[The following notes were generated by Mark Slivkoff, PhD]

IAMSE Webinar Series, Winter 2019

Speaker: Daniel P. Harrington, M.D.
Interim Dean
Virginia Tech Carilion School of Medicine
Title: The Learning Environment System and Case Studies
Series: The Learning Environment in Health Sciences Education

Dr. Harrington initially presented the viewers with a list of objectives:

• Development of Learning Environment in a new medical school
• Review LCME Element 3.5
• Review the development of the Learning Environment program at VTCSOM
• Describe the Learning Environment Advocacy Committee
• Review the examples of concerns registered with the committee
• Describe the periodic review of the LE in the VTCSOM and affiliates
• Review the clerkship year LE

Some Background: The Virginia Tech Carilion School of Medicine

• VTCSOM was founded in 2008 as a public-private partnership between Virginia Tech and Carilion Clinic
• VTCSOM is the smallest medical school in the country with 42 student/class and 168 total students
• Innovative curriculum with 4 domains – Basic Science, Clinical Science, Research and Interprofessionalism integrated across the 4 years
• The curriculum in the first two years is centered on Problem Based Learning
• As of July 1, 2018 VTCSOM became the 9th college of Virginia Tech
• VTCSOM receives over 4,000 application for 42 positions
• The Multiple Mini Interview is used to rank 300+ interviewees for 42 positions
• Of the 5 graduating classes, all students have USMLE Step 1 and 2 scores above the national mean
• Students comment that the intimacy of the small classes, rigorous research requirement, and close relationship to Carilion Clinic are elements that make the school successful
• All 5 graduating classes have 100% MATCH

LCME Element 3.5 Review: The Learning Environment/Professionalism

“A medical school ensures that the learning environment of its medical education program is conducive to the ongoing development of explicit and appropriate professional behaviors in its medical students, faculty, and staff at all locations and is one in which all individuals are treated with respect. The medical school and its clinical affiliates share the responsibility for periodic evaluation of the learning environment in order to identify positive and negative influences on the maintenance of professional standards, develop and conduct appropriate strategies to enhance positive and mitigate negative influences, and identify and promptly correct violations of professional standards.”

Development of a Learning Environment Program

• VTCSOM did not have a formal learning environment program prior to 2014
• The LCME accreditation visit in 2013 cited the school because only a small number of student concerns (unprofessional/mistreatment issues) had been documented prior to the LCME visit and that there was no formal program in place to address student complaints and to promote a healthy LE
• In order to correct the citation VTCSOM developed a program to address the learning environment in all aspects
• The core of the program is the Learning Environment Advocacy Committee (LEAC)
  • Multidisciplinary membership: 7 students (peer elected), 3 residents, 5 faculty (appointed by the dean), a nurse representative, a staff representative, a Carilion HR representative, and dean advisors
  • The committee meets monthly
  • Concerns may be received from students, residents, faculty, deans, staff; but most are from students
  • Concerns may be anonymous and are generally logged on the end of block or clinical rotation student evaluations in the One45 system or on an anonymous website called BEACON
  • Concerns can also be brought directly to members of the committee, clerkship director, residency director, dean or faculty member

Summary of the LEAC Committee Work, 2013-2019

Summary of Concerns Reported to LEAC in AY 2017-2018

• During Academic year 2017-2018, the thirty-four (34) total concerns reported involved twenty-six (26) different individuals.
• Twenty-one (21) of the twenty-six (26) total individuals were faculty members representing appointments in six different departments.
• Of the twenty-one (21) different faculty members, there were six (6) individuals for whom multiple concerns were reported.
• All concerns were of “unprofessional behavior” and no concerns were of “mistreatment”
• Three (3) of the twenty-six (26) individuals were residents
• For all three (3) of the individuals, concerns were made about “unprofessional behavior”
• Two (2) of the twenty-six individuals were students
• One (1) student concern was made if “unprofessional behavior” and the other one (1) was made of “mistreatment”

Learning Environment Summary

• An additional component to the LE program that was developed as a result of the LCME citation, was a periodic survey of the learning environment of all constituents
• Three surveys (2014, 2015, 2017) have been conducted and are planned every other year (the next one is in March 2019)
• The LE survey is sent to all students, all residents, all faculty, all staff, and the selected group of nurse representatives
• The survey results are reviewed by the dean, dean’s group, chairs, staff
• The survey results are presented to each class
• A summary of the survey results are sent to all faculty, residents, and selected nurses
• An action plan is developed to address areas of concern
• Overall, the VTCSOM learning environment was perceived quite favorably in 2017.

• All stakeholder groups perceived a very high degree of sensitivity to culture, diversity, and inclusion on average – to an even greater extent than in prior years.
• On average, all four student groups (M1-M4) rated their maintenance of a healthy work/life balance lower than other items. Moreover, three groups of students (M1, M2, and M3) rated their work/life balance lower than M1, M2, and M3 students in 2015.
• Most stakeholder groups rated items regarding teamwork and peer support higher than in previous years, although these items were not the highest rated items on average.
• Almost all stakeholders were knowledgeable about VTCSOM policies and procedures related to the learning environment.

Other Elements of the Learning Environment Program

• Each incoming class has an orientation about professionalism and mistreatment
• The incoming class learns about the importance of the learning environment and the LEAC committee, appropriate policies, and ways to report concerns
• An annual review of the LEAC is presented to each class(LCME requirement, membership, and how to report concerns)
• The third year class orientation to clerkship includes a two hour workshop presenting actual cases. Following each case a facilitator discusses the students’ emotional responses to the case and options on how to address the issue
• The LCME Independent student survey and the annual GQ survey results report that students know the policy on unprofessionalism and mistreatment and how to report concerns

VTCSOM 2018 GC – Learning Environment Results

Details of The Year 3 Clerkship Learning Environment Work Shop Training

• The M3 Clerkship LE Work Shop occurs in the 2nd or 3rd week of the first clerkship in July each year
• Students are divided into four group of 10 or 11 students each group with a facilitator
• 10 cases are presented with discussion by the students
• Discussion includes the severity of each learning environment issue and ways to address or report each concern
• Discussion as to the severity of the concern is often lively while discussion on how to address is fairly uniform
• Most student do not feel comfortable addressing the issues directly but want to come to a dean or present the issue anonymously
• Two examples of cases were described

Dr. Harrington concluded with:

Lessons Learned since the Learning Environment Program was established

• That unprofessional behavior and mistreatment occurs at all levels of the medical school education process
• Perpetrators exist at all levels from students, residents, staff, attendings, and nurses
• Despite processes that are in place to anonymously report, the GQ shows that students still fear retribution
• Due to the power differential, the expectation that students can address these issues directly remains unlikely
• The educational process to promote the LE is difficult at many levels including the clinical areas
• Anonymous reporting makes correcting the issues with the right person very difficult
• There is a need to educate students on what are appropriate reportable issues
• We fail to adequately prepare a student for residency where these issues continue but are more enculturated and thus more difficult to eradicate
• Concerns are often reported as unprofessional behavior or mistreatment and in the opinion of the committee are not valid

[The following notes were generated by Will Brooks, PhD]

IAMSE Webinar Series, Winter 2019

Speakers: Luke Mortensen – Professor and Chair, Pharmacology, Physiology & Pathology, Idaho College of Osteopathic Medicine
Cindy Anderson – Associate Dean for Academic Affairs and Educational Innovation, The Ohio State University
Karen Hills – Chief, Educational Development, Physician Assistant Education Association (PAEA)
Title: The Learning Environment Panel Discussion
Series: The Learning Environment in Health Sciences Education

Osteopathic Medical School Learning Environment

• 35 accredited osteopathic medical schools, 30,000 students
• Greatly increased focus on well-being and mental health amongst learners in recent years
• DO students have spear-headed many national initiatives on mental health and self-care including the Mental Health Awareness Task Force, a part of the AACOM
• DO student leadership group developed a set of videos on wellness to promote the topic, which have gained much attention
• Empathy tends to erode as learners progress through training, but this decline has not been observed in osteopathic medical education

Nursing Education Learning Environment

• National Academy of Medicine has called to action a focus on burnout for all healthcare providers including nursing
• Burnout affects nurses and has negative effects on the clinician and on patient outcomes
• Impaired physical and mental health increase the odds of making medical errors among nurses
• The Ohio State has developed a Nurse Athlete program to promote wellness among graduates as they transition into the workforce. Participants exhibited fewer symptoms of depression and better overall health. This could be a strategy to promote health and wellness from the early stages of career.
• The College of Nursing utilizes a LIVE WELL curricular model, which is embedded into its programs: Lead, Innovate, Vision, Execute, Wellness-focused, Evidence-based, Lifelong learners, Lights for the world.
• To establish a culture of wellness, The Ohio State has utilized a variety of strategies including a wellness onboarding program for all health sciences students
• Health coaching at least once a week resulted in healthier lifestyle behaviors for both coaches and those being coached

Physician Assistant Education Learning Environment

• 238 ARC-PA Accredited PA programs
• Learning environments include classrooms, simulations, clinical settings, and longitudinal rotation settings
• PA learners participate in interprofessional educational activities in addition to traditional didactics and case/team/problem-based activities
• Mistreatment and unprofessional behaviors occur in PA education as they do in other health professions programs
• Strategies to reduce these behaviors include role playing difficult scenarios, stress management and self-care in orientation, professional coaching, preceptor orientation and communication, and faculty development
• PAEA provides a variety of faculty development activities for PA faculty in areas of wellness

ARC-PA accreditation standards include wellness of faculty and staff

[The following notes were generated by Will Brooks, PhD]

IAMSE Webinar Series, Winter 2019

Speakers: John Co, MD, MPH, CPPS, FAAP
Title: The Learning Environment During Residency
Series: The Learning Environment in Health Sciences Education

The IAMSE 2019 Winter Webinar Series, The Learning Environment in Health Sciences Education, continued on January 24, 2019, with a presentation by Dr. John Patrick Co, Director of Graduate Medical Education at Partners HealthCare and Co-Chair of the Clinical Learning Environment Review (CLER) Evaluation Committee for the ACGME. His webinar entitled “The Learning Environment During Residency” took listeners on an informative journey through the learning environment as viewed by the ACGME and CLER program.

Dr. Co began the webinar with a background on how the CLER program began and noted that the learning environment is foundational for everything that occurs within programs and institutions. When the learning environment is less than ideal, the learning that should occur does not occur efficiently and may not occur at all. CLER recognizes six focus areas: patient safety, healthcare quality, supervision, transitions in care, well-being, and professionalism. Dr. Co described three components to the CLER program. First, site visits are conducted to provide formative feedback to programs in each of the six focuses. Second, CLER tracks aggregate data from site visits over time to monitor progress in the six focuses at the national level. And third, CLER develops resources to support stakeholders in their progress toward improving the learning environment for graduate medical education (GME).

Dr. Co provided listeners with a description of the ins and outs of institutional CLER site visits. These site visits can be summarized as a look at how GME is integrated into patient care and education within an institution and what are the measures of success and areas of improvement identified by the institution. Dr. Co stressed that CLER site visits are not accreditation visits, but they are linked to ACGME accreditation in that sponsoring institutions must have a CLER visit every 18-24 months. While accreditation decisions are not made from CLER visits, identification of an egregious violation that would threaten patient and/or resident safety could result in an accreditation action.

CLER is currently in its third cycle of institutional visits. In the first cycle, 298 sponsoring institutions were visited between 2012-2015. These visits were restricted to those institutions with three or more core residency programs. The second cycle of site visits, which occurred 2015-2018, also included those ‘small programs’ with fewer than three core residencies. Site visits are conducted by a team of 1-4 site visitors over the course of 2-3 days. Visits include meetings with senior leadership (CEO and DIO attendance is required); group meetings with a broad representation of residents, core faculty, and program directors; and walking rounds.

Dr. Co went on in the webinar to describe the CLER Evaluation Committee, which he co-chairs. This committee, which is comprised of national experts in GME and the six focus areas mentioned above, meets quarterly to review data from CLER site visits. He then discussed the CLER Pathways to Excellence document, which provides guidance to GME leadership on the learning environment using synthesized input from experts in the field, published literature, and data from CLER visits. CLER National Report of Findings documents have also been released and are available for download. These documents summarize findings from each of the first two CLER site visit cycles.

The webinar continued with Dr. Co providing high-level data from the CLER site visits to the IAMSE community. He first noted a set of overarching themes gleaned from the CLER program.

• Theme 1: Clinical learning environments (CLEs) vary in their approach to and capacity for addressing patient safety and health care quality.
• Theme 2: GME is largely developed and implemented independently of the organization’s other areas of strategic planning and focus.
• Theme 3: A limited number of CLEs have implemented educational programs to ensure all faculty and program directors have the knowledge, skills, and attitudes necessary for their respective roles in training GME learners in patient safety and quality improvement.
• Theme 4: CLEs vary in the degree to which they coordinate and implement interprofessional learning in the context of delivering patient care.
• Theme 5: In general, CLEs lack the mechanisms to identify and eliminate organizational factors that contribute to burnout.
• Theme 6: Health care system consolidation and organizational changes create new challenges for CLEs to align GME with initiatives to improve patient care.

Dr. Co presented data comparing results of the first and second cycles of CLER site visits in the areas of patient safety, healthcare quality improvement, care transitions, and professionalism. While many positive trends were noted between the first and second visits, some lacked the magnitude of improvement perhaps expected, and some data indicated negative trends in specific areas such as care transitions. From these data, a group of challenges and opportunities have been identified for future focus.

Dr. Co concluded the webinar with a summary of recent changes and future directions for the CLER program. Included amongst these are the transition from a focus on fatigue management to more comprehensive examination at well-being, development of subprotocols in addition to the main site visit protocol, the pursuing excellence initiative, and a new focus area on ‘teaming’.