Advancing Positive Medical Student Academic Learning Environments to Enhance Student Well-Being by Jackie Gruber Abstract Problem: Learner mistreatment is common in medical education and comes with an array of effects for learners and the profession. Mistreatment can truncate learning if a learner does not feel safe to speak up. This can limit learners in reporting patient safety issues, particularly if there are potential negative consequences to their careers. This study sought to understand what impedes speaking up culture by examining undergraduate medical students’ perspectives on barriers to speaking up, and reporting hesitancy drawing on theories of power imbalances, implicit voice, fear of reprisal, and learners’ social locations and identity. Methods: This study employed a participatory research design. Stakeholders from the Max Rady College of Medicine (MRCM) provided feedback on the study design, implementation, and study results. Mixed-methods electronic semi-structured survey that captured both quantitative and qualitative data was administered. The study population was the undergraduate medical learners’ years one to four who were enrolled as of 2018 at the MRCM. Analyses were performed using statistical and qualitative analysis programs. Results: We identified the comfort level of learners speaking up to different power roles and learners’ implicit voice theories, which acted as barriers to speaking up. We identified gendered differences in comfort with speaking up about mistreatment. We described the implicit theories students held about risks of reporting including impact on future career and harm to reputation. Themes of what learners wanted to contribute to a positive learning environment were identified, such as supporting one another. Conclusions: We concluded that reporting processes must consider power, gender, third party and multi-party reporting in their processes. Institutions need to address speaking up and fear of reprisal by means of education on anti-racism, rights and responsibilities, implicit bias, and gender and social orientation discrimination. This research could inform intervention studies by clarifying the sources of resistance to reporting and allow for the design of reporting mechanisms that specifically address these perceived risks. We attempted to identify who felt unsafe speaking up as it relates to intersectionality, however, given the relatively small sample size, we were not able to make conclusive statements in this regard. Further research is needed.