Psychological Safety - Why "Asheville" Works

Over the last few months, I have reflected at length about my experience as a medical student in the "integrated clerkship" or "Asheville" model. For those of you new to this concept, the idea is that medical students in their 3rd year learn the basics of clinical medicine in a radically different format from the norm. In the "traditional" model, student-doctors rotate through different fields of medicine in "blocks." For example, they may spend 8 full weeks in Internal Medicine, 8 weeks in Surgery, 4 weeks in Neurology, 4 weeks in Family Medicine, etc. Students get a taste of each of these core clerkships to help them decide which specialty they will pursue. In this curriculum, students often work with many different "attending" physicians (docs at the top of the hierarchy), fellows, residents, interns, and other medical students as they rotate through their clerkships.

The Asheville model transforms the way medicine is taught to budding clinicians. Instead of block scheduling, students do all their clerkships at the same time. They generally work in the outpatient (out-of-hospital) setting, one-on-one with the same attending physicians for an entire year. This may mean working half-days in each clinic; for example, Monday mornings in Family Medicine, Monday afternoons in Neurology, Tuesday mornings in Pediatrics, etc. Space is blocked off to see certain "longitudinal" patients in the hospital and in other clinics. These patients are seen many times throughout the year, and provide an opportunity for the student to become truly invested in the health care of other human beings over an entire year. Students generally begin their year with a few weeks in the hospital in order to garner "inpatient" experience.

Some believe this model of teaching offers a better environment in which to learn, because it humanizes medicine with intimate patient contact. I certainly felt this was the case. My experience was very different from that of my colleagues in the traditional model. Instead of me watching the intern watch the residents watch the fellows watch the attending in action, I was partnered with my attending physician, not as an equal, but as someone who was expected to perform in tandem at a high level. Such a close relationship can be daunting at first, but over time the sense of team is palpable. Attending - Student - Patient. Published data now exists (as well as yet-to-be-published data) suggesting that this type of learning is extremely positive for both students and faculty.

But, why?

I have often pondered this question. Why did I feel so invested in my patients, and why did I feel like I was really part of a team? How did these close relationships with attendings affect how I learned? I am starting to find some answers whilst studying leadership. One idea that has caught my attention is Dr. Amy Edmonson's concept of "psychological safety," and how it affects learning environments in teams.

Roughly, psychological safety "describes individuals' perceptions regarding the consequences of interpersonal risks in their work environment." Team members often worry they will be thought of as ignorant or incompetent if they speak up or make mistakes (e.g., the medical student who asks a "dumb" question may get a lower grade). In a psychologically safe environment, however, asking for help is encouraged, and reporting mistakes is a way to learn, not a route to punishment. Here, mistakes lead to learning and speaking up leads to innovation. Institutions that have psychologically safe environments succeed. In hospitals, this can mean the difference between a nurse who thinks a medication dose is inappropriate, but administers it anyway for fear of being wrong, and one who double-checks with the physician to make sure the dose is correct. Medical errors are unfortunately all too common, and patients often find themselves at the mercy of these mistakes.

Dr. Edmonson breaks down work environments into four different "zones," each with different characteristics based on levels of psychological safety and accountability.

• Low Psychological Safety + Low Accountability = Apathy Zone
• High Psychological Safety + Low Accountability = Comfort Zone
• Low Psychological Safety + High Accountability = Anxiety Zone
• High Psychological Safety + High Accountability = Learning Zone

The second I saw this table in her book, Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy, a light bulb went on in my head. Third year medical students fit very well into these categories. Most medical students would undoubtedly perceive their environment as high accountability. Thus, they would find themselves either in the Anxiety Zone or Learning Zone (or some may find themselves in the Apathy Zone during a particularly awful rotation), depending upon whether their environment is one of high or low psychological safety. To maximize clinical education, one would hope that students find themselves in the Learning Zone environment with high psychological safety, as this should be the most effective teaching environment.

As a student of the integrated model, I cannot speak too much to traditional learning and its level of psychological safety; however, the hierarchical structure of the traditional medical team model has had some difficulties in this area (and its shortcomings are well-documented). I can, though, attest to why the integrated model helps students find themselves in the Learning Zone. I think there are three reasons why this model promotes a psychologically safe environment: 1) medical students work with the same attending throughout their clerkship, 2) students work with that attending for an entire year instead of just a few weeks, and 3) students often find themselves one-on-one with these attendings, providing numerous opportunities to build strong relationships and a sense of "team." This relationship for some may start out in Anxiety Zone, but it often quickly moves to a psychologically safe environment as the two parties become more comfortable with one another.

As an example, one of my favorite clerkships last year was Family Medicine. It was a clerkship I enjoyed, and in which I excelled. Every Monday morning I worked in this clinic from 8am to 12pm, first seeing a patient by myself, then again in conjunction with my attending. Right off the bat, every mistake became a learning opportunity or a "teaching point." Expectations were clear. I was a third year medical student so mistakes were anticipated. But, I was expected to learn from my mistakes and get better (high accountability). From a grading perspective, I didn't worry about "messing up." If I was unsure whether I heard a heart murmur or "crackles" in the lungs, I told my attending. I knew I would have many opportunities during the year to listen to hearts, and my grade wouldn't be affected by asking questions. I wasn't worried about being seen as "ignorant" or "incompetent" (high psychological safety). Looking back, I spent all my time in the Learning Zone.

I suspect there are many reasons why the integrated clerkship model is such a successful learning experience, and I don't believe creating an environment of psychological safety is a panacea for improving medical education across the board. I do have a sneaky suspicion, though, that fostering a Learning Zone environment would go a very long way toward that goal. I hope to study this concept further, both in medical education and in Surgery. I would be interested in your thoughts and comments.

References

• Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med. 2007;82(4):397-404.
• Edmonson, Amy. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. Jossey-Bass, 2012.