Building on Strengths: An Affirmational and Systems-Level Approach to Revisiting Character in Medicine.

ABSTRACT: Although U.S. medical education has continued to place increased emphasis on defining competency standards and ensuring accountability to the public, health care inequities have persisted, several basic health outcomes have worsened, public trust in the health care system has eroded, and moral distress, burnout, and attrition among practicing physicians have escalated. These opposing trends beg the question of how the "good doctor" concept may be strengthened. In this perspective, the authors argue that revisiting the construct of physician character from an affirmational perspective could meaningfully improve medical education's impact on overall health by more holistically conceptualizing what-and who-a good doctor is. The authors introduce positive psychology's framework of character strengths, probe the distinction between character strengths and medical professionalism, and summarize the role of character strengths in promoting physician engagement and well-being in health care work. They contend that a systems-level approach to cultivating character strengths will foster physician moral agency and well-being and, by extension, transformational change in health care. Consistent with best practice in modern character education, the authors propose that institutions mindfully cultivate moral community among all stakeholders (students, faculty, staff, postgraduate trainees, and patients) and that moral community interaction centers on each member's personal aspirations with respect to living a good life, guided by the character strengths framework and informed by patient perspectives.

Impact of a Regional Grant Program Through the Lens of Social Cognitive Career Theory: A Mixed-Method Evaluation.

PURPOSE: Evaluations of educational grant programs have focused on research productivity, with few examining impacts on grantees or effective program characteristics. This evaluation examined the regional grant program sponsored by Group on Educational Affairs to examine if and how grantees' careers were affected by funding, and if these experiences aligned with program goals. METHOD: In this concurrent, mixed-methods theory-driven evaluation, quantitative and qualitative data were analyzed independently and then integrated to examine complementarity. Quantitative data examined differences among 4 geographic regions and included proposal and grantee characteristics abstracted from administrative records of 52 funded proposals from 2010-2015 grant cycles. Qualitative data from 23 interviews conducted from 2018 to 2019 explored the impact on grantees, with Social Cognitive Career Theory (SCCT) serving as a framework for deductive thematic analysis. To facilitate integration of findings, quantitative data were layered onto each interview to permit exploration of associations between the 2 data types. RESULTS: Although significant regional differences existed in project length and amount of funding, there were few regional differences in grantee experiences. Despite small funding amounts, grants were perceived as career launching pads. The SCCT framework accounted for grantee experiences, including researcher identity formation and subsequent research, but did not capture collaboration phenomena. Integration of the 2 data types identified experience patterns unique to different groups of grantees (e.g., more or less research experience). The diversity among grantees suggests that clarification of program goals and stronger alignment with criteria for funding may be warranted. CONCLUSIONS: This evaluation illuminates why small educational grant programs may or may not impact interest and productivity in research. Implications exist for funders, including clarifying program goals and providing support for less experienced grantees. Future research should explore grantee subsets (e.g., underrepresented in medicine) to further identify what fosters or inhibits careers of medical education scholars.

Editors as Gatekeepers: One Medical Education Journal's Efforts to Resist Racism in Scholarly Publishing.

PURPOSE: Journals have begun to expand the racial diversity of editors as a first step to countering institutional racism. Given the power editors hold as gatekeepers, a diverse team helps ensure that minoritized scholars have equal opportunity to contribute. In 2021, Teaching and Learning in Medicine ( TLM ) created an editorial internship for racially minoritized individuals. This study examines the first 6 months of this program to better understand its creation and initial successes. METHOD: The authors employed critical collaborative autoethnography, a qualitative methodology, focusing on the underlying assumptions around power and hierarchy that are implicit in the design and implementation of the TLM internship. Participants included 13 TLM editorial board members (10 internship selection committee members, 3 mentors, 2 independent researchers), 3 external selection committee members, and 3 interns, with some holding multiple roles. Ten participants served as authors of this report. Data included archival emails, planning documents, and focus groups. The initial analysis explored what happened and how and was followed by a thematic analysis in which participants reflected on their responsibility for implementing an antiracist program. RESULTS: While the program developed interns' editorial skills, which they greatly valued, and diversified the TLM editorial board, it did not achieve the goal of fostering antiracism. Mentors focused on conducting joint peer reviews with interns, assuming that racial experiences can and should be separate from the editorial process, thus working within, rather than trying to change, the existing racist system. CONCLUSIONS: Given these findings, greater structural change is needed to disrupt the existing racist system. These experiences underscore the importance of recognizing the harmful impact a race-neutral lens can have on antiracist efforts. Moving forward, TLM will implement lessons learned ahead of offering the internship again with the goal of creating the transformative change intended with the creation of the program.

If You Build It, Will They Come? Exploring the Impact of Medical Student Engagement on Clerkship Curriculum Outcomes.

Introduction: Inconsistent or superficial access to workplace learning experiences can impede medical students' development. Well-designed clerkship curricula provide comprehensive education by offering developmental opportunities in and out of the workplace, explicitly linked to competency objectives. Questions remain about how students engage with clerkship curriculum offerings and how this affects their achievement. This study investigated student engagement as the source of an apparent clerkship curriculum malfunction: increasing rate of substandard summative clinical competency exam (SCCX) performance over 3 years following curriculum reform. Materials and Methods: We sampled from three cohorts of US medical students (classes of 2018-2020) based on their post-clerkship SCCX performance: substandard (N = 33) vs. exemplary (N = 31). Using a conceptually based, locally developed rubric, a five-person team rated students' engagement in a curriculum offering designed to provide standardized deliberate practice on the clerkship's competency objectives. We examined the association between engagement and SCCX performance, taking prior academic performance into account. Results: Rate of substandard SCCX performance could not be explained by cohort differences in prior academic performance. Student engagement differed across cohorts and was significantly associated with SCCX performance. However, engagement did not meaningfully predict individual students' SCCX performance, particularly in light of prior academic performance. Discussion: Engagement with a particular learning opportunity may not affect clerkship outcomes, but may reflect students' priorities when navigating curricular offerings, personal learning goals, and curriculum policy. Proposing four patterns of engagement in clerkship learning, this study prompts reflection on the complex interaction among factors that affect engagement and outcomes.

The Case for Feedback-in-Practice as a Topic of Educational Scholarship.

The importance of clinical performance feedback is well established and the factors relevant to its effectiveness widely recognized, yet feedback continues to play out in problematic ways. For example, learning culture modifications shown to facilitate feedback have not seen widespread adoption, and the learner-educator interactions prescribed by research rarely occur organically. Nevertheless, medical learners achieve clinical competence, suggesting a need to expand educational scholarship on this topic to better account for learner growth. This Scholarly Perspective argues for a more extensive exploration of feedback as an educational activity embedded in clinical practice , where joint clinical work that involves an educator and learner provides a locus for feedback in the midst of performance. In these clinically embedded feedback episodes, learning and performance goals are constrained by the task at hand, and the educator guides the learner in collaboratively identifying problematic elements, naming and reframing the source of challenge, and extrapolating implications for further action. In jointly conducting clinical tasks, educators and learners may frequently engage in feedback interactions that are both aligned with workplace realities and consistent with current theoretical understanding of what feedback is. However, feedback embedded in practice may be challenged by personal, social, and organizational factors that affect learners' participation in workplace activity. This Scholarly Perspective aims to provide a conceptual framework that helps educators and learners be more intentional about and fully participatory in this important educational activity. By topicalizing this feedback-in-practice and exploring its integration with the more commonly foregrounded feedback-on-practice , future educational scholarship may achieve optimal benefit to learners, educators, and clinical practice.

Applying Conceptual and Theoretical Frameworks to Health Professions Education Research: An Introductory Workshop.

Introduction: Literature suggests that the quality and rigor of health professions education (HPE) research can be elevated if the research is anchored in existing theories and frameworks. This critical skill is difficult for novice researchers to master. We created a workshop to introduce the practical application of theories and frameworks to HPE research. Methods: We conducted two 60- to 75-minute workshops, one in 2019 at an in-person national conference and another in 2021 during an online national education conference. After a brief role-play introduction, participants applied a relevant theory to a case scenario in small groups, led by facilitators with expertise in HPE research. The workshop concluded with a presentation on applying the lessons learned when preparing a scholarly manuscript. We conducted a postworkshop survey to measure self-reported achievement of objectives. Results: Fifty-five individuals participated in the in-person workshop, and approximately 150 people completed the online workshop. Sixty participants (30%) completed the postworkshop survey across both workshops. As a result of participating in the workshop, 80% of participants (32) indicated they could distinguish between frameworks and theories, and 86% (32) could apply a conceptual or theoretical framework to a research question. Strengths of the workshop included the small-group activity, access to expert facilitators, and the materials provided. Discussion: The workshop has been well received by participants and fills a gap in the existing resources available to HPE researchers and mentors. It can be replicated in multiple settings to model the application of conceptual and theoretical frameworks to HPE research.

Problem-Based Learning About Problem-Based Learning: Lessons Learned from a Student-Led Initiative to Improve Tutor Group Interaction.

This article summarizes a student-led effort to improve tutor group interactions among second-year medical students in a hybrid problem-based learning (PBL) curriculum. Dissatisfaction with PBL had led to superficial tutorial discussions that students escaped to study for board certification exams. Following the PBL principle of using intrinsically motivating problems, the student investigators created board-style questions with accompanying facilitation guides for tutors to present as 'mini-problems' to stimulate case-related discussion. Tutor groups used and enjoyed the questions, but interaction quality did not improve. Like the hybrid curriculum itself, the intervention embodied conflicting educational philosophies; implementation challenges reflected the tension between them.

Fundamentals of Scholarly Peer Review: A Workshop for Health Professions Educators on Practicing Scholarly Citizenship.

Introduction: Education scholarship requires peer reviewers. For novice scholars, reviewing is an important developmental activity that cultivates deeper participation in the scholarship community. Yet getting started with reviewing is challenging for those not involved with the educational scholarship community. Beyond scientific expertise, reviewers must have a mentoring mindset, skills in providing constructive feedback, and knowledge of common ethical challenges associated with producing and evaluating scholarship. Methods: Our workshop introduced novice health professions educators to peer reviewing. It included four stimulus presentations about the peer reviewer's mindset and skills, followed by reinforcement activities. The workshop could be adapted to variously sized groups. An 8:1 ratio of participants to facilitators was ideal for activities. Topics covered included considerations before accepting an invitation, the review process, the good citizen approach to reviewing, and reviewer ethics. The session concluded with suggestions for continued development of peer reviewer competencies. The workshop was evaluated using a custom survey. Results: Throughout 2019 and early 2020, 58 health professions educators and trainees participated in the workshop across varied venues. Evaluations were obtained from 33 participants (57%). Nearly all rated the workshop as high quality and valuable to peer reviewer preparation. Most (26 of 33; 75%) gained confidence about their qualifications to serve as reviewers. Eighty percent (28 of 33) believed they could recognize ethical dilemmas. Discussion: This workshop provided a springboard for peer reviewing health professions education scholarship. Participants generally praised the experience for introducing them to the world of peer review and preparing them for it.

Extending "Beyond Diversity": Culturally Responsive Universal Design Principles for Medical Education.

This commentary follows up on Maduakolam et al. (2020) "Beyond Diversity: Envisioning Inclusion in Medical Education Research and Practice," which introduced Culturally Responsive Universal Design for Learning (CRUDL) as an approach to accounting for learner diversity in educational theory development and curriculum design. We flesh out the principles of CRUDL, using publications in this issue of Teaching and Learning in Medicine as case examples for how the principles work in action. With this scholarly thought exercise, we seek to demonstrate the feasibility and promise of curriculum that is accountable to diverse learners and the impact of historical trauma. We also explore how research inclusive of diverse social identities could inform curriculum design by identifying how social identity, learning environment, educational activities, and learner engagement interact to produce diverse learning experiences and performance. Scholarly thought exercises such as this one may help bridge the gap between professed ideals and action with respect to inclusive medical education; CRUDL principles provide a helpful framework for planning and evaluating accountable curriculum design.

Machine Scoring of Medical Students' Written Clinical Reasoning: Initial Validity Evidence.

PURPOSE: Developing medical students' clinical reasoning requires a structured longitudinal curriculum with frequent targeted assessment and feedback. Performance-based assessments, which have the strongest validity evidence, are currently not feasible for this purpose because they are time-intensive to score. This study explored the potential of using machine learning technologies to score one such assessment-the diagnostic justification essay. METHOD: From May to September 2018, machine scoring algorithms were trained to score a sample of 700 diagnostic justification essays written by 414 third-year medical students from the Southern Illinois University School of Medicine classes of 2012-2017. The algorithms applied semantically based natural language processing metrics (e.g., coherence, readability) to assess essay quality on 4 criteria (differential diagnosis, recognition and use of findings, workup, and thought process); the scores for these criteria were summed to create overall scores. Three sources of validity evidence (response process, internal structure, and association with other variables) were examined. RESULTS: Machine scores correlated more strongly with faculty ratings than faculty ratings did with each other (machine: .28-.53, faculty: .13-.33) and were less case-specific. Machine scores and faculty ratings were similarly correlated with medical knowledge, clinical cognition, and prior diagnostic justification. Machine scores were more strongly associated with clinical communication than were faculty ratings (.43 vs .31). CONCLUSIONS: Machine learning technologies may be useful for assessing medical students' long-form written clinical reasoning. Semantically based machine scoring may capture the communicative aspects of clinical reasoning better than faculty ratings, offering the potential for automated assessment that generalizes to the workplace. These results underscore the potential of machine scoring to capture an aspect of clinical reasoning performance that is difficult to assess with traditional analytic scoring methods. Additional research should investigate machine scoring generalizability and examine its acceptability to trainees and educators.

Physician-scientist or basic scientist? Exploring the nature of clinicians' research engagement.

Theoretical understanding of what motivates clinician researchers has met with some success in launching research careers, but it does not account for professional identification as a factor determining sustained research engagement over the long-term. Deeper understanding of clinicians' research-related motivation may better foster their sustained research engagement post-training and, by extension, the advancement of medicine and health outcomes. This study used an integrated theoretical framework (Social Cognitive Career Theory and Professional Identity Formation) and appreciative inquiry to explore the interplay of professional identification and research context in shaping post-training research success narratives. To foreground professional identification, 19 research-active clinicians and 17 basic scientists served as interviewees. A multi-institutional, multi-national design was used to explore how contextual factors shape external valuation of research success. The findings suggest that research-active clinicians do not identify as the career scientists implied by the modern physician-scientist construct and the goal of many clinician research-training programs. Their primary identification as care providers shapes their definition of research success around extending their clinical impact; institutional expectations and prevailing healthcare concerns that value this aim facilitate their sustained research engagement. Integrated developmental and organizational interventions adaptive to research context and conducive to a wider range of medical inquiry may better leverage clinicians' direct involvement in patient care and advance progress toward human health and well-being.

Beyond Diversity: Envisioning Inclusion in Medical Education Research and Practice.

This commentary examines the publications in Teaching and Learning in Medicine's Issue 32(5) from the perspectives of Black, female medical trainees. Its purpose is to demonstrate how including diverse perspectives in general medical education scholarship could prompt reconsideration of basic concepts and the development of richer, more nuanced, and practicable understanding of who medical learners are. An inclusive concept of medical education is a first step toward "culturally responsive universal design for learning," an approach to educational design that views barriers to learning as a systems problem, recognizes racism as a learning barrier, and offers learners multiple means to achieve academic success. Augmenting studies that explicitly target the experiences of trainees and faculty from marginalized racial groups, this commentary aims to establish a vision for what to do educationally with the knowledge that people bring diverse backgrounds and perspectives to their learning.

Problems No One Looked For: Philosophical Expeditions into Medical Education.

Issue: Medical education has "muddy zones of practice," areas of complexity and uncertainty that frustrate the achievement of our intended educational outcomes. Slowing down to consider context and reflect on practice are now seen as essential to medical education as we are called upon to examine carefully what we are doing to care for learners and improve their performance, professionalism, and well-being. Philosophy can be seen as the fundamental approach to pausing at times of complexity and uncertainty to ask basic questions about seemingly obvious practices so that we can see (and do) things in new ways. Evidence: Philosophy and medical education have long been related; many of our basic concepts can be traced to philosophical ideas. Philosophy is a problem-creation approach, and its method is analysis; it is a constant process of shifting frames and turning into objects of analysis the lenses through which we see the world. However, philosophy is not about constant questioning for the sake of questioning. Progression in medical education practice involves recognizing when to switch from a philosophical to a practical perspective, and when to switch back. Implications: In medical education, a philosophical approach empowers us to "slow down when we should," thereby engaging us more directly with our subjects of study, revealing our assumptions, and helping us address vexing problems from a new angle. Doing philosophy involves thinking like a beginner, getting back to basics, and disrupting frames of reference. Being philosophical is about wonder and intense, childlike curiosity, human qualities we all share. Taking a philosophical approach to medical education need not be an unguided endeavor, but can be a dialog through which medical educators and philosophers learn together.

Evaluating clerkship competency without exams.

BACKGROUND: Using examination scores for grading clerkship threatens students' engagement at a time when clinical immersion is critical for socialising into medicine. Narratives of student performance, composed during training by multiple preceptors across diverse settings, may be used to judge competence instead. Preceptor commentary is not trusted as a basis for grading, but the alignment between performance narratives and examination scores has not yet been investigated. METHODS: Performance data were gathered retrospectively from five cohorts of internal medicine clerkship students at one institution. The correlation between end-of-rotation examination scores and the grading committee's ratings of student competency based on preceptors' comments was examined. Patterns in the performance narratives of high- and low-scoring students were also explored. RESULTS: The grading committee's narrative-based ratings of student competence were correlated with examination scores. The majority of preceptors' comments were positive and professionalism-oriented, although students who scored lowest on exams received fewer comments overall and more recommendations for improvement than their highest-scoring peers. Recommendations for the lowest-scoring students equally emphasised knowledge, clinical skill and professionalism, whereas recommendations to highest-scoring students emphasised knowledge and clinical skill at more than twice the rate of professionalism. DISCUSSION: Clerkship preceptors' narratives of student performance can inform competency judgements that are grounded in actual workplace learning and are related to the independent examination of knowledge and clinical performance. Using performance narratives as the basis for grading may be a viable approach to balancing learning and assessment needs during core clerkship block rotations.

Learning Theory and Educational Intervention: Producing Meaningful Evidence of Impact Through Layered Analysis.

Like evidence-based medicine, evidence-based education seeks to produce sound evidence of impact that can be used to intervene successfully in the future. The function of educational innovations, however, is much less well understood than the physical mechanisms of action of medical treatments. This makes production, interpretation, and use of educational impact evidence difficult. Critiques of medical education experiments highlight a need for such studies to do a better job of deepening understanding of learning in context; conclusions that "it worked" often precede scrutiny of what "it" was. The authors unpack the problem of representing educational innovation in a conceptually meaningful way. The more fundamental questions of "What is the intended intervention?" and "Did that intervention, in fact, occur?" are proposed as an alternative to the ubiquitous evaluative question of "Did it work?" The authors excavate the layers of intervention-techniques at the surface, principle in the middle, and philosophy at the core-and propose layered analysis as a way of examining an innovation's intended function in context. The authors then use problem-based learning to illustrate how layered analysis can promote meaningful understanding of impact through specification of what was tried, under what circumstances, and what happened as a result. Layered analysis should support innovation design and evaluation by illuminating what principled adaptation of educational technique to local context could look like. It also promotes theory development by enabling more precise description of the learning conditions at work in a given implementation and how they may evolve with broader adoption.

Conversation Starter: Advancing the Theory of Peer-Assisted Learning.

This Conversation Starter article uses four selected abstracts, one each from the four regional Association of American Medical Colleges (AAMC) Group on Educational Affairs (CGEA) 2018 spring meetings, as a springboard for unpacking the definition of peer-assisted learning (PAL). The aim of this article is to prompt deeper reflection on this phenomenon and, in so doing, to foster scholarly program evaluation of this widely adopted instructional approach. This analysis calls for a more nuanced definition of PAL, one that emphasizes process over structure, one that stimulates examination of "doing" PAL and how this affects the personal and professional development of all involved.