[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’.

[The following notes were generated by Michele Haight, PhD]

IAMSE Webinar Series, Winter 2019

Speakers: Sean Tackett MD, MPH
Title: The Learning Environment: An International Perspective
Series: The Learning Environment in Health Sciences Education

• Learning environment definition: “The learning environment refers to the social interactions, organizational culture and structures and physical and virtual spaces that surround and shape the learners’ experiences, perceptions and learning.” (Josiah Macy Jr. Conference, 2018)
• Review of the four domains of Gruppen’s 2018 conceptual model for the learning environment:
  • Personal
  • Social
  • Organizational
  • Physical and Virtual Spaces

These domains correspond to the JHLES and DREEM frameworks.

DREEM is the most popular framework for measuring learning environment

perceptions.

• The learning environment is messy, challenging and important. Given this, we should not back down from challenges of engaging with it.
• The global medical education landscape:
  • 3000 medical schools in 185 countries with an estimate of >2million medicals students.

• The US medical education landscape:
  • 183 medical schools with 0.09 million students.
  • Cost in US $300K/student (cost in China $14K/student).

• Globally, the number of medical schools has been increasing while the ratio of medical schools to population has been decreasing. We need more medical schools.
• Models of medical education systems vary a lot making the learning environment more complex and more difficult to measure.
• Factors contributing to the overall complexity of learning environments in international medical education include the following:
  • rapidly growing number of medical schools
  • increasing institutional collaborations
  • increasing student migration
  • variation in curricular models
  • uneven coverage by regulatory/accreditation authorities (limit abilities to standardize medical education systems)
  • Uneven resources with exceptionally challenging situations

• Understanding one individual’s learning environment is already complex. Complexity increases when measuring at an institution, health system and inter-health system levels.
• A plurality of research done on the learning environment comes from high-income countries.
• International comparison studies in learning environment perceptions appear to yield useful data. For example, in an international comparison study, learning environment perceptions associated with quality of life but did not strongly associate with empathy. Much more research needs to be done to strengthen the evidence.
• Accreditation bodies need to spearhead research on the learning environment. There is a movement to standardize international accreditation and therefore standardize the data collection for accrediting purposes. This will enable research across institutions.

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

IAMSE Webinar Series, Winter 2019

Speakers: Larry Gruppen, PhD
Title: An Overview and Introduction to the Learning Environment
Series: The Learning Environment in Health Sciences Education

The IAMSE 2019 Winter Webinar Series, The Learning Environment in Health Sciences Education, kicked off to a strong start on January 10, 2019 with a presentation by Dr. Larry Gruppen, Professor in the Department of Learning Health Sciences at the University of Michigan Medical School. His webinar entitled “An Overview and Introduction to the Learning Environment” provided a framework on the topic upon with other speakers in the series will build in the coming weeks.

Dr. Guppen began with an acknowledgment of the recent scoping review of literature on the learning environment for the Josiah Macy Foundation in 2018 from which much of the webinar would be based. He noted that the learning environment and associated concepts are defined variably by individuals and that theories and measurements surrounding the topic have not yet been fully established. The AMA defines the learning environment as a social system that includes the learner (including the external relationships and other factors affecting the learner), the individuals with whom the learner interacts, the setting and purposes of the interaction, and the formal and informal rules/policies/norms governing the interaction (AMA, 2007). However, a modified definition was put forth by the Josiah Macy Conference in 2018: the social interactions, organizational culture and structures, and physical and virtual spaces that surround and shape the learners’ experiences, perceptions, and learning.

A challenge faced by those exploring the learning environment is that virtually anything could be considered a part of it including physical facilities, faculty, the patient population, curriculum, institutional culture, assessments, clinical settings, etc. As Dr. Gruppen stated, “If everything is part of the learning environment, then effectively nothing is part of the learning environment.” Another challenge lies in the absence of a common language; educational climate, social environment, and work environment are all synonyms in common use. Dr. Gruppen contrasted the hidden curriculum from the learning environment as separate entities, though some literature may equate the two.

As the root word environ means ‘to surround’, the learning environment can be considered those factors which surround learning. Five dimensions of the learning environment grouped into three domains were defined by Dr. Gruppen: in the Sociocultural Domain, (1) person, (2) social, and (3) organization; within the Spatial Domain, (4) the physical environment; and in the Technology Domain, (5) the virtual learning spaces.

Differences within the person such as personality, resilience, and life experiences all influence how one learns and thus affect the learning environment. Interactions between the learner and his/her peers, faculty, patients, and interprofessional colleagues all impact the social dimension of the learning environment. The organizational level is often blamed for toxic learning environments due to factors including work load, stress, etc. Physical spaces including classrooms, meeting rooms, and their furnishings in addition to critical general features such as new versus old facilities and the proximity of spaces all comprise the spatial domain. Virtual patients, electronic health records, online learning, and technology driven simulation affect the virtual dimension of the learning environment.

A variety of instruments have been utilized to measure the learning environment, but all depend upon self-reporting of the learner through survey questionnaires. As such, data collected to date have been dependent on learner perspectives.

Dr. Gruppen completed the webinar with a discussion of ideas currently circulating in health professions education and in the literature on how to fix the learning environment. The first discussed was curricular change. A publication was discussed which detailed the effects on the learning environment of a comprehensive curricular change that included transition to an organ system-based structure with pass/fail grading. This intervention yielded a moderate to large effect size on the learning environment, but it cannot be possible to pinpoint which factors were most important for the improvement, underscoring the complexity of the issue. Secondly, a Dutch study that examined key factors predicting work engagement among faculty was discussed. This study highlights the fact that faculty engagement and faculty satisfaction impact the learning environment. Faculty are both contributors to and recipients of the learning environment. Faculty development is thus an important cog to consider when thinking about improving the learning environment. Finally, Dr. Gruppen noted that much of the literature on the learning environment centers on student experiences and mistreatment.

While the learning environment is a complex and still poorly defined topic, its importance in medical and health professions education cannot be understated. It is critical for issues related to stress, burn-out, and suicide; it impacts productivity and patient care; and failures in the learning environment can have punitive financial consequences for an organization.