Civilian and Military Medical School Graduates' Readiness for Deployment: Areas of Strength and Opportunities for Growth.

INTRODUCTION: Past research has examined civilian and military medical schools' preparation of physicians for their first deployment. Most recently, our research team conducted a large-scale survey comparing physicians' perceptions of their readiness for their first deployment. Our results revealed that military medical school graduates felt significantly more prepared for deployment by medical school than civilian medical school graduates. In order to further investigate these results and deepen our understanding of the two pathways' preparation of military physicians, this study analyzed the open-ended responses in the survey using a qualitative research design. MATERIALS AND METHODS: We used a descriptive phenomenological design to analyze 451 participants' open-ended responses on the survey. After becoming familiar with the data, we coded the participants' responses for meaningful statements. We organized these codes into major categories, which became the themes of our study. Finally, we labeled each of these themes to reflect the participants' perceptions of how medical school prepared them for deployment. RESULTS: Four themes emerged from our data analysis: (1) Civilian medical school equipped graduates with soft skills and medical knowledge for their first deployment; (2) Civilian medical school may not have adequately prepared graduates to practice medicine in an austere environment to include the officership challenges of deployment; (3) Military medical school prepared graduates to navigate the medical practice and operational aspects of their first deployment; and (4) Military medical school may not have adequately prepared graduates for the realism of their first deployment. CONCLUSIONS: Our study provided insight into the strengths and areas for growth in each medical school pathway for military medical officers. These results may be used to enhance military medical training regardless of accession pathway and increase the readiness of military physicians for future large-scale conflicts.

Priority Competencies for Designated Education Officers in the Veterans Health Administration.

INTRODUCTION: Designated Education Officers (DEOs) at Veteran Health Administration (VHA) hospitals are senior educational leaders tasked with oversight of all clinical training at a particular facility. They prioritize dozens of tasks and responsibilities each day, from educational policy and strategy to staff management, financial planning, onboarding of trainees, and facility planning and management. Clarifying priority competencies for the role can help executives recruit, appoint, and evaluate capable personnel and promote effective, efficient performance. MATERIALS AND METHODS: Using a federally developed method of competency analysis, researchers consulted a panel of subject-matter experts to identify priority competencies for DEOs, using data from a 2013 study that operationalizes competencies for more than 200 federal jobs. RESULTS: The research identified 25 primary competencies within 6 leadership domains. Five of the primary competencies cut across all leadership domains. CONCLUSIONS: Veteran Health Administration subject-matter experts in educational leadership say the identified competencies are urgently needed, critical for effective leadership, and valuable for distinguishing superior DEO performance. The competencies are relevant to VHA and perhaps other senior academic leaders who develop health professions education programs, oversee clinical training, and manage educational change. In military training facilities, attending to these competencies can help Designated Institutional Officials responsible for graduate medical education become more credible partners to other hospital leaders and contribute to becoming a high reliability organization. Executives identifying, recruiting, and appointing VHA DEOs and Designated Institutional Officials at military training facilities should consider these competencies when assessing candidates.

Physician educators' perceptions of experiences contributing to teaching.

INTRODUCTION: Physician educators are essential in training the next generation of physicians. However, physician educators' perspectives about what experiences they find beneficial to their teaching and the prevalence of these experiences remain unknown. Guided by social cognitive career theory (SCCT) and communities of practice (CoP), we explored what experiences physician educators perceive as beneficial in preparing them to teach. METHODS: In 2019, the Uniformed Services University School of Medicine in the United States surveyed its physician alumni to understand their education experiences during medical school, their current career path and what has contributed to their teaching role. Content analysis was applied to extract themes across the text response. Chi-square analysis was applied to examine if perceived contributing factors vary based on physician educators' gender, specialty and academic ranks. RESULTS: The five most prevalent contributing factors participants (n = 781) identified are (1) experiences gained during residency and fellowship (29.8%), (2) teaching as faculty member (28.9%) and (3) class experiences and peer interaction during medical school (26%). We organised three themes that reflected major avenues of how physician educators acquire teaching skills: reflection about quality teaching, journey as learners and learning by doing. Gender and clinical specialty were differentially associated with contributing factors such as faculty development and meta-reflection. CONCLUSION: The results are in line with theories of SCCT and CoP, in which we identified self-directed learning and regulation in shaping physician educators' teaching. The findings also revealed gaps and potential contexts for more formalised teaching practices to develop physician educators.

Assessment of management reasoning: Design considerations drawn from analysis of simulated outpatient encounters.

PURPOSE: Management reasoning is a distinct subset of clinical reasoning. We sought to explore features to be considered when designing assessments of management reasoning. METHODS: This is a hybrid empirical research study, narrative review, and expert perspective. In 2021, we reviewed and discussed 10 videos of simulated (staged) physician-patient encounters, actively seeking actions that offered insights into assessment of management reasoning. We analyzed our own observations in conjunction with literature on clinical reasoning assessment, using a constant comparative qualitative approach. RESULTS: Distinguishing features of management reasoning that will influence its assessment include management scripts, shared decision-making, process knowledge, illness-specific knowledge, and tailoring of the encounter and management plan. Performance domains that merit special consideration include communication, integration of patient preferences, adherence to the management script, and prognostication. Additional facets of encounter variation include the clinical problem, clinical and nonclinical patient characteristics (including preferences, values, and resources), team/system characteristics, and encounter features. We cataloged several relevant assessment approaches including written/computer-based, simulation-based, and workplace-based modalities, and a variety of novel response formats. CONCLUSIONS: Assessment of management reasoning could be improved with attention to the performance domains, facets of variation, and variety of approaches herein identified.

Exploring sleep duration and clinical reasoning process in resident physicians: a thematic analysis.

STUDY OBJECTIVES: Connecting resident physician work hours and sleep deprivation to adverse outcomes has been difficult. Our study explores clinical reasoning rather than outcomes. Diagnostic errors are a leading cause of medical error and may result from deficits in clinical reasoning. We used simulated cases to explore relationships between sleep duration and diagnostic reasoning. METHODS: Residents were recruited for a 2-month study (inpatient/outpatient). Each participant's sleep was tracked (sleep diary/actigraphy). At the end of each month, residents watched two brief simulated clinical encounters and performed "think alouds" of their clinical reasoning. In each session, one video was straightforward, and the other video contained distracting contextual factors. Sessions were recorded, transcribed, and interpreted. We conducted a thematic analysis using a constant comparative approach. Themes were compared based on sleep duration and contextual factors. RESULTS: Residents (n=17) slept more during outpatient compared to inpatient months (450.5±7.13 v 425.6±10.78, p=0.02). We found the following diagnostic reasoning themes: uncertainty, disorganized knowledge, error, semantic incompetence, emotional content, and organized knowledge. Themes reflecting suboptimal clinical reasoning (disorganized knowledge, error, semantic incompetence, uncertainty) were observed more in cases with contextual factors (distractors). "Think alouds" from cases with contextual factors following sleep restriction had a greater number of themes concerning for problematic diagnostic reasoning. CONCLUSIONS: Residents obtained significantly more sleep during outpatient compared to inpatient months. Several negative clinical reasoning themes emerged with less sleep combined with cases containing contextual distractors. Our findings reinforce the importance of adequate sleep and supervision in house officers, particularly in cases with distracting elements.

Physiologic measurements of cognitive load in clinical reasoning.

OBJECTIVES: Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as heart rate variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress. METHODS: Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level. RESULTS: Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen's d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [-0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation -0.446; 95 % CI [-0.720, -0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation -0.845; 95 % CI [-0.990, 0.147]). CONCLUSIONS: Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.

In Search of a "Metric System" for Measuring Faculty Effort: A Qualitative Study on Educational Value Units at U.S. Medical Schools.

PURPOSE: Faculty at academic health centers (AHCs) are charged with engaging in educational activities. Some faculty have developed educational value units (EVUs) to track the time and effort dedicated to these activities. Although several AHCs have adopted EVUs, there is limited description of how AHCs engage with EVU development and implementation. This study aimed to understand the collective experiences of AHCs with EVUs to illuminate benefits and barriers to their development, use, and sustainability. METHOD: Eleven faculty members based at 10 AHCs were interviewed between July and November 2022 to understand their experiences developing and implementing EVUs. Participants were asked to describe their experiences with EVUs and to reflect on benefits and barriers to their development, use, and sustainability. Transcripts were analyzed using thematic analysis. RESULTS: EVU initiatives have been designed and implemented in a variety of ways, with no AHCs engaging alike. Despite differences, the authors identified shared themes that highlighted benefits and barriers to EVU development and implementation. Within and between these themes, a series of tensions were identified in conjunction with the ways in which AHCs attempted to mitigate them. Related to barriers, the majority of participants abandoned or paused their EVU initiatives; however, no differences were identified between those AHCs that retained EVUs and those that did not. CONCLUSIONS: The collective themes identified suggest that AHCs implementing or sustaining an EVU initiative would need to balance benefits and barriers in light of their unique context. Study findings align with reviews on EVUs and provide additional nuance related to faculty motivation to engage in education and the difficulties of defining EVUs. The lack of differences observed between those AHCs that retained EVUs and those that did not suggests that EVUs may be challenging to implement because of the complexity of AHCs and their faculty.

Striking up a Conversation: Exploring Advising in Graduate Programs in Health Professions Education.

INTRODUCTION: Advising is happening across the medical education continuum, within non-medical graduate education programs, and is central to the advancement of said learners. This suggests that advising should play a role in graduate health progressions education (HPE) programs. MATERIALS AND METHODS: To explore advising curricula among HPE programs, we conducted a website review of all published HPE programs on the Foundation for Advancement of International Medical Education and Research's website. RESULTS: We recognized the lack of information published on advisory roles in graduate HPE programs. This prompted a literature review, which revealed a similar gap. CONCLUSIONS: Advising serves to benefit a student, advisor, and program thus carrying importance and need for discussion. This article is intended to kick-start a scholarly discussion about advising within graduate HPE programs.

Masters in health professions education programs as they choose to represent themselves: A website review.

Introduction: In an age of increasingly face-to-face, blended, and online Health Professions Education, students have more choices of institutions at which to study their degree. For an applicant, oftentimes, the first step is to learn more about a program through its website. Websites allow programs to convey their unique voice and to share their mission and values with others such as applicants, researchers, and academics. Additionally, as the number of master in health professions education (MHPE), or equivalent, programs rapidly grows, websites can share the priorities of these programs. Methods: In this study, we conducted a website review of 158 MHPE websites to explore their geographical distributions, missions, educational concentrations, and various programmatic components. Results: We compiled this information and synthesized pertinent aspects, such as program similarities and differences, or highlighted the omission of critical data. Conclusions: Given that websites are often the first point of contact for prospective applicants, curious collaborators, and potential faculty, the digital image of MHPE programs matters. We believe our findings demonstrate opportunities for growth within institutions and assist the field in identifying the priorities of MHPE programs. As programs begin to shape their websites with more intentionality, they can reflect their relative divergence/convergence compared to other programs as they see fit and, therefore, attract individuals to best match this identity. Periodic reviews of the breadth of programs, such as those undergone here, are necessary to capture diversifying goals, and serves to help advance the field of MHPE as a whole.

Exploring Impostor Phenomenon During Onboarding Into a Military Medical School.

INTRODUCTION: Impostor phenomenon (IP) is an experience where an individual believes that their success was because of chance or luck and was not associated with the mastery of skills. There is a gap in the literature in understanding what role, if any, onboarding (e.g., orientation weeks) into a military medical school plays into student experiences with IP. For many, onboarding serves as the first exposure to the climate, culture, and learning environment of both medical school and the military. Prevention, or early intervention, of IP may reduce potential effects on a medical trainee's confidence and competence in their profession, which may ultimately enhance health care team performance and impact patient outcomes. This study explores if and why military medical students experience IP during a 2-week-long orientation into a military medical school. MATERIALS AND METHODS: The study participants were medical students at a military medical school. Researchers conducted semi-structured interviews in August 2022 to explore if and why students experienced IP and deployed the Clance IP Scale as a measure with validity evidence for ascertaining the presence and magnitude of IP. Researchers calculated total scores from the Clance IP Scale and thematically analyzed interview transcripts. RESULTS: Researchers interviewed 29 matriculating military medical students. Twenty-one (75%) students reported frequent or intense IP experiences on the Clance IP Scale indicating that IP was present in our study sample. Thematic analysis identified six themes that drove one's experience with IP: reevaluation of merit, individualized diversity and inclusion experiences, administrative and financial support, preconceived expectations, building relationships, and new community roles. CONCLUSIONS: Our identified themes provide us with a better understanding of if and why military medical students experience IP during onboarding. Our findings are also consistent with the situated learning theory, which places emphasis on the sense of belonging and may provide a unique and insightful lens through which IP can be further explored and studied, particularly at a military medical school where various identities, dynamics, and aspirations can converge simultaneously. Additionally, our findings suggest that existing practices may benefit from a number of improvements including, but not limited to, tailoring onboarding activities to entail more reflective discussion using small groups, especially for topics related to diversity and inclusion, revisiting areas where students may feel inadequately prepared to transition and perform well in a medical school, reevaluating administrative and financial support that can be roadblocks to a student's transition into the new environment and removing these barriers, and ensuring cultural coherence (organizational alignment of vision and mission) among faculty, staff, and upperclassmen. Future research directions include better understanding how developing single or multiple, identities can impact a medical students' experience with IP during onboarding, pre-clerkship, clerkship, or post-clerkship period, if at all.

A Comparison of Uniformed Services University and Health Professions Scholarship Program Graduates' First Deployment Readiness.

INTRODUCTION: Military physicians must be prepared to lead health care teams across complex landscapes of war during future small- and large-scale combat operations. This preparation optimally begins in medical school so that early career physicians are fully ready for their first deployment. Past qualitative research has suggested that military physicians who attended civilian medical school are not as well prepared for the operational environment as physicians who attended the Uniformed Services University (USU), our nation's military medical school. However, there is a lack of larger-scale quantitative research comparing the readiness differences between the two medical school pathways. The purpose of this study, therefore, was to quantify any differences in first deployment preparation between students attending USU and civilian medical schools through the Health Professions Scholarship Program (HPSP). MATERIALS AND METHODS: We compared USU and HPSP graduates' first deployment experiences by distributing a 14-item Likert survey to active duty military physicians in the U.S. Army, U.S. Navy, and U.S. Air Force who graduated within the past 10 years from medical school (USU or civilian). RESULTS: The USU graduates rated themselves significantly higher than the HPSP graduates on their readiness for deployment (3.83 vs. 3.24; P < .001); ability to navigate the operational environment (3.59 vs. 2.99; P < .001); confidence in communicating with their commanding officer (3.59 vs. 2.99; P = .002); navigating the combined role as physician and officer (3.33 vs. 2.84; P = .004); leading a health care team (3.94 vs. 3.43; P = .001); preparation by a medical school (3.78 vs. 2.52; P < .001); and overall readiness compared to peers (4.20 vs. 3.49; P < .001). There was no significant difference between the two pathways regarding their stress level at the beginning of deployment (2.74 vs. 2.68; P = .683); clinical preparation (3.94 vs. 3.76; P = .202); and success of first deployment (3.87 vs. 3.91; P = .792). The largest effect size of the difference between the two pathways was noted on the question "How well did medical school prepare you for your first deployment" (Cohen's d = 1.02). CONCLUSIONS: While both groups believed that they were prepared for their first deployment, USU graduates consistently reported being more prepared by medical school for their first deployment than HPSP graduates. To close this readiness gap, supplemental military unique curricula may help to optimize HPSP students' readiness.

Using Self-Regulated Learning Microanalysis to Examine Regulatory Processes in Clerkship Students Engaged in Practice Questions.

Introduction: Self-regulated learning is a cyclical process of forethought, performance, and self-reflection that has been used as an assessment tool in medical education. No prior studies have evaluated SRL processes for answering multiple-choice questions (MCQs) and most evaluated one or two iterations of a non-MCQ task. SRL assessment during MCQs may elucidate reasons why learners are successful or not on these questions that are encountered repeatedly during medical education. Methods: Internal medicine clerkship students at three institutions participated in a SRL microanalytic protocol that targeted strategic planning, metacognitive monitoring, causal attributions, and adaptive inferences across seven MCQs. Responses were transcribed and coded according to previously published methods for microanalytic protocols. Results: Forty-four students participated. In the forethought phase, students commonly endorsed prioritizing relevant features as their diagnostic strategy (n = 20, 45%) but few mentioned higher-order diagnostic reasoning processes such as integrating clinical information (n = 5, 11%) or comparing/contrasting diagnoses (n = 0, 0%). However, in the performance phase, students' metacognitive processes included high frequencies of integration (n = 38, 86%) and comparing/contrasting (n = 24, 55%). In the self-reflection phase, 93% (n = 41) of students faulted their management reasoning and 84% (n = 37) made negative references to their abilities. Less than 10% (n = 4) of students indicated that they would adapt their diagnostic reasoning process for these questions. Discussion: This study describes in detail student self-regulatory processes during MCQs. We found that students engaged in higher-order diagnostic reasoning processes but were not explicit about it and seldom reflected critically on these processes after selecting an incorrect answer. Self-reflections focused almost exclusively on management reasoning and negative references to abilities which may decrease self-efficacy. Encouraging students to identify and evaluate diagnostic reasoning processes and make attributions to controllable factors may improve performance.

Clinical Reasoning Curricula in Health Professions Education: A Scoping Review.

OBJECTIVES: This scoping review aimed to explore and synthesize current literature to advance the understanding of how to design clinical reasoning (CR) curricula for students in health professions education. METHODS: Arksey and O'Malley's 6-stage framework was applied. Peer-reviewed articles were searched in PubMed, Web of Science, CINAHL, and manual searches, resulting in the identification of 2932 studies. RESULTS: Twenty-six articles were included on CR in medical, nursing, physical therapy, occupational therapy, midwifery, dentistry, and speech language therapy education. The results describe: features of CR curriculum design; CR theories, models, and frameworks that inform curricula; and teaching content, methods, and assessments that inform CR curricula. CONCLUSIONS: Several CR theories, teaching, and assessment methods are integrated into CR curricula, reflecting the multidimensionality of CR among professions. Specific CR elements are addressed in several curricula; however, no all-encompassing CR curriculum design has been identified. These findings offer useful insights for educators into how CR can be taught and assessed, but they also suggest the need for further guidance on educational strategies and assessments while learners progress through an educational program.

Teaching Clinical Reasoning in the Preclinical Period.

INTRODUCTION: Developing the clinical reasoning skills necessary to becoming an astute diagnostician is essential for medical students. While some medical schools offer longitudinal opportunities for students to practice clinical reasoning during the preclinical curriculum, there remains a paucity of literature fully describing what that curriculum looks like. As a result, medical educators struggle to know what an effective clinical reasoning curriculum should look like, how it should be delivered, how it should be assessed, or what faculty development is necessary to be successful. We present our Introduction to Clinical Reasoning course that is offered throughout the preclinical curriculum of the Uniformed Services University of the Health Sciences. The course introduces clinical reasoning through interactive lectures and 28 case-based small group activities over 15 months.The curriculum is grounded in script theory with a focus on diagnostic reasoning. Specific emphasis is placed on building the student's semantic competence, constructing problem lists, comparing and contrasting similar diagnoses, constructing a summary statement, and formulating a prioritized differential diagnosis the student can defend. Several complementary methods of assessment are utilized across the curriculum. These include assessments of participation, knowledge, and application. The course leverages clinical faculty, graduate medical education trainees, and senior medical students as small group facilitators. Feedback from students and faculty consistently identifies the course as a highly effective and engaging way to teach clinical reasoning. CONCLUSION: Our Introduction to Clinical Reasoning course offers students repeated exposure to well-selected cases to promote their development of clinical reasoning. The course is an example of how clinical reasoning can be taught across the preclinical curriculum without extensive faculty training in medical education or clinical reasoning theory. The course can be adapted into different instructional formats to cover a variety of topics to provide the early learner with sequential exposure and practice in diagnostic reasoning.

What Stops Fairness from Emerging in Assessment? The Forces on a Complex Adaptive System.

Introduction: Workplace-based assessment occurs in authentic, dynamic clinical environments where reproducible, measurement-based assessments can often not be implemented. In these environments, research approaches that respect these multiple dynamic interactions, such as complexity perspectives, are encouraged. Previous research has shown that fairness in assessment is a nonlinear phenomenon that emerges from interactions between its components and behaves like a complex adaptative system. The aim of this study was to understand the external forces on the complex adaptive system which may disrupt fairness from emerging. Methods: We conducted online focus groups with a purposeful sample of nineteen academic leaders in the Netherlands. We used an iterative approach to collection, analysis and coding of the data and interpreted the results using a lens of complexity, focusing on how individual elements of fairness work in concert to create systems with complex behaviour. Results: We identified three themes of forces which can disrupt fairness: forces impairing interactivity, forces impairing adaption and forces impairing embeddedness. Within each of these themes, we identified subthemes: assessor and student forces, tool forces and system forces. Discussion: Consistent with complexity theory, this study suggests there are multiple forces which can hamper the emergence of fairness. Whilst complexity thinking does not reduce the scale of the challenge, viewing forces through this lens provides insight into why and how these forces are disrupting fairness. This allows for more purposeful, meaningful changes to support the use of fair judgement in assessment in dynamic authentic clinical workplaces.

Do All Roads Lead to Full Participation? Examining Trajectories of Clinical Educators in Graduate Medical Education through Situated Learning Theory.

Phenomenon: As new faculty members begin their careers in Graduate Medical Education, each begins a journey of Professional Identity Formation from the periphery of their educational communities. The trajectories traveled vary widely, and full participation in a given educational community is not assured. While some medical school and post-graduate training programs may nurture Professional Identity Formation, there is scant support for faculty. To date, the trajectories that Graduate Medical Education faculty travel, what may derail inbound trajectories, and what tools Graduate Medical Education faculty use to navigate these trajectories have not been explicitly described. We explore these three questions here. Approach: Communities of Practice, a component of Situated Learning Theory, serves as a helpful framework to explore trajectories of educator identity development among Graduate Medical Educators. We used a inductive and deductive approach to Thematic Analysis, with Situated Learning Theory as our interpretive frame. Semi-structured interviews of faculty members of GME programs matriculating into a Health Professions Education Program were conducted, focusing on participants' lived experiences in medical education and how these experiences shaped their Professional Identity Formation. Findings: Participants noted peripheral, inbound, boundary, and outbound trajectories, but not an insider trajectory. Trajectory derailment was attributed to competing demands, imposter syndrome and gendered marginality. Modes of belonging were critical tools participants used to shape PIF, not only engagement with educator roles but disengagement with other roles; imagination of future roles with the support of mentors; and fluid alignment with multiple mutually reinforcing identities. Participants identified boundary objects like resumes and formal roles that helped them negotiate across Community of Practice boundaries. Insights: Despite a desire for full participation, some clinical educators remain marginal, struggling along a peripheral trajectory. Further research exploring this struggle and potential interventions to strengthen modes of belonging and boundary objects is critical to create equitable access to the inbound trajectory for all of our colleagues, leaving the choice of trajectories up to them.

Does Masking MCAT Scores During Admissions Increase Equity?

PURPOSE: To improve admissions process equity, the Uniformed Services University masked Medical College Admission Test (MCAT) scores at or above the 51st percentile to admissions committee members. This policy was aimed at improving admissions rates for applicants in 2 priority groups: those from races and ethnicities underrepresented in medicine (URM) and those from lower socioeconomic status, represented by first-generation college (FGC) graduates. METHOD: All applicants invited to interview were included: 1,624 applicants from admissions years 2014-2016 before MCAT score masking and 1,668 applicants from admissions years 2018-2020 during MCAT score masking. Logistic regression determined admissions likelihood before and during masking. Independent sample t tests compared average admissions committee scores for all applicants and for those in priority groups. Linear regression determined the weight of MCAT scores on admissions committee scores. RESULTS: Despite there being more priority group applicants during MCAT score masking, the admissions likelihood for an individual priority group applicant decreased during this period. URM applicants had an odds ratio of 0.513 for acceptance during MCAT score masking compared to before masking, and FGC applicants had an odds ratio of 0.695. Masking significantly reduced mean admissions committee scores, which decreased approximately twice as much for priority group applicants as for nonpriority group applicants (0.96 points vs 0.51 points). These score decreases were highest for priority group applicants with MCAT scores above the 67th percentile. Masking reduced the weight of MCAT scores; 10.9% of admissions committee score variance was explained by MCAT scores before masking and only 1.2% during masking. CONCLUSIONS: Despite known disparities in MCAT scores with respect to race, ethnicity, and socioeconomic status, admissions decisions in this study were more equitable when MCAT scores were included. While masking MCAT scores reduced the influence of the exam in admissions decisions, it also reduced admissions rates for URM and FGC applicants.

Reframing context specificity in team diagnosis using the theory of distributed cognition.

Context specificity refers to the vexing phenomenon whereby a physician can see two patients with the same presenting complaint, identical history and physical examination findings, but due to specific situational (contextual) factors arrives at two different diagnostic labels. Context specificity remains incompletely understood and undoubtedly leads to unwanted variance in diagnostic outcomes. Previous empirical work has demonstrated that a variety of contextual factors impacts clinical reasoning. These findings, however, have largely focused on the individual clinician; here we broaden this work to reframe context specificity in relation to clinical reasoning by an internal medicine rounding team through the lens of Distributed Cognition (DCog). In this model, we see how meaning is distributed amongst the different members of a rounding team in a dynamic fashion that evolves over time. We describe four different ways in which context specificity plays out differently in team-based clinical care than for a single clinician. While we use examples from internal medicine, we believe that the concepts we present apply equally to other specialties and fields in health care.