Time to Publication in Medical Education Journals: An Analysis of Publication Timelines During COVID-19 (2019-2022).

Introduction: COVID-19 changed scholarly publishing. Yet, its impact on medical education publishing is unstudied. Because journal articles and their corresponding publication timelines can influence academic success, the field needs updated publication timelines to set evidence-based expectations for academic productivity. This study attempts to answer the following research questions: did publication timelines significantly change around the time of COVID-19 and, if so, how? Methods: We conducted a bibliometric study; our sample included articles published between January 2018, and December 2022, that appeared in the Medical Education Journals List-24 (MEJ-24). We clustered articles into three time-based groups (pre-COVID, COVID-overlap, and COVID-endemic), and two subject-based groups (about COVID-19 and not about COVID-19). We downloaded each article's metadata from the National Library of Medicine and analyzed data using descriptive statistics, analysis of variance, and post-hoc tests to compare mean time differences across groups. Results: Overall, time to publish averaged 300.8 days (SD = 200.8). One-way between-groups ANOVA showed significant differences between the three time-based groups F (2, 7473) = 2150.7, p < .001. The post-hoc comparisons indicated that COVID-overlap articles took significantly longer (n = 1470, M= 539; SD = 210.6) as compared to pre-COVID (n = 1281; M = 302; SD = 172.5) and COVID-endemic articles (n = 4725; M = 226; SD = 136.5). Notably, COVID-endemic articles were published in significantly less time than pre-pandemic articles, p < .001. Discussion: Longer publication time was most pronounced for COVID-overlap articles. Publication timelines for COVID-endemic articles have shortened. Future research should explore how the shift in publication timelines has shaped medical education scholarship.

The Next Era of Assessment Within Medical Education: Exploring Intersections of Context and Implementation.

In competency-based medical education (CBME), which is being embraced globally, the patient-learner-educator encounter occurs in a highly complex context which contributes to a wide range of assessment outcomes. Current and historical barriers to considering context in assessment include the existing post-positivist epistemological stance that values objectivity and validity evidence over the variability introduced by context. This is most evident in standardized testing. While always critical to medical education the impact of context on assessment is becoming more pronounced as many aspects of training diversify. This diversity includes an expanding interest beyond individual trainee competence to include the interdependency and collective nature of clinical competence and the growing awareness that medical education needs to be co-produced among a wider group of stakeholders. In this Eye Opener, we wish to consider: 1) How might we best account for the influence of context in the clinical competence assessment of individuals in medical education? and by doing so, 2) How could we usher in the next era of assessment that improves our ability to meet the dynamic needs of society and all its stakeholders? The purpose of this Eye Opener is thus two-fold. First, we conceptualize - from a variety of viewpoints, how we might address context in assessment of competence at the level of the individual learner. Second, we present recommendations that address how to approach implementation of a more contextualized competence assessment.

Examining self-efficacy among recent graduates of postgraduate dental education programs.

PURPOSE: To examine the perceived self-efficacy of dentists who recently completed Graduate Dental Education (GDE) programs and identify how closely it aligns with their supervisors' assessments of them. Self-efficacy has been associated with academic pursuits, motivation, and engagement, which may affect how dental providers practice, seek continuing education, and pursue future opportunities.  METHODS: Recent graduates of military GDE programs rated their self-efficacy on specific tasks within each of the seven domains of dental competencies. Their supervisors completed a similar survey, rating the graduate's performance in the same tasks. Graduates' mean ratings were calculated for each domain, spearman correlations were calculated for all graduate-supervisor task ratings, and the magnitude of differences between graduate and supervisor domain means were examined. RESULTS: Graduates' perceived self-efficacy ranged from 3.57 to 4.41 out of 5.0. Correlations for each task were universally weak (ρ  =  -0.04-0.27). Correlations for domain means were also weak (ρ  =  0.06-0.14).  Overall, graduates rated themselves lower than their supervisors, with mean differences ranging from -0.17 (p = 0.003, Cohen's d = 0.20) for Professionalism to -0.95 (p < 0.001, Cohen's d = 0.90) for Health Promotion. CONCLUSIONS: Overall, graduates' perceived self-efficacy was moderate to high for 26 tasks across seven domains. However, in aggregate, graduates underestimated their abilities compared to performance measures from their current supervisors, although effect sizes were small. The accuracy of graduates' self-efficacy varied by program length and the clinical specialty of their supervisors. High-performing graduates always underestimated themselves while low-performing graduates often overestimated themselves.

Assessment Tools for Patient Notes in Medical Education: A Scoping Review.

PURPOSE: Physician proficiency in clinical encounter documentation is a universal expectation of medical education. However, deficiencies in note writing are frequently identified, which have implications for patient safety, health care quality, and cost. This study aimed to create a compendium of tools for educators' practical implementation or future research. METHOD: A scoping review was conducted using the Arksey and O'Malley framework. PubMed, Embase, Ovid All EBM Reviews, Web of Science, and MedEdPortal were searched for articles published from database inception to November 16, 2023, using the following search terms: documentation, note-writing, patient note, electronic health record note, entrustable professional activity 5, and other terms. For each note-writing assessment tool, information on setting, section(s) of note that was assessed, tool properties, numbers and roles of note writers and graders, weight given, if used in grading, learner performance, and stakeholder satisfaction and feasibility was extracted and summarized. RESULTS: A total of 5,257 articles were identified; 32 studies were included. Eleven studies (34.4%) were published since 2018. Twenty-two studies (68.8%) outlined creating an original assessment tool, whereas 10 (31.2%) assessed a curriculum intervention using a tool. Tools varied in length and complexity. None provided data on equity or fairness to student or resident note writers or about readability for patients. Note writers often had missing or incomplete documentation (mean [SD] total tool score of 60.3% [19.4%] averaged over 25 studies), often improving after intervention. Selected patient note assessment tool studies have been cited a mean (SD) of 6.3 (9.2) times. Approximately half of the tools (53.1%) or their accompanying articles were open access. CONCLUSIONS: Diverse tools have been published to assess patient notes, often identifying deficiencies. This compendium may assist educators and researchers in improving patient care documentation.

Optimizing e-Learning in CPD: Preferences and Perceptions of Health Professionals.

INTRODUCTION: Continuing professional development for health professionals increasingly relies on e-learning. However, there is insufficient research into the instructional strategies health professionals prefer to engage with in e-learning. An empirical study was undertaken to answer the research question: What instructional strategies do learners prefer in e-learning modules to improve their learning experience? METHODS: The Department of Health Professions Education at the Uniformed Services University of Health Sciences developed six, stand-alone, self-paced modules for health professionals focusing on education and leadership. The module evaluation survey consisted of six Likert scale questions and two open-ended questions. Responses from these anonymized module evaluations from 2019 to 2022 were analyzed. Descriptive statistics for the Likert scale questions were calculated. Responses to the two open-ended questions were compiled and analyzed thematically. RESULTS: All survey respondents found the content of the modules helpful and met their stated learning objectives. A majority (94%) agreed or strongly agreed that readings and videos increased their knowledge in the topic area and that quizzes effectively strengthened their understanding of the topics. Four themes emerged from the qualitative data: pedagogical strategies, technology issues, feedback and interaction, and transfer of learning. CONCLUSIONS: This study foregrounds the voice of the learner, which emphasizes health professionals' preference for instructional strategies that align with their needs as adult learners. The findings highlight the value of content relevance, expert creation, and authentic examples in enhancing learner satisfaction.

A Scalable Advising Model for Part-Time, Distant Learners in Graduate Health Professions Education Programs.

PROBLEM: There is a need within graduate health professions education (HPE) programs to align advising practices to support an increasing number of working adult learners, especially those studying part-time and from remote locations. Despite the recognized importance of the advisor-advisee relationship in graduate learner success, many advisors lack formal training and have to manage multiple completing priorities. Furthermore, a lack of established evidence-based practices for graduate HPE advising has left each program navigating advising independently. APPROACH: The Department of Health Professions Education, Uniformed Services University, established a small cadre of faculty to serve as academic advisors (n = 7) in August 2018. This cadre uses an advising model based on 5 advising practices, called TOTAL Advising- train the advisors, onboard the learners, touch base frequently, annually review learners, and learner review. These advising practices are meant to provide a wrap-around support system to ensure learners feel empowered to fully engage in the program, while managing the demands of their personal and professional lives. TOTAL Advising provides the framework needed to achieve 3 guiding beliefs: each learner is capable of completing the program, fostering community, and providing clear communication. OUTCOMES: Between May 2020-May 2024, learners who completed a degree (n = 21) were interviewed about their advising experiences by a program evaluator after they graduated. The themes observed from these reflect the program's 3 guiding beliefs. Additionally, from May 2018-May 2024, of the 574 learners who enrolled in the program, 568 (99%) graduated with a certificate or degree, only 6 (1%) were disenrolled. NEXT STEPS: The next steps for TOTAL Advising involve a comprehensive evaluation of the effectiveness of the training program for advisors and collaborating with other graduate HPE programs to share best practices in advising, discuss emerging challenges, and shape advising practices in the broader HPE community.

Controlled Burn: Managing the "Forest Fire" of Leaving a Professional Identity in Medical Education.

INTRODUCTION: Professional identity formation is central to physicians' identity over their full careers. There is little guidance within military service on how to leave careers as clinician educator faculty in graduate medical education programs. The objective of our study was to explore how leaving this community of practice (COP) affects a clinician educator's professional identity. METHODS: We used reflexive thematic analysis with Communities of Practice as a sensitizing construct. Fifteen semi-structured interviews were conducted among active-duty clinician educators at the point of their retirement from the military. Interview questions focused participants' lived experiences as clinician educators and professional identity changes leading to and resulting from the decision to retire. RESULTS: We found the clinician educators' journey through a time of professional transition led to three connected themes: Loss Precedes Growth, Fallow Season-Liminal Space, and New Growth. DISCUSSION: The experiences of military clinician educators retiring from active duty demonstrate how leaving one COP emanates across a range of professional identities. In addition, the decision to leave a professional COP can lead to a sense of disloyalty to that community. Normalizing this transition in a way that honors the community's values offers the opportunity to enable the decision to retire. Understanding retirement as a process that first involves identity loss, followed by the discomfort of a liminal space before achieving new growth creates the opportunity to engage in rituals that celebrate the service of departing community members, releasing them to grow into new identities.

Military Medical Student Specialty Preferences During the DHA Transition: A Retrospective Analysis.

BACKGROUND: The Military Health System is a unique subsector within the nation's Graduate Medical Education (GME), with a different incentive structure for specialty selection for military medical students compared with their civilian counterparts. Changes by the Defense Health Agency (DHA) in 2017 emphasized a shift in military GME to training "operational" medical specialties. This study sought to gain insight into military medical students' reactions to the 2017 DHA transition by examining whether students continued to select "operational" specialties at similar rates as well as whether students remained satisfied with attending medical school. METHODS: We performed a retrospective analysis of Uniformed Services University (USU) post-match students from 2015 to 2020 using anonymized data from the Association of American Medical Colleges (AAMC) Graduation Questionnaire, separated into pre-DHA (2015-2017) and post-DHA (2018-2020) transition groups. RESULTS: Regarding both intent to practice an operational specialty and satisfaction with choosing medical school, there was no statistically significant difference between the preand post-DHA transition groups. CONCLUSIONS: Whether preor post-DHA transition, USU medical students demonstrated similar preferences for operational specialties as well as similar levels of satisfaction with medical school attendance, suggesting that this transition may not significantly influence medical students' career preferences nor blunt their desire to enter military medicine.

Perceptions of Key Responsibilities and Professional Development Interests of Senior Educational Leaders: A Needs Assessment.

PURPOSE: High-ranking educational leaders in academic medicine oversee multiple clinical programs. This requires them to prioritize dozens of emergent tasks and responsibilities daily, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Identifying their key responsibilities and frequently used skills and competencies may clarify the educational needs of senior educational leaders and facilitate targeted professional development to promote effective and efficient performance. METHOD: In August 2022 researchers interviewed 12 designated education officers (DEOs) from U.S. Department of Veterans Affairs (VA) Veterans Health Administration medical centers about their daily work and most challenging responsibilities. Content analysis of interview transcripts identified key responsibilities and activities identified by participants and prioritization of the perceived skills needed to complete them. RESULTS: Participants emphasized 4 key areas of responsibility: fiscal, administrative, affiliate partnership, and educational duties. They identified 12 skills as baseline requirements for effective performance for which additional professional development would be useful and suggested that both new and more established educational leaders receive targeted professional development and mentoring to foster these capacities. CONCLUSIONS: The key skills participants identified by area of perceived responsibility are relevant to VA DEOs, designated institutional officers, and senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. Structured orientation programs and ongoing professional development for senior educational leaders could emphasize these areas of responsibility, potentially enriching DEOs' performance and reducing burnout.

The Military Medicine Leadership Life Cycle: A Model for Longitudinal Leadership Development for Staff Physicians.

Leadership development is a challenge for all health care systems. Military Medicine has unique challenges with increased frequency of physician turnover and more junior leaders taking on positions of leadership earlier in their careers. Military medical corps officers are also challenged with leading in clinical, academic, and operational settings. Effective leadership within the Military Healthcare System requires an intentional and ongoing leadership development process across the careers of military medical corps officers. This article describes the leadership lifecycle of military medical corps officers, highlighting existing leadership development opportunities and providing an example of a leadership lifecycle from junior staff to senior executive for other organizations. The article concludes with specific recommendations that will allow military medicine to continue to strengthen the leadership skills of its officers to meet ever growing challenges.

The Military Medicine Leadership Life Cycle: A Model for Longitudinal Leadership Development in Medicine-Undergraduate and Graduate Medical Education.

Physicians must be leaders more than ever with innumerable challenges. Despite this need, there is a paucity of consistent leadership development (LD) from medical student to staff physician. Military medicine has additional challenges-working within a large health care organization, constant turnover, working in a variety of contexts-that make the need for LD even more pressing. The purpose of this paper is to describe the LD life cycle for military undergraduate and graduate medical education (UME and GME), providing examples for other organizations while identifying steps to meet the future needs in military medicine. The Health Professions Scholarship Program produces over 75% of graduates for military medicine each year. Yet, since learners are dispersed throughout civilian medical schools any LD results in a heterogeneous experience. Uniformed Services University has a 4-year LD program required for all students as well as other opportunities for leadership professional growth. Military GME programs are unique, requiring a military unique curriculum to prepare graduates for their initial assignments. Military unique curriculum vary, but include clinical topics relevant to military medicine as well as leadership. There is no Military Healthcare System-wide leadership curriculum used by everyone at this time. Based on these UME and GME approaches to LD, there have been multiple lessons learned formed on the authors experience and published literature: learners do not typically see themselves as leaders; learners want applicable curriculum with less lecturing and more application and discussion; programs are often siloed from one another and sharing curriculum content does not typically occur; no one-size-fits-all model. On the basis of the lessons learned and the current state of UME and GME leadership education, there are 5 recommendations to enhance UME and GME leadership programs: (1) develop a Health Professions Scholarship Program Leadership Curriculum; (2) develop a MHS GME Leadership Curriculum; (3) integrate UME and GME Leadership Curricula; (4) develop faculty to teach leadership; and (5) conduct research on UME and GME in military and share lessons learned. We suggest a roadmap for strengthening LD within military medicine and civilian institutions.

Teaching clinical reasoning: principles from the literature to help improve instruction from the classroom to the bedside.

Clinical reasoning has been characterized as being an essential aspect of being a physician. Despite this, clinical reasoning has a variety of definitions and medical error, which is often attributed to clinical reasoning, has been reported to be a leading cause of death in the United States and abroad. Further, instructors struggle with teaching this essential ability which often does not play a significant role in the curriculum. In this article, we begin with defining clinical reasoning and then discuss four principles from the literature as well as a variety of techniques for teaching these principles to help ground an instructors' understanding in clinical reasoning. We also tackle contemporary challenges in teaching clinical reasoning such as the integration of artificial intelligence and strategies to help with transitions in instruction (e.g., from the classroom to the clinic or from medical school to residency/registrar training) and suggest next steps for research and innovation in clinical reasoning.

Beyond thinking fast and slow: Implications of a transtheoretical model of clinical reasoning and error on teaching, assessment, and research.

From dual process to a family of theories known collectively as situativity, both micro and macro theories of cognition inform our current understanding of clinical reasoning (CR) and error. CR is a complex process that occurs in a complex environment, and a nuanced, expansive, integrated model of these theories is necessary to fully understand how CR is performed in the present day and in the future. In this perspective, we present these individual theories along with figures and descriptive cases for purposes of comparison before exploring the implications of a transtheoretical model of these theories for teaching, assessment, and research in CR and error.

Programmatic Assessment of Clinical Reasoning: New Opportunities to Meet an Ongoing Challenge.

Issue: Clinical reasoning is essential to physicians' competence, yet assessment of clinical reasoning remains a significant challenge. Clinical reasoning is a complex, evolving, non-linear, context-driven, and content-specific construct which arguably cannot be assessed at one point in time or with a single method. This has posed challenges for educators for many decades, despite significant development of individual assessment methods. Evidence: Programmatic assessment is a systematic assessment approach that is gaining momentum across health professions education. Programmatic assessment, and in particular assessment for learning, is well-suited to address the challenges with clinical reasoning assessment. Several key principles of programmatic assessment are particularly well-aligned with developing a system to assess clinical reasoning: longitudinality, triangulation, use of a mix of assessment methods, proportionality, implementation of intermediate evaluations/reviews with faculty coaches, use of assessment for feedback, and increase in learners' agency. Repeated exposure and measurement are critical to develop a clinical reasoning assessment narrative, thus the assessment approach should optimally be longitudinal, providing multiple opportunities for growth and development. Triangulation provides a lens to assess the multidimensionality and contextuality of clinical reasoning and that of its different, yet related components, using a mix of different assessment methods. Proportionality ensures the richness of information on which to draw conclusions is commensurate with the stakes of the decision. Coaching facilitates the development of a feedback culture and allows to assess growth over time, while enhancing learners' agency. Implications: A programmatic assessment model of clinical reasoning that is developmentally oriented, optimizes learning though feedback and coaching, uses multiple assessment methods, and provides opportunity for meaningful triangulation of data can help address some of the challenges of clinical reasoning assessment.

Priority Competencies for Designated Education Officers in the Veterans Health Administration.

INTRODUCTION: Designated Education Officers (DEOs) at Veteran Health Administration (VHA) hospitals are senior educational leaders tasked with oversight of all clinical training at a particular facility. They prioritize dozens of tasks and responsibilities each day, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Clarifying priority competencies for the role can help executives recruit, appoint, and evaluate capable personnel and promote effective, efficient performance. MATERIALS AND METHODS: Using a federally developed method of competency analysis, researchers consulted a panel of subject-matter experts to identify priority competencies for DEOs, using data from a 2013 study that operationalizes competencies for more than 200 federal jobs. RESULTS: The research identified 25 primary competencies within 6 leadership domains. Five of the primary competencies cut across all leadership domains. CONCLUSIONS: Veteran Health Administration subject-matter experts in educational leadership say the identified competencies are urgently needed, critical for effective leadership, and valuable for distinguishing superior DEO performance. The competencies are relevant to VHA and perhaps other senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. In military training facilities, attending to these competencies can help Designated Institutional Officials responsible for graduate medical education become more credible partners to other hospital leaders and contribute to becoming a high reliability organization. Executives identifying, recruiting, and appointing VHA DEOs and Designated Institutional Officials at military training facilities should consider these competencies when assessing candidates.

Civilian and Military Medical School Graduates' Readiness for Deployment: Areas of Strength and Opportunities for Growth.

INTRODUCTION: Past research has examined civilian and military medical schools' preparation of physicians for their first deployment. Most recently, our research team conducted a large-scale survey comparing physicians' perceptions of their readiness for their first deployment. Our results revealed that military medical school graduates felt significantly more prepared for deployment by medical school than civilian medical school graduates. In order to further investigate these results and deepen our understanding of the two pathways' preparation of military physicians, this study analyzed the open-ended responses in the survey using a qualitative research design. MATERIALS AND METHODS: We used a descriptive phenomenological design to analyze 451 participants' open-ended responses on the survey. After becoming familiar with the data, we coded the participants' responses for meaningful statements. We organized these codes into major categories, which became the themes of our study. Finally, we labeled each of these themes to reflect the participants' perceptions of how medical school prepared them for deployment. RESULTS: Four themes emerged from our data analysis: (1) Civilian medical school equipped graduates with soft skills and medical knowledge for their first deployment; (2) Civilian medical school may not have adequately prepared graduates to practice medicine in an austere environment to include the officership challenges of deployment; (3) Military medical school prepared graduates to navigate the medical practice and operational aspects of their first deployment; and (4) Military medical school may not have adequately prepared graduates for the realism of their first deployment. CONCLUSIONS: Our study provided insight into the strengths and areas for growth in each medical school pathway for military medical officers. These results may be used to enhance military medical training regardless of accession pathway and increase the readiness of military physicians for future large-scale conflicts.

Physician educators' perceptions of experiences contributing to teaching.

INTRODUCTION: Physician educators are essential in training the next generation of physicians. However, physician educators' perspectives about what experiences they find beneficial to their teaching and the prevalence of these experiences remain unknown. Guided by social cognitive career theory (SCCT) and communities of practice (CoP), we explored what experiences physician educators perceive as beneficial in preparing them to teach. METHODS: In 2019, the Uniformed Services University School of Medicine in the United States surveyed its physician alumni to understand their education experiences during medical school, their current career path and what has contributed to their teaching role. Content analysis was applied to extract themes across the text response. Chi-square analysis was applied to examine if perceived contributing factors vary based on physician educators' gender, specialty and academic ranks. RESULTS: The five most prevalent contributing factors participants (n = 781) identified are (1) experiences gained during residency and fellowship (29.8%), (2) teaching as faculty member (28.9%) and (3) class experiences and peer interaction during medical school (26%). We organised three themes that reflected major avenues of how physician educators acquire teaching skills: reflection about quality teaching, journey as learners and learning by doing. Gender and clinical specialty were differentially associated with contributing factors such as faculty development and meta-reflection. CONCLUSION: The results are in line with theories of SCCT and CoP, in which we identified self-directed learning and regulation in shaping physician educators' teaching. The findings also revealed gaps and potential contexts for more formalised teaching practices to develop physician educators.

Assessment of management reasoning: Design considerations drawn from analysis of simulated outpatient encounters.

PURPOSE: Management reasoning is a distinct subset of clinical reasoning. We sought to explore features to be considered when designing assessments of management reasoning. METHODS: This is a hybrid empirical research study, narrative review, and expert perspective. In 2021, we reviewed and discussed 10 videos of simulated (staged) physician-patient encounters, actively seeking actions that offered insights into assessment of management reasoning. We analyzed our own observations in conjunction with literature on clinical reasoning assessment, using a constant comparative qualitative approach. RESULTS: Distinguishing features of management reasoning that will influence its assessment include management scripts, shared decision-making, process knowledge, illness-specific knowledge, and tailoring of the encounter and management plan. Performance domains that merit special consideration include communication, integration of patient preferences, adherence to the management script, and prognostication. Additional facets of encounter variation include the clinical problem, clinical and nonclinical patient characteristics (including preferences, values, and resources), team/system characteristics, and encounter features. We cataloged several relevant assessment approaches including written/computer-based, simulation-based, and workplace-based modalities, and a variety of novel response formats. CONCLUSIONS: Assessment of management reasoning could be improved with attention to the performance domains, facets of variation, and variety of approaches herein identified.

In Search of a "Metric System" for Measuring Faculty Effort: A Qualitative Study on Educational Value Units at U.S. Medical Schools.

PURPOSE: Faculty at academic health centers (AHCs) are charged with engaging in educational activities. Some faculty have developed educational value units (EVUs) to track the time and effort dedicated to these activities. Although several AHCs have adopted EVUs, there is limited description of how AHCs engage with EVU development and implementation. This study aimed to understand the collective experiences of AHCs with EVUs to illuminate benefits and barriers to their development, use, and sustainability. METHOD: Eleven faculty members based at 10 AHCs were interviewed between July and November 2022 to understand their experiences developing and implementing EVUs. Participants were asked to describe their experiences with EVUs and to reflect on benefits and barriers to their development, use, and sustainability. Transcripts were analyzed using thematic analysis. RESULTS: EVU initiatives have been designed and implemented in a variety of ways, with no AHCs engaging alike. Despite differences, the authors identified shared themes that highlighted benefits and barriers to EVU development and implementation. Within and between these themes, a series of tensions were identified in conjunction with the ways in which AHCs attempted to mitigate them. Related to barriers, the majority of participants abandoned or paused their EVU initiatives; however, no differences were identified between those AHCs that retained EVUs and those that did not. CONCLUSIONS: The collective themes identified suggest that AHCs implementing or sustaining an EVU initiative would need to balance benefits and barriers in light of their unique context. Study findings align with reviews on EVUs and provide additional nuance related to faculty motivation to engage in education and the difficulties of defining EVUs. The lack of differences observed between those AHCs that retained EVUs and those that did not suggests that EVUs may be challenging to implement because of the complexity of AHCs and their faculty.