How to Help Students Strategically Prepare for the MCAT Exam and Learn Foundational Knowledge Needed for Medical School No abstract available

First They Came for the Socialists… Commentary on “First They Came for the Socialists…” No abstract available

The Architecture of an Internal, Scientific, Pre-Submission Review Program Designed to Increase the Impact and Success of Grant Proposals and Manuscripts Securing extramural grant funding and publishing in peer-reviewed journals are key indicators of success for many investigators in academic settings. As a result, these expectations are also sources of stress for investigators and trainees considering such careers. As competition over grant funding, costs of conducting research, and diffusion of effort across multiple demands increase, the need to submit high quality applications and publications is paramount. For over three decades, the Center for AIDS Prevention Studies at the University of California, San Francisco has refined an internal, pre-submission, peer-review program to improve the quality and potential success of products before external submission. In this article, the rationale and practical elements of the system are detailed, and recent satisfaction reports, grant submission outcomes, and plans for ongoing tracking of the success rates of products reviewed are discussed. The program includes both early-stage concept reviews of ideas in their formative state and full product reviews of near-final drafts. Recent evaluation data indicate high levels of reviewee satisfaction with multiple domains of the process, including scheduling the review sessions, preparedness and expertise of the reviewers, and overall quality of the review. Outcome data from reviews conducted over a recent 12-month period demonstrate subsequent funding of 44% of proposals reviewed through the program, a success rate that surpasses the National Institutes of Health funding success rates for the same time period. Suggestions for the sustainability of the program and for its adoption at other institutions and settings less dependent on extramural funding are provided. Acknowledgments: The authors would like to thank the academic community whose participation in the program is vital to its success. The authors also thank Dr. Susan Folkman for her leadership and vision in setting up the original iteration of the center’s peer review program. Funding/Support: The program described in this article is supported by grant number P30MH062246 from the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH). Ethical approval: Reported as not applicable. Other disclosures: None reported. Disclaimers: None reported. Previous presentations: None reported. Data: All data are from the authors’ program and institution. Correspondence should be addressed to Mallory O. Johnson, Department of Medicine, University of California, San Francisco, 550 16th street, 3rd Floor, San Francisco, CA, 94158; email: Mallory.Johnson@ucsf.edu. © 2019 by the Association of American Medical Colleges

Mission Drift: Are Medical School Admissions Committees Missing the Mark on Diversity? Diversity initiatives in U.S. medical education, following the passage of the Civil Rights Act of 1964, were geared towards increasing the representation of African Americans—blacks born in the United States whose ancestors suffered under slavery and Jim Crow laws. Over time, blacks and, subsequently, underrepresented groups in medicine (URMs), became a proxy for African Americans, Puerto Ricans, Mexican Americans, and Native Americans, thus obscuring efforts to identify and recruit specifically African Americans. Moreover, demographic shifts resulting from recent immigration of black people from Africa and the Caribbean have both expanded the definition of “African American medical students” and shifted the emphasis from those with a history of suffering under U.S. oppression and poverty to anyone who meets a black phenotype. Increasingly, research indicates that African American patients fare better when their physicians share similar historical and social experiences. While all people of color risk discrimination based on their skin color, not all have the lived experience of U.S.-based, systematic, multigenerational discrimination shared by African Americans. In the high-stakes effort to increase URM representation in medical school classes, admissions committees may fail to look beyond the surface of phenotype, thus missing the original intent of diversity initiatives while simultaneously conflating all people of color, disregarding their divergent historical and social experiences. In this Perspective, the authors contend that medical school admissions committees must show greater discernment in their holistic reviews of black applicants if historical wrongs and continued underrepresentation of African Americans in medicine are to be redressed. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Kenneth G. Poole Jr, Department of Internal Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, Arizona 85259; telephone: (314) 325-5729; poole.kenneth@mayo.edu. © 2019 by the Association of American Medical Colleges

The Homeless Hospital Liaison Program: An Interprofessional Program to Improve Students’ Skills at Facilitating Transitions of Care for Patients Experiencing Homelessness Problem: Traditional medical school curricula lack specific training on caring for individuals experiencing homelessness, and the literature suggests that medical students’ attitudes toward these individuals become increasingly negative during medical school. Approach: To increase discharge planning support for individuals experiencing homelessness, the Homeless Hospital Liaison (HHL) program was developed at the University Medical Center New Orleans in January 2017–May 2017. Student liaisons are recruited from all four years of medical school and a graduate-level social work program. Liaisons administer a social needs questionnaire to assess patients’ connections to services and identify gaps in care, coordinate with hospital social workers to avoid duplicating work, coordinate with the medical team, help patients complete any needed documentation or applications for social benefits, provide patients with referrals to outpatient resources, and provide patients assistance with a variety of basic needs. Outcomes: As of December 2017, HHL has trained 70 students (65 medical students and 5 social work students) to serve as liaisons and has enrolled 99 patients. For the majority of these patients, student liaisons were able to facilitate successful referrals to community-based services. Next Steps: Future directions of the HHL program include developing a formal, staffed consult service at the hospital (e.g., the HHL program was awarded hospital funding for two full-time staff in the summer of 2019, which will increase the HHL’s capacity); assessing the program’s effect on student knowledge, attitudes, and proficiency related to individuals experiencing homelessness and/or interprofessional collaboration; and assessing the impact of the program on patients’ experiences. Acknowledgments: The authors would like to acknowledge the support of the University Medical Center New Orleans, Tulane University School of Medicine, Tulane University School of Social Work, Street Medicine New Orleans, and the many community organizations they work with. Additionally, the authors would like to express gratitude to Drs. Charles Zhang, C.J. Kwan, Joe Kanter, and Chayan Chakraborti for providing continued advice, mentorship, and support. Funding/Support: One student leader was able to dedicate time to coordinating and evaluating this program with support from a National Institutes for Health TL1 grant from the Center for Clinical and Translational Science at Tulane University School of Public Health and Tropical Medicine (award number 5TL1TR001418). Other disclosures: None reported. Ethical approval: The evaluation of this program was approved by the Tulane University Institutional Review Board on July 20, 2018 (#2018-891). Previous presentations: The conceptualization of this project was presented as a poster at the International Street Medicine Symposiums in September 2017 (Allentown, Pennsylvania) and October 2018 (Rotterdam, the Netherlands) and at the Institute for Health Improvement Forums in December 2017 (Orlando, Florida) and December 2018 (Orland, Florida) Correspondence should be addressed to Frances Gill, 1467 N. Galvez St., New Orleans, LA 70119; telephone: (425) 753-3997; email: fgill1@tulane.edu. © 2019 by the Association of American Medical Colleges

Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care Purpose: The authors previously found attending physicians conceptualize hospital admission purpose according to three perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. Method: Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. Results: The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge-focused vs optimization-focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspective, using authority to shut down and re-direct discussion. Trainees’ maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). Conclusions: Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and covert maneuvers by trainees, potentially affecting trust and professional identify development. To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s web site (https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=65) follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the December 2018 issue for submission instructions and for more information about this feature). Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on trust in health care and health professions education. Acknowledgments: The authors wish to thank the study participants, all of whom were invaluable to the completion of this study. The authors would also like to thank Jennifer Campi for all of her support in editing the final manuscript. The article is a better read as a result of her efforts. Funding/Support: This study was funded in part by the Ontario Medical Students’ Association (OMSA) Open Medical Student Education Research and in part by Academic Medical Organization of Southwestern Ontario (AMOSO) Innovations Grant Project R3381A06. Other disclosures: The authors have no competing interests to declare. Ethical approval: The study was approved by the University of Western Ontario Health Sciences Research Ethics Board (Project ID 6822). Previous presentations: Canadian Conference on Medical Education; April 29, 2018; Halifax, Nova Scotia, Canada. Correspondence should be addressed to Mark Goldszmidt, Centre for Education Research and Innovation, Schulich School of Medicine & Dentistry, Western University, Health Sciences Addition Room 115, London, Ontario, Canada, N6A 5C1; telephone: 519-858-5007; email: Mark.Goldszmidt@schulich.uwo.ca. © 2019 by the Association of American Medical Colleges

Toward Cultural Competency in Health Care: A Scoping Review of the Diversity and Inclusion Education Literature Purpose: To explore best practices for increasing cultural competency and reducing health disparities, the authors conducted a scoping review of the existing literature. Method: The review was guided by two questions: (1) Are health care professionals and medical students learning about implicit bias, health disparities, advocacy, and the needs of diverse patient populations? (2) What educational strategies are being used to increase student and educator cultural competency? In August 2016 and July 2018, the authors searched 10 databases (including Ovid MEDLINE, Embase, and Scopus) and MedEdPORTAL, respectively, using keywords related to multiple health professions and cultural competency or diversity and inclusion education and training. Publications from 2005 to August 2016 were included. Results were screened using a two-phase process (title and abstract review followed by full-text review) to determine if articles met the inclusion or exclusion criteria. Results: The search identified 89 articles that specifically related to cultural competency or diversity and inclusion education and training within health care. Interventions ranged from single-day workshops to a 10-year curriculum. Eleven educational strategies used to teach cultural competency and about health disparities were identified. Many studies recommended using multiple educational strategies to develop knowledge, awareness, attitudes, and skills. Less than half of the studies reported favorable outcomes. Multiple studies highlighted the difficulty of implementing curricula without trained and knowledgeable faculty. Conclusions: For the field to progress in supporting a culturally diverse patient population, comprehensive training of trainers, longitudinal evaluations of interventions, and the identification and establishment of best practices will be imperative. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A748, http://links.lww.com/ACADMED/A749, and http://links.lww.com/ACADMED/A750. Funding/Support: This study was funded by the Faculty Fellows and Emerging Scholar-Professional Grant Program, Center for Diversity and Inclusion, Washington University in Saint Louis. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: The principal investigators presented the preliminary results of this scoping literature review orally at the iTeach Symposium at Washington University in St. Louis, St. Louis, Missouri, in January 2018. Preliminary results were presented as a poster at the National Academies of Practice Annual Meeting & Forum in Atlanta, Georgia, in April 2018. Correspondence should be addressed to Douglas M. Char, Division of Emergency Medicine, Campus Box #8072, Washington University School of Medicine, 660 S. Euclid Ave., St Louis, MO 63110; telephone: (314) 362-4346; email: chard@wustl.edu. © 2019 by the Association of American Medical Colleges

A Reliability Analysis of Entrustment-Derived Workplace-Based Assessments Purpose: To examine the reliability and attributable facets of variance within an entrustment-derived workplace-based assessment system. Method: Faculty at the University of Cincinnati Medical Center internal medicine residency program assessed residents using discrete workplace-based skills called observable practice activities (OPAs) rated on an entrustment scale. Ratings from July 2012–December 2016 were analyzed using applications of generalizability theory (G-theory) and decision study framework. Given the limitations of G-theory applications with entrustment ratings (the assumption that mean ratings are stable over time), a series of time-specific G-theory analyses and an overall longitudinal G-theory analysis were conducted to detail the reliability of ratings and sources of variance. Results: During the study period, 166,686 OPA entrustment ratings were given by 395 faculty members to 253 different residents. Raters were the largest identified source of variance in both the time-specific and overall longitudinal G-theory analyses (37% and 23%, respectively). Residents were the second largest identified source of variation in the time-specific G-theory analyses (19%). Reliability was approximately 0.40 for a typical month of assessment (27 different OPAs, 2 raters, and 1–2 rotations) and 0.63 for the full sequence of ratings over 36 months. A decision study showed doubling the number of raters and assessments each month could improve the reliability over 36 months to 0.76. Conclusions: Ratings from the full 36 months of the examined program of assessment showed fair reliability. Increasing the number of raters and assessments per month could improve reliability, highlighting the need for multiple observations by multiple faculty raters. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This project was approved by the University of Cincinnati Institutional Review Board. Correspondence should be addressed to Matthew Kelleher, 231 Albert Sabin Way, Room 7559, ML 0535, Cincinnati, OH 45267-0535; email: kellehmw@ucmail.uc.edu; Twitter: @kelzj3. © 2019 by the Association of American Medical Colleges

Tensions in Assessment: The Realities of Entrustment in Internal Medicine Purpose: A key unit of assessment in competency-based medical education (CBME) is the entrustable professional activity. The variations in how entrustment is perceived and enacted across specialties are not well understood. This study aimed to develop a thorough understanding of the process, concept, and language of entrustment as it pertains to internal medicine (IM). Method: Attending supervisors of IM trainees on the clinical teaching unit were purposively sampled. Sixteen semistructured interviews were conducted and analyzed using constructivist grounded theory. The study was conducted at the University of Toronto from January to September 2018. Results: Five major themes were elucidated. First, the concepts of entrustment, trust, and competence are not easily distinguished and sometimes conflated. Second, entrustment decisions are not made by attendings, but rather are often automatic and predetermined by program or trainee level. Third, entrustment is not a discrete, point-in-time assessment due to longitudinality of tasks and supervisor relationships with trainees. Fourth, entrustment scale language does not reflect attendings’ decision making. Fifth, entrustment decisions affect the attending more than the resident. Conclusions: A tension arises between the need for a common language of CBME and the need for authentic representation of supervision within each specialty. With new assessment instruments required to operationalize the tenets of CBME, it becomes critically important to understand the nuanced and specialty-specific language of entrustment to ensure validity of assessments. Acknowledgments: The authors acknowledge Stephen Durant for assistance with interviewing and transcription and the participants for sharing their insights. Funding/Support: This study was funded by the University of Toronto Department of Medicine Challenge Grant. L. Stroud is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. Other disclosures: None reported. Ethical approval: This study was approved by the University of Toronto Health Sciences Research Ethics Board. Previous presentations: Peer-reviewed oral abstracts were presented at the International Conference on Residency Education, Halifax, Ontario, Canada, October 2018, and the Canadian Conference on Medical Education, Niagara Falls, Ontario, Canada, April 2019. Correspondence should be addressed to Lindsay Melvin, Toronto Western Hospital, 399 Bathurst St., 8E-425, Toronto, ON M5T 2S8 Canada; email: lindsay.melvin@uhn.ca; Twitter: @LMelvinMD. © 2019 by the Association of American Medical Colleges

Open Office Space: The Wave of the Future for Academic Health Centers? Facing space constraints similar to those experienced by many urban campuses, the University of California, San Francisco (UCSF) looked to innovative office workplace design to curb growing facilities expenditures. Mission Hall, a new office building primarily for desktop and clinical researchers and staff, was designed as an activity-based workplace (ABW), a type of open-space design. ABW was simultaneously being proposed as the template for future UCSF desktop research workspaces. ABWs can be less costly to construct than other designs and their mix of shared and open workspaces is intended to improve efficiency and interaction. Evaluations of ABWs in corporate settings have yielded mixed results. Examples of ABW buildings for faculty in academic health centers (AHCs) are rare. The Mission Hall experience provided a unique opportunity to understand the impact of an ABW design on faculty satisfaction, work effectiveness, well-being, and engagement. In a 2016 survey of faculty, one year after occupancy, respondents reported adverse changes in all four areas. The most common complaints involved noise exposure and lack of visual and auditory privacy. In response to these issues, faculty reported working at home or elsewhere more frequently, making collaboration more difficult. In 2018, UCSF retrofitted the building to create some private offices and adjusted its overall program to balance private office and open workspaces in future projects. Lessons drawn from this experience can inform workplace solutions at other AHCs. Most critical are the needs to assess functional requirements of work and align design, change management, and technologies to support those requirements. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A747. Acknowledgments: The authors are grateful for the data analysis provided by Joo Young Ro, formerly of Perkins + Will, and Dr. Yongha Hwang of University of Michigan and for the administration of the survey by Dr. Lindsay Graham of the Center for the Built Environment at the University of California, Berkeley. Funding/Support: Funding for this research was provided by the University of California Capital Programs Office. Other disclosures: None reported. Ethical approval: The University of California, San Francisco institutional review board approved the study as minimal risk. Correspondence should be addressed to Nancy Adler, 3333 California Street, Suite 465, San Francisco, California 94118; telephone: 415-476-7759; email: Nancy.adler@ucsf.edu. © 2019 by the Association of American Medical Colleges