News and Commentary Practices that Promote Inclusion in the Clinical Learning Environment

Headshot of David Diller in a suit and tie

When medical students leave the classroom and transition to the clinical phase of their training, they are entering a learning environment that is complex, heterogenous, and siloed. Students will learn through experiential practice in a wide array of healthcare-based settings ranging from the operating room to the pediatrician’s office, interacting with a multitude of clinical instructors during these formative educational years. Different from the classroom-based instruction students have long been accustomed to, this type of learning environment can be viewed as on-the-job training, and the pace of learning is fast. Each specialty that students rotate through is steeped in its own culture, and there is a longstanding hierarchy in the team-based delivery of patient care, with medical students at the bottom.

The clinical learning environment can be intimidating, as students are paired with physicians who have years, if not decades, more experience, but the growth that a student experiences during this immersive phase of their training is unparalleled. To support student growth, providing a safe and inclusive clinical learning environment is paramount. This is especially true for students who identify as underrepresented in medicine (URiM) and/or LBGBTQ. Numerous studies have demonstrated that these students disproportionately experience higher rates of exclusionary practices like discrimination, microaggressions, racism, and bias, leading to worsened academic outcomes and individual wellness.

So, how can we promote an inclusive clinical learning environment for our medical students? First, we must continue to work towards building a diverse physician workforce that is not only representative of the patients we serve, but of the students we teach. The sense of belonging that a student feels when they see their own individual racial, cultural, or socioeconomic identity represented in the faculty they work with cannot be understated. Additionally, avoiding and condoning exclusionary practices like discrimination, microaggressions, racism, and bias both on an organizational and individual level is vital.

Based on interviews of senior medical students, residents, and faculty at the Keck School of Medicine of the University of Southern California, a clear next step in promoting inclusiveness in the clinical learning environment involves providing compassionate patient care. Students, especially those from URiM backgrounds, relate strongly to the minoritized patients they encounter in the clinical learning environment. Students internalize the attitudes that are expressed about these patients by other members of the healthcare team, and the delivery of compassionate, trauma-informed patient care nurtures their sense of belonging.

Another practice that promotes inclusion is through deliberate education. Deliberate education recognizes that being a learner is central to a medical student’s professional identity. Faculty who deliberately engage with students and provide formalized instruction and entrust them with specific patient care responsibilities foster a sense of respect from their students, which in turn promotes a sense of belonging.

But there is more to inclusion than promoting a student’s sense of belonging. Inclusion is defined as a collection of organizational practices and cultural norms that promote a sense of belonging, while simultaneously recognizing and valuing individual uniqueness. It is in the latter half of this definition where we identified that to promote a deeper sense of inclusion, faculty must use an individualized, learner-centered approach to clinical education.

A learner-centered approach protects and celebrates a student’s individual identity. The approach begins with a faculty member’s commitment to learning about a student as a unique individual, and then targets select educational experiences that foster the student’s engagement and promotion of their emerging professional identity as a junior physician. A learner-centered approach recognizes the unique circumstances that URiM students face in the clinical learning environment, and tailors the learning experience to support their growth.

This individualized approach not only requires a genuine and deliberate effort from faculty, but it requires trust from students. Students who have previously experienced bias and mistreatment will be justifiably apprehensive to share aspects of their authentic individuality. Further, as long as performative assessment in the clinical learning environment is used as a metric for career selection through the residency Match process, students will be reluctant to share certain elements of their individuality to instructors who also serve as assessors. Institutional and organizational leaders should further investigate best practices to mitigate the undue effects that assessment may have on promoting an inclusive learning environment.

Finally, both the medical school and the healthcare system must pursue efforts to help shift organizational culture regarding inclusion in the clinical learning environment. Protecting the educational mission within academic medicine and ensuring that learners have appropriate space, time, and resources can promote their sense of inclusion within the healthcare team.

Promoting inclusion in the clinical learning environment requires a deliberate and individualized approach from both faculty and institutional leaders, and it starts by building trust, respecting, and authentically listening to our medical students.

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