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.

Reducing the Environmental Impact of Health Care Conferences: A Study of Emissions and Practical Solutions.

PURPOSE: We aimed to examine the impact of different conference formats (in-person, virtual, and hybrid) of the ASCO conference on greenhouse gas (GHG) emissions and to recommend sustainable options for future conferences. MATERIALS AND METHODS: This study used data on the number of attendees, their departure locations, and the type of attendance (in-person v virtual) provided by ASCO between 2019 and 2022. The GHG emissions resulting from air and ground travel, remote connectivity, conference space utilization, hotel stays, distributed conference materials, and electricity use were estimated for each year. Emissions were stratified by attendee country of origin, type of attendance, and year. Simulations were conducted to evaluate how changes in conference size, location, and format impact emissions, as well as estimate the resulting mitigations from adopting the proposed changes. RESULTS: The highest estimated GHG emissions, calculated in carbon dioxide equivalents (CO2e), were associated with the 2019 in-person conference (37,251 metric tons of CO2e). Although international attendees had the largest contribution to emissions in all years (>50%), location optimization models, which selected conference locations that most minimized GHG emissions, yielded only minimal reductions (approximately 3%). Simulations examining changes to the conference format, location, and attendance percentage suggested that hub-and-spoke, where multiple conference locations are selected by global region, or hybrid models, with both in-person and virtual components, are likely to cause the largest drops in emissions (up to 86%). CONCLUSION: Using historical conference data, this study identifies key aspects that can be modified to reduce emissions and consequently promote more sustainable and equitable conference attendance. Hybrid conferences may be the best solution to maintain the networking opportunities provided by conferences while balancing out their environmental footprint.

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.

URM: Underrepresented or Underrecognized? A Case Study of Black Pediatric Critical Care Physicians.

PURPOSE: This study explored Black physicians' experience via an antideficit lens to gain new ideas for advancing minoritized physicians in academic medicine more broadly. Increasingly, systemic racism in academic medicine is intentionally acknowledged and named. However, many solutions to tackle racism and the overall paucity of Black physicians use a deficit framing, painting Black physicians and trainees as lacking preparation, interest, or experience and qualifications. Such solutions aim to help Black people assimilate into the "White Space" of academic medicine, rather than focusing on Black people's strengths. METHOD: This qualitative study included 15 Black physicians and trainees in pediatric critical care medicine (PCCM) from across the country who participated in semistructured interviews. Through an antideficit lens, the researchers examined the social, cultural, and structural contexts influencing the participants' individual experiences. They analyzed the data combining thematic and narrative qualitative analysis approaches, including restorying. RESULTS: The data help promote understanding of the landscape and context in which Black PCCM physicians become successful. Achievement took on different forms for the participants. Participants described enablers of achievement that supported them through their individual journeys spanning 3 general domains-intrinsic, interpersonal, and systemic. Three additional enablers were tied specifically to participants' Black identities-harnessing Blackness as a superpower, leaning in to lead, and successfully navigating the "unwritten rules." CONCLUSIONS: By using an antideficit framework, this study delineates and centers participants' ingenuity in cultivating repertoires of practice that enabled them to succeed, despite challenges rooted in systemic racism. Going forward, rather than focus solely on what is missing, academic medicine should try to shift systems and regularly recognize and value the knowledge, expertise, and merit Black that physicians bring. Perhaps an appropriate framing is not that Black physicians are underrepresented in medicine; maybe instead, it is that they are underrecognized.

Developing Evidence for Equitable Assessment Characteristics Based on Clinical Learner Preferences Using Discrete Choice Experiments.

PURPOSE: Medical education is only beginning to explore the factors that contribute to equitable assessment in clinical settings. Increasing knowledge about equitable assessment ensures a quality medical education experience that produces an excellent, diverse physician workforce equipped to address the health care disparities facing patients and communities. Through the lens of the Anti-Deficit Achievement framework, the authors aimed to obtain evidence for a model for equitable assessment in clinical training. METHOD: A discrete choice experiment approach was used which included an instrument with 6 attributes each at 2 levels to reveal learner preferences for the inclusion of each attribute in equitable assessment. Self-identified underrepresented in medicine (UIM) and not underrepresented in medicine (non-UIM) (N = 306) fourth-year medical students and senior residents in medicine, pediatrics, and surgery at 9 institutions across the United States completed the instrument. A mixed-effects logit model was used to determine attributes learners valued most. RESULTS: Participants valued the inclusion of all assessment attributes provided except for peer comparison. The most valued attribute of an equitable assessment was how learner identity, background, and trajectory were appreciated by clinical supervisors. The next most valued attributes were assessment of growth, supervisor bias training, narrative assessments, and assessment of learner's patient care, with participants willing to trade off any of the attributes to get several others. There were no significant differences in value placed on assessment attributes between UIM and non-UIM learners. Residents valued clinical supervisors valuing learner identity, background, and trajectory and clinical supervisor bias training more so than medical students. CONCLUSIONS: This study offers support for the components of an antideficit-focused model for equity in assessment and informs efforts to promote UIM learner success and guide equity, diversity, and inclusion initiatives in medical education.

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.

Student and Teacher Perspectives on Equity in Clinical Feedback: A Qualitative Study Using a Critical Race Theory Lens.

PURPOSE: The authors aimed to gain a better understanding of students' and teachers' perspectives about whether clinical clerkship feedback is provided equitably irrespective of a student's race/ethnicity. METHOD: A secondary analysis of existing interview data was conducted, focusing on racial/ethnic disparities in clinical grading. Data had been acquired from 29 students and 30 teachers at 3 U.S. medical schools. The authors performed secondary coding on all 59 transcripts, writing memos focused on statements related to aspects of feedback equity and developing a template for coding students' and teachers' observations and descriptions specific to clinical feedback. Using the template, memos were coded, and thematic categories emerged describing perspectives on clinical feedback. RESULTS: Forty-eight (22 teachers and 26 students) participants' transcripts provided narratives about feedback. Both student and teacher narratives described how students who are racially/ethnically underrepresented in medicine may receive less helpful formative clinical feedback needed for professional development. Thematic analysis of narratives yielded 3 themes related to feedback inequities: 1) teachers' racial/ethnic biases influence the feedback they provide students, 2) teachers have limited skill sets to provide equitable feedback, and 3) racial/ethnic inequities in the clinical learning environment shape clinical and feedback experiences. CONCLUSIONS: Narratives indicated that both students and teachers perceived racial/ethnic inequities in clinical feedback. Teacher- and learning environment-related factors influenced these racial/ethnic inequities. These results can inform medical education's efforts to mitigate biases in the learning environment and provide equitable feedback to ensure every student has what they need to develop into the competent physician they aspire to be.

Aspiring physicians program: description and characterization of the support processes for an undergraduate pathway program to medicine.

Latinx physician rates are lower than non-Latinx white physicians. Many pathway programs to careers in medicine have been established for underrepresented students, yet few focus on premedical college education or undergraduate pathway programs, which marks a critical junction in the commitment to and preparation for application to medical school. Moreover, little is known about the program components which prepare and support learners. Framed by Swail's Model for Persistence and Achievement, we characterize how a given program's components impact support and growth for participating students. Using the process step of the Context, Input, Process, and Product evaluation model, we conducted focus groups at the end of the program, with four cohorts of student participants between 2019 and 2022. Focus groups identified strengths and limitations in content and delivery to improve program effectiveness and plan for the future of a program. We used thematic analysis, following an inductive approach, to analyze data from transcribed focus groups. A total of 66 of 81 (81.5%) students participated in focus groups. Students described that supportive program components include long-term mentorship and advising that builds trust, academic preparation for medical school, early exposure to clinical career exploration, tools to articulate students' personal narrative, methods to recognize and address challenging situations in the professional environment, community leadership development, and leveraging health policy and advocacy to empower students to create systems change within communities. Our findings affirm and provide a needed account of program components known to be contributors to student success in undergraduate pathway programs. Our evaluation also characterizes additional supportive processes not discussed elsewhere. Our findings contribute to knowledge about development and implementation of undergraduate pathway programs and the components by which these programs create opportunities for success among underrepresented students aspiring to careers in medicine.

Identifying Value Factors in Institutional Leaders' Perspectives on Investing in Health Professions Educators.

Importance: Investing in educators, educational innovation, and scholarship is essential for excellence in health professions education and health care. Funds for education innovations and educator development remain at significant risk because they virtually never generate offsetting revenue. A broader shared framework is needed to determine the value of such investments. Objective: To explore the value factors using the value measurement methodology domains (individual, financial, operational, social or societal, strategic or political) that health professions leaders placed on educator investment programs, including intramural grants and endowed chairs. Design, Setting, and Participants: This qualitative study used semi-structured interviews with participants from an urban academic health professions institution and its affiliated systems that were conducted between June and September 2019 and were audio recorded and transcribed. Thematic analysis was used to identify themes with a constructivist orientation. Participants included 31 leaders at multiple levels of the organization (eg, deans, department chairs, and health system leaders) and with a range of experience. Individuals who did not respond initially were followed up with until a sufficient representation of leader roles was achieved. Main Outcomes and Measures: Outcomes include value factors defined by the leaders for educator investment programs across the 5 value measurement methodology domains: individual, financial, operational, social or societal, and strategic or political. Results: This study included 29 leaders (5 [17%] campus or university leaders; 3 [10%] health systems leaders; 6 [21%] health professions school leaders; 15 [52%] department leaders). They identified value factors across the 5 value measurement methods domains. Individual factors emphasized the impact on faculty career, stature, and personal and professional development. Financial factors included tangible support, the ability to attract additional resources, and the importance of these investments as a monetary input rather than output. Operational factors identified educational programs and faculty recruitment or retention. Social and societal factors showcased scholarship and dissemination benefits to the external community beyond the organization and to the internal community of faculty, learners, and patients. Strategic and political factors highlighted impact on culture and symbolism, innovation, and organizational success. Conclusions and Relevance: These findings suggest that health sciences and health system leaders find value in funding educator investment programs in multiple domains beyond direct financial return on investment. These value factors can inform program design and evaluation, effective feedback to leaders, and advocacy for future investments. This approach can be used by other institutions to identify context-specific value factors.

Faculty Development for Education for Sustainable Health Care: A University System-Wide Initiative to Transform Health Professional Education.

Health professionals (HPs) are increasingly called upon to care for patients experiencing the health impacts of climate change, while working in the high eco-footprint health care system, which is starting to embrace a culture of sustainability. HPs are uniquely positioned to drive health care culture toward ecological responsibility and, consequently, improve patient care, health equity, and public health. Education for sustainable health care (ESHC or ESH) is the first step in developing health care practitioners able to think critically about and act upon the health impacts of the climate crisis. University of California Education for Sustainable Healthcare (UC-ESH) Faculty Development Initiative was developed to address the following goals: educate faculty on eco-medical literacy, empower faculty to build community and lead ESH at their institutions, and expand coverage of ESH to reach students beyond those for whom sustainability is already a focus. The initiative provided training to faculty across health professions and 6 health science campuses to integrate ESH into their courses using the train-the-trainer model, key knowledge and pedagogical skills, and longitudinal guidance and networking opportunities. Using a survey, questionnaire, and interviews, the initiative was evaluated using the process/elements and product/outcomes steps of the Context, Input, Process, and Product evaluation model. The UC-ESH educated over 100 faculty members and led to ESH integration into 99 existing and new courses that subsequently reached over 7,000 learners. The UC-ESH increased empowerment, awareness, and knowledge about the climate crisis, and built an ESH community of practice. Initiative elements that contributed to these outcomes included engaging training; creation of supportive group dynamics; helpful resources and activities; ongoing support; and integration approaches to ESH. This university-system-wide initiative provides a transferable model to institutions, schools, and departments seeking to develop eco-medical literate faculty who educate their students about the climate, ecosystem, and health crisis.

Interview Without Harm: Reimagining Medical Training's Financially and Environmentally Costly Interview Practices.

The looming threat of climate change urgently calls for reimagining unsustainable systems and practices, including academia's culture of emissions-intensive travel. Given that medical educators are uniquely invested in the future of the trainees they represent, this reimagination can and should begin with medical education. Making significant reforms to the application process has historically been challenging, but the COVID-19 pandemic catalyzed an abrupt shift from in-person to virtual interviews for medical school, residency, and fellowship. Programs and applicants alike demonstrated resilience, innovation, and satisfaction in adapting to virtual interviews during 2 full application cycles. This restructuring has prompted consideration of the necessity of environmentally costly, expensive, and time-consuming cross-country travel for single-day interviews. However, evolving conversations about the future of medical training interviews have not prioritized environmental impact, despite the sizeable historical emissions generated by interview-related travel and the incompatibility between ecological damage and population health. Beyond environmental impact, virtual interviews are more equitable, with significantly fewer financial costs, and they are more efficient, requiring less time off from school or work. Many concerns associated with virtual interviews, including interview inflation and limited applicant exposure to programs and their surrounding areas, can be addressed via creative and structural solutions, such as interview caps and in-person second-look programs. The medical training interview process underwent a forced restructuring due to the unprecedented disruption caused by COVID-19. This moment presents a strategic inflection point for medical education leadership to build on the momentum and permanently transform the process by focusing on sustainability and equity.

The Clinical Microsystems Clerkship at University of California, San Francisco: Integrating Clinical Skills and Health Systems Improvement for Early Medical Students.

PROBLEM: Medical educators recognize that partnering actively with health system leaders closes significant health care experience, quality, and outcomes gaps. Medical schools have explored innovations training physicians to care for both individual patients and populations while improving systems of care. Yet, early medical student education fails to include systems improvement as foundational skills. When health systems science is taught, it is often separated from core clinical skills. APPROACH: The Clinical Microsystems Clerkship at the University of California, San Francisco School of Medicine, launched in 2016, integrates clinical skills training with health systems improvement from the start of medical school. Guided by communities of practice and workplace learning principles, it embeds first-year and second-year students in longitudinal clinical microsystems with physician coaches and interprofessional clinicians one day per week. Students learn medical history, physical examination, patient communication, interprofessional teamwork, and health systems improvement. Assessments include standardized patient examinations and improvement project reports. Program outcome measures include student satisfaction and attitudes, clinical skills performance, and evidence of systems improvement learning, including dissemination and scholarship. OUTCOMES: Students reported high satisfaction (first-year, 4.10; second-year, 4.29, on a scale of 1-5) and value (4.14) in their development as physicians. Clinical skills assessment accuracy was high (70%-96%). Guided by interprofessional clinicians across 15 departments, students completed 258 improvement projects in 3 health systems (academic, safety net, Veterans Affairs). Sample projects reduced disparities in hypertension, improved opiate safety, and decreased readmissions. Graduating students reported both clinical skills and health systems knowledge as important to physician success, patient experience, and clinical outcomes (4.73). Most graduates discussed their projects in residency applications (85%) and disseminated related papers and presentations (54%). NEXT STEPS: Integrating systems improvement, interprofessional teamwork, and clinical skills training can redefine early medical student education. Health system perspectives, long-term outcomes, and sustainability merit further exploration.

When students' words hurt: 12 tips for helping faculty receive and respond constructively to student evaluations of teaching.

Student evaluations of curricular experiences and instructors are employed by institutions to obtain feedback and guide improvement. However, to be effective, evaluations must prompt faculty action. Unfortunately, evaluative comments that engender strong reactions may undermine the process by hindering innovation and improvement steps. The literature suggests that faculty interpret evaluation feedback as a judgment not just on their teaching ability but on their personal and professional identity. In this context, critical evaluations, even when constructively worded, can result in disappointment, hurt, and shame. The COVID pandemic has challenged institutions and faculty to repeatedly adapt curricula and educational practices, heightening concerns for faculty burnout. In this context, the risk of 'words that hurt' is higher than ever. This article offers guidance for faculty and institutions to support effective responses to critical feedback and ameliorate counterproductive effects of learner evaluations.

"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.

How Should Health Systems Science Promote Health Systems' Sustainability?

An expanded sustainability framework for health systems science (HSS) could promote health systems' capacity to deliver efficient, effective care for patients and to care for the planet by decreasing emissions and solid waste while cutting costs. This framework aligns well with the HSS mission to reform curricula and practice and has direct implications for patient care and systems-based practice competency development. Training clinicians to think critically about health system function, resilience, and sustainability will help prepare trainees to lead, innovate, and transform current health systems to prioritize planetary health, resource stewardship, and patient outcomes in a circular supply chain with low emissions.

Racial/Ethnic Disparities in Clerkship Grading: Perspectives of Students and Teachers.

PURPOSE: Racial/ethnic disparities exist in clinical clerkship grading, yet little is known about medical student and faculty perspectives on why these disparities occur. This study explored what happens during clerkships that might explain grading disparities. METHOD: Medical students and clerkship teachers at 3 U.S. medical schools completed a demographic survey and semistructured interview. The constant comparative method was used to analyze transcripts by inductively developing codes; grouping codes in categories; and refining codes, descriptions, and group assignments to identify themes. Interpretations of and relationships among themes were iteratively discussed to develop a grounded theory. RESULTS: Fifty-nine participants (29 medical students, 30 teachers [28 clinical faculty, 2 residents]) were interviewed in 2020. The Social Milieu of Medical Education (relationships, fit, opportunities, and judgments in the clinical-learning setting) was the organizing theme, influenced by 5 additional themes: Societal Influence (experiences in society), Students' Characteristics and Background (personal characteristics and experiences outside medical school), Assessment Processes (collection of student performance data and how data inform grades), Learning Environment (resources available and messaging within the clinical setting), and Students' Interactions and Reactions (interactions with and reactions to peers and teachers). The grounded theory highlights complex, multilayered aspects of how the social milieu of medical education is shaped by and shapes students' experiences, relationships, and clerkship assessments and promotes clerkship-grading disparities. CONCLUSIONS: Mitigating clerkship-grading disparities will require intervening on interrelated, contextual factors to provide equitable opportunities for students from diverse backgrounds and with varying styles of engagement in clinical-learning settings, along with attending to modifying assessment processes.