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The concept of relationship-centered care was first introduced approximately 20 years ago, but this important concept has not yet been widely disseminated in clinical practice. Relationship-centered care in the health profession focuses on all relevant relationships in health care, not only between health care professionals and patients but also among colleagues, staff members, students, community, and self. This review summarizes the key literature to date on relationship-centered care as it pertains to the physician-patient relationship. Becoming more aware of the physician (self) and patient is a form of metacognition, thinking about what is happening in the moment as physicians and patients come together. Considering the complexity of the physician-patient relationship, we can implement simple metacognitive techniques toward the daily habitual practice of relationship-centered care.

Introduction To gain a more fulsome understanding of professional behavior, as viewed through the lens of three levels of clinical seniority at Yale New Haven Hospital. Methods Sample:This was a qualitative research study. Participants included three groups who work within one hospital environment: 7 Departmental Chairs, 12 Clerkship Directors and 15 Resident Doctors (from Departments of Neurology, Surgery, Emergency Medicine (EM), Anaesthesia, Obstetrics and Gynaecology, Internal Medicine, and Psychiatry). Data Collection:Trained interviewers implemented semi-structured individual and focus group interviews. All interviews were recorded and transcribed. Data Analysis:Two of the authors (JEH, JPH) analysed the transcripts, coded the data, identified themes, and recorded verbatim quotes represented within those themes. Results The study identified four different understandings(Leadership, Communication, Reporting, and Training)of professional behaviorwithin a single workplace culture, around a singular code of conduct policy. Conclusions Results indicated that one’s understanding of professionalism depends on one’s position and ‘standing’ within an organization and has important implications for policy setting. Although most medical institutions have policies and definitions of what is expected of professional behavior, further research is needed to understand how faculty come to operationalize and ‘live’ these policies and whether steps can be taken to match definitions with the lived experience. &nbsp

The current demand for adult hematologists in the United States is projected to exceed the existing supply. However, no national study has systematically evaluated factors affecting the adult hematology workforce. In collaboration with the American Society of Hematology (ASH), we performed a mixed methods study consisting of surveys from the annual ASH In-Service Exam for adult hematology/oncology fellows from 2010 to 2016 (8789 participants); interviews with graduating or recently graduated adult hematology/oncology fellows in a single training program (8 participants); and 3 separate focus groups for hematology/oncology fellowship program directors (12 participants), fellows (12 participants), and clinicians (10 participants) at the 2016 ASH annual meeting. In surveys, the majority of fellows favored careers combining hematology and oncology, with more fellows identifying oncology, rather than hematology, as their primary focus. In interviews with advanced-year fellows, mentorship emerged as the single most important career determinant, with mentorship opportunities arising serendipitously, and oncology faculty perceived as having greater availability for mentorship than hematology faculty. In focus group discussions, hematology, particularly benign hematology, was viewed as having poorer income potential, research funding, job availability, and job security than oncology. Focus group participants invariably agreed that the demand for clinical care in hematology, particularly benign hematology, exceeded the current workforce supply. Single-subspecialty fellowship training in hematology and the creation of new clinical care models were offered as potential solutions to these workforce problems. As a next step, ASH is conducting a national, longitudinal study of the adult hematology workforce to improve recruitment and retention in the field.

Objective To explore leadership perspectives on how to maintain high quality efficient care that is also person-centered and humanistic. Methods The authors interviewed and collected narrative transcripts from a convenience sample of 32 institutional healthcare leaders at seven U.S. medical schools. The institutional leaders were asked to identify factors that either promoted or inhibited humanistic practice. A subset of authors used the constant comparative method to perform qualitative analysis of the interview transcripts. They reached thematic saturation by consensus on the major themes and illustrative examples after six conference calls. Results Institutional healthcare leaders supported vision statements, policies, organized educational and faculty development programs, role modeling including their own, and recognition of informal acts of kindness to promote and maintain humanistic patient-care. These measures were described individually rather than as components of a coordinated plan. Few healthcare leaders mentioned plans for organizational or systems changes to promote humanistic clinician-patient relationships. Conclusions Institutional leaders assisted clinicians in dealing with stressful practices in beneficial ways but fell short of envisaging systems approaches that improve practice organization to encourage humanistic care. PRACTICE IMPLICATIONS: To preserve humanistic care requires system changes as well as programs to enhance skills and foster humanistic values and attitudes.

Background Changes in the organization of medical practice have impeded humanistic practice and resulted in widespread physician burnout and dissatisfaction. Objective To identify organizational factors that promote or inhibit humanistic practice of medicine by faculty physicians. Design From January 1, 2015, through December 31, 2016, faculty from eight US medical schools were asked to write reflectively on two open-ended questions regarding institutional-level motivators and impediments to humanistic practice and teaching within their organizations. Participants Sixty eight of the 92 (74%) study participants who received the survey provided written responses. All subjects who were sent the survey had participated in a year-long small-group faculty development program to enhance humanistic practice and teaching. As humanistic leaders, subjects should have insights into motivating and inhibiting factors. Approach Participants’ responses were analyzed using the constant comparative method. Key Results Motivators included an organizational culture that enhances humanism, which we judged to be the overarching theme. Related themes included leadership supportive of humanistic practice, responsibility to role model humanism, organized activities that promote humanism, and practice structures that facilitate humanism. Impediments included top down organizational culture that inhibits humanism, along with related themes of non-supportive leadership, time and bureaucratic pressures, and non-facilitative practice structures. Conclusions While healthcare has evolved rapidly, efforts to counteract the negative effects of changes in organizational and practice environments have largely focused on cultivating humanistic attributes in individuals. Our findings suggest that change at the organizational level is at least equally important. Physicians in our study described the characteristics of an organizational culture that supports and embraces humanism. We offer suggestions for organizational change that keep humanistic and compassionate patient care as its central focus. Electronic supplementary material The online version of this article (10.1007/s11606-018-4470-2) contains supplementary material, which is available to authorized users.

Background The National Institutes of Health define African Americans or Blacks, American Indians, Alaska Natives, Hispanics or Latinos, Native Hawaiians, and other Pacific Islanders as being underrepresented in medicine. A number of studies have demonstrated that improving diversity of such underrepresented demographics within the medical profession improves patient outcomes, medical education and reduces health disparities in patients from vulnerable racial or socioeconomic groups. Despite this recognition, significant underrepresentation of various racial, ethnic, and sexual identities still exists within nearly all medical specialties. Aims The purpose of this study was to a gain a greater understanding of the current state of diversity, equity, and inclusion (DEI) efforts among U.S. hematology and medical oncology fellowship training programs. We explored the perspectives of adult and pediatric fellowship program directors regarding current recruitment strategies and suggestions for improvement to help mitigate the effects of implicit and explicit bias. Here, we present an interim analysis of the data using descriptive statistics. Methods: We convened a multi-institutional collaboration of fellowship program directors, teaching faculty, and staff members of the American Society of Hematology to develop a survey examining perceptions of DEI efforts among hematology and medical oncology fellowship program directors. The survey was pilot tested in a small group of program directors representing 6 different academic programs (5 adult, 1 pediatric). The final online survey was distributed via email to 224 fellowship program directors at U.S. adult and pediatric hematology and medical oncology fellowship programs. The survey included 29 questions regarding perspectives on bias within the fellowship selection process, current DEI initiatives, and current faculty and fellow demographics. Survey respondents were asked to rate the importance of numerous factors in determining which applicants to invite utilizing a scale of 0-10, with 0 and 10 representing lowest and highest importance, respectively. To measure program director perceptions of certain applicant groups, survey respondents were asked to rate applicant demographics as being advantaged/disadvantaged based on survey options ranging from 0-5, with 0 and 5 representing very disadvantaged and very advantaged, respectively. Results: At interim analysis, 41 of 224 program directors completed the survey for an interim response rate of 21%, including 25 adult program directors and 16 pediatric program directors, with representation from university and community programs. Of the program directors surveyed, 28 (68%) reported having access to a dedicated diversity committee or DEI policies in place to improve recruitment of underrepresented applicants. In determining which applicants to invite, respondents placed highest value on the applicant's program director letter (mean score ± standard deviation: 7.44±1.93), caliber of the applicant's residency program (7.28±2.06) and letters of recommendations (7.15±2.23). Survey respondents viewed white and male applicants as representing the most advantaged demographic group, while LGBTQI, age>40, and U.S. citizen and non-citizen international medical graduates were the most disadvantaged (Table 1). Suggestions regarding improving DEI in the fellowship selection process included implementing bias training, identifying potentially disadvantaged applicants in ERAS, increasing faculty diversity, and pairing underrepresented applicants with interviewers based on applicant preference. Conclusion: While the majority of hematology and medical oncology fellowship program directors report having DEI programs or policies to improve recruitment of underrepresented applicants, perceptions of advantaged/disadvantaged groups may extend beyond demographics traditionally viewed as being underrepresented in medicine. As our survey is ongoing, we plan to reanalyze our data when the survey has been finalized with a higher response rate utilizing multivariable regression to identify themes that may further improve DEI efforts within the fellowship selection process. Figure 1 Figure 1. Disclosures LaCasce: Bristol-Myers Squibb Company.: Other: Data Safetly and Monitoring. Murphy: North American Thrombosis Foundation: Honoraria. Naik: Rigel: Research Funding. Podoltsev: Pfizer: Honoraria; Blueprint Medicines: Honoraria; Incyte: Honoraria; Novartis: Honoraria; Celgene: Honoraria; PharmaEssentia: Honoraria; Bristol-Myers Squib: Honoraria; CTI BioPharma: Honoraria.

Supplemental Digital Content is available in the text., The authors describe the first 11 academic years (2005–2006 through 2016–2017) of a longitudinal, small-group faculty development program for strengthening humanistic teaching and role modeling at 30 U.S. and Canadian medical schools that continues today. During the yearlong program, small groups of participating faculty met twice monthly with a local facilitator for exercises in humanistic teaching, role modeling, and related topics that combined narrative reflection with skills training using experiential learning techniques. The program focused on the professional development of its participants. Thirty schools participated; 993 faculty, including some residents, completed the program. In evaluations, participating faculty at 13 of the schools scored significantly more positively as rated by learners on all dimensions of medical humanism than did matched controls. Qualitative analyses from several cohorts suggest many participants had progressed to more advanced stages of professional identity formation after completing the program. Strong engagement and attendance by faculty participants as well as the multimodal evaluation suggest that the program may serve as a model for others. Recently, most schools adopting the program have offered the curriculum annually to two or more groups of faculty participants to create sufficient numbers of trained faculty to positively influence humanistic teaching at the institution. The authors discuss the program’s learning theory, outline its curriculum, reflect on the program’s accomplishments and plans for the future, and state how faculty trained in such programs could lead institutional initiatives and foster positive change in humanistic professional development at all levels of medical education.

Background Many of the 70,000 graduating US medical students [per year] have reported participating in a global health activity at some stage of medical school. This case study design provided a method for understanding the student's experience that included student’s learning about culture, health disparities, exposure and reaction to a range of diseases actually encountered. The broad diversity of themes among students indicated that the GCE provided a flexible, personalized experience. We need to understand the student’s experience in order to help design appropriate curricular experiences [and valid student assessment]. Objective Our research aim was to analyze medical student reflection papers to understand how they viewed their Global Clinical Experience (GCE). Methods A qualitative case study design was used to analyze student reflection papers. All 28 students who participated in a GCE from 2008-2010 and in 2014-2015 and submitted a reflection paper on completion of the GCE were eligible to participate in the study. One student did not submit a reflection paper and was not included in the study. Findings All 27 papers were coded by paragraph for reflection and for themes. System of Care/Range of Care was mentioned most often, Aids to Adjustment Process was mentioned least. The theme, “Diseases,” referred to any mention of a disease in the reflection papers, and 44 diseases were mentioned in the papers. The analysis for depth of reflection yielded the following data: Observation, 81/248 paragraphs; Observation and Interpretation, 130/248 paragraphs; and Observation, Interpretation, and Suggestions for change, 36/248 paragraphs; 9 reflection papers contained 27 separate accounts of a transformational experience. Conclusions This study provided a method for understanding the student's experience that included student’s learning about culture, health disparities, and exposure and reaction to a range of diseases actually encountered. The broad diversity of themes among students indicated that the GCE provided a flexible, personalized experience. How we might design a curriculum to facilitate transformational learning experiences needs further research.

Global health education (GHE) continues to be a growing initiative in many medical schools across the world. This focus is no longer limited to participants from high-income countries and has expanded to institutions and students from low- and middle-income settings. With this shift has come a need to develop meaningful curricula through engagement between educators and learners who represent the sending institutions and the diverse settings in which GHE takes place. The Bellagio Global Health Education Initiative (BGHEI) was founded to create a space for such debate and discussion and to generate guidelines towards a universal curriculum for global health. In this article, we describe the development and process of our work and outline six overarching principles that ought to be considered when adopting an inclusive approach to GHE curriculum development.

Soil-transmitted helminths (STH) have remained a major threat to humans, especially children in developing countries, including Nigeria. Interventions have always been geared towards school-aged children, neglecting preschool-aged children and occupational risk adults. The Soil-Transmitted Helminthiasis Advisory Committee (STHAC) recently suggested incorporating other at-risk groups.

What's New Fellows as Medical Educators (FAME) is the first department-wide curriculum for pediatric subspecialty fellows that includes experiential learning activities, faculty and peer coaching and self-reflection through journaling. Fellows who participated in the pilot curriculum demonstrated an improvement in objective teaching skills and self-efficacy.

167 Background: The relationship between the physician and patient is directly associated with positive patient satisfaction. High patient satisfaction is associated with improved health outcomes, treatment adherence, and quality of life. The goal was to explore patients’ perceptions on their hospital experience, focusing on quality of care. Methods: A mixed-methods study design with a sample of 58 patients at Yale New Haven Hospital. Data were from patient interviews and observation of rounds. Results: Two themes emerged: patient experience and patient communication with physicians. Within patient experience positive factors identified were feeling attended to (45.9%), nurses (43.2%), staff (27.0%), doctors (27.0%), facility (10.8%) and coordination of care (8.1%). Negative factors were low quality of life (82.8%), lack of physician emotional support, attentiveness and availability (24.1%), and poor coordination of care (20.7%). Within physician communication positive factors included effectively engaging the patient (27.5%) and attending to patient needs (7.5%). Negative factors were nature of distilling information (17.5%), lack of coordination of care (15.0%), inadequate involvement of the patient and/or family (12.5%), use of medical jargon (10.0%), and inability to elicit patients’ perspective (7.5%). The quantitative data supported qualitative results of overall satisfaction with 72.4% of patients (n = 58) rating their experience as an ‘A’. Areas of dissatisfaction (an ‘A’ rating < 70% of time) included describing team member roles, explaining next steps in care or treatment to the patient and/or family, and meeting patients’ needs. Conclusions: Our findings, demonstrate that physician attentiveness or lack thereof defines the quality of patient experience, is an important theme in communication and that patients perceive their needs are not being fully addressed. Agreement in themes from mixed-method approach shows effectiveness of methods in exploring patients’ perceptions on quality of care. The study intends to inform clinical and operational practices physicians can incorporate into their patient relationships. These data are being used to design a faculty development program to address physician communication.

This study assesses the prevalence of bullying and barriers to its eradication among US surgeons.

Translational Medicine (TM) is a comparatively new field of study that focusses on the continuum of activities from the conception of an idea, to advanced clinical testing and the development of a new medical technology or drug. In recent years, graduate education programs have been established internationally to train a new generation of professionals with specific skills necessary to navigate the translational landscape. Literature in the area highlights the importance of integrating specific competencies relevant to translational medicine as part of curriculum development. In addition to developing a working understanding of core knowledge (e.g., ethics, funding, regulation, policy, etc.), skills including effective communication, reflection, interdisciplinary, and interprofessional collaboration are critical components of a skilled TM professional. Curriculum development must focus on content, while carefully selecting the teaching strategies that are most effective to achieve the desired outcomes, which is for learners to comprehend the complex material. The following publication presents a series of vignettes that describe the experiences of an associate professor of molecular biology, who is looking to explore her role in translational medicine and develop skills for an innovative approach to problem-solving. The vignettes are focused on a variety of teaching and learning strategies that can be used to teach translational medicine. Each vignette includes a description of the experience from the perspective of the learner and the faculty as it pertains to the teaching strategy, method of delivery, and learning outcomes. TM is as complex to teach as it is to learn. The specialized skills and knowledges that are part of the TM toolbox cannot all be taught in a lecture format. Educators must consider multiple strategies and select those which are most effective for achieving the learning outcomes.

Background Delivering difficult news to patients and families is an essential but challenging communication skill. Pediatric trainees report limited training, competence, or comfort in this skill, and when tested, perform poorly. Objective To assess the effectiveness of a modified American Academy of Pediatrics (AAP) Resiliency Curriculum (Part B) to improve skills and self-efficacy of pediatric trainees in delivering bad news. Methods A quantitative research design was used to study the impact of the modified curriculum, offered at one institution with 78 residents and 48 fellows. The course consisted of interactive didactics with faculty role modeling. Fellows also participated in role playing and in novel simulations and self-reflection activities. Self-efficacy surveys were used to assess knowledge, confidence, and comfort with delivering difficult news. Objective performance was assessed during simulations with standardized patients using a bad news delivery framework checklist (“SPIKES”) and the mini Master Interview Rating Scale (mMIRS). Self-efficacy was analyzed using hierarchical mixed effects linear modeling and simulation performance was evaluated using Wilcoxon signed-rank tests. Results Pediatric trainees (n=67, 29 residents, 38 fellows) improved their scores on each of the 13 self-efficacy items (p=0.007 to Conclusion Pediatric residents had significant improvement in self-efficacy and fellows in both self-efficacy and observable skill in delivering difficult news after participation in an AAP modified Resiliency course, with the use of simulation for fellows. These learning activities could serve as a model for other institutions to address gaps in training for difficult news delivery.

Objective This study aims to elicit physician and nursing perceptions about initiation of minimal enteral feedings (MEF) in very low-birth-weight (VLBW) infants. Study Design A three-phase, mixed methods study including a quantitative chart review of 37 VLBW infants, followed by 26 qualitative observations of morning rounds, 26 interviews of neonatal intensive care unit (NICU) medical team members, tailored interventions based on the identified barriers to MEF, and finally a postintervention chart audit of 50 VLBW infants. Results The main barriers to initiation of MEF were failure to appreciate the differences between the goals of MEF versus nutritive feedings, inconsistent definition of “sick” infant, indomethacin for intraventricular hemorrhage prophylaxis, awaiting mother's own milk, complicated feeding protocols/algorithms for feeding intolerance, and lack of buy-in from nurses/nurse practitioners. The compliance with early initiation of MEF per the feeding guidelines rose from 25 to 92% after our interventions. Conclusion Understanding the complex interplay of provider, system and patient-based factors that interfere with initiation of MEF may enable NICUs to develop consensus guidelines and targeted interventions and to achieve timely initiation of nonnutritive feedings.

Psychologists’ roles within academic medicine have expanded well beyond research and scholarship. They are active as providers of patient care, medical education, and clinical supervision. Although the number of psychologists in academic health centers continues to grow, they represent a small portion of total medical school faculties. However, with the movement toward collaborative care models, emphasis on interprofessional teams, and increased emphasis on psychological science topics in medical curricula, psychologists are well-positioned to make further contributions. Another path through which psychologists can further increase their contributions and value within academic health centers is to aspire to leadership roles. This article describes the first author’s reflections on her experiences in a two-year, cohort-based, educational leadership development certificate program in academic medicine. The cohort was comprised largely of physicians and basic scientists, and a small number of non-physician participants of which the first author was the only clinical psychologist. The insights gained from this experience provide recommendations for psychologists interested in leadership opportunities in academic medicine.

Objective:To assess whether communication training for house staff via role-playing exercises (1) is well received and (2) improves patient experience scores in house staff clinics.Methods:We conducted a pre–post study in which the house staff for 3 adult hospital departments participated in communication training led by trained faculty in small groups. Sessions centered on a published 5-step strategy for opening patient-centered interviews using department-specific role-playing exercises. House staff completed posttraining questionnaires. For 1 month prior to and 1 month following the training, patients in the house staff clinics completed surveys with Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) questions regarding physician communication, immediately following clinic visits. Preintervention and postintervention results for top-box scores were compared.Results:Forty-four of a possible 45 house staff (97.8%) participated, with 31 (70.5%) indicating that the role-playing exercise increased their perception of the 5-step strategy. No differences in patient responses to CG-CAHPS questions were seen when comparing 63 preintervention surveys to 77 postintervention surveys.Conclusion:Demonstrating an improvement in standard patient experience surveys in resident clinics may require ongoing communication coaching and investigation of the “hidden curriculum” of training.

Objective Major reorganizations of medical practice today challenge physicians’ ability to deliver compassionate care. We sought to understand how physicians who completed an intensive faculty development program in medical humanism sustain their humanistic practices. Methods Program completers from 8 U.S. medical schools wrote reflections in answer to two open-ended questions addressing their personal motivations and the barriers that impeded their humanistic practice and teaching. Reflections were qualitatively analyzed using the constant comparative method. Results Sixty-eight physicians (74% response rate) submitted reflections. Motivating factors included: 1) identification with humanistic values; 2) providing care that they or their family would want; 3) connecting to patients; 4) passing on values through role modelling; 5) being in the moment. Inhibiting factors included: 1) time, 2) stress, 3) culture, and 4) episodic burnout. Conclusions Determination to live by one’s values, embedded within a strong professional identity, allowed study participants to alleviate, but not resolve, the barriers. Collaborative action to address organizational impediments was endorsed but found to be lacking. Practice implications Fostering fully mature professional development among physicians will require new skills and opportunities that reinforce time-honored values while simultaneously partnering with others to nurture, sustain and improve patient care by addressing system issues.

Phenomenon: As an impending shortage of primary care physicians is expected, understanding career trajectories of medical students will be useful in supporting interest in primary care fields and careers. The authors sought to characterize recent trends in primary care interest and career trajectories among medical students at an academic medical institution that did not have a family medicine department.Match data for 2,477 graduates who matched into resident training programs between 1989 and 2014 were analyzed to determine the proportion entering primary care residency programs. An online search and confirmatory phone call methodology was used to determine primary care career trajectories for the 795 graduates who matched into primary care residency programs between 1989 to 2010. Subanalyses were performed to characterize primary care career entrance among graduates who matched into the three primary care residency programs: Family Medicine, Categorical and Primary Care Internal Medicine, and Categorical and Primary Care Pediatrics.Between 1989 and 2014, 911 (37%) of all matched graduates matched into primary care residency programs. Of the 795 graduates who matched into these programs between 1989 and 2010, less than half (245; 31%) entered primary care careers. Of the graduates who ultimately entered primary care careers, 82% matched into either internal medicine or pediatrics residency programs and 18% matched into family medicine programs. Although there have been fluctuations in primary care interest that seem to parallel health care trends over the 26-year period, the overall percentage of graduates entering primary care residency programs and careers has remained fairly stable. Between 2006 and 2010, entrance into both primary care residency programs and primary care careers steadily increased. Despite this, the overall percentage of matched graduates who entered primary care careers over the 22-year study period (12%) was less than the national average (16%-18%). Insights: In the 26-year period between 1989 and 2014, primary care career interest increased slightly among medical students at this academic medical institution, with fluctuations that seem to coincide with national health care trends. Year-to-year fluctuations appear to be driven by rising numbers of Categorical Pediatrics and Categorical Internal Medicine matchers pursuing careers in primary care. There may be a need for specialized curricula and strategies to promote and retain interest in primary care at academic medical institutions, especially at institutions without family medicine training programs.

Medical student literature has broadly established the importance of differentiating between formal-explicit and hidden-tacit dimensions of the physician education process. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors. The authors extend the concept of the hidden curriculum from students to faculty, and in so doing, they frame the acquisition by faculty of knowledge, skills, and values as a more global process of identity formation. This process includes a subset of formal, formative activities labeled "faculty development programs" that target specific faculty skills such as teaching effectiveness or leadership; however, it also includes informal, tacit messages that faculty absorb. As faculty members are socialized into faculty life, they often encounter conflicting messages about their role. In this article, the authors examine how faculty development programs have functioned as a source of conflict, and they ask how these programs might be retooled to assist faculty in understanding the tacit institutional culture shaping effective socialization and in managing the inconsistencies that so often dominate faculty life.

The emphasis on resident competencies advocated by the Accreditation Council for Graduate Medical Education and other medical educators1 has brought new focus on the teaching competencies of our faculty. The expectation that teaching faculty possess a minimum level of teaching competency has been under discussion at our institution. In our recent (2008) peer-reviewed workshop at the Association of American Medical Colleges, we found that, among the 28 participants, no school was providing faculty development for competence in teaching. As increasing public scrutiny focuses on the medical professions, medical educators will be asked to be more accountable for training programs they are involved in and the teaching skills they possess.2

We hypothesized that an interested medical student group would be helpful in reviewing tutorial cases and giving relevant feedback on the curricular integration of cross-cultural content using case triggers in a preclinical gastrointestinal pathophysiology course. Self-selected student leaders ( n = 9) reviewed pre-existing problem-based learning tutorial cases ( n = 3) with cross-cultural triggers, and provided narrative feedback to course faculty. The cases were modified and used for the entire class in the following 2 years. Participating course students' comments and teaching faculty feedback were also noted. Outcomes were a change in case content, student global evaluations of the course, and self-reported faculty comfort with teaching the cases. All three tutorial cases were reviewed by a separate group of 2–3 students. Major and minor revisions were made to each case based on the student feedback. These cases were used in 2007 and 2008 and were the major change to the course during that time. Overall course evaluation scores improved significantly from 2006 to 2008 ( p = 0.000). Tutors ( n = 22 in 2007; n = 23 in 2008) expressed relief during tutor meetings that students had reviewed the cases. A general framework for eliciting student feedback on problem-based cases was developed. Student feedback, consisting of self-selected students' case reviews and solicited course and tutor comments, added value to a curricular reform to improve the integration of cross-cultural content into a problem-based learning curriculum. Our study underscores the fundamental link between teachers and students as partners in curricular development.

BACKGROUND: Pediatric housestaff are required to learn basic procedural skills and demonstrate competence during training. To our knowledge, an evidenced-based procedural skills curriculum does not exist. OBJECTIVE: To create, implement, and evaluate a modular procedural skills curriculum for pediatric residents. METHODS: A randomized, controlled trial was performed. Thirty-eight interns in the Boston Combined Residency Program who began their training in 2005 were enrolled and randomly assigned. Modules were created to teach residents bag-mask ventilation, venipuncture, peripheral intravenous catheter (PIV) insertion, and lumbar puncture skills. The curriculum was administered to participants in the intervention group during intern orientation. Interns in the control group learned procedural skills by usual methods. Subjects were evaluated by using a structured objective assessment on simulators immediately after the intervention and 7 months later. Success in performing live-patient procedures was self-reported by subjects. The primary outcome was successful performance of the procedure on the initial assessment. Secondary outcomes included checklist and knowledge examination scores, live-patient success, and qualitative assessment of the curriculum. RESULTS: Participants in the intervention group performed PIV placement more successfully than controls (79% vs 35%) and scored significantly higher on the checklist for PIV placement (81% vs 61%) and lumbar puncture (77% vs 68%) at the initial assessment. There were no differences between groups at month 7, and both groups demonstrated declining skills. There were no statistically significant differences in success on live-patient procedures. Those in the intervention group scored significantly higher on knowledge examinations. CONCLUSIONS: Participants in the intervention group were more successful performing certain simulated procedures than controls when tested immediately after receiving the curriculum but demonstrated declining skills thereafter. Future efforts must emphasize retraining, and residents must have sufficient opportunities to practice skills learned in a formal curriculum.

Background & Aims Our study describes a faculty development program to encourage the integration of racial, cultural, ethnic, and socioeconomic factors such as obesity, inability to pay for essential medications, the use of alternative medicine, dietary preferences, and alcoholism in a gastrointestinal pathophysiology course. Methods We designed a 1-hour faculty development session with longitudinal reinforcement of concepts. The session focused on showing the relevance of racial, ethnic, cultural, and socioeconomic factors to gastrointestinal diseases, and encouraged tutors to take an active and pivotal role in discussion of these factors. The study outcome was student responses to course evaluation questions concerning the teaching of cultural and ethnic issues in the course as a whole and by individual tutorials in 2004 (pre-faculty development) and in 2006 to 2008 (post-faculty development). Results Between 2004 and 2008, the proportion of students reporting that "Issues of culture and ethnicity as they affect topics in this course were addressed" increased significantly ( P = .000). From 2006 to 2008, compared with 2004, there was a significant increase in the number of tutors who "frequently" taught culturally competent care according to 60% or greater of their tutorial students ( P = .003). The tutor's age, gender, prior tutor experience, rank, and specialty did not significantly impact results. Conclusions An innovative faculty development session that encourages tutors to discuss racial, cultural, ethnic, and socioeconomic issues relevant to both care of the whole patient and to the pathophysiology of illness is both effective and applicable to other preclinical and clinical courses.

Background Surgery residents teach medical students; feedback is one critical teaching skill. We investigated whether feedback given by surgery residents to students could be improved through an online spaced education program. Methods Surgery residents were randomized to receive either a weekly spaced education e-mail during a 9-month period containing teaching bullets on how to provide effective feedback, or no intervention. Medical students rated the frequency and quality of feedback they received from the residents. Results Students reported 45% (67 of 149) of the spaced education residents gave frequent feedback, compared with 31% (55 of 175) of control residents (relative risk [RR], 1.43; P = .016). Students reported resident feedback was “helpful in their learning” in 92% (132 of 143) of their evaluations of spaced education residents, compared with 82% (132 of 161) of their evaluations of control residents (RR, 1.13; P = .01). Conclusions Educational programs using feedback bullets e-mailed weekly can significantly improve the frequency and quality of feedback that surgical residents provide medical students.

Background: Medical regulatory organizations worldwide require competency in communication skills. Pediatric communication competencies are unique, and little is known about pediatric residents’ perceptions regarding these skills. Aim: The purpose of this study was to examine pediatric residents’ attitudes about communication skills, their perceptions of the importance of learning 15 specific communication skills relevant to pediatrics, confidence in these skills, and relevant program supports. Methods: We developed a 47-item cross-sectional questionnaire to study pediatric residents’ attitudes and perceptions regarding communication competencies. 104 pediatric housestaff in a university-affiliated program in the US were asked to complete the questionnaire. Scale variables were created and evaluated for reliability. Data were analysed using descriptive and univariate statistics. Results: Response rate was 86% (89/104). Cronbach’s alpha reliabilities of the Importance Scale (r ¼ 0.92) and Confidence Scale (r ¼ 0.90) were excellent. Ninety nine percent of the participants agreed that learning to communicate effectively with patients was a priority. All agreed it is important to demonstrate empathy and caring, and to teach medical students to communicate effectively with patients. Pediatric residents agreed that the 15 communication competencies studied were important to learn. Most reported confidence in core communication competencies (interviewing, listening, building rapport, demonstrating caring and empathy), but only half or fewer were confident in 7 more advanced communication skills (ability to discuss end-of-life issues, speaking with children about serious illness, giving bad news, dealing with the ‘difficult’ patient/parent, cultural awareness/sensitivity, understanding psychosocial aspects, and understanding patients’ perspectives). Few reported the availability of relevant program supports for learning these skills. Conclusions: Pediatric residents perceive communication competencies as important and a priority for learning, yet report a lack of confidence in advanced communication skills and insufficient program supports. Our measurement scales can add to the evaluation of residency programs, and may provide suggestions for pediatric curricular content in core and advanced communication skills.

OBJECTIVE. The objective of this study was to assess the opinions of pediatric program directors regarding procedural skills training of pediatric residents.METHODS. We developed a survey based on the Residency Review Committee's guidelines for procedural training. It included items about the importance of 29 procedures encountered in pediatric training, estimates of residents' competence in performing them, and the teaching of procedural skills. The survey was sent to members of the Association of Pediatric Program Directors. The primary outcome was the perceived importance for residents to achieve competence in these procedures, rated on a 10-point Likert scale. Secondary outcomes included perception of resident competence to perform procedures and educational methods used by respondents for teaching procedural skills. Associations between demographic characteristics and perceived importance or competence were also assessed.RESULTS. Surveys were sent to 139 programs, and 112 responded. Thirteen procedures were rated 8 or higher by >75% of program directors. Seven skills that were prioritized by the Residency Review Committee did not achieve this level of consensus. Respondents reported that many residents failed to achieve competence by the end of training in 9 of 13 procedures that they rated as very important, including venipuncture, neonatal intubation, and administering injections. Residents who perform the majority of venipunctures and intravenous catheter placements at their institutions were more likely to be judged competent in performing these skills than residents who do not.CONCLUSIONS. The Residency Review Committee's list of procedures does not necessarily reflect the opinions of pediatric program directors on the most essential skills for trainees. Many residents may not develop competence in several important procedures by the end of residency, most notably vascular access and life-saving skills. A more robust and standardized method is needed for teaching procedural skills and for documenting competence.

Background In 1999, the ACGME introduced the 6 competencies that have become the basis for resident education. Since the operating room (OR) has traditionally been the major focus for resident teaching in surgery, we performed an observational study to determine whether it is an appropriate setting for the teaching and/or assessment of the competencies. Methods A 3-person team observed 11 operations and recorded all teaching events. Observers then determined whether each event involved the teaching of a competency by faculty or demonstration of a competency by residents. Frequency counts, mean times, and ranges were calculated for each competency taught and demonstrated. Results The Patient Care competency was both the most commonly taught and demonstrated. Faculty spent an average of 33% of operative time instructing in patient care, and residents demonstrated it 65% of the time. The Interpersonal/Communication Skills (4%) and Practice-Based Learning/Improvement (4%) competencies were also occasionally demonstrated by residents. The remaining competencies were addressed less frequently. Conclusions OR teaching was primarily devoted to the Patient Care competency. The OR was also an appropriate setting for evaluating resident performance in this area. New approaches to OR teaching or educational efforts in other settings such as the clinic are necessary for teaching and assessing the remaining competencies.

During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made.During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students' overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05.In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P.05). The students reported that the tutorial made a more important contribution to their learning (P.05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002.The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam's mean score.

Objective Resident physicians have reported spending upward of 25% of their time teaching fellow residents and medical students. Until relatively recently, there have not been formal requirements in residency programs to learn teaching skills. The first goal of this study was to develop a novel residents-as-teachers training program to educate Ophthalmology residents on facilitating group learning and emphasizing critical-thinking skills. The second goal was to educate residents on how to teach clinical reasoning skills. Design We designed a longitudinal residents-as-teachers program that consisted of a 2-hour workshop, voluntary observation of their teaching in the small group, and student feedback on their teaching. The focus of the workshop was to educate the residents on how to facilitate critical thinking and clinical reasoning in a small group format. Voluntary video recording of residents’ teaching was offered, and feedback on their teaching was provided. Setting Yale University School of Medicine, Department of Ophthalmology and Visual Science. Participants In total, ten second-year medical student groups consisting of approximately 7 to 11 students in each group were organized in this course and each group had one teacher: 4 senior Ophthalmology residents and 6 community faculty. Results This study found that the resident teachers who completed the residents-as-teachers program were equally as effective as community faculty teachers in building medical students’ comprehension of ophthalmic principles during small group seminars according to the students’ evaluation of teaching performance. We also found that all of the medical students’ responses were overwhelmingly positive toward having residents as teachers. The medical students particularly noted residents’ preparedness and effectiveness in facilitating a discussion during the small group seminars. Conclusions Our novel program was effective at teaching residents how to teach critical-thinking skills and the resident teachers were well received by medical students in the classroom. Given the requirement that residents learn teaching skills during residency and our preliminary success, we plan to continue inviting residents to teach small group seminars in Ophthalmology, and we will continue to provide them with the residents-as-teachers program.

United States public health goals call for increased physician counseling about diet and exercise, but many medical schools lack adequate curriculum on these topics. At Harvard Medical School, second-year students take a preventive medicine and nutrition (PMN) course. This study evaluated the impact of this innovative curriculum on students' confidence about addressing patients' diet and exercise patterns and on their own health habits.Students enrolled in the 2003 PMN course (N =137) completed a confidential 43-item written survey before and after the course. Surveys were completed by 134 students (98%) and 118 students (86%), respectively. The survey assessed students' diet and exercise habits and students' confidence in their ability to address diet and exercise with patients and family members.Students' confidence in their ability to assess and counsel about diet and exercise significantly improved after the course (all p0.001). The course was also associated with a decrease in students' self-reported consumption of saturated fat (p =0.002) and trans fatty acids (p0.001). Following the course, 72% of students perceived an improvement in their diet but only 18% perceived an improvement in exercise habits.An innovative PMN course improved medical students' confidence in diet and exercise counseling and perceived dietary habits. Improving these mediators of physician counseling in medical students may translate into changes in their practice patterns.

Background.—The schooling of 1 of every 8 children is influenced by the Individuals with Disabilities Education Act (IDEA). The IDEA also governs, to a degree, the relationship between interdisciplinary hospital clinics that evaluate many of these children and the schools that provide educational services. Little is known about how this relationship functions or how educational personnel perceive reports from hospital settings. Objectives.—To describe special education administrator and hospital evaluator perspectives on hospital assessments of children with learning problems. Methods.—A survey of attendees at a 1998 meeting of the Massachusetts Association of Special Education Administrators was conducted by use of a questionnaire using closed and open-ended questions. Subsequently, focus groups were held with hospital evaluators. Results.—Special education administrators describe a high level of frustration with hospital-school relations. They state that hospital reports do not meet the needs of children in the educational setting. They seek closer collaboration with medical evaluators. Evaluators working in hospital settings acknowledge frustration perceived by school personnel. They state that communication with educational personnel improves the quality of their reports and outcomes for the child. Conclusions.—Hospital assessments of children with learning problems are associated with high levels of frustration among special education administrators. These assessments might be made more useful if careful attention were paid to the needs of educators. Greater communication between hospital evaluators and school personnel may increase the usefulness of hospital clinic assessments of children with learning problems.

While global health (GH) opportunities have expanded at schools of medicine, nursing, and public health, few examples of interprofessional approaches to GH education have been described. The elective GH program at our university serves as an important opportunity for high-quality interprofessional education. We undertook a qualitative study to examine the experience of student, faculty and administrative leaders of the program. We used content analysis to code responses and analyze data. Among the leadership, key themes fell within the categories of interprofessional education, student–faculty collaboration, professional development, and practical considerations for the development of such programs. The principles described could be considered by institutions seeking to develop meaningful partnerships in an effort to develop or refine interprofessional global health education programs.

Introduction/Background: The American Society of Hematology and National Heart Lung and Blood Institute have long recognized the need for increased training of physicians for positions in academic and non-malignant hematology. Literature from a number of medical specialty fields supports the value of preclinical education in directing student interest and ultimately determining career choice. Many medical schools are currently changing their preclinical curricula with aims to improve student learning, increase preparedness for clinical responsibilities, and foster specialty interest. Student surveys and focus groups provide valuable feedback regarding such curricular changes. In 2015, the Yale School of Medicine (YSM) unveiled a new preclinical curriculum, which included an extensive and systemic revision of the hematology course based on several years of student feedback. We present the new YSM hematology curriculum as a model for course design and a potential tool for generating medical student interest in hematology. Methods: Two sources of feedback were collected annually from 2010-2015. YSM students completed anonymous surveys assessing different aspects of the previous hematology course. In addition, for each year, a randomly selected cohort of students met with course directors via a focus group discussion to provide direct, in-person feedback about the curriculum. Each year, the hematology course was modified according to specific recommendations from the surveys and the focus groups. The final hematology course, launched in 2015, was a novel curriculum combining traditional lecture formats with small-group workshops, team-based learning (TBL) sessions (which replaced traditional small-group laboratory sessions), case-based clinicopathologic correlation (CPC) sessions (jointly led by hematology and pathology faculty), large-group boards review sessions, evening faculty-student career interest dinners, and clinical shadowing experiences with designated hematology faculty. Students in the 2015-2016 class were then surveyed to assess effectiveness of the new hematology curriculum. Results: Prior to the new curriculum, medical students had mostly favorable impressions of the previous hematology course, with the exception of the small-group laboratory sessions, which were consistently identified as ineffective, uninteresting, and "redundant" in their material. Students evaluating the prior curriculum generally rated case-based workshops favorably for being "clinically focused" and "g[etting] everyone involved" in the learning process by "stimulat[ing] discussion." Students also specifically asked for more "interactive" sessions that "could not be done at home." With the gradual introduction of changes to the hematology curriculum each year, the percentage of students who gave the course top ratings rose considerably, from 57.1% in 2012 to 90.9% 2014. The final 2015 hematology curriculum was identified by the students as a "Gold standard" that could "serve as a model" with respect to creating a "cohesive learning experience." Students specifically highlighted the unique role of TBL and CPC sessions in the new curriculum. Using a Likert scale of up to 5 points, students found TBL to be effective (4.49) and to increase understanding of class material (4.42) by "review[ing] what we learned in lectures" and fostering "learn[ing of] the material at a deeper level." The CPC sessions were rated as "Excellent" by 88% of students, who described them as "cohesive" and "balanced" with "excellent integration" of clinical and pathologic material. Conclusions: A multi-modality curriculum incorporating TBL, joint hematology and pathology faculty-led CPC sessions, and out-of-classroom enrichment is an effective method for engaging students in hematology and may serve as a model for other medical schools revising preclinical curricula. Disclosures No relevant conflicts of interest to declare.

INTRODUCTION/BACKGROUND The majority of graduating fellows from hematology/oncology subspecialty training programs in the U.S. pursue careers in medical oncology or in non-academic fields. A workforce shortage of physicians specializing in hematology has been predicted for the next decade. Large-scale surveys have identified a number of factors responsible for this trend, including financial considerations, educational debt, work-life balance, and fellowship exposure. Qualitative studies in other subspecialty fields have yielded unique insights into specific factors motivating career decisions, but no such study has been conducted in hematology. We performed a qualitative study to identify factors influencing trainees' perceptions of careers in hematology. METHODS Senior or graduating fellows in the hematology/oncology training program at Yale School of Medicine were invited to participate in this study. Semi-structured interviews lasting between 30 and 90 minutes were conducted. Recordings were transcribed and analyzed using the framework method. RESULTS Eight trainees participated in the study, five in their senior year of training, three shortly after graduation. Five were female. Three held dual M.D. and Ph.D. degrees. Most were planning on an academic career or a career with an academic affiliation; two were specifically pursuing careers in benign or malignant hematology. Trainees' career decisions and perceptions of hematology revolved around five major themes: serendipity, mentorship, clinical exposure and teaching, intellectual interest, and lifestyle factors. Most trainees identified seminal, career-defining experiences prior to medical school but were not influenced by medical school classroom experiences and were not differentiated at the start of fellowship with respect to a hematology- or oncology-oriented career. By the end of their first year of fellowship, almost all had decided to pursue careers in solid tumor oncology owing to clinical exposure and research opportunities. Mentorship was identified as the single most important determinant, with mentorship opportunities tending to occur "randomly" or by "happenstance," and with oncology having "more" "available mentors" who played a "huge role" in the career-decision process. Trainees characterized hematology as having a less desirable work/life balance than oncology, and trainees' experiences on the inpatient hematology services caused some of them to feel "burned out." Despite this, fellows commonly perceived hematology to be more "interesting" and "challenging" than oncology, with "much more complex" disease pathology. Financial considerations were of importance to only a minority of trainees. CONCLUSIONS Mentorship and research opportunities are the major factors guiding career decisions among hematology/oncology fellows. An increase in structured mentorship opportunities in hematology may lead to greater trainee recruitment. Trainees view hematology as an intellectually engaging field although lifestyle factors render it less desirable than oncology. Disclosures Podoltsev: Incyte: Consultancy, Honoraria; Ariad: Consultancy, Honoraria.

Cultural sensitivity is crucial for optimal mental health outcomes. In particular, differing expectations can interfere with the delivery of quality care when clinicians and patients do not share the same background and belief systems. Cultural influences are linked to health disparities and the providers’ attitudes in the clinical encounter. Thus, education in cultural sensitivity should include experiences to help learners become aware of unconscious stereotypes, as well as understanding the impact of social and cultural influences on health outcomes [1–3]. There are multiple teaching approaches and cross-cultural curricular designs that address attitudes, knowledge, and skills [4]. The most comprehensive approach, grounded in the social sciences, uses the trainee’s awareness of their own cultural background to teach them how to respond effectively to their patient’s issues that involve culture and ethnicity [5]. We developed a curriculum using experiential learning as the main teaching approach [6]. Residents were the teachers, also addressing the need for trainees to acquire teaching skills [7]. In this paper, we describe the design and implementation of an innovative cultural psychiatry curriculum.

Resident physicians spend numerous hours every week teaching medical students and fellow residents, and only rarely are they taught how to teach. They can, however, be taught to teach more effectively. Teaching skills improvement initiatives for residents are taking a more prominent place in the educational literature. Limited evidence now suggests that better resident teachers mean better academic performance by learners. A small but important body of research supports selected interventions designed to improve residents' teaching skills, but not all studies have demonstrated significant educational benefits for learners. An increasing number of valid and reliable instruments are available to assess residents' clinical teaching, including objective structured teaching examinations and rating scales. In all specialties, rigorous research in evidence-based teacher training for residents will help prepare academic medical centers to meet the diverse and changing learning needs of today's physicians-in-training.resident physicians, medical students, fellow residents, teaching, graduate medical education.

Objective. To describe factors that prompt pediatric practitioners to suspect child sexual abuse, the barriers to inquiry, and the approach to management of cases of possible abuse. Design. Qualitative, descriptive, and case-based. Methods. Six focus group interviews were conducted. Maternal and Child Health Bureau-sponsored collaborative office rounds groups nationwide participated in discussions of five vignettes. Each group interview lasted 1.5 hours and had 7 to 16 participants (n = 65). Audiotaped data were transcribed and analyzed independently for themes by two reviewers. Results. Five themes emerged from the group interviews: anticipatory guidance, red flags, approach to management, terminology used in discussions, and barriers to inquiry. All groups discussed giving anticipatory guidance about sexual abuse. Half (3/6) believed girls were more likely to be victimized, and some (2/6) gave more anticipatory guidance to girls for this reason. Although some groups reported giving anticipatory guidance about sexual abuse, many reported inconsistencies in their practice. All groups identified historical, behavioral, and physical red flags for sexual abuse but believed that they were not trained in residency to recognize these signs. There was no consensus regarding the approach to management of cases of possible sexual abuse, and many participants did not know the types of questions that they should be asking children when they suspect abuse. Members of all groups reported using imprecise terms when they discuss sexual issues with families. Most (4/6) believed that it was a practitioner's responsibility to inquire about abuse but believed that their discomfort with sexual topics was a barrier to inquiry. All believed that the most significant barrier to inquiry was inadequate training in the area of sexual abuse and that cases are missed because of lack of training. Conclusions. Highly motivated pediatric practitioners reported that they give anticipatory guidance about sexual abuse inconsistently, that they were not trained to recognize red flags for sexual abuse, and that they do not have a consistent approach to cases of suspected abuse. Additionally, they reported that they are not comfortable discussing sexual issues and that they miss cases of sexual abuse primarily because of lack of training. Educational interventions that target these themes are essential to improve the ability of pediatricians to screen children and to intervene when sexual abuse is identified.

These data characterize and illuminate an analysis of experiences about teaching during each year of a pediatric residency training program in a tertiary care center. The curriculum sought to introduce many concepts about teaching, and residents reported that they: 1. Used concepts introduced about feedback; 2. Began to appreciate that teaching is more than imparting knowledge; 3. Began to identify teaching opportunities in the context of patient care; and 4. Incorporated the practice of establishing goals and expectations for learning with their learners. These data suggest that as interns are exposed to concepts about teaching, they are able to identify what they can offer students, irrespective of the amount of knowledge and clinical experience they have about pediatric medicine. Helping interns appreciate that teaching stems from one's experiences and is much more than just "telling what one knows" was an explicit goal of the Teaching Program's curriculum design group. Another conclusion is that PGY-2 residents are aware that patient care responsibilities pose challenges to teaching. PGY-2 residents at CHB are transitioning from a relatively intense teaching experience as PGY-1 interns to becoming team leaders as PGY-3 residents. Thus, the issues about teaching in the PGY-2 year seem less defined. Helping PGY-2 residents better integrate teaching with patient care continues to be a challenge. Although the focus of the PGY-2 curriculum in the Teaching Program focused on developing skills to become teachers during the final year of residency, what emerged from PGY-2 residents were their concerns and insights about teaching better in situations in which patient care responsibilities were the priority. In addition to using concepts introduced in the sessions, residents in all three training years unanimously reported one impact of the Teaching Program: it made them more "aware" of the importance of teaching and of developing teaching skills. They also began to realize that they require feedback about their teaching from peers, attending physicians, and learner sources. By experiencing the Teaching Program, residents identified other useful approaches and resources to learning about teaching, mainly by observing their peers. Additionally, many residents were beginning to develop individualized approaches toward teaching based on their experiences in the clinical setting and their development as clinicians—the examples shared by interns about how they actually engaged learners—support this conclusion. Finally, the Teaching Program stimulated the process of reflection about teaching—mainly the importance of teaching, the challenges of performing as better teachers, and learning ways to understand how individuals learn. The importance of developing reflective practice skills about teaching has been stated by Schon28 and Boud et al,29 and as a result of the Teaching Program, residents identified situations and moments in which they thought more about their teaching. Assisting residents in developing reflective practice to improve their teaching and to understand their learners better remains a further challenge to resident-as-teacher programs. There was one unanimity: residents and faculty who taught in the program agreed to continue the Teaching Program. Residents became "co-owners" of the Teaching Program by becoming cofaculty with attending physicians. Residents replaced the medical educators as core teaching faculty. The educator's teaching role changed from direct contact to a consultant's role, allowing the resident-attending physician teams to teach the program. Finally, those resident-attending physician teaching teams meet to review and redesign the instructional formats and materials for each workshop. The chief resident assumed a more responsible role by getting the resident-faculty teams together to deliver their respective workshops. Potential for the Future In reviewing the 3-year experience with the Teaching Program—from conceptualization to realization to evaluation—several insights were gained, which may prove useful to other residency training program efforts. 1. Leadership was vital to implementing the Teaching Program. 2. Professional leaders from several levels of medical education were actively involved in the process: from the hospital, the CHB's associate physician-in-chief (also the residency training program director), the CHB's chief resident, and resident and faculty members of the planning group; and from the medical school, the HMS dean of medical education, the associate director for faculty development, and the HMS physician fellow in medical education. 3. Setting aside time simply to discuss teaching was an integral part of all processes, as were the opportunities for residents and attending faculty to share their experiences and perspectives on teaching as it related to their needs as developing physicians. 4. The workshop sessions were an integral aspect of the residents' work weeks. During these sessions, residents had opportunities to explore teaching and learning in relation to their concurrent experiences of residency training. 5. Educator and physician teams emerged as key and useful elements in collaborating to develop a strategy to develop residents as teachers. 6. Evaluation strategies and methods varied in their individual effectiveness in evaluating the Teaching Program; however, in combination they revealed useful insight into what residents think about their development as teachers and how they go about teaching based on their level of clinical training. This work provides one model for others to use in developing a curriculum on teaching. Given different circumstances—ie, if medical educators are not available, if the residency program is a small one, or if a hospital opts not to develop a separate, self-standing curriculum—faculty can elect to train themselves in the use of this curriculum and then implement the program. Copies of the curriculum are available on request from the corresponding author. In the end, the CHB experience with the Teaching Program can be looked at as an approach to how disciplines of education and medicine can merge to meet the teaching and learning needs of medical professionals as they develop as educators in a specialized training setting.