Variation in Entrustment When Sharing a Single Assessment System Between University- and Community-Based Residency Programs: A Comparison Purpose: Given resource constraints, many residency programs would consider adopting an entrustment-based assessment system from another program if given the opportunity. However, it is unclear if a system developed in one context would have similar or different results in another. This study sought to determine if entrustment varied between programs (community-based and university-based) when a single assessment system was deployed in different contexts. Method: The Good Samaritan Hospital (GSH) internal medicine residency program adopted the Observable Practice Activity (OPA) workplace-based assessment system from the University of Cincinnati (UC). Comparisons for OPA-mapped subcompetency entrustment progression for programs and residents were made at specific timepoints over the course of 36 months of residency. Data collection occurred from August 2012 to June 2017 for UC, and from September 2013 to June 2017 for GSH. Results: GSH entrustment ratings were higher than UC for all but the 11th, 15th, and 36th months of residency (P < .0001), and were also higher for the majority of subcompetencies and competencies (P < .0001). The rate of change for average monthly entrustment was similar, with GSH having an increase of 0.041 each month versus 0.042 for UC (P = .73). Most residents progressed from lower to higher entrustment but there was significant variation between residents in each program. Conclusions: Despite the deployment of a single entrustment-based assessment system, important outcomes may vary by context. Further research is needed to understand the contributions of tool, context, and other factors on the data these systems produce. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The institutional review boards of both University of Cincinnati and Good Samaritan Hospital approved this study. Previous presentations: Portions of these data were presented at New York University Medical Education Grand Rounds in New York City in September 18, 2018, and the International Conference on Residency Education in Halifax in October 18, 2018. Data: Not applicable (no data from outside sources). Correspondence should be addressed to Eric J. Warm, University of Cincinnati College of Medicine, 231 Albert Sabin Way M.L. 0557, Cincinnati, Ohio 45267-0557; email: warmej@ucmail.uc.edu; Twitter: @CincyIM. © 2019 by the Association of American Medical Colleges

From Monotony to Motivation: Effective Presentation of Epidemiological Data No abstract available

Exploring How Pediatric Residents Develop Adaptive Expertise in Communication: The Importance of “Shifts” in Understanding Patient and Family Perspectives Purpose: Communication with patients and families can be complex, especially in challenging discussions. To communicate effectively, expert physicians must often use flexible approaches. This innovative use of knowledge to handle complexity is an essential capability of adaptive expertise. Despite its importance for effective communication and implications for medical education, little is known about how adaptive expertise develops in trainees. The purpose of this study was to explore how pediatric residents developed adaptive expertise in communication. Method: A constructivist grounded theory study, using observations of physician–patient communication and semi-structured interviews as data sources, and purposeful sampling of 10 pediatric subspecialty residents at the University of Toronto, was conducted in 2016–2017. Data collection and analysis occurred iteratively and themes were identified through the research team’s constant comparative analysis. Results: Residents navigated challenging discussions with patients and families by enabling them to express their own narratives and integrating these with their medical knowledge to provide care. At times, a “shift” in the residents’ understanding of the families’ perspectives was needed to effectively navigate the discussion. Residents used this shift purposefully to create new communication strategies, resulting in an opportunity for learning. Conclusions: “Shifts” are defined as adjustments in the resident’s understanding of a family’s perspective that affects clinical care. Analysis suggests that these “shifts” can be understood to support development of adaptive expertise. The workplace learning environment promoted this development by providing opportunities that prepared residents for future learning through active experimentation, offering multiple perspectives, and enhancing deeper conceptual learning. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A742. Funding/Support: Bloorview Research Institute Catalyst Grant. Other disclosures: None reported. Ethical approval: This study was approved by the research ethics boards from the Bloorview Research Institute, University of Illinois at Chicago, and Hospital for Sick Children. Previous presentations: This work was presented at the International Association for Medical Education (AMEE) 2108 meeting, August 27, 2018, Basel, Switzerland. Correspondence should be addressed to Anne Kawamura, Holland Bloorview Kids Rehabilitation Hospital, 150 Kilgour Road, Toronto, ON, Canada M4G 1R8; telephone: (416) 425-6220, ext. 3586; email: akawamura@hollandbloorview.ca. © 2019 by the Association of American Medical Colleges

#Shemergency: Use of a Professional Development Group to Promote Female Resident Recruitment and Retention Problem: Gender inequity in academic medicine is a pervasive challenge. Recommendations have been implemented to reduce inequities for female faculty. However, there are no well-established guidelines for the recruitment and retention of female residents. Approach: To address challenges faced by female physicians and support the recruitment and retention of female residents, female emergency medicine residents and attending physicians at the Hospital of the University of Pennsylvania formed a professional development group (PDG), #Shemergency, in July 2017. From July 2017 to July 2018, this PDG developed events and initiatives for female residents that addressed methods to improve awareness of and develop skills relevant to well-described gender disparities in mentorship, speakership and conference representation, compensation, evaluations, wellness and service, and award recognition. Outcomes: Over its first year (July 2017–July 2018), the PDG created a professional community and enhanced mentorship through a number of events and initiatives. The PDG secured funding for five residents to attend a national conference and nominated five residents and two attending physicians for professional organization awards (four nominees won). Next Steps: After the first year, the PDG expanded to include joint activities with both male and female colleagues and organized a city-wide event for female residents and faculty representing five different residency programs. Future work will focus on sustainability (e.g., holding fundraising events), generalizability (e.g., expanding the gender disparity areas addressed), developing additional events and initiatives (e.g., expanding the number of joint activities with male colleagues), and outcome assessments (e.g., distributing pre- and post-event surveys). The authors have informed the journal that they agree that U.G. Khatri, J. Love, and A. Zeidan completed the intellectual and other work typical of the first author. Acknowledgments: The authors would like to acknowledge the emergency medicine residents and faculty at the Hospital of the University of Pennsylvania for their continued support and participation in #Shemergency. The authors would also like to acknowledge the Academy for Women in Academic Emergency Medicine and FemInEM (Females Working in Emergency Medicine) for their continued leadership and inspiration in addressing gender inequities in emergency medicine. Funding/Support: C.H. Hsu is supported by a National Institutes of Health grant (NIH K12HL133304-01). Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: This work was presented as a didactic session entitled “Six Effective #Shemergency Strategies for Recruitment and Retention of Female Emergency Medicine Residents” at the 2019 Society of Academic Emergency Medicine Annual Meeting in Las Vegas, Nevada, on May 16, 2019. Correspondence should be addressed to Angela M. Mills, Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th St., VC2-Suite 260, New York, NY 10032; telephone: (212) 305-8556; email: angela.mills@columbia.edu; Twitter: @AngelaMMills. © 2019 by the Association of American Medical Colleges

A Responsible Educational Handover: Improving Communication to Improve Learning An important tenet of competency-based medical education is that the educational continuum should be seamless. The transition from undergraduate medical education (UME) to graduate medical education (GME) is far from seamless, however. Current practices around this transition drive students to focus on appearing to be competitively prepared for residency. A communication at the completion of UME—an educational handover—would encourage students to focus on actually preparing for the care of patients. In April 2018, the American Medical Association’s Accelerating Change in Medical Education consortium meeting included a debate and discussion on providing learner performance measures as part of a responsible educational handover from UME to GME. In this Perspective, the authors describe the resulting five recommendations for developing such a handover: (1) The purpose of the educational handover should be to provide medical school performance data to guide continued improvement in learner ability and performance; (2) the process used to create an educational handover should be philosophically and practically aligned with the learner’s continuous quality improvement; (3) the educational handover should be learner-driven with a focus on individualized learning plans that are coproduced by the learner and a coach or advisor; (4) the transfer of information within an educational handover should be done in a standardized format; and (5) together, medical schools and residency programs must invest in adequate infrastructure to support learner improvement. These recommendations are shared to encourage implementation of the educational handover and to generate a potential research agenda that can inform policy and best practices. Acknowledgments: The authors wish to thank all of the American Medical Association’s Accelerating Change in Medical Education consortium members who participated in and contributed to the discussion. Funding/support: None reported. Other disclosures: Richard Hawkins is co-editor of a textbook on the assessment of clinical competence, for which he receives royalties from Elsevier. Ethical approval: Reported as not applicable. Disclaimer: This article reflects discussion during an April 2018 meeting of the AMA Medical Education Consortium at the Warren Alpert Medical School of Brown University. It does not necessarily reflect the positions of the organizations represented by the meeting participants. Correspondence should be addressed to Helen K. Morgan, Department of Obstetrics and Gynecology, University of Michigan Medical School, 1500 E. Medical Center Dr., L4000 Von Voigtlander Women’s Hospital, Ann Arbor, MI 48109; telephone: 734-936-3110; email: hjkang@med.umich.edu. © 2019 by the Association of American Medical Colleges

Models of Faculty Involvement in Primary Care Residency Teaching Clinics Through site visits to 42 teaching clinics in family and internal medicine residency programs during 2013–2018, the authors observed a spectrum of faculty involvement. In this Perspective, they describe and share examples of the 3 faculty models they identified. Some programs have a small, focused faculty whose members spend at least 5 half-day sessions/week seeing patients or precepting residents in the clinic. Others have a large, dispersed faculty with many faculty physicians who spend 1 or 2 half-day sessions/week in the clinic. Some use a hybrid model with a small focused faculty group plus other faculty with little clinic time. The dispersed model was observed only in university-based residencies and the focused faculty model was commonly seen in community-based residencies. While faculty in both settings must juggle multiple responsibilities, several studies have confirmed the value of having faculty committed to ambulatory care and teaching. In site-visit interviews, clinic leaders indicated focused faculty play an important role in teaching clinics by championing clinic improvement, improving continuity of care, and enhancing the resident experience. Faculty physicians who spend substantial time in the clinic know the residents’ patients, provide greater continuity of care, anchor clinic teams, and coordinate coverage for residents when they are on other rotations. Clinic and residency program leaders generally favored a shift toward a focused or hybrid model. The authors view the hybrid model as a practical way to balance the challenges of having a focused faculty with the multiple responsibilities facing university- and community-based faculty. Funding/Support: This work was funded in part by the Josiah Macy Jr Foundation (grant 127672A). Other disclosures: None reported. Ethical approval: The project was reviewed by the University of California, San Francisco, Committee on Human Research and deemed exempt. Correspondence should be addressed to Thomas Bodenheimer, University of California, San Francisco, 995 Potrero Avenue, 3rd floor, San Francisco CA 94110; telephone: 425-269-5021; email: Thomas.Bodenheimer@ucsf.edu. © 2019 by the Association of American Medical Colleges

Relationships as the Backbone of Feedback: Exploring Preceptor and Resident Perceptions of Their Behaviors During Feedback Conversations Purpose: Newer definitions of feedback emphasize learner engagement throughout the conversation, yet teacher and learner perceptions of each other’s behaviors during feedback exchanges have been less well studied. This study explored perceptions of residents and faculty regarding effective behaviors and strategies during feedback conversations and factors that affected provision and acceptance of constructive feedback. Method: Six outpatient internal medicine preceptors and 12 residents at Brigham and Women’s Hospital participated (2 dyads per preceptor) between September 2017 and May 2018. Their scheduled feedback conversations were observed by the lead investigator, and one-on-one interviews were conducted with each member of the dyad to explore their perceptions of the conversation. Interviews were transcribed and analyzed for key themes. Because participants repeatedly emphasized teacher–learner relationships as key to meaningful feedback, a framework method of analysis was performed using the 3-step relationship-centered communication model REDE (relationship establishment, development, and engagement). Results: After participant narratives were mapped onto the REDE model, key themes were identified and categorized under the major steps of the model. First, establishment: revisit and renew established relationships, preparation allows deeper reflection on goals, set a collaborative agenda. Second, development: provide a safe space to invite self-reflection, make it about a skill or action. Third, engagement: enhance self-efficacy at the close, establish action plans for growth. Conclusions: Feedback conversations between longitudinal teacher–learner dyads could be mapped onto a relationship-centered communication framework. Our study suggests that behaviors that enable trusting and supportive teacher-learner relationships can form the foundation of meaningful feedback. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A743 Funding/Support: This study was funded by the Department of Medicine Clinical Education Research Scholars Grant at Brigham and Women’s Hospital. Dedication: A major source of inspiration and guidance to the research team and a personal role model to S. Ramani was the late Karen V. Mann, PhD, whose mentoring, wisdom, and guidance are sorely missed. Acknowledgments:The authors gratefully acknowledge the residents and faculty who enthusiastically participated in the study and shared their perceptions, challenges, and suggestions for best practices related to feedback, as well as the leadership of the Department of Medicine at Brigham and Women’s Hospital for active support of educational research in general and this research in particular. Other disclosures: None reported. Ethical approval: The study was granted exempt status by the Partners Institutional Review Board, the review board for Brigham and Women’s Hospital (Protocol #2013P002270/BWH). The board deemed that verbal consent was adequate, provided that narratives were deidentified. Previous presentations: The results of this research study were presented as part of S. Ramani’s PhD defense at Maastricht University, Maastricht, the Netherlands, on October 31, 2018. Correspondence should be addressed to Subha Ramani, Internal Medicine Residency Program, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115; telephone: (617) 732-6040; email: sramani@bwh.harvard.edu. © 2019 by the Association of American Medical Colleges

Leveraging Economies of Scale via Collaborative Interdisciplinary Global Health Tracks (CIGHTs): Lessons From Three Programs As interest in global health education continues to increase, residency programs seeking to accommodate learners’ expectations for global health learning opportunities often face challenges providing high-quality global health training. To address these challenges, some residency programs collaborate across medical specialties to create interdepartmental global health residency tracks or collaborative interdepartmental global health tracks (CIGHTs). In this Perspective, the authors highlight the unique aspects of interdepartmental tracks that may benefit residency programs by describing three established U.S.-based programs as models: those at Indiana University, Mount Sinai Hospital, and the University of Virginia. Through collaboration and economies of scale, CIGHTs are able to address some of the primary challenges inherent to traditional global health tracks: lack of institutional faculty support and resources, the need to develop a global health curriculum, a paucity of safe and mentored international rotations, and inconsistent resident interest. Additionally, most published global health learning objectives and competencies (e.g., ethics of global health work, pre-departure training) are not discipline-specific and can therefore be addressed across departments—which, in turn, adds to the feasibility of CIGHTs. Beyond simply sharing the administrative burden, however, the interdepartmental learning central to CIGHTs provides opportunities for trainees to gain new perspectives in approaching global health not typically afforded in traditional global health track models. Residency program leaders looking to implement or modify their global health education offerings, particularly those with limited institutional support, might consider developing a CIGHT as an approach that leverages economies of scale and provides new opportunities for collaboration. Acknowledgments: The authors would like to acknowledge and thank educators—in both global and local health care settings—who are committed to meaningful global health training for the next generation of physicians and other health care professionals. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The views and opinions are those of the authors and do not necessarily represent the views of their universities. Correspondence should be addressed to Megan S. McHenry, 1044 West Walnut Street, R4 402D, Indianapolis, Indiana 46202; telephone: (317) 274-8940; email: msuhl@iu.edu; Twitter: @MeganS_Mchenry. © 2019 by the Association of American Medical Colleges

Synthesizing and Reporting Milestones-Based Learner Analytics: Validity Evidence From a Longitudinal Cohort of Internal Medicine Residents Purpose: Coordinating and operationalizing assessment systems that effectively streamline and measure fine-grained progression of residents at various stages of graduate medical training can be challenging. This article describes development, administration, and psychometric analyses of a learner analytics system to resolve challenges in implementation of milestones by introducing the Scoring Grid Model, operationalized in an internal medicine (IM) residency program. Method: A three-year longitudinal cohort of 34 residents at the University of Illinois at Chicago College of Medicine began using this learner analytics system, from entry (July 2013) to graduation (June 2016). Scores from 23 assessments used throughout the 3-year training were synthesized using the Scoring Grid Model learner analytics system, to generate scores corresponding to the 22 reportable IM subcompetencies. A consensus model was used to develop and pilot test the model using feedback from IM faculty members and residents. Scores from the scoring grid were used to inform promotion decisions and reporting of milestone levels. Descriptive statistics and mixed-effects regression were used to examine data trends and gather validity evidence. Results: Initial validity evidence for content, internal structure, and relations to other variables that systematically integrate assessment scores aligned with the reportable milestones framework are presented, including composite score reliability of scores generated from the learner analytics system. The scoring grid provided fine-grained learner profiles and showed predictive utility in identifying low-performing residents. Conclusions: The Scoring Grid Model and associated learner analytics data platform may provide a practical, reasonable solution for generating fine-grained, milestones-based profiles supporting resident progress. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was approved by the institutional review board of the University of Illinois at Chicago. Disclaimers: Reported as not applicable. Previous presentations: Annual Meeting of the American Educational Research Association (AERA), New York, NY, April 13, 2018. Correspondence should be addressed to Yoon Soo Park, Department of Medical Education, College of Medicine, University of Illinois at Chicago, 808 South Wood Street, 963 CMET (MC 591), Chicago, IL 60612-7309; telephone: (312) 355-5406; email: yspark2@uic.edu; Twitter: @YoonSooPark2. © 2019 by the Association of American Medical Colleges

Medical Student Psychological Distress and Mental Illness Relative to the General Population: A Canadian Cross-Sectional Survey Purpose: To provide national data on Canadian medical students’ mental health and show how their mental health compares to similarly aged postsecondary graduates from the general population. Method: In 2015-2016, the authors conducted a survey of medical students in all years of study at all 17 Canadian medical schools. The surveys included validated items and instruments to assess for psychological distress, suicidal ideation, and diagnosed mood and anxiety disorders. Comparative analyses were performed between medical students and similarly aged postsecondary graduates using data from the Canadian Community Health Survey - Mental Health 2012. Results: The participation rate across all medical students was 40.2% (4,613/11,469). Relative to the general population of postsecondary graduates aged 20-34, medical students aged 20-34 had significantly higher rates of diagnosed mood disorders, diagnosed anxiety disorders, suicidal ideation, and psychological distress. Among medical students, being female was associated with having a mood or anxiety disorder, lifetime suicidal ideation, moderate or severe psychological distress, and higher mean K6 summative scores. Being in clinical training was associated with having suicidal ideation, moderate or severe psychological distress, and mood and anxiety disorders. Conclusions: Compared to postsecondary graduates from the general population, medical student respondents had significantly higher rates of psychological distress, suicidal ideation, and mood and anxiety disorders. Further research is needed to understand the factors that are contributing to these higher rates. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A740 and http://links.lww.com/ACADMED/A741. Acknowledgments: The authors wish to thank the Canadian Federation of Medical Students and the Fédération médicale étudiante du Québec, which provided organizational support in all aspects of study development and implementation; Christopher Simon, PhD, at the Canadian Medical Association for logistical support in implementing the study; Derek Puddester, MD, at the University of Ottawa for logistical support in implementing the study; Bryce Durafourt, MD, at Queen’s University for his work in the conceptual design of the study; Marie-Pier Bastrash, MD, at McGill University for her assistance with study design and implementation; Sue Mills, PhD, at the University of British Columbia for her assistance with project management and study design; Han Yan, MD, at the University of Toronto for her assistance with study implementation; Julien Dallaire, MD, at Université de Sherbrooke for his assistance with study implementation and survey questionnaire translation; Emily Hodgson, MD, at McMaster University for her assistance with survey questionnaire translation; Carl White Ulysse, MD, at the University of Toronto for his assistance with study implementation; and Franco Rizzuti, MD, at the University of Calgary for his assistance with project management. Funding/Support: This work was supported by a grant from the Canadian Medical Foundation, administered through the former Canadian Physician Health Institute of the Canadian Medical Association. E. Frank’s time was supported by the Canada Research Chair program. These sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. Other disclosures: None reported. Ethical approval: The Behavioural Research Ethics Board at the University of British Columbia approved all components of this study on October 1, 2015, with approval to study amendments on November 26, 2015. Ethics approval reference number: H14-02774. Previous presentations: Poster presentation, 2016 Canadian Conference on Medical Education, Montreal, Québec, Canada, April 2016; oral presentation, 2016 International Conference on Physician Health, Boston, Massachusetts, September 2016; oral presentation, 2017 Canadian Conference on Medical Education, Winnipeg, Manitoba, Canada, May 2017; oral presentation, 6th Annual Thomas and Alice Morgans Fear Memorial Conference, Halifax, Nova Scotia, Canada, March 2017; oral presentation, 5th Canadian Conference on Physician Health, Ottawa, Ontario, Canada, September 2017; oral presentation, 2018 Canadian Conference on Medical Education, Halifax, Nova Scotia, Canada, April 2018. Data: Data from the Canadian Community Health Survey - Mental Health 2012 for the Canadian general population was obtained and analyzed with permission from Statistics Canada (Government of Canada). This manuscript has been reviewed by Statistics Canada. Correspondence should be addressed to Brandon Maser, 555 University Ave., Toronto, ON, Canada, M5G 1X8; telephone: 416-813-7654, ext 228349; email: brandon.maser@mail.utoronto.ca. © 2019 by the Association of American Medical Colleges