Leadership in Medical Education: Creating a Positive Learning Climate

By Michael A.Gisondi (@MikeGisondi) and Nounou Taleghani (@Benzorv)

The Learning Climate

Learning climate refers to the mood, tone, or atmosphere experienced by students and teachers in a classroom or clinical learning space.

Negative learning climates stifle student achievement. Two dominant experiences promote a negative climate: chaos and fear. Think back to your first clinical rotations.

Chaos: Were you overwhelmed when you first entered a crowded, loud emergency department? Could you discern order? Did anyone orient you to the space, the process of care delivery, the roles of team members, or your learning goals? Or were you thrown in, wasting cognitive load in an attempt to make sense of it all?

Fear: Did certain attending physicians have you shaking in your boots during floor rounds? Could you process what was happening on rounds or were you preoccupied by a fear of failure? Were you too intimated to ask questions? Did you feel like an imposter, like you didn’t belong?

Positive learning climates facilitate student accomplishment. Requisite features of a positive climate include psychological safety and encouragement. Reflect on times when you were safe and supported.

Psychological Safety: When did you first learn to comfortably say, “I don’t know”?  When were you empowered to ask questions? How did your attendings ensure that you felt included?

Encouragement: Which faculty members best supported you? Did they guide you outside your comfort zone? How did they instill confidence? When were you joyful at work?

Creating a Positive Learning Climate

During the pandemic, our faculty meetings are held via Zoom© (Zoom Video Communications, Inc., San Jose, CA, USA). One of the best features of Zoom is the Team Chat. Used wisely, the Chat can become a repository for wisdom, learning resources, and community-building during meetings and class sessions. At a recent faculty meeting, we asked our colleagues to each post an answer in the Chat to the following question:

How might we create a positive learning climate in our emergency departments?

The following is a transcript of the Chat, with faculty member attributions after permissions to post. Answer the above question yourself as you scroll through the following comments. Importantly, commit to one action that you will take to promote a positive learning climate when you next teach in the classroom or a clinical space. Here are a few suggestions from our faculty members:

Wednesday, October 14, 2020
1:00 – 3:00pm

Chat Transcript regarding Learning Climate

02:14:08 Holly Caretta-Weyer:
“What could I have done to make this shift better for you?” It’s a great question to ask all of our learners – both students and residents. Creating a culture of feedback involves all of us!

02:15:00 Youyou Duanmu:
Do an observed history and physical with your learners, and give feedback.

02:15:35 Viveta Lobo:
At the start of my shift, we choose a relevant topic that we will research during downtime and discuss towards the end of the shift. I ask the team to give a 5 minute, informal presentation and we discuss it together. (I add my clinical experience…)

02:15:37 Monica Saxena:
I like to ask, “What do you hope to learn on this shift?” I ask trainees to think about how the shift and the rotation fit into their greater learning.

02:16:26 Jennifer Kanapicki:
Sometimes it’s good to start with the basics…”Do you need an emergency medicine-specific tutorial for our electronic health record?” I often find they need help with logistics.

02:17:41 Cherrelle Smith:
I make sure they always have a space that is their own, usually a place near me. And that they feel a part of the team. I give them a tour of emergency department and a quick computer “tour”. Even if they are assigned to a resident, I ask that students present to me on at least one patient, so I can give them direct feedback.

02:18:10 Eddie Garcia:
Some people use the phrase “diagnosing the learner” for the initial introduction to the student. Get to know what students have already done on previous rotations, how many shifts they have done in the emergency department, what specialty they plan to go into, etc.

02:18:19 Meredith Masters:
I set expectations early, focusing on the positive, such as things that they can do to feel like they’re helping patients and part of the team.

02:20:40 Sarah Williams:
Get to know the learners, including the students, off-service residents, and our residents. Target their learning to what they need. Short, digestible, timed to when they can hear it. Make them feel seen and heard.

[A little side chat]
02:21:43 Nounou Taleghani:
Teaching nuggets.
02:21:49 Holly Caretta-Weyer:
02:21:58 Jennifer Kanapicki:
Ohhh…that’s catchy.

02:22:27 Monica Saxena:
To echo what Meredith said about being a team – I think often the medical student can feel a little lost and pushed aside. I don’t do it enough – but maybe start with a comment about how we work as a team, and we encourage their thoughts and questions about their patients (or other patients in the pod).

02:23:13 Grant Lipman:
I like to bring food, break it out around 3:00 or 3.30am. Then while I feed the residents, I take 5 minutes to teach. Captive audience.

02:23:31 Christopher Bennett:
I ask what has made a “good shift” for them – and what has made a less than ideal shift – and how we can ensure they get what they want out of the shift together.

02:23:37 Alfredo Urdaneta:
Role model engagement and self-compassion during shift.

02:23:50 Jennifer Kanapicki:
Always ask for goals in the beginning of the shift. Sometimes they don’t want to set goals, but I like to push them a little because it requires some self-reflection.

02:23:54 Milana Boukhman:
I often take medical students along when I see patients, after or before the residents see them. That feels like more individualized and special learning for them.

02:24:10 Phillip Harter:
Ask the student, “What did you learn today?” And, “Did you have fun?”

02:24:15 Andra Blomkalns:
Address the reality of COVID anxiety. To us, it is kind of old news. To them and their families, they are worried.

02:24:24 Jennifer Kanapicki:
It’s okay to tag ‘non-clinical’ teaching —> systems, operations, social emergency medicine, interpersonal communication.

02:24:25 Michelle Feltes:
Let the student put in orders on their patients – the orders will need to be cosigned, but they need the experience.

02:24:26 Stefanie Sebok-Syer:
Ask students to tell you something they want to work on.

02:24:28 Karen Stuart:
How about creating “Families” with nurses to help support and welcome the students. One of our nurses did this at her previous hospital and it was well received. It helped students feel more at home.

02:24:29 Sam Shen:
At end of shift, ask what went well, what didn’t, and what you need to do for next shift.

02:24:36 Al’ai Alvarez:
Also, asking students what they’ve learned at the end of the shift reinforces the notion that they’re learning.

02:24:42 Peter D’Souza:
I try to task the medical student with updating their patients with the plan and being the primary point of contact for their patients.

02:24:47 Al’ai Alvarez:
And if they haven’t, it gives you an opportunity to plug a couple of learning points.

02:25:35 Al’ai Alvarez:
@Karen, that’s a fabulous idea… belonging is key. Feeling they are part of a family is very important, as they learn in a new environment.

02:25:45 Kristen Ng:
I tell medical students that the patients who are taken care of by students get the best care because they get the most reassessments, updates, and thorough thinking. This statement communicates some behavior expectations, creates a self-fulfilling prophecy, and makes them feel like important patient advocates.

02:25:52 Collin Michels:
Start the shift with a teaching point or recent case. Check in at the middle of the shift to course correct if something is not working well.

02:26:46 David Hao:
I ask at the start of the shift what the resident(s) want to work on and then use that as the basis for choosing a topic for feedback at the end of the shift, which goes into their daily evaluations. 🙂

02:26:56 Ryan Ribeira:
I second the comment about ‘non-clinical teaching’, especially for our more senior residents who will soon be in practice. I find they really like tips and tricks on efficiency, insights into how other emergency departments work, highlighting differences between university and community hospital environments, etc.

02:28:44 Jennifer Hunter:
I would like to make a plug for the physician assistant students that come through the emergency department. They appreciate it when they are acknowledged (e.g., referring to the team as both medical students and PA students). Advance Practice Providers in general appreciate, and feel more included, when the title ‘clinician’ is used rather than always referring to doctors and physicians when addressing a mixed group of MDs and APPs.

End transcript.

Total faculty development time: 14 minutes.


About the authors:

Michael A. Gisondi, MD is an emergency physician, medical educator, and education researcher who lives in Palo Alto, California. Michael currently holds a position as Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford University. Twitter: @MikeGisondi

N. Nounou Taleghani, MD, PhD is an Academic Advising Dean at Stanford School of Medicine. Nounou is an Associate Professor and Director of Undergraduate Medical Education in the Department of Emergency Medicine at Stanford University. Twitter: @Benzorv  

Photo Credit: M.Gisondi

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