Teachers and learners in academic medical centers

Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Robert Shochet, a physician and professor and David Sklar, a former peer review journal editor, focused on efforts to build trust in academic medical settings.

David Sklar: We’re going to have a conversation about trust in medical education. And trust is a, it’s a challenge because as physicians and as folks who are trying to train medical students, we have to make sure that our patients are safe, and we also are evaluating our students at the same time. And on top of all of this, as physicians, many of us are wearing many hats. So we’re moving around and sometimes our relationships with students are somewhat fragmented. So I’m just wondering if you could maybe get us started and talk a little bit about how you’ve tried to overcome some of this in your program at Johns Hopkins.

Robert Shochet: Certainly. So the Colleges Advisory Program started in 2005 and it’s a learning community program that offers continuity for students and clinical skills training and a focus on professional development as well as advising. Entering students are divided into one of four colleges. We have 120 students, so that’s 30 students in each class year in each college and then further subdivided into learning units. What we call Molecules. They’re five students in each molecule and they’re connected to a faculty advisor who becomes their clinical skills teacher and remains their advisor throughout medical school. The program at Johns Hopkins actually started because we were in a very difficult spot with student advising. We had a volunteer advising program and one student in fact set on a climate survey, I just want someone to know me here. Which was quite outstanding and became a rallying call for us.

David Sklar: And why don’t they know him? I mean, it seems like they would have clerkships and classes. So why do you think he felt that they didn’t know him?

Robert Shochet: You know, like you had mentioned, I think there is a quality of rotating teachers and sometimes for certain students, they never really get to be known in a very important and meaningful way by teachers. And I think this is critical really if we’re thinking about students seriously developing their professional identity in a very durable way.

David Sklar: And Robert, I heard you mentioned that you’ve kind of developed these learning communities. Could you explain to us what a learning community is? Because I’m not sure everybody is familiar with that.

Robert Shochet: Sure. Well, the concept of learning communities was really brought to America in the early 20th century to university and it gradually picked up steam and now it’s mainstream in most undergraduate universities. The concept of learning communities in that setting is about integrating classes for students, creating longitudinal connections with faculty and providing opportunities for deeper learning because of a sense of wholeness and coherence to studying subjects from multiple aspects. With several teachers, they get to know well.

David Sklar: And how was it altered for medical students? Were there’s some specific changes that were made so that it would work better for medical students?

Robert Shochet: Yes, I think there are two key leaders in this field. Louise Arnold at the University of Missouri, Kansas City, back in the 70s, created a communities of practice model in the clinic where students over years would work with the same team developing their skills and have an opportunity for authentic and honest feedback from their supervisors and near peers. Erica Goldstein at the University of Washington did something similar but focused on clinical skills, education and professionalism for students within courses. And that created continuity and trust between students and teachers in a new way.

David Sklar: And I know that the learning community is one of the things that happens is we break down the overall class into smaller pieces. In some groups, groupings of four or five, ten, whatever. And I believe in your program, they’re five, although they get together in larger grouping also.

Robert Shochet: That’s right.

David Sklar: And then there are faculty who are especially designated, is that right? And who kind of stick with their group of students over maybe four or five years and certainly, the whole four years of medical school.

Robert Shochet: Yes, that’s absolutely right. We think that breaking students down into smaller groups and then subdividing them further into learning units, create both a sense of social identity at the school and a sense of belonging and then a sense of intimacy and trust within the learning units. And within the learning units, we call them at Hopkins Molecules, five students and an advisor. They stay together for years well beyond the duration of a single course.

David Sklar: Okay. Now how do you how do you keep these programs from getting into the problem of the faculty member being also an evaluator? Because you know, one of the things that our students are very concerned about, and I think one of the areas that’s really broken down trust has been a really kind of frightening aspect of what they call the sort of step one climate where they’re worried about the score they’re going to get on the step one exam for the National Board of Medical Examiners. And they’re also worried about the grades that going to get. And all of that is somewhat tied up in the relationship they have with their faculty members. So how do you kind of protect the faculty members from getting into conflict with the students over that evaluation process?

Robert Shochet: Well, specifically for the learning communities, we have a negotiation with each faculty member that their primary responsibility is to serve as advocates and coaches for their students that they’re assigned to longitudinally. So if they find themselves in a different teaching role, traditional teaching role…

David Sklar: Like in a clinic.

Robert Shochet: Like in a clinic or on a clerkship then they’re asked not to be the one who does a summative evaluation of a student so that they’re there’s any sense of favoritism on the one hand or any kind of disengagement or mistrust from their advising relationship.

David Sklar: Is there individual evaluations though of their experience with the student on the clinic in the clinic?

Robert Shochet: In our learning community, we have them teach the clinical skills course in first year and they write a detailed narrative that’s descriptive of the student’s development during the course. But that’s not used for their summative grade. It’s really used as a learning piece, a learning essay for the students.

David Sklar: You know, one experience I had, I an emergency physician and I had a resident that was, she was very early in her career, but I can remember writing one of—and we write these kind of every shift little evaluations, and I can remember writing one for her and trying to give her some constructive feedback. Her communication skills weren’t very good with a particular patient. And the patient ended up being very angry based upon the interaction that she had with this particular resident. And I remember writing an evaluation and I told her also about that. But the next week, she came into my office and was crying and very upset and told me that no one had ever said anything critical about her skills before. And I tried to explain to her that it was really meant to try to improve her interaction with the patient. How do you deal with those kinds of things? Cause because I can tell you that it was difficult to regain trust with that student after that that experience.

Robert Shochet: Well, I can tell you from a role of an advisor with students, students bring their evaluations to us from their other teachers and we help not only to decode the evaluation because sometimes students think that they’re doing wonderfully, and the evaluation actually doesn’t say that. And on the other hand, when evaluations are fairly critical, we try to understand them together and put them in context and learn from them.

David Sklar: And do you think they able to accept them? Because my experience with medical students is that they’ve gone through life generally, you know, getting a lot of very positive feedback. Most of the time, you know, they get all the you know, the five stars, whatever. And so if you try to give them any critical feedback, there’s often some defensiveness and it’s very difficult to do that in a way that doesn’t impair the relationship that you’re trying to develop with that student or resident. And so how, how do you do that?

Robert Shochet: Well, you know, it’s interesting. In our learning community, in our course first semester, students say about the Molecules that it becomes their safe place to fail. And in many cases, it’s their very first time in school taking the kinds of risks that can lead to failure without feeling a sense of humiliation. Ultimately, I think that students are, from a personal standpoint, still in development as adults when they’re in medical school and becoming more mature adults, being able to accept your vulnerabilities and weaknesses is, you know, it’s part of growing up, I think.

David Sklar: You know, one of the concepts that now is developing in medical education is the concept of entrustment and the idea that as a physician faculty member, I’m going to begin to trust a student or a resident to be able to do things with patients, even though I’m ultimately responsible, that I give them more and more freedom in a sense to be able to do things because I’m trusting them that they can do them well and that they won’t harm the patient. And there’s various ways in which people look at this in terms of, do I need to be in the room with the student or the resident? And if it’s a surgical thing, do I actually watch everything, or do I kind of be at a distance? So how do you feel about this entrustment model? Is this something that you believe is sort of the future as far as our relationship with our students and residents?

Robert Shochet: Yes, absolutely. I do believe in the entrustment model. And you know, I think it’s as challenging for the teacher as it is for the student or trainee to maintain the appropriate level of tension between autonomy and supervision. And but that’s part of the art of teaching, I think.

David Sklar: And one of the issues with entrustment, I know that most of the emphasis has been, can I trust the student or the resident to do certain things independently? But then we also have to have them trust us. And not all faculty are necessarily trustworthy as we know that there are, have been experiences of faculty members being abusive. You know, either saying things, doing things physically, mentally, and many, many of our students feel somewhat mistreated at times. So how do you address that particular problem? Because I think it is a problem, unfortunately, in medical education.

Robert Shochet: You know, I’m a big believer that educational systems are really deliberately developmental for both teachers and for students. And teachers develop over time. I’m a big Parker Palmer fan and the way he would talk about courage in teaching would really, what he really meant was being able to open yourself up as a teacher to be transparent and show your inner workings to the student. And that requires genuineness and honesty and humility. And then, I think the other thing that truly helps build trust is being learner-centered, really being able to understand the learner from their perspective and working in the best interests of the students.

David Sklar: Well, thank you very much, Rob. Sir. I think this has been a very rich conversation and thanks for explaining to all of us about your program. It really sounds wonderful.

Robert Shochet: Thank you very much, David. I’ve enjoyed it.

Narrator: Visit buildingtrust.org to learn more.