"It's Time to Do It, to Make It a Major Part of Medicine": Faculty Experience With a Shift Toward an Antioppressive Medical School Curriculum

PURPOSE

Health inequities compel medical educators to transform curricula to prepare physicians to improve the health of diverse populations. This mandate requires curricular focus on antioppression, which is a change for faculty who learned and taught under a different paradigm. This study used the Concerns-Based Adoption Model (CBAM) to explore faculty perceptions of and experiences with a shift to a curriculum that prioritizes antioppressive content and process.

METHOD

In this qualitative study, authors interviewed faculty course directors and teachers at the University of California, San Francisco School of Medicine from March 2021 to January 2022. Questions addressed faculty experience and understanding regarding the curriculum shift toward antioppression, perceptions of facilitators and barriers to change, and their interactions with colleagues and learners about this change. Using the CBAM components as sensitizing concepts, the authors conducted thematic analysis.

RESULTS

Sixteen faculty participated. Their perceptions of their experience with the first year of an antioppression curriculum initiative were characterized by 3 broad themes: (1) impetus for change, (2) personal experience with antioppressive curricular topics, and (3) strategies necessary to accomplish the change. Faculty described 3 driving forces for the shift toward antioppressive curricula: moral imperative, response to national and local events, and evolving culture of medicine. Despite broad alignment with the change, faculty expressed uncertainties on 3 subthemes: uncertainty about what is an antioppressive curriculum, the scientific perspective, and fear. Faculty also reflected on primary facilitators and barriers to accomplishing the change.

CONCLUSIONS

The shift to an antioppressive curriculum compels faculty to increase their knowledge and skills and adopt a critical, self-reflective lens on the interplay of medicine and oppression. This study's findings can inform faculty development efforts and highlight curricular leadership and resources needed to support faculty through this type of curricular change.

'We're like Spider-Man; with great power comes great responsibility': Coaches' experiences supporting struggling medical students

BACKGROUND

Medical students can experience a range of academic and non-academic struggles. Coaching is a valuable strategy to support learners, but coaches describe working with struggling learners as taxing. Transformative learning theory (TLT) provides insights into how educators grow from challenging experiences to build resilience. This study explores how coaches evolve as educators through supporting struggling students.

METHODS

This qualitative study grounded in an interpretivist paradigm used interviews of longitudinal medical student coaches at two academic institutions. Interviews, using TLT as a sensitizing concept, explored coaches' experience coaching struggling learners. We performed thematic analysis.

RESULTS

We interviewed 15 coaches. Coaches described supporting students through multi-faceted struggles which often surprised the coach. Three themes characterized coaches' experiences: personal responsibility, emotional response, and personal learning. Coaches shouldered high personal responsibility for learners' success. For some, this burden felt emotional, raised parental instincts and questions about maintaining boundaries with learners. Coaches evolved their coaching approach, challenged biases, and built skills. Coaches learned to better appreciate the learner point of view and employ resources to support students.

DISCUSSION

Through navigating learner struggles, educators can gain self-efficacy, learn to understand learners' perspectives, and evolve their coaching approach to lessen their personal emotional burden through time.

'Yourself in all your forms': A grounded theory exploration of identity safety in medical students

INTRODUCTION

Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment.

METHODS

This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations.

RESULTS

Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment.

DISCUSSION

Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

Stereotype Threat and Gender Bias in Internal Medicine Residency: It is Still Hard to be in Charge

BACKGROUND

Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities.

OBJECTIVE

To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat.

DESIGN

We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat.

PARTICIPANTS

The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September-November 2019. Focus groups were conducted at UCSF in Spring 2020.

APPROACH

The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources.

KEY RESULTS

Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women's experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship.

CONCLUSIONS

Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women's vulnerability to stereotype threat.

Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME)

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

How Teachers Can Promote Assessment for Learning During All Phases of Learning

Assessment for Learning (AFL) includes all educational activities designed to improve teaching and learning through gathering, sharing, and acting on information. AFL expands on the concept of formative assessment-which focuses mainly on an in-the-moment assessment activity-to include all processes that facilitate teachers and learners actively seeking and interpreting evidence to guide learning. AFL involves teachers and learners as partners and uses evidence to identify what the learner needs to learn (planning), review where the learner is in their learning (observing), and strategize how to maximize learning (supporting). 1 We provide the following guidelines for teachers to implement AFL within these 3 phases of a learning activity. Teachers should tailor their choice of AFL strategies to suit their relationship with the learner and learning environment context, aiming to support the development of self-regulated learning and metacognitive skills.

ChatGPT and Generative Artificial Intelligence for Medical Education: Potential Impact and Opportunity

ABSTRACT

ChatGPT has ushered in a new era of artificial intelligence (AI) that already has significant consequences for many industries, including health care and education. Generative AI tools, such as ChatGPT, refer to AI that is designed to create or generate new content, such as text, images, or music, from their trained parameters. With free access online and an easy-to-use conversational interface, ChatGPT quickly accumulated more than 100 million users within the first few months of its launch. Recent headlines in the popular press have ignited concerns relevant to medical education over the possible implications of cheating and plagiarism in assessments as well as excitement over new opportunities for learning, assessment, and research. In this Scholarly Perspective, the authors offer insights and recommendations about generative AI for medical educators based on literature review, including the AI literacy framework. The authors provide a definition of generative AI, introduce an AI literacy framework and competencies, and offer considerations for potential impacts and opportunities to optimize integration of generative AI for admissions, learning, assessment, and medical education research to help medical educators navigate and start planning for this new environment. As generative AI tools continue to expand, educators need to increase their AI literacy through education and vigilance around new advances in the technology and serve as stewards of AI literacy to foster social responsibility and ethical awareness around the use of AI.

'It's more like checking in with an old friend': A qualitative study of medical students' experiences with longitudinal coaches throughout medical school

PURPOSE

Coaching in medical education facilitates learners' growth and development through feedback, goal-setting and support. This study explored how coaching relationships evolve throughout medical school and the impact of longitudinal coaching relationships on medical students' approach to feedback and goal setting in the clinical years.

METHOD

In this qualitative study using a constructivist paradigm, authors purposively sampled 15 senior medical students at University of California, San Francisco, to participate in individual semi-structured interviews (October-November 2021). The authors used an inductive approach to thematic analysis.

RESULTS

The authors identified four themes: First, the student-coach relationship deepened over the course of medical school. Second, students identified factors that sustained and strengthened the student-coach relationship over time: a strong foundation to the relationship, the non-evaluative nature of the relationship, coach supportiveness and responsiveness, and coach knowledge of the institutional landscape. Third, coaches provided individualized advice, assessed trajectory, and guided feedback interpretation. Lastly, students applied skills of soliciting and responding to feedback and creating learning goals, originally learned through coaching experience.

CONCLUSIONS

Coaching relationships, grounded in trust, evolve to meet students' changing needs as they grow into physicians. Students apply feedback and goal-setting skills learned with the coach in clinical settings with other supervisors.

From Eggshells to Action: A Qualitative Study of Faculty Experience Responding to Microaggressions Targeting Medical Students

PURPOSE

Microaggressions targeting clinical learners cause harm and threaten learning. Clinical supervisors can be powerful allies by intervening when microaggressions occur. This study explored general and student-nominated skilled supervisors' perspectives on responding to microaggressions targeting clinical learners.

METHOD

This single-institution, qualitative study within a constructivist paradigm explored faculty supervisor experiences with bystander response to microaggressions targeting learners. Clinical supervisors in medicine and surgery departments and those across departments nominated by students as skilled microaggression responders were invited to discuss microaggression scenarios targeting students in semistructured focus groups in the U.S. in 2020-2021. Investigators applied the framework method of thematic analysis to identify themes.

RESULTS

Forty-two faculty (31 medicine and surgery ["general"], 11 "student-nominated" as skilled responders) joined 10 focus groups (6 "general," 3 "student-nominated," 1 mixed). Four themes characterized experiences responding to microaggressions targeting learners: bystander goals, noticing, acting, and continuous learning. Participants' response goals were protecting learners, safeguarding learning, and teaching microaggression response skills. Noticing was influenced by past experiences with microaggressions and acculturation to clinical environments. Bystander action stemmed from (1) microaggression type, (2) personal emotional vulnerability, (3) knowledge of student preferences for supervisor response, and (4) clinical and educational context. Bystander action was more common when participants regarded all microaggressions as harmful, understood student preferences for faculty response, expected to err (growth mindset), and framed microaggressions as opportunities for humble reflection, intellectual candor, and teaching. Microaggression response required continuous learning through informal and formal skills development.

CONCLUSIONS

Complex factors govern faculty bystander response to microaggressions targeting clinical learners. Efforts to strengthen faculty bystander response should incorporate skill-building around preemptive discussions with learners and using intellectual candor to promote psychological safety, learning, and bystander action. Additional investigation is needed on how to incorporate these skills into team workflows and to assess outcomes of specific response strategies.

Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments

PURPOSE

Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training.

METHOD

A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most.

RESULTS

Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students.

CONCLUSIONS

This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.

Having a Bad Day Is Not an Option: Learner Perspectives on Learner Handover

PURPOSE

Learner handover is the sharing of learner-related information between supervisors involved in their education. The practice allows learners to build upon previous assessments and can support the growth-oriented focus of competency-based medical education. However, learner handover also carries the risk of biasing future assessments and breaching learner confidentiality. Little is known about learner handover's educational impact, and what is known is largely informed by faculty and institutional perspectives. The purpose of this study was to explore learner handover from the learner perspective.

METHOD

Constructivist grounded theory was used to explore learners' perspectives and beliefs around learner handover. Twenty-nine semistructured interviews were completed with medical students and residents from the University of Ottawa and University of California, San Francisco. Interviews took place between April and December 2020. Using the constant comparative approach, themes were identified through an iterative process.

RESULTS

Learners were generally unaware of specific learner handover practices, although most recognized circumstances where both formal and informal handovers may occur. Learners appreciated the potential for learner handover to tailor education, guide entrustment and supervision decisions, and support patient safety, but worried about its potential to bias future assessments and breach confidentiality. Furthermore, learners were concerned that information-sharing may be more akin to gossip rather than focused on their educational needs and feared unfair scrutiny and irreversible long-term career consequences from one shared mediocre performance. Altogether, these concerns fueled an overwhelming pressure to perform.

CONCLUSIONS

While learners recognized the rationale for learner handover, they feared the possible inadvertent short- and long-term impact on their training and future careers. Designing policies that support transparency and build awareness around learner handover may mitigate unintended consequences that can threaten learning and the learner-supervisor relationship, ensuring learner handover benefits the learner as intended.

The Problem and Power of Professionalism: A Critical Analysis of Medical Students' and Residents' Perspectives and Experiences of Professionalism

PURPOSE

Professionalism has historically been viewed as an honorable code to define core values and behaviors of physicians, but there are growing concerns that professionalism serves to control people who do not align with the majority culture of medicine. This study explored how learners, particularly those from historically marginalized groups, view the purpose of professionalism and how they experience professionalism as both an oppressive and valuable force.

METHOD

The authors conducted a qualitative study with a critical orientation. In 2021 and 2022, they interviewed fourth-year medical students and senior residents at 3 institutions about their perceptions and experiences of professionalism. After cataloguing participants' stories, the authors combined critical theory with narrative and thematic analysis to identify mechanisms by which professionalism empowered or disempowered individuals or groups based on identities.

RESULTS

Forty-nine trainees (31 medical students and 18 senior residents from multiple specialties) participated in interviews; 17 identified as a race/ethnicity underrepresented in medicine and 15 as people of color not underrepresented in medicine. Their stories, especially those of participants underrepresented in medicine, identified professionalism as an oppressive, homogenizing force that sometimes encoded racism through various mechanisms. These mechanisms included conflating differences with unprofessionalism, enforcing double standards of professionalism, and creating institutional policies that regulated appearance or hindered advocacy. Participants described deleterious consequences of professionalism on their learning and mental health. However, participants also described useful aspects of professionalism as a means of advocating for marginalized groups. Additionally, participants described how they reconceived professionalism to include their own identities and values.

CONCLUSIONS

Trainees, especially those from historically marginalized groups, experience professionalism as a restrictive, assimilative force while also finding value in and constructive adaptations for professionalism. Understanding both the destructive and empowering aspects of professionalism on individual and institutional levels can help improve the framing of professionalism in medical education.

Reimagining a pass/fail clinical core clerkship: a US residency program director survey and meta-analysis

Pass/fail (P/F) grading has emerged as an alternative to tiered clerkship grading. Systematically evaluating existing literature and surveying program directors (PD) perspectives on these consequential changes can guide educators in addressing inequalities in academia and students aiming to improve their residency applications. In our survey, a total of 1578 unique PD responses (63.1%) were obtained across 29 medical specialties. With the changes to United States Medical Licensure Examination (USMLE), responses showed increased importance of core clerkships with the implementation of Step 2CK cutoffs. PDs believed core clerkship performance was a reliable representation of an applicant's preparedness for residency, particularly in Accreditation Council for Graduate Medical Education's (ACGME)Medical Knowledge and Patient Care and Procedural Skills. PDs disagreed with P/F core clerkships because it more difficult to objectively compare applicants. No statistically significant differences in responses were found in PD preferential selection when comparing applicants from tiered and P/F core clerkship grading systems. If core clerkships adopted P/F scoring, PDs would further increase emphasis on narrative assessment, sub-internship evaluation, reference letters, academic awards, professional development and medical school prestige. In the meta-analysis, of 6 studies from 2,118 participants, adjusted scaled scores with mean difference from an equal variance model from PDs showed residents from tiered clerkship grading systems overall performance, learning ability, work habits, personal evaluations, residency selection and educational evaluation were not statistically significantly different than from residents from P/F systems. Overall, our dual study suggests that while PDs do not favor P/F core clerkships, PDs do not have a selection preference and do not report a difference in performance between applicants from P/F vs. tiered grading core clerkship systems, thus providing fertile grounds for institutions to examine the feasibility of adopting P/F grading for core clerkships.

"It's All About the Trust And Building A Foundation:" Evaluation of a Longitudinal Medical Student Coaching Program

Coaching is increasingly implemented in medical education to support learners' growth, learning, and wellbeing. Data demonstrating the impact of longitudinal coaching programs are needed.

We developed and evaluated a comprehensive longitudinal medical student coaching program designed to achieve three aims for students: fostering personal and professional development, advancing physician skills with a growth mindset, and promoting student wellbeing and belonging within an inclusive learning community. We also sought to advance coaches' development as faculty through satisfying education roles with structured training. Students meet with coaches weekly for the first 17 months of medical school for patient care and health systems skills learning, and at least twice yearly throughout the remainder of medical school for individual progress and planning meetings and small-group discussions about professional identity. Using the developmental evaluation framework, we iteratively evaluated the program over the first five years of implementation with multiple quantitative and qualitative measures of students' and coaches' experiences related to the three aims.

The University of California, San Francisco, School of Medicine, developed a longitudinal coaching program in 2016 for medical students alongside reform of the four-year curriculum. The coaching program addressed unmet student needs for a longitudinal, non-evaluative relationship with a coach to support their development, shape their approach to learning, and promote belonging and community.

In surveys and focus groups, students reported high satisfaction with coaching in measures of the three program aims. They appreciated coaches' availability and guidance for the range of academic, personal, career, and other questions they had throughout medical school. Students endorsed the value of a longitudinal relationship and coaches' ability to meet their changing needs over time. Students rated coaches' teaching of foundational clinical skills highly. Students observed coaches learning some clinical skills with them - skills outside a coach's daily practice. Students also raised some concerns about variability among coaches. Attention to wellbeing and belonging to a learning community were program highlights for students. Coaches benefited from relationships with students and other coaches and welcomed the professional development to equip them to support all student needs.

Students perceive that a comprehensive medical student coaching program can achieve aims to promote their development and provide support. Within a non-evaluative longitudinal coach relationship, students build skills in driving their own learning and improvement. Coaches experience a satisfying yet challenging role. Ongoing faculty development within a coach community and funding for the role seem essential for coaches to fulfill their responsibilities.

"My Assessments Are Biased!" Measurement and Sociocultural Approaches to Achieve Fairness in Assessment in Medical Education

Assessing learners is foundational to their training and developmental growth throughout the medical education continuum. However, growing evidence shows the prevalence and impact of harmful bias in assessments in medical education, accelerating the urgency to identify solutions. Assessment bias presents a critical problem for all stages of learning and the broader educational system. Bias poses significant challenges to learners, disrupts the learning environment, and threatens the pathway and transition of learners into health professionals. While the topic of assessment bias has been examined within the context of measurement literature, limited guidance and solutions exist for learners in medical education, particularly in the clinical environment. This article presents an overview of assessment bias, focusing on clinical learners. A definition of bias and its manifestations in assessments are presented. Consequences of assessment bias are discussed within the contexts of validity and fairness and their impact on learners, patients/caregivers, and the broader field of medicine. Messick's unified validity framework is used to contextualize assessment bias; in addition, perspectives from sociocultural contexts are incorporated into the discussion to elaborate the nuanced implications in the clinical training environment. Discussions of these topics are conceptualized within the literature and the interventions used to date. The article concludes with practical recommendations to overcome bias and to develop an ideal assessment system. Recommendations address articulating values to guide assessment, designing assessment to foster learning and outcomes, attending to assessment procedures, promoting continuous quality improvement of assessment, and fostering equitable learning and assessment environments.

The Consequences of Step 2 Clinical Skills Examination Discontinuation for Medical Schools and Sustainability Plans for Clinical Skills Assessment

PURPOSE

Comprehensive clinical skills examinations using standardized patients are widely used to assess multiple physician competencies. However, these exams are resource intensive. With the discontinuation of the Step 2 Clinical Skills (CS) exam in 2021, how medical schools will change their approaches to comprehensive clinical skills exams is unknown. This study explores school responses to this change and future directions of comprehensive clinical skills exams using the program sustainability framework.

METHOD

This cross-sectional, descriptive study surveyed medical school curriculum deans at 150 Liaison Committee on Medical Education-accredited U.S. medical schools from September to October 2021. The 30-question survey included questions about medical school and participant role, current comprehensive clinical skills exams, sustainability dimensions, and challenges and future directions. Descriptive statistics were used to characterize responses, and content analysis was used to identify themes in the open-ended responses.

RESULTS

Educators at 75 of 150 institutions (50%) responded. Sixty-three respondents (84%) reported conducting a comprehensive clinical skills exam. The comprehensive clinical skills exam assessed readiness for graduation (51 [81%]), provided feedback for students (49 [78%]), evaluated curricula (38 [60%]), provided information for medical student performance evaluation or communication with residency (10 [16%]), and assessed other factors (6 [10%]), including preparation for Step 2 CS in the past and readiness for advancement to fourth year of medical school (multiple responses were allowed). Factors facilitating sustainability included sufficient funding to continue the exam (55 [87%]) and the belief that clinical skills assessment in medical school is now more important after discontinuation of the Step 2 CS exam (55 [87%]). Challenges to sustainability included organizational capacity and limited interinstitutional collaboration.

CONCLUSIONS

Educators remain committed to the purpose of comprehensive clinical skills exams. Adapting to changed licensing requirements while sustaining clinical skills exams enables innovation and improvement in assessment of clinical competence.

Students' Perspectives on Basic and Clinical Science Integration When Step 1 is Administered After the Core Clerkships

Phenomenon: According to adult learning theories, effective cognitive integration of basic and clinical science may promote the transfer of knowledge to patient care. The placement of the U.S. Medical Licensing Examination (USMLE) Step 1 after the core clerkships is one strategy intended to facilitate cognitive integration, though learner experiences with this model are unexplored. The purpose of this study is to understand students' perspectives on basic and clinical science integration in a post-clerkship Step 1 curriculum. Approach: Focus groups were conducted between August and September 2020 with senior medical students from the University of California, San Francisco School of Medicine and University of Michigan Medical School. Data were analyzed using a constructivist approach to thematic analysis. Findings: Thirty-three students participated in six focus groups. Participants described multiple barriers to cognitive integration in the clerkship learning environment, though they also identified examples of teaching and learning that facilitated integration. Early in their clerkships, students struggled to integrate because of their tenuous basic science foundation, cognitive overload, and difficulty perceiving the relevance of basic science to patient care. They felt that educators primarily focused on clinical science, and many basic science teaching sessions during clerkships felt irrelevant to patient care. However, students also described experiences that made the connection between basic and clinical science more explicit, including modeling by educators and clerkship learning activities that more overtly encouraged the application of basic science to clinical care. In addition, the return to basic science studying during the post-clerkship dedicated Step 1 study period offered powerful integration opportunities. These facilitators of cognitive integration helped students recognize the value of integration for enduring learning. Insights: There are myriad barriers to cognitive integration of basic and clinical science during clerkships in a post-clerkship Step 1 curriculum. The relevance of basic science to patient care needs to be made more explicit to students through modeling by clinician educators to augment the potential benefits of curricular change. The post-clerkship Step 1 study period appears to offer a unique opportunity for cognitive integration later in a learner's trajectory that may be related to curricular design. When learners recognize the applicability of basic science to patient care, they may more intentionally transfer basic science knowledge to clinical practice.

Blue Skies With Clouds: Envisioning the Future Ideal State and Identifying Ongoing Tensions in the UME-GME Transition

The transition from medical school to residency in the United States consumes large amounts of time for students and educators in undergraduate and graduate medical education (UME, GME), and it is costly for both students and institutions. Attempts to improve the residency application and Match processes have been insufficient to counteract the very large number of applications to programs. To address these challenges, the Coalition for Physician Accountability charged the Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) with crafting recommendations to improve the system for the UME-GME transition. To guide this work, the UGRC defined and sought stakeholder input on a "blue-skies" ideal state of this transition. The ideal state views the transition as a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. This manuscript uses polarity thinking to analyze 3 persistent key tensions in the system that require ongoing management. First, the formative purpose of assessment for learning and growth is at odds with the use of assessment data for ranking and sorting candidates. Second, the function of residents as learners can conflict with their role as workers contributing service to health care systems. Third, the current residency Match process can position the desire for individual choice-among students and their programs-against the workforce needs of the profession and the public. This Scholarly Perspective presents strategies to balance the upsides and downsides inherent to these tensions. By articulating the ideal state of the UME-GME transition and anticipating tensions, educators and educational organizations can be better positioned to implement UGRC recommendations to improve the transition system.

The Undergraduate to Graduate Medical Education Transition as a Systems Problem: A Root Cause Analysis

The transition from undergraduate medical education (UME) to graduate medical education (GME) constitutes a complex system with important implications for learner progression and patient safety. The transition is currently dysfunctional, requiring students and residency programs to spend significant time, money, and energy on the process. Applications and interviews continue to increase despite stable match rates. Although many in the medical community acknowledge the problems with the UME-GME transition and learners have called for prompt action to address these concerns, the underlying causes are complex and have defied easy fixes. This article describes the work of the Coalition for Physician Accountability's Undergraduate Medical Education to Graduate Medical Education Review Committee (UGRC) to apply a quality improvement approach and systems thinking to explore the underlying causes of dysfunction in the UME-GME transition. The UGRC performed a root cause analysis using the 5 whys and an Ishikawa (or fishbone) diagram to deeply explore problems in the UME-GME transition. The root causes of problems identified include culture, costs and limited resources, bias, systems, lack of standards, and lack of alignment. Using the principles of systems thinking (components, connections, and purpose), the UGRC considered interactions among the root causes and developed recommendations to improve the UME-GME transition. Several of the UGRC's recommendations stemming from this work are explained. Sustained monitoring will be necessary to ensure interventions move the process forward to better serve applicants, programs, and the public good.

Making sense of competency-based medical education (CBME) literary conversations: A BEME scoping review: BEME Guide No. 78

BACKGROUND

Competency-based medical education (CBME) received increased attention in the early 2000s by educators, clinicians, and policy makers as a way to address concerns about physician preparedness and patient safety in a rapidly changing healthcare environment. Opinions and perspectives around this shift in medical education vary and, to date, a systematic search and synthesis of the literature has yet to be undertaken. The aim of this scoping review is to present a comprehensive map of the literary conversations surrounding CBME.

METHODS

Twelve different databases were searched from database inception up until 29 April 2020. Literary conversations were extracted into the following categories: perceived advantages, perceived disadvantages, challenges/uncertainties/skepticism, and recommendations related to CBME.

RESULTS

Of the 5757 identified records, 387 were included in this review. Through thematic analysis, eight themes were identified in the literary conversations about CBME: credibility, application, community influence, learner impact, assessment, educational developments, organizational structures, and societal impacts of CBME. Content analysis supported the development of a heat map that provides a visual illustration of the frequency of these literary conversations over time.

CONCLUSIONS

This review serves two purposes for the medical education research community. First, this review acts as a comprehensive historical record of the shifting perceptions of CBME as the construct was introduced and adopted by many groups in the medical education global community over time. Second, this review consolidates the many literary conversations about CBME that followed the initial proposal for this approach. These findings can facilitate understanding of CBME for multiple audiences both within and outside of the medical education research community.

The Clinical Microsystems Clerkship at University of California, San Francisco: Integrating Clinical Skills and Health Systems Improvement for Early Medical Students

PROBLEM

Medical educators recognize that partnering actively with health system leaders closes significant health care experience, quality, and outcomes gaps. Medical schools have explored innovations training physicians to care for both individual patients and populations while improving systems of care. Yet, early medical student education fails to include systems improvement as foundational skills. When health systems science is taught, it is often separated from core clinical skills.

APPROACH

The Clinical Microsystems Clerkship at the University of California, San Francisco School of Medicine, launched in 2016, integrates clinical skills training with health systems improvement from the start of medical school. Guided by communities of practice and workplace learning principles, it embeds first-year and second-year students in longitudinal clinical microsystems with physician coaches and interprofessional clinicians one day per week. Students learn medical history, physical examination, patient communication, interprofessional teamwork, and health systems improvement. Assessments include standardized patient examinations and improvement project reports. Program outcome measures include student satisfaction and attitudes, clinical skills performance, and evidence of systems improvement learning, including dissemination and scholarship.

OUTCOMES

Students reported high satisfaction (first-year, 4.10; second-year, 4.29, on a scale of 1-5) and value (4.14) in their development as physicians. Clinical skills assessment accuracy was high (70%-96%). Guided by interprofessional clinicians across 15 departments, students completed 258 improvement projects in 3 health systems (academic, safety net, Veterans Affairs). Sample projects reduced disparities in hypertension, improved opiate safety, and decreased readmissions. Graduating students reported both clinical skills and health systems knowledge as important to physician success, patient experience, and clinical outcomes (4.73). Most graduates discussed their projects in residency applications (85%) and disseminated related papers and presentations (54%).

NEXT STEPS

Integrating systems improvement, interprofessional teamwork, and clinical skills training can redefine early medical student education. Health system perspectives, long-term outcomes, and sustainability merit further exploration.

Beyond Checking Boxes: Exploring Tensions With Use of a Workplace-Based Assessment Tool for Formative Assessment in Clerkships

PURPOSE

To understand the role of a workplace-based assessment (WBA) tool in facilitating feedback for medical students, this study explored changes and tensions in a clerkship feedback activity system through the lens of cultural historical activity theory (CHAT) over 2 years of tool implementation.

METHOD

This qualitative study uses CHAT to explore WBA use in core clerkships by identifying feedback activity system elements (e.g., community, tools, rules, objects) and tensions among these elements. University of California, San Francisco core clerkship students were invited to participate in semistructured interviews eliciting experience with a WBA tool intended to enhance direct observation and feedback in year 1 (2019) and year 2 (2020) of implementation. In year 1, the WBA tool required supervisor completion in the school's evaluation system on a computer. In year 2, both students and supervisors had WBA completion abilities and could access the form via a smartphone separate from the school's evaluation system.

RESULTS

Thirty-five students participated in interviews. The authors identified tensions that shifted with time and tool iterations. Year 1 students described tensions related to cumbersome tool design, fear of burdening supervisors, confusion over WBA purpose, WBA as checking boxes, and WBA usefulness depending on clerkship context and culture. Students perceived dissatisfaction with the year 1 tool version among peers and supervisors. The year 2 mobile-based tool and student completion capabilities helped to reduce many of the tensions noted in year 1. Students expressed wider WBA acceptance among peers and supervisors in year 2 and reported understanding WBA to be for low-stakes feedback, thereby supporting formative assessment for learning.

CONCLUSIONS

Using CHAT to explore changes in a feedback activity system with WBA tool iterations revealed elements important to WBA implementation, including designing technology for tool efficiency and affording students autonomy to document feedback with WBAs.

Moving toward Mastery: Changes in Student Perceptions of Clerkship Assessment with Pass/Fail Grading and Enhanced Feedback

ProblemClerkship grades contribute to a summative assessment culture in clerkships and can therefore interfere with students' learning. For example, by focusing on summative, tiered clerkship grades, students often discount accompanying feedback that could inform future learning. This case report seeks to explore whether an assessment system intervention which eliminated tiered grades and enhanced feedback was associated with changes in student perceptions of clerkship assessment and perceptions of the clinical learning environment. Intervention: In January 2019, our institution eliminated tiered clerkship grading (honors/pass/fail) for medical students during the core clerkship year and implemented pass/fail clerkship grading along with required twice weekly, work-based assessments for formative feedback. Context: In this single institution, cross-sectional survey study, we collected data from fourth-year medical students one year after an assessment system intervention. The intervention entailed changing from honors/pass/fail to pass/fail grading in all eight core clerkships and implementing an electronic system to record twice-weekly real-time formative work-based assessments. The survey queried student perceptions on the fairness and accuracy of grading and the clinical learning environment-including whether clerkships were mastery- or performance-oriented. We compared responses from students one year after the assessment intervention to those from the class one year before the intervention. Comparisons were made using unpaired, two-tailed t-tests or chi-squared tests as appropriate with Cohen's d for effect size estimation for score differences. Content analysis was used to analyze responses from two open-ended questions about feedback and grading. Impact: Survey response rates were similar before and after intervention (76% (127/168) vs. 72% (118/163), respectively) with no between-group differences in demographics. The after-intervention group showed statistically significant increases in the following factors: "grades are transparent and fair" (Cohen's d = 0.80), "students receive useful feedback" (d = 0.51), and "resident evaluation procedures are fair" (d = 0.40). After-intervention respondents perceived the clerkship learning environment to be more mastery-oriented (d = 0.52), less performance approach-oriented (d = 0.63), and less performance avoid-oriented (d = 0.49). There were no statistical differences in the factors "attending evaluation procedures are fair," "evaluations are accurate," "evaluations are biased," or "perception of stereotype threat." Open-ended questions revealed student recommendations to improve clerkship summary narratives, burden of work-based assessment, and in-person feedback. Lessons Learned: After an assessment system change to pass/fail grading with work-based assessments, we observed moderate to large improvements in student perceptions of clerkship grading and the mastery orientation of the learning environment. Our intervention did not improve perceptions around bias in assessment in clerkships. Other medical schools may consider similar interventions to begin to address student concerns with clerkship assessment and promote a more adaptive learning environment.

How preceptors develop trust in continuity clinic residents and how trust influences supervision: A qualitative study

INTRODUCTION

To advance in their clinical roles, residents must earn supervisors' trust. Research on supervisor trust in the inpatient setting has identified learner, supervisor, relationship, context, and task factors that influence trust. However, trust in the continuity clinic setting, where resident roles, relationships, and context differ, is not well understood. We aimed to explore how preceptors in the continuity clinic setting develop trust in internal medicine residents and how trust influences supervision.

METHODS

In this qualitative study, we conducted semi-structured interviews with faculty preceptors from two continuity clinic sites in an internal medicine residency program at an urban academic medical center in the United States from August 2018-June 2020. We analyzed transcripts using thematic analysis with sensitizing concepts related to the theoretical framework of the five factors of trust.

RESULTS

Sixteen preceptors participated. We identified four key drivers of trust and supervision in the continuity clinic setting: 1) longitudinal resident-preceptor-patient relationships, 2) direct observations of continuity clinic skills, 3) resident attitude towards their primary care physician role, and 4) challenging context and task factors influencing supervision. Preceptors shared challenges to determining trust stemming from incomplete knowledge about patients and limited opportunities to directly observe and supervise between-visit care.

DISCUSSION

The continuity clinic setting offers unique supports and challenges to trust development and trust-supervision alignment. Maximizing resident-preceptor-patient continuity, promoting direct observation, and improving preceptor supervision of residents' provision of between-visit care may improve resident continuity clinic learning and patient care.

Exploring how feedback reflects entrustment decisions using artificial intelligence

CONTEXT

Clinical supervisors make judgements about how much to trust learners with critical activities in patient care. Such decisions mediate trainees' opportunities for learning and competency development and thus are a critical component of education. As educators apply entrustment frameworks to assessment, it is important to determine how narrative feedback reflecting entrustment may also address learners' educational needs.

METHODS

In this study, we used artificial intelligence (AI) and natural language processing (NLP) to identify characteristics of feedback tied to supervisors' entrustment decisions during direct observation encounters of clerkship medical students (3328 unique observations). Supervisors conducted observations of students and collaborated with them to complete an entrustment-based assessment in which they documented narrative feedback and assigned an entrustment rating. We trained a deep neural network (DNN) to predict entrustment levels from the narrative data and developed an explainable AI protocol to uncover the latent thematic features the DNN used to make its prediction.

RESULTS

We found that entrustment levels were associated with level of detail (specific steps for performing clinical tasks), feedback type (constructive versus reinforcing) and task type (procedural versus cognitive). In justifying both high and low levels of entrustment, supervisors detailed concrete steps that trainees performed (or did not yet perform) competently.

CONCLUSIONS

Framing our results in the factors previously identified as influencing entrustment, we find a focus on performance details related to trainees' clinical competency as opposed to nonspecific feedback on trainee qualities. The entrustment framework reflected in feedback appeared to guide specific goal-setting, combined with details necessary to reach those goals. Our NLP methodology can also serve as a starting point for future work on entrustment and feedback as similar assessment datasets accumulate.

Does being a coach benefit clinician-educators? A mixed methods study of faculty self-efficacy, job satisfaction and burnout

INTRODUCTION

Coaching is a growing clinician-educator role. Self-efficacy is a powerful faculty motivator that is associated positively with job satisfaction and negatively with burnout. This study examines self-efficacy, job satisfaction, and burnout in coaches and other clinician-educators.

METHODS

We conducted a mixed methods study using a quantitative survey followed by qualitative interviews of faculty at the University of California, San Francisco. Coaches (funded 20% full-time equivalents), faculty with other funded education positions ("funded"), and faculty without funded education positions ("unfunded") completed a 48-item survey addressing self-efficacy (teaching, professional development, and scholarship), job satisfaction, and burnout. Data were analyzed using analysis of variance followed by post-hoc tests and chi-square tests. To elaborate quantitative results, we conducted qualitative interviews of 15 faculty and analyzed data using framework analysis.

RESULTS

202 of 384 faculty (52.6%) responded to the survey; 187 complete surveys were analyzed. Teaching self-efficacy was similar across groups. Coaches and funded educators had significantly higher professional development self-efficacy and job satisfaction than unfunded educators. Burnout was more prevalent in coaches and unfunded educators. Qualitative analysis yielded three themes: sources of reward, academic identity, and strategies to mitigate burnout. Educator roles provide reward that enhances self-efficacy and job satisfaction but also generate competing demands. Coaches cited challenges in forming professional identities and working with struggling learners.

DISCUSSION

The coaching role provides faculty with benefits similar to other funded educator roles, but the particular demands of the coach role may contribute to burnout.

How supervisor trust affects early residents' learning and patient care: A qualitative study

INTRODUCTION

Trust between supervisors and trainees mediates trainee participation and learning. A resident (postgraduate) trainee's understanding of their supervisor's trust can affect their perceptions of their patient care responsibilities, opportunities for learning, and overall growth as physicians. While the supervisor perspective of trust has been well studied, less is known about how resident trainees recognize supervisor trust and how it affects them.

METHODS

In this qualitative study, 21 pediatric residents were interviewed at a single institution. Questions addressed their experiences during their first post-graduate year (PGY-1) on inpatient wards. Each interviewee was asked to describe three different patient care scenarios in which they perceived optimal, under-, and over-trust from their resident supervisor. Data were analyzed using thematic analysis.

RESULTS

Residents recognized and interpreted their supervisor's trust through four factors: supervisor, task, relationship, and context. Optimal trust was associated with supervision balancing supervisor availability and resident independence, tasks affording participation in decision-making, trusting relationships with supervisors, and a workplace fostering appropriate autonomy and team inclusivity. The effects of supervisor trust on residents fell into three themes: learning experiences, attitudes and self-confidence, and identities and roles. Optimal trust supported learning via tailored guidance, confidence and lessened vulnerability, and a sense of patient ownership and team belonging.

DISCUSSION

Understanding how trainees recognize supervisor trust can enhance interventions for improving the dialogue of trust between supervisors and trainees. It is important for supervisors to be cognizant of their trainees' interpretations of trust because it affects how trainees understand their patient care roles, perceive autonomy, and approach learning.

Excellence in medical training: developing talent-not sorting it

Many medical schools have reconsidered or eliminated clerkship grades and honor society memberships. National testing organizations announced plans to eliminate numerical scoring for the United States Medical Licensing Examination Step 1 in favor of pass/fail results. These changes have led some faculty to wonder: "How will we recognize and reward excellence?" Excellence in undergraduate medical education has long been defined by high grades, top test scores, honor society memberships, and publication records. However, this model of learner excellence is misaligned with how students learn or what society values. This accolade-driven view of excellence is perpetuated by assessments that are based on gestalt impressions influenced by similarity between evaluators and students, and assessments that are often restricted to a limited number of traditional skill domains. To achieve a new model of learner excellence that values the trainee's achievement, growth, and responsiveness to feedback across multiple domains, we must envision a new model of teacher excellence. Such teachers would have a growth mindset toward assessing competencies and learning new competencies. Actualizing true learner excellence will require teachers to change from evaluators who conduct assessments of learning to coaches who do assessment for learning. Schools will also need to establish policies and structures that foster a culture that supports this change. In this new paradigm, a teacher's core duty is to develop talent rather than sort it.

No One Size Fits All: A Qualitative Study of Clerkship Medical Students' Perceptions of Ideal Supervisor Responses to Microaggressions

PURPOSE

This study explores medical students' perspectives on the key features of ideal supervisor responses to microaggressions targeting clerkship medical students.

METHOD

This single-institution, qualitative focus group study, based in an interpretivist paradigm, explored clerkship medical students' perceptions in the United States, 2020. During semistructured focus groups, participants discussed 4 microaggression scenarios. The authors employed the framework method of thematic analysis to identify considerations and characteristics of ideal supervisor responses and explored differences in ideal response across microaggression types.

RESULTS

Thirty-nine students participated in 7 focus groups, lasting 80 to 92 minutes per group. Overall, students felt that supervisors' responsibility began before a microaggression occurred, through anticipatory discussions ("pre-brief") with all students to identify preferences. Students felt that effective bystander responses should acknowledge student preferences, patient context, interpersonal dynamics in the room, and the microaggression itself. Microassaults necessitated an immediate response. After a microaggression, students preferred a brief one-on-one check-in with the supervisor to discuss the most supportive next steps including whether further group discussion would be helpful.

CONCLUSIONS

Students described that an ideal supervisor bystander response incorporates both student preferences and the microaggression context, which are best revealed through advanced discussion. The authors created the Bystander Microaggression Intervention Guide as a visual representation of the preferred bystander microaggression response based on students' discussions. Effective interventions promote educational safety and shift power dynamics to empower the student target.

The Dissolution of the Step 2 Clinical Skills Examination and the Duty of Medical Educators to Step Up the Effectiveness of Clinical Skills Assessment

In this Invited Commentary, the authors explore the implications of the dissolution of the Step 2 Clinical Skills Examination (Step 2 CS) for medical student clinical skills assessment. The authors describe the need for medical educators (at both the undergraduate and graduate levels) to work collaboratively to improve medical student clinical skills assessment to assure the public that medical school graduates have the requisite skills to begin residency training. The authors outline 6 specific recommendations for how to capitalize on the discontinuation of Step 2 CS to improve clinical skills assessment: (1) defining national, end-of-clerkship, and transition-to-residency standards for required clinical skills and for levels of competence; (2) creating a national resource for standardized patient, augmented reality, and virtual reality assessments; (3) improving workplace-based assessment through local collaborations and national resources; (4) improving learner engagement in and coproduction of assessments; (5) requiring, as a new standard for accreditation, medical schools to establish and maintain competency committees; and (6) establishing a national registry of assessment data for research and evaluation. Together, these actions will help the medical education community earn the public's trust by enhancing the rigor of assessment to ensure the mastery of skills that are essential to providing safe, high-quality care for patients.

Does Delaying the United States Medical Licensing Examination Step 1 to After Clerkships Affect Student Performance on Clerkship Subject Examinations?

Phenomenon: Schools are considering the optimal timing of Step 1 of the United States Medical Licensing Examination (USMLE). Two primary reasons for moving Step 1 after the core clerkships are to promote deeper, more integrated basic science learning in clinical contexts and to better prepare students for the increasingly clinical focus of Step 1. Positioning Step 1 after the core clerkships leverages a major national assessment to drive learning, encouraging students to deepen their basic science knowledge while in the clinical setting. Previous studies demonstrated small increases in Step 1 scores, reductions in failure rates, and similar Step 2 Clinical Knowledge scores when Step 1 was after the clerkships. Some schools that have moved Step 1 reported declines in clinical subject examination (CSE) performance. This may be due to shortened pre-clerkship curricula, the absence of the Step 1 study period for knowledge consolidation, or exposure to fewer National Board of Medical Examiners type questions prior to taking CSEs. This multi-institutional study aimed to determine whether student performance on CSEs was affected by moving Step 1 after the core clerkships. Approach: CSE scores for students from eight schools that moved Step 1 after core clerkships between 2012 and 2016 were analyzed in a pre-post format. Hierarchical linear modeling was used to quantify the effect of the curriculum on CSE performance. Additional analysis determined if clerkship order impacted clinical subject exam performance and whether the curriculum change resulted in more students scoring in the lowest percentiles (as defined as below the national fifth percentile) before and after the curricular change. Findings: After moving Step 1 to after the clerkships, collectively these eight schools demonstrated statistically significant lower performance on four CSEs (Medicine, Neurology, Pediatrics, and Surgery) but not Obstetrics/Gynecology or Psychiatry. Comparing performance within the three years pre and post Step 1 change, differences across all clerkships ranged from 0.3 to -2.0 points, with an average difference of -1.1. CSE performance in clerkships taken early in the sequence was more affected by the curricular change, and differences gradually disappeared with subsequent examinations. Medicine and Neurology showed the largest average differences between curricular-group when taken early in the clinical year. Finally, there was a slightly higher chance of scoring below the national fifth percentile in four of the clinical subject exams (Medicine, Neurology, Pediatrics, and Psychiatry) for the cohort with Step 1 after the clerkships. Insights: Moving Step 1 after core clerkships had a small impact on CSE scores overall, with decreased scores for exams early in the clerkship sequence and an increased number of students below the fifth percentile. Score differences have minor effects on clerkship grades, but overall the size of the effect is unlikely to be educationally meaningful. Schools can use a variety of mitigation strategies to address CSE performance and Step 1 preparation in the clerkship phase.

Strategies From 11 U.S. Medical Schools for Integrating Basic Science Into Core Clerkships

Calls for curricular reform in medical schools and enhanced integration of basic and clinical science have resulted in a shift toward preclerkship curricula that enhance the clinical relevance of foundational science instruction and provide students with earlier immersion in the clinical environment. These reforms have resulted in shortened preclerkship curricula, yet the promise of integrated basic science education into clerkships has not been sufficiently realized because of barriers such as the nature of clinical practice, time constraints, and limited faculty knowledge. As personalized medicine requires that physicians have a more nuanced understanding of basic science, this is cause for alarm. To address this problem, several schools have developed instructional and assessment strategies to better integrate basic science into the clinical curriculum. In this article, faculty and deans from 11 U.S. medical schools discuss the strategies they implemented and the lessons they learned to provide guidance to other schools seeking to enhance basic science education during clerkships. The strategies include program-level interventions (e.g., longitudinal sessions dedicated to basic science during clerkships, weeks of lessons dedicated to basic science interspersed in clerkships), clerkship-level interventions (e.g., case-based learning with online modules, multidisciplinary clerkship dedicated to applied science), bedside-level interventions (e.g., basic science teaching scripts, self-directed learning), and changes to formative and summative assessments (e.g., spaced repetition/leveraging test-enhanced learning, developing customized examinations). The authors discovered that: interventions were more successful when buy-in from faculty and students was considered, central oversight by curricular committees collaborating with faculty was key, and some integration efforts may require schools to provide significant resources. All schools administered the United States Medical Licensing Examination Step 1 exam to students after clerkship, with positive outcomes. The authors have demonstrated that it is feasible to incorporate basic science into clinical clerkships, but certain challenges remain.

Twelve tips for learners to succeed in a CBME program

The international movement to competency-based medical education (CBME) marks a major transition in medical education that requires a shift in educators' and learners' approach to clinical experiences, the way assessment data are collected and integrated, and in learners' mindsets. Learners entering a CBME curriculum must actively drive their learning experiences and education goals. For some, this expectation may be a significant change from their previous approach to learning in medicine. This paper highlights 12 tips to help learners succeed within a CBME model.

Growth mindset in competency-based medical education

The ongoing adoption of competency-based medical education (CBME) across health professions training draws focus to learner-centred educational design and the importance of fostering a growth mindset in learners, teachers, and educational programs. An emerging body of literature addresses the instructional practices and features of learning environments that foster the skills and strategies necessary for trainees to be partners in their own learning and progression to competence and to develop skills for lifelong learning. Aligned with this emerging area is an interest in Dweck's self theory and the concept of the growth mindset. The growth mindset is an implicit belief held by an individual that intelligence and abilities are changeable, rather than fixed and immutable. In this paper, we present an overview of the growth mindset and how it aligns with the goals of CBME. We describe the challenges associated with shifting away from the fixed mindset of most traditional medical education assumptions and practices and discuss potential solutions and strategies at the individual, relational, and systems levels. Finally, we present future directions for research to better understand the growth mindset in the context of CBME.

Key considerations in planning and designing programmatic assessment in competency-based medical education

Programmatic assessment as a concept is still novel for many in clinical education, and there may be a disconnect between the academics who publish about programmatic assessment and the front-line clinical educators who must put theory into practice. In this paper, we clearly define programmatic assessment and present high-level guidelines about its implementation in competency-based medical education (CBME) programs. The guidelines are informed by literature and by lessons learned from established programmatic assessment approaches. We articulate five steps to consider when implementing programmatic assessment in CBME contexts: articulate the purpose of the program of assessment, determine what must be assessed, choose tools fit for purpose, consider the stakes of assessments, and define processes for interpreting assessment data. In the process, we seek to offer a helpful guide or template for front-line clinical educators. We dispel some myths about programmatic assessment to help training programs as they look to design-or redesign-programs of assessment. In particular, we highlight the notion that programmatic assessment is not 'one size fits all'; rather, it is a system of assessment that results when shared common principles are considered and applied by individual programs as they plan and design their own bespoke model of programmatic assessment for CBME in their unique context.

Diagnosing conflict: Conflicting data, interpersonal conflict, and conflicts of interest in clinical competency committees

Clinical competency committees (CCCs) are increasingly used within health professions education as their decisions are thought to be more defensible and fairer than those generated by previous training promotion processes. However, as with most group-based processes, it is inevitable that conflict will arise. In this paper the authors explore three ways conflict may arise within a CCC: (1) conflicting data submissions that are presented to the committee, (2) conflicts between members of the committee, and (3) conflicts of interest between a specific committee member and a trainee. The authors describe each of these conflict situations, dissect out the underlying problems, and explore possible solutions based on the current literature.

The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education

In 2010, several key works in medical education predicted the changes necessary to train modern physicians to meet current and future challenges in health care, including the standardization of learning outcomes paired with individualized learning processes. The reframing of a medical expert as a flexible, adaptive team member and change agent, effective within a larger system and responsive to the community's needs, requires a new approach to education: competency-based medical education (CBME). CBME is an outcomes-based developmental approach to ensuring each trainee's readiness to advance through stages of training and continue to grow in unsupervised practice. Implementation of CBME with fidelity is a complex and challenging endeavor, demanding a fundamental shift in organizational culture and investment in appropriate infrastructure. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium developed and implemented CBME, including common challenges and successes. Critical supporting factors include adoption of the master adaptive learner construct, longitudinal views of learner development, coaching, and a supportive learning environment.

From Grading to Assessment for Learning: A Qualitative Study of Student Perceptions Surrounding Elimination of Core Clerkship Grades and Enhanced Formative Feedback

Problem: Medical students perceive honors grading during core clerkships as unfair and inequitable, and negatively impacting their learning and wellbeing. Eliminating honors grading, a powerful extrinsic motivator, and emphasizing formative feedback may address these problems and promote intrinsic motivation and learning. However, it is unknown how transitioning from honors to pass/fail grading with enhanced formative feedback in the core clerkship year may affect student learning experiences, wellbeing, and perceptions of the learning environment. Intervention: Core clerkship grading was transitioned from honors/pass/fail to pass/fail at one US medical school. In addition, the requirement for students to obtain formative supervisor feedback was formalized to twice per week. Context: This qualitative study utilized semi-structured interviews to explore the perceptions among core clerkship students of learning and assessment. Interview questions addressed motivation, wellbeing, learning behaviors, team dynamics, feedback, and student and supervisor attitudes regarding assessment changes. The authors analyzed data inductively using thematic analysis informed by sensitizing concepts related to theories of motivation (goal orientation theory and self-determination theory). Impact: Eighteen students participated, including five with experience in both honors-eligible and pass/fail clerkships. The authors identified three major themes in students' descriptions of the change in approach to assessment: student engagement in clerkships, wellbeing, and recognition of learning context. Student engagement subthemes included intrinsic motivation for patient care rather than performing; sense of agency over learning, including ability to set learning priorities, seek and receive feedback, take learning risks, and disagree with supervisors, and collaborative relationships with peers and team members. Positive wellbeing was characterized by low stress, sense of authenticity with team members, prioritized physical health, and attention to personal life. Learning context subthemes included recognition of variability of clerkship contexts with pass/fail grading mitigating fairness and equity concerns, support of the grading change from residents and some attendings, and implications surrounding future stress and residency selection. Lessons Learned: Students perceive a transition from honors grading to pass/fail with increased feedback as supporting their engagement in learning, intrinsic motivation, and wellbeing. Drivers of wellbeing appear to include students' feelings of control, achieved through the ability to seek learning opportunities, teaching, and constructive feedback without the perceived need to focus on impressing others. Ongoing evaluation of the consequences of this shift in assessment is needed.

Assessment to Optimize Learning Strategies: A Qualitative Study of Student and Faculty Perceptions

Phenomenon: The format of medical knowledge assessment can promote students' use of effective learning strategies from the learning sciences literature, such as elaboration, interleaving, retrieval practice, and distributed learning. Assessment format can also influence faculty teaching. Accordingly, our institution implemented a new assessment strategy in which pre-clerkship medical students answered weekly formative quizzes with constructed response questions (also referred to as open-ended questions) and multiple-choice questions in preparation for summative open-ended question examinations, to support students' use of recommended learning strategies. Our qualitative study explored medical student and faculty perceptions of this assessment strategy on learning and teaching. Approach: We conducted semi-structured interviews with 16 second-year medical students to explore their preparation for quizzes and summative examinations. We also interviewed 10 faculty responsible for writing and grading these assessments in the pre-clerkship foundational sciences curriculum regarding their approach to writing assessments and rubrics, and their perceptions of how their teaching may have changed with this assessment strategy. We analyzed interview transcripts using thematic analysis with a priori sensitizing concepts from the learning sciences literature. Findings: We identified four major themes characterizing student and faculty perceptions of weekly formative quizzes and summative OEQ examinations. Participants found that this assessment strategy helped (1) prioritize conceptual understanding, (2) simulate clinical problem solving, and (3) engage students and faculty in continuous improvement in their approach to learning or teaching. Faculty and students also recognized challenges and potential tradeoffs associated with these assessment formats. Participants identified (4) facilitators and barriers when implementing this assessment strategy. Insights: Our findings suggested that assessment of medical knowledge through weekly formative quizzes and summative open-ended question examinations can facilitate students' use of effective learning strategies. Faculty also recognized improvements in their teaching and in quality of assessment. This format of assessment also presented some challenges and potential tradeoffs and significant institutional resources were required for implementation.

Gender Differences in Milestone Ratings and Medical Knowledge Examination Scores Among Internal Medicine Residents

PURPOSE

To examine whether there are group differences in milestone ratings submitted by program directors working with clinical competency committees (CCCs) based on gender for internal medicine (IM) residents and whether women and men rated similarly on milestones perform comparably on subsequent in-training and certification examinations.

METHOD

This national retrospective study examined end-of-year medical knowledge (MK) and patient care (PC) milestone ratings and IM In-Training Examination (IM-ITE) and IM Certification Examination (IM-CE) scores for 2 cohorts (2014-2017, 2015-2018) of U.S. IM residents at ACGME-accredited programs. It included 20,098/21,440 (94%) residents, with 9,424 women (47%) and 10,674 men (53%). Descriptive statistics and differential prediction techniques using hierarchical linear models were performed.

RESULTS

For MK milestone ratings in PGY-1, men and women showed no statistical difference at a significance level of .01 (P = .02). In PGY-2 and PGY-3, men received statistically higher average MK ratings than women (P = .002 and P < .001, respectively). In contrast, men and women received equivalent average PC ratings in each PGY (P = .47, P = .72, and P = .80, for PGY-1, PGY-2, and PGY-3, respectively). Men slightly outperformed women with similar MK or PC ratings in PGY-1 and PGY-2 on the IM-ITE by about 1.7 and 1.5 percentage points, respectively, after adjusting for covariates. For PGY-3 ratings, women and men with similar milestone ratings performed equivalently on the IM-CE.

CONCLUSIONS

Milestone ratings were largely similar for women and men. Generally, women and men with similar MK or PC milestone ratings performed similarly on future examinations. Although there were small differences favoring men on earlier examinations, these differences disappeared by the final training year. It is questionable whether these small differences are educationally or clinically meaningful. The findings suggest fair, unbiased milestone ratings generated by program directors and CCCs assessing residents.