Resident physicians should not be expected to have every answer. They should be allowed to ask the tough questions. And, when necessary, residents should feel comfortable speaking up.

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When those ideals aren’t actually followed on the wards, a resident’s psychological safety can be affected.

“No one wants to look ignorant, incompetent, intrusive or negative,” said John Byrne, DO, a professor of medicine at Loma Linda University. “So, it’s easy to manage that. You just don’t ask questions, don’t admit mistakes, don’t offer ideas and don’t critique the status quo.”

Dr. Byrne and colleague Lawrence K. Loo, MD, presented on the importance of psychological safety in graduate medical education during the ChangeMedEd® 2021 conference.

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Psychological safety is the feeling that sharing one’s concerns and mistakes will not result in embarrassment, shame or retribution. It is vital that it exist in residency training.

“In a psychologically safe environment, team members feel safe taking interpersonal risk,” Dr. Byrne said. “That means speaking up, asking for feedback, are interpersonal risks. They risk us feeling ridiculed or embarrassed.”

When people are willing to take those risks, they work collaboratively to address errors, engage in innovations and improve the environment around them. Still, in hierarchical environments such as residency programs, impression management—a process in which people attempt to influence the perceptions of others—causes those who feel lower on the pecking order to question less.

Dr. Byrne presented research from his work with the Department of Veterans Affairs showing that psychological safety can affect the learning environment—and a hospital’s ability to retain physicians.

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Dr. Loo, vice chair of education and faculty development at Loma Linda, offered a definition of a dynamic culture that includes accumulated shared learning because of shared benefits—which, in GME, may include program accreditation. Such a culture should be based on open and honest communication.

“What’s really key about culture is that it often becomes taken for granted and drops out of the cultural awareness,” Dr. Loo said.

Dr. Loo said faculty members can be “cursed by knowledge.” That puts them in a situation in which they find it hard to imagine that others don’t have the same knowledge base.

An environment lacking in psychological safety can result in lower patient safety because it lessens information-seeking and communication, and it is associated with burnout.

Drs. Loo and Byrne have worked to promote a psychologically safe environment by setting the stage for residents, inviting their participation and responding productively to their contributions.

At Loma Linda, when residency programs got lower scores from residents on questions regarding psychological safety, Drs. Loo and Byrne helped form an action plan to fix the problem. Those remedies included the creation of a dashboard for psychological safety for program directors and increased faculty-development sessions on the topic to why it’s important to create a psychologically safe learning environment and tips on how to do so.

Check out these great tips for residents on sleep, resiliency and well-being.

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