Undesirable features of the medical learning environment: a narrative review of the literature.

The objective of this narrative review of the literature is to draw attention to four undesirable features of the medical learning environment (MLE). First, students' fears of personal inadequacy and making errors are enhanced rather than alleviated by the hidden curriculum of the clinical teaching setting; second, the MLE projects a denial of uncertainty, although to a lesser degree than in the past; third, many students feel publicly belittled and subject to other forms of abuse; and fourth, the MLE fails in overcoming students' prejudice against mental illness and reluctance to seek help when emotionally distressed. The variability of students' appreciation of the MLE across medical schools, as well as across clinical departments within medical schools, suggests that the unwanted aspects of the MLE are modifiable. Indeed, there have been calls to promote a "nurturing" MLE, in which medical students are treated as junior colleagues. It stands to reason that faculty cannot humiliate medical students and still expect them to respect patients, just as it is impossible to ignore students' distress, and still teach them to empathize with patients. Hopefully, an egalitarian attitude to students will make them also realize that they are not alone in their fears, and that their instructors share their doubts. Therefore, a major challenge of contemporary medical education is to advance a clinical MLE, where errors and uncertainties are acknowledged rather than denied, and trainees are trusted and supported, rather than judged and, occasionally, derided.