Discovering social learning ecosystems during clinical clerkship from United States medical students' feedback encounters: a content analysis.

PURPOSE: We examined United States medical students' self-reported feedback encounters during clerkship training to better understand in situ feedback practices. Specifically, we asked: Who do students receive feedback from, about what, when, where, and how do they use it? We explored whether curricular expectations for preceptors' written commentary aligned with feedback as it occurs naturalistically in the workplace. METHODS: This study occurred from July 2021 to February 2022 at Southern Illinois University School of Medicine. We used qualitative survey-based experience sampling to gather students' accounts of their feedback encounters in 8 core specialties. We analyzed the who, what, when, where, and why of 267 feedback encounters reported by 11 clerkship students over 30 weeks. Code frequencies were mapped qualitatively to explore patterns in feedback encounters. RESULTS: Clerkship feedback occurs in patterns apparently related to the nature of clinical work in each specialty. These patterns may be attributable to each specialty's "social learning ecosystem"­the distinctive learning environment shaped by the social and material aspects of a given specialty's work, which determine who preceptors are, what students do with preceptors, and what skills or attributes matter enough to preceptors to comment on. CONCLUSION: Comprehensive, standardized expectations for written feedback across specialties conflict with the reality of workplace-based learning. Preceptors may be better able­and more motivated­to document student performance that occurs as a natural part of everyday work. Nurturing social learning ecosystems could facilitate workplace-based learning such that, across specialties, students acquire a comprehensive clinical skillset appropriate for graduation.

Asian Conscientization: Reflections on the Experiences of Asian Faculty in Academic Medicine.

ISSUE: Asians have experienced a rise in racialized hate crimes due to the anti-Asian rhetoric that has accompanied the COVID-19 pandemic. However, there has been little acknowledgement of anti-Asian discrimination within the medical education community. While anti-Asian hate is not new or unfamiliar to us, four authors of Asian descent, it has given us an opportunity to reflect on how we have been complicit in and resistant to the larger racial narratives that circulate in our communities. EVIDENCE: In this article, we provide a brief history of Asians in the Americas with a focus on anti-Asian hate. Next, while presenting stories from the perspective of Asian medical education researchers who were born/have settled in the U.S. and Canada, we take the opportunity to reflect on how our personal experiences have shaped our perceptions of ourselves, and the representations of Asians in the field of medicine. IMPLICATIONS: We hope to create awareness about how stereotypes of success tied to Asians can be used as a tool of oppression creating strife between Black communities, Asian communities, and other people of color. There is a need to develop critical consciousness to address the issues of equity in academia and in clinical practice.

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.

Faculty Experiences Related to Career Advancement and Success in Academic Medicine.

Phenomenon: Faculty career success in academic medicine is complex. Dynamic interactions among faculty and between faculty and their socio-cultural working environments contribute to the mystique of academic advancement. There are few empirical studies that analyze the social practice of faculty career advancement in academic medicine, especially those that focus on relations between individual and environmental contexts. This study aimed to investigate various faculty members' experiences around career advancement in a medical school. Through the analytical lens of Bourdieu's theory of practice, we focused on the relationship among individuals, positions, and environmental contexts.Approach: Following a general process of interpretive grounded theory, we collected faculty members' perceptions and experiences related to their career development and advancement via in-depth semi structured-interviews of 23 faculty at a medical school in the United States. We analyzed the interview transcripts using thematic and constant-comparison analyses, informed by Bourdieu's theory of practice emphasizing the concepts of habitus, field, doxa, illusio, and capital.Findings: While there was a general perception of collaborative success in the school, access to resources seemed to be unequally distributed and linked to faculty positions. Career opportunities, such as leadership and promotion, were mostly granted by leaders based on interpersonal relationships (social capital). Clinical faculty's limited access to professional development activities (cultural capital), including research, limited their likelihood for promotion (symbolic capital) at the school. An institutional emphasis on clinical productivity reinforced clinical faculty's constraints on academic scholarship, which led to perceived inequities by clinical faculty. Participants also perceived subtle gender bias and an unequal distribution of power among the specialties, which contradicted a culture of collaboration and support in the school.Insights: Complex power structures influence faculty career success. Unequal access and differential power among faculty positions resulted in disparities in career advancement. Greater transparency, equity, and inclusivity are obvious suggestions for change to allow all faculty to benefit from essential resources and career building opportunities. Furthermore, building high-quality relationships between leaders and faculty and mutual respect between specialties are essential to sustaining an organizational culture conducive to career success for all faculty. Faculty will benefit from a greater awareness of the structural and normative aspects of a medical school that are less obvious and more difficult to change. This is the value of applying Bourdieu's theory of practice to the socio-cultural dynamics of the medical school.

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.

Research Methodologies in Health Professions Education Publications: Breadth and Rigor.

PURPOSE: Research methodologies represent assumptions about knowledge and ways of knowing. Diverse research methodologies and methodological standards for rigor are essential in shaping the collective set of knowledge in health professions education (HPE). Given this relationship between methodologies and knowledge, it is important to understand the breadth of research methodologies and their rigor in HPE research publications. However, there are limited studies examining these questions. This study synthesized current trends in methodologies and rigor in HPE papers to inform how evidence is gathered and collectively shapes knowledge in HPE. METHOD: This descriptive quantitative study used stepwise stratified cluster random sampling to analyze 90 papers from 15 HPE journals published in 2018 and 2019. Using a research design codebook, the authors conducted group coding processes for fidelity, response process validity, and rater agreement; an index quantifying methodological rigor was developed and applied for each paper. RESULTS: Over half of research methodologies were quantitative (51%), followed by qualitative (28%), and mixed methods (20%). No quantitative and mixed methods papers reported an epistemological approach. All qualitative papers that reported an epistemological approach (48%) used social constructivism. Most papers included participants from North America (49%) and Europe (20%). The majority of papers did not specify participant sampling strategies (56%) or a rationale for sample size (80%). Among those reported, most studies (81%) collected data within 1 year.The average rigor score of the papers was 56% (SD = 17). Rigor scores varied by journal categories and research methodologies. Rigor scores differed between general HPE journals and discipline-specific journals. Qualitative papers had significantly higher rigor scores than quantitative and mixed methods papers. CONCLUSIONS: This review of methodological breadth and rigor in HPE papers raises awareness in addressing methodological gaps and calls for future research on how the authors shape the nature of knowledge in HPE.

A Systematic Approach to Provide Feedback to Presenters at Virtual and Face-to-Face Professional Meetings.

Introduction: To promote their personal and professional growth, medical educators need practical, actionable feedback on their scholarship, as well as guidance for documenting their scholarship in educator portfolios. We offer a framework and resources to provide formative and summative feedback to faculty, administrators, and/or learners delivering an oral presentation at a face-to-face or virtual health professions education meeting. Methods: In 2014, the leadership of the Central Group on Educational Affairs (CGEA) meeting planning committee developed and piloted a process to provide individuals with formative and summative feedback on their oral CGEA research presentations at face-to-face meetings and create a transparent process for determining the Best Presentation Award. The feedback process was implemented for 7 years until revised in 2021 for the CGEA's first virtual meeting. Past and present meeting organizers conducted four focus groups in 2021 with presenters and peer reviewers via Zoom. Transcripts were analyzed for major themes using conventional content analysis. Results: To date, 102 presentation assessments have been conducted, including formative and summative assessments. Sixty-two volunteer assessors have participated, 19 (31%) of whom served for more than 2 years. Focus groups identified best practices and suggestions to improve the feedback process. Discussion: This resource offers a feasible, systematic process to provide individuals with formative feedback on presentations at professional conferences, promote a community of practice for personal and professional development, and create a transparent process for determining a Best Presentation Award. Participants valued providing and receiving feedback and recommended implementation at other professional meetings.

Analyzing Expert Criteria for Authentic Resident Communication Skills.

Phenomenon: Training and assessing communication skills requires flexible and holistic approaches, including feedback practices. Historically, assessing communication skills has predominantly relied on itemized scoring, which is less useful for providing meaningful feedback to learners. Even more troublesome, theoretical scoring criteria tend to become a refractive lens allowing observation of only the conduct that aligns with the theory. Few skills assessment efforts have embraced a holistic understanding of how physician-patient communication skills are enacted in real patient care. Therefore, this study focused on what experts refer to when they speak about physicians' communication skills and what they treat as important when evaluating these skills enacted during real patient encounters.Approach: This qualitative study was based on observations and grounded theory. Residents' encounters with real patients were recorded as part of a formative communication skills assessment program from July 2015 to June 2016. Evaluation panels with diverse backgrounds (e.g., medicine, education, communication, conversation analysis, and layperson) listened to these recordings and jointly developed feedback comments for the resident from January 2016 to July 2017. For this study, we recorded forty-one panel discussions to observe their consensus evaluation. We conducted open and axial coding using a constant comparison approach to generate themes from the data.Findings: Elements of communication skills were connected and interdependent around the concepts of thoroughness and natural flow, which were not addressed by formative assessment criteria. Themes included (1) thoroughness within a boundary via agenda-setting; (2) natural yet, controlled flow: authentic conversation by active listening and questioning; (3) making agenda setting explicit to all parties in the beginning; (4) designing questions using both open-ended and closed questions; (5) pre-/post-conditions for patient education: patient contextual factors and teach-back; (6) preconditions for shared decision-making: patient education and patient contextual factors; and (7) multifaceted empathy demonstrated in multiple ways.Insights: The main message of the study findings is that communication skills criteria should be treated as organically interrelated and connected in assessing physicians' communication skills. Current communication skills assessment practice should be revisited as it itemizes physicians' communication skills as distinct and separate constructs rather than mutually affecting dynamics. Rather than imposing a theoretical rubric, assessment criteria should evolve through naturalistic observations of physician-patient communication.

On pandemics and pivots: a COVID-19 reflection on envisioning the future of medical education.

The required adjustments precipitated by the coronavirus disease 2019 crisis have been challenging, but also represent a critical opportunity for the evolution and potential disruptive and constructive change of medical education. Given that the format of medical education is not fixed, but malleable and in fact must be adaptable to societal needs through ongoing reflexivity, we find ourselves in a potentially transformative learning phase for the field. An Association for Medical Education in Europe ASPIRE Academy group of 18 medical educators from seven countries was formed to consider this opportunity, and identified critical questions for collective reflection on current medical education practices and assumptions, with the attendant challenge to envision the future of medical education. This was achieved through online discussion as well as asynchronous collective reflections by group members. Four major themes and related conclusions arose from this conversation: Why we teach: the humanitarian mission of medicine should be reinforced; what we teach: disaster management, social accountability and embracing an environment of complexity and uncertainty should be the core; how we teach: open pathways to lean medical education and learning by developing learners embedded in a community context; and whom we teach: those willing to take professional responsibility. These collective reflections provide neither fully matured digests of the challenges of our field, nor comprehensive solutions; rather they are offered as a starting point for medical schools to consider as we seek to harness the learning opportunities stimulated by the pandemic.

What Is an Innovation Article? A Systematic Overview of Innovation in Health Professions Education Journals.

PURPOSE: Innovation articles have their own submission category and guidelines in health professions education (HPE) journals, which suggests innovation might be a unique genre of scholarship. Yet, the requirements for innovation submissions vary among journals, suggesting ambiguity about the core content of this type of scholarship. To reduce this ambiguity, the researchers conducted a systematic overview to identify key features of innovation articles and evaluate their consistency in use across journals. Findings from this review may have implications for further development of innovation scholarship within HPE. METHOD: In this systematic overview, conducted in 2020, the researchers identified 13 HPE journals with innovation-type articles and used content analysis to identify key features from author guidelines and publications describing what editors look for in innovation articles. The researchers then audited a sample of 39 innovation articles (3/journal) published in 2019 to determine presence and consistency of 12 innovation features within and across HPE journals. Audit findings informed the researchers' evaluation of innovation as a genre in HPE. RESULTS: Findings show variability of innovation feature presence within and across journals. On average, articles included 7.8 of the 12 innovation features (SD 2.1, range 3-11). The most common features were description of: how the innovation was implemented (92%), a problem (90%), what was new or novel (79%), and data or outcomes (77%). On average, 5.5 (SD 1.5) out of 12 innovation features were consistently used in articles within each journal. CONCLUSIONS: The authors identified common features of innovation article types based on journal guidelines, but there was variability in presence and consistency of these features, suggesting HPE innovations are in an emerging state of genre development. The authors discuss potential reasons for variability within this article type and highlight the need for further discussion among authors, editors, and reviewers to improve clarity.

Effects of the non-contact cardiopulmonary resuscitation training using smart technology.

AIMS: Accurate cardiopulmonary resuscitation (CPR) performance is an essential skill for nursing students so they need to learn the skill correctly from the beginning and carry that forward with them into their clinical practice. For the new normal after coronavirus disease 2019 (COVID-19), safe training modules should be developed. This study aimed to develop non-contact CPR training using smart technology for nursing students and to examine its effects, focusing on the accuracy of their performance. The study used a prospective, single-blind, randomized, and controlled trial with repeated measures. METHODS AND RESULTS: The non-contact CPR training with smart technology consisted of a 40-min theoretical online lecture session and an 80-min non-contact practice session with real-time feedback devices and monitoring cameras. Sixty-four nursing students were randomly assigned to either an experimental group (n = 31) using non-contact training or a control group (n = 33) using general training. The accuracy of chest compression and mouth-to-mouth ventilation, and overall performance ability were measured at pretest, right after training, and at a 4-week post-test. The non-contact CPR training significantly increased the accuracy of chest compression (F = 63.57, P < 0.001) and mouth-to-mouth ventilation (F = 33.83, P < 0.001), and the overall performance ability (F = 35.98, P < 0.001) compared to the general CPR training over time. CONCLUSIONS: The non-contact CPR training using smart technology help nursing students develop their techniques by self-adjusting compression depth, rate, release and hand position, and ventilation volume and rate in real time. Nursing students can learn CPR correctly through the training allowing real-time correction in safe learning environments without face-to-face contact.

Attendings' Perceptions of Authentic Evaluation Criteria for Effective Surgical Consults.

OBJECTIVE: The authors aimed to investigate faculty evaluation criteria for an effective oral surgical presentation in actual patient care contexts. DESIGN: We conducted a 2-step observation-based qualitative study. Residents audiotaped oral presentations of a surgical consult to an attending. Evaluation panels listened to the recordings and discussed to develop joint feedback for the resident. The panel discussions were recorded and served as the data source for this study. We analyzed the data following the grounded theory approach using open coding and axial coding. SETTING: The study setting was at Southern Illinois University School of Medicine, a 5-year general surgery residency program in Springfield, Illinois. PARTICIPANTS: Thirteen residents out of 19 in the program participated by virtue of having submitted recordings of a patient care consult presentation via phone. Evaluation panels consisted of general surgery academic and community faculty, as well as senior residents. RESULTS: Several criteria for effective oral presentations emerged that have rarely been discussed in prior literature. Themes included: (1) The strategic opening is critical as it "sets the stage" and frames how the attending will listen. Situational factors, such as consideration of time of the day and urgency, should be accounted for in the opening. (2) A deductive structure defines the relevance of the presented information. Clinical judgement should precede supporting evidence. Attending physicians perceive important information as unnecessary if provided outside of this framework. (3) Established trust between a resident and a surgeon determines the level of detail expected of the presenting resident. With increasing trust, surgeons expect residents to present fewer details; if too much detail is included, the presentation may be assessed as ineffective. (4) Surgical descriptions are appreciated for their value in promoting the attending's visualization or mental picture of the patient condition. (5) Oral emphasis using voice tone and pace can be helpful for capturing attending attention. CONCLUSIONS: These findings can be utilized to improve the current training program and assessment rubrics toward contextualized work-based assessment practices in surgery. Oral patient presentation skills are neither static nor universal, but fluid and reflexive, based on trust, and situational factors.

Medical students' reflections on surgical educators' professionalism: Contextual nuances in the hidden curriculum.

INTRODUCTION: Surgical educators' professional behavior constitutes a hidden curriculum and impacts trainee's professional identity formation. This study explores the nuances of professional behaviors as observed in varying surgical settings. METHODS: 411 Transcripts originated from essays written by MS3 students during their surgical clerkship from 2010 to 2016 were collated. Employing a qualitative research methodology, we conducted a thematic analysis to uncover specific meaning emerging from medical student reflections' on surgical professionalism. RESULTS: In clinics, taking time and protecting patient privacy; in the OR, control over emotion during difficult situations and attention to learners; and in the inpatient setting, showing accountability above normal expected behavior were noted as professional. Similarly, unprofessional behaviors in these contexts paralleled lack of these attributes. CONCLUSIONS: Behaviors observed and the attributes of professionalism in the surgical learning environment have contextual nuances. These variations in professionalism can be utilized in deliberate development of professionalism in surgery.

Teaching online: foundational concepts of online learning and practical guidelines.

Medical schools have been slowly adopting online learning into pedagogical methods for more than a decade. While some medical educators are reluctant to accept these changes, the ongoing coronavirus disease 2019 (COVID-19) pandemic poses a threat to the delivery of traditional medical education, which has accelerated the inevitable implementation of online learning. This sudden change may be a new challenge to medical educators who are new to this territory. Therefore, this review aims to provide foundational concepts of online learning and practical guidelines in the context of medical education. The authors first identify three foundational concepts, which are transactional distance, presence, and independent learners. In online learning, transactional distance, determined by dialogue and structure, becomes more important than physical distance. Furthermore, effective and successful online learning requires the achievement and accommodation of cognitive, social, and teaching presences. It is also crucial to recognize learners not as passive recipients of information predefined by a teacher, but as active, capable, and independent individuals. The authors, then, discuss the practical guidelines for designing an effective online curriculum. Five online pedagogical guidelines are laid out in this review: design structures and flows to embrace experiential learning, accommodate both synchronous and asynchronous learning, design/facilitate interactions, promote practice opportunities, and promote a learning community. By understanding the foundational concepts and applying these guidelines, the adoption of online learning in the medical school may supplement the traditional medical education or even provide additional benefits in the new normal after the COVID-19 pandemic.

Medical Students' Progress in Detecting and Interpreting Visual and Auditory Clinical Findings.

Phenomenon: Detection of visual and auditory clinical findings is part of medical students' core clinical performance abilities that a medical education curriculum should teach, assess, and remediate. However, there is a limited understanding of how students develop these skills. While training physical exam technical skills has received significant attention and emphasis, teaching and assessing medical students' ability to detect and interpret visual and auditory clinical findings skills has been less systematic. Therefore, the purpose of this study is to investigate how medical students' visual and auditory clinical findings skills progress and develop over their four years of undergraduate medical education. This study will provide educators insights that can guide curriculum refinements that lead to improving students' abilities in this area. Approach: A computer-based progress exam was created to measure the longitudinal development of students' abilities to detect and interpret visual and auditory findings. After pilot testing, sixty test items were developed in collaboration with six clinical faculty members and two medical education researchers. The exam includes detection and description of ECG, x-ray, heart sounds, breath sounds, skin lesions, and movement findings. The exam was administered to students at the beginning of each training year since 2014. Additionally, the exam was administered to the Class of 2017 prior to their graduation. Measurement validity and reliability tests were conducted. Descriptive statistics and ANOVA were used to determine progress. Findings: More than 98% of students in four years of training completed the exam each year. The exam instrument had high reliabilities and demonstrated acceptable concurrent validity when compared with other academic performance data. Findings showed that students' visual and auditory clinical findings skills increased each training year until their fourth year. There was no performance improvement between incoming Year 4 students and graduating Year 4 students. While group means increased, class performance did not become more homogeneous across four years. Longitudinal data showed the same performance patterns as the cross-sectional data. Performance of the bottom quartile of graduating fourth-year students was not significantly higher than the performance of the top quartile of incoming first-year students who had not had formal medical training. Insights: A longitudinal study to follow learners' performance in detecting and interpreting visual and auditory clinical findings can provide meaningful insights regarding the effects of medical training programs on performance growth. The present study suggests that our medical curriculum is not effective in bringing all students to a higher level of performance in detecting and interpreting visual and auditory clinical findings. This study calls for further investigation how medical students can develop visual and auditory detection and interpretation skills in undergraduate medical education. There is a need for planned curriculum and assessment of medical students' skills in detecting and interpreting visual and auditory clinical findings.

Looking into the labyrinth of gender inequality: women physicians in academic medicine.

CONTEXT: Gender inequality remains prevalent worldwide in academic medicine. A closer look into women physicians' gendered experiences through the lens of culture is necessary to advance understanding of gender inequality in this context. Relatively few studies, however, have investigated how social and cultural practices implicitly yet significantly affect gender inequality throughout women physicians' careers. OBJECTIVES: This study aimed to investigate the lived experiences of South Korean women physicians working in academic medicine and to focus on social and cultural influences on the gendered process of their career journeys. The study will extend our understanding of gender inequality in academic medicine through an in-depth analysis of social and cultural practices that affect the phenomenon. METHODS: We conducted a qualitative study utilising a grounded theory approach. Twenty-one women physicians participated in semi-structured interviews. Data were recorded, transcribed and analysed through a process of constant comparison using grounded theory to extract themes. RESULTS: Junior women physicians were more vulnerable to gender discrimination and channelled to 'ghettos' through the seniority-based, patriarchal, collectivist and business hospital culture in South Korea. Under pressure to excel at work, they had no work-family balance and experienced identity crises as competent doctors and mothers. They felt themselves to be 'othered' in multiple cultural contexts, including school ties, rankism and a culture of after-work gatherings. Minimal levels of leadership aspiration created a vicious cycle of a lack of social networking and mentoring. Pursuing individual excellence, they attributed their struggles to personal choices and rarely sought organisational support. CONCLUSIONS: The dynamics of cultural and social practices constantly and implicitly recreate mechanisms to maintain gender inequality in academic medicine in South Korea. Planned culture changes at individual, organisational and national levels are imperative to discontinue the vicious cycle that exists in the labyrinth of women physicians' career development in academic medicine.

The Most Common Feedback Themes in Communication Skills Training in an Internal Medicine Residency Program: Lessons from the Resident Audio-Recording Project.

Individualized structured feedback is an integral part of a resident's learning in communication skills. However, it is not clear what feedback residents receive for their communication skills development in real patient care. We will identify the most common feedback topics given to residents regarding communication skills during Internal Medicine residency training. We analyzed Resident Audio-recording Project feedback data from 2008 to 2013 by using a content analysis approach. Using open coding and an iterative categorization process, we identified 15 emerging themes for both positive and negative feedback. The most recurrent feedback topics were Patient education, Thoroughness, Organization, Questioning strategy, and Management. The residents were guided to improve their communication skills regarding Patient education, Thoroughness, Management, and Holistic exploration of patient's problem. Thoroughness and Communication intelligibility were newly identified themes that were rarely discussed in existing frameworks. Assessment rubrics serve as a lens through which we assess the adequacy of the residents' communication skills. Rather than sticking to a specific rubric, we chose to let the rubric evolve through our experience.