Stereotype Threat and Gender Bias in Internal Medicine Residency: It is Still Hard to be in Charge.

BACKGROUND: Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities. OBJECTIVE: To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat. DESIGN: We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat. PARTICIPANTS: The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September-November 2019. Focus groups were conducted at UCSF in Spring 2020. APPROACH: The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources. KEY RESULTS: Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women's experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship. CONCLUSIONS: Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women's vulnerability to stereotype threat.

'Yourself in all your forms': A grounded theory exploration of identity safety in medical students.

INTRODUCTION: Identity threats, such as stereotype threat and microaggressions, impair learning and erode well-being. In contrast to identity threat, less is known about how learners experience feelings of safety regarding their identity. This exploratory study aims to develop a theory of identity safety in the clinical learning environment. METHODS: This multi-institutional, qualitative interview study was informed by constructivist grounded theory and critical pedagogy. Participants were clinical students at three public medical schools in the United States in 2022. Investigators purposively sampled participants for interviews based on their responses to an 11-item survey with an open-ended question soliciting students' personal identities and responses to both the racial/ethnic and gender Stereotype Vulnerability Scales. The investigators interviewed, coded, constantly compared and continued sampling until the codes could be developed into categories, then concepts and finally into a theory. The team engaged in critical reflexivity throughout the analytic process to enrich data interpretations. RESULTS: Sixteen diverse students were interviewed. We organised their identity-salient experiences into identity threat, threat mitigation and identity safety. Participants experienced identity threat through unwelcoming learning environments, feeling compelled to change their behaviour in inauthentic ways or sociopolitical threat. Threat mitigation occurred when a participant or supervisor intervened against an identity threat, dampening but not eliminating the threat impact. Participants characterised identity safety as the ability to exist as their authentic selves without feeling the need to monitor how others perceive their identities. Identity safety manifested when participants demonstrated agency to leverage their identities for patient care, when others upheld their personhood and saw them as unique individuals and when they felt they belonged in the learning environment. DISCUSSION: Attending to identity safety may lead to educational practices that sustain and leverage team members' diverse identities. Identity safety and threat mitigation may work together to combat identity threats in the learning environment.

'We're like Spider-Man; with great power comes great responsibility': Coaches' experiences supporting struggling medical students.

BACKGROUND: Medical students can experience a range of academic and non-academic struggles. Coaching is a valuable strategy to support learners, but coaches describe working with struggling learners as taxing. Transformative learning theory (TLT) provides insights into how educators grow from challenging experiences to build resilience. This study explores how coaches evolve as educators through supporting struggling students. METHODS: This qualitative study grounded in an interpretivist paradigm used interviews of longitudinal medical student coaches at two academic institutions. Interviews, using TLT as a sensitizing concept, explored coaches' experience coaching struggling learners. We performed thematic analysis. RESULTS: We interviewed 15 coaches. Coaches described supporting students through multi-faceted struggles which often surprised the coach. Three themes characterized coaches' experiences: personal responsibility, emotional response, and personal learning. Coaches shouldered high personal responsibility for learners' success. For some, this burden felt emotional, raised parental instincts and questions about maintaining boundaries with learners. Coaches evolved their coaching approach, challenged biases, and built skills. Coaches learned to better appreciate the learner point of view and employ resources to support students. DISCUSSION: Through navigating learner struggles, educators can gain self-efficacy, learn to understand learners' perspectives, and evolve their coaching approach to lessen their personal emotional burden through time.

Student, Staff and Faculty Experience with a Medical School Racial and Sociopolitical Trauma Protocol: A Mixed Methods Study.

Problem: Medical students experience racial and sociopolitical trauma that disrupts their learning and wellbeing. Intervention: University of California, San Francisco (UCSF) School of Medicine students advocated for a systems approach to responding to traumatic events. Students partnered with educators to introduce an innovative protocol that affords short-term flexibility in curricular expectations (e.g., defer attendance, assignments, assessments) to empower students to rest, gather, or pursue community advocacy work. This study explored students' protocol utilization and student, staff, and faculty experience with its implementation. Context: UCSF is a public medical school with a diverse student body. Students raised the need to acknowledge the effects of trauma on their learning and wellbeing. Consequently, students and educators created the UCSF Racial and Sociopolitical Trauma protocol ('protocol') to allow students time-limited flexibility around academic obligations following events anticipated to inflict trauma on a school community level. The protocol affords students space to process events and engage with affected communities while ensuring all students achieve school competencies and graduation requirements. Impact: We conducted a two-phase mixed methods study: (1) retrospective analysis of quantitative data on students' protocol use and (2) focus groups with students, staff, and faculty. We used descriptive statistics to summarize students' protocol use to adjust attendance, assignment submission, and assessments and thematic analysis of focus group data. Across eight protocol activations June 2020 - November 2021, 357 of 664 (54%) students used it for 501 curricular activities: 56% (n = 198) for attendance, 71% (n = 252) for assignments, and 14% (n = 51) for assessments. When deciding to utilize the protocol, student focus group participants considered sources of restoration; impact on their curricular/patient responsibilities; and their identities. The protocol symbolized an institutional value system that made students feel affirmed and staff and faculty proud. Staff and faculty initially faced implementation challenges with questions around how to apply the protocol to curricular components and how it would affect their roles; however, these questions became clearer with each protocol activation. Questions remain regarding how the protocol can be best adapted for the clerkship setting. Lessons Learned: High protocol usage and focus group data confirmed that students found value in the protocol, and staff and faculty felt invested in the protocol mission. This student-initiated intervention supports a cultural shift beyond diversity toward trauma-informed medical education. Partnership among learners and educators can contribute to transforming learning and healthcare environments by enacting systems and structures that enable all learners to thrive.

Advancing anti-oppression and social justice in healthcare through competency-based medical education (CBME).

Competency-based medical education (CBME) focuses on preparing physicians to improve the health of patients and populations. In the context of ongoing health disparities worldwide, medical educators must implement CBME in ways that advance social justice and anti-oppression. In this article, authors describe how CBME can be implemented to promote equity pedagogy, an approach to education in which curricular design, teaching, assessment strategies, and learning environments support learners from diverse groups to be successful. The five core components of CBME programs - outcomes competency framework, progressive sequencing of competencies, learning experiences tailored to learners' needs, teaching focused on competencies, and programmatic assessment - enable individualization of learning experiences and teaching and encourage learners to partner with their teachers in driving their learning. These educational approaches appreciate each learner's background, experiences, and strengths. Using an exemplar case study, the authors illustrate how CBME can afford opportunities to enhance anti-oppression and social justice in medical education and promote each learner's success in meeting the expected outcomes of training. The authors provide recommendations for individuals and institutions implementing CBME to enact equity pedagogy.

'It's more like checking in with an old friend': A qualitative study of medical students' experiences with longitudinal coaches throughout medical school.

PURPOSE: Coaching in medical education facilitates learners' growth and development through feedback, goal-setting and support. This study explored how coaching relationships evolve throughout medical school and the impact of longitudinal coaching relationships on medical students' approach to feedback and goal setting in the clinical years. METHOD: In this qualitative study using a constructivist paradigm, authors purposively sampled 15 senior medical students at University of California, San Francisco, to participate in individual semi-structured interviews (October-November 2021). The authors used an inductive approach to thematic analysis. RESULTS: The authors identified four themes: First, the student-coach relationship deepened over the course of medical school. Second, students identified factors that sustained and strengthened the student-coach relationship over time: a strong foundation to the relationship, the non-evaluative nature of the relationship, coach supportiveness and responsiveness, and coach knowledge of the institutional landscape. Third, coaches provided individualized advice, assessed trajectory, and guided feedback interpretation. Lastly, students applied skills of soliciting and responding to feedback and creating learning goals, originally learned through coaching experience. CONCLUSIONS: Coaching relationships, grounded in trust, evolve to meet students' changing needs as they grow into physicians. Students apply feedback and goal-setting skills learned with the coach in clinical settings with other supervisors.

"It's All About the Trust And Building A Foundation:" Evaluation of a Longitudinal Medical Student Coaching Program.

Coaching is increasingly implemented in medical education to support learners' growth, learning, and wellbeing. Data demonstrating the impact of longitudinal coaching programs are needed.We developed and evaluated a comprehensive longitudinal medical student coaching program designed to achieve three aims for students: fostering personal and professional development, advancing physician skills with a growth mindset, and promoting student wellbeing and belonging within an inclusive learning community. We also sought to advance coaches' development as faculty through satisfying education roles with structured training. Students meet with coaches weekly for the first 17 months of medical school for patient care and health systems skills learning, and at least twice yearly throughout the remainder of medical school for individual progress and planning meetings and small-group discussions about professional identity. Using the developmental evaluation framework, we iteratively evaluated the program over the first five years of implementation with multiple quantitative and qualitative measures of students' and coaches' experiences related to the three aims.The University of California, San Francisco, School of Medicine, developed a longitudinal coaching program in 2016 for medical students alongside reform of the four-year curriculum. The coaching program addressed unmet student needs for a longitudinal, non-evaluative relationship with a coach to support their development, shape their approach to learning, and promote belonging and community.In surveys and focus groups, students reported high satisfaction with coaching in measures of the three program aims. They appreciated coaches' availability and guidance for the range of academic, personal, career, and other questions they had throughout medical school. Students endorsed the value of a longitudinal relationship and coaches' ability to meet their changing needs over time. Students rated coaches' teaching of foundational clinical skills highly. Students observed coaches learning some clinical skills with them - skills outside a coach's daily practice. Students also raised some concerns about variability among coaches. Attention to wellbeing and belonging to a learning community were program highlights for students. Coaches benefited from relationships with students and other coaches and welcomed the professional development to equip them to support all student needs.Students perceive that a comprehensive medical student coaching program can achieve aims to promote their development and provide support. Within a non-evaluative longitudinal coach relationship, students build skills in driving their own learning and improvement. Coaches experience a satisfying yet challenging role. Ongoing faculty development within a coach community and funding for the role seem essential for coaches to fulfill their responsibilities.

Students' Perspectives on Basic and Clinical Science Integration When Step 1 is Administered After the Core Clerkships.

Phenomenon: According to adult learning theories, effective cognitive integration of basic and clinical science may promote the transfer of knowledge to patient care. The placement of the U.S. Medical Licensing Examination (USMLE) Step 1 after the core clerkships is one strategy intended to facilitate cognitive integration, though learner experiences with this model are unexplored. The purpose of this study is to understand students' perspectives on basic and clinical science integration in a post-clerkship Step 1 curriculum. Approach: Focus groups were conducted between August and September 2020 with senior medical students from the University of California, San Francisco School of Medicine and University of Michigan Medical School. Data were analyzed using a constructivist approach to thematic analysis. Findings: Thirty-three students participated in six focus groups. Participants described multiple barriers to cognitive integration in the clerkship learning environment, though they also identified examples of teaching and learning that facilitated integration. Early in their clerkships, students struggled to integrate because of their tenuous basic science foundation, cognitive overload, and difficulty perceiving the relevance of basic science to patient care. They felt that educators primarily focused on clinical science, and many basic science teaching sessions during clerkships felt irrelevant to patient care. However, students also described experiences that made the connection between basic and clinical science more explicit, including modeling by educators and clerkship learning activities that more overtly encouraged the application of basic science to clinical care. In addition, the return to basic science studying during the post-clerkship dedicated Step 1 study period offered powerful integration opportunities. These facilitators of cognitive integration helped students recognize the value of integration for enduring learning. Insights: There are myriad barriers to cognitive integration of basic and clinical science during clerkships in a post-clerkship Step 1 curriculum. The relevance of basic science to patient care needs to be made more explicit to students through modeling by clinician educators to augment the potential benefits of curricular change. The post-clerkship Step 1 study period appears to offer a unique opportunity for cognitive integration later in a learner's trajectory that may be related to curricular design. When learners recognize the applicability of basic science to patient care, they may more intentionally transfer basic science knowledge to clinical practice.

Making sense of competency-based medical education (CBME) literary conversations: A BEME scoping review: BEME Guide No. 78.

BACKGROUND: Competency-based medical education (CBME) received increased attention in the early 2000s by educators, clinicians, and policy makers as a way to address concerns about physician preparedness and patient safety in a rapidly changing healthcare environment. Opinions and perspectives around this shift in medical education vary and, to date, a systematic search and synthesis of the literature has yet to be undertaken. The aim of this scoping review is to present a comprehensive map of the literary conversations surrounding CBME. METHODS: Twelve different databases were searched from database inception up until 29 April 2020. Literary conversations were extracted into the following categories: perceived advantages, perceived disadvantages, challenges/uncertainties/skepticism, and recommendations related to CBME. RESULTS: Of the 5757 identified records, 387 were included in this review. Through thematic analysis, eight themes were identified in the literary conversations about CBME: credibility, application, community influence, learner impact, assessment, educational developments, organizational structures, and societal impacts of CBME. Content analysis supported the development of a heat map that provides a visual illustration of the frequency of these literary conversations over time. CONCLUSIONS: This review serves two purposes for the medical education research community. First, this review acts as a comprehensive historical record of the shifting perceptions of CBME as the construct was introduced and adopted by many groups in the medical education global community over time. Second, this review consolidates the many literary conversations about CBME that followed the initial proposal for this approach. These findings can facilitate understanding of CBME for multiple audiences both within and outside of the medical education research community.

Reimagining a pass/fail clinical core clerkship: a US residency program director survey and meta-analysis.

Pass/fail (P/F) grading has emerged as an alternative to tiered clerkship grading. Systematically evaluating existing literature and surveying program directors (PD) perspectives on these consequential changes can guide educators in addressing inequalities in academia and students aiming to improve their residency applications. In our survey, a total of 1578 unique PD responses (63.1%) were obtained across 29 medical specialties. With the changes to United States Medical Licensure Examination (USMLE), responses showed increased importance of core clerkships with the implementation of Step 2CK cutoffs. PDs believed core clerkship performance was a reliable representation of an applicant's preparedness for residency, particularly in Accreditation Council for Graduate Medical Education's (ACGME)Medical Knowledge and Patient Care and Procedural Skills. PDs disagreed with P/F core clerkships because it more difficult to objectively compare applicants. No statistically significant differences in responses were found in PD preferential selection when comparing applicants from tiered and P/F core clerkship grading systems. If core clerkships adopted P/F scoring, PDs would further increase emphasis on narrative assessment, sub-internship evaluation, reference letters, academic awards, professional development and medical school prestige. In the meta-analysis, of 6 studies from 2,118 participants, adjusted scaled scores with mean difference from an equal variance model from PDs showed residents from tiered clerkship grading systems overall performance, learning ability, work habits, personal evaluations, residency selection and educational evaluation were not statistically significantly different than from residents from P/F systems. Overall, our dual study suggests that while PDs do not favor P/F core clerkships, PDs do not have a selection preference and do not report a difference in performance between applicants from P/F vs. tiered grading core clerkship systems, thus providing fertile grounds for institutions to examine the feasibility of adopting P/F grading for core clerkships.

Exploring how feedback reflects entrustment decisions using artificial intelligence.

CONTEXT: Clinical supervisors make judgements about how much to trust learners with critical activities in patient care. Such decisions mediate trainees' opportunities for learning and competency development and thus are a critical component of education. As educators apply entrustment frameworks to assessment, it is important to determine how narrative feedback reflecting entrustment may also address learners' educational needs. METHODS: In this study, we used artificial intelligence (AI) and natural language processing (NLP) to identify characteristics of feedback tied to supervisors' entrustment decisions during direct observation encounters of clerkship medical students (3328 unique observations). Supervisors conducted observations of students and collaborated with them to complete an entrustment-based assessment in which they documented narrative feedback and assigned an entrustment rating. We trained a deep neural network (DNN) to predict entrustment levels from the narrative data and developed an explainable AI protocol to uncover the latent thematic features the DNN used to make its prediction. RESULTS: We found that entrustment levels were associated with level of detail (specific steps for performing clinical tasks), feedback type (constructive versus reinforcing) and task type (procedural versus cognitive). In justifying both high and low levels of entrustment, supervisors detailed concrete steps that trainees performed (or did not yet perform) competently. CONCLUSIONS: Framing our results in the factors previously identified as influencing entrustment, we find a focus on performance details related to trainees' clinical competency as opposed to nonspecific feedback on trainee qualities. The entrustment framework reflected in feedback appeared to guide specific goal-setting, combined with details necessary to reach those goals. Our NLP methodology can also serve as a starting point for future work on entrustment and feedback as similar assessment datasets accumulate.

Moving toward Mastery: Changes in Student Perceptions of Clerkship Assessment with Pass/Fail Grading and Enhanced Feedback.

ProblemClerkship grades contribute to a summative assessment culture in clerkships and can therefore interfere with students' learning. For example, by focusing on summative, tiered clerkship grades, students often discount accompanying feedback that could inform future learning. This case report seeks to explore whether an assessment system intervention which eliminated tiered grades and enhanced feedback was associated with changes in student perceptions of clerkship assessment and perceptions of the clinical learning environment. Intervention: In January 2019, our institution eliminated tiered clerkship grading (honors/pass/fail) for medical students during the core clerkship year and implemented pass/fail clerkship grading along with required twice weekly, work-based assessments for formative feedback. Context: In this single institution, cross-sectional survey study, we collected data from fourth-year medical students one year after an assessment system intervention. The intervention entailed changing from honors/pass/fail to pass/fail grading in all eight core clerkships and implementing an electronic system to record twice-weekly real-time formative work-based assessments. The survey queried student perceptions on the fairness and accuracy of grading and the clinical learning environment-including whether clerkships were mastery- or performance-oriented. We compared responses from students one year after the assessment intervention to those from the class one year before the intervention. Comparisons were made using unpaired, two-tailed t-tests or chi-squared tests as appropriate with Cohen's d for effect size estimation for score differences. Content analysis was used to analyze responses from two open-ended questions about feedback and grading. Impact: Survey response rates were similar before and after intervention (76% (127/168) vs. 72% (118/163), respectively) with no between-group differences in demographics. The after-intervention group showed statistically significant increases in the following factors: "grades are transparent and fair" (Cohen's d = 0.80), "students receive useful feedback" (d = 0.51), and "resident evaluation procedures are fair" (d = 0.40). After-intervention respondents perceived the clerkship learning environment to be more mastery-oriented (d = 0.52), less performance approach-oriented (d = 0.63), and less performance avoid-oriented (d = 0.49). There were no statistical differences in the factors "attending evaluation procedures are fair," "evaluations are accurate," "evaluations are biased," or "perception of stereotype threat." Open-ended questions revealed student recommendations to improve clerkship summary narratives, burden of work-based assessment, and in-person feedback. Lessons Learned: After an assessment system change to pass/fail grading with work-based assessments, we observed moderate to large improvements in student perceptions of clerkship grading and the mastery orientation of the learning environment. Our intervention did not improve perceptions around bias in assessment in clerkships. Other medical schools may consider similar interventions to begin to address student concerns with clerkship assessment and promote a more adaptive learning environment.

From Grading to Assessment for Learning: A Qualitative Study of Student Perceptions Surrounding Elimination of Core Clerkship Grades and Enhanced Formative Feedback.

Problem: Medical students perceive honors grading during core clerkships as unfair and inequitable, and negatively impacting their learning and wellbeing. Eliminating honors grading, a powerful extrinsic motivator, and emphasizing formative feedback may address these problems and promote intrinsic motivation and learning. However, it is unknown how transitioning from honors to pass/fail grading with enhanced formative feedback in the core clerkship year may affect student learning experiences, wellbeing, and perceptions of the learning environment. Intervention: Core clerkship grading was transitioned from honors/pass/fail to pass/fail at one US medical school. In addition, the requirement for students to obtain formative supervisor feedback was formalized to twice per week. Context: This qualitative study utilized semi-structured interviews to explore the perceptions among core clerkship students of learning and assessment. Interview questions addressed motivation, wellbeing, learning behaviors, team dynamics, feedback, and student and supervisor attitudes regarding assessment changes. The authors analyzed data inductively using thematic analysis informed by sensitizing concepts related to theories of motivation (goal orientation theory and self-determination theory). Impact: Eighteen students participated, including five with experience in both honors-eligible and pass/fail clerkships. The authors identified three major themes in students' descriptions of the change in approach to assessment: student engagement in clerkships, wellbeing, and recognition of learning context. Student engagement subthemes included intrinsic motivation for patient care rather than performing; sense of agency over learning, including ability to set learning priorities, seek and receive feedback, take learning risks, and disagree with supervisors, and collaborative relationships with peers and team members. Positive wellbeing was characterized by low stress, sense of authenticity with team members, prioritized physical health, and attention to personal life. Learning context subthemes included recognition of variability of clerkship contexts with pass/fail grading mitigating fairness and equity concerns, support of the grading change from residents and some attendings, and implications surrounding future stress and residency selection. Lessons Learned: Students perceive a transition from honors grading to pass/fail with increased feedback as supporting their engagement in learning, intrinsic motivation, and wellbeing. Drivers of wellbeing appear to include students' feelings of control, achieved through the ability to seek learning opportunities, teaching, and constructive feedback without the perceived need to focus on impressing others. Ongoing evaluation of the consequences of this shift in assessment is needed.

Assessment to Optimize Learning Strategies: A Qualitative Study of Student and Faculty Perceptions.

Phenomenon: The format of medical knowledge assessment can promote students' use of effective learning strategies from the learning sciences literature, such as elaboration, interleaving, retrieval practice, and distributed learning. Assessment format can also influence faculty teaching. Accordingly, our institution implemented a new assessment strategy in which pre-clerkship medical students answered weekly formative quizzes with constructed response questions (also referred to as open-ended questions) and multiple-choice questions in preparation for summative open-ended question examinations, to support students' use of recommended learning strategies. Our qualitative study explored medical student and faculty perceptions of this assessment strategy on learning and teaching. Approach: We conducted semi-structured interviews with 16 second-year medical students to explore their preparation for quizzes and summative examinations. We also interviewed 10 faculty responsible for writing and grading these assessments in the pre-clerkship foundational sciences curriculum regarding their approach to writing assessments and rubrics, and their perceptions of how their teaching may have changed with this assessment strategy. We analyzed interview transcripts using thematic analysis with a priori sensitizing concepts from the learning sciences literature. Findings: We identified four major themes characterizing student and faculty perceptions of weekly formative quizzes and summative OEQ examinations. Participants found that this assessment strategy helped (1) prioritize conceptual understanding, (2) simulate clinical problem solving, and (3) engage students and faculty in continuous improvement in their approach to learning or teaching. Faculty and students also recognized challenges and potential tradeoffs associated with these assessment formats. Participants identified (4) facilitators and barriers when implementing this assessment strategy. Insights: Our findings suggested that assessment of medical knowledge through weekly formative quizzes and summative open-ended question examinations can facilitate students' use of effective learning strategies. Faculty also recognized improvements in their teaching and in quality of assessment. This format of assessment also presented some challenges and potential tradeoffs and significant institutional resources were required for implementation.

Twelve tips for learners to succeed in a CBME program.

The international movement to competency-based medical education (CBME) marks a major transition in medical education that requires a shift in educators' and learners' approach to clinical experiences, the way assessment data are collected and integrated, and in learners' mindsets. Learners entering a CBME curriculum must actively drive their learning experiences and education goals. For some, this expectation may be a significant change from their previous approach to learning in medicine. This paper highlights 12 tips to help learners succeed within a CBME model.

Does Delaying the United States Medical Licensing Examination Step 1 to After Clerkships Affect Student Performance on Clerkship Subject Examinations?

Phenomenon: Schools are considering the optimal timing of Step 1 of the United States Medical Licensing Examination (USMLE). Two primary reasons for moving Step 1 after the core clerkships are to promote deeper, more integrated basic science learning in clinical contexts and to better prepare students for the increasingly clinical focus of Step 1. Positioning Step 1 after the core clerkships leverages a major national assessment to drive learning, encouraging students to deepen their basic science knowledge while in the clinical setting. Previous studies demonstrated small increases in Step 1 scores, reductions in failure rates, and similar Step 2 Clinical Knowledge scores when Step 1 was after the clerkships. Some schools that have moved Step 1 reported declines in clinical subject examination (CSE) performance. This may be due to shortened pre-clerkship curricula, the absence of the Step 1 study period for knowledge consolidation, or exposure to fewer National Board of Medical Examiners type questions prior to taking CSEs. This multi-institutional study aimed to determine whether student performance on CSEs was affected by moving Step 1 after the core clerkships. Approach: CSE scores for students from eight schools that moved Step 1 after core clerkships between 2012 and 2016 were analyzed in a pre-post format. Hierarchical linear modeling was used to quantify the effect of the curriculum on CSE performance. Additional analysis determined if clerkship order impacted clinical subject exam performance and whether the curriculum change resulted in more students scoring in the lowest percentiles (as defined as below the national fifth percentile) before and after the curricular change. Findings: After moving Step 1 to after the clerkships, collectively these eight schools demonstrated statistically significant lower performance on four CSEs (Medicine, Neurology, Pediatrics, and Surgery) but not Obstetrics/Gynecology or Psychiatry. Comparing performance within the three years pre and post Step 1 change, differences across all clerkships ranged from 0.3 to -2.0 points, with an average difference of -1.1. CSE performance in clerkships taken early in the sequence was more affected by the curricular change, and differences gradually disappeared with subsequent examinations. Medicine and Neurology showed the largest average differences between curricular-group when taken early in the clinical year. Finally, there was a slightly higher chance of scoring below the national fifth percentile in four of the clinical subject exams (Medicine, Neurology, Pediatrics, and Psychiatry) for the cohort with Step 1 after the clerkships. Insights: Moving Step 1 after core clerkships had a small impact on CSE scores overall, with decreased scores for exams early in the clerkship sequence and an increased number of students below the fifth percentile. Score differences have minor effects on clerkship grades, but overall the size of the effect is unlikely to be educationally meaningful. Schools can use a variety of mitigation strategies to address CSE performance and Step 1 preparation in the clerkship phase.

Key considerations in planning and designing programmatic assessment in competency-based medical education.

Programmatic assessment as a concept is still novel for many in clinical education, and there may be a disconnect between the academics who publish about programmatic assessment and the front-line clinical educators who must put theory into practice. In this paper, we clearly define programmatic assessment and present high-level guidelines about its implementation in competency-based medical education (CBME) programs. The guidelines are informed by literature and by lessons learned from established programmatic assessment approaches. We articulate five steps to consider when implementing programmatic assessment in CBME contexts: articulate the purpose of the program of assessment, determine what must be assessed, choose tools fit for purpose, consider the stakes of assessments, and define processes for interpreting assessment data. In the process, we seek to offer a helpful guide or template for front-line clinical educators. We dispel some myths about programmatic assessment to help training programs as they look to design-or redesign-programs of assessment. In particular, we highlight the notion that programmatic assessment is not 'one size fits all'; rather, it is a system of assessment that results when shared common principles are considered and applied by individual programs as they plan and design their own bespoke model of programmatic assessment for CBME in their unique context.

Diagnosing conflict: Conflicting data, interpersonal conflict, and conflicts of interest in clinical competency committees.

Clinical competency committees (CCCs) are increasingly used within health professions education as their decisions are thought to be more defensible and fairer than those generated by previous training promotion processes. However, as with most group-based processes, it is inevitable that conflict will arise. In this paper the authors explore three ways conflict may arise within a CCC: (1) conflicting data submissions that are presented to the committee, (2) conflicts between members of the committee, and (3) conflicts of interest between a specific committee member and a trainee. The authors describe each of these conflict situations, dissect out the underlying problems, and explore possible solutions based on the current literature.

The critical role of infrastructure and organizational culture in implementing competency-based education and individualized pathways in undergraduate medical education.

In 2010, several key works in medical education predicted the changes necessary to train modern physicians to meet current and future challenges in health care, including the standardization of learning outcomes paired with individualized learning processes. The reframing of a medical expert as a flexible, adaptive team member and change agent, effective within a larger system and responsive to the community's needs, requires a new approach to education: competency-based medical education (CBME). CBME is an outcomes-based developmental approach to ensuring each trainee's readiness to advance through stages of training and continue to grow in unsupervised practice. Implementation of CBME with fidelity is a complex and challenging endeavor, demanding a fundamental shift in organizational culture and investment in appropriate infrastructure. This paper outlines how member schools of the American Medical Association Accelerating Change in Medical Education Consortium developed and implemented CBME, including common challenges and successes. Critical supporting factors include adoption of the master adaptive learner construct, longitudinal views of learner development, coaching, and a supportive learning environment.

Growth mindset in competency-based medical education.

The ongoing adoption of competency-based medical education (CBME) across health professions training draws focus to learner-centred educational design and the importance of fostering a growth mindset in learners, teachers, and educational programs. An emerging body of literature addresses the instructional practices and features of learning environments that foster the skills and strategies necessary for trainees to be partners in their own learning and progression to competence and to develop skills for lifelong learning. Aligned with this emerging area is an interest in Dweck's self theory and the concept of the growth mindset. The growth mindset is an implicit belief held by an individual that intelligence and abilities are changeable, rather than fixed and immutable. In this paper, we present an overview of the growth mindset and how it aligns with the goals of CBME. We describe the challenges associated with shifting away from the fixed mindset of most traditional medical education assumptions and practices and discuss potential solutions and strategies at the individual, relational, and systems levels. Finally, we present future directions for research to better understand the growth mindset in the context of CBME.