Motivators and barriers for rural community preceptors in teaching: A qualitative study.

PURPOSE: Increasing challenges in recruiting and retaining community-based teaching physicians (e.g., community preceptors) call for a better understanding of motivators and barriers community preceptors perceive in their teaching role. Given the importance of medical school partnerships with community-based sites for student training, it is essential to understand the perspectives of community preceptors as teaching physicians in a context away from the medical school, such as rural, and the factors affecting their career choice to engage in teaching while practising medicine. METHODS: We conducted semi-structured interviews with rural community preceptors and used open coding to conceptualise data and axial coding to connect codes into categories. We used the socio-cognitive career theory framework to organise categories into themes. RESULTS: Eleven rural community preceptors from two medical schools participated. Specialties included family medicine, internal medicine and paediatrics; clinical practice and teaching experience ranged from 3-36 and 2-29 years, respectively. Readiness for teaching ('self-efficacy') was pivotal in community preceptors' decision to teach and derived largely from vicarious learning from teaching attendings in medical school or residency; social persuasion and encouragement from clinical partners; and their accomplishments as practising physicians. However, limited faculty development, incomplete knowledge of expectations, disengagement from the medical school and lack of current mentors hindered their self-confidence. Teaching fulfilled their aspirations ('outcome expectations') to give back to the profession, but they felt undervalued and disconnected from other clinician educators. Teaching increased job satisfaction, but clinical workload, and financial impact impeded their goals for achieving excellence ('performance'). CONCLUSIONS: Self-efficacy was a pivotal motivator in rural community preceptors' decision to teach. Role models from early training inspired them to teach. Internal awards sustained teaching efforts. Future research should explore structural barriers influencing rural community preceptors' teaching experiences to better support their career choice to become medical educators.

Strategies for Advancing Equity in Frontline Clinical Assessment.

Educational equity in medicine cannot be achieved without addressing assessment bias. Assessment bias in health professions education is prevalent and has extensive implications for learners and, ultimately, the health care system. Medical schools and educators desire to minimize assessment bias, but there is no current consensus on effective approaches. Frontline teaching faculty have the opportunity to mitigate bias in clinical assessment in real time. Based on their experiences as educators, the authors created a case study about a student to illustrate ways bias affects learner assessment. In this paper, the authors use their case study to provide faculty with evidence-based approaches to mitigate bias and promote equity in clinical assessment. They focus on 3 components of equity in assessment: contextual equity, intrinsic equity, and instrumental equity. To address contextual equity, or the environment in which learners are assessed, the authors recommend building a learning environment that promotes equity and psychological safety, understanding the learners' contexts, and undertaking implicit bias training. Intrinsic equity, centered on the tools and practices used during assessment, can be promoted by using competency-based, structured assessment methods and employing frequent, direct observation to assess multiple domains. Instrumental equity, focused on communication and how assessments are used, includes specific, actionable feedback to support growth and use of competency-based narrative descriptors in assessments. Using these strategies, frontline clinical faculty members can actively promote equity in assessment and support the growth of a diverse health care workforce.

Reviewing Internal Medicine Clerkship Grading Through a Proequity Lens: Results of a National Survey.

PURPOSE: Equity in assessment and grading has become imperative across medical education. Although strategies to promote equity exist, there may be variable penetrance across institutions. The objectives of this study were to identify strategies internal medicine (IM) clerkship directors (CDs) use to reduce inequities in assessment and grading and explore IM CDs' perceptions of factors that impede or facilitate the implementation of these strategies. METHOD: From October to December 2021, the Clerkship Directors in Internal Medicine of the Alliance for Academic Internal Medicine conducted its annual survey of IM core CDs at 137 U.S. and U.S. territory-based medical schools. This study is based on 23 questions from the survey about equity in IM clerkship assessment and grading. RESULTS: The survey response rate was 73.0% (100 of 137 medical school CDs). Use of recommended evidence-based strategies to promote equity in clerkship assessment and grading varied among IM clerkships. Only 30 respondents (30.0%) reported that their clerkships had incorporated faculty development on implicit bias for clinical supervisors of students; 31 (31.0%) provided education to faculty on how to write narrative assessments that minimize bias. Forty respondents (40.0%) provided guidance to clerkship graders on how to minimize bias when writing final IM clerkship summaries, and 41 (41.0%) used grading committees to determine IM clerkship grades. Twenty-three CDs (23.0%) received formal education by their institution on how to generate clerkship grades and summaries in a way that minimized bias. CONCLUSIONS: This national survey found variability among medical schools in the application of evidence-based strategies to promote equity in assessment and grading within their IM clerkships. Opportunities exist to adopt and optimize proequity grading strategies, including development of programs that address bias in clerkship assessment and grading, reevaluation of the weight of standardized knowledge exam scores on grades, and implementation of grading committees.

Faculty Development for Community Preceptors: a Narrative Review of the Literature.

Community teaching physicians (i.e., community preceptors) have assumed an important role in medical education. More than half of medical schools use community settings to train medical students. Whether community preceptors are well prepared for their teaching responsibilities is unknown. In addition, best practice for faculty development (FD) of this population of preceptors has not been defined. The authors conducted a narrative review of the literature to describe FD programs for community preceptors that may be helpful to medical schools for future planning. Many databases were searched from their establishment to May 2022. Studies that described FD programs for community preceptors were included. Data were organized according to program aim, duration, setting, participants, content, and outcomes. The Communities of Practice theoretical framework was used to present findings. From a total of 6308 articles, 326 were eligible for full review, 21 met inclusion criteria. Sixty-seven percent (14/21) conducted a needs assessment; 57% (12/21) were developed by the medical school; 81% (17/21) included only community preceptors. Number of participants ranged from six to 1728. Workshops were often (24%, 5/21) used and supplemented by role-play, online modules, or instructional videos. Few programs offered opportunities to practice with standardized learners. Content focused primarily on teaching skills. Five programs offered CME credits as an incentive for engagement. Participant surveys were most often used for program evaluation. Learner evaluations and focus groups were used less often. Participants reported satisfaction and improvement in teaching skills after attending the program. Faculty development for community preceptors is primarily delivered through workshops and online materials, although direct observations of teaching with feedback from FD faculty and learners may be more helpful for training. Future studies need to focus on the long-term impact of FD on community preceptors' teaching skills, identity formation as medical educators, and student learning.

Medical student advising during virtual residency recruitment: results of a national survey of internal medicine clerkship and sub-internship directors.

INTRODUCTION: The residency application process is a critical time for medical students. The COVID-19 pandemic prompted changes to the residency recruitment procedures with the conversion of interviews to a virtual format. For medical school advisors guiding students on an all-virtual residency application process brought uncertainty to their advising practices. Thus, this study aimed to identify advising practices during the 2021 virtual application cycle. METHODS: We administered an IRB-exempt national survey through the Clerkship Directors in Internal Medicine to 186 internal medicine core/co-/associate/assistant clerkship directors and sub-internship directors representing 140 Liaison Committee on Medical Education-accredited U.S./U.S.-territory-based medical schools in spring 2021. The 23-question survey was designed and pilot-tested by faculty-educators and leaders with expertise in undergraduate medical education. Data analysis included paired t- and z-tests and thematic analysis of open-ended questions. RESULTS: The institutional response rate was 67% (93/140) and individual rate 55% (103/186). Half of the respondents felt prepared/very prepared (40% and 13% respectively) for their advising roles. Compared to pre-pandemic cycles, respondents advised a typical student in the middle-third of their class at their institution to apply to more residency programs (mean 24 programs vs 20, p < 0.001) and accept more interviews (mean 14 interviews vs 12, p < 0.001). Sixty-three percent (64/101) of respondents spent more time on student advising; 51% (51/101) reported more students asked them for informal advice. Fifty-nine percent (60/101) of respondents reported their advisees were able to assess a residency program 'somewhat well;' 31% (31/101) expressed that residency recruitment should remain entirely virtual in the future. CONCLUSION: The transition to virtual residency recruitment due to COVID-19 prompted advising practices that may have contributed to application inflation and increased advising workload. Future studies should explore longitudinal outcomes of virtual interviews on student success to guide best practices in how to advise students during residency recruitment.

Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey.

BACKGROUND: COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown. OBJECTIVE: To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education. DESIGN: A nationally representative web survey. PARTICIPANTS: IM CDs from 137 LCME-accredited US medical schools in 2020. MAIN MEASURES: Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended." KEY RESULTS: Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity. CONCLUSIONS: Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

Roles and Responsibilities of Medicine Subinternship Directors : Medicine Subinternship Director Roles.

BACKGROUND: The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described. OBJECTIVE: We sought to describe the current role of IM subinternship directors with respect to their responsibilities, salary support, and reporting structure. DESIGN: Nationally representative, annually recurring thematic survey of IM core clerkship directors with membership in an academic professional association as of September 2017. PARTICIPANTS: A total of 129 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited U.S./U.S.-territory-based medical schools. MAIN MEASURES: Responsibilities, salary support, and reporting structure of subinternship directors. KEY RESULTS: The survey response rate was 83.0% (107/129 medical schools). Fifty-one percent (54/107) of respondents reported overseeing both core clerkship inpatient experiences and/or one or more subinternships. For oversight, 49.1% (28/53) of subinternship directors also reported that they were the clerkship director, 26.4% (14/53) that another faculty member directed all medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. The most frequently reported responsibilities for the subinternship directors were administration, including scheduling, and logistics of student schedules (83.0%, 44/53), course evaluation (81.1%, 43/53), and setting grades 79.2% (42/53). The modal response for estimated FTE per course was 10-20% FTE, with 33.3% (16/48) reporting this level of support and 29.2% (14/54) reporting no FTE support. CONCLUSIONS: The role of the IM subinternship director has become increasingly complex. Since the IM subinternship is critical to preparing students for residency, IM subinternship directors require standard expectations and adequate support. Future studies are needed to determine the appropriate level of support for subinternship directors and to define essential roles and responsibilities.

Mutual Rewards: Engaging the Field and Creating a Path Toward Academic Journal Editorship.

In this commentary, the inaugural cohort of Academic Medicine assistant editors shares their experiences in this role and the value of creating a path toward academic journal editorship for early- and mid-career scholars. They are a group with diverse backgrounds and a common commitment to advance scholarship in medical education. They collectively describe how they have contributed to the journal in multiple ways, reflect on how they navigated onboarding challenges in the midst of a pandemic, and, most important, share why this role matters for the medical education scholarship community. They express how the assistant editor role has been mutually rewarding, allowing the assistant editors to gain entry to academic journal editorship while also serving the journal and its community.

Medical School to Residency: How Can We Trust the Process?

Background To say that the transition from undergraduate medical education (UME) to graduate medical education (GME) is under scrutiny would be an understatement. Findings from a panel discussion at the 2018 Association of American Medical Colleges Annual meeting entitled, "Pass-Fail in Medical School and the Residency Application Process and Graduate Medical Education Transition" addressed what and when information should be shared with residency programs, and how and when that information should be shared. Materials and Methods Over 250 participants representing UME and GME (e.g. leadership, faculty, medical students) completed worksheets addressing these questions. During report-back times, verbal comments were transcribed in real time, and written comments on worksheets were later transcribed. All comments were anonymous. Thematic analysis was conducted manually by the research team to analyze the worksheet responses and report back comments. Results Themes based on suggestions of what information should be shared included the following: 1) developmental/assessment benchmarks such as demonstrating the ability/competencies to do clinical work; 2) performance on examinations; 3) grades and class ranking; 4) 360 evaluations; 5) narrative evaluations; 6) failures/remediation/gaps in training; 7) professionalism lapses; 8) characteristics of students such as resiliency/reliability; and 9) service/leadership/participation. In terms of how this information should be shared, the participants suggested enhancements to the current process of transmitting documents rather than alternative methods (e.g., video, telephonic, face-to-face discussions) and information sharing at both the time of the match and again near/at graduation to include information about post-match rotations. Discussion Considerations to address concerns with the transition from medical school to residency include further enhancements to the Medical Student Performance Evaluation, viewing departmental letters as ones of evaluation and not recommendation, a more meaningful educational handoff, and limits on the number of residency applications allowed for each student. The current medical education environment is ready for meaningful change in the UME to GME transition.

Vismodegib as Eye-Sparing Neoadjuvant Treatment for Locally Advanced Periocular Basal Cell Carcinoma.

Locally-advanced periocular basal cell carcinoma (BCC) pose many therapeutic challenges due to the need to preserve functionality and cosmesis of the orbit and periocular area. Surgical excision and subsequent orbital exenteration are two recognized modalities of treatment. Vismodegib is currently an FDA-approved monotherapy for locally-advanced and metastatic BCC. We present a case of the use of vismodegib as neoadjuvant therapy prior to surgical excision of a locally-advanced periocular recurrent BCC in a 75-year-old male. The patient’s tumor successfully responded to vismodegib allowing surgical excision with clear margins. The orbit was saved in a patient who otherwise would have required complete orbital exenteration. J Drugs Dermatol. 20(5):552-554. doi:10.36849/JDD.5661.

An Evaluation of Faculty Development Programs for Clinician-Educators: A Scoping Review.

PURPOSE: Faculty development (FD) has become increasingly important for clinician-educators. An array of FD programs has been developed, but the impact of these programs on clinician-educators and their learners and workplace is less known. The authors conducted a scoping review to explore the status of program evaluation in FD for clinician-educators to inform future planning and research. METHOD: Five databases were searched for articles published from January 1998 to August 2018 using Arksey and O'Malley's framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Studies that described evaluation methods and outcomes of FD programs for clinician-educators were included. Data were collected and organized according to program domain (teaching, research/scholarship, leadership, or a combination of skills). A modified version of the Kirkpatrick model was used to compare results among studies. RESULTS: From a total of 2,091 articles, 1,095 were eligible for full review, and 31 met the inclusion criteria. Seven programs targeted only teaching skills, 3 research/scholarship skills, 7 leadership skills, and 14 a combination of skills. Eighteen programs required the completion of a project; fewer offered fellowships, master's degrees, or certificates. Participant surveys were the most common evaluation method across all domains. Often used metrics included participant satisfaction and self-reported knowledge, skills, behavior changes, scholarly output, and leadership positions. Less common evaluation methods included learner and peer evaluations, interviews, and focus groups. Change at the institutional level was evaluated in 11 programs. CONCLUSIONS: Program evaluation remains an underdeveloped area in FD for clinician-educators. Developers expend significant effort on program design and implementation but approach evaluation less purposefully. Rigorous metrics that align with program goals and are used longitudinally are needed to accurately assess the impact of FD programs on participants and their learners, workplace, and institutions at large.

Clinician-Educator Training and Its Impact on Career Success: a Mixed Methods Study.

BACKGROUND: Clinician-educator (CE) careers in academic medicine are heterogeneous. Expectations for CEs have grown, along with a need to better prepare CEs for these roles. OBJECTIVE: To assess whether advanced education training is associated with productivity and success. DESIGN: We used a sequential mixed methods approach, collecting quantitative survey data and qualitative focus groups data. We developed a three-tiered categorization of advanced training to reflect intensity by program type. PARTICIPANTS: We surveyed CEs in the Society of General Internal Medicine (SGIM) and conducted two focus groups at an SGIM annual meeting. MAIN MEASURES: Primary outcomes were academic productivity (manuscripts, presentations, etc.) and leadership role attainment. Secondary analysis examined the interactive effect of gender and training intensity on these outcomes. KEY RESULTS: A total of 198 completed the survey (response rate 53%). Compared with medium- or low-intensity training, high-intensity training was associated with a greater likelihood of publishing ≥ 3 first- or senior-author manuscripts (adjusted OR 2.6; CI 0.8-8.6; p = 0.002), teaching ≥ 3 lectures/workshops at the regional/national/international level (adjusted OR 5.7; CI 1.5-21.3; p = 0.001), and having ≥ 3 regional/national committee memberships (adjusted OR 3.4; CI 1.0-11.7; p = 0.04). Among participants in the "no training" and "high-intensity training" categories, men were more likely to have ≥ 3 publications (OR 4.87 and 3.17, respectively), while women in the high intensity category had a likelihood similar to men with no training (OR 4.81 vs. OR 4.87). Participants felt the value of advanced training exists not only in content but also in networking opportunities that programs provide. CONCLUSIONS: While opinions were divided as to whether advanced training is necessary to position oneself for education roles, it is associated with greater academic productivity and reduced gender disparity in the publication domain. Institutions should consider providing opportunities for CEs to pursue advanced education training.

Clerkship Roles and Responsibilities in a Rapidly Changing Landscape: a National Survey of Internal Medicine Clerkship Directors.

BACKGROUND: In the rapidly changing landscape of undergraduate medical education (UME), the roles and responsibilities of clerkship directors (CDs) are not clear. OBJECTIVE: To describe the current roles and responsibilities of Internal Medicine CDs. DESIGN: National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS: One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. MAIN MEASURES: Responsibilities of core CDs, including oversight of other faculty, and resources available to CDs including financial support and dedicated time. KEY RESULT: The survey response rate was 83% (107/129). Ninety-four percent of the respondents oversaw the core clerkship inpatient experience, while 47.7% (n = 51) and 5.6% (n = 6) oversaw the outpatient and longitudinal integrated clerkships respectively. In addition to oversight, CDs were responsible for curriculum development, evaluation and grades, remediation, scheduling, student mentoring, and faculty development. Less than one-third of CDs (n = 33) received the recommended 0.5 full-time equivalent (FTE) support for their roles, and 15% (n = 16) had less than 20% FTE support. An average 0.41 FTE (SD .2) was spent in clinical work and 0.20 FTE (SD .21) in administrative duties. Eighty-three percent worked with other faculty who assisted in the oversight of departmental UME experiences, with FTE support varying by role and institution. Thirty-five percent of CDs (n = 38) had a dedicated budget for managing their clerkship. CONCLUSIONS: The responsibilities of CDs have increased in both number and complexity since the dissemination of previous guidelines for expectations of and for CDs in 2003. However, resources available to them have not substantially changed.

Interprofessional Education in the Internal Medicine Clerkship Post-LCME Standard Issuance: Results of a National Survey.

BACKGROUND: Several decades of work have detailed the value and goals of interprofessional education (IPE) within the health professions, defining IPE competencies and best practices. In 2013, the Liaison Committee for Medical Education (LCME) elevated IPE to a U.S. medical school accreditation standard. OBJECTIVE: To examine the status of IPE within internal medicine (IM) clerkships including perspectives, curricular content, barriers, and assessment a year after the LCME standard issuance. DESIGN: Anonymous online survey. PARTICIPANTS: IM clerkship directors from each of the Clerkship Directors in Internal Medicine's 121 U.S. and Canadian member medical schools in 2014. METHODS: In 2014, a section on IPE (18 items) was included in the Clerkship Directors in Internal Medicine annual survey of its 121 U.S. and Canadian member medical schools. MAIN MEASURES: Items (18) assessed clerkship director (CD) perspectives, status of IPE curricula in IM clerkships, and barriers to IPE implementation. Data were analyzed using descriptive statistics and qualitative analysis of free-text responses to one of the survey questions. KEY RESULTS: The overall survey response rate was 78% (94/121). The majority (88%) agreed that IPE is important to the practice of IM, and 71% believed IPE should be part of the IM clerkship. Most (76%) CDs agreed there is need for faculty development programs in IPE; 27% had such a program at their institution. Lack of curricular time, scheduling conflicts, and lack of faculty trained in IPE were the most frequently cited barriers. Twenty-nine percent had formal IPE activities within their IM clerkships, and 38% were planning to make changes. Of those with formal IPE activities, over a third (37%) did not involve student assessment. CONCLUSIONS: Since LCME standard issuance, only a minority of IM clerkships have included formal IPE activities, with lectures as the predominant method. Opportunities exist for enhancing educational methods as well as IPE faculty development.