are, and that to understand how to create positive learning environments, one must look at multiple factors, including the degree to which the environment is learner-centered, how expectations are shared, and the attributes that learners and teachers bring.

Conclusion

Learner mistreatment in medical education is a major problem, is multifactorial, and difficult to eliminate. Our study has highlighted several factors that influence whether learning encounters are viewed as successful or challenging. Our findings detail factors that promote learning; with careful and consistent attention to increasing learner centeredness, developing shared understanding and cultivating positive learner and teacher attributes we believe we can make progress toward achieving the exceptional learning environment.    

Acknowledgements: We are grateful to Tisha Mentnech for her assistance in helping us conduct our literature review. We are also grateful to the participants who shared their stories with us.

References

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Appendix

**This is a semi-structured interview protocol, adapted from a guide originally developed by Drs. Williamson and Suchman.1 Probes will be used as necessary to elicit additional pertinent information.

Interview questions

  • Introduction: This is going to be what we call an appreciative interview. I am going to ask you questions about times when you experienced educational things working at their best here at [institution]. Many times, we try to ask questions about things that aren’t working well—the problems—so that we can fix them. In this case, we are trying to find out about the things at their best—the successes—so that we can find out what works and why, and find ways to infuse more of it into our practice.
  • As we get started, I’d like to know a little bit about you. Just so you know, this information will not be associated with any of your stories or quotes, but will just be used to provide context to our findings.
    • What’s your role here at [institution] and how long have you been here?
  • People do their best work when they are doing things that they find personally meaningful, and when they feel that their work makes a difference. During your time at [institution], there have no doubt been high points and low points. For now, I’d invite you to think of a teaching and learning moment that meant a lot to you, when things went right, a time that brought out the best in you.
    • Please tell the story of that time.  (If they are very general, try to probe for more specificity.)
    • Without worrying about being modest, please tell me what it was about you—your unique qualities, gifts or capacities; decisions you made; or actions you took—that contributed to this teaching/learning experience?
    • What did others contribute or do?
    • What aspects of the situation made this a success (for example, the place, the time of day or year, recent events)?
  • Now, think of a time at [institution] when you or your values were challenged.
    • Please tell me a story about that time. (If participant needs clarification about what a value is, explain that a value is “a person’s principles or standards of behavior; one’s judgment of what is important in life.”)
  • We each have different qualities, gifts and skills we bring to the world and to our work. Think about the things you value about yourself, the nature of your work and the university. At work, we’re always dealing with challenges and change.
  • How have your strengths and values helped you deal with challenges and change?
    • Your work: When you are feeling good about your work, what do you like about the work itself?
    • Yourself: Imagine you’re at your retirement party. What do you think your colleagues would say they liked most about you?
    • Yourself: Now what do you think your students would say they’ve liked most about you?
    • How do your personal values match those of [institution]? (for example, honesty, compassion, teamwork)?
    • Where have you seen examples of these values at [institution]?
  • Where do you think these reports of mistreatment are coming from?

Focus group questions

  • What was it about you—your unique qualities, gifts or capacities; decisions you made; or actions you took—that contributed to these peak learning experiences? What did others contribute or do?
    • What aspects of the situation made this a success (for example, the place, the time of day or year, recent events)?
    • What are the commonalities among all of your stories?
    • What are two things you can do, as students, to promote more of these experiences? What are two things that curricular leaders can do to promote more of these experiences?
  • This project arose out of a desire to understand why student mistreatment in clerkships occurs. So next, I would like you to think about how these moments of success differ from moments of challenge.
    • Assuming that moments of success were to happen all the time, how likely is it that mistreatment would occur?
    • What are two things that need to happen to prevent mistreatment?

References

  1. Williamson P, Suchman A. Appendix A. In: Caudlin C, Sarangi S. Handbook of Communication in Organizations and Professions. Berlin, Germany: DeGruyter Mouton; 2011.


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Two sides of the same coin: Elements that can make or break clinical learning encounters by Candace Chow, PhD, Chanta'l Babcock, MAS, Todd Christensen, Luke Buchman, MD, Tiffany Weber, MD, Sara Lamb, MD & Brigette Smith, MD