Fostering Psychological Safety in the Clinical Learning Environment

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On this episode of the Academic Medicine Podcast, guests Addie McClintock, MD, and Joshua Jauregui, MD, join hosts Toni Gallo and Research in Medical Education (RIME) Committee members Andrea Leep, MD, and Paolo Martin, PhD, MS CHPR, MEd, to discuss clinical teachers’ behaviors and how they support or harm students’ sense of psychological safety in the clinical learning environment.

This is the first episode in this year’s 3-part series of discussions with RIME authors about their medical education research and its implications for the field.

This episode is now available through Apple Podcasts, Spotify, and anywhere else podcasts are available.

A transcript is below.

Read the article discussed in this episode: 

Read the complete collection of articles included in the 2022 RIME supplement at academicmedicine.org.

Transcript

Toni Gallo:

Hi, everyone. I’m Toni Gallo, host of today’s episode. Every year, Academic Medicine publishes the proceedings of the annual Research in Medical Education sessions that take place at the AAMC’s Learn Serve Lead meeting. This year, the RIME papers, including the one we’ll be talking about today, will be presented throughout the LSL meeting, which is taking place in-person in Nashville, Tennessee, in November. The RIME papers are also available now to read for free on academicmedicine.org.

Toni Gallo:

As in previous years, I’ll be talking to some of the RIME authors on this podcast about their medical education research and its implications for the field. For the first of this year’s conversations, I’m joined by RIME Committee members, Dr. Andrea Leep and Dr. Paolo Martin. And we’ll be talking to Dr. Addie McClintock and Dr. Joshua Jauregui, who coauthored the paper, “Clinician Teacher as Leader: Creating Psychological Safety in the Clinical Learning Environment for Medical Students.” I’ll put the link to that article in the notes for this episode. So I’d like to start our conversation today with some introductions. Andrea, could you get us started?

Andrea Leep:

Sure. Thanks, Toni. I’m Andrea Leep. I’m associate professor of neurology at the Mayo Clinic in Rochester, Minnesota. Really excited to be here today on behalf of the RIME Committee.

Paolo Martin:

Hi, everyone. I am Paolo Martin. I am an assistant professor at Uniformed Services University of the Health Sciences and also assistant director of scholarly communications. And I’m also representing the RIME Committee here, actually as Andrea’s mentee.

Addie McClintock:

Hi, I’m Addie McClintock. I’m an assistant professor of medicine at the University of Washington in the Division of General Internal Medicine.

Joshua Jauregui:

Hello, I’m Joshua Jauregui and I’m an associate professor of emergency medicine at the University of Washington.

Toni Gallo:

Thank you all for being on the podcast today. So our discussion is really going to focus on the work that Addie and Joshua and their coauthors did to study clinical teachers’ leadership behaviors and how they support or harm students’ sense of psychological safety in the clinical learning environment.

Andrea Leep:

Well, I was so excited to see psychological safety as the topic of your paper submission and to see it get selected as one of the RIME papers. As someone who works in an academic health center to think about ways of measuring and continuously improving learning and work environments, this is something that’s getting a lot of attention, not only because of its relevance to learners from an education perspective, but also its broad implications for inclusion, for learning, for innovation. It’s part of the Institute for Healthcare Improvement’s framework for the safe, reliable, and effective patient care. So this work is really important and you highlight the important role of leaders and look forward to diving into that deeper, through the lens of creating safety for medical students. Paolo, from your perspective, what excites you most about this topic?

Paolo Martin:

Oh my gosh, a lot, particularly as a former classroom teacher. We talk about learning and teaching with respect to outcomes, but we rarely talk about teaching with respect to how the environment, how our actions, how our choices affect our learners, in terms of their own sense of agency and self and whatnot and their wellbeing. And so, it’s so wonderful to see this paper out in the medical education world and just to see how that translates as well.

Toni Gallo:

So maybe, Addie and Joshua, you can just tell us a little bit about what psychological safety is, for listeners who maybe are not familiar with that term, and what it looks like in undergraduate medical education, why it’s important, why this is something that you wanted to study.

Addie McClintock:

Yeah, sure. I think just to answer why we wanted to study it first even is because we felt like a lot of what was out there was about environments that were manufactured to be safe or simulation or talked really about broad culture change that’s needed, which of course, we agree. But it often lacked sort of the granularity of, how are we going to do this? And so, I think that’s what we were really interested in was that the conversation we had was just like, “This is such a great concept that we really need in medical education, but how?”

Addie McClintock:

Especially when we think about how steeped we are in hierarchy in medical education and how important a lack of hierarchy is to psychological safety. That, to us, was like, “There’s a lot of work to be done.” So let me give a definition since I already started talking about parts of it, but it’s basically the belief of team members that they won’t be shamed, blamed, or ignored for speaking up or asking a question or taking a risk. And keeping in mind that, for medical students, this could be something that we consider really small, like saying a wrong answer on rounds, having to admit that they don’t know something.

Addie McClintock:

Those are very risky situations for students very often, because of the sort of constant specter of evaluation in our learning climates. In medical education, what we have seen, in our paper and others, is that, when it’s present, it allows students to show up as kind of their authentic selves. They can focus on learning without a lot of distracting cognitive load about image and evaluation, that can really be pushed to the forefront when it’s absent. And we really just, in the words of students, it’s sort of like, “I don’t feel judged when I do something maybe wrong or I have negative feedback that I’m receiving. It doesn’t come with judgment. It feels like the person here is on my team and they’re invested and that the whole team is focused on learning, above all else.” And I think just dovetailing on what Paolo said, when we think about outcomes, it’s sort of how we get there.

Joshua Jauregui:

And I think what that means to us is that you have to have an environment works for students to be able to learn and thrive in. Similar to how you have to have certain elements to create an environment for patients to be treated safely. We have to have certain basic tenants to an environment, because an environment is what creates or does not allow for psychological safety. It is the environmental characteristics that are important for students to then embody that environment and learn. So much of what seems to exist, to us anyway, was what we were doing poorly or what we weren’t doing well. And reframing things to think about in a positive way, how can we achieve the kind of learning outcomes that we want by thinking about the required elements to building that engine of psychological safety?

Andrea Leep:

So you’ve done a great job and you certainly convinced us. I presume you’ve convinced the listeners that this psychological safety and unpacking how it works, what it looks like, not just in its absence, but also in its presence. And like good scholars, good researchers, then you follow up that good idea with thinking about a study design and how you might approach a study to answer that question or get the sort of information you were looking for. Can you tell us a little bit about how you designed the study and organized the findings?

Joshua Jauregui:

Yeah, I think we started off by thinking about how we perceive reality. And although that sounds really vague, I’ve learned a lot from mentors in medical education, especially in qualitative research, but really in any type of research, that it’s important to, first, reflect on the way that you see the world and how that impacts your study design and the questions you’re even asking. And so, I think we started within a research paradigm of constructivism, where we acknowledge that multiple realities exist and that those are often socially constructed between folks and people. And along those lines, we chose to use a grounded theory methodology and then ended up with the method of semi-structured interviews, in order to create an environment for individuals to tell us their stories in as safe of an environment as we potentially could create, rather than doing other types of qualitative tools, like focus groups, for instance.

Addie McClintock:

I’ll just add to that idea about how important perception is. I think, when we talk about psychological safety as part of faculty development, we like to acknowledge that it’s, in some ways, it’s a little bit of an unfair task. You’re sort of being asked to manage someone’s perception of the environment. And that is part of why we sort of took that approach is, because there are multiple realities to the same situation for everybody. And how just important this piece about what the perception is and why then it’s so important to be really explicit about expectations and your intent of always learning and teaching when you do things. Because it does really help create where there’s just no space for a different interpretation that’s a little bit more negative or destructive to the climate.

Joshua Jauregui:

And I think one of the choices we made early on is that we wanted to do two things. We wanted to pick an environment that was as real as possible. So rather than studying something like a simulated environment or a classroom environment, we really wanted to focus on, and this was a choice, the clinical learning environment. Because our second priority was thinking about a place that arguably held the most risk. And so, when we think about what’s life like after medical school for a medical student, it’s applying to residency programs and third year clerkships, required clerkships, which is the typical language in most medical schools within the United States at least, is a high risk environment where you’re being continually evaluated and assessed in a way that builds an application for a job afterwards. And so, thinking about a higher risk environment, we wanted to find out, what were the elements that clinical teachers incorporate into their teaching that create a psychologically safe environment, even when it’s the highest risk that we can think about in medical school?

Addie McClintock:

Joshua, do you want to highlight what the specific results were?

Joshua Jauregui:

So maybe this will just wet your appetite to read the paper, because there’s a lot of great stuff that I would love to share. But I’m just going to summarize it into three big things. First thing is how team leaders, so our clinical teachers, can really embody team leader behaviors to create psychological safety in the clinical environment are, first, set your students up for success in learning. And you do this by setting expectations that emphasize teamwork and explicitly emphasizing their expectations as individual students and what you expect of them, in terms of mastery learning or ability. Second, encourage engagement in learning. And you do this primarily through empowering them to function autonomously in certain ways that are safe for the patient and for their learning. And be humble by modeling lifelong learning and acknowledging when you don’t know something.

Joshua Jauregui:

And thirdly, reinforce every effort as an opportunity for learning, through emphasizing learning when errors or mistakes occur and acknowledging student effort that is made towards learning and towards patient care. I think the biggest thing is that you’re really setting them up for success in learning, encouraging engagement in learning, and reinforcing every opportunity for learning. As you can see, the keyword here is learning. It’s coming up a lot. And by doing this, students start feeling safe, because you’re building relationships with them. And by building relationships with them, you’re creating safety. And by creating safety, you’re building relationships and it can become circular.

Paolo Martin:

Along that vein of how to create psychological safety for learners. Sometimes, we think about creating psychological safety or safety in general or good educational practices as these grand acts. What I loved about the paper is that the participants mention some smaller, but meaningful, I want to call them, small and mighty acts, that fostered psychological safety. I think a few times in the paper you brought up just calling students by their names. Can you talk a little bit more and maybe give some more examples of these small but mighty acts and their potential impact on changing culture in the learning environment?

Addie McClintock:

Yeah. This was really one of the things that surprised me really early on in the interviews was like, “Wow, these things are small. They are really small and they are things…” So I’ll just name a couple of them that we heard frequently. Introducing yourself as the educator, like, “Hi, I’m blank.” Asking their name, using their name when you address them. And then, some of the things that Joshua mentioned about being curious about them, getting to know them, ask them questions about themselves. I think this was really about, they see me as a person outside of what’s happening here in our sort of immediate context, paying attention to them when they talk or when they present. So things that were not safe were things like “I’m talking and my attendee is on their phone” or “I’m talking and they gave me a one word answer and then they rolled their eyes.”

Addie McClintock:

So really just giving true attention through your body language, facing them when they talk, when they’re talking or trying to make their contribution. Like we’ve already alluded to, a really explicit statement about the priority of learning in the team, the sort of creator of psychological safety calls this a learning oriented environment. And that’s sort of what that’s about, setting that up and again, really explicitly. And then, giving them some really clear expectations, like Joshua said, about what I want you to do, how I want you to do it, what I think a third year can do by the end of this rotation, those types of things. And I think the other thing to emphasize is, again, with this, it’s not that big of a lift is that these were doable, even in the context of shift work. So we heard some students at both institutions say “I had the most amazing experience on my ER rotation or anesthesia,” where we think of that as really short continuity and potentially zero continuity, you’ll never see this person, again, relationships.

Addie McClintock:

And yet, somebody taking three to five minutes at the first meeting to just say like, “Hey, what’s your name? How’s it going? What are some things you want to learn? Or, oh, if you can’t think of any, here are some things that the ER is so well suited to teach everybody, no matter what you’re going into.” Just these building relationship and team formation in the ways that we do in other areas of our life all the time, but that we just sometimes forget in the busyness and stress of medical care and teaching. And it is culture change, in some ways. I think what we heard was like, “Gosh, it’s so small,” but people have a lot of examples of where it’s not there. And there is some culture change that we’re working on with these things, but it doesn’t have to be hard. I think is what we really took away and hope that other people will take away as well.

Joshua Jauregui:

Yeah. I love that small but mighty way to phrase it, because I think the way I think about it is it’s human first communication. And I find that simple things, like someone’s name, is really humanizing and can immediately change the course of an interaction, when you’re meeting a ton of different people, new people every day. And I think the truth is that being in medicine can be really challenging and we are all just human trying to do our best. And when we are maybe not our best selves, because we’re stressed and tired and overworked, it can be easy to not do simple acts that are mighty, in terms of creating relationships with folks. And I think, as we change culture, things will be more common. But I think, for now, it’s often easy for folks to be treated as their role, rather than as a person, or be seen as a certain behavior, rather than as a person. And so, I think these small things start changing the way we think and changing the way we see the people in front of us.

Andrea Leep:

It reminds me of the conversation around patients, of thinking about patients in terms of their disease or their condition or their status as a patient, as opposed to as a person. So really resonate with that idea of human first communication and reminding each other that learners are part of that. So one of the questions I’ve sometimes run into from faculty, when we talk about learning oriented environments and learning as an important priority and emphasizing the commitment to learning and the like, is a perception sometimes that this is intention with the goal of being there to serve the needs of patients or meet the needs of patients or a patient centered. Can you reflect a little on how you might respond to that sort of concern, as you’re talking with faculty and other staff?

Addie McClintock:

Are you talking a little bit about the providing autonomy parts of learning? Is that sort of…?

Andrea Leep:

Yeah, definitely. That creates those tensions between safety and supervision and learning. But I think just thinking about the why we’re all here. Should we be thinking about learning and the need for autonomy and things like that to support it as being intentioned with a commitment to patients? Or is there a way to reframe it as really learning orientation, being in service of good patient care? And these really move together.

Addie McClintock:

When we think about this setting expectations piece, the way I do it, and that’s because the way I heard students talk about it, was there’s both. They come together. There are two sort of main goals. Every time I’m working with someone new, I tell them “Our first two goals here are learning and excellent patient care.” I definitely hear from faculty a couple different sources of tension, which I’m happy to share, because Joshua and I do think a lot about, “Well, gosh, how do we think about it in the form of this comment that we heard?” Because there is a lot of sometimes misunderstanding about what psychological safety means. It’s not just being nice, but also, there are some things that I think are hard to conceptualize in the context of what we do. So one thing we definitely hear is, from people who are in high risk situations in their clinical care — surgeons, people who do other sort of procedural things — “Well, I can’t let the student do this procedure” or “I can’t let the student do the operation.”

Addie McClintock:

You can still provide autonomy to students and find ways to engage them in care, by either sort of talking them through the procedure. For other options, maybe it’s a code and it’s not a good time to explain to the student what everyone’s doing. But you can huddle with them afterwards and give them some context about what was happening, what did you observe. A debriefing, but also one that’s kind of learning focused. You can also ask them, “What would you do here?” You don’t necessarily need to do that thing if it’s not a good idea, but you can certainly engage them in the cognitive exercise of patient care. And it shows them that you value their opinion. It shows them that you care about what they have to say. And sometimes, it might even be that you honestly want their input, because maybe they’re closer to their basic sciences or something like that.

Addie McClintock:

And that shows them that you value them. So it doesn’t have to be, “Let’s send the students off to just do whatever, because autonomy is good for the environment.” Number one, that’s not true. I will just add that the other part of this is that, if you give them autonomy without adequate supervision, that is unsafe to them. So there’s sort of this middle ground of, “I believe you can do it AND I’m here if you need help.” And so, this middle place of like, no, don’t send them out to perform surgery. We all agree that’s a not safe plan. But there are ways that you can engage them in the surgery, like explaining what you’re doing or talking to them about the goals of the surgery or the surgical disease as you do it, or before or after. Whatever’s most appropriate. I will introduce one that you have not asked about, which is humility.

Addie McClintock:

Humility is a really hard one. A lot of people feel like, “Gosh, if I say, I don’t know, I’m going to lose my credit here and my capital as the team leader.” And I think that is a really common fear. And we hear it a lot, especially from junior faculty who are sort of closer to the trainees and really want to sort of establish their place. But I don’t know how to say it other than that’s just not the case. We really hear from students how much they appreciate that and how far it goes, with respect to belonging. And I really never heard from students. I did actually ask, because I hear this a lot. “Well, did them acknowledging that they didn’t know something make you feel like they didn’t really belong as your team leader?” And it’s just not the case. I get why that’s a concern, but it doesn’t really play out in the mind of the student.

Joshua Jauregui:

And I would go so far, Andrea, as to say, if you care about patient safety, you will prioritize psychological safety for your entire team. We’re looking at this from the lens of learners, especially ones who you could argue have the least amount of power on a team, if you’re thinking about a comprehensive medical team to include students and residents and different stages of training for all of those. And so, if you’re thinking about psychological safety for everyone on a team, I think that’s going to make the patients more safe, if we consider this idea of moving away from a hero type mindset that I think a lot of our culture and specifically medicine has had with leadership.

Joshua Jauregui:

Where it’s this one person who has all the information and all the ability and can do everything, when the truth is, there’s just too much to know. And especially now when we think about things like health advocacy and patient advocacy and other ways that different populations of our students are going to have expertise are going to be different than maybe the majority of folks who are currently in medicine.

Joshua Jauregui:

And historically marginalized groups in medicine are going to come with much more expertise of how to treat certain patients than maybe the team “leader” has at the time. And I think, by empowering the entire team and creating safety, you create patient safety as well. In the same way that we’ve seen the patient safety literature and the nursing literature and the management literature show that your teams are going to be more effective by creating this. An effective team that’s focused on patient care is going to mean a safer patient, when they’re psychologically safe. And then, the other construct I’ll add to all the incredible examples that Addie gave you. Big picture, if you’re thinking about just the patient in front of you, that’s what this matters for. But I think also we’re thinking about patients more broadly than that. We’re thinking about the safety of the patient in front of us, but also the safety of the patients in the future or in the entire hospital. And a lot of that depends on the psychological safety of the future physicians, the ones that we’re training.

Andrea Leep:

So that’s a great opportunity to challenge ourselves to push the conversation. There’s a lot of emphasis on the leader behavior and those interpersonal interactions for creating psychological safety. If we challenge ourselves to start thinking beyond that exact moment to bigger populations across time and thinking about broader constructs, like social or structural and systemic factors and things, so that sometimes we talk about the hidden curriculum as the manifestation of some of those larger influences beyond the interpersonal interactions. What are your reflections on that, in relation to fostering or harming psychological safety?

Addie McClintock:

The message that just showed up again and again, without ever being explicitly stated, was power and really about the power differentials and the hierarchy and sort of the harmful effects of that, which as Joshua and you were alluding to, we have seen that play out, as patient safety literature. But I think we haven’t seen it play out so much yet, as far as how that impacts the medical students who currently reside typically at the bottom of the hierarchy. And a lot of people, there were so many moments of sort like, “Well, I expect that. It’s okay, because I’m a student” or “I get it, because they’re very senior.” There was a lot of tacit forgiveness for bad behavior. It was, “Well, they were more senior to me” or “Well, I’m at the bottom, so I’m not so surprised this occurred.” There was a lot of that type of thing that sort of really referenced how they were perceiving power within the team, without explicitly saying it.

Addie McClintock:

What Joshua and I think a lot about now, having done this, is this idea of, yes, for patient safety, your team needs a leader. You need an organizational structure to your team, such that there is a person who has the most expertise and has spent the most time doing this that is leading the medical nature of the care. But there’s really not a reason why that needs to translate to a statement about social hierarchy and about value or worth within the team, which is where we have ended up now. And that’s a real, again, culture shift and a huge change in how we think about medicine and training.

Addie McClintock:

One of the other things that I thought was really interesting is we talk a lot about, “Well, how are we teaching this hidden curriculum that we didn’t even mean to teach?” And there is just so much about .. this is students are watching. They are watching everything and they take meaning from everything we do. And I don’t think it’s such a huge leap to sort of understand the idea that I might say [in a chipper tone of voice], “Hi, it’s so good to see you.” Or I might say [in a flat tone of voice], “Hi, it’s so good to see you.” And people would take a very different meaning from those exact same words. And that’s what’s happening. Students are watching these interpersonal interactions, whether they are directed at the student or between other team members. They’re watching and they’re taking meaning from these things. And Joshua and I also reflect it’s like parenting. It’s like, they watch. They will do what we do, not what we say. And so, there needs to be this treating each other a certain way, that is a change in how we view the different roles of the team members and what they bring. But we’ve decided that these interpersonal interactions are how we teach the hidden curriculum.

Paolo Martin:

I’m going to jump in with a follow up really quickly, because when I read that part of the paper where the participants, the students, talked about this belief that they didn’t have a say, I think I’m paraphrasing here, I was seeing this as we’re seeing this reproduction or these hierarchies of how it’s sort of being reproduced in these students and also how the clinical teachers might be enacting them as well. And when you talked about psychological safety, the sense of the importance, of the ethos of care and maybe humanizing pedagogy or whatnot, it makes me wonder. This is about a mindset. So how do you think we can shift mindsets within both clinical teachers and perhaps even students, about the nature of hierarchies or whatnot?

Joshua Jauregui:

Yeah, that is a really good question, Paolo. I think that’s our hope, to circle back to Addie’s setting the stage of why we did what we did and trying to figure out the behaviors. We really like to approach our scholarship, in terms of translational research. How can we actually make this work and bridge these concepts to behavior change in the environment? And I think it starts with conversations and I think it starts with acknowledging the fact that a lot of folks, who are in positions and responsibilities of educating our students, don’t really have formal training in education, at no fault of their own, other than the fact that they are doing what they’ve been taught. And I think recognizing that medical education as a discipline is relatively young and this paper is just a very tiny, tiny aspect of trying to move our scholarship forward and our ways of thinking about education forward.

Joshua Jauregui:

And I think hopefully, impactful, one, in the sense that we’re learning now that maybe best education practices have a different type of cultural mindset. Maybe it hasn’t always been this way. I think, a lot of times, one of the earlier critiques that Addie and I really tossed around was this idea of, “Well, if I yell at you, you’re going to have an emotional response and then remember it better.” Well, I think the evidence is showing that that actually hurts long-term retention. And you remember that emotional response and that event, but you are less likely to engage in future learning that day or that week, or show up in an authentic way that has enough cognitive load to focus on your learning, rather than being stressed about that harm that you experienced.

Joshua Jauregui:

And then, long term retention is really lost. And so, I think that the way that we think about education as a science is constantly evolving. And I think equipping the folks who are given responsibilities to be teachers with the appropriate faculty development to support them in those roles and a community of educators themselves. And I think this gets into the whole faculty development literature, but I think that we have to work with scholarship and faculty development, hand in hand, in order to really support the people who are expected to teach.

Addie McClintock:

And Paolo, I’ll just add, I think another thing you were asking was sort of about, how are we going to do the culture change? And how are we going to build the mindset? And the literature, again from other places, but some within academic medicine as well, is really about … it does actually have to come from the leadership. It really does. It’s not something that the student can just wake up and say, “I have a growth mindset today,” and then, they’re going to come to work and be shamed, blamed, and ignored. So I think it really does need to be … It’s extremely valuable to have the current leadership model this as best they can, with the acknowledgement that it’s hard, but even modeling that acknowledgement goes a long way.

Addie McClintock:

I think it does have to come from the people that are currently in power in our system. And I think there are other structural ways that we could build more continuity in our teams and sort of create those relationships that are wonderful to have, but we have seen that it doesn’t have to be there. It really is more about the time that you invest in the relationship and the person right up front.

Andrea Leep:

Now, one of the things that was intriguing about your paper was how quickly students were making judgements about the environment. And for those of us who might be listening to you and thinking, “Oh man, I’ve done this wrong. Can I recover if I get off to a start on the wrong foot?” Could you briefly speak to those two parts of your paper?

Joshua Jauregui:

Yeah, thanks for asking. That was another thing that really surprised us, to be honest, was that learners made a judgment of whether an environment was safe or not quickly. And it tended to be durable. And the instances in which, say, a safe environment became unsafe or it was already unsafe and it was then recovered to become safe was when the team leader actually initiated repair. And so, I think the way Addie and I have processed this is it seems to us that psychological safety begets psychological safety. So if you have a psychologically safe environment, it creates relationship that then creates more psychological safety. And so, it perpetuates itself. And I think, in the same way, an unsafe environment can also perpetuate itself. And so, once an environment becomes one or the other, it’s really hard to change it, especially if it becomes unsafe.

Joshua Jauregui:

And I think the reason why it’s harder to switch from unsafe to safe is because oftentimes, their power differential that does exist requires that, if a student is going to then initiate that process to have enough emotional resilience to then overcome this power differential, not only in a hidden curriculum way, but also in the fact that they’re getting assessed and evaluated, to initiate recovery. I think a lot of times about just relationships between any two human beings, that if you have conflict, in order to repair that conflict, create safety in that relationship again, somebody has to initiate that process. And so, I think when things become unsafe or start out as unsafe, it really takes the person who has more power in this type of workplace environment and assessing environment to initiate that conversation. So I would say, have hope. I think if you are willing to be brave and admit, “Hey, I messed up. I’m so sorry.”

Joshua Jauregui:

I think that goes a long way, but I think that it’s hard to do and that it’s hard for folks to do that. And I think students perceive a lot around an environment and have been in a clinical environment for so long that they can perceive what’s safe and what’s not safe. And I think I’ll highlight something Addie already mentioned is that it’s not only about how you treat them, it’s how you treat other people. And so, sometimes you’ll have folks who really focus on med student education and are very focused on the psychological safety of the student, but then, maybe treat the other folks in the environment differently, like residents or nursing staff. And that really makes it hard for students to feel safe as well, because when are they going to make a mistake that will then potentially create harm?

Toni Gallo:

We’re just about at the end of our time. So I want to give everybody a chance to share some final thoughts. And specifically, if you have recommendations or takeaways for listeners, what would you like them to get out of our conversation today and out of, Addie and Joshua, your paper?

Joshua Jauregui:

Yeah, thanks, Toni. I would say, have hope. One of the important things in our work is recognizing that, at least the way I try to approach things is with unconditional positive regard, everyone’s trying to do the best that they can. We hope that this extra piece of evidence will help support folks with some tools that they can use to create a psychologically safe environment, maybe change the culture a little bit for better learning and ultimately better patient care.

Addie McClintock:

For me, I think my takeaway or just my final thoughts are that it really does mean a lot to trainees. And as we mentioned, these are generally kind of small things and it really means a lot. And I think for me, it feels a little bit like the secret sauce we’ve been looking for in medical education, allowing people to feel that they belong and to feel like they can show up as their sort of authentic self, as they go through this really difficult time in their life of becoming, or if we’re talking about culture change, being a doctor. And so, I think to me, it’s just sort that it’s not too hard and it really goes a long, long way.

Andrea Leep:

I’ve always enjoyed those one or two word summaries as takeaways. And I think I might pick small and mighty, I know that relates to what you were just sharing, Addie, and is also part of what feeds hope. Because if small changes can have a big impact, it feels doable. It feels possible. And it makes that reassurances about humility being something that could be viewed as a strength, as might. So I think that would be something I would take away from this and be excited to share forward.

Paolo Martin:

Great. So mine is related to what Andrea said, but my biggest takeaway from this paper and this talk is that students and learners are watching. They’re watching more than we think they are. These participants had a lot to say, a lot to offer about what could be really helpful for them. And so, I think, one, I want to acknowledge that it’s hard being a teacher and educator. So breathe. Right, step back and understand that. But also, at the same time, think about what your students might be watching about you or taking away from you and think about what small and mighty acts you might be able to implement today.

Toni Gallo:

I want to thank you all for being here for our discussion today. And I want to encourage our listeners to visit academicmedicine.org to find the article that we discussed today, as well as the complete RIME supplement. Be sure to check back next month in October for our next conversation in this year’s RIME podcast series. We’ll be talking about a scoping review of the literature on including standardized patients with diverse gender identities. From the journal’s website, you can access the latest articles and our archive dating back to 1926, as well as additional content, including free eBooks and article collections. Subscribe to Academic Medicine through the subscription services link under the journal info tab or visit shop.lww.com and enter Academic Medicine in the search bar. Be sure to follow us and interact with the journal staff on Twitter at @AcadMedJournal and subscribe to this podcast anywhere podcasts are available. Always leave us a rating and a review when you do. Let us know how we’re doing. Thanks so much for listening.