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Improving Trust Between Learners and Teachers in Medicine

Abruzzo, Dane; Sklar, David P., MD; McMahon, Graham T., MD

doi: 10.1097/ACM.0000000000002514
From the Editor

Third-year medical student, University of New Mexico School of Medicine, Albuquerque, New Mexico.

Editor-in-chief, Academic Medicine.

President and chief executive officer, Accreditation Council for Continuing Medical Education, Chicago, Illinois.

Editor’s Note: The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members.

Trust forms the foundation of the relationship between learner and teacher, providing the conditions for the transfer of information and the development of expertise.1 In medical education the relationship often requires an assessment of risk and vulnerability, particularly in the clinical environment, where patients are exposed to the activities of learners. Damodaran et al2 have defined trust in medical education as

a judgment by the trustor, requiring the acceptance of resultant vulnerability and risk, that the trustee (individual or organization) has the competence, willingness, integrity and capacity (i.e., trustworthiness) to perform a specified task under particular conditions.

Without trust between a teacher and a learner, the learner may reject or resist the teacher’s new information and modeling of professional behaviors, and the teacher may be unlikely to share patient care responsibilities and information and provide mentorship.

Caldwell and Clapham3 have described factors common to trust decisions made by individuals and organizations: ability (skills, competence, expertise), benevolence (desire to do good, responsibility to inform), and integrity (character, fairness, credibility). However, the current learning environment creates challenges to building trust between learner and teacher. Teachers are increasingly being expected to make entrustment decisions about their learners’ ability to take on risk and responsibility, yet teachers increasingly do not have control of the learning environment or have longitudinal relationships with learners. Development of new technology, introduction of educational innovations, and changes in the learning environment can also challenge the development of trust between learners and teachers. The near-instantaneous availability of information on smartphones and computers tests the teachers’ current knowledge and expertise and can erode trust through challenges to teachers’ credibility. In the preclinical environment, learning models such as problem-based learning and team-based learning have changed the relationship of teachers and learners from one where the teacher transmits information and controls the classroom to a group process where learners and teachers work together to facilitate learning. In the clinical environment, organizational and financial pressures can reduce the availability of resources, such as social workers or adequate numbers of nurses, that are needed to assure high-quality health care services, which increases risk for teachers, learners, and patients.

In the following vignette, we illustrate elements of trust between learner and teacher in a problem-based learning session and show some of the challenges that can threaten trust. We then consider trust from the perspectives of the learner and the teacher and discuss the influences of the learning environment on both. We conclude with suggestions for improving trust between teachers and learners in our current educational system.

Gordon, a first-year student, swings open the door to the conference room in the pediatric neurology unit that houses his late-morning neuroscience small-group session. His facilitator, Dr. Brennan, a clinical neurologist, sits with six of Gordon’s classmates in the familiar spots they have occupied each Wednesday over the last five weeks. Gordon opens his laptop and pulls up the case for the day, which is about new-onset seizures in a nine-month-old infant.

During the previous week, Gordon was supposed to have investigated metabolic causes of seizures, and had skimmed a Wikipedia page about hyponatremia, hypocalcemia, and hypomagnesemia. During the evening before the session, he had intended to research the pathophysiology behind why these electrolyte disorders caused seizures, but the time he had set aside to do that was cut short by a plumbing disaster in his house. Before he knew it, the hour was late and he had to get some sleep, fearing that otherwise he would doze off in class the coming day.

Gordon’s anxiety had begun building that day when he was rushing to the conference room. He knew that Dr. Brennan had a reputation for being demanding and sometimes degrading, and that there had apparently been minimal efforts from the school to correct her behavior despite formal complaints. She would be upset if he left out the underlying pathophysiology, but he hoped he could move the conversation to the clinical manifestations of electrolyte disorders, prompting Dr. Brennan to share her experience with the class. But as Gordon began to present his information to the group, Dr. Brennan’s phone buzzed and she left the room. When she returned, she asked Gordon to repeat his presentation. Gordon became flustered. The impatience from Dr. Brennan worsened his anxiety, and he confused the details of hyponatremia with those of hypocalcemia. Dr. Brennan shook her head and said: “How can your team trust you when you mix up the basic facts? You are sloppy, and I don’t like working with sloppy people. Now you’ve confused your classmates. There are always going to be distractions in medicine. If this were a real patient and you mixed this up, you might have killed this baby. This is serious business.”

Gordon apologized to the group, and Dr. Brennan ran off to see a patient waiting for her in the emergency department, telling the group to review metabolic causes of seizures together while she was gone. Gordon’s classmates tried to console him about his error, but he felt ashamed and a total failure.

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Trust as Viewed by the Learner

Learning requires the opportunity to explore problems, adjust, and improve based on feedback. Feedback is most valuable when it comes from a trusted source, such as an expert teacher, in an environment in which learners feel safe to expose their vulnerability and identify gaps in their knowledge or skills. To be vulnerable, learners need to feel that exposure of their knowledge gaps will help them improve rather than result in a personal judgment or criticism that could be demoralizing and might also affect their course assessments or progress through their program. Mann et al4 have described the tension within learners when they want feedback but fear that feedback would be negative or critical. Learners want to ask questions and learn but do not want to appear incompetent. They may also fear that unfavorable feedback will find its way into formal assessment documentation. Criticism can sometimes result in shame, as shown in the vignette presented earlier, especially when feedback focuses on personal deficiencies and characteristics rather than behaviors. Shame can adversely affect future learning and lead to depressive symptoms.5 This may be particularly of concern for those students at risk for developing depression. In this issue, Dyrbye et al6 describe an index for identifying those students at highest risk for developing depressive symptoms. Such an index may be helpful in conjunction with addressing the learning environment and the trust relationships between learners and teachers.

Ultimately, both the teacher and learner must recognize that the goal of a trusting relationship between them is to foster the development of the learner’s competence in giving medical care to patients. The learner, therefore, must trust that the teacher will guarantee the best interest of patients while simultaneously offering opportunities for the learner to engage at an appropriate level in directing real patient care. Such trust is not instantly formed in a single session or day, but over the course of a longitudinal learner–teacher relationship. Ever-shortening time with a teacher limits opportunities for the development of trust, and limits how giving meaningful feedback based on longitudinal observation can be leveraged to consolidate trust.

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Trust as Viewed by the Teacher

Medical educators are often volunteers, motivated by the opportunity to share their expertise and see a learner or group of learners grow. Just as learners must trust their teachers, so, too, do teachers need to realize that they usually can trust their learners to engage and participate and exhibit appropriate professional behaviors and respect.

The teacher–learner relationship is intrinsically unbalanced, with the teacher typically having more knowledge, experience, and power than the learner. The power imbalance is reinforced if the teacher is also a contributor to an assessment system; this may create additional vulnerability for the learner. Negotiating the power imbalance and fostering transparency regarding whether information about the learner’s performance will be shared with the assessment system is critical for the relationship to develop into one of trust and productive learning. Because of the power imbalance, boundaries between teachers and learners should maintain professional distance, and social relationships should be avoided during the time of actual supervision.

The approach, or perspective, chosen by the teacher for the learning activities should be the one that will best help to develop trust. Pratt et al7 have described five perspectives, or lenses, through which teachers view their work as teachers: transmission, developmental, apprenticeship, nurturing, and social reform. Each perspective has its key beliefs, responsibilities, strategies, and difficulties, and overcoming the difficulties and meeting the expected responsibilities will build trust.

With the transmission perspective as an example, the key beliefs are that the teacher should present the content accurately and efficiently, in a manageable amount. If this occurs and the learner is motivated, the knowledge can be transferred to the learner. Trust will be based on the teacher being prepared, organized, and using objective and fair assessment processes.

In the developmental perspective, good teachers adapt their knowledge to the learners’ abilities with reasoning, problem solving, and actions that foster each learner’s preferred style of learning. Trust is based on participating in shared goals, creatively posing problems, guiding questions, and involving learners in the assessment process.

If we think about how the developmental perspective operates in the vignette, we see that learning occurs as the learners seek information to address questions raised by the case, and build their knowledge through the process of understanding the problem. The teacher in this case is a facilitator of the group process rather than an expert who will transmit knowledge. In the developmental perspective, trust is created when the process is followed and the teacher clearly guides the group’s learning journey by being present, attentive, and active. Because learners are directing their learning, the sort of criticism of a learner’s errors that occurred in the vignette disrupts the core principles of the group learning process.

In the apprenticeship perspective, typically used in the clinical environment, teaching and learning occur in the process of caring for actual patients. In that perspective, trust develops as the teacher demonstrates competence in patient care and gradually involves the learner in care activities while monitoring the learner and fostering improvement in his or her performance.

In the nurturing and social reform perspectives, which are not commonly used in medical education, trust would require an understanding of goals such as personal growth or engagement in community health and adherence to the chosen learning perspective. Development of trust will vary depending on which perspective is being used and how the teacher’s and learner’s activities conform to the expectations of that perspective.

No matter which perspective is being used, a number of factors foster trust between teachers and medical learners. For example, in the clinical environment, Hauer et al8 describe several factors that contribute to trust between a clinical supervisor and a medical trainee: the supervisor’s expertise, experience, attitude, and sense of accountability; the trainee’s competence, attitude, and self-confidence; the relationship between supervisor and trainee shown by interpersonal dynamics, concordance, and amount of contact; the context, including workplace opportunities and resources; and systems issues such as workload, workplace culture, task complexity, appropriateness, and risk.

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Trust in the Context of the Environment and Team

While trust is a fundamental feature of the learner–teacher relationship, it occurs in an environment that can either facilitate or limit it. Classroom space, lighting, books, computers, other educational materials, and information support influence the relationship between teacher and learner, particularly if online and distance learning are integrated into the classroom activities.

In the clinical environment, a teacher may generally trust a resident to perform a procedure such as intubation, but in a specific context, such as a patient with a facial burn, the teacher may decide to take over the performance of the procedure because of the unique challenges for patient safety. Patients’ attitudes and choices may also alter the context for learning. Patients should have the ability to decide about the involvement of learners in their care, and teachers should select patients for learners based on learning goals, risk, and the level of expertise of the learner.

The presence of other health professionals—such as nurses, pharmacists, social workers, psychologists, or physician assistants—can also alter the learning environment, providing the opportunity for the learner to understand the functions of teams and how they can add information and skills to the care delivery system. Many skills for learners may be better taught by nonphysician health professionals, and an environment that integrates interprofessional care offers opportunities to understand teams and team-based care, which is increasingly becoming an element of hospital and ambulatory practice.

At times, the clinical environment can present complications that affect safe practice— such as lack of critical equipment, inadequate nursing support, or nonavailability of imaging—that raise risks to such a dangerous level that entrustment is impossible. While every learning environment includes unexpected problems that impair learning experiences, in some learning environments the disruptions are frequent, severe, and predictable, and learners should not be exposed to them. Commitment to a healthy work environment is part of creating trust between learners and teachers. Shanafelt et al9 in this issue describe how institutions can create programs that emphasize learner and faculty well-being with leadership from an institutional wellness officer. We believe that such programs can highlight the interplay between employee wellness, trust, and learning. Koh et al10 describe current efforts on the part of the Accreditation Council for Graduate Medical Education to improve the learning environment through the accreditation process; they report mixed results.

As much as trust is key to interpersonal relationships, trust is also an organizational attribute.3 Trust is fragile and subject to easy disruption if the stated values of the organization are not matched by its behavior or the attitudes of its leaders. Organizations and their leaders must exhibit behaviors that reflect their espoused values, and also be seen to act decisively when those values are undermined. In the vignette, the continued use of a teacher who had been reported to be disruptive can be seen as a mismatch of values and behavior. Medical professionals share responsibility for fostering an environment and atmosphere within their organizations that reflect institutional values, and for acting appropriately to protect those values. Recently, Henderson et al11 described a disconnect between a medical school’s values of equitable care and a hospital’s decisions to limit care for underserved patients covered by Medicaid. This decision presented a conflict between what was being taught to learners and what was actually done in practice. In such a situation, some learners would likely experience a loss of trust in their teachers and the institution, and some teachers would lose trust in their institution and realize that the trust of their students was being eroded.

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Suggestions

Below, we make several suggestions for improving trust between learners and teachers.

  • Because feedback is critical for learning but can be perceived as harmful if negative information becomes integrated into a student assessment, we suggest separation of assessment for learning (formative) and assessment of learning (summative).
  • Longitudinal relationships between learners and teachers can facilitate the development of trust that demonstrates the commitment of the teacher to the learner’s education and professional development.
  • Because there are many ways in which teachers participate in the learning process, they need to recognize which teaching perspective they are using (e.g., transmission, developmental, apprentice) and how to build trust with their learners by following the principles of that perspective.
  • Critiques of a learner’s performance should identify performance issues and not personal attributes of learners, and should avoid shaming.
  • Boundaries between teachers and learners should maintain professional distance, and social relationships should be avoided during the time of active supervision.
  • Institutional leaders can help promote trust between learners and teachers by improving the institutional learning environment. This can occur through supporting wellness programs; addressing and remediating any disruptive or disrespectful behaviors of teachers, staff, or learners; and making sure that organizational policies align with the values that are taught to learners.

Trust between learners and teachers is the foundation of successful health professions education. By becoming mindful of the importance of trust and fostering it by supporting relationships between teachers and learners while ensuring a nurturing learning environment, we in academic medicine can create experiences for both learners and teachers that will inspire professional and personal development and ensure patient safety. In doing so, we can also build trust between health professionals and the public they serve.

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Acknowledgments:

Many of the ideas presented in this editorial were inspired by discussions that occurred at the American Board of Internal Medicine Foundation (ABIMF) meeting in Albuquerque, New Mexico, July 28–31, 2018. The authors wish to thank those individuals who contributed to the discussions: Darrell Kirch, MD, Holly Humphrey, MD, and Marianne Green, MD, as well as the organizers of the ABIMF meeting.

Dane Abruzzo

Third-year medical student, University of New Mexico School of Medicine, Albuquerque, New Mexico.

David P. Sklar, MD

Editor-in-chief, Academic Medicine.

Graham T. McMahon, MD

President and chief executive officer, Accreditation Council for Continuing Medical Education, Chicago, Illinois.

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