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Problem The COVID-19 pandemic restricted in-person gatherings, including residency conferences. The pressure to quickly reorganize educational conferences and convert content to a remote format overwhelmed many programs. This article describes the pilot event of a large-scale, interactive, virtual educational conference modeled, designed, and implemented by Academic Life in Emergency Medicine (ALiEM), called ALiEM Connect. Approach The pilot ALiEM Connect event was conceptualized and implemented within a 2-week period in March 2020. The pilot was livestreamed via a combination of Zoom and YouTube and was archived by YouTube. Slack was used as a backchannel to allow interaction with other participants and engagement with the speakers (via moderators who posed questions from the backchannel to the speakers live during the videoconference). Outcomes The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework was used for program evaluation, showing that 64 U.S. Accreditation Council for Graduate Medical Education-accredited emergency medicine residency programs participated in the pilot event, with 1,178 unique users during the event (reach). For effectiveness, 93% (139/149) of trainees reported the pilot as enjoyable and 85% (126/149) reported it was equivalent to or better than their usual academic proceedings. Adoption for ALiEM Connect was fairly good with 64/237 (27%) of invited residency programs registering and participating in the pilot event. Implementation was demonstrated by nearly half of the livestream viewers (47%, 553/1,178) interacting in the backchannel discussion, sending a total of 4,128 messages in the first 4 hours. Next Steps The final component of the RE-AIM framework, maintenance, will take more time to evaluate. Further study is required to measure the educational impact of events like the ALiEM Connect pilot. The ALiEM Connect model could potentially be used to replace educational conferences that have been canceled or to implement and/or augment a large-scale, shared curriculum among residency programs in the future., American Board of Emergency Medicine (ABEM), The American Board of Emergency Medicine (ABEM) provided exclusive financial sponsorship support for ALiEM Connect.

Entrustable professional activities (EPAs) have been increasingly used as an assessment framework to formally capture the myriad ad hoc entrustment decisions that occur on a daily basis in clinical settings with learners present. Following the definition of Core EPAs for Entering Residency by the Association of American Medical Colleges in 2014, the American Board of Surgery (ABS) began to explore the utility of EPAs as a framework to support competency-based resident education within general surgery in 2016. As the complement of EPAs drafted for a specialty serve to define the core tasks of a professional within that discipline, initial efforts to define the entire scope of general surgery were fraught with difficulty as no commonly accepted definition of a general surgeon currently exists. Opting to prioritize a pilot of the EPA conceptual framework within surgical training rather than defining the entirety of the specialty, ABS leaders identified 5 EPAs that represent a core of general surgery with which to begin. This article details the process of choosing the initial set of EPAs and provides a roadmap for other disciplines interested in testing the feasibility of this assessment framework while garnering buy-in among the community of educators. Future steps, including implementation of the existing 5 EPAs beyond the initial pilot sites and drafting and implementation of the additional complement of EPAs, are also described.

The transition to the assessment of entrustable professional activities as part of competency-based medical education (CBME) has substantially increased the number of assessments completed on each trainee. Many CBME programs are having difficulty synthesizing the increased amount of assessment data. Learning analytics are a way of addressing this by systematically drawing inferences from large datasets to support trainee learning, faculty development, and program evaluation. Early work in this field has tended to emphasize the significant potential of analytics in medical education. However, concerns have been raised regarding data security, data ownership, validity, and other issues that could transform these dreams into nightmares. In this paper, the authors explore these contrasting perspectives by alternately describing utopian and dystopian futures for learning analytics within CBME. Seeing learning analytics as an important way to maximize the value of CBME assessment data for organizational development, they argue that their implementation should continue within the guidance of an ethical framework.

To establish a research and development agenda for Entrustable Professional Activities (EPAs) for the coming decade, the authors, all active in this area of investigation, reviewed recent research papers, seeking recommendations for future research. They pooled their knowledge and experience to identify 3 levels of potential research and development: the micro level of learning and teaching; the meso level of institutions, programs, and specialty domains; and the macro level of regional, national, and international dynamics. Within these levels, the authors categorized their recommendations for research and development. The authors identified 14 discrete themes, each including multiple questions or issues for potential exploration, that range from foundational and conceptual to practical. Much research to date has focused on a variety of issues regarding development and early implementation of EPAs. Future research should focus on large-scale implementation of EPAs to support competency-based medical education (CBME) and on its consequences at the 3 levels. In addition, emerging from the implementation phase, the authors call for rigorous studies focusing on conceptual issues. These issues include the nature of entrustment decisions and their relationship with education and learner progress and the use of EPAs across boundaries of training phases, disciplines and professions, including continuing professional development. International studies evaluating the value of EPAs across countries are another important consideration. Future studies should also remain alert for unintended consequences of the use of EPAs. EPAs were conceptualized to support CBME in its endeavor to improve outcomes of education and patient care, prompting creation of this agenda.

Entrustable professional activities (EPAs) have emerged as a meaningful framework for achieving competency-based medical education (CBME). However, little is known about how to adapt EPAs to large-scale, multispecialty, system-wide implementations. The authors describe the design and experience of creating such a system based on EPAs and the Van Melle Core Components Framework for all accredited training programs under the auspices of the Royal College of Physicians and Surgeons of Canada. The resulting design is a unique configuration and use of EPAs, called Royal College EPAs. Others looking to implement EPAs for large-scale health professions education systems may want to consider this design approach.

The Core EPAs for Entering Residency Pilot project aimed to test the feasibility of implementing 13 entrustable professional activities (EPAs) at 10 U.S. medical schools and to gauge whether the use of the Core EPAs could improve graduates' performance early in residency. In this manuscript, the authors (members of the pilot institutions and Association of American Medical Colleges staff supporting the project evaluation) describe the schools' capacity to collect multimodal evidence about their students' performance in each of the Core EPAs and the ability of faculty committees to use those data to make decisions regarding learners' readiness for entrustment. In reviewing data for each of the Core EPAs, the authors reflected on how each activity performed as an EPA informed by how well it could be assessed and entrusted. For EPAs that did not perform well, the authors examined whether there are underlying practical and/or theoretical issues limiting its utility as a measure of student performance in medical school.

Contains fulltext : 235350.pdf (Publisher’s version ) (Closed access) Postgraduate medical education in the Netherlands has adopted competency-based education since the turn of the century. In 2006, the CanMEDS competency framework was introduced. A 2013 government plan to reduce the length and budgets of training programs led the Dutch Association of Medical Specialists (DAMS) to respond with a proposal to create more flexibility and individualization rather than a blunt cut in the length across all training programs. DAMS launched a government-funded, nation-wide, 4-year project (2014-2018) to blueprint the reform of postgraduate medical education in this direction. To achieve competency-based individualization, the fixed duration of postgraduate programs was abandoned, and entrustable professional activities (EPAs) were introduced in all specialty programs. Implementation of this new generation of programs took place in 2017-2019 in all disciplines. The project focused on EPA-based individualization of all programs, while addressing issues of the continuity of patient care in time-variable programs and the legal and regulatory consequences of individualization. About 30 specialty programs were revised at national, regional, local, and individual levels to incorporate EPAs; portfolio systems were adapted, clinical competency committees were installed for all programs, and procedures for summative entrustment decision making were elaborated. This paper reports on the rationale and the process that led to a more time-variable postgraduate education landscape, and, on average, a shortening of training length by 3 months.

Educators use entrustment, a common framework in competency-based medical education, in multiple ways, including frontline assessment instruments, learner feedback tools, and group decision making within promotions or competence committees. Within these multiple contexts, entrustment decisions can vary in purpose (i.e., intended use), stakes (i.e., perceived risk or consequences), and process (i.e., how entrustment is rendered). Each of these characteristics can be conceptualized as having 2 distinct poles: (1) purpose has formative and summative, (2) stakes has low and high, and (3) process has ad hoc and structured. For each characteristic, entrustment decisions often do not fall squarely at one pole or the other, but rather lie somewhere along a spectrum. While distinct, these continua can, and sometimes should, influence one another, and can be manipulated to optimally integrate entrustment within a program of assessment. In this article, the authors describe each of these continua and depict how key alignments between them can help optimize value when using entrustment in programmatic assessment within competency-based medical education. As they think through these continua, the authors will begin and end with a case study to demonstrate the practical application as it might occur in the clinical learning environment.

The adoption of entrustment ratings in medical education is based on a seemingly simple premise: to align workplace-based supervision with resident assessment. Yet it has been difficult to operationalize this concept. Entrustment rating forms combine numeric scales with comments and are embedded in a programmatic assessment framework, which encourages the collection of a large quantity of data. The implicit assumption that more is better has led to an untamable volume of data that competency committees must grapple with. In this article, the authors explore the roles of numbers and words on entrustment rating forms, focusing on the intended and optimal use(s) of each, with a focus on the words. They also unpack the problematic issue of dual-purposing words for both assessment and feedback. Words have enormous potential to elaborate, to contextualize, and to instruct; to realize this potential, educators must be crystal clear about their use. The authors set forth a number of possible ways to reconcile these tensions by more explicitly aligning words to purpose. For example, educators could focus written comments solely on assessment; create assessment encounters distinct from feedback encounters; or use different words collected from the same encounter to serve distinct feedback and assessment purposes. Finally, the authors address the tyranny of documentation created by programmatic assessment and urge caution in yielding to the temptation to reduce words to numbers to make them manageable. Instead, they encourage educators to preserve some educational encounters purely for feedback, and to consider that not all words need to become data.

While sociopolitical advances have improved the rights of sexual and gender minorities (i.e., lesbian, gay, bisexual, transgender, queer [LGBTQ+] persons), they continue to face a health system that discriminates against them and does not provide competent, comprehensive care. Despite calls for advancing research, there remains limited sexual and gender minority health research funding, mentorship, and institutional support. Academic medical centers are best suited to systematically tackle disparities and improve care for all sexual and gender minority people through their tripartite missions of patient care, education, and research. In this article, the authors outline discrimination experienced by LGBTQ+ persons and highlight the unique disparities they experience across access and outcomes. The authors posit that by systematically improving clinical care of, incorporating education and training about, and research with LGBTQ+ people into their core missions, academic medical centers can dramatically change the health care landscape. Academic medical centers can eliminate health disparities, expand necessary research endeavors about sexual and gender minorities, and prepare the health care workforce to address the unique needs of these overlooked populations.

Purpose Evaluation of the medical profession at all levels has exposed episodes of gender-based role misidentification whereby women physicians are disproportionately misidentified as nonphysicians. The authors of this study investigate this phenomenon and its repercussions, quantifying the frequency with which resident physicians experience role misidentification and the effect this has on their experience and behavior. Method In 2018, the authors conducted a cross-sectional survey study of internal medicine, surgical, and emergency medicine residents at a single, large, urban, tertiary academic medical center. The survey tool captured both the self-reported frequency and effect of professional misidentification. The authors used a t test and linear multivariate regression to analyze the results. Results Of the 260 residents who received the survey, 186 (72%) responded, and the authors analyzed the responses of 182. All 85 of the women respondents (100%) reported being misidentified as nonphysicians at least once in their professional experience by patients or staff members, compared with 49% of the 97 men respondents. Of those 182 residents, 35% of women were misidentified more than 8 times per month by patients compared with 1% of men. Of the 85 women physicians responding to the survey, 38% felt angry and 36% felt less satisfied with their jobs as a result of misidentification compared with, respectively, 7% and 9% of men. In response to role misidentification, 51% of women changed their manner of attire and 81% changed their manner of introduction, compared with, respectively, 7% and 37% of men. Conclusions These survey results demonstrate that women physicians are more likely than men physicians to be misidentified as nonphysicians and that role misidentification provokes gender-polarized psychological and behavioral responses that have potentially important professional ramifications.

COVID-19 is a worldwide pandemic, with frontlines that look drastically different than in past conflicts: that is, women now make up a sizeable majority of the health care workforce. American women have a long history of helping in times of hardship, filling positions on the home front vacated by men who enlisted as soldiers during World War I and similarly serving in crucial roles on U.S. military bases, on farms, and in factories during World War II. The COVID-19 pandemic has represented a novel battleground, as the first in which women have taken center stage, not only in their roles as physicians, respiratory therapists, nurses, and the like, but also by serving in leadership positions and facilitating innovations in science, technology, and policy. Yet, the pandemic has exacerbated multiple pain points that have disproportionally impacted women in health care, including shortages in correctly sized personal protective equipment and uniforms, inadequate support for pregnant and breastfeeding providers, and challenges associated with work-life balance and obtaining childcare. While the pandemic has facilitated several positive advancements in addressing these challenges, there is still much work to be done for women to achieve equity and optimal support in their roles on the frontlines.

The National Institutes of Health (NIH) has prioritized efforts to increase diversity in the biomedical research workforce. NIH-funded institutional career development awards may serve as one mechanism to facilitate these efforts. In 2013, the Duke University KL2 program, an internal career development program funded by the National Center for Advancing Translational Sciences, set a goal to increase the number of investigators from underrepresented racial and ethnic groups (UREGs) to ≥ 50% of KL2 awardees. From 2013 to 2019, 133 KL2 applications were received, 38% from UREG investigators. Of the 21 scholars selected, 10 (47.6%) were UREG investigators; all were Black/African American. This represents a threefold increase in the proportion of UREG applications and a sixfold increase in the proportion of UREG KL2 scholars compared with Duke's previous KL2 cycles (2003-2012), during which only 13% of applicants and 8.3% of funded scholars were UREGs. Of the 12 KL2 scholars (7 UREG) who completed the program, 5 have received NIH funding as principal investigators of an external K award or R01, and 4 of them are UREG investigators; this constitutes a post-KL2 NIH funding success rate of 57% (4/7) for UREG scholars. Achieving this programmatic priority was facilitated by institutional support, clear communication of goals to increase the proportion of UREG KL2 awardees, and intentional strategies to identify and support applicants. Strategies included targeted outreach to UREG investigators, partnerships with other institutional entities, structured assistance for investigators with preparing their applications, and a KL2 program structure addressing common barriers to success for UREG investigators, such as lack of consistent mentorship, protected research time, and peer support. The authors' experience suggests that KL2 and other internal career development programs may represent a scalable, national strategy to increase diversity in the biomedical research workforce.

Purpose When the Centers for Medicare and Medicaid Services (CMS) changed policies about medical student documentation, students with proper supervision may now document their history, physical exam, and medical decision-making in the electronic health record (EHR) for billable encounters. Since documentation is a core entrustable professional activity for medical students, the authors sought to evaluate student opportunities for documentation and feedback across and between clerkships. Method In February 2018, a multidisciplinary workgroup was formed to implement student documentation at Duke University Health System, including educating trainees and supervisors, tracking EHR usage, and enforcing CMS compliance. From August 2017 to August 2018, locations and types of student-involved services (student-faculty, or student-resident-faculty) were tracked using billing data from attestation statements. Student end-of-clerkship evaluations included opportunity for documentation and receipt of feedback. Since documentation was not allowed prior to August 2018 it was not possible to compare to prior student experiences. Results In the first half of the academic year, 6,972 patient encounters were billed as student-involved services, 52% (n = 3,612) in the inpatient setting and 47% (n = 3,257) in the outpatient setting. Most (74%) of the inpatient encounters also involved residents and most (92%) of outpatient encounters were student-teaching physician only.Approximately 90% of students indicated having had opportunity to document in the EHR across clerkships, except for procedure-based clerkships such as surgery and obstetrics. Receipt of feedback was present along with opportunity for documentation more than 85% of the time on services using evaluation and management coding. Most students (>90%) viewed their documentation as having a moderate or high impact on patient care. Conclusions Changes to student documentation were successfully implemented and adopted; changes met both compliance and education needs within the health system without resulting in potential abuses of student work for service.

Purpose Socioeconomic and geographic determinants of medical school application and matriculation may help explain the unequal distribution of physicians in the United States. This study describes trends in MD-granting medical school application and matriculation rates and explores the relationship between county median family income, proximity to a medical school, and medical school application and matriculation rates. Method Data were obtained from the Association of American Medical Colleges, including the age, gender, and Federal Information Processing Standards code for county of legal residence for each applicant and matriculant to MD-granting medical schools in the United States from 2001 through 2015. The application and matriculation rates in each county were calculated using the number of applicants and matriculants per 100,000 residents. Counties were classified into 4 groups according to the county median family income (high-income, middle-income, middle-low-income, low-income). The authors performed Chi-square tests to assess trends across the study period and the association of county median family income with application and matriculation rates. Results There were 581,833 applicants and 262,730 (45.2%) matriculants to MD-granting medical schools between 2001 and 2015. The application rate per 100,000 residents during 2001-2005, 2006-2010, and 2011-2015 was 57.2, 62.7, and 69.0, respectively, and the corresponding matriculation rate was 27.5, 28.1, and 29.8, respectively. The ratio of the application rate in high-income counties to that in low-income counties during the 3 time periods was 1.9, 2.4, and 2.8, respectively. Conclusions The application and matriculation rates to MD-granting medical schools increased steadily from 2001 to 2015. Yet, applicants and matriculants disproportionately came from high-income counties. The differences in the application and matriculation rates between low-income and high-income counties grew during this period. Exploring these differences can lead to better understanding of the factors that drive geographic differences in physician access and the associated health disparities across the United States.

Shared decision making, a collaborative approach between patient and provider that considers the patient's values and preferences in addition to the scientific evidence, is a complex clinical activity that has not realized its full potential. Gaps in education and training have been cited as barriers to shared decision making, and evidence is inconsistent on effective educational interventions. Because individual agents with their own social and behavioral contexts co-construct a shared decision, the educational approach may need to consider the role of patient agency and sociocultural influences. To address the inherent complexity in shared decision making, the authors identified cultural historical activity theory (CHAT) as a framework for analysis. Although certainly not the only relevant theory, CHAT offers an appropriate lens through which the multivoiced nature of shared decision making can be more clearly appreciated. In this article, the authors demonstrate the application of CHAT as a lens for researchers and educators to examine the complexity of shared decision making. The fictitious case presented in this article describes the use of CHAT with a patient who experiences 2 clinical encounters; during the second, shared decision making takes place. Elements of the case are threaded through the article, demonstrating a sample analysis of the interacting activity systems of the patient and physician and highlighting inherent tensions and contradictions. The authors propose CHAT as a tool for future research around the role of agency in shared decision making and other complex topics and as a framework for design of novel instructional strategies. Although not applicable to all topics and settings, CHAT has significant potential within health professions education.

PURPOSE To explore the prevalence of major anxiety and its associated risk factors in residents in China. METHOD This multicenter, cross-sectional study was conducted from December 2019 to February 2020; 1,343 residents from 8 hospitals in Northeast China were included in the final analysis (effective response rate of 86.48%). Demographic characteristics, dietary habits, life-related factors, work-related factors, and psychological characteristics were collected from participants via a self-reported questionnaire. This questionnaire measured sleep quality, physical activity, anxiety, perceived organizational support, psychological capital, and burnout. Adjusted odds ratios (ORs) and 95% confidence intervals were determined using binary logistic regression. Cutoff values and the area under the curve were calculated for risk factors using receiver operating characteristic curve analysis. RESULTS Of participants, 441 (32.80%) reported anxiety symptoms and 133 (9.90%) reported major anxiety symptoms. Four independent risk factors for major anxiety were identified: poor sleep quality (OR = 1.282, P < .001) and 3 dimensions of burnout: higher emotional exhaustion (OR = 1.085, P < .001), higher depersonalization (OR = 1.064, P = .002), and reduced personal accomplishment (OR = 0.951, P < .001). The optimal cutoff values for these risk factors were 7, 10, 9, and 22 scores, respectively. CONCLUSIONS This study found a considerable prevalence of major anxiety symptoms in residents in China and identified poor sleep quality and higher levels of burnout as having a close association with major anxiety. These findings enrich the existing literature on anxiety and demonstrate a critical need for additional studies that investigate intervention strategies to improve sleep quality and combat burnout, which could improve the mental health of residents.

The glaring racial inequities in the impact of the COVID-19 pandemic and the devastating loss of Black lives at the hands of police and racist vigilantes have catalyzed a global reckoning about deeply rooted systemic racism in society. Many medical training institutions in the United States have participated in this discourse by denouncing racism, expressing solidarity with people of color, and reexamining their diversity and inclusion efforts. Yet, the stagnant progress in recruiting, retaining, and supporting racial/ethnic minority trainees and faculty at medical training institutions is well documented and reflects unaddressed systemic racism along the academic pipeline. In this article, the authors draw upon their experiences as early-career physicians of color who have led and supported antiracism efforts within their institutions to highlight key barriers to achieving meaningful progress. They describe common pitfalls of diversity and inclusion initiatives and call for an antiracist approach to systems change. The authors then offer 9 recommendations that medical training institutions can implement to critically examine and address racist structures within their organizations to actualize racial equity and justice.

Purpose Physician burnout is endemic across medical education and has numerous deleterious effects. Given the prevalence and negative effects of burnout, there is an urgent need to understand how residents experience and cope with stress and develop explanatory models that inform the development of more effective interventions. Method Using a qualitative, constructivist approach informed by grounded theory, the authors conducted semistructured interviews from March to April 2019, in which psychiatry residents were asked about their experiences of stress and how they coped. First- through fourth-year trainees at Zucker Hillside Hospital at Northwell Health, Glen Oaks, New York, were invited. Two authors independently and inductively coded deidentified transcripts. A constant comparative approach was used to analyze data and support construction of themes. Theoretic sufficiency was observed after 14 interviews. Results The authors constructed an explanatory model for how residents cope with stress and whether they tended toward burnout or wholehearted engagement. The model included 3 themes: self-care, work relationships, and meaning making. Self-care, including time spent with others, provided connection and belonging that bolstered physicians' developing identities. Interpersonal relationships at work profoundly influenced the experience of residents. Positive peer and supervisor relationships enhanced confidence and perseverance. Negative role models and conflict engendered feelings of inadequacy. The ability to shift perspective and build meaning through examining moral values in the face of challenges was crucial for residents who reported success at coping with stress. Residents identified personal psychotherapy as an especially important strategy to facilitate meaning making. Conclusions These findings provide guidance for how residency programs may help residents cope with stress and move away from burnout toward wholehearted engagement. Strategies may include reducing barriers to self-care and to accessing help early in training, creating spaces that promote peer connection and providing training in addressing conflict, and facilitating engagement in meaning-making activities.

PROBLEM: There are significant barriers for resident physicians seeking mental health care, including lack of time, cost, and concerns about confidentiality. The authors sought to improve access to mental health resources by addressing these barriers through the development of a confidential opt-out mental health pilot program for interns and to assess the feasibility, acceptability, and resident satisfaction with the program. APPROACH: All internal medicine and internal medicine-pediatrics interns in the 2017–2018 residency class at the University of Colorado were enrolled in the confidential opt-out mental health program. Each intern was provided with an additional half-day off during their continuity clinic week, during which a mental health screening appointment at the campus health center with an in-network mental health provider was scheduled. All costs were covered by the residency program. An anonymous follow-up survey was sent to all interns to assess participation in the program and its perceived impact on their wellness. OUTCOMES: Appointments were made for 80 interns: 23 (29%) attended the appointment, 45 (56%) opted out in advance, and 12 (15%) were no-shows. The total cost of the program was $940 or $11.75 per intern. Of the 41 interns who responded to the survey, 35 (85%) agreed the program should continue next year. The majority of interns felt the program positively affected their wellness regardless of whether they attended the appointment. Of the 16 interns who attended the appointment and completed the survey, 4 (25%) reported receiving additional mental health referrals or follow-up appointments. NEXT STEPS: This confidential opt-out mental health pilot program for interns was feasible, relatively low cost and simple to implement, and had positive impacts on self-reported wellness. Further study of interventions that remove barriers to accessing mental health care for residents is urgently needed.

These are challenging times for physicians. Extensive changes in the practice environment have altered the nature of physicians’ interactions with patients and their role in the health care delivery system. Many physicians feel as if they are “cogs in the wheel” of austere corporations that care more about productivity and finances than compassion or quality. They often do not see how the strategy and plan of their organization align with the values of the profession. Despite their expertise, they frequently do not feel they have a voice or input in the operational plan of their work unit, department, or organization. At their core, the authors believe all of these factors represent leadership issues. Many models of leadership have been proposed, and there are a number of effective philosophies and approaches. Here, the authors propose a new integrative model of Wellness-Centered Leadership (WCL). WCL includes core skills and qualities from the foremost leadership philosophies along with evidence on the relationship between leadership and physician well-being and distills them into a single framework designed to cultivate leadership behaviors that promote engagement and professional fulfillment. The 3 elements of WCL are: care about people always, cultivate individual and team relationships, and inspire change. A summary of the mindset, behaviors, and outcomes of the elements of the WCL model is presented, and the application of the elements for physician leaders is discussed. The authors believe that learning and developing the skills that advance these elements should be the aspiration of all health care leaders and a foundational focus of leadership development programs. If cultivated, the authors believe that WCL will empower individual and team performance to address the current problems faced by health care organizations as well as the iterative innovation needed to address challenges that may arise in the decades to come.

Professional burnout has reached epidemic levels among U.S. medical providers. One key driver is the burden of clinical documentation in the electronic health record, which has given rise to medical scribes. Despite the demonstrated benefits of scribes, many providers-especially those in academic health systems-have been unable to make an economic case for them. With the aim of creating a cost-effective scribe program in which premedical students gain skills that better position them for professional schooling, while providers at risk of burnout obtain documentation support, the authors launched the Clinical Observation and Medical Transcription (COMET) Program in June 2015 at Stanford University School of Medicine. COMET is a new type of postbaccalaureate premedical program that combines an apprenticeship-like scribing experience and a package of teaching, advising, application support, and mentored scholarship that is supported by student tuition. Driven by strong demand from both participants and faculty, the program grew rapidly during its first 5 years (2015-2020). Program evaluations indicated high levels of satisfaction among participants and faculty with their mentors and mentees, respectively; that participants felt the experience better positioned them for professional schooling; and that faculty reported improved joy of practice. In summary, tuition-supported medical scribe programs, like COMET, appear to be feasible and cost-effective. The COMET model may have the potential to help shape future health professions students, while simultaneously combating provider burnout. While scalability and generalizability remain uncertain, this model may be worth exploring at other institutions.

Supplemental Digital Content is available in the text., Purpose This qualitative study examined fiscal and administrative (i.e., pre- and post-award grants process) barriers and facilitators to community-engaged research among stakeholders across 4 Clinical and Translational Science Awards (CTSA) institutions. Method A purposive sample of 24 key informants from 3 stakeholder groups—community partners, academic researchers, and research administrators—from the CTSA institutions at the University of North Carolina at Chapel Hill, Medical University of South Carolina, Vanderbilt University Medical Center, and Yale University participated. Semistructured interviews were conducted in March–July 2018, including questions about perceived challenges and best practices in fiscal and administrative processes in community-engaged research. Transcribed interviews were independently reviewed and analyzed using the Rapid Assessment Process to facilitate key theme and quote identification. Results Community partners were predominantly Black, academic researchers and research administrators were predominantly White, and women made up two-thirds of the overall sample. Five key themes were identified: level of partnership equity, partnership collaboration and communication, institutional policies and procedures, level of familiarity with varying fiscal and administrative processes, and financial management expectations. No stakeholders reported best practices for the institutional policies and procedures theme. Cross-cutting challenges included communication gaps between stakeholder groups; lack of or limits in supporting community partners’ fiscal capacity; and lack of collective awareness of each stakeholder group’s processes, procedures, and needs. Cross-cutting best practices centered on shared decision making and early and timely communication between all stakeholder groups in both pre- and post-award processes. Conclusions Findings highlight the importance of equitable processes, triangulated communication, transparency, and recognizing and respecting different financial management cultures within community-engaged research. This work can be a springboard used by CTSA institutions to build on available resources that facilitate co-learning and discussions between community partners, academic researchers, and research administrators on fiscal readiness and administrative processes for improved community-engaged research partnerships.

The COVID-19 pandemic has disrupted medical research, pushing mentors and mentees to decide if COVID-19 research would be germane to the early career investigator's developing research portfolio. With COVID-19 halting hundreds of federal trials involving non-COVID-19 research, mentors and mentees must also consider the broader moral calling of contributing to COVID-19 research. At the time of writing, the National Institutes of Health had responded to the pandemic with significant funding for COVID-19 research. However, because this pandemic is a new phenomenon, few mentors have expertise in the disease and relevant established resources. As a result, many mentors are unable to provide insight on COVID-19 research to early career investigators considering a pivot toward research related to this disease. The authors suggest 4 ways for mentees and mentors to respond to the changes the pandemic has brought to research funding and opportunities: (1) include COVID-19 research in existing portfolios to diversify intellectual opportunities and reduce funding risks; (2) negotiate the mentor-mentee relationship and roles and expectations early in project discussions-considering, as relevant, the disproportionate burden of home responsibilities often borne by early career faculty members who are women and/or from a minority group; (3) address any mentor limitations in content expertise; and (4) if the decision is to pivot to COVID-19 research, select projects with implications generalizable beyond this pandemic to other infectious outbreaks or to the redesign of health care delivery. Mentors and mentees must weigh the relevance of COVID-19 research projects to the postpandemic world and the amount of available funding against the developing interests of early career investigators. Academic medical centers nationwide must enable seasoned and early career researchers to contribute meaningfully to COVID-19 and non-COVID-19 research.

After a medical student prompted medical faculty to tell their stories of depression and related mental health issues, the author wrote this article with the aim of decreasing the stigma of mental illness and encouraging treatment, as needed, in the medical profession. The professional culture of the house of medicine not only mimics society in attributing stigma to people with mental health issues but may also contribute to high rates of suicide in the ranks of health care professionals by leading to a delay in seeking treatment. Acculturation accelerates in the first year of medical school such that medical students experience an increase in burnout and depressive symptoms from prematriculation levels. It follows that faculty have a responsibility to improve the learning environment. Survey data from medical faculty at the author's institution showed that depression decreased respondents' willingness to seek mental health treatment because of the stigma and issues of access to help. Faculty attitudes toward mental health issues, including reluctance to admit having such issues, may be conveyed to medical students in the hidden curriculum that teaches them to keep depression hidden. Moreover, the fear of mental disorders is manifested in licensing and privileging applications under the guise of patient safety, contributing to a culture of shame and silence. As creators and guardians of this professional culture, medical faculty and other physicians must be the ones who change it. The same faculty who play a part in causing and perpetuating stigma related to mental health issues have the power to derive and enact some of the solutions. In addition to giving voice to a personal experience of mental health issues, this article offers suggestions for normalizing moderate to severe depression as a medical disorder, decreasing the stigma of mental health issues, and encouraging faculty to seek treatment.

Purpose To describe the prevalence and scope of wellness programs at U.S. and Canadian medical schools. Method In July 2019, the authors surveyed 159 U.S. and Canadian medical schools regarding the prevalence, structure, and scope of their wellness programs. They inquired about the scope of programming, mental health initiatives, and evaluation strategies. Results Of the 159 schools, 104 responded (65%). Ninety schools (93%, 90/97) had a formal wellness program, and across 75 schools, the mean full-time equivalent (FTE) support for leadership was 0.77 (standard deviation [SD] 0.76). The wellness budget did not correlate with school type or size (respectively, P = .24 and P = .88). Most schools reported adequate preventative programming (62%, 53/85), reactive programming (86%, 73/85), and cultural programming (52%, 44/85), but most reported too little focus on structural programming (56%, 48/85). The most commonly reported barrier was lack of financial support (52%, 45/86), followed by lack of administrative support (35%, 30/86). Most schools (65%, 55/84) reported in-house mental health professionals with dedicated time to see medical students; across 43 schools, overall mean FTE for mental health professions was 1.62 (SD 1.41) and mean FTE per student enrolled was 0.0024 (SD 0.0019). Most schools (62%, 52/84) evaluated their wellness programs; they used the Association of American Medical Colleges Graduation Questionnaire (83%, 43/52) and/or annual student surveys (62%, 32/52). The most commonly reported barrier to evaluation was lack of time (54%, 45/84), followed by lack of administrative support (43%, 36/84). Conclusions Wellness programs are widely established at U.S. and Canadian medical schools, and most focus on preventative and reactive programming, as opposed to structural programming. Rigorous evaluation of the effectiveness of programs on student well-being is needed to inform resource allocation and program development. Schools should ensure adequate financial and administrative support to promote students' well-being and success.

Clerkship grades (like money) are a social construct that function as the currency through which value exchanges in medical education are negotiated between the system’s various stakeholders. They provide a widely recognizable and efficient medium through which learner development can be assessed, tracked, compared, and demonstrated and are commonly used to make decisions regarding progression, distinction, and selection for residency. However, substantial literature has demonstrated how grades imprecisely and unreliably reflect the value of learners. In this article, the authors suggest that challenges with clerkship grades are fundamentally tied to their role as currency in the medical education system. Associations are drawn between clerkship grades and the history of the U.S. economy; 2 major concepts are highlighted: regulation and stock prices. The authors describe the history of these economic concepts and how they relate to challenges in clerkship grading. Using lessons learned from the history of the U.S. economy, the authors then propose a 2-step solution to improve upon grading for future generations of medical students: (1) transition from grades to a federally regulated competency-based assessment model and (2) development of a departmental competency letter that incorporates competency-based assessments rather than letter grades and meets the needs of program directors.

Problem Distress, depression, and burnout are common during medical training. Stigma surrounding seeking help for mental illness during medical training may involve fear of negative peer perceptions, academic jeopardy, and adverse future career consequences. Faculty disclosure of personal mental health illness may reduce stigma surrounding mental health disorders and reassure and encourage trainees to seek help when needed. Approach The authors aimed to assess the impact of faculty disclosure of mental health issues on stigma toward help-seeking during training, self-reflection about mental health, and resident physician awareness of mental health resources. Three self-selected faculty members shared their personal experiences with depression and mental health during a confidential noon conference intended for internal medicine residents at Mayo Clinic Rochester as part of their core curriculum in December 2016. Institutional and community mental health resources were provided. After the conference, attendees completed an anonymous survey assessing self-reported knowledge, attitudes, and behaviors surrounding mental health during medical training. Outcomes One hundred percent of residents (39/39) agreed that they enjoyed the conference. Thirty-five of 39 (89.7%) respondents agreed that their knowledge of available mental health resources increased and 33/39 (84.6%) agreed they were more likely to pursue mental health resources after attending the conference. Thirty-eight of 39 (97.4%) residents agreed that faculty sharing their personal struggles destigmatizes mental health issues during training, and the same percentage reported engaging in postconference self-reflection regarding their own mental health and well-being. Next steps Resident conference sessions during which faculty self-disclose personal mental health experiences may help decrease the stigma of mental health issues during medical training and increase the likelihood residents will seek assistance when needed. The authors encourage further study of longer-term outcomes and actual help-seeking behaviors across learner levels and training environments.

Purpose Assessment of the Core Entrustable Professional Activities for Entering Residency (Core EPAs) requires direct observation of learners in the workplace to support entrustment decisions. The purpose of this study was to examine the internal structure validity evidence of the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) scale when used to assess medical student performance in the Core EPAs across clinical clerkships. Method During the 2018-2019 academic year, the Virginia Commonwealth University School of Medicine implemented a mobile-friendly, student-initiated workplace-based assessment (WBA) system to provide formative feedback for the Core EPAs across all clinical clerkships. Students were required to request a specified number of Core EPA assessments in each clerkship. A modified O-SCORE scale (1= "I had to do" to 4 = "I needed to be in room just in case") was used to rate learner performance. Generalizability theory was applied to assess the generalizability (or reliability) of the assessments. Decision studies were then conducted to determine the number of assessments needed to achieve a reasonable reliability. Results A total of 10,680 WBAs were completed on 220 medical students. The majority of ratings were completed on EPA 1 (history and physical) (n = 3,129; 29%) and EPA 6 (oral presentation) (n = 2,830; 26%). Mean scores were similar (3.5-3.6 out of 4) across EPAs. Variance due to the student ranged from 3.5% to 8%, with the majority of the variation due to the rater (29.6%-50.3%) and other unexplained factors. A range of 25 to 63 assessments were required to achieve reasonable reliability (Phi > 0.70). Conclusions The O-SCORE demonstrated modest reliability when used across clerkships. These findings highlight specific challenges for implementing WBAs for the Core EPAs including the process for requesting WBAs, rater training, and application of the O-SCORE scale in medical student assessment.

Estimates in a 1989 study indicated that physicians in the United States were unable to reach a diagnosis that accounted for their patient's symptoms in up to 90% of outpatient patient encounters. Many proponents of artificial intelligence (AI) see the current process of moving from clinical data gathering to medical diagnosis as being limited by human analytic capability and expect AI to be a valuable tool to refine this process. The use of AI fundamentally calls into question the extent to which uncertainty in medical decision making is tolerated. Uncertainty is perceived by some as fundamentally undesirable and thus, for them, optimal decision making should be based on minimizing uncertainty. However, uncertainty cannot be reduced to zero; thus, relative uncertainty can be used as a metric to weigh the likelihood of various diagnoses being correct and the appropriateness of treatments. Here, the authors make the argument, using as examples the experiences of 2 AI systems, IBM Watson on Jeopardy and Watson for Oncology, that medical decision making based on relative uncertainty provides a better lens for understanding the application of AI to medicine than one that minimizes uncertainty. This approach to uncertainty has significant implications for how health care leaders consider the benefits and trade-offs of AI-assisted and AI-driven decision tools and ultimately integrate AI into medical practice.

Purpose Combined baccalaureate-MD programs exist to fulfill a variety of educational missions, including to promote the development of physician-scientists, increase workforce diversity, promote primary care careers, and meet the needs of underserved patients. The authors sought to determine the demographics of combined program graduates, as well as their intention to practice in primary care (IPPC) and intention to work with the medically underserved (IWMU), as compared with graduates of traditional MD programs. Method Data from the 2010-2017 Association of American Medical Colleges Graduation Questionnaire, a national survey of graduating medical students, were recategorized (e.g., as combined program or traditional program) before analysis. Logistic regression models on the 2 primary outcomes (IPPC and IWMU) were conducted to estimate odds ratios for the effects of covariates and predictors (e.g., gender, underrepresented in medicine [URM] group member, type of medical degree program). Results Data from a total of 109,028 respondents were included (3,182 from combined and 105,846 from traditional programs). Compared with students in traditional programs, those in combined programs were more likely to be younger (age at graduation ≤ 29: 3,143, 98.8% vs 89,688, 84.7%) and female (1,813, 57.0% vs 52,013, 49.1%) but less likely to identify as a URM group member (276, 8.7% vs 14,757, 13.9%). In an adjusted logistic regression model, graduating from a combined program, identifying as female, and IWMU predicted significantly greater odds of IPPC, while identifying as a URM, identifying as female, and having debt predicted significantly greater odds of IWMU. Graduating medical students who indicated family medicine as a career specialty were more likely to indicate an IWMU. Conclusions Medical students graduating from combined programs were more likely to indicate an IPPC but were no more likely to indicate an IWMU than traditional program graduates.

PURPOSE Some evidence indicates that physician empathy declines during medical training, which has made it the subject of much research. Qualitative studies are relevant in this context, focusing as they do on how students themselves conceive and understand empathy during medical school. The aim of this study was to explore medical students' perspectives on empathy by conducting a metasynthesis, including a systematic review of the literature and analysis of included studies. METHOD The authors systematically searched 4 databases through June 17, 2019, for qualitative studies reporting medical students' perspectives on empathy in medical school. They assessed article quality using the Critical Appraisal Skills Program, and they applied thematic analysis to identify key themes and synthesize them. RESULTS The authors included 35 articles from 18 countries in their analysis. Four main themes emerged: (1) Defining empathy, with a lack of understanding of the concept; (2) Teaching empathy, with a focus on the hidden curriculum and clinical supervisors; (3) Willingness to be an empathetic doctor, with ambivalence expressed by some study participants; and (4) Evolution of empathy during medical school, specifically its decline. CONCLUSIONS Medical students are beset by theoretical confusion regarding the concept of empathy, and they express doubts about its utility and relevance. Instruction should focus on simpler concepts such as listening, and schools should leverage clinical supervisors' strong influence on students' empathy. Prioritizing certain types of knowledge (clinical facts) during medical education has a globally negative effect on medical students' empathy.

Supplemental Digital Content is available in the text., Purpose Although shared decision making (SDM) is considered the preferred approach in medical decision making, it is currently not routinely used in clinical practice. To bridge the transfer gap between SDM training and application, the authors aimed to reach consensus on entrustable professional activities (EPAs) for SDM and associated behavioral indicators as a framework to support self-directed learning during postgraduate medical education. Method Using existing literature on SDM frameworks and competencies; input from an interview study with 17 Dutch experts in SDM, doctor–patient communication, and medical education; and a national SDM expert meeting as a starting point, in 2017, the authors conducted a modified online Delphi study with a multidisciplinary Dutch panel of 32 experts in SDM and medical education. Results After 3 Delphi rounds, consensus was reached on 4 EPAs—(1) the resident discusses the desirability of SDM with the patient, (2) the resident discusses the options for management with the patient, (3) the resident explores the patient’s preferences and deliberations, and (4) the resident takes a well-argued decision together with the patient. Consensus was also reached on 18 associated behavioral indicators. Of the 32 experts, 30 (94%) agreed on this list of SDM EPAs and behavioral indicators. Conclusions The authors succeeded in developing EPAs and associated behavioral indicators for SDM for postgraduate medical education to improve the quality of SDM training and the application of SDM in clinical practice. These EPAs are characterized as process EPAs for SDM in contrast with content EPAs related to diverse medical complaints. A next step is the implementation of the SDM EPAs in existing competency-based workplace curricula.

Supplemental Digital Content is available in the text., Problem Dissemination and implementation (D&I) science provides the tools needed to close the gap between known intervention strategies and their effective application. The authors report on the Mentored Training for Dissemination and Implementation Research in Cancer (MT-DIRC) program—a D&I training program for postdoctoral or early-career cancer prevention and control scholars. Approach MT-DIRC was a 2-year training institute in which fellows attended 2 annual Summer Institutes and other conferences and received didactic, group, and individual instruction; individualized mentoring; and other supports (e.g., pilot funding). A quasi-experimental design compared changes in 3 areas: mentoring, skills, and network composition. To evaluate mentoring and D&I skills, data from fellows on their mentors’ mentoring competencies, their perspectives on the importance of and satisfaction with mentoring priority areas, and their self-rated skills in D&I competency domains were collected. Network composition data were collected from faculty and fellows for 3 core social network domains: contact, mentoring, and collaboration. Paired t tests (mentoring), linear mixed models (skills), and descriptive analyses (network composition) were performed. Outcomes Mentors were rated as highly competent across all mentoring competencies, and each mentoring priority area showed reductions in gaps between satisfaction and importance between the 6 and 18 months post-first Summer Institute. Fellows’ self-rated skills in D&I competencies improved significantly in all domains over time (range: 42.5%–52.9% increase from baseline to 18 months post-first Summer Institute). Mentorship and collaboration networks grew over time, with the highest number of collaboration network ties for scholarly manuscripts (n = 199) in 2018 and for research projects (n = 160) in 2019. Next Steps Building on study findings and existing literature, mentored training of scholars is an important approach for building D&I skills and networks, and thus to better applying the vast amount of available intervention evidence to benefit cancer control.

The practice of medicine is changing rapidly as a consequence of electronic health record adoption, new technologies for patient care, disruptive innovations that breakdown professional hierarchies, and evolving societal norms. Collectively, these have resulted in the modification of the physician's role as the gatekeeper for health care, increased shift-based care, and amplified interprofessional team-based care. Technological innovations present opportunities as well as challenges. Artificial intelligence, which has great potential, has already transformed some tasks, particularly those involving image interpretation. Ubiquitous access to information via the Internet by physicians and patients alike presents benefits as well as drawbacks: patients and providers have ready access to virtually all of human knowledge, but some websites are contaminated with misinformation and many people have difficulty differentiating between solid, evidence-based data and untruths. The role of the future physician will shift as complexity in health care increases and as artificial intelligence and other technologies advance. These technological advances demand new skills of physicians; memory and knowledge accumulation will diminish in importance while information management skills will become more important. In parallel, medical educators must enhance their teaching and assessment of critical human skills (e.g., clear communication, empathy) in the delivery of patient care. The authors emphasize the enduring role of critical human skills in safe and effective patient care even as medical practice is increasingly guided by artificial intelligence and related technology, and they suggest new and longitudinal ways of assessing essential noncognitive skills to meet the demands of the future. The authors envision practical and achievable benefits accruing to patients and providers if practitioners leverage technological advancements to facilitate the development of their critical human skills.

PURPOSE: Despite efforts to increase the representation of women in the national scientific workforce, results still lag. While women’s representation in health-related sciences has increased substantially, women remain underrepresented in senior leadership roles. This study was conducted to elucidate influences at the individual, interpersonal, organizational, and societal levels that present as barriers to and facilitators for advancement in research careers for women, with the goal of promoting and retaining a more diverse leadership. METHOD: The authors conducted individual, 1-hour, in-depth, semistructured interviews with 15 female early stage investigators pursuing careers in health sciences research at a large minority-serving institution in Florida in 2018. Interview guides were designed by using a social ecological framework in order to understand the influence of multilevel systems. Employing a qualitative approach, drawing from a phenomenological orientation, 2 researchers independently coded transcripts and synthesized codes into broad themes. RESULTS: Barriers and facilitators were reported at all ecological levels explored. Illustrative quotations reflect the unequal distribution of familial responsibilities that compete with career advancement, family members’ lack of understanding of the demands of a research career, the importance of female mentors, perceived differences in the roles and expectations of female and male faculty at institutions, and normative upheld values that influence early career progression. CONCLUSIONS: Achieving pervasive and sustained changes that move toward gender equity in research requires solutions that address multilevel, explicit and implicit influences on women’s advancement in science. Suggestions include shifting familial and institutional norms, creating support systems for women with female mentors, and enforcing consistent policies regarding the roles and expectations of faculty. Findings shed light on the influence of gender on career progression by providing context for the experiences of women and underscore the importance of addressing pervasive societal and structural systems that maintain inequities hindering women’s progress in the scientific workforce.

Problem The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. Approach The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum-including 2 years dedicated to global surgery-with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. Outcomes There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. Next steps To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step toward contributing to the delivery of safe surgical care worldwide.

Purpose Stakeholders have expressed concerns regarding the impact of visiting trainees and physicians from high-income countries (HICs) providing education and/or short-term clinical care in low- and middle-income countries (LMICs). This systematic review aimed to summarize LMIC host perceptions of visiting trainees and physicians from HICs during short-term experiences in global health (STEGH). Method In September 2018 then again in August 2020, the authors searched 7 databases (PubMed, Embase, Scopus, Web of Science, ERIC, Cochrane Library, Global Index Medicus) for peer-reviewed studies that described LMIC host perceptions of STEGH. They extracted information pertaining to study design, participant demographics, participant perceptions, representation of LMICs and HICs, and HIC visitors' roles and used thematic synthesis to code the text, develop descriptive themes, and generate analytical themes. Results Of the 4,020 studies identified, 17 met the inclusion criteria. In total, the studies included 448 participants, of which 395 (88%) represented LMICs. The authors identified and organized 42 codes under 8 descriptive themes. They further organized these descriptive themes into 4 analytical themes related to STEGH: (1) sociocultural and contextual differences, (2) institutional and programmatic components, (3) impact on host institutions and individuals, and (4) visitor characteristics and conduct. Conclusions STEGH can have both beneficial and detrimental effects on LMIC host institutions and individuals. The authors translated these findings into a set of evidence-based best practices for STEGH that provide specific guidance for LMIC and HIC stakeholders. Moving forward, LMIC and HIC institutions must work together to focus on the quality of their relationships and create conditions in which all stakeholders feel empowered to openly communicate to ensure equity and mutual benefit for all parties.

Medical schools implemented holistic review more than a decade ago, which led to more deliberate consideration and inclusion of applicants historically underrepresented in medicine. This article presents a theory of holistic enrollment management that unites holistic review with enrollment management principles. This theory contextualizes medical school admissions as a complex marketplace with multifaceted, competing forces. Applying an enrollment management framework of mission, market, means, and metrics can improve the capacity of a medical school to efficiently advance its mission over time. Medical schools employing a clear, compelling, and focused mission to direct all aspects of the medical education enterprise can more effectively attract applicants who are better prepared to enact that mission throughout their careers. Medical schools share a marketplace and collectively compete to identify, attract, admit, and matriculate the most mission-aligned student body within the pool of applicants they share. Institutions that deliberately mobilize resources within this dynamic marketplace will engage, admit, and matriculate the most suiting applicants and attract even more mission-aligned matriculants over time. Widespread adoption of this holistic framework of enrollment management may enhance the capacity of the medical education system to better capitalize on the existing diversity in the national pool of applicants, encourage more underrepresented applicants to apply in the future, admit and matriculate a more diverse national student body, and ultimately better prepare new physicians to meet the increasingly diverse health care needs of the nation.

Problem High-quality training opportunities for providers in limited-resource settings are often scarce or nonexistent. This can lead to a dearth of boots-on-the-ground workers capable of translating knowledge into effective action. The tested telehealth education model of Project ECHO (Extension for Community Healthcare Outcomes) can help address this disparity. However, the planning and logistical coordination required can be limiting. Approach Medical student volunteers interested in health disparities and global health can be leveraged to reduce the costs of administration for Project ECHO programs. From mid-2018 to present (2020), student organizations have been formed at Vanderbilt University School of Medicine, University of California, San Francisco, School of Medicine, and Albert Einstein College of Medicine. These organizations have recruited and trained volunteers, who play an active role in assessing the needs of local clinics and providers, developing curricula, and coordinating the logistical aspects of programs. Outcomes In the first 4 student-coordinated Project ECHO cohorts (2019-2020), 25 clinics in 14 countries participated, with a potential impact on over 20,000 cancer patients annually. Satisfaction with the telehealth education programs was high among local clinicians and expert educators. Students' perceived ability to conduct activities important to successfully orchestrating a telehealth education program was significantly greater among students who had coordinated one or more Project ECHO programs than among students who had yet to participate for 7 of 9 competencies. There also appears to be an additive effect of participating in additional Project ECHO programs on perceived confidence and career path intentions. Next steps The student-led model of coordinating telehealth education programs described here can be readily expanded to medical schools across the nation and beyond. With continued expansion, efforts are needed to develop assessments that provide insights into participants' learning, track changes in patient outcomes, and provide continuing medical education credits to local clinicians.

PurposeEffective nonverbal communication is associated with empathic behavior and improved patient outcomes. Touch, as a form of nonverbal communication, is relatively unexplored in medical education. This study sought to gain in-depth insights into physicians' experiences communicating with touch and to examine how these insights could inform communication skills curricula.MethodCollaborative inquiry, a form of action research, was used. Six experienced physician-educators from the University of Calgary met 8 times between 2015 and 2018 to critically reflect on their experiences of touch in clinical practice, teaching, and learning. Data comprised meeting transcripts, individual narrative accounts, and digital recordings of roleplays. Interpretative phenomenology, the study of lived experience, guided analysis.ResultsTwo themes were identified-touch as presence and touch as risk. Participants used touch to demonstrate presence and a shared humanity with patients, to express "being with" a patient. Risk was not associated with the physical experience of touch but, rather, with its social meaning, interpreted through gender, culture, relationships, and context. Individual experiences were open to many interpretations. Participants expressed tension between their personal experience communicating with touch to express empathy and formal curricular structures. Reflection, role-modeling, and clinical debriefs were suggested as ways to encourage situational awareness and sensitive use of touch.ConclusionsTouch is a powerful means to communicate with patients but is highly subjective. Rather than avoiding touch for fear of misinterpretation, encouraging dialogue about its complexity could promote a more balanced understanding of touch and its potential to convey empathy and help physicians more effectively manage risk when using touch.

Purpose Efforts to address inequities in medical education are centered on a dialogue of deficits that highlight negative underrepresented in medicine (UIM) learner experiences and lower performance outcomes. An alternative narrative explores perspectives on achievement and equity in assessment. This study sought to understand UIM learner perceptions of successes and equitable assessment practices. Method Using narrative research, investigators selected a purposeful sample of self-identified UIM fourth-year medical students and senior-level residents and conducted semi-structured interviews. Questions elicited personal stories of achievement during clinical training, clinical assessment practices that captured achievement, and equity in clinical assessment. Using re-storying and thematic analysis, investigators coded transcripts and synthesized data into themes and representative stories. Results Twenty UIM learners (6 medical students and 14 residents) were interviewed. Learners often thought about equity during clinical training and provided personal definitions of equity in assessment. Learners shared stories that reflected their achievements in patient care, favorable assessment outcomes, and growth throughout clinical training. Sound assessments that captured achievements included frequent observations with real-time feedback on pre-defined expectations by supportive, longitudinal clinical supervisors. Finally, equitable assessment systems were characterized as sound assessment systems that also avoided comparison to peers, used narrative assessment, assessed patient care and growth, trained supervisors to avoid bias, and acknowledged learner identity. Conclusions UIM learners characterized equitable and sound assessment systems that captured achievements during clinical training. These findings guide future efforts to create an inclusive, fair, and equitable clinical assessment experience.

In July 2020, the Kaiser Permanente Bernard J. Tyson School of Medicine opened in Pasadena, California, with an inaugural class of 50 students. The school endeavors to address systemic barriers that have contributed to health care and educational disparities in the United States. To realize its vision for change, equity, inclusion, and diversity (EID) have been woven throughout the school. Board members were chosen in part based on their commitment to the core values of EID. The board developed mission, vision, and values statements that explicitly avow a commitment to EID and recruited a dean (and the dean recruited leaders) who espoused and evinced these values. Leaders, faculty, and staff received training to foster an inclusive environment and ensure accountability. The school developed a curriculum that has been thoroughly evaluated for its representative and inclusive content by a team drawn from all departments. The diverse first class, selected through a holistic admissions approach, has access to student support systems that emphasize an appreciation of the distinct experiences and context of each student. The school plans a rigorous evaluation program to assess its performance in EID. Although the school may well fall short of achieving all of its EID objectives, by learning from its experiences and from evidence of others in academic medicine, the school recognizes its opportunity to continue to come closer to achieving its goals and to help shape and contribute to the national and international discourse on EID.

Purpose Faculty from different racial and ethnic backgrounds developed and piloted an anti-racism curriculum initially designed to help medical students work more effectively with patients of color. Learning objectives included developing stronger therapeutic relationships, addressing the effects of structural racism in the lives of patients, and mitigating racism in the medical encounter. Method The anti-racism curriculum was delivered and evaluated in 2019 through focus groups and written input before and after each module. The process and outcome evaluation utilized a grounded theory approach. Results Three emergent themes reflect how medical students experienced the anti-racism curriculum and inform recommendations for integrating an anti-racism curriculum into future medical education. The themes are: 1) the differential needs and experiences of persons of color and Whites; 2) the need to address issues of racism within medical education as well as in medical care; 3) the need for structures of accountability in medical education. Conclusions Medical educators must address racism in medical education before seeking to direct students to address it in medical practice.

A major goal of Healthy People 2020 is healthy equity, or the attainment of the highest level of health for all groups of people. Yet, disparities based on race remain the most persistent and difficult to address. Getting at the root causes of disparities, inequities, and injustices is essential for health equity to become a reality. The authors elucidate the urgent need for the nursing profession (and all health care professions) to push beyond cultural humility to structural competency and shift the focus from individuals to institutions, systems, practices, and policies to address racism, bias, and discrimination as root causes of disparities and inequities in health, health care delivery, and health care outcomes.Through a case study approach, the authors demonstrate the need for faculty to contextualize learning to help integrate the necessary historic and contemporary drivers of racism, bias, and discrimination into health care. They discuss strategies for faculty to develop the knowledge, skills, and attitudes to teach about the importance of addressing structural racism and discrimination in health care. Through a "no shame, no blame" approach, the authors encourage faculty to develop the courage to engage with students, colleagues, other health care professionals, and communities in conversations about racism, bias, and discrimination.

Successfully teaching about race and racism requires a careful balance of emotional safety and honest truth-telling. Creating such environments where all learners can thrive and grow together is a challenge, but a consistently doable one. This article describes 12 lessons learned within 4 main themes: ground rules; language and communication; concepts of social constructs, intersectionality, and bidirectional biases; and structural racism, solutions, and advocacy. The authors' recommendations for how to successfully teach health professions students about race and racism come from their collective experience of over 60 years of instruction, research, and practice. Proficiency in discussing race and addressing racism will become increasingly relevant as health care institutions strive to address the social needs of patients (e.g., food insecurity, housing instability) that contribute to poor health and are largely driven by structural inequities. Having interprofessional team-based care, with teams better able to understand and counteract their own biases, will be critical to addressing the social and structural determinants of health for marginalized patients. Recognizing that implicit biases about race impact both patients and health professions students from underrepresented racial/ethnic backgrounds is a critical step toward building robust curricula about race and health equity that will improve the learning environment for trainees and reduce health disparities.

PROBLEM Gender equity in leadership across academic medicine remains a concern. The case of chief resident (CR) offers an opportunity to explore novel strategies in leadership selection in graduate medical education (GME). Means of identifying potential candidates for CR often rely on faculty assessment of resident performance, yet implicit gender bias has the potential to influence this assessment. APPROACH To diversify the metrics used in CR selection, an intervention was implemented to solicit resident input to identify candidates for CR at 2 U.S. internal medicine residency programs in 2018 and 2019. This involved a simple, cross-sectional survey of residents in which they were asked to identify individual residents as good candidates for consideration for CR. OUTCOMES There were 298 of 518 internal medicine resident responses to this intervention across sites and years (mean 58.2% response rate). Nomination patterns of residents and program leaders correlated significantly (correlation coefficient 0.62, P < .001). Controlling for site and year, gender was a significant factor associated with who residents nominated for CR (β-coefficient 0.325, P = .004) with women residents more likely to identify women for CR (odds ratio 1.38, 95% confidence interval 1.11-1.73). Fifty residents nominated themselves for CR, and there was no significant difference by gender (β-coefficient 0.038, P = .91). NEXT STEPS Soliciting resident input to identify candidates for CR may enable gender representation of candidates for this position. Influencing candidate choices may be a promising way to impact leadership selection in medicine.

The prevalence of harmful bias and discrimination within the health professions is staggering. Moreover, literature consistently demonstrates their persistence and their negative impact on patient care. Several professional codes of conduct for health professionals highlight the importance of addressing these forces in practice. However, despite this, these forces are often discussed as tangential within health professions curricula. This paper examines the prevalence of bias and discrimination, its effects on patient care and health professions trainees, and reviews the historical context of societal bias and discrimination within the health professions institution. The authors argue that addressing harmful bias and discrimination is the professional responsibility of every provider and essential to effective and equitable care.

Bias and discrimination are embedded within the history, norms, and practices of the health professions institution, and their negative impacts are pervasive in the health professions learning environment. These forces impair the ability to take care of patients, recruit and support diverse health care providers, and prepare the next generation of clinicians for practice. Fortunately, there are effective interventions and strategies for addressing bias and discrimination within learning environments and to both prevent and ameliorate their negative effects. This Perspective lays out a vision for health professions learning environments that are free from bias and discrimination and makes 5 recommendations, with supporting actions, that will help the leaders of health care institutions achieve this goal.

Purpose Students perceive bias in learning environments. Curricula targeting implicit bias recognition and management increase student awareness and achieve strategy identification, but fall short of actual skill development to address bias. In light of this gap, the authors developed and evaluated a skills-based elective to recognize and manage implicit bias in the learning environment. Method Nine 1.5-hour sessions were delivered to 15 first-year medical students from 2017 to 2019. An evidence-based conceptual framework and transformative learning theory informed the instructional design; it incorporated active learning exercises. Skills assessment occurred through direct observation of student performances in role-play exercises. Using thematic analysis, the authors conducted a program evaluation based on focus groups with students and data from notes taken by the investigative team. Results Students engaged with all aspects of instruction, including role-plays. Authors identified 3 themes from the program evaluation: (1) Student engagement can be enhanced, (2) Instruction is empowering, and (3) It (addressing bias in one's own and witnessed encounters) can be done! Analysis additionally highlighted opportunities for improvement and lessons learned. Conclusions This innovative course achieved skill development and practice for medical students in implicit bias recognition and management as it pertains to 3 facets of clinical care present at every stage of a health professional's career. These include interpersonal encounters, advocating for patients when bias is perceived in witnessed encounters with peers and supervisors, and addressing comments made by others within the learning environment. Outcomes could inform novel, skills-based curricula across the spectrum of health professions training and practice.