Storylines of family medicine II: foundational building blocks-context, community and health.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'II: foundational building blocks-context, community and health', authors address the following themes: 'Context-grounding family medicine in time, place and being', 'Recentring community', 'Community-oriented primary care', 'Embeddedness in practice', 'The meaning of health', 'Disease, illness and sickness-core concepts', 'The biopsychosocial model', 'The biopsychosocial approach' and 'Family medicine as social medicine.' May readers grasp new implications for medical education and practice in these essays.

Fostering Alignment and the Catalytic Potential of Community-Engaged Research With US Military Veterans and Advocates.

This paper explores the concept of "community-engaged research" (CEnR) within the context of Veteran health care delivery and reintegration programs. A multi-sector expert panel (msExP) was formed to evaluate and make recommendations on Veteran community reintegration research and programs. The panel consisted of Veterans, care partners, clinical providers, researchers, community stakeholders, and subject matter experts. The paper examines the composition and lifecycle of the panel, highlighting the characteristics and experiences of the participants. Shifts in the panel's purpose and engagement levels occurred in response to unanticipated disruptions, particularly the COVID-19 pandemic. The transformation of the panel emphasizes the importance of aligning individual and group needs and deepening intrapersonal relationships Findings based on observations, surveys, and interviews with panel members contribute to the field of community-engaged research by demonstrating the utility of catalytic validity that balances group and individual development. As part of a broader study on Veteran reintegration, the panel and its development over time allowed for various perspectives on Veteran experiences and reintegration within the community that shaped the overall project. Despite the challenges of developing and maintaining a panel alongside a research study, feedback from the panel members on their participation provides insight into the potential for future working alliances in community-engaged health research.

Reducing decisional conflict in decisions about prenatal genetic testing: the impact of a dyadic intervention at the start of prenatal care.

OBJECTIVES: Decisional conflict and regret about prenatal genetic screening and diagnostic tests may have important consequences in the current pregnancy and for future reproductive decisions. Identifying mechanisms that reduce conflict associated with the decision to use or decline these options is necessary for optimal patient counseling. METHODS: We conducted a cluster-randomized controlled trial of a shared decision-making tool (NEST) at the beginning of prenatal care. Enrolled patients completed follow-up surveys at the time of testing (QTT) and in the second-third trimester (QFF), including the Decision Conflict Scale (DCS). Total DCS scores were analyzed using a multivariate linear mixed-effect model. RESULTS: Of the total number of participants (n=502) enrolled, 449 completed the QTT and QFF surveys. The mean age of participants was 31.6±3.8, with most parous at the time of study participation (n=321; 71.7 %). Both the NEST (the intervention) and control groups had lower median total DCS scores at QFF (NEST 13.3 [1.7, 25.0] vs. control 16.7 [1.7, 25.0]; p=0.24) compared to QTT (NEST 20.8 [5.0, 25.0] vs. control 18.3 [3.3, 26.7]; p=0.89). Participants exposed to NEST had lower decisional conflict at QFF compared to control (ß -3.889; [CI -7.341, -0.437]; p=0.027). CONCLUSIONS: Using a shared decision-making tool at the start of prenatal care decreased decisional conflict regarding prenatal genetic testing. Such interventions have the potential to provide an important form of decision-making support for patients facing the unique type of complex and preference-based choices about the use of prenatal genetic tests.

Making Meaning Matter: an Editor's Perspective on Publishing Qualitative Research.

The term qualitative research refers to a family of primarily non-numeric methods for describing, analyzing, and interpreting the lived experiences of people in their day to day lives. Originally developed to study social problems such as poverty, juvenile delinquency, and race relations, qualitative research methods have been used in the health sciences since the 1960s to better understand the socialization of medical professionals and the culture of medical education and practice. More recently, qualitative research has been employed in health services research to address and improve the quality and safety of care. While quantitative researchers generally ask "what" or "how many" questions, qualitative researchers generally ask, "why" or "how"? Publishing qualitative research comes with a number of challenges, among them, manuscript length, unfamiliarity of reviewers with qualitative traditions, and sample sizes that, by design, are difficult to generalize from. In addition, while there is general agreement about the quality of evidence and types of research designs used in quantitative studies, the same is not yet the case for qualitative and mixed methods research although a variety of useful guidelines have recently appeared. From the perspective of journal editors, we raise and offer guidance on three important questions: (1) Is the study under review suitable for this journal? (2) What is the rationale for using qualitative methods to carry out the research? (3) What are editors/reviewers looking for in a qualitative submission? In unpacking the third question, we describe common strategies editors use and challenges that we have encountered in the abstract, background, methods, results, discussion, and conclusions sections of qualitative submissions we and our colleagues have reviewed.

Learning from women veterans who navigate invisible injuries, caregiving, and reintegration challenges.

BACKGROUND: As women comprise a greater proportion of military service members, there is growing recognition of how their experiences in the early phase of military to civilian transitions have an important influence on their health and reintegration outcomes. Qualitative accounts of women veterans can inform programs that support transitioning service members. OBJECTIVES: We examined narratives of civilian reintegration among women veterans to understand their experiences of adjusting to community life while coping with mental health challenges. METHODS/PARTICIPANTS: We interviewed 16 post-911 era women who were within 5 years of separating from military service and developed a case study based on three participants. MAIN APPROACH: Interviews were audio-recorded and transcribed verbatim. Inductive thematic analysis was conducted to establish categories about reintegration. Immersion/crystallization techniques were used to identify exemplary cases that illustrated salient themes. KEY RESULTS: Women veterans identified establishing a future career direction, drawing on social support, and navigating health care services as major factors influencing how they adjusted to civilian life. In addition, participants also highlighted the navigation of complex and intersecting identities (i.e., wife, mother, employee, friend, veteran, patient, etc.), further magnified by gender inequalities. These women performed emotional labor, which is often rendered invisible and oriented toward their family and loved ones, while simultaneously monitoring self-care activities. During the early period of reintegration, they described how they felt marginalized in terms of accessing healthcare compared to their military spouses and male veteran peers. CONCLUSIONS: Our case study suggests that there are key gaps in addressing healthcare and readjustment needs for women servicemembers, a high priority VA group, as they transition into post-military life. It is important to consider innovative ways to address specific needs of women in veteran-focused policies and programs.

Modeling Contingency in Veteran Community Reintegration: A Mixed Methods Approach.

Researchers need approaches for analyzing complex phenomena when assessing contingency relationships where specific conditions explain an outcome only when combined with other conditions. Using a mixed methods design, we paired configurational methods and qualitative thematic analysis to model contingency in veteran community reintegration outcomes, identifying combinations of conditions that led to success or lack of success in community reintegration among US military veterans. This pairing allowed for modeling contingency at a detailed level beyond the capabilities of either approach alone. Our analysis revealed multiple contingent relationships at work in explaining reintegration, including social support, purpose, cultural adjustment, and military separation experiences. This study contributes to the field of mixed methods by pairing a mathematical cross-case method with a qualitative method to model contingency.

Impact of Telehealth on the Delivery of Prenatal Care During the COVID-19 Pandemic: Mixed Methods Study of the Barriers and Opportunities to Improve Health Care Communication in Discussions About Pregnancy and Prenatal Genetic Testing.

BACKGROUND: The COVID-19 pandemic brought significant changes in health care, specifically the accelerated use of telehealth. Given the unique aspects of prenatal care, it is important to understand the impact of telehealth on health care communication and quality, and patient satisfaction. This mixed methods study examined the challenges associated with the rapid and broad implementation of telehealth for prenatal care delivery during the pandemic. OBJECTIVE: In this study, we examined patients' perspectives, preferences, and experiences during the COVID-19 pandemic, with the aim of supporting the development of successful models to serve the needs of pregnant patients, obstetric providers, and health care systems during this time. METHODS: Pregnant patients who received outpatient prenatal care in Cleveland, Ohio participated in in-depth interviews and completed the Coronavirus Perinatal Experiences-Impact Survey (COPE-IS) between January and December 2021. Transcripts were coded using NVivo 12, and qualitative analysis was used, an approach consistent with the grounded theory. Quantitative data were summarized and integrated during analysis. RESULTS: Thematic saturation was achieved with 60 interviews. We learned that 58% (35/60) of women had telehealth experience prior to their current pregnancy. However, only 8% (5/60) of women had used both in-person and virtual visits during this pregnancy, while the majority (54/60, 90%) of women participated in only in-person visits. Among 59 women who responded to the COPE-IS, 59 (100%) felt very well supported by their provider, 31 (53%) were moderately to highly concerned about their child's health, and 17 (29%) reported that the single greatest stress of COVID-19 was its impact on their child. Lead themes focused on establishing patient-provider relationships that supported shared decision-making, accessing the information needed for shared decision-making, and using technology effectively to foster discussions during the COVID-19 pandemic. Key findings indicated that participants felt in-person visits were more personal, established greater rapport, and built better trust in the patient-provider relationship as compared to telehealth visits. Further, participants felt they could achieve a greater dialogue and ask more questions regarding time-sensitive information, including prenatal genetic testing information, through an in-person visit. Finally, privacy concerns arose if prenatal genetic testing or general pregnancy conversations were to take place outside of the health care facility. CONCLUSIONS: While telehealth was recognized as an option to ensure timely access to prenatal care during the COVID-19 pandemic, it also came with multiple challenges for the patient-provider relationship. These findings highlighted the barriers and opportunities to achieve effective and patient-centered communication with the continued integration of telehealth in prenatal care delivery. It is important to address the unique needs of this population during the pandemic and as health care increasingly adopts a telehealth model.

The Impact of Outpatient Prenatal Care Visitor Restrictions on Pregnant Patients and Partners During the COVID-19 Pandemic.

Introduction: During the early months of the COVID-19 pandemic, several health care facilities enacted visitor restrictions to help reduce the spread of SARS-CoV-2 among patients, front-line workers in health care systems, and communities. The impact and burden of policy updates on visitor restrictions put forth by the COVID-19 pandemic can be seen on patients and families, most often in the acute care setting and skilled nursing facilities. Yet, the effects of visitor restrictions in the prenatal care setting were unknown. We conducted a study to investigate the impact of these policies on pregnant patients who received outpatient prenatal care. Methods: We conducted a qualitative study to explore pregnant patients' experiences with prenatal health care delivery between May and July 2020. In-depth interviews were conducted with pregnant patients in the first and second trimester of pregnancy, who received their prenatal care at the onset of the pandemic in the United States. Results: Participants noted increased maternal concern, anxiety, and mental health concerns stemming from the lack of in-person partner support. They noted disappointment and lost experiences for the patient during pregnancy, seeking support from her partner during pregnancy, experiences felt to be critical for postpartum health and wellbeing. There was also concern about the negative impact of restrictions on prenatal care quality and experience. Conclusions: This study demonstrates the impact of visitor restrictions on patients' prenatal care experience and perception of health care quality during the COVID-19 pandemic. Future public health strategies should be individualized to different patient populations addressing knowledge, health literacy, and socioeconomic status, and developed in conjunction with pregnant patients as key stakeholders in the delivery of prenatal health care.

The Successes and Challenges of Implementing Telehealth for Diverse Patient Populations Requiring Prenatal Care During COVID-19: Qualitative Study.

BACKGROUND: Although telehealth appears to have been accepted among some obstetric populations before the COVID-19 pandemic, patients' receptivity and experience with the rapid conversion of this mode of health care delivery are unknown. OBJECTIVE: In this study, we examine patients' prenatal care needs, preferences, and experiences during the COVID-19 pandemic, with the aim of supporting the development of successful models to serve the needs of pregnant patients, obstetric providers, and health care systems during this time. METHODS: This study involved qualitative methods to explore pregnant patients' experiences with prenatal health care delivery at the onset of the COVID-19 pandemic. We conducted in-depth interviews with pregnant patients in the first and second trimester of pregnancy who received prenatal care in Cleveland, Ohio, from May to July 2020. An interview guide was used to probe experiences with health care delivery as it rapidly evolved at the onset of the pandemic. RESULTS: Although advantages of telehealth were noted, there were several concerns noted with the broad implementation of telehealth for prenatal care during the pandemic. This included concerns about monitoring the pregnancy at home; the need for additional reassurance for the pregnancy, given the uncertainties presented by the pandemic; and the ability to have effective patient-provider discussions via a telehealth visit. The need to tailor telehealth to prenatal health care delivery was noted. CONCLUSIONS: Although previous studies have demonstrated that telehealth is a flexible and convenient alternative for some prenatal appointments, our study suggests that there may be specific needs and concerns among the diverse patient groups using this modality during the pandemic. More research is needed to understand patients' experiences with telehealth during the pandemic and develop approaches that are responsive to the needs and preferences of patients.

The impact of COVID-19 on professional identity.

BACKGROUND: The COVID-19 pandemic has had a profound impact on medical care and medical student education as clinical rotations were halted and students' clinical activities were drastically curtailed. Learning experiences in medical school are known to promote identity formation through teamwork, reflection, and values-based community discussion. This study explored the impact of the COVID-19 pandemic on medical students' professional identity formation (PIF). METHODS: Students in all cohorts of medical education were invited by email in May 2020 to submit a written reflection about their learning experiences and impact of the pandemic on their PIF. We used iterative individual and team reviews, known as the "immersion/crystallisation" method, to code and analyse the data. FINDINGS: Twenty-six students (20%) submitted reflections in which they discussed "changing conceptions of the role and image of a physician," "views about medical education," and the "role of students in a pandemic." Students viewed physicians as altruistic, effective communicators, and pledged to be like them in the future. Their perceptions of virtual learning were mixed, along with considerations of lost interactions with patients, and wanting to be more useful as professionals-in-training. DISCUSSION: COVID-19 has impacted students' views of themselves and reshaped their ideas, both negatively and positively, about the profession they are entering and their role(s) in it. CONCLUSION: Exploring PIF and the impact of disruptions has allowed us to address the issues raised regarding clinical learning now and into the future. Reflection enhances PIF and unexpected events, such as COVID-19, offer opportunities for reflection and development.

ASPIRE: A Program for Developing Clinician Educators' Scholarship, Advancement, and Sense of Community.

INTRODUCTION: Faculty development programs encouraging clinician educators' scholarship have been established at many medical schools. The same is true for programs that address the isolation and loneliness many faculty members feel in their day-to-day clinical work and administration. Few programs have explicitly combined development of scholarship and sense of community. AIM: The goals of the Advanced Scholars Program for Internists in Research and Education (ASPIRE) are as follows: (1) provide training in scholarship development including research methods, implementation, and dissemination; (2) provide expert mentoring and support for professional development; and (3) create a greater sense of campus community. SETTING: ASPIRE scholars are clinician educators in the Department of Medicine at Indiana University School of Medicine. PROGRAM DESCRIPTION: The program runs 18 months, includes intensive mentoring, covered time for scholars and mentors, resources, and two half-day educational sessions per month focused on scholarship and community development. PROGRAM EVALUATION: Institutional leaders' public statements and actions regarding ASPIRE were documented by program leadership. Data collected from ASPIRE mentors and scholars through interviews and free text survey responses were analyzed using an immersion/crystallization approach. Two central themes were identified for both scholars and mentors: benefits and challenges of the program. Benefits included mentors, program design, community development, increased confidence, skills development, improved patient care, and institutional impact. Challenges included time to accomplish the program, balance of community-building and skills development, and lack of a clear path post-ASPIRE. DISCUSSION: Combining skills-based learning with safe psychological space were judged important elements of success for the ASPIRE program. Conversations are ongoing to identify opportunities for scholars who have completed the program to continue to pursue scholarship, expand their skills, and build community. We conclude that the program both is feasible and was well-received. Sustainability and generalizability are important next steps in ensuring the viability of the program.

Goals of care communication and higher-value care for patients with advanced-stage cancer: A systematic review of the evidence.

CONTEXT: Goals-of-care communication (GOCC) is recommended to increase the value of cancer care near the end of life (EOL). OBJECTIVES: Conduct a systematic review of the evidence that GOCC is associated with higher-value care. METHODS: We searched PubMed, Scopus, Ovid MEDLINE, EMBASE, EMB Reviews, CINAHL, and PsycInfo from inception to July 2019. We analyzed the population,design, and results and the authors' definitions of GOCC. Risk of bias was assessed. RESULTS: Thirty-two articles were selected. Ten articles reported results from 8 interventions; 17 characterized participants' perspectives; and 5 were retrospective The topics, behaviors, timing, and anticipated outcomes of GOCC varied significantly and were indistinguishable from practices such as advance care planning. GOCC typically focused on treatment outcomes rather than patients' goals. Four of 5 interventions increased evidence of GOCC after clinician training. Only one reported improved patient outcomes. CONCLUSION: No consensus exists about what GOCC entails. There is limited evidence that GOCC increases the value of EOL care. PRACTICE IMPLICATIONS: Future studies should focus on how to engage patients in conversations about their personal goals and integrate their goals into care planning. Clinicians can encourage GOCC by explaining how patients' goals influence decisions especially as treatment options become limited.

Personalizing the BioPsychoSocial Approach: "Add-Ons" and "Add-Ins" in Generalist Practice.

Generalist practitioners often find interacting with patients deeply satisfying and joyful; they also experience encounters that are challenging and complex. In both cases, they must be aware of the many issues that affect the processes and outcomes of patient care. Although using the BioPsychoSocial approach is an important, time-tested framework for cultivating one's awareness of patients' presenting concerns, recent developments suggest that additional frames of reference may enhance communication and relationships with patients. In this article, we describe several additions to the BioPsychoSocial approach, considerations we call "add-ons" and "add-ins". We invite generalist practitioners and, indeed, all health care practitioners, to consider how they can improve their ongoing care of patients by personalizing these and other additions in their day-to-day work with patients.

Barriers to single-dose intravesical chemotherapy in non-muscle invasive bladder cancer: what's the problem?

INTRODUCTION: The intravesical instillation of mitomycin C immediately following surgery for non-muscle invasive bladder cancer has been shown to be efficacious in reducing cancer recurrence. As a result, the American Urological Association adopted guidelines for non-muscle invasive bladder cancer care to support its use in low to intermediate risk patients. Despite this, urologists' use of this drug following transurethral resection of a bladder tumor (TURBT) has been reported as low as 5% or less. Our study objective was to better understand the barriers urologists experience in using mitomycin C. METHODS: Semi-structured interviews were conducted with 13 practicing urologists at 4 geographically distinct practice locations throughout Indiana between 2017 and 2018. Cognitive task analysis was used to explore factors that influenced their clinician decision-making about Mitomycin C use following TURBT in specific patient cases. Interview transcripts were coded and analyzed using immersion/crystallization to identify emergent themes. RESULTS: The median age of the urologists interviewed was 44 (IQR 40-48). Eighty-five percent were male. Approximately 30% had completed urologic fellowship training; 62% were in private practice. Three major themes related to the use of mitomycin C emerged: cumbersome workflow processes, urologists' fears of side effects, and issues of identifying patients most likely to benefit. CONCLUSION: Workflow, fear, and value are key factors and also represent complexities of translating efficacy into effectiveness for a drug with known benefits to patients. Areas of potential intervention development to improve the use of mitomycin C to reduce recurrence of bladder cancer are suggested. Alternatives such as gemcitabine may also help overcome these barriers.

The impact of the emergence of COVID-19 on women's prenatal genetic testing decisions.

OBJECTIVE: We conducted a study to examine the impact of COVID on patients' access and utilization of prenatal genetic screens and diagnostic tests at the onset of the COVID-19 pandemic in the United States. METHODS: We conducted telephone interviews with 40 patients to examine how the pandemic affected prenatal genetic screening and diagnostic testing decisions during the initial months of the pandemic in the United States. An interview guide queried experiences with the ability to access information about prenatal genetic testing options and to utilize the tests when desired. Audio recordings were transcribed and coded using NVivo 12. Analysis was conducted using Grounded Theory. RESULTS: The pandemic did not alter most participants' decisions to undergo prenatal genetic testing. Yet, it did impact how participants viewed the risks and benefits of testing and timing of testing. There was heightened anxiety among those who underwent testing, stemming from the risk of viral exposure and the fear of being alone if pregnancy loss or fetal abnormality was identified at the time of an ultrasound-based procedure. CONCLUSION: The pandemic may impact patients' access and utilization of prenatal genetic tests. More research is needed to determine how best to meet pregnant patients' decision-making needs during this time.

"It Matters What I Think, Not What You Say": Scientific Evidence for a Medical Error Disclosure Competence (MEDC) Model.

OBJECTIVE: This study sought to validate the ability of a "Medical Error Disclosure Competence" (MEDC) model to predict the effects of physicians' communication skills on error disclosure outcomes in a simulated context. METHOD: A random sample of 721 respondents was assigned to 16 experimental disclosure conditions that tested the MEDC model's constructs across 2 severity conditions (i.e., minor error and sentinel event). RESULTS: Severity did not affect survey respondents' perceptions of the physician's disclosure style. Respondents who viewed the nonverbally skilled disclosure perceived the disclosure as more adequate compared to respondents in the "low nonverbal skill" disclosure condition. Interpersonal adaptability did not affect respondents' adequacy ratings. Consistent with the MEDC model, those who viewed the physician's error disclosure as inadequate indicated that they would be more prone to engage in relational distancing behaviors, while those who rated the disclosure as adequate were more likely to reinvest into their relationship with their physician. These respondents also had higher resilience scores. In the context of a sentinel event, perceived adequacy significantly predicted endorsing legal redress or remedies (e.g., lawsuit). Verbal apology (e.g., "I'm sorry," "I apologize") did not predict any significant variance in the model beyond the physician's nonverbal skill. CONCLUSION: In a simulated disclosure setting, physicians' communicative skills-particularly effective nonverbal communication during a disclosure-trigger outcomes that affect the patient, the physician, and the provider-patient relationship. Findings from this study suggest that MEDC guidelines may be helpful in reducing financial and reputational risks to individual providers and institutions, particularly in the context of a sentinel event.

In Search of Medical Professionalism Research: Preliminary Results from a Review of Widely Read Medical Journals.

INTRODUCTION: Professionalism is a core concept in medicine. The extent to which knowledge about professionalism is anchored in empirical research is unknown. Understanding the current state of research is necessary to identify significant gaps and create a road map for future professionalism efforts. The authors conducted an exploratory literature review to characterize professionalism research published in widely read medical journals, identify knowledge gaps, and describe the sources of funding for the identified studies. METHODS: The authors focused on Medline's Abridged Index Medicus and 4 core Medline education-oriented journal and developed a search filter using text words found in the article title or abstract addressing professionalism. Articles were further filtered to include those indicating a research focus. RESULTS: The search strategy resulted in 461 professionalism research articles for analysis. Articles were divided into themes of education (n = 212, 45.9%), performance (n = 83, 18%), measurement development (n = 13, 2.8%), remediation (n = 53, 11.5%), and well-being (n = 100, 21.6%). There were 36 studies from 1980 to 2002 (Era 1: before publication of Accreditation Council for Graduate Medical Education competencies) and 425 from 2003 to 17 (Era 2: after Accreditation Council for Graduate Medical Education publication of competencies). Professionalism education was the most common topic area, and most studies were from single institutions with results based on convenience samples. Most studies received no funding or were funded by the authors' own institution. DISCUSSION: Little empirical research is available on professionalism in widely read medical journals. There has been limited external research funding available to study this topic. CONCLUSION: More investment in high quality professionalism research is justified and should be encouraged.

"If your feelings were hurt, I'm sorry ": How Third-Year Medical Students Observe, Learn From, and Engage in Apologies.

BACKGROUND: Apologies may play a significant role in medical care, especially in the context of patient safety, medical error disclosure, and malpractice. Studies have shown that when state laws, institutional policies, and individual skills align-including the ability to offer a sincere apology-patients and families benefit. However, little is known about how, and under what conditions, physicians offer apologies in day-to-day care. Even less is known about what medical students learn about apologies from observing their superiors in these settings. OBJECTIVE: Characterize third-year medical students' experiences of observing and engaging in apologies. DESIGN: Qualitative descriptive analysis of student professionalism narratives. PARTICIPANTS: Third-year medical students at Indiana University School of Medicine. APPROACH: A search of 7,384 unique narratives yielded 238 with apologies. A rubric based on four key elements of genuine apologies ((1) acknowledgement, (2) explanation, (3) regret/remorse, and (4) reparation) was used to classify the kind of apology offered. Apology completeness, impact, and timing were also coded. KEY RESULTS: Seventeen percent of all apologies were complete (i.e., contained all four elements). Over 40% were coded as incomplete or "non-apology" apologies (i.e., those with only the first two elements). A significant relationship between apology completeness and positive student experience was found. Most apologies were offered by the attending physician or resident to patients and family members. Students were generally positive about their experiences, but one in five were coded as negative. Some students were distressed enough to offer apologies on behalf of the faculty. Apology timing did not make a significant difference in terms of student experience. CONCLUSIONS: Few education programs target apologies in the context of routine practice. With little formal instruction, students may rely on adopting what their seniors do. Faculty have an important role to play in modeling the apology process when harms-both great and small-occur.