Thread by @RJmdphilly

1/Tweetorial! Exploring a novel conceptual model of the clinical Learning & Working Environment (LWE) #MedEd
Do you wonder what the Clinical LWE *is*? Given the energy we put into making the LWE better, why is this still such a confusing question?
So - can you define the LWE?

2/In July 2017 an @AAIMOnline collaborative was tasked to recommend strategies for LWE improvement. In early discussions we realized we had no shared mental model of the LWE w/ which to systematically approach improvement. 2yrs later we are publishing a conceptual model.

3/Let’s start w/ the model & then explain its development:The LWE is the nesting of personal, relational, curricular, & structural domains as traversed by multiple learners, centered on the needs of individual or populations of patients, & influenced by the sociocultural context

4/Discussing the LWE resembles the fable of the Elephant & the blind men. In this story, each man has a different mental image of the animal in front of him, based on his own sensory experience. There is no shared understanding of how the parts contribute to the whole.

5/Improvement is difficult in a situation like this. Systems are defined by interactions, not by parts. Russel Ackoff uses fixing a car as an analogy - you can’t just put a Mercedes engine in a Rav4 because it’s a better engine…it isn’t the right piece for the specific system.

6/#SystemsThinking teaches that all elements of a system are interconnected, & the whole = more than the sum of the parts. A living system is a great example (esp for health profs). A whole cow can do more than each part could do if removed from the system called “cow.”

7/Systems also have boundaries. Our cow is supported/influenced by the surrounding farm (ie fed, sheltered), but these elements are external to the living system. They are not a part of the cow. A LWE without a boundary would be overwhelming.

8/If the clinical LWE is a system, what are the interconnected elements? Educational theorists have constructed models of other types of learning environments. One of the most influential was published by Rudolf Moos in 1973. Moos defined three domains:

9/Could this be it?!? Why not use Moo’s model for the modern Clinical LWE? Well, we still had questions:
-Where are patients?
-Do learners' (#IPE, #UME, #GME, #CME) needs differ?
-Where is the boundary?
-How do Moos’s domains translate to a #clinical setting?
-How is model used?

10/Let's review:
The LWE is the nesting of personal, relational, curricular, & structural domains as traversed by multiple learners, centered on the needs of individual or populations of patients, & influenced by the sociocultural context. bit.ly/lweajmpre

11/In our model, the patient is the axis around which the LWE rotates. Without the patient there is no clinical LWE. We learn in service to our patients and their communities. There is superb writing on this topic in multiple contexts (incl #hiddencurriculum #communityengagement)

12/The domains were derived from Moos & LWE definitions/statements in the lit. LWE factors may overlap domains. It is more important to consider interactions between the 4 domains than perfectly map a factor to the “right” one. For example, what domain contains “assessment”?

13/The #personal domain is the lens through which a learner experiences the LWE & the set of intrinsic qualities the learner adds to the LWE. Includes self identification, and the attitudes, biases, skills, experiences & vulnerabilities possessed.
Which is NOT personal?

14/The relational domain incl the ways individuals/groups interact, & the impact of these interactions on individuals & the system. Includes LWE culture & unique relationships betwn peers, staff, patients, supervisors, mentors, educators, & family/friends
Which is NOT relational?

15/The curricular domain incl factors relating to formal & informal #MedEd experiences, consisting of overt or implied learning objectives & a process of assessment/feedback. The hidden curric is part of this domain though overlaps signif with the others.
Which is NOT curricular?

16/The structural domain is the organizational, programmatic, & physical context w/i which #clinical learning occurs. Components may be specific to the local LWE (ie workspaces), or pertain to the implementation of external requirements (ie work hours).
Which is NOT structural?

17/While the domains may look static, their weight shifts depending on learner. This flexibility accommodates learners across professions & stages of the #MedEd continuum. Example: UME may need more formal curricula, & GME may need structures allowing for #SelfDirectedLearning.

18/Learners are both influenced by the LWE, and exert influence upon it. They do this through importing their own cultural contexts, changing relationships, & leaving curricular/structural artifacts. A related @macyfoundation publication offers this broad definition of “Learner:”

19/The broader sociocultural context is *outside* the LWE. This explicitly acknowledges the sociocultural context as the atmosphere that shapes & supports the LWE, while allowing educators to consider some factors beyond their immediate locus of control.

20/Sociocultural changes necessitate adaptation w/i 1 or more LWE domains. Educators/learners may still engage in advocacy/activism to change the factors outside the boundary of the LWE. Ex: inc prevalence of mumps 2/2 dec vaccination rates leads to changes in curricular content.

21/This conceptual model was designed to #empower front line clinicians & educators to improve their local #LWE through creating shared mental models & applying #systemsthinking. Three use-cases were designed to aid in this process. These are #Reactive, #Holistic, & #Proactive.

22/See the *next* @AAimOnline #LWE Optimization Collaborative #MedEd #tweetorial to learn more about the 3 use-cases. Until then, we hope you’ll start to practice analyzing your LWE through the lens of this model. Can you define the LWE now? bit.ly/lweajmpre

Missed @kathywalsh08 in tagging this pic! Sorry Kathy!!