Transformational learning and professional identity formation in postgraduate competency-based medical education.

INTRODUCTION: Residency programmes are in transition to a framework for competency-based medical education (CBME). The intersection of CBME with transformational learning (TL) experiences and professional identity formation (PIF) - particularly within senior learners in transitional states - is unknown but important to understand in order to develop and implement strategies to support trainees' professional development. METHODS: Through inductive qualitative methods, we conducted semi-structured interviews (n = 22) of current trainees and recent graduates from adult cardiology residency training programmes within Canada to explore the impact of TL experiences on residents' professional growth and identity formation. Interviews were analysed using thematic analysis informed by TL theory. RESULTS: CBME did not appear to influence trainees' experiences of disorienting dilemmas and TL. Important clinical encounters and interpersonal relationships - in particular, those between mentor and mentee - shaped trainees' professional development as cardiologists ('enabling factors' for TL and PIF). 'Imposter phenomenon' was widely prevalent in our sample study population even among graduates who had already completed their training. Requisite elements for transformation (disorienting dilemmas, critical reflection, discourse and action) also contributed to PIF. DISCUSSION: TL experiences influenced PIF in senior learners but infrequently intersected with CBME; these experiences were more commonly prompted by disorienting dilemmas relating to clinical outcomes or interpersonal interactions independent of CBME-specific architecture.

Beyond the Task: Developing a Tool to Measure Workplace Characteristics That Affect Cognitive Load and Learning.

PURPOSE: Educators lack tools to measure the workplace characteristics that learners perceive to affect learning. Without a tool that encompasses the social, organizational, and physical components of workplace learning environments (WLEs), it is challenging to identify and improve problematic workplace characteristics. Using echocardiography WLE, this study developed a tool to measure workplace characteristics that cardiology fellows perceive to affect learning. METHOD: The Workplace-Cognitive Load Tool (W-CLT) was developed, which encompasses 17 items to measure workplace characteristics that could affect perceived cognitive load and learning. Exploratory factor analysis was used to identify the most parsimonious structure. A total of 646 cardiology subspeciality fellows were recruited from 60 cardiology fellowship programs to complete the survey between November 2020 and February 2021. Validity evidence was collected, guided by the unified model of validity. RESULTS: A total of 308 fellows (response rate, 49%) participated in the survey. The most parsimonious structure included 4 factors: (1) workplace-task, (2) workplace-environment, (3) workplace-orientation, and (4) workplace-teaching and feedback. All factors had high reliability (Cronbach α = 0.92, 0.92, 0.96, and 0.94, respectively). Social, organizational, and physical components of WLEs were represented in the items. Workplace-teaching and feedback had moderate negative correlations with workplace-environment (r = -0.41, P < .001) and workplace-orientation (r = -0.36, P < .001). A moderate positive correlation was found between workplace-task and workplace-teaching and feedback (r = 0.42, P < .001). Workplace-task had weak negative correlations with workplace-environment (r = -0.22, P < .001) and workplace-orientation (r = -0.23, P < .001). CONCLUSIONS: The W-CLT measures workplace characteristics that cardiology fellows perceive to affect their learning. The presence of social, organizational, and physical components emphasizes how workplace characteristics can enhance or impede learning. The W-CLT provides a foundation to explore how learning can be optimized in other WLEs.

Designing a Multidisciplinary Cardio-obstetrics Curriculum for General Cardiology and Obstetrics Residents: A National Survey of Educational Needs.

Background: The increasing and potentially preventable cardiac events in pregnant patients have led to calls to enhance multidisciplinary cardio-obstetrics education. To design a multidisciplinary cardio-obstetrics curriculum for general cardiology and obstetrics and gynecology (OBGYN) residents, we need to define educational needs from the perspectives of both cardiology and OBGYN residents. Our study characterizes the educational needs of Canadian cardiology and OBGYN residents. Methods: Canadian cardiology and OBGYN residents were surveyed on clinical exposures, perceived needs for topics, unperceived needs for topics (multiple-choice questions) and preferences for educational formats. High priorities were defined as ≥ 50% of responses indicating a perceived need or ≥ 50% indicating an unperceived need. Results: A total of 154 residents participated (cardiology n = 44, OBGYN n = 110). Residents reported insufficient clinical exposure to nearly all cardiac disorders, with 33% of exposures occurring in multidisciplinary contexts. All topics aside from gestational hypertension were rated as high priority on perceived needs by both specialties. High-priority unperceived needs were congenital heart disease (both specialties), pre-existing acquired heart disease (both specialties), medication safety (OBGYN), peripartum management (OBGYN), and pregnancy-related heart disease (OBGYN). Cardiology and OBGYN residents shared preferences for in-person simulation, virtual simulation, and online modules. Conclusions: Residents in both specialties reported low clinical exposure to most cardiac disorders during pregnancy, identified high-priority perceived needs in multiple topics, and shared 2 high-priority unperceived needs. OBGYN residents identified 3 additional high-priority unperceived needs. These data can inform design of multidisciplinary cardio-obstetrics curricula for general cardiology and OBGYN residents.

Contexte: L'augmentation du nombre d'événements cardiaques potentiellement évitables chez les patientes enceintes a conduit à des appels pour renforcer la formation multidisciplinaire en cardio-obstétrique. Afin de concevoir un programme d'études multidisciplinaires en cardio-obstétrique pour les résidents en cardiologie générale et en obstétrique et gynécologie (OBGYN), nous devons définir les besoins éducatifs du point de vue des résidents en cardiologie et en OBGYN. Notre étude caractérise les besoins éducatifs des résidents canadiens en cardiologie et en OBGYN. Méthodes: Les résidents canadiens en cardiologie et en OBGYN ont été interrogés sur leurs expositions cliniques, les besoins perçus et non perçus en matière de thématique à aborder (questions à choix multiples) et leurs préférences en matière de formats éducatifs. Les priorités élevées ont été définies comme représentant ≥ 50 % des réponses indiquant un besoin perçu ou ≥ 50 % indiquant un besoin non perçu. Résultats: Cent cinquante-quatre résidents ont participé (cardiologie n = 44, OBGYN n = 110). Les résidents ont signalé une exposition clinique insuffisante pour presque tous les troubles cardiaques, 33 % des expositions se produisant dans des contextes multidisciplinaires. Toutes les thématiques, à l'exception de l'hypertension gestationnelle, ont été jugées hautement prioritaires en ce qui concerne les besoins perçus par les deux spécialités. Les besoins non perçus comme hautement prioritaires comprenaient les cardiopathies congénitales (les deux spécialités), les cardiopathies acquises préexistantes (les deux spécialités), la sécurité des médicaments (OBGYN), la gestion du péripartum (OBGYN) et les cardiopathies liées à la grossesse (OBGYN). Les résidents en cardiologie et en OBGYN partageaient des préférences pour les simulations en personne, les simulations virtuelles et les modules de formation en ligne. Conclusions: Les résidents des deux spécialités ont rapporté une faible exposition clinique à la plupart des troubles cardiaques pendant la grossesse, ont identifié des besoins perçus comme hautement prioritaires dans plusieurs domaines, et ont partagé 2 besoins non perçus comme hautement prioritaires. Les résidents en OBGYN ont identifié 3 autres besoins non perçus comme hautement prioritaires. Ces données peuvent éclairer la conception de programmes d'études multidisciplinaires en cardio-obstétrique pour les résidents en cardiologie générale et en OBGYN.

Quarantining From Professional Identity: How Did COVID-19 Impact Professional Identity Formation in Undergraduate Medical Education?

Introduction: Professional Identity Formation (PIF) entails the integration of a profession's core values and beliefs with an individual's existing identity and values. Within undergraduate medical education (UGME), the cultivation of PIF is a key objective. The COVID-19 pandemic brought about substantial sociocultural challenges to UGME. Existing explorations into the repercussions of COVID-19 on PIF in UGME have predominantly adopted an individualistic approach. We sought to examine how the COVID-19 pandemic influenced PIF in UGME from a sociocultural perspective. This study aims to provide valuable insights for effectively nurturing PIF in future disruptive scenarios. Methods: Semi structured interviews were conducted with medical students from the graduating class of 2022 (n = 7) and class of 2023 (n = 13) on their medical education experiences during the pandemic and its impact on their PIF. We used the Transformation in Medical Education (TIME) framework to develop the interview guide. Direct content analysis was used for data analysis. Results: The COVID-19 pandemic significantly impacted the UGME experience, causing disruptions such as an abrupt shift to online learning, increased social isolation, and limited in-person opportunities. Medical students felt disconnected from peers, educators, and the clinical setting. In the clerkship stage, students recognized knowledge gaps, producing a "late blooming" effect. There was increased awareness for self-care and burnout prevention. Discussion: Our study suggests that pandemic disruptors delayed PIF owing largely to slower acquisition of skills/knowledge and impaired socialization with the medical community. This highlights the crucial role of sociocultural experiences in developing PIF in UGME. PIF is a dynamic and adaptable process that was preserved during the COVID-19 pandemic.

How do residents respond to uncertainty with peers and supervisors in multidisciplinary teams? Insights from simulations with epistemic fidelity.

BACKGROUND: Residents struggle to express clinical uncertainty, often exhibiting negative cognitive, behavioral, and emotional responses to uncertainty when engaging with patients or supervisors. However, the Integrative Model of Uncertainty Tolerance posits that individuals may have positive or negative responses to perceived uncertainty. Situational characteristics, such as interactions with other health professionals, can impact whether the response is positive or negative. The team context in which residents interact with resident peers and supervisors could represent varying situational characteristics that enable a spectrum of responses to uncertainty. Understanding the situational characteristics of multidisciplinary teams that allow residents to display positive responses to perceived uncertainty could inform strategies to foster positive responses to uncertainty in other contexts. We explored resident responses to perceived uncertainty in a simulated multidisciplinary team context. METHODS: A simulation-primed qualitative inquiry approach was used. Fourteen residents from Cardiology and Obstetrics and Gynecology participated in simulation scenarios involving pregnant patients with heart disease. We incorporated epistemic fidelity through the deliberate inclusion of ambiguity and complexity to prompt uncertainty. Audio recordings of debriefing sessions were analyzed using directed content analysis. RESULTS: Residents recognized that uncertainty is unavoidable, and positive responses to uncertainty are crucial to team dynamics and patient safety. While residents had positive responses to expressing uncertainty to peers, they had predominantly negative responses to expressing uncertainty to supervisors. Predominant negative response to supervisors related to judgement from supervisors, and impacts on perceived trustworthiness or independence. Although residents recognized expressing uncertainty to a supervisor could identify opportunities for learning and resolve their uncertainty, the negative responses overshadowed the positive responses. Residents highly valued instances in which supervisors were forthcoming about their own uncertainty. CONCLUSIONS: Through participation in simulations with epistemic fidelity, residents reflected on how they perceive and respond to uncertainty in multidisciplinary teams. Our findings emphasize the role of situational characteristics, particularly peers and supervisors, in moderating responses to perceived uncertainty. The productive discussions around responses to uncertainty in debriefing sessions suggest further studies of multidisciplinary simulations could enhance our understanding of how uncertainty is expressed, and potentially be used as an instructional intervention to promote positive responses to uncertainty.

Trainee selection of tasks in postgraduate medical education: Is there a role for 'cherry-picking' to optimise learning?

PURPOSE: Learning is optimised when postgraduate trainees engage in clinical tasks in their zone of proximal development (ZPD). However, workplace learning environments impose additional non-learning goals and additional tasks that may lead to trainees engaging in tasks that do not fall within their ZPD. We do not fully understand how trainees select clinical tasks in the workplace learning environment. If we knew the goals and factors they consider when selecting a task, we could better equip trainees with strategies to select tasks that maximise learning. We explored how postgraduate trainees select clinical tasks using echocardiography interpretation as a model. METHODS: Canadian General Cardiology residents and Echocardiography fellows were invited to participate in semi-structured interviews. Aligning with a theory-informed study, two independent researchers used a deductive, directed content analysis approach to identify codes and themes. RESULTS: Eleven trainees from seven Canadian universities participated (PGY4 = 4, PGY5 = 3, PGY6 = 1 and echocardiography fellows = 3). Goals included learning content, fulfilling assessment criteria and contributing to clinical demands. Trainees switched between goals throughout the day, as it was too effortful for them to engage in tasks within their ZPD at all times. When trainees had sufficient mental effort available, they selected higher complexity tasks that could advance learning content. When available mental effort was low, trainees selected less complex tasks that fulfilled numerically based assessment goals or contributed to clinical demands. Trainees predominantly used perceived complexity of the echocardiogram as a factor to select tasks to achieve their desired goals. CONCLUSION: Postgraduate trainees select tasks within their ZPD that enable them to maximise learning when they perceive to have sufficient mental effort available and workplace affordances are adequate. These findings can inform individual and systemic strategies to maximise learning when selecting tasks.

Framing asynchronous interprofessional education: a qualitative study on medical, physiotherapy and nursing students.

Objectives: To explore how virtual, asynchronous modules can be used in interprofessional health education curricula and to identify any advantages and shortcomings of asynchronous interprofessional education. Methods: A sample of 27 health professional students who attended in-person interprofessional education workshops at the McMaster Centre for Simulation-Based Learning from 2019-2020 were recruited through email discourse. Participants were asked to complete an asynchronous interprofessional education module and take part in a semi-structured interview that was recorded and transcribed verbatim. Techniques of direct content analysis were used to analyze the qualitative data from recorded transcripts. Results: The following emergent themes from participants' responses were identified: 1) the modules, as well as the features interspersed throughout, taught strategies for conflict resolution and interprofessional communication, 2) the modules have utility in preparing students for future interprofessional learning, 3) the convenience of virtual asynchronous modules introduces a sense of learner safety, and 4) a sense of isolation and fatigue was identified as a consequence of the lack of face-to-face interaction in these modules. Conclusion: Asynchronous interprofessional education modules may be best suited to prepare students for future interprofessional learning in a synchronous setting. Asynchronous modules effectively provide an introduction to interprofessional objectives such as conflict resolution and role clarification, yet the competency of team functioning is more difficult to achieve in an asynchronous environment. Future studies may focus on establishing a sequence of completing asynchronous modules for ideal development of interprofessional competencies in health professions learners.

Cardiovascular events more than 6 months after pregnancy in patients with congenital heart disease.

OBJECTIVES: Patients with congenital heart disease (CHD) are increasingly pursuing pregnancy, highlighting the need for data on late cardiovascular events (more than 6 months after delivery). We aimed to determine the incidence of late cardiovascular events in postpartum patients with CHD and evaluate the accuracy of the existing risk scores in predicting these events. STUDY DESIGN: We identified patients with CHD who delivered between 2008 and 2020 at a tertiary centre and had follow-up data for greater than 6 months post partum. Late cardiovascular events were defined as heart failure, arrhythmia, thromboembolic events, endocarditis, urgent cardiovascular interventions or death. Survival analysis and Cox proportional model were used to estimate the incidence of late cardiovascular events and determine the hazard ratio of factors associated with these events. RESULTS: Of 117 patients, 19% had 36 late cardiovascular events over a median follow-up of 3.8 years. Annual incidence of any late cardiovascular event was 5.7%. Hazards of late cardiovascular events were significantly higher among those with higher Cardiac Disease in Pregnancy Study (CARPREG) II and Zwangerschap bij Aangeboren HARtAfwijking-Pregnancy in Women With Congenital Heart Disease (ZAHARA) risk scores and among patients with prepregnancy New York Heart Association class≥II. C-statistic to predict the late cardiovascular events was highest for ZAHARA (0.7823), followed by CARPREG II (0.6902) and prepregnancy New York Heart Association class≥ II (0.6677). CONCLUSIONS: Currently available risk tools designed for prognostication during the peripartum period can also be used to determine risks of late maternal cardiovascular events among those with CHD. These findings provide important new information for counselling and risk modification.

How workplace-based assessments guide learning in postgraduate education: A scoping review.

INTRODUCTION: Competency-based medical education (CBME) led to the widespread adoption of workplace-based assessment (WBA) with the promise of achieving assessment for learning. Despite this, studies have illustrated tensions between the summative and formative role of WBA which undermine learning goals. Models of workplace-based learning (WBL) provide insight, however, these models excluded WBA. This scoping review synthesizes the primary literature addressing the role of WBA to guide learning in postgraduate medical education, with the goal of identifying gaps to address in future studies. METHODS: The search was applied to OVID Medline, Web of Science, ERIC and CINAHL databases, articles up to September 2020 were included. Titles and abstracts were screened by two reviewers, followed by a full text review. Two members independently extracted and analysed quantitative and qualitative data using a descriptive-analytic technique rooted in Billett's four premises of WBL. Themes were synthesized and discussed until consensus. RESULTS: All 33 papers focused on the perception of learning through WBA. The majority applied qualitative methodology (70%), and 12 studies (36%) made explicit reference to theory. Aligning with Billett's first premise, results reinforce that learning always occurs in the workplace. WBA helped guide learning goals and enhanced feedback frequency and specificity. Billett's remaining premises provided an important lens to understand how tensions that existed in WBL have been exacerbated with frequent WBA. As individuals engage in both work and WBA, they are slowly transforming the workplace. Culture and context frame individual experiences and the perceived authenticity of WBA. Finally, individuals will have different goals, and learn different things, from the same experience. CONCLUSION: Analysing WBA literature through the lens of WBL theory allows us to reframe previously described tensions. We propose that future studies attend to learning theory, and demonstrate alignment with philosophical position, to advance our understanding of assessment-for-learning in the workplace.

Hyperpolarized 129Xe Pulmonary MRI and Asymptomatic Atrial Septal Defect.

In an asymptomatic 19-year-old who regularly underwent cardiopulmonary fitness testing for national lifeguard-accreditation, 129Xe MRI unexpectedly revealed an abnormally augmented RBC signal and RBC-to-alveolar-capillary-tissue ratio with spatially homogeneous ventilation, tissue barrier, and RBC images. Pulmonary function was normal, but cardiopulmonary follow-up including transthoracic and transesophageal echocardiogram, heart catheterization, and contrast-enhanced cardiac CT imaging led to the diagnosis of a large (20 × 27 mm) secundum atrial septal defect (ASD) with a net right-to-left shunt (Qp:Qs = 0.5) and normal pulmonary pressures. This novel, unexpected case revealed that 129Xe RBC signal intensity likely reflected erythrocytosis, compensatory to the abnormal cardiovascular hemodynamics that resulted from a large congenital ASD. Unlike ASD cases that present with dyspnea and exercise limitation, this 129Xe MRI abnormality was detected in an asymptomatic teenager. This is the first report of asymptomatic adult congenital heart disease diagnosed subsequent to novel 129Xe MRI that led to early intervention, avoiding long-term complications of cyanosis, including ventricular fibrosis and thromboembolic and bleeding risks.

A rare case of giant left circumflex coronary artery fistula to coronary sinus in patient with persistent left superior vena cava and bicuspid aortic valve.

A 61-year-old male presented with symptoms of decompensated heart failure and cardiogenic shock. Transthoracic and transesophageal echocardiography showed severely impaired left ventricular (LV) systolic function (LVEF of 20-25%), bicuspid aortic valve with moderate aortic insufficiency and no significant stenosis, dilated coronary sinus and a tortuous vascular structure in the left-sided atrioventricular groove. Cardiac computed tomography confirmed the diagnosis of persistent left superior vena cava and a giant coronary artery fistula to the coronary sinus. Cardiac magnetic resonance illustrated non-specific late gadolinium enhancement in the mid-wall of the septum. The patient was treated medically and with cardiac re-synchronization therapy.

Outcomes among adult survivors of total cavopulmonary Fontan palliation for single ventricle.

OBJECTIVE: This tertiary centre study aims to identify factors associated with adverse outcomes in adult survivors with total cavopulmonary connection (TCPC) Fontan palliation for single ventricle. METHODS: This retrospective review of medical records identified adult (≥18 years) survivors of TCPC Fontan palliation who were followed at a single tertiary centre between 1 January 2000 and 1 July 2019. Adverse outcomes were defined as arrhythmia, pacemaker/implantable cardioverter defibrillator placement, liver cirrhosis, protein losing enteropathy, hospitalisation for heart failure, thromboembolic complication and/or death. RESULTS: 160 adult TCPC patients met the inclusion criteria: 117 (73.1%) extracardiac and 43 (26.9%) lateral tunnel. The median (IQR) duration of follow-up since TCPC palliation was 17.5 (11.8-21.3) years. An adverse outcome occurred in 87 (54.4%) patients. Adverse outcome-free survival rates at 10, 20 and 25 years post TCPC were 89% (95% CI 82% to 93%), 60% (95% CI 50% to 69%) and 24% (95% CI 15% to 35%), respectively. On multivariate analysis, extracardiac Fontan (HR 2.21, 95% CI 1.20 to 4.08, p=0.011) was observed to be an independent risk factor for adverse outcomes after adjusting for age, race, morphology of the systemic ventricle and history of fenestration. CONCLUSIONS: In this single-centre retrospective study of adult survivors of TCPC palliation, extracardiac Fontan was associated with an increased hazard for adverse outcomes. This finding could guide clinicians in developing risk modification strategies and management decisions to improve long-term outcomes in these patients.

The critical role of direct observation in entrustment decisions.

BACKGROUND: Entrustment decisions may be retrospective (based on past experiences with a trainee) or real-time (based on direct observation). We investigated judgments of entrustment based on assessor prior knowledge of candidates and based on systematic direct observation, conducted in an objective structured clinical exam (OSCE). METHODS: Sixteen faculty examiners provided 287 retrospective and real-time entrustment ratings of 16 cardiology trainees during OSCE stations in 2019 and 2020. Reliability and validity of these ratings were assessed by comparing correlations across stations as a measure of reliability, differences across postgraduate years as an index of construct validity, correlation to standardized in-training exam (ITE) as a measure of criterion validity, and reclassification of entrustment as a measure of consequential validity. RESULTS: Both retrospective and real-time assessments were highly reliable (all intra-class correlations >0.86). Both increased with a year of postgraduate training. Real-time entrustment ratings were significantly correlated with standardized ITE scores; retrospective ratings were not. Real-time ratings explained 37% (2019) and 46% (2020) of variance in examination scores vs. 21% (2019) and 7% (2020) for retrospective ratings. Direct observation resulted in a different level of entrustment compared with retrospective ratings in 44% of cases (p = <0.001). CONCLUSIONS: Ratings based on direct observation made unique contributions to entrustment decisions.

CONTEXTE: La décision de confier une activité peut être rétrospective (basée sur les expériences antérieures avec un apprenant) ou en temps réel (basée sur l'observation directe). Nous avons étudié les évaluations de niveaux de confiance fondées sur des interactions antérieures des candidats par les évaluateurs et celles fondées sur l'observation directe systématique, dans le cadre d'un examen clinique objectif structuré (ECOS). MÉTHODES: Seize évaluateurs du corps professoral ont fourni 287 évaluations rétrospectives et en temps réel du niveau de confiance faites lors des stations d'ECOS en 2019 et 2020 concernant 16 stagiaires en cardiologie. La fiabilité et la validité de ces évaluations ont été analysées en comparant les corrélations entre les stations comme mesure de la fiabilité, les différences entre les années d'études postdoctorales comme indice de la validité de construit, la corrélation avec l'examen normalisé en cours de formation (ITE) comme mesure de la validité de critère, et le reclassement des évaluations de la confiance comme mesure de la validité corrélative. RÉSULTATS: Les évaluations rétrospectives et en temps réel étaient toutes les deux très fiables (toutes les corrélations intra-classes >0,86). Les deux augmentaient avec le niveau de formation postdoctorale. Les évaluations de la confiance en temps réel étaient significativement corrélées aux scores de l'examen normalisé en cours de formation; les évaluations rétrospectives ne l'étaient pas. Les évaluations en temps réel expliquaient 37 % (2019) et 46 % (2020) de la variance des notes d'examen, contre 21 % (2019) et 7 % (2020) pour les évaluations rétrospectives. L'observation directe a permis de reclasser 44 % des évaluations rétrospectives de la confiance (p=<0,001 dans les deux cas). CONCLUSION: Les évaluations basées sur l'observation directe contribuent de façon importante à la décision de confier une activité.

Race and Gender Bias in Internal Medicine Program Director Letters of Recommendation.

BACKGROUND: While program director (PD) letters of recommendation (LOR) are subject to bias, especially against those underrepresented in medicine, these letters are one of the most important factors in fellowship selection. Bias manifests in LOR in a number of ways, including biased use of agentic and communal terms, doubt raising language, and description of career trajectory. To reduce bias, specialty organizations have recommended standardized PD LOR. OBJECTIVE: This study examined PD LOR for applicants to a cardiology fellowship program to determine the mechanism of how bias is expressed and whether the 2017 Alliance for Academic Internal Medicine (AAIM) guidelines reduce bias. METHODS: Fifty-six LOR from applicants selected to interview at a cardiology fellowship during the 2019 and 2020 application cycles were selected using convenience sampling. LOR for underrepresented (Black, Latinx, women) and non-underrepresented applicants were analyzed using directed qualitative content analysis. Two coders used an iteratively refined codebook to code the transcripts. Data were analyzed using outputs from these codes, analytical memos were maintained, and themes summarized. RESULTS: With AAIM guidelines, there appeared to be reduced use of communal language for underrepresented applicants, which may represent less bias. However, in both LOR adherent and not adherent to the guidelines, underrepresented applicants were still more likely to be described using communal language, doubt raising language, and career trajectory bias. CONCLUSIONS: PDs used language in a biased way to describe underrepresented applicants in LOR. The AAIM guidelines reduced but did not eliminate this bias. We provide recommendations to PDs and the AAIM on how to continue to work to reduce this bias.