The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) Fellowship, a Novel Training Program in Public Health for Infectious Diseases Physicians.

The severe acute respiratory syndrome coronavirus 2 pandemic demonstrated a critical need for partnerships between practicing infectious diseases (ID) physicians and public health departments. The soon-to-launch combined ID and Epidemic Intelligence Service fellowship can only address a fraction of this need, and otherwise US ID training lacks development pathways for physicians aiming to make careers working with public health departments. The Leaders in Epidemiology, Antimicrobial Stewardship, and Public Health (LEAP) fellowship is a model compatible with the current training paradigm with a proven track record of developing careers of long-term collaboration. Established in 2017 by the ID Society of America, Society for Healthcare Epidemiology of America, Pediatric ID Society, and supported by the Centers for Disease Control and Prevention, LEAP is a single-year in-place, structured training for senior trainees and early career ID physicians. In this viewpoint, we describe the LEAP fellowship, its outcomes, and how it could be adapted into ID training.

The mitigated carbon emissions of transitioning to virtual medical school and residency interviews: A survey-based study.

PURPOSE: Prior to COVID, thousands of medical school and residency applicants traversed their countries for in-person interviews each year. However, data on the greenhouse gas emissions from in-person interviews is limited. This study estimated greenhouse gas emissions associated with in-person medical school and residency interviews and explored applicant interview structure preferences. METHODS: From March to June 2022, we developed and distributed a nine-question, website-based survey to collect information on applicant virtual interview schedule, demographics and preference for future interview format. We calculated theoretical emissions for all interviews requiring air travel and performed a content analysis of interview preference explanations. RESULTS: We received responses from 258 first-year and 253 fourth-year medical students at 26 allopathic US medical schools who interviewed virtually in 2020-2021 and 2021-2022, respectively. Residency applicants participating in the study were interviewed at a mean of 15.3 programs (SD 5.4) and had mean theoretical emissions of 4.31 tons CO2 eq. Medical school applicants participating in the study were interviewed at a mean of 6.9 programs and had mean theoretical emissions of 2.19 tons CO2 eq. Ninety percent of medical school applicants and 91% of residency applicants participating in the study expressed a preference for hybrid or virtual interviews going forward. CONCLUSION: In-person medical training interviews have significant greenhouse gas emissions. Virtual and hybrid alternatives have a high degree of acceptability among applicants.

A multi-residency elective to address well-being as a systems issue.

WHAT WAS THE EDUCATIONAL CHALLENGE?: Burnout is a well-established issue in medical training, but optimal systems approaches for well-being and ways to engage residents in well-being work are unknown. WHAT WAS THE SOLUTION?: The authors developed a multi-residency well-being elective with participants from internal medicine, anesthesiology, and urology residency programs. The elective included an asynchronous learning curriculum, a mentored independent project on system drivers of well-being, and participation in a cross-residency group that set elective priorities. HOW WAS THE SOLUTION IMPLEMENTED?: The authors worked with each residency's leadership to protect time for participation. Concepts from Quality Improvement were used to structure the elective. Project work and resident participation were assessed continually to monitor engagement. WHAT LESSONS WERE LEARNED THAT ARE RELEVANT TO A WIDER GLOBAL AUDIENCE?: Projects led to short- and long-term changes to support well-being in residency programs. Creating opportunities for residents from different specialties to discuss well-being work allowed ideas to spread across residencies. Protecting time to work on well-being issues may enhance a culture of well-being by demonstrating commitment to well-being as a priority equivalent to other educational endeavors. WHAT ARE NEXT STEPS?: Further research is needed to assess the impact on resident participants and to understand how to optimally incorporate resident interventions into broader organizational strategies for well-being.

Academic Leadership Academy Summer Program: Clerkship Transition Preparation for Underrepresented in Medicine Medical Students.

PROBLEM: Enhancing workforce diversity by increasing the recruitment of students who have been historically excluded/underrepresented in medicine (UIM) is critical to addressing healthcare inequities. However, these efforts are inadequate when undertaken without also supporting students' success. The transition to clerkships is an important and often difficult to navigate inflection point in medical training where attention to the specific needs of UIM students is critical. INTERVENTION: We describe the design, delivery, and three-year evaluation outcomes of a strengths-based program for UIM second year medical students. The program emphasizes three content areas: clinical presentations/clinical reasoning, community building, and surfacing the hidden curriculum. Students are taught and mentored by faculty, residents, and senior students from UIM backgrounds, creating a supportive space for learning. CONTEXT: The program is offered to all UIM medical students; the centerpiece of the program is an intensive four-day curriculum just before the start of students' second year. Program evaluation with participant focus groups utilized an anti-deficit approach by looking to students as experts in their own learning. During focus groups mid-way through clerkships, students reflected on the program and identified which elements were most helpful to their clerkship transition as well as areas for programmatic improvement. IMPACT: Students valued key clinical skills learning prior to clerkships, anticipatory guidance on the professional landscape, solidarity and learning with other UIM students and faculty, and the creation of a community of peers. Students noted increased confidence, self-efficacy and comfort when starting clerkships. LESSONS LEARNED: There is power in learning in a community connected by shared identities and grounded in the strengths of UIM learners, particularly when discussing aspects of the hidden curriculum in clerkships and sharing specific challenges and strategies for success relevant to UIM learners. We learned that while students found unique benefits to preparing for clerkships in a community of UIM students, near peers, and faculty, future programs could be enhanced by pairing this formal intensive curriculum with more longitudinal opportunities for community building, mentoring, and career guidance.

"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.

The Tea House Series: Striving Together to be Antiracist.

BACKGROUND: Though awareness of health care structures that are racist and oppressive is increasing among health care professionals, there is a gap in continuing education curricula focused on antiracist anti-oppressive practices, and limited faculty and staff development to guide individuals towards action. AIM: To develop, implement, and evaluate a novel antiracist faculty and staff development program called the Tea House Series. SETTING AND PARTICIPANTS: A five-part continuing education series with an accompanying online community for faculty and staff at the divisions of Hospital Medicine in one institution in the western United States. PROGRAM DESCRIPTION: The four foundational pillars integral to the Tea House Series were as follows: educational framework based on the pedagogy of Paulo Freire, local disparities data, welcoming space to establish a community of practice and accountability. Each session contained participant dialogue in small group activities. PROGRAM EVALUATION: Qualitative analysis of participant survey responses demonstrated transformation towards a hope to act with a sense of community. Quantitative analysis measured increased confidence for the program learning objectives. DISCUSSION: The Tea House Series may be used as a model for continuing education to provide the tools and the community to confront systems of racism and oppression in any institution.

Patient Advocacy Assessment in the Medicine Clerkship: A Qualitative Study of Definition, Context, and Impact.

BACKGROUND: Advocacy is a core value of the medical profession. However, patient advocacy (advocacy) is not uniformly assessed and there are no studies of the behaviors clinical supervisors consider when assessing advocacy. OBJECTIVE: To explore how medical students and supervisors characterize advocacy during an internal medicine clerkship, how assessment of advocacy impacted students and supervisors, and elements that support effective implementation of advocacy assessment. DESIGN: A constructivist qualitative paradigm was used to understand advocacy assessment from the perspectives of students and supervisors. PARTICIPANTS: Medical students who completed the internal medicine clerkship at UCSF during the 2018 and 2019 academic years and supervisors who evaluated students during this period. APPROACH: Supervisor comments from an advocacy assessment item in the medicine clerkship and transcripts of focus groups were used to explore which behaviors students and supervisors deem to be advocacy. Separate focus groups with both students and supervisors examined the impact that advocacy assessment had on students' and supervisors' perceptions of advocacy and what additional context was necessary to effectively implement advocacy assessment. KEY RESULTS: Students and supervisors define advocacy as identifying and addressing social determinants of health, recognizing and addressing patient wishes and concerns, navigating the health care system, conducting appropriate evaluation and treatment, and creating exceptional therapeutic alliances. Effective implementation of advocacy assessment requires the creation of non-hierarchical team environments, supervisor role modeling, and pairing assessment with teaching of advocacy skills. Inclusion of advocacy assessment reflects and dictates institutional priorities, shapes professional identity formation, and enhances advocacy skill development for students and their supervisors. CONCLUSIONS: Students and supervisors consider advocacy to be a variety of behaviors beyond identifying and addressing social determinants of health. Effectively implementing advocacy assessment shapes students' professional identity formation, underscoring the critical importance of formally focusing on this competency in the health professions education.

A is for advocacy: How introducing student advocacy assessment impacts longitudinal integrated clerkship students and clinical supervisors.

To improve health, physicians are increasingly called to advocate. Yet medical schools have only recently focused on health advocacy skill-building. Limited work to date addresses assessing medical student advocacy on behalf of patients. We describe how students and clinical supervisors (CS) in two urban longitudinal integrated clerkships (LIC) experience patient advocacy and how introducing a new advocacy assessment impacts them. Using a thematic approach, we analyzed transcripts of focus groups during 2018-2019. Seventeen of 24 (71%) students and 15 of 21 (71%) CS participated in the focus groups. We describe how students perceive their advocacy role as they accompany the patient, amplify their voice, and facilitate connection. The rationale for advocacy assessment includes that it (1) adds a novel dimension to the written and verbal assessment, (2) drives student learning, (3) aligns with the institutional goal to promote equity, and (4) impacts CS teaching and clinical practice. Challenges are the ambiguity of expectations, pressure to 'perform,' and a moral overlay to advocacy assessment. Findings demonstrate how educational alliances between students and CS and longitudinal relationships between LIC students and patients offer a constructive opportunity for advocacy assessment. We describe suggestions to hone and expand the reach of advocacy assessment.

Residents' Experiences of Negative Emotions toward Patients: Challenges to their Identities.

PhenomenonMedical learners are more likely than practicing physicians to experience negative emotions toward some patients whom they find challenging, and medical students experience such emotions related to their identity as learners. Little is known about experiences of residents, who are further along in their physician identity formation and have greater autonomy and competence. We explored and characterized how residents understand their experiences of the phenomenon of feeling negative emotions toward patients in relation to their identities as residents. Approach: In 2018, 305 final-year obstetrics and gynecology residents were invited to participate in interviews, which we conducted until reaching theoretical sufficiency. In semi-structured interviews conducted by phone, we probed interactions when residents felt negative emotions toward patients, including reasons for their feelings related to their professional identities, strategies, and curricular desires. The authors coded data and identified patterns using thematic analysis. Findings: Nineteen residents were interviewed by phone. Residents experienced negative emotions toward patients because of challenges to their identities as: physicians - wanting respect and specific unexpected patient behaviors; learners - desiring complete autonomy and experiencing challenges with attending physicians; teachers - wanting to be a role model and protect junior learners; and workers - trying to complete tasks. Among the strategies used to manage feelings toward patients, they struggled with "venting", or complaining about patients, which was not always helpful and residents recognized as perceived negatively by students. They desired curricular support for these interactions such as debriefs and other supported reflection, faculty modeling, and communication skills training. Insights: Like medical students and physicians in practice, residents experience negative emotions toward patients, often because of and made more difficult by their identities as physicians, learners, teachers, and workers. Educators should support residents' reflections about these interactions, model compassionate behavior when feeling challenged by patients, and address unhealthy coping strategies.

Human Immunodeficiency Virus Training Pathways in Residency: A National Survey of Curricula and Outcomes.

BACKGROUND: The Ending the HIV Epidemic initiative, which aims to decrease the annual incidence of HIV infections in the United States (US) by 90% over the next decade, will require growth of a limited HIV provider workforce. Existing HIV training pathways within Family Medicine (FM) and Internal Medicine (IM) residency programs may address the shortage of HIV medical providers, but their curricula and outcomes have not previously been assessed. METHODS: We identified HIV residency pathways via literature review, Internet search, and snowball sampling and designed a cross-sectional study of existing HIV pathways in the US. This survey of pathway directors included 33 quantitative items regarding pathway organization, curricular content, graduate outcomes, and challenges. We used descriptive statistics to summarize responses. RESULTS: Twenty-five residency programs with dedicated HIV pathways in the US were identified (14 FM and 11 IM), with most located in the West and Northeast. All 25 (100%) pathway directors completed the survey. Since 2006, a total of 228 residents (77 FM and 151 IM) have graduated from these HIV pathways. Ninety (39%) of 228 pathway graduates provide primary care to persons with HIV (PWH). CONCLUSIONS: HIV pathways are effective in graduating providers who can care for PWH, but generally are not located in nor do graduates practice in the geographic areas of highest need. Our findings can inform quality improvement for existing programs, development of new pathways, and workforce development strategies. Specifically, expanding pathways in regions of greatest need and incentivizing pathway graduates to work in these regions could augment the HIV workforce.

First year medical student perceptions of physician advocacy and advocacy as a core competency: A qualitative analysis.

PURPOSE: Medical societies have embraced advocacy as a core professional competency, but little is known about how entering medical students view physician advocacy. This study examined how first year medical students define advocacy, their motivations for and anticipated challenges to advocacy, and whether they believe advocacy should be a core competency. METHOD: This study used a qualitative content analysis approach to analyze first year medical student narrative responses about physician advocacy. The analysis included the written responses of 95% of the first-year medical students at the University of California, San Francisco (UCSF) School of Medicine during two academic years. RESULTS: Students shared consensus that physicians should advocate on behalf of their individual patients. Students had varying opinions on whether all physicians should engage in societal level advocacy and whether it should be a core competency in medical school. Students find several compelling reasons for physicians to engage in societal advocacy but nevertheless anticipate challenges to physician advocacy. CONCLUSION: Given increasing consensus that advocacy is a core competency of physicians, providing medical students the skills to successfully engage in advocacy is increasingly important. Any new mandatory curricula will need to focus on how to engage learners with varied views on advocacy.

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.

Integrating Concept Maps into a Medical Student Oncology Curriculum.

Expanding frontiers of knowledge have prompted medical schools to reconsider how best to promote learning in the face of information overload. Concept mapping (CM) promotes knowledge retention and integration. Students have perceived CM positively in prior studies, but the feasibility and utility of integrating CM into a medical student oncology curriculum as a learning and assessment tool have not been described. At the University of California, San Francisco, 152 medical students in a second-year hematology/oncology course produced concept maps about a single cancer type over 4 weeks. We collected student evaluations about CM. Two of three graders independently scored each map using a standard rubric. We compared CM scores with USMLE Step 1 scores and clerkship grades using regression. All students produced a concept map. Student perception was mixed, and students provided feedback to improve CM utility as a learning tool. Grading was feasible, and inter-rater reliability was high. CM scores did not predict USMLE Step 1 scores or clerkship grades. CM was feasible as a learning tool, and we present strategies based on student feedback and literature review to improve utility. CM was feasible and reliable as an assessment tool; additional validity evidence may improve utility. Future studies should explore whether CM integrated into medical student oncology curricula early, serially, and collaboratively, with iterative practice and feedback, may predict meaningful learning and performance outcomes.

Faculty development and partnership with students to integrate sustainable healthcare into health professions education.

There is an urgent need for health professionals to address the impacts of accelerating global environmental change. Healthcare faculty therefore have to educate the rising generation of health professionals in subjects unfamiliar to themselves, such as planetary health and sustainable healthcare. This creates a new paradigm where faculty have to learn a new subject area and incorporate and teach it within their own material. It is important to develop faculty knowledge and confidence to integrate education for sustainable healthcare into their educational practice, as faculty can rapidly acquire and build on these skills. Partnership between students and faculty can enhance this faculty development as students bring fresh ideas and possibly greater knowledge of the climate and ecological crisis. Under supervision, they can co-create the necessary new learning. Students can also act as partners in advocating for social and environmental fairness and systemic change toward a sustainable healthcare system. We summarize the impact of various activities of health professions students around the world which advocate for institutional change and enhance faculty development in education for sustainable healthcare. Through diverse case studies from different countries, we illustrate faculty development in education for sustainable healthcare, highlighting student involvement which has enhanced educators' learning.

How to identify, address and report students' unprofessional behaviour in medical school.

This AMEE guide provides a research overview of the identification of, and responding to unprofessional behaviour in medical students. It is directed towards medical educators in preclinical and clinical undergraduate medical education. It aims to describe, clarify and categorize different types of unprofessional behaviours, highlighting students' unprofessional behaviour profiles and what they mean for further guidance. This facilitates identification, addressing, reporting and remediation of different types of unprofessional behaviour in different types of students in undergraduate medical education. Professionalism, professional behaviour and professional identity formation are three different viewpoints in medical education and research. Teaching and assessing professionalism, promoting professional identity formation, is the positive approach. An inevitable consequence is that teachers sometimes are confronted with unprofessional behaviour. When this happens, a complementary approach is needed. How to effectively respond to unprofessional behaviour deserves our attention, owing to the amount of time, effort and resources spent by teachers in managing unprofessional behaviour of medical students. Clinical and medical educators find it hard to address unprofessional behaviour and turn toward refraining from handling it, thus leading to the 'failure to fail' phenomenon. Finding the ways to describe and categorize observed unprofessional behaviour of students encourages teachers to take the appropriate actions.

Developing a two-dimensional model of unprofessional behaviour profiles in medical students.

Standardized narratives or profiles can facilitate identification of poor professional behaviour of medical students. If unprofessional behaviour is identified, educators can help the student to improve their professional performance. In an earlier study, based on opinions of frontline teachers from one institution, the authors identified three profiles of medical students' unprofessional behaviour: (1) Poor reliability, (2) Poor reliability and poor insight, and (3) Poor reliability, poor insight and poor adaptability. The distinguishing variable was Capacity for self-reflection and adaptability. The current study used Nominal Group Technique and thematic analysis to refine these findings by synthesizing experts' opinions from different medical schools, aiming to develop a model of unprofessional behaviour profiles in medical students. Thirty-one experienced faculty, purposively sampled for knowledge and experience in teaching and evaluation of professionalism, participated in five meetings at five medical schools in the Netherlands. In each group, participants generated ideas, discussed them, and independently ranked these ideas by allocating points to them. Experts suggested ten different ideas, from which the top 3 received 60% of all ranking points: (1) Reflectiveness and adaptability are two distinct distinguishing variables (25%), (2) The term reliability is too narrow to describe unprofessional behaviour (22%), and (3) Profiles are dynamic over time (12%). Incorporating these ideas yielded a model consisting of four profiles of medical students' unprofessional behaviour (accidental behaviour, struggling behaviour, gaming-the-system behaviour and disavowing behaviour) and two distinguishing variables (reflectiveness and adaptability). The findings could advance educators' insight into students' unprofessional behaviour, and provide information for future research on professionalism remediation.

Characterizations of motivation and identity in medical students' reflections about challenging patient interactions.

Purpose: Students' negative emotions in patient interactions can relate to their learning motivation and identity. Educators can support learning from these interactions by advocating for reflection. We explored how students, in reflection essays about emotionally difficult patient interactions that challenged their notions of professionalism, described aspects of motivation and identity. Materials and Methods: All third-year medical students on the ob-gyn clerkship complete written reflections about a "clinical situation that challenged or affirmed your professionalism." We conducted directed content analysis of essays (academic years 2014-2017) using relevant theories (self-determination, goal orientation and identity formation) based on previous work and organized the data into categories. Results: In 265 essays (of 396, 67%), students described patient interactions that challenged their notions of professionalism, of which 90% included descriptions of their emotions. When reflecting on these interactions, students described psychological needs acknowledged in self-determination theory, competence, autonomy in patient care and connection to the team. Students indicated challenges in identity when advocating for patients due to team hierarchy and evaluation concerns. Conclusions: Reflection essays about difficult patient interactions allow students to explore emotions, motivation and identity. They help educators understand whether the clinical learning environment is meeting students' needs to support learning in challenging interactions.

What Do Medical Students Do and Want When Caring for "Difficult Patients"?

Phenomenon: Medical students, like physicians, experience negative emotions such as frustration when interacting with some patients, and many of these interactions occur for the first time during clinical clerkships. Students receive preclinical training in the social and behavioral sciences, often including learning about "difficult patient" interactions, yet little is known about their desire for training during clinical education. We explored students' strategies in these difficult clinical interactions, whether they felt prepared by the curriculum, and what support they would have liked. These data inform proposed strategies for supporting clinical learning. Approach: We interviewed 4th-year students about interactions with patients toward whom they felt negative emotions and sought to identify strategies and supports needed in these interactions. Interviews ended when theoretical sufficiency was achieved. We used qualitative content analysis to organize strategies into themes about areas benefiting from curricular supports. We mapped students' desired curricular support examples to cognitive apprenticeship teaching methods-modeling, coaching, reflection, scaffolding, exploration, and articulation-and aligned them with traditional pedagogical techniques. Findings: We interviewed 26 medical students (44 volunteered/180 invited). Their strategies formed five themes: finding empathy (with a subtheme of focusing on social determinants of health), using learned communication approaches, anticipating challenging interactions, seeking support, and considering it an opportunity for more responsibility. Students described ideal clinical teaching, including postinteraction debriefs with an emphasis on validating their emotional reactions and challenges. Students mentioned all cognitive apprenticeship teaching methods, most prominently modeling (observing supervisors in such interactions) and supported oral reflection. They also identified a need for faculty and resident development to enact these teaching methods. Insights: Although students use some learned strategies in interactions in which they feel negative emotions toward patients, they desire more preparation and support during their clinical rotations. Their desires map to traditional pedagogical techniques and to methods of cognitive apprenticeship. Our findings point to the need to use these techniques to enhance clinical learning for students who experience emotionally challenging patient interactions.

Investigating US medical students' motivation to respond to lapses in professionalism.

CONTEXT: As unprofessional behaviour in physicians can compromise patient safety, all physicians should be willing and able to respond to lapses in professionalism. Although students endorse an obligation to respond to lapses, they experience difficulties in doing so. If medical educators knew how students respond and why they choose certain responses, they could support students in responding appropriately. OBJECTIVES: The aim of this study was to describe medical students' responses to professionalism lapses in peers and faculty staff, and to understand students' motivation for responding or not responding. METHODS: We conducted an explorative, qualitative study using template analysis, in which three researchers independently coded transcripts of semi-structured, face-to-face interviews. We purposefully sampled 18 student representatives convening at a medical education conference. Preliminary open coding of a data subset yielded an initial template, which was applied to further data and modified as necessary. All transcripts were coded using the final template. Finally, three sensitising concepts from the Expectancy-Value-Cost model were used to map participants' responses. RESULTS: Students mentioned having observed lapses in professionalism in both faculty staff and peers. Students' responses to these lapses were avoiding, addressing, reporting or initiating policy change. Generally, students were not motivated to respond if they did not know how to respond, if they believed responding was futile and if they feared retaliation. Students were motivated to respond if they were personally affected, if they perceived the individual as approachable and if they thought that the whole group of students could benefit from their actions. Expectancy of success, value and costs each appeared to be influenced by (inter)personal and system factors. CONCLUSIONS: The Expectancy-Value-Cost model effectively explains students' motivation for responding to lapses. The (inter)personal and system factors influencing students' motivation to respond are modifiable and can be used by medical educators to enhance students' motivation to respond to lapses in professionalism observed in medical school.