Why a medical student’s learning environment matters: the enabling effect of supportive social climates

An essential aspect of maturing is developing the ability to take increasing responsibility for (our own) lives; to become increasingly self-directing. (‘The Adult Learner. A Neglected Species’. Knowles et al.¹ For clarity, we have slightly modified what Knowles et al. wrote)

Introduction

Knowles had a powerful influence on professional education. Building on humanist ideas of Rogers and Maslow, he proposed that providing education in socially warm climates, where teachers facilitate rather than instruct, helps adults take charge of their learning. ¹ Schmidt and Moust further developed what came to be known as self-directed learning principles (SDLP) by showing that teachers who relate to students both intellectually and socially are best at kindling students’ agency. ² Following those principles, problem based learning came into vogue for medical curricula. This was short-lived because regulators soon reined in students’ agency, preferring them to achieve measurable, standardised learning outcomes.

SDLP ran into other problems: some clinicians abandoned students rather than actively facilitated their learning, and students were critical of SDLP. ³ It was hard for them to be intrinsically motivated without pedagogic support (teachers instructing, observing and giving feedback on clinical skills) and social support (clinicians welcoming and inducting them to placements, exercising leadership, encouraging fellow staff to support students’ learning, organising appropriate clinical experiences and providing learning resources). ⁴ These were so consistently important that just eight response items now form a reliable and valid measure of the quality of clerkship learning environments, the Manchester Clinical Placement index (MCPI). ⁴ This has proved valid in three English language contexts (UK, Ireland and South Africa) and when translated into Hungarian and Baha Indonesian. The nature and importance of supportive learning environments, these findings confirm, transcend context and culture.

Whilst educationalists present supportive behaviour as self-evidently valuable, ⁵ clinicians persist in believing that students ‘have to jump in at the deep end’ and ‘shouldn’t be mollycoddled’. ⁶ Of course, students must experience the challenging nature of practice, but a baptism of fire is not a good induction to it. To explain how supportive climates help students expand their capabilities, we first consider the relationship between education and practice.

Complex causality

The engineer deals mainly with measurable factors. Their factor of uncertainties is within fairly narrow limits. The reasoning of the medical student is much more (complex). They handle that at one and the same time elements belong to vastly different categories: physical, biological, psychological elements are involved in each other. ⁷

Flexner’s seminal report recommended the now ubiquitous science-before-practice medical curriculum (There have, in recent years, been vigorous semantic debates, which have shown that ‘complicated’, the term used by Flexner, refers to a different metaphysics from ‘complex’, which Flexner clearly meant). He assumed that scientific habits of mind would help students learn the complexity of practice. They would discover empirically, rather than assume or be taught, how factors that cause ill health intertwine. Longitudinal, collegial relationships with clinicians would facilitate this. His assumptions prevailed until more recent societal concerns about the safety of medical practice led regulators to change medical education. Rather than primarily learning practice ‘in vivo’, students should demonstrate attainment of measurable learning outcomes. The high-stakes assessments in which students demonstrate competence must be reliable, which can only be assured ‘in vitro’: in examination spaces, free from the confounding effects of practice. To define learning outcomes precisely, assessors must atomise the complex practice of medicine into measurable component parts.

Teaching and testing ‘atoms’ of safe practice ‘in vitro’ is a paradoxical approach to assuring patient safety because harm results from whole, complex problems, encountered in context. ⁸ Clinical teaching has also been atomised and often decontextualised: education takes place without patient care, patient care without education, teaching without learning and students learning without a clinician’s guiding hand. ⁹ Disaggregating complex systems into parts (for convenience) is ‘a mischief that has crept into into much of the way we conceptualise the world’. ¹⁰ It is a mischief because the best education (certainly for safe practice) takes place in communities of clinical educational practice (COP) where practice, teaching and learning overlap. ¹¹ The philosophy of cause and effect (metaphysics) helps explain why collegial behaviour in vivo is preferable to baptisms of fire and regimes of in vitro testing.

The term ‘complex adaptive system’ refers to systemic interactions between cause and effect that feed back on themselves and are open to contextual influences, ¹² in contrast to ‘simple’ or ‘closed’ systems, whose outputs follow predictably from their inputs. So-called ‘complexity thinking’ is evolving. The metaphors first applied to complex causality in healthcare came from the physical and biological sciences rather than human social sciences, but these had limitations. Patients, doctors and students are not nebulae, molecules or rats. They form social systems with unique potential complexity because they are imbued with values,^{13, 14} This must surely be true, also, of medical education. The different sociocultural milieus where students learn each have their own implicit values, which give language situated meanings that influence social interaction. We next look at how embracing this complexity could lead to simple and effective, rather than simplistic and ineffective, education.

Affects of students and doctors

Medical education addresses the emotional realm by ignoring, detaching from, and distancing from emotions. ¹⁵

Shapiro ¹⁵ proposed that medical education engenders ‘professional alexithymia’: a failure to recognise, process and regulate emotions. Human emotions and values together form a potentially self-reinforcing nexus, referred to as ‘affects’. ¹⁶ Students and doctors integrate several domains of affect into their practice: affects of the self (mood states, motivation and confidence); affects towards others (empathy and compassion); and professional values (also referred to as attitudes). ¹⁷ Affects can be negative or positive and reciprocate dynamically within social transactions: for example, baptising a student with fire may increase a clinical teacher’s self-belief (positive affect) while shaming the student and making the patient feel uncomfortable (negative affects). Alliances formed between patients, students and doctors, in contrast, can have positive effects on all three parties, enhancing their mood, motivation and agency. Complexity makes this possible, ¹⁸ sometimes even in the face of incurable disease. Education within the penumbra of supportive clinical practice can motivate students in a way that no high-stakes assessment could rival.

Medicine’s affective domain, particularly the motivation to practise, has changed in recent years. Formerly, the uncertainty engendered by complexity and the attending frisson of fear motivated doctors to exercise their capabilities to the benefit of patients and feel rewarded for having done so. Stringent regulation now requires students and doctors to prove they are adherent to algorithms of action compiled by ‘experts’ and risk being censured when patients have adverse outcomes. This negative, extrinsic motivation has supplanted the intrinsic positive motivation of values-based practice. It has changed clinical uncertainty itself from something complex to the simple, naked fear of being deemed ‘unprofessional’. ¹⁹ New doctors entering practice describe how their lack of practical experience has left them unprepared to start practice. ²⁰ Distress and burnout have become rife, leading significant numbers of recently qualified doctors to leave medicine ²¹ to the extent that there may be no doctors, let alone safe ones, if we do not make workplaces more supportive.

Implications

I can be me only if you are fully you. (Archbishop Desmond Tutu)

Recipient of the Nobel Peace Prize, Desmond Tutu, captured the nature and importance of social complexity in the 10 words quoted above. The beauty of engaging with complexity is that, when we seek naively to understand a system that is having negative effects, simple (but not simplistic) interventions can ‘tip’ the system into positivity. The most immediate implication is that thoughtful clinicians should help members of society, notably politicians, understand how the delicate balance between benefit and harm makes it impossible for clinicians to do good without ever causing harm. A second implication is that we should recognise the existence of a problem within our profession: not all doctors who educate students and trainees share Tutu’s vision, as evidenced by the ‘baptism of fire’ mentality and, according to recent evidence, senior doctors distancing themselves from junior doctors’ plight during the coronavirus disease 2019 pandemic. ²⁰ By Tutu’s reasoning, failing to support students and new doctors is everyone’s loss.

It does not cost anything to behave well towards others, particularly in educational settings. Allowing Tutu’s wisdom to permeate relationships between medical students, doctors and patients could foster the development of therapeutic alliances (both immediately and in students’ future practice) that optimise benefit and manage risk. Doctors should act as facilitators, role models and critical friends at the point of convergence between practice and learning ⁹ and educate students and doctors-in-training, by example, to be wise and empathic too. This could release latent social energy currently tied up in ineffective educational practices and meet the regulatory imperative to inculcate humanistic values. Supportive social interactions combat loneliness and draw people together into psychologically safer COPs. Here, eager students with young pairs of hands can enter the medical workforce, shouldering increasing levels of responsibility alongside trained doctors. THAT is why medical students’ learning environments matter.