The Importance of an Environment Conducive to Education.

T he first national report of findings from the Clinical Learning Environment Review (CLER) Program, published as a supplement to this issue of the Journal of Graduate Medical Education, is a very important initiative recently undertaken by the Accreditation Council for Graduate Medical Education (ACGME). Prior discussions about interventions to improve the quality of graduate medical education (GME) have included important issues, such as standard setting, the balance of service and education, assessment, sites of training, and the content of training. The focus has been primarily on individual program review. More recently, the general quality of the learning environment in which GME takes place has been raised as one of the most important elements in determining the quality of the educational experience. This, of course, is not an entirely new idea, but it has risen in significance in an era of more rapid clinical throughput, increasing intensity of care in all clinical settings and increasing economic pressures on faculty and sponsoring institutions. One of the conclusions of a Macy Report on GME in 2011 was that ‘‘GME must be organized and supported at the institutional and national levels to ensure that residency and fellowship programs are designed and conducted according to sound, broadly endorsed educational practices, within an environment conducive to education.’’ The CLER initiative is the first significant attempt to formally assess that learning environment so it can be improved. The review chose 6 areas of focus to evaluate the environment: patient safety, health care quality (including health care disparities), care transitions, supervision, duty hours/fatigue, and professionalism. The findings should serve as a wake-up call; there is much we can do to improve the learning environment. This is not because we do not have conscientious faculty overseeing training programs; rather, it reflects the intensity and complexity of the environment in which training is occurring. There has generally not been enough effort to make the education mission synchronous with the care mission and with the overall success of the institutions. As a consequence there is the risk (and the reality) that education becomes marginalized and is seen as less relevant to the institution’s mission. The specific findings of the report include both encouraging news and guidance for areas of improvement. In the area of safety, it is encouraging that almost all residents are being exposed to the principles of patient safety. Much more needs to be done, however, to involve them in a meaningful way in the real work of reporting, analyzing, and improving patient safety in their institutions. This is a missed opportunity for learning and a missed opportunity for using the experiences of talented front line health professionals. In the area of health care quality, residents are aware of the quality priorities in their institutions, and most are participating in some projects. They are not, however, as knowledgeable as one would want them to be in the concepts and methodology of quality improvement work. This is another lost opportunity for learning and for institutional improvement. In the related area of improving health care disparities, resident knowledge and involvement is highly variable. Unlike patient safety and quality of care where there are mandated structures, activities, and reporting in all institutions, there are not comparable standards or structures in health disparities. This creates an opportunity for residency programs to take a leadership role in this important area. Care transitions are central to the activities of all residency programs, including both ‘‘internal’’ transitions (handoffs) and transitions from one site of care to another. This is another area where residency programs could (and in some cases they have) provide institutional leadership. This also is an important area for residents to be engaged in interprofessional collaboration and interprofessional learning. Supervision is an area that has improved markedly in recent years, and the residents do report that they feel they are closely supervised. There is still much we have to learn about how to titrate supervision appropriately to allow for the full development of clinical judgment and the ultimate readiness for independent practice. We need to achieve greater understanding of how appropriate supervision can positively contribute to professional development. We DOI: http://dx.doi.org/10.4300/JGME-D-16-00129.1