Show Notes
Description
Dr Alex Grieco visits the studio as we consider the medical learning environment. The spaces we create for clinical teaching impact the development of tomorrow’s physicians. Trainees can thrive… or flounder… depending on the type of space we create. Tune in to learn more!
Topics
Safe Learning Spaces
Medical Student Mistreatment
Learning Objectives
At the end of this activity, participants should be able to:
- Describe key features of positive and negative clinical learning environments.
- Differentiate clearly inappropriate behaviors and ambiguous interactions in teaching environments.
- Analyze case examples to identify impact, intention, and opportunities for faculty intervention.
- Apply restorative and reflective practices to address harm and foster safer learning cultures.
FD-ED Credit
Guest
This episode is approved for FD-ED credit through the Center for Faculty Development at Nationwide Children’s Hospital. FD-ED credit expires 3 years from this episode’s release date.
Links
Mistreatment of University Students Most Common During Medical Studies
Challenges and Opportunities in the 6 Focus Areas: CLER National Report of Findings 2018
Maintaining an Appropriate Learning Environment (Ohio State Faculty Handbook for the MD Curriculum)
Episode Transcript
[Dr Mike Patrick]
This episode of FAMEcast is brought to you by the Center for Faculty Advancement, Mentoring, and Engagement at The Ohio State University College of Medicine.
[Music]
[Dr Mike Patrick]
Hello, everyone, and welcome to another episode of FAMEcast. We are a faculty development podcast from The Ohio State University College of Medicine.
This is Dr. Mike coming to you from the campus of Ohio State. It’s episode 16. We’re calling this one Creating Safe, Impactful Space for Medical Learners.
Want to welcome all of you to the program. We are so happy to have you with us. You know, the clinical environment really shapes how tomorrow’s physicians grow, learn, and thrive.
So, in this episode of FAMEcast, we will explore what makes a learning environment healthy or harmful, and how faculty members can recognize, reflect, and respond to learner mistreatment. We’ll also share practical strategies for restoring trust and promoting growth when challenges arise. Of course, in our usual FAMEcast fashion, we have a terrific guest joining us in the studio to discuss the topic.
Dr. Alex Grieco is Associate Dean for Student Life at The Ohio State University College of Medicine. He has lots to say on this very important topic, and I’m excited to share the conversation with all of you. This particular episode also comes along with FD-ED credit.
So, this is Faculty Development for Medical Educators credit. So, if your institution or department requires Faculty Development Education credit, again, also known as FD-ED, we have good news for you. Select episodes of FAMEcast, including this one, ones that deal with teaching and learners, comes with FD-ED credit from the Center for Faculty Development at Nationwide Children’s Hospital.
And it’s easy to claim the credit. Just listen to the podcast, which you are about to do. Look for the FD-ED link in the show notes over at famecast.org.
Again, this is episode 16. Follow that link to Cloud CME. If you don’t already have an account in Cloud CME, go ahead and register.
It’s free, or sign into your free account. And then you’re gonna wanna take a brief survey. It’s under the Materials tab.
So, once you click that link and you get logged into Cloud CME, you’ll wanna click on the Materials tab, and you’ll just wanna take a quick survey and score the credit. You can even download a transcript of your credits to share with your institution or department. I also wanna remind you about some other resources that we have for medical faculty over at our website, famecast.org.
If you click on the Resources tab, that’s up at the top of the page on the landing site there at famecast.org, we have two links to faculty development modules on Scarlet Canvas. One is a group of modules called Advancing Your Clinical Teaching, very important. And then we also have another set of modules called FD4ME, which is Faculty Development for Medical Educators.
And there are scores of learning modules at both of these sites on Scarlet Canvas. So be sure to follow those links to find lots more useful information specifically targeting academic medical faculty. I also wanna remind you the information presented in every episode of our podcast is for general educational purposes only.
Your use of this audio program is subject to the FAMEcast Terms of Use Agreement, which you can also find at famecast.org. So, let’s take a quick break. We’ll get Dr. Alex Grieco settled into the studio, and then we will be back to talk about creating safe, impactful spaces for medical learners. It’s coming up right after this.
[Music]
[Dr Mike Patrick]
Dr. Alex Grieco is an Associate Professor of Biomedical Education and Anatomy and Associate Dean for Student Life at the Ohio State University College of Medicine. He is passionate about creating learning environments that are psychologically safe with a balance of autonomy and supervision and with clear expectations, feedback, and inclusion.
When any of these elements are missing, student mistreatment becomes a real possibility. That is what he is here to talk about, medical student mistreatment, healthy learning environments, and the reasons why these are important considerations. Before we dive into our topic, let’s offer a warm fame cast welcome to our guest, Dr. Alex Grieco. Thank you so much for visiting with us today.
[Dr Alex Grieco]
Oh my gosh, Dr. Mike, it is an honor and a privilege to be here. And I appreciate the work that you do. And for something that I do, as you said, it’s probably the area closest to my heart, you know, and I think a lot of us that are maybe listening or participating in sessions like this, we’ve been there, you know, to quote the phrase.
[Dr Mike Patrick]
On both sides of it, right? I mean, we have probably in our own training, you know, maybe not been acutely mistreated, but maybe we have. And certainly, we have witnessed it.
And I think that it was more common in the past that, you know, it was sort of more like a rite of passage, I think, in past decades. And now we’re really learning that it’s, you know, when you don’t have a great learning environment, things go off the tracks pretty quickly. And that impacts someone for the rest of their life, really.
It has the potential to anyway. Let’s start with just what are the key features of the ideal clinical learning environment? And of course, in clinical medicine, things aren’t always ideal, right?
We can’t always predict exactly what’s gonna happen. But you know, if we could design an ideal learning environment in the clinic space, what would that look like?
[Dr Alex Grieco]
Yeah, Mike, thank you. And you said it actually, the most important part of that is the context when we think about this, because we know even in our day-to-day practice sometimes for whatever role and the specific specialties that we are a part of, we could name some things that might not be ideal about the day to start with, you know, based on a number of different factors. But when I think about the clinical learning environment, what would be the theoretical ideal?
Some words come to mind, Mike, you know, and some of them are probably not very surprising and they’re probably not a brand-new concept, but I think about welcoming, collegial, right? You know, we understand that many a time when I’m working with elements of the learning environment, certainly thinking about students, they’re not the captain of the team or not necessarily the ones on that team with the most experience. But what I’m looking for an ideal space for them and what they are seeking and deserve is a learning environment that can be trusting, can be safe to ask the questions that we want them to ask as they engage more and more with patients.
I think of a team that is, this sounds quite obvious, but team oriented, right? What is it that, you know, there’s certainly gonna be a gradient to the function of the team, but having each team member there, regardless of their level of training and previous experience or the knowledge that they bring, that they can feel supported and that that space above all, you know, Mike, in honoring the mission to those patients is teaching oriented. There’s something to learn, patient having a really, really difficult course since time or a patient where maybe, you know, the attending who’s been doing it for 20 years think, well, gosh, that’s a relatively straightforward diagnosis.
That might be the first time the student’s running into that, and they feel supported in making those connections.
[Dr Mike Patrick]
Yeah, yeah. So really welcoming and, you know, with expectations that are set ahead of time. I think that’s always a good thing too, so that folks sort of know what’s expected in terms of behavior.
And then really that just an opportunity to learn and to talk about things. And sometimes that, especially in a busy clinical learning environment, there’s not always time for that teaching. When things are really busy, what kind of strategies can we use to make the learning environment better despite that sort of pressure to get through patients?
[Dr Alex Grieco]
Right, and as we plan for thinking about that new tower opening, for example, it’s hard to think of a not busy time that our teams will have. Mike, you know, it’s not about quantity, right? It’s not about, you know, having what would be that ideal, you know, starting as a team and having that sit down time without interruption for everybody to kind of share what rotation they came from and what year they’re in, what, you know, maybe what, if they would like to, what specialty they’re thinking about.
To me, in the busiest of times, that could be the emergency room, right? The emergency department. That could be, you know, one of, I’m coming from my side, a busy, a very, very busy radiology service in either diagnostic or interventional.
Even it could be a sub-60, 60 second, hey, greetings, oh, good, you’re here from 30. We’re working, we gotta get right within this patient. We’re gonna get to know and connect and talk about those expectations throughout the course of our time together.
Let’s get in there. And easy to say here on our podcast, you know, we got that situation. But I think one thing that I’ve run into sometimes talking with faculty, and I have the privilege of talking with a lot of faculty leaders for various parts of the curriculum, that sort of sense of, gosh, there’s just not time to do that well.
And I don’t think for even what we just discussed, it’s not about the time per se as just a quick eye contact, here we go. Thanks for being here.
[Dr Mike Patrick]
Yeah, yeah. You know, time is one of the things we can’t really control so well. I mean, we may be able to have a little bit of control of, you know, how many patients are on our service or, you know, like what’s the maximum or what’s the maximum number of folks that we could see during a clinic day or what are the maximum number of films that you could read?
So, we might have a little bit of control in that sense, but there are other things that we do really have absolute control over that could signal a poor or unsafe learning environment. What are those things that are in our control that we really wanna be intentional about, you know, making sure they’re a part of the environment or not part of the environment?
[Dr Alex Grieco]
Mike, that’s a great question. And you alluded to this before. I loved when you were even, we were talking through the earlier question, setting expectations, setting expectations, right?
And again, it’s not that there’s always a super adequate amount of time to do that, but setting expectations, you know, we’re gonna meet at this time, at this place, here’s what I’d like you to do for this service at this time in the day. We know that’s gonna be, it’s gonna vary by service, by patient acuity, there’s gonna be a lot of variables, but on top of expectations, even just a brief outline. So, you know, you’re gonna see a lot of really very, very, very ill patients.
There’s gonna be some very busy times. What I would like you to do and focus on is ABC, right? Setting that out there, because then if there’s, you know, if there is that little time for communication or things get busy, or there’s not as quite timely feedback as we would hope, can still go back to that outline, that foundation, and that leads to another thing that we can control, which is that ability and that sort of psychological safety to ask questions.
If there’s, gosh, I’m not clear about what I should do right now, or what should I, should I be the one to go talk to that patient’s family? Is it better to go with the resident for this? Would you like me to go to that consult?
All of those things that are gonna, in so many ways, be unique to the situation. I would say what we might have and probably do have the best control over is creating a place where it’s safe enough to ask.
[Dr Mike Patrick]
Yeah, yeah. That is so important, and it really does reflect sort of the shared responsibility of all medical educators, but also of medical learners as well, and just, you know, to sort of have that permission to ask questions and to, you know, not that it’s that you’re necessarily saying, oh, it shouldn’t be this way, or to give a learner a chance to say, I don’t like this for whatever reason, but just to be able to say, hey, why? Or, because a lot of times, those kind of questions get kind of shunned. Like, well, this is just the way we always do it.
Or, and whether that be in the practice of medicine or in the structure of how the clinic environment works, there’s still, well, it’s always been done this way, but we want our learners to feel safe enough to be able to question those things.
[Dr Alex Grieco]
Mm-hmm, mm-hmm. Probably one of the best elements we could cultivate, if you will, in students that are gonna go through here, and Mike, they walk in the door, you know, basically just budding, you know, medical students. They’re gonna walk out the door as interns, right?
And maybe not yet, or they don’t have their name badge or the long white coat yet, but we know that to graduate is to be out there and ready. Probably the best thing we can do for them is to have them with a mindset of, I’m gonna ask questions, I’m gonna do my research to understand why we do something, why we don’t do something. Yes, that’s a pathway, I learned it.
I read that in, you know, first aid, studying for the licensure exam. I’ve seen this, we do this. Why exactly, or is there a way for patients in general, or even more, for my specific patient I’m gonna care for as an intern or as a second year, why do I actually need to do it that way?
And some, maybe as you alluded to the earlier eras, et cetera, within medicine, maybe it wasn’t okay to ask that and what the attending physician said was the way to do it. That’s it, go with it. And more so, and I think in a really positive way now, with the shared understanding that there’s gonna be a differential expertise, differential experience, the attending of 30 years is gonna have, of course, have more experience with pathways or why one is or isn’t pursued.
But even in talking with some of our learners over the last year, it’s the ability to say, yeah, no, I haven’t had a patient like that before. For my own learning, I just wanna understand why we’re pursuing this specific therapy.
[Dr Mike Patrick]
I actually love those kind of questions because it helps me to think critically, why am I doing it that way? Because that particular learner may have been with a different attending who did it in a completely different way. And then what the learner has to understand, what they can learn from this is that there oftentimes is more than one way to get to the desired result.
There are cases where there is a clear right way, but in medicine, there’s also a lot of gray areas where depending on not only our training, but also our experience, we may do it a little bit differently. And I think going through the explanations of why we do it differently can really, I think, help the learning process compared to just this is the way it’s done.
[Dr Alex Grieco]
Right, right. I know. And there’s, well, I think, and even, and I have definitely shared this with learners too, is in our respective roles, Dr. Mike, Dr. Alex, I mean, we can have those moments still, even in our current roles and say, gosh, I’m in the position now to ask that question and to do.
[Dr Mike Patrick]
So, then the way that we conduct ourselves during a clinical rotation can either be a positive learning experience for the student, or it can be a negative learning experience, which can have very different outcomes. But especially when we sort of have micro-engagements with our students, especially on a very busy clinical shift, how do we judge whether we are having a positive versus a negative learning environment? How can we as educators kind of take a step back and say, am I doing this in a productive way, or could I improve the way that I engage with my learners?
[Dr Alex Grieco]
I think that’s a great question, Mike. And I know, again, going back to what was maybe previously the expectation or the way versus what the ideal way is that we understand now. Maybe previously, how I would as an attending, assess if I’m creating a space for learning and creating a space for a learner to progress, build skills, build knowledge and awareness is if I see them emulating me.
And I’d say, oh, okay. So obviously I gave some feedback about this style of history taking, about what I want to be emphasized for this type of patient. And they just, they do that.
And that, oh, well, clearly, I must have created a safe space to have them build that skill that they’re modeling back for me now. And I absolutely have had moments, med school, residency, fellowship, the like, where that was the case. I think now, you said, again, we are battling that time factor.
How do we find that time and space to do that? It can be something as simple, Mike, as if you’ve, let’s say, the learner has contributed or given a differential diagnosis that is close to, or perhaps not very close to the mark. Typical, that we would have recognition of by virtue of our longer area, longer time and expertise.
Maybe it’s, okay, so I like that. You are saying A and B. C is the key here.
And I want you to think about the fit with what we know about this patient so far. Does that fit? And with what you have heard now from the side of physical examination labs, et cetera, is it more likely that category C or D or E is, right?
And if there’s not time for that, let’s say there’s a more brief correction. Okay, good. It’s actually, see, we need to go and move on this.
Does that make sense why that is gonna fit better with this patient? I think, again, that would be fleshed out certainly by granular clinical examples in the moment, but the part there, and if I could name the number of students that said, gosh, my attending just never, never asked me if I understood, right? And I think there’s a lot wrapped up in that expression, right?
But even asking, maybe not understand. Does that make sense? Does that make sense?
You know, look at this. This is how I’m viewing that. Maybe, how about that again?
We’ll have this discussion later or continue this discussion later, and then really seeing if that moment was able to make a correction, right? Having an ideal learning environment is not being right all the time. It’s being, having the safety to be redirected or to be given some additional knowledge so that you can be right the next time.
[Dr Mike Patrick]
Yeah, yeah. So important, and there’s really a subtle way that this could go positive versus go negative, because at this, you know, on one hand, we want to encourage our learners to engage and to participate in the learning process, and given the fact they don’t know everything yet, we can’t expect them to be perfect. And so, we want them to get the right information, but we also don’t want to shame them or make them feel like they’re less than because they didn’t know, you know, they’ve not had the 20 years of experience that the attending has had.
And so just even our body language, the words that we use, all of those things, and in fact, body language probably as important, if not more important than the words that we use, but really how we respond to learners who aren’t quite getting it right yet, it, you know, makes a huge difference, right?
[Dr Alex Grieco]
It does. I am so glad that you said body language, Mike, because as much as we appropriately focus on words, some of which are just suboptimal, some of which would not be acceptable under any circumstance, if we’re talking about some of those cases of mistreatment that we need to address, I think the body language, and that’s, now, I don’t know about you, I sometimes, or I went through phases, let’s say I’m an arm folder, and that can come across, you know, a little, you know, we can be variably intimidated by things, but I, if anything, you know, as simple as the eye contact, a nod or two, you know, and sort of, okay, all right, good, and you can be helped a lot, right? If the presentation is going on a little, you got a 10-minute presentation for about a two-minute slot, there’s a very formative and positive way that we can help somebody move along for that.
The body language, if I could eliminate the eye roll, Mike, got what a world it would be, right? Yeah, yeah, yeah, yeah, absolutely.
[Dr Mike Patrick]
When we engage with our learners, oftentimes our own personality is a part of that engagement, and some of us are, you know, sarcastic, some of us, you know, may make jokes that people have laughed at in the past, although whether they’re laughing because you’re in the position of power and they are not, you know, could be, and so how do we sort of distinguish between a behavior that’s, you know, kind of questionable versus it’s not good at all versus this is okay in terms of our own personalities?
So in other words, there are folks who don’t understand sarcasm, there are folks who don’t understand that this is my normal tone when I’m stressed, or, you know, and that can all come across as inappropriate, but then if it’s part of a person’s personality, you know, like how do you distinguish between what’s just quirk and what is inappropriate?
[Dr Alex Grieco]
I can, that’s a, you know, in considering that, I go back to an expression, I don’t know when the first time I ever heard this, but as you can imagine, and for student life, and for, well, for any, it’s that there could be any instructor at the place or any of the staff, you know, as I work with people, anybody that is, you know, a part of the College of Medicine could have a student come in and say, I, you know, gosh, I had this thing happen or this dynamic yesterday on my round service, and I, can I talk with you about that?
Right, so I don’t mean to say it is just student life, but I heard this expression about, you know, just taking, pausing for a moment sometimes to take the temperature of the room, okay? And I’m not talking about the thermostat on the wall kind of thing, but sort of, how about, you know, if we have those quirks, okay, everybody has a different personality. I’m not terribly serious a lot of the times.
I think when ideally before the moment of, you know, that perhaps innocently intended, sarcastic little pithy, right, remark about something, but more often than not, just after the fact, right? Because we have our personalities, and as you said, we don’t turn those on and off, basically, when we are in our long white coat or not. You know, it’s just sort of a pausing for a minute and seeing, gosh, if I said something and it’s a little bit more of a nervous laughter or more wide eyes and silence, that’s a good indicator.
Yeah, quick temperature check. What did I just sort of, you know, say or not say or whatnot there? Bottom line, of course, and I would gladly and happily say this, that sarcasm, you know, and especially in a high intensity setting, we understand from the human side of that, there’s a, you know, what do they say, an evolutionary benefit that helps dissuade stress.
Great. We need to remember that, you know, if we, as the attending or the chief resident or that person who is, let’s say, functionally the captain of that team at that moment, if you’re stressed, think about the other people that are there, that are kind of looking to you or trying to perform their best, trying to comprehend the situation. And if anything, you know, if you have a sense that, gosh, that might’ve not fallen right, you know, it made sense in my head.
And then just looking at the temperature of the room and not taking the temperature of the room, that might’ve not hit how I thought or intended or didn’t intend, Mike, and this alludes a little bit to something I would say or maybe share in a later question. The time is then to say, gosh, you know, and just, I wanna clarify something, right? And if that might’ve sounded that I was making that sort of remark about the patient’s situation, we’ve had that before, and I just wanna clarify, it’s about the system that has, you know, X, Y, Z, or, you know, and I just wanna say there, sometimes I just, I have that way of looking at something.
I understand that’s a little bit different than ways. I definitely, if anybody was caught off guard by that, please do let me know.
[Dr Mike Patrick]
Yeah, yeah. And that right there is gonna avoid going to, needing to go to the associate dean for student life because- Sometimes. Now, well, because if you sort of give permission to say, hey, if I’m making you feel a certain way, please let me know.
I want that feedback. A lot of times learners don’t feel comfortable giving that feedback understandably. So, then it really does come on us to reflect on are those sort of things happening?
Because if those little, and I’ll call them microaggressions where, you know, we may come off in a wave, in a, you know, just in a comment, and then we’re moving on, we’re moving on to the next patient. Like it can be, by the time rounds are over, this is old history. So, I think it’s really important for us to reflect on rounds at the end in our own minds.
And like, how’d that go? What could I have done differently? What could have gone better?
And reflection is not an easy thing. You know, you and I were both back in the day, portfolio coaches for medical students at Ohio State. And part of that job was helping students reflect on, you know, what they had just gone through, you know, the experience, how it impacted them, you know, what surprised them, what are they gonna take moving forward, all of those sorts of things.
And we don’t always use reflection like we should. How can we really make reflection a part of our daily practice?
[Dr Alex Grieco]
Mike, for, I agree with you, reflection is, it’s a tool, right? And I, the amazing Dr. Jack Kopachek, I believe had used that, who’s our, you know, our leader for the portfolio and now the professional coaching program. It is a tool, right?
It’s a tool that not unlike in our various, if we have a workshop or the tool area at our apartment or home, tools can gather dust and be in mint condition or they can get a little dirty and get used. And I think what might hold back people from reflection is that, oh gosh, what if I come across something and I really, I need to do a little repair, right? Or that was not my best moment.
Whatever it is, Mike, for reflection, and I’ve had some clinicians come in and talk with me and not necessarily that they’ve had a mistreatment concern or something, but like, gosh, Alex, how do I, you know, from the student life standpoint, how do I make this better? How might I encourage my colleagues to navigate this better? And I always say, okay, it’s not just student life, it’s all of us standpoint, right?
Because I want to be inclusive. If there’s no, if the bounds of that time and space for reflection, nothing more than let me jump for two seconds into the shoes or the sneakers, the whatever of that third-year medical student, okay? If we just witnessed a patient have a challenging event, if we’re just part of a really difficult conversation, if we were as a group in sort of a mistreatment situation, because the biggest thing I learned in this job is not that it’s the student always the recipient solely, it could be a student and the resident together and the attending and the nurse, you know, if there’s in those, with those complex, you know, demands and issues that arise. What was it like to be back in that moment, right?
Thinking about this, all of the above, plus I’m thinking about my future residency and how am I performing? And am I gonna look like I’m not engaged if I’m traumatized by what just happened, but I’m not empowered at that moment to speak up? Mike, going no further than that brief, it’s like a time jump or something, right?
You know, just saying, what would it be like if I was standing in those shoes in this very square of floor for a minute? I’ve heard and seen and been rewarded to learn of situations that were eased, smoothed, sort of made functional on the spot. And so again, like with so many of our other elements that we care about deeply, maybe the biggest fallacy about reflection is that you need two hours on a Saturday to do so, can be literally in the moment.
[Dr Mike Patrick]
Yeah, yeah. The car ride home after a shift has become a reflection time for me, just thinking about what went right, what went wrong, what could I do differently next time, those sorts of things. But yeah, you have to be intentional about reflection, though, right?
It doesn’t just happen.
[Dr Alex Grieco]
It’s something that should be as much a part of your day as documentation, closing your charts, or in my case, closing reports. We’re on the side of over at College of Madison, I mean, seeing what still needs to be done tomorrow, what am I preparing for this staff meeting or that next big meeting with the vice provost, right? It should be as much woven in as do I have my keys for the car ride home.
[Dr Mike Patrick]
Absolutely, and as I think back, I’m 30 years out now from medical school, but I still remember positive and negative interactions. Like to this day, I can remember the attendings that I was with on particular rotations and how they treated their learners. And I would just say that one good practice, I think, is reflect back on your time as a medical student and think about, because we get so involved in our current day-to-day that we sort of forget what those interactions were like.
And I think just thinking back on that time can be very helpful.
[Dr Alex Grieco]
And Mike, some of the sessions when I’ve had the opportunity to present to some of our clinical departments about clinical learning environment, student mistreatment topics, the range there, I do an exercise that’s not terribly original, not patented remotely, but something where, as you can imagine with typical clinical department, you have the chair, right? You have the vice chairs of this and that, everybody from residents, fellows to the rotating students, right? And if they have advanced practice providers that are there as well.
And it’s a very effective exercise when I just pause for a second and I don’t always make it about, I don’t come out and say, I want you to think about when you’re mistreated, okay? I don’t group it like that because I think we have human defense mechanisms and from the various constraints and things as we’ve detailed already. So, think about one of your best moments of time, maybe getting feedback or just working with an attending physician during fellowship, residency, med school, okay?
And then have a second there, take a minute, what was the best? Hopefully there’s many to choose from. And then the latter part is I said, you know, predictably, once you think about one of the most troubling times or the most troubling time with, could be a fellow learner, attending physician, somebody senior to you, again, in the same timeframes, maybe even as a junior attending, fellow resident, med student, and without fail, you know, and I’m sure I’m very open when I talk about some of mine that I can remember. And the point I make that seems to resonate, Mike, with as many different departments and ranges and specialties and supposed personality types as you can imagine, talking about the lore of medicine, people come and say, you know, that moment when you said, if you’re thinking about it, five or 10 or 15 or 20 or 25 or 30 years after the fact that that negative experience, there’s a really good chance that that has formed at least part of the physician or the provider that you are right now. Is there something you can act on or recognize through reflection or through your day-to-day practice that can keep that from happening for somebody else?
[Dr Mike Patrick]
Yeah, so important. And because we really are molding the next generation of physicians as we teach. And so that is an honor to be able to do that, but it’s also a pretty great responsibility as well, for sure.
Now, we’ve talked about ways in which learners may be mistreated in terms of engagement and communication. Another issue is the possibility of students being left out of patient care opportunities. And a couple of examples that come to mind, you know, there may be a trauma in the emergency department and there’s already, there’s too many people in the room and the medical student gets shuffled out, or it could be a procedure that’s being done and another student seems to always get to take part in those because maybe that’s an area that they’re interested in, they wanna go into.
And so, they get all the experience in a particular procedure. But when students are left out of patient care opportunities, that is another way that they can, it’s an example of mistreatment. Explain how that’s an issue.
Definitely, Mike.
[Dr Alex Grieco]
The biggest misconception I certainly had as a med student, like I said, we were there, you know, just maybe many different times, et cetera, but we’re there. Biggest misconception as a student, and then certainly in the time with the College of Medicine student life, is that mistreatment was always something said or done. Something, you know, there’s the egregious example, some equipment thrown, et cetera, thankfully rare and hopefully of the past.
There are the comments that it said, you know, microaggressions, so huge as you brought up. Mike, one of the biggest ones that I work with students over time is I wasn’t even there, right? I was a square of tile on the floor or part of the wall scenery.
They didn’t involve me. They never, I know I don’t have a lot to add to this big complex discussion. I wasn’t, I could have gone home and sat with my U World, et cetera, and the team wouldn’t have been any different.
And it is so critical. It goes back, Mike, believe it or not, I mean, it goes back to that setting expectations. And I know hindsight is always perfect.
Just 20, 20 beautifully corrected vision hindsight. Maybe in that first talk, you know, in the, if you have the luxury of that few minutes, right? When that new rotation starts, say, you know, gosh, there may be times these services, our patients tend to change rapidly, right?
Somebody’s doing well. 20 minutes later, we’re not. Not just limited to critical care setting, as we know, but there’s gonna be times when if we’re not interacting much or I’m pretty much focusing on the residents and fellows and somebody hopefully nicely says, you know, I’m gonna need you to take a couple steps back for us, we gotta get in there.
I wanna tell you that is not that we don’t want you to see or be involved with what is happening. It’s that we have an acutely ill or unstable patient that we gotta get into. The other side of this is, you know, I can say, you know, there is not to put everything in the procedure room, right, or the ICU.
You know, there’s gonna be times we get very, very late consults that come in and maybe on a case-by-case basis, we could discuss if you have a lot due for your other parts of your curriculum the next day or it’s we’re getting toward exams, I want us to come to an agreement about what you should take part in because I don’t want you to get, you know, feel that you’re not involved or that this once in a career, you know, diagnosis that I don’t want you to miss that, but at the same time, I’m just wanting you to know that we’re respectful of the fact that you’re a student and still got exams and reflections to write, so.
[Dr Mike Patrick]
Yeah, it’s so important to have that empathy of where the student is and understanding the context of how that impacts the learning environment. You know, as we do practice more and more in teams, we don’t always have control over the other team members and how they may engage with our learners. And so just as an example, and I’m not, I love nurses, I’m married to a nurse, so I just wanna point that out first, but nurses can, you know, they advocate for their patients and they may, you know, like in the operating room, they may tell, you know, they may yell at a student, they may say, you know, you stand over here, you do that.
And we wanna, usually the nurse has the situation’s best interest in mind. I mean, most of them aren’t like trying to single out learners and many nurses are very good teachers. But when one of our learners has a negative experience with someone else on our team, how should we respond to that, both in terms of maybe our teammate and the learner?
[Dr Alex Grieco]
Like in that, you know, we, for the team-based arena, the medicine is, right, that’s a very, very key point. I guess I’d relate, you know, MRI technicians, similarly, they have the safety of the patient in mind. If they’re not assured that you’re walking in that room, that you have not been divested of your metal, they’re gonna let you know.
And you might have an arm across you for a minute, you know, hopefully, you know, in a professional manner, et cetera. Your point is taken, we have for the vibrant teams that we have with many different layers, levels of expertise, multidisciplinary, interprofessional teams, that’s a reality, right? There’s going to be those moments, how we, I guess, in this sense, speaking of the attending physician, right, on that service or same team, et cetera, or in the OR, et cetera.
I think, you know, the first is recognizing the fact that there are different views that could be present. There are different levels of commands. I hate to make it a hierarchical thing, but there’s different, let’s say, routes of reporting for the various disciplines there.
I will say the first thing you could do, recognizing and with the good faith, you know, gosh, they probably had the patient’s best interest in mind. The number one thing you could do, Mike, is maybe not in the moment. We know that, you know, delaying a little can be therapeutic sometimes.
If the, let’s say the temperature’s really warm in that OR, et cetera, just student decides to, hey, want you to know that I was, I heard that as well, the comment, the move, the, you know, et cetera, with that, let’s say, non-physician provider who was there helping and part of the team. I want you to know I heard that as well. And if you’re having some questions about that, I’m having some questions about that too.
And what I’m going to do is, and then that’s where we need to be professional and creative, you know, and think, is it, you know, the nurse manager? Is it the lead technician? I’ll keep, you know, pop back to Mike, core radiology, that just to let the student know that we’re going to give that feedback, right?
We are going to carry that through as though that was a resident or an attending in the physician side. We’re going to address that and look into it with the same level of, let’s say, appreciative inquiry to ensure that the loop is closed, right? And we’re going to let you know, this is me to the student frequently, that that feedback’s been given and here’s the plan going forward and how we’re going to try the best that we can, knowing that we cannot control every space and place and moment of the clinical experience.
This is what we’re going to do going forward.
[Dr Mike Patrick]
Yeah, yeah. And that in and of itself is a learning opportunity because there are going to be situations where you witness a teammate interacting with a different teammate and as the leader of a team, you’re going to have to deal with this. And so, it is learning opportunities for us, it’s learning opportunities for the learner because they’re going to be in those kinds of situations in the future, for sure.
And one thing that often can help in these situations is to think about perception versus intention, right? How does that come into play when we think about teams?
[Dr Alex Grieco]
It is front and center, Mike, to be direct about it. I am privileged in a lot of ways to have had connections with almost every clinical department and with almost every part of our curriculum, the many moving parts that it is. Concerns that arise by students, Mike, that is going to be a part of what we do and deal with and handle.
I would say, I don’t know that I’ve ever run into a case or through careful, cautious, supportive discussion that let’s say the person of concern or persons of concern had malintent, right? Oh no, my intention was that I needed to let the student know that this assignment can’t be laid again. Oh no, no, my intention was the patient was at risk for harm if they did X, Y, Z, right?
Now, jump over as we’ve been into that role with a student. The perception is they don’t want me here. They don’t respect me as an adult learner in this space.
They’re not hearing me to be able to share why I had that challenge, et cetera. There’s that gap, Mike. And it’s not incredibly often we have a sit down or a connection, let’s say with the person of concern, usually with the student’s preference.
Like, no, I just want the feedback to go. I wanna continue to talk through you about that. But where I land, Mike, is that in speaking with a student and making sure to gather the data, right?
The perception on the part of the student, the impact is the additional word we’re talking about, perception, intention, impact. The impact is what we focus on. And a perception on the part of the person of concern, oh, I didn’t intend that.
I will honor that, we’ll discuss it, but I will clearly say that, well, the impact, even if unintended, was this. That’s what I’d like to talk about and how we can try to avoid that in the future.
[Dr Mike Patrick]
You know, when we’re working in teams, and as you mentioned, our teammate may have a different line that they report to with their particular manager, sometimes just silence on these issues and just sort of reassuring the learner that, okay, this sometimes happens or that person has a habit of doing this or that, but not really addressing the issue to ensure that experiences moving forward with different learners in that particular teammate are more positive than negative. It may be easier just to be silent.
But when we’re silent, then we also tell the learner that they weren’t important enough to act on this. So, then that raises this idea of second trauma. And explain how not only is the incident an issue of mistreatment, but really being silent is another mistreatment.
Absolutely.
[Dr Alex Grieco]
And Mike, you know, again, we’ve touched on so many of the points that have been a part of working on the learning environment, ameliorating mistreatment. If I could name one of the biggest, biggest ones that if I could get every team to at least internalize in here, it’s this very notion that you brought up about the second trauma. Well, first of all, what’s the first trauma, okay?
And that’s a big word, right? And I appreciate that and I understand that. And I’ve had occasion to talk with some of our supports and trained individuals at main campus and say, you know, you use that word because you can’t jump into the other person as much as we try to for reflecting purposes and know exactly how that felt.
If it was a comment, if it was an exclusion, if it was some sort of thing that happened in the moment, and I include Mike, sometimes, unfortunately, these comments or actions or things could come from patients and the student heard it, everybody heard it, the team heard it there. This gets back a little bit to one of the earlier questions that operating room setting, high intensity rounds, et cetera, what have you, that first trauma happened in the moment. And it might even take, whether it’s the student or a resident or whoever it would be, a minute to understand, OMG, what just happened, right?
And that’s the human element of it. And it could be relatively, even in the big scheme, you know, sometimes if it was a misunderstanding, it could be all the way up to using some type of a phrase or comment that would warrant an investigation by the civil rights office, right? It is the range.
That’s the, that happened. And as much as we would wish, I can’t believe that happened, I really wish that hadn’t happened in the moment. The second trauma and what almost uniformly is the biggest concern brought forth by a student that I meet with and they said, yep, that happened.
It was at this part on that rotation, that clinic area, this procedure room. And the 20 people there that heard this and saw this and saw me be the target of that or joined me in being targets of that, nobody talked about it, nobody brought it up, nobody even took me aside for two seconds to say, gosh, that wasn’t okay. And what I’ve dealt with and had to just, and I’ve talked with a student who it was six months later before they even wanted to bring it forward about what had happened because of that deafening silence.
They said, well, I assumed it was my fault then if nobody said anything and they were just trying to be nice. Like we can’t always, is to the best of our preparatory nature and prevention methods for elements of mistreatment and other negative aspects of the learning environment, we can’t always prevent things, but we can, maybe not in the moment, but five minutes, five hours, five days, not quite as good, but sometime go back and say, hey, that moment that happens, right? That we were there for and that was not okay.
I want you to know that that was not okay. I know it, everybody else knows it. How are you feeling?
Number one, don’t take away further power by telling the student what you’re, yeah, how they feel, et cetera. What could we talk about it? Because I have some thoughts of how I want to address it.
[Dr Mike Patrick]
Yeah, yeah. In terms of addressing those kinds of situations, the concept of restorative justice then comes to play. Tell us about that and how that can at least make things a little more positive.
It can sort of take a negative and at least turn a positive outcome, hopefully, from the negative experience.
[Dr Alex Grieco]
Yeah, and Mike, after any type of a situation, we just talked about one and that the worry and the real impact, the caustic nature of that second trauma, yeah, it could be about a very, any type of a situation where something’s gone wrong and there was either mistreatment by omission or commission, et cetera. Restorative justice, there’s a lot of different ways people have defined that, and it is certainly not limited to medicine, right? And the clinical learning environment, it is across multiple different spheres, as we know in our daily discourse.
The notion of restorative justice, as I think about it here is, first of all, recognizing that we cannot go back in time and whether it’s part of a system or part of a single individual type of negative interaction, as much as we wish, we can’t undo that that happened. But what we can do is look at how can we, just literally taking the word, what is it about that situation’s sequelae that we can restore autonomy, purpose, sense of professional identity, as that could be in the situation, sense of being respected or having a tone of respect on that team working in the clinical learning environment. And no two ways about that are the same, almost invariably what it would involve is what might be on the surface, the most uncomfortable or initially seeming discomforting thing would be sitting down and dialoguing about it, debriefing.
Back to your earlier question. Well, my intention was, X, Y, Z, I’m understanding now that the impact actually was something I totally didn’t envision, right? And it is not exactly synonymous with apology, but portions or layers of apology for what occurred are a part of it.
And to me, the biggest thing, Mike, is looking at how, whether it’s climate and culture, right? Whether it is the sense of how teams should work or can work or how do we, in general, treat our more junior learners, it has that element of putting back, restoring what is probably never gonna be a perfect clinical learning environment, but trying to let the people who were impacted negatively regain what it was that allowed them to be in the environment in the first place.
[Dr Mike Patrick]
Yeah, yeah, so very important. I feel like we could continue this conversation for another hour, but we should probably, should probably wrap things up. It’s such an important topic, though, because we truly are, I don’t think it’s overstating it to say we are molding the next generation of physicians and how they treat their learners in the future.
They’re learning from us now, not only medical science, they’re also learning how to teach and engage and really have conversations in heated environments and in stressful situations. And it’s so, so very important all around. So, I thank you for the conversation.
We are gonna have a lot of resources in the show notes. So, if folks want to think and read more about medical student mistreatment, please do head over to famecast.org. This is episode 16.
We’re gonna have several articles for you. One on the underlying mechanisms of mistreatment in the surgical learning environment, a thematic analysis of medical student perceptions. That one really pulls in a lot of the things that we’ve been talking about.
This treatment of university students most common during medical studies. Gosh, that was an eye opener. We are some of the worst mistreaters of our learners.
And so, we really do want to turn that around and to have positive learning environments for students who are studying medical science. Also challenges and opportunities in the six focus areas, the CLER National Report of Findings for 2018. This also, tell us a little bit about that resource.
[Dr Alex Grieco]
Yep, the part that that’s a bit of a compendium, Mike, from some different sources, the clinical learning environment rounds is what the clear stands for. Interesting that that’s undergoing some changes right now, predominantly centered in the GME space. So graduate medical education, as we think of our residents and fellows.
That source shares various parts of how the environment is viewed broadly, partly as we’ve discussed. There’s a lens there and looking from now we have graduated from med school. Now we’re in that space, both as a learner or trainee, some have one preference or the other terminology, but now also as a hospital employee, right?
And that added dimension of thinking about both responsibilities, challenges, and then also some opportunities to make your own positive contribution to the learning environment.
[Dr Mike Patrick]
So, we’ll have a link to that in the show notes as well. And then really important, especially if you are faculty at Ohio State, we’ll have a link to Maintaining an Appropriate Learning Environment, which is in the Ohio State Faculty Handbook for the medical student curriculum. So, you may not have known that that was even a thing, but now you do.
So please do head over to famecast.org, click on the show notes for episode 16, and you’ll find a link to that very important document. So once again, Dr. Alex Grieco, Associate Dean for Student Life at the Ohio State University College of Medicine. Thank you so much for stopping by today.
[Dr Alex Grieco]
Oh my gosh, Dr. Mike, thank you so much for having me. And I look forward to collaborating in the future.
[Music]
[Dr Mike Patrick]
We are back with just enough time to say thanks, once again, to all of you for taking time out of your day and making FAMEcast a part of it. We really do appreciate your support. Also, thanks again to our guest this week, Dr. Alex Grieco, Associate Dean for Student Life at the Ohio State University College of Medicine. I just want to say, having just recorded the interview, that both Alex and I love nurses and MRI techs. I just want to put that out there. And his example of an MRI tech like putting their arm up against the student, it wasn’t physical abuse.
It was, you know, safety. Because if the student had gone another step forward, something may have gone flying across the room from their pocket, or they may be injured. And so that particular situation, we don’t want to give the impression that MRI techs, you know, get physical.
They’re just protecting everyone, both the patient and their staff and the learner. So just wanted to point that out. I do want to remind you that you can find FAMEcast wherever podcasts are found.
We are in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, and most other podcast apps for iOS and Android. So, there may be an easier way for you to subscribe and listen. We also have our landing site over at famecast.org.
You’ll find our entire archive of past programs there, show notes for each of the episodes, our terms of use agreement, and that handy contact page. If you would like to suggest a future topic for the program, or if you just want to say hi, we love hearing from listeners. Reviews are also helpful wherever you get your podcasts.
We always appreciate when you share your thoughts about the show. And don’t forget, you can get a FD-ED credit for this particular episode. It’s absolutely free.
So, if your institution or department requires a faculty development education credit, also known as FD-ED, then we have good news for you. Select episodes of FAMEcast, including this one, ones that deal with teaching and learners, do come with FD-ED credit from the Center for Faculty Development at Nationwide Children’s Hospital, which is where the Department of Pediatrics is housed for the Ohio State University College of Medicine. It’s really easy to claim credit.
Just listen to the podcast, which you have already done. Look for the FD-ED link in the show notes over at famecast.org. This is episode 16.
Follow that link to Cloud CME, register or sign in to your free account, and then click on the Materials tab, take a brief survey, and score the credit. You can even download a transcript of your credits to share with your institution or department. Some other episodes that we have done that included FD-ED credit, one was Mentorship and Coaching in Academic Medicine, and another, Teaching on a Busy Clinical Service.
Those were episodes one and seven, respectively. Don’t forget, we do have additional resources for you. Also, over at famecast.org, click on the Resources tab up at the top of the page. Two links to faculty development modules on Scarlett Canvas, Advancing Your Clinical Teaching, and another group called FD4ME, or Faculty Development for Medical Educators. There are scores of learning modules at both of those links, so be sure to follow them and find lots of more useful information specifically targeting academic medical faculty. And with that, I will say thanks again for stopping by.
And until next time, this is Dr. Mike saying, stay focused, stay balanced, and keep reaching for the stars. So long, everybody.
[Music]
