Training in medicine has long been thought of as a tough process, but the issue of creating a psychologically safe environment for young doctors is now being highlighted as an important way of providing an improved learning environment, which will ultimately lead to better patient care. And cardiology is one field that needs to work harder on this.
“We all remember attendings who made our training experience memorable, who made us excited to come to work and learn, and who inspired us to become better,” Vivek Kulkarni, MD, writes in a recent commentary. “Unfortunately, we also all remember the learning environments where we were terrified, where thriving took a backseat to surviving, and where learning was an afterthought.”
Writing in an article in JACC, published online on October 31, 2023, Kulkarni asks the question: “Why are some learning environments better than others, and what can we do to improve the learning environment for our trainees?”
Kulkarni, director of the training program for cardiology fellows at Cooper University Hospital, Camden, New Jersey, says cardiology is a specialty that hasn’t paid much attention to the idea of psychological safety in training.
“There may be some people in some institutions that do pay attention to this but as wider field we could do better.”
Kulkarni explains that psychological safety is the comfort to engage with others genuinely, with honesty and without fear.
It has been defined as a “willingness to take interpersonal risks at work, whether to admit error, ask a question, seek help, or simply say ‘I don’t know,'” or as “the perception that a working environment is safe for team members to express a concern, ask a question, or acknowledge a mistake without fear of humiliation, retaliation, blame, or being ignored.”
“In the medical environment we usually work in teams: older doctors, younger doctors, nurses, other staff,” Kulkarni told theheart.org | Medscape Cardiology. “A psychologically safe environment would be one where a trainee feels comfortable so that they can ask a question about something that they don’t understand. That comfort comes from the idea that it is okay to get something wrong or to not know something and to ask for help.”
“The flip side of that is an environment in which people are so afraid to make a mistake out of fear of retribution or punishment that they don’t take risks, or they don’t openly acknowledge when they might need help with something,” he said. “That would be a psychologically unsafe environment.”
What exactly this looks like varies in different environments and culture of the group, he notes, “but in general, you can tell if you are part of a psychologically safe environment because you are excited to come to work and feel comfortable at work.”
Kulkarni adds that a growing body of literature now shows that psychological safety is critical for optimal learning but that cardiovascular fellowship training poses unique barriers to psychological safety.
‘Arrogant, Unkind, and Unwelcoming’
First, he says that the “high-stakes” nature of cardiology, in which decisions often must be made quickly and can have life-or-death consequences, can create fear about making mistakes and that some trainees may be so afraid that they cannot speak up and ask for help when struggling or cannot incorporate feedback in real time.
Second, in medicine at large, there is a stereotype that cardiologists can be “arrogant, unkind, and unwelcoming,” which may discourage new fellows from honest interaction.
Third, cardiology involves many different technical skills that fellows have little to no previous experience with; this may contribute to a perceived sense of being judged when making mistakes or asking for help.
Finally, demographics may be a factor, with only 1 in 8 cardiologists in the United States being women and only 7.5% of cardiologists being from traditionally underrepresented racial and ethnic minority groups, which Kulkarni says may lead to a lack of psychological safety due to “bias, microaggressions, or even just a lack of mentors of similar backgrounds.”
But he believes that the cardiology training culture is improving.
“I think it is getting better. Even the fact that I can publish this article is a positive sign. I think there’s an audience for this type of thing now.”
He believes that part of the reason for this is the availability of research and evidence showing there are better ways to teach than the old traditional approaches.
He notes that some teaching physicians receive training on how to teach and some don’t, and this is an area that could be improved.
“I think the knowledge of how to produce psychologically safe environments is already there,” he said. “It just has to be standardized and publicized. That would make the learning environment better.”
“Nothing about this is groundbreaking,” he adds. “We all know psychologically unsafe environments exist. The novelty is just that it is now starting to be discussed. It’s one of those things that we can likely improve the ways our trainees learn and the kind of doctors we produce just by thinking a little bit more carefully about the way we interact with each other.”
Kulkarni says trainees often drop out because they have had a negative experience of feeling psychologically unsafe. “They may drop out of medicine all together or they may choose to pursue a career in a different part of medicine, where they perceive a more psychologically safe environment.”
He also suggests that this issue can affect patient care.
“If the medical team does not provide a psychologically safe environment for trainees, it is very likely that that team is not operating as effectively as it could, and it is very likely that patients being taken care of by that team may have missed opportunities for better care,” he concludes. Examples could include trainees recognizing errors and bringing things that might not be right to the attention of their superiors. “That is something that requires some degree of psychological safety.”
Action for Improvement
Kulkarni suggests several strategies to promote psychological safety in cardiology training.
As a first step, institutions should investigate the culture of learning within their fellowship programs and gather feedback from anonymous surveys of fellows. They can then implement policies to address gaps.
He notes that at Cooper University Hospital, standardized documents have been created that explicitly outline policies for attendings on teaching services, which establish expectations for all team members, encourage fellows to ask for help, set guidelines for feedback conversations with fellows, and delineate situations when calling the attending is expected.
Kulkarni also suggests that cardiologists involved in teaching fellows can try several strategies to promote psychological safety. These include setting clear expectations on their tasks and graded autonomy, inviting participation in decisions, acknowledging that gaps in knowledge are not a personal failure but rather a normal part of the growth process, encouraging fellows to seek help when they need it, fostering collegial relationships with fellows, acknowledging your own uncertainty in difficult situations, checking in about emotions after challenging situations, and seeking feedback on your own performance.
He added that changes on a larger scale are also needed, such as training for cardiology program directors including more on this issue as well as developing best practices.
“If we as a community could come together and agree on the things needed to create a psychologically safe environment for training, that would be a big improvement.”
Addressing the Challenges of Different Generations
In a response to Kulkarni’s article, Margo Vassar, MD, The Queen’s Medical Center, Honolulu, Hawaii, and Sandra Lewis, MD, Legacy Health System, Portland, Oregon, make the case that to succeed in providing psychological safety, the cardiovascular community also needs to address intergenerational cultural challenges.
“Twenty years ago, to have raised the idea of psychological safety in any phase of training would likely have been met with intergenerational pushback and complete disregard,” they say, adding that: “Asking senior Baby Boomer cardiologists to develop skills to implement psychological safety, with just a list of action items, to suddenly create safe environments, belies the challenges inherent in intergenerational understanding and collaboration.”
To theheart.org | Medscape Cardiology, Lewis elaborated: “Many cardiology training program directors are Baby Boomers, but there is a whole new group of younger people moving in, and the way they deal with things and communicate is quite different.”
Lewis gave an example of when she was in training the attending was the “be all and end all,” and it was not expected that fellows would ask questions. “I think there is more communication now and a willingness to take risks and ask questions.”
But she says because everyone is so busy now, building relationships within a team can be difficult.
“We don’t have the doctors’ lounge anymore. We don’t sit and have lunch together. Computers are taking over now, no one actually talks to each other anymore,” she says.
“We need to try to get to know each other and become colleagues. It’s easy when you don’t know somebody to be abrupt or brusque; it’s harder when you’re friends.”
She notes that the Mayo Clinic is one institution that is doing a lot of work on this, arranging for groups of doctors to go out for dinner together to get to know each other.
“This bringing people together socially happens in a lot of workplaces, and it can happen in medicine.”
Lewis, who has some leadership positions at the American College of Cardiology (ACC), says the organization is focusing on “intergenerational opportunities and challenges” to help improve psychological safety for trainees.
Noting that a recent survey of medical residents found that “contemporary residents were more likely than their predecessors to agree with negative perceptions of cardiology,” Lewis says the ACC is also reaching out to medical residents who may think that cardiology is an unwelcoming environment to enter and to minority groups of medical residents such as women and ethnic minorities to try and attract them to become cardiology fellows.
“If fellows find in hard to speak up because they are in this hierarchical learning situation, that can be even more difficult if you feel you’re in in a minority group.”
“We need to create a culture of colleagues rather than perpetuating a culture of us and them, to provide a safe and thriving cardiovascular community,” she adds.
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