REVIEW ARTICLE

Mapping the scientific research on the negative

aspects of the medical school learning environment

Rodolfo F. Damiano, MD1

Andrey O. da Cruz, MS 2
José G. de Oliveira, MS 2
Lisabeth F. DiLalla, PhD 3
Sean Tackett, MD, MPH 4
Oscarina da Silva Ezequiel, MD, PhD 5
Giancarlo Lucchetti, MD, PhD 5

1. Institute of Psychiatry, University of São Paulo, São Paulo, SP, Brasil

2. Pontifical Catholic University of São Paulo, Sorocaba, SP, Brasil
3. Family and Community Medicine, Southern Illinois University School of Medicine, Carbondale, Illinois, USA
4. Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
5. School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, MG, Brasil

http://dx.doi.org/10.1590/1806-9282.64.11.1050

SUMMARY
Objective: We sought to understand the landscape of published articles regarding medical schools’ learning environments (LE) world-
wide, with an explicit focus on potentially negative aspects of the LE as an effort to identify areas specifically in need of remediation or
intervention that could prevent future unprofessional behaviours, burnout, violence and mistreatment among students and physicians.
Methods: A bibliometric analysis was conducted in six electronic databases (PubMed/Medline, Web of Science, Cochrane Library,
SCOPUS, ERIC-ProQuest and PsycINFO) through December 31, 2016, including 12 themes: learning environment – general, hidden
curriculum (negative), unethical behaviours, bullying/hazing, violence, sexual discrimination, homophobia, racism, social discrimina-
tion, minorities’ discrimination, professional misconduct, and “other” negative aspects. Results: Of 9,338 articles found, 710 met the
inclusion criteria. The most common themes were general LE (233 articles), unprofessional behaviours (91 articles), and sexual discrim-
ination (80 articles). Approximately 80% of articles were published in the 21st century. Conclusion: There is a clear increase in scientific
articles on negative aspects of the medical school LE in high-quality journals, especially in the 21st century. However, more studies are
needed to investigate negative LE aspects with greater attention paid to experimental, longitudinal, and cross-cultural study designs.
KEYWORDS: Learning Environment, Medical Education, Medical Students, Ethics, Professionalism.

INTRODUCTION

Environment can be defined as “the surroundings cians. The terminology used to describe this environ-
or conditions in which a person, animal, or plant lives ment varies, and has included educational environ-
or operates”.1 This concept, derived from the biolog- ment,2 teaching environment,3 and, most commonly,
ical sciences, has increasingly been the subject of the learning environment.4
study in medical sciences and educational research. The first study that focused on studying learning
Specifically for medical schools, a student’s “sur- environments (LE) in higher education dates back to
roundings or conditions” encompass physical, social, 1958.5 Concerning medical schools’ LEs, Hutchins (in
and psychological influences and must be conducive 1961)6 developed the first questionnaire and the first
to developing the knowledge, attitudes, skills, and attempt to understand quantitatively how the envi-
behaviours students will need to practice as physi- ronment might impact students’ attitudes, values,

DATE OF SUBMISSION: 07-Aug-2018

DATE OF ACCEPTANCE: 27-Aug-2018
Corresponding Author: Rodolfo F. Damiano
University of São Paulo, Brasil – Institute of Psychiatry
R. Dr. Ovídio Pires de Campos, 875 – Cerqueira César – São Paulo, SP – Brasil – 05403-903
E-mail: damianorf@gmail.com

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 DAMIANO, R. F. ET AL

and behaviours. Since then, many tools have been gy can be observed through the overall production of
developed to assess medical students’ perceptions scientific literature”19 (p. 6) and is used to map a field
of their LE,7 showing the growing importance of this of research, providing a statistical description of this
subject to medical researchers. According to Cohen,8 (recent and/or historical) data.19-21
if medical schools intend to deal with the erosion of Since this is a review of literature, ethical approv-
professionalism during the course of medical train- al is not required for this project. The sequence of the
ing, “purging their own learning environments of un- main phases is described below.
professional practices” (p. 610) is a key endeavour.
Much research now supports Cohen’s8 idea that
KEYWORDS SELECTION
this purging of negative aspects of the LE is criti-
cal for developing a professional physician. Much Initially, three authors (R.F.D., A.O.C., J.G.O.) re-
of this focuses on the cognitive/curricular or social viewed a sample of LE articles and independently
aspects of the LE and was derived from small pop- generated a list of keywords focusing on capturing all
ulations of students.9 Reported perceptions of poor potentially negative aspects of medical school LEs. Af-
LE have already been correlated with high levels of ter each list was created, four authors (R.F.D., A.O.C.,
student burnout and worse perception of quality of J.G.O., G.L.) examined the list to eliminate redundan-
life,10 decreased personal growth,11 worse academic cies and add new words to the list. Then, each indepen-
performance on the United States Medical Licensing dent researcher (R.F.D., A.O.C., J.G.O.) created a list
Examination Step 1,12 and also less time spent by stu- of themes (clusters) made up of related keywords and
dents on activities involving direct patient contact.13 compared them with the Learning Environment litera-
However, many LE general instruments used in ture to check for alignment with the current scientific
research might not encompass all aspects of the LE data. For this initial stage of development of themes,
that influence students’ lives. Specifically, it may we examined systematic reviews and the most promi-
be especially important to consider the negative as- nent articles published in high tier journals.
pects of the LE because these are likely to have en- One author (R.F.D.), in collaboration with the in-
suing negative effects on medical students, as has stitution librarian, was responsible for comparing
been demonstrated for unprofessional/unethical be- each list of themes, merging similar ones and re-
haviours, violence, and harassment, and their impact moving duplicates. A discussion among all authors
on students’ professionalism and quality of life.14-18 brought a consensus of twelve thematic clusters, in-
Mapping the research on the negative aspects cluding the “general LE” and eleven negative aspects
of the LE will help to identify areas that are already of medical schools’ LE: hidden curriculum (negative),
well explored, areas where more work needs to be unethical behaviours, bullying/hazing, violence, sex-
done, how interests have trended over time among ual discrimination, homophobia, racism, social dis-
researchers, and the geographic and cultural areas crimination, minorities discrimination, professional
where interest in these topics is greatest. Thus, the misconduct, and other negative aspects. These clus-
purpose of this study was to build on our current un- ters were arbitrarily defined by the authors of this
derstanding of LEs through a comprehensive biblio- paper. The general theme was based on articles with
metric analysis that develops a broader framework a focus on the Learning Environment, usually con-
for LEs and their negative aspects, which can guide taining “Learning Environment” in the title and us-
further investigation about each specific topic (such ing LE measurement instruments. However, the neg-
as original studies and systematic reviews) and med- ative aspects included research that did not always
ical curricula interventions. define the negative aspect as a component of the LE.
Figure 1 summarizes the conceptual framework of
the LE used by this manuscript.
METHODS

From September 2016 to January 2017, we car-

ELIGIBILITY CRITERIA
ried out a bibliometric analysis to evaluate all original
articles related to medical schools’ LE up to Decem- Inclusion criteria were: original studies (longi-
ber 31st, 2016. This bibliometric approach is defined tudinal studies - cohort and case-control, cross-sec-
as “a tool by which the state of science and technolo- tional studies, case reports, experience reports and

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MAPPING THE SCIENTIFIC RESEARCH ON THE NEGATIVE ASPECTS OF THE MEDICAL SCHOOL LEARNING ENVIRONMENT

TABLE 1. CHARACTERISTICS OF STUDIES ON MEDICAL

SCHOOLS’ LEARNING ENVIRONMENT including all studies published up to December 31,
All Studies (N = 710) 2016. A variety of Boolean expressions based on the
Characteristics No. Studies twelve thematic clusters were created to guide the
Publication year search in these databases (see Supplemental Materi-
Until 1980 15 (2.1%) al 1), and then each database outcome was exported
1981-1990 32 (4.4%) to Mendeley Desktop version 1.17.6 (a free reference
1991-2000 97 (13.7%) management program - ELSEVIER®) and sorted al-
2001-2010 236 (33.2%) phabetically in order to facilitate the review process.
2011-2016 330 (46.5%) A hand search of references from the oldest articles
Study Design identified one additional article6 that was included in
Cross-Sectional 551 (77.6%)
our analysis.
Longitudinal 75 (10.6%)
Experimental 41 (5.8%)
Data collection
Experience Report 39 (5.5%)
Case Report 4 (0.6%)
Three reviewers (R.F.D., A.O.C., J.G.O.) inde-
Measurement Methods (only if cross-sectional or longitudinal) pendently screened the title, authors, and abstracts
Quantitative 422 (67.4%) to determine if they met inclusion and exclusion
Qualitative 160 (25.6%) criteria. If excluded, the reason for exclusion as
Qualitative / Quantitative 44 (7.0%) described in the previous section was noted, and if
Journals included, the classification into one of the twelve
Academic Medicine 126 (18.4%) clusters as defined above was noted. Papers that
Medical Education 67 (9.8%) mentioned more than one theme mentioned above
Medical Teacher 48 (7.0%)
were discussed by all authors, who came to consen-
BMC Medical Education 29 (4.2%)
sus on the most relevant finding of the article. Any
Teaching and Learning in Medicine 17 (2.5%)
discrepancies were resolved by a discussion among
Impact factor journals (WoS)
No impact factor 188 (26.5%)
the reviewers in a follow-up meeting. The intra-class
0.000 - 1.00 65 (9.2%)
correlation between reviewers was assessed for the
1.01 - 3.00 219 (30.8%) first 100 studies, based on the choice of inclusion/ex-
> 3.00 237 (33.4%) clusion criteria, and we found an intra-class correla-
Countries (by author’s affiliation) tion coefficient of 0.915, showing excellent reliability
United States 309 (43.5%) between the three reviewers.
United Kingdom 61 (8.6%)
Canada 39 (5.5%) Bibliometric analysis
Australia 32 (4.5%) All included articles were exported to Excel for
Netherlands 23 (3.2%)
Mac version 14.7.2 (Microsoft®), and then each ar-
ticle was classified according to its characteristics:
title, authors’ name, journal title, journal’s impact
experimental studies) carried out with medical stu- factor (by Web of Science, 2015), study design, year
dents and related to their LE. Studies considered out of publication, article’s number of citations (by Web
of area (not related to LE) and out of population (not of Science and Google Scholar), and country of origin
with medical students) were excluded. Furthermore, (of the corresponding author). Then descriptive sta-
as our focus was on original studies, reviews, repli- tistics of all variables were analysed.
cations, theoretical pieces, articles without abstracts
(because we needed the abstracts in order to review
RESULTS
the paper), and book chapters were not included. No
language limit was applied. We found 9,337 articles across 6 databases and 1
article via hand search, resulting in a total of 9,338
Databases search articles (see Supplemental Material 2). After drop-
We conducted a search in six electronic data- ping duplicates (using the automatic Mendeley func-
bases (PubMed/Medline, Web of Science, Cochrane tion), 5,155 articles remained. Based on our eligibili-
Library, ERIC-ProQuest, SCOPUS, and PsycINFO) ty criteria, 4,445 articles were withdrawn due to one

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 DAMIANO, R. F. ET AL

TABLE 2. MOST CITED ARTICLES ON MEDICAL SCHOOLS’ LEARNING ENVIRONMENT

Rank Article No. WoS No. Goo- Average
Citations gle Scholar Citations/
Citations Year - WoS
1 Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative 190 471 15.8
study of medical students’ perceptions of teaching. BMJ. 2004;329(7469):770-3.
2 Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot study of medical 190 311 7.3
student ‘abuse’. Student perceptions of mistreatment and misconduct in medical school.
JAMA. 1990;263(4):533-7.
3 Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical 189 358 15.7
school is associated with subsequent disciplinary action by a state medical board. Acad Med.
2004;79(3):244-9.
4 Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical 151 248 6.6
students confront. Acad Med. 1993;68(4):249-54.
5 Dyrbye LN, Massie FS Jr, Eacker A, Harper W, Power D, Durning SJ, Thomas MR, Moutier C, 149 318 24.8
Satele D, Sloan J, Shanafelt TD. Relationship between burnout and professional conduct and
attitudes among US medical students. JAMA. 2010;304(11):1173-80.
6 Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and 122 236 5.1
correlates of reported medical student abuse. JAMA. 1992;267(5):692-4.
7 Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Acad Med. 97 205 5.4
1998;73(11):1149-58.
8 Moffat KJ, McConnachie A, Ross S, Morrison JM. First-year medical student stress and cop- 95 298 7.9
ing in a problem-based learning medical curriculum. Med Educ. 2004;38(5):482-91.
9 Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. Medical students’ professional- 90 154 15
ism narratives: a window on the informal and hidden curriculum. Acad Med. 2010;85(1):124-
33.
10 Baxter N, Cohen R, McLeod R. The impact of gender on the choice of surgery as a career. Am 87 136 4.3
J Surg. 1996;172(4):373-6.
11 Madigosky WS, Headrick LA, Nelson K, Cox KR, Anderson T. Changing and sustaining medi- 85 167 8.5
cal students’ knowledge, skills, and attitudes about patient safety and medical fallibility. Acad
Med. 2006;81(1):94-101.
12 Papadakis MA, Osborn EH, Cooke M, Healy K. A strategy for the detection and evaluation of 85 127 5
unprofessional behavior in medical students. University of California, San Francisco School of
Medicine Clinical Clerkships Operation Committee. Acad Med. 1999;74(9):980-90.
13 Patenaude J, Niyonsenga T, Fafard D. Changes in students’ moral development during medi- 83 223 6.4
cal school: a cohort study. CMAJ. 2003; 168(7): 840–844.
14 Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilem- 76 207 5.1
mas that shape medical students’ ethical development: questionnaire survey and focus group
study. BMJ. 2001; 322(7288): 709–710.
15 Roberts LW, Warner TD, Lyketsos C, Frank E, Ganzini L, Carter D. Perceptions of academ- 74 135 4.9
ic vulnerability associated with personal illness: a study of 1,027 students at nine medical
schools. Collaborative Research Group on Medical Student Health. Compr Psychiatry.
2001;42(1):1-15.
16 Dyrbye LN, Thomas MR, Harper W, Massie FS Jr, Power DV, Eacker A, Szydlo DW, Novotny 70 153 10
PJ, Sloan JA, Shanafelt TD. The learning environment and medical student burnout: a multi-
centre study. Med Educ. 2009;43(3):274-82.
17 Edwards MT, Zimet CN. Problems and concerns among medical students--1975. J Med Educ. 68 98 1.7
1976;51(8):619-25.
18 Stern DT, Frohna AZ, Gruppen LD. The prediction of professional behaviour. Med Educ. 66 130 6
2005;39(1):75-82.
19 Frank E, Carrera JS, Stratton T, Bickel J, Nora LM. Experiences of belittlement and harassment 64 162 6.4
and their correlates among medical students in the United States: longitudinal survey. BMJ.
2006;333(7570):682.
20 Wolf TM, Randall HM, von Almen K, Tynes LL. Perceived mistreatment and attitude change 63 116 2.5
by graduating medical students: a retrospective study. Med Educ. 1991;25(3):182-90.

of the following reasons: no abstract (416 articles); metric analysis. Each article was classified into one
book chapter (20 articles); duplicate (missed by Men- of the twelve themes, resulting in a final distribution
deley; 376 articles); review (123 articles); theoretical as follows: learning environment – general (233 arti-
articles (467 articles); out of population (not on medi- cles – 32.8%); unprofessional behaviours (91 articles –
cal students; 567 articles); and out of area (not on LE; 12.8%); sexual discrimination (80 articles – 11.3%); mi-
2,476 articles). norities discrimination (76 articles – 10.7%); violence
Finally, 710 articles were included in this biblio- (65 articles – 9.1%); hidden curriculum (52 articles –

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MAPPING THE SCIENTIFIC RESEARCH ON THE NEGATIVE ASPECTS OF THE MEDICAL SCHOOL LEARNING ENVIRONMENT

FIGURE 1. CONCEPTUAL FRAMEWORK OF LE USED IN THIS ARTICLE.

7.3%); unethical behaviours (49 articles – 6.9%); racism Science (WoS) and 10 articles having more than 200
(16 articles – 2.2%); homophobia (13 articles – 1.8%); citations in Google Scholar.
bullying/hazing (7 articles – 1.0%); social discrimina- Supplemental Materials 4-7 present the charac-
tion (5 articles – 0.7%); and other (23 articles – 3.2%). teristics of each of the 12 themes defined by this arti-
Supplemental Material 3 shows the distribu- cle. The journal Academic Medicine has published the
tion of publications of all articles related to medical most articles on medical students’ LE across most of
schools’ LE included in this manuscript. The first the dimensions we examined. Whereas researchers
such publication dates back to 1961;6 publications from the United States published most of the papers
remained relatively stable and infrequent until the in this field, Pakistan published the most in bullying/
21st century, when there was a notable increase in hazing. Finally, some areas are quite new in the sci-
manuscripts related to medical schools’ LE. In fact, entific literature, and until the 1980s there were no
80% of all articles related to medical schools’ LE were published articles on the following areas: unprofes-
published after 1999. Notably, a large spike occurs at sional behaviours, violence, hidden curriculum (neg-
approximately 2006; almost 70% of all articles were ative), unethical behaviour, racism, homophobia, and
published from 2006 through 2016. bullying/hazing.
The characteristics of these studies are shown in In relation to the instruments used to measure
Table 1. Most of them (77.6%) are cross-sectional and the LE, we found high use of the following tools:
quantitative studies (67.4%). We found only 41 (5.8%) the Dundee Ready Education Environment Measure
experimental studies and 75 (10.5%) longitudinal (DREEM),2 the Medical Student Learning Environ-
studies. Almost two-thirds of the articles were pub- ment Scale (MSLES),22,23 and the most recent Johns
lished in journals with an impact factor (IF) greater Hopkins Learning Environment Scale (JHLES).4
than 1.00, with one third published in journals with Comparing articles using these tools (cluster: learn-
IF greater than 3.00. Academic Medicine (IF 4.194), ing environment – general) with all articles, we found
Medical Education (IF 3.369), Medical Teacher (IF an even higher proportion of manuscripts published
2.355), BMC Medical Education (IF 1.312) and Teach- between 2011-2016 (53%) that used these popular
ing and Learning in Medicine (IF 1.159) represent five measurement tools.
leading journals in this area. Most articles on this
topic had corresponding authors who resided in the
DISCUSSION
United States (43.5%), followed by the United King-
dom (8.6%) and Canada (5.5%). This study represents the first comprehensive bib-
Finally, Table 2 presents the 20 most-cited ar- liometric description for learning environment (LE)
ticles in the area of medical schools’ LE. The num- research in medical schools with a focus on negative
ber of citations for these articles is quite high, with aspects. We identify here the relatively recent rapid
6 articles having more than 100 citations in Web of increase in interest in LE globally, demonstrating in-

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 DAMIANO, R. F. ET AL

creased awareness of the importance of this topic, and began supporting a longitudinal study of medical stu-
also the recent attempts to improve LE research study dents at 28 medical schools in 2010 that has already
designs. For educators, this is an important call to in- led to several publications.37,38 Third, medical school
crease our attention to the importance of the medical accreditation standards may play a role, as the cre-
school LE as well as to explore in greater depth the ation of a new Liaison Committee on Medical Edu-
potentially negative aspects of medical school LEs. cation39 (LCME) standard related to LE quality coin-
To facilitate our understanding about the con- cides with the rapid increase in LE studies.
ceptual framework of the LE area, we developed a The United States has by far the most LE research
concept map (Figure 1) based on the authors’ own ex- identified in this study, followed by the United King-
perience and the most prominent studies reviewed dom, Canada, Australia, and the Netherlands. These
by this manuscript. First, our understanding is that findings are similar to analyses of all medical edu-
both positive and negative aspects might influence cation articles40,41 and global scientific production as
students’ perception of their LE. In this article, we a whole. Given that medical education research on
decided to focus more on the negative ones. We have the learning environment is dominated by several
identified ten main negative areas that might impact countries that do not represent most of the world’s
students’ perception of their LE (in parentheses the medical schools, educators and investigators must
most cited on each area): unprofessional behaviors;17 be cautious to ensure that they focus on local needs
sexual discrimination;24 minorities discrimination;25 and do not seek to overgeneralize their results. For
violence;26 hidden curriculum (negative);27 unethi- example, in the field of empathy research, a decline
cal behaviors;28 racism;28 homophobia;30 bullying/ in student empathy during medical schools seems to
hazing;31 and social discrimination.32 These nega- have been largely driven by several studies from the
tive themes may be concomitantly the source and U.S., and they were not corroborated by the bulk of
the consequence of a “bad” LE; that is, these nega- international studies.42 At the same time, when re-
tive environments may create a poor perception that viewing the top countries by topic, we saw that some
creates a positive feedback on these unacceptable developing countries had the greatest number of pub-
behaviours. Educators should be aware of this, at- lications for certain clusters. For example, Pakistan
tempting to prevent a state where the “mean” turns had the most publications on bullying/hazing and
inherent and cannot be seen, such as in the famous Nigeria had the third most in violence. Future stud-
study of the Stanford prison experiment.33 ies should explore whether these findings reflect the
Noteworthy is that while there has been an in- initiative of individuals or research teams or a larger
creasing number of articles published in medical trend in negative LE aspects. Considering that, like
education in general, not all content areas receive most medical education research, cross-sectional
the same attention.34 In our study, we found a re- and single site studies comprised the majority of LE
cent and rapidly growing interest in medical school research, future work should use multiple methods
LE research, with the great majority (approx. 70%) across cultures to better understand the complex in-
of studies having been published from 2006 onward teractions between students and their LEs.
and in journals with an IF greater than 1.00, further Our findings have implications for health man-
indicating interest in this field among medical educa- agers and medical educators, providing further evi-
tion researchers. What may be driving this interest dence that the LE could have a positive but also a neg-
in the medical school? First, our data suggest that ative influence on medical students. Educators must
the availability of LE measurement instruments may promote appropriate infrastructure, active learning
facilitate research. Over half of the published arti- strategies, good clinical scenarios, high- and low-fi-
cles that utilized the most frequently used measures delity labs, formative feedback, valuable educational
were published since 2011. Second, interest is likely content, and consistent theoretical and practical as-
being driven by greater concern for the potential neg- sessments. Yet, on the other hand, educators must be
ative impact of poor learning environments in med- aware that unethical behaviours, bullying, violence,
ical schools, particularly student mistreatment and sexual discrimination, professional misconduct, and
overwork, as these impact trainees’ empathy and the hidden curriculum could impair medical stu-
well-being.10,34-36 For example, in the U.S., the Amer- dents’ academic performance and mental health.
ican Medical Association, driven by these concerns, Thus, they must become aware of these possible be-

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MAPPING THE SCIENTIFIC RESEARCH ON THE NEGATIVE ASPECTS OF THE MEDICAL SCHOOL LEARNING ENVIRONMENT

haviours occurring in their curricula. The early iden- identify research that is related to negative outcomes
tification of these negative aspects of the LE and the for medical students and that has potential for reme-
implementation of educational and preventive inter- diation. In the future, it will be important to incorpo-
ventions should serve to minimize medical training rate both negative and positive aspects of the medical
distress and future unprofessional behaviours. school LE that contribute to changes in students’ em-
This research has several limitations. First, we pathy and well-being.
focused only on original studies to characterize the
current evidence base related to negative aspects of
CONCLUSION
the LE, which meant that we excluded many other
highly cited reviews and theoretical studies that may Our analysis identifies the most important areas
be influential in this field. Second, we may not have that articles, authors, and countries have studied or re-
identified every relevant original research article, as ported on in terms of negative aspects of the learning
no database has every paper and no search strategy environment in medical schools. We demonstrated an
can find every paper. However, we did not limit by lan- important growth of scientific production in high-qual-
guage, so this is truly an international search. Third, ity journals, especially in the 21st century. However, more
the databases that we searched tended to be more fo- studies are needed that investigate the negative aspects
cused on American and European journals, possibly of medical students’ LE, with particular attention to
excluding important contributions from the southern experimental and cross-cultural/multi-school studies.
hemisphere. Fourth, this is a novel operationalization Heightened awareness of negative aspects of the medi-
of the learning environment and has limitations and cal student LE should be useful in empowering medical
potential biases; however, it is important to initiate a professionals to make changes in the LE that will, in
discussion about all these possible important aspects turn, improve student professionalism.
of the LE. Fifth, many of the articles included more
than one of the negative areas identified in this study. Acknowledgments
However, we tried to isolate the most important sub- The authors wish to show our gratitude to Anto-
ject of each manuscript in order to facilitate our un- nio P. de Melo Maricato for his contribution, and Dr.
derstanding. Finally, we focused more on negative Robert B. Shochet and Dr. J. Kevin Dorsey for their
aspects of the learning environment. Positive aspects, kind review and support for this article.
such as role models, peer relationships, and sense of
engagement, clearly are important in understanding Declarations of Interest
medical students’ LE. However, we concentrated on The authors report no conflict of interest.
negative aspects because the focus of this paper was to Funding Source: None

RESUMO
OBJETIVO: Buscou-se entender o panorama dos artigos publicados sobre os ambientes de aprendizagem (AA) das escolas médicas
em todo o mundo, com um foco explícito nos aspectos potencialmente negativos do AA como um esforço para identificar áreas es-
pecificamente necessitadas de remediação ou intervenção que poderiam evitar futuros comportamentos não profissionais, violência
e maus-tratos entre estudantes e médicos. Métodos: Foi realizada uma análise bibliométrica em seis bases de dados eletrônicas
(PubMed/Medline, Web of Science, Biblioteca Cochrane, Scopus, Eric-ProQuest e PsycInfo) até 31 de dezembro de 2016, incluindo 12
temas: ambiente de aprendizagem - geral, currículo oculto (negativo), comportamentos antiéticos, bullying/trote, violência, discrimi-
nação sexual, homofobia, racismo, discriminação social, discriminação de minorias, má conduta profissional e “outros” aspectos nega-
tivos. Resultados: Dos 9.338 artigos encontrados, 710 preencheram os critérios de inclusão. Os temas mais comuns foram LE geral (233
artigos), comportamentos não profissionais (91 artigos) e discriminação sexual (80 artigos). Aproximadamente 80% dos artigos foram
publicados no século XXI. Conclusão: Há um claro aumento em artigos científicos sobre aspectos negativos da escola de medicina
LE em periódicos de alta qualidade, especialmente no século XXI. No entanto, mais estudos são necessários para investigar aspectos
negativos do LE com maior atenção aos desenhos de estudos experimentais, longitudinais e transculturais.
PALAVRAS-CHAVE: Ambiente de aprendizagem. Educação médica. Estudantes de medicina. Ética. Profissionalismo.

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 DAMIANO, R. F. ET AL

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