On the second morning of my first-ever combat skills course with the US Air Force, I broke the preeminent rule of tactical military bearing: never, ever lose track of your weapon. Fortunately, after 5 minutes of panicked, adrenaline-fused searching, I located it in the classroom I had just departed, still under the watchful eye of my instructor. The distressed look on my face must have betrayed my inner turmoil and acknowledgment of the error: instead of berating me, he mercifully encouraged me to be more careful in the future.
As I walked out of the room, with my proverbial tail between my legs, I seriously questioned how I would perform the litany of combat skills I needed to learn if I couldn't even keep up with my weapon. I was 2 weeks from my first overseas deployment, and my self-doubt—rooted in my anxiety about learning foreign, intimidating skills—left me feeling exceptionally vulnerable and concerned about my adequacy as a military physician about to deploy. These painful feelings were exacerbated by the presence of my more experienced classmates, most of whom had prior combat training or deployments. Compared with the seemingly seasoned professionals around me, I felt like a rookie who barely knew how to put on his body armor or load a weapon.
The psychological and physiological effects of my vulnerability and impaired belonging made the first few days of my military training miserable. I was nervous, hesitant to speak up, hyperaware of my actions and how I was being perceived, and full of self-doubt. I longed to be back in the comfortable confines of the hospital.
Surprisingly, the learning environment at my training site—hardly the Full Metal Jacket version depicted in Hollywood1—helped me turn things around. Charged with teaching us serious life-and-death skills, the instructors emphasized the critical nature of our training in a way that built confidence, normalized fear, and avoided intimidation. They openly acknowledged that we would make mistakes, encouraged us to learn from them, and provided extra instruction to ensure that we did. They were the consummate professionals, with the hidden curriculum important to them and consistent with the formal one.
My more combat-savvy classmates were equally supportive. They offered their free time to teach me, laughed with me—not at me—as I made mistakes (save the occasional well-deserved chuckle), and provided gentle indoctrination into foreign aspects of military culture. Above all, they were kind and civil, and they looked well beyond their own interests to support and ensure the success of all team members.
In the midst of a physically and mentally challenging experience, the respectful, constructive, and supportive learning environment allowed me to fully engage with my own discomfort and vulnerability, overcome my fears, and learn the requisite combat skills for a prepared deployment.
Military Learning Environment Versus Medical Learning Environment
My experience is not unlike what medical learners encounter at multiple stages in their careers. We enter unknown environments possessing underdeveloped skills and knowledge, lacking an understanding of the culture, and being acutely aware that everyone else knows more than we do (or so it seems). We want to be effective and competent but must go through a long, rigorous learning process to realize this goal, often feeling exactly the opposite. The vulnerability we experience can be excruciating, and internal questions often arise about our ability to adequately perform, learn, and advance within the profession.
Unfortunately, many medical learning environments may actually resemble those depicted in Full Metal Jacket, thanks to high rates of mistreatment, excessive competition, rigid hierarchies, and low levels of psychological safety. Insert into these environments medical learners grappling with vulnerability, fear of the unknown, self-doubt, and nagging questions about whether they belong. The result? The potential for significant, prolonged intrapersonal distress, emotional struggle, and impaired wellness.
After my combat skills training, I completed another training course, this time in a civilian teaching hospital. During my time there, I observed harsh teaching tactics, punitive responses to mistakes, hierarchical rigidity, and dysfunctional team dynamics. While I was not directly mistreated, the environment was unfriendly and not conducive to asking questions, reaching out for help, or showing weakness—doing so incurred heavy psychological risk. As a result, I found myself longing to be back at combat skills training and away from the not-so-friendly confines of the hospital walls. Unlike my military training, the vulnerability and self-doubt I felt at the beginning of the hospital training grew over time with inverse effects on my self-confidence, willingness to take risks, and sense of belonging.
How the Military Learning Environment Can Inform the Medical Learning Environment
I do not mean to suggest that all medical learning environments are suboptimal and all military environments are perfect; my disparate experiences were highly personal and are certainly not generalizable. Upon reflection, however, I have identified 3 key elements of my military training environment that were underemphasized in my hospital training and may assist ongoing efforts to build a better medical learning environment. The first was a shared purpose among all members of the military training environment. All students, regardless of career field, rank, or skill level, possessed and expressed fundamental, selfless devotion to our shared mission and to one another. In preparing to deploy to dangerous parts of the world, we acknowledged and shared our vulnerability and expressed appreciation for one another's sacrifice. In medicine, we too possess a shared purpose of selfless devotion to our patients and to the health of our communities. Our training requires hard work, delayed gratification, and psychological risk that are worthy of our mutual admiration and appreciation. Yet, how often do we openly acknowledge this sacrifice and express our admiration for one another to one another?
A second key feature of the military learning environment was the profound importance of the team. In our training, we prioritized and nurtured team dynamics, mitigated threats to team unity, leveraged our diversity, and constantly built team cohesion and belonging. The team—and its effective functioning—always reigned supreme. In the medical learning environment, teams serve an equally vital function, but competition, marginalization, and lack of diversity undermine their ability to provide support and belonging during challenging learning experiences. Building and maintaining supportive, inclusive teams should be a top priority as we reform our learning environments.
Finally, my military learning environment was defined by a commitment to civility and respect that permeated all levels of the organization. The culture of the training program left little room for disrespect, mistreatment, or uncivil behavior. It was simply not an accepted part of the culture, and thus no potential space existed for it to develop. In medicine, we should be treating one another with the utmost civility and respect, but we often do not. Our culture leaves too much potential space for disrespect and mistreatment, a reality that flies in the face of our shared mission of service to others. We simply need to be more kind to one another and nurture the value that all team members bring to our mission.
As we come together to build a better medical learning environment, we should begin by acknowledging and promoting a shared sense of purpose, the vital role of teams (and the joy of belonging to them), and a commitment to respectful treatment of all members of our enterprise.
Emulating the learning environments and everyday heroes in our armed forces may be a good place to start.
References
Competing Interests
The views expressed in this article are the author's own and do not represent those of the US Department of Defense, US Air Force, US government, or its agencies.
