Taken out of Context: Hazards in the Interpretation of Written Assessment Comments Purpose: Written comments are increasingly valued for assessment; however, a culture of politeness and the conflation of assessment with feedback lead to ambiguity. Interpretation requires reading between the lines, which is untenable with large volumes of qualitative data. For computer analytics to help with interpreting comments, the factors influencing interpretation must be understood. Method: Using constructivist grounded theory, the authors interviewed 17 experienced internal medicine faculty at 4 institutions between March and July, 2017, asking them to interpret and comment on 2 sets of words: those that might be viewed as “red flags” (e.g., good, improving) and those that might be viewed as signaling feedback (e.g., should, try). Analysis focused on how participants ascribed meaning to words. Results: Participants struggled to attach meaning to words presented acontextually. Four aspects of context were deemed necessary for interpretation: (1) the writer; (2) the intended and potential audiences; (3) the intended purpose(s) for the comments, including assessment, feedback, and the creation of a permanent record; and (4) the culture, including norms around assessment language. These contextual factors are not always apparent; readers must balance the inevitable need to interpret others’ language with the potential hazards of second-guessing intent. Conclusions: Comments are written for a variety of intended purposes and audiences, sometimes simultaneously; this reality creates dilemmas for faculty attempting to interpret these comments, with or without computer assistance. Attention to context is essential to reduce interpretive uncertainty and ensure that written comments can achieve their potential to enhance both assessment and feedback. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A765. Funding/Support: This study was funded by a Medical Council of Canada Grant for Research in Clinical Assessment (MCC-4/1516). Other disclosures: None reported. Ethical approval: This study was approved by the Health Sciences Research Ethics Board at the University of Toronto. Previous presentations: This work was presented at the Canadian Conference on Medical Education, April 2019, Niagara Falls, Ontario, Canada, and at the International Conference on Residency Education, September 2019, Ottawa, Canada. Correspondence should be addressed to Shiphra Ginsburg, Mount Sinai Hospital, 600 University Ave., Room 433, Toronto, Ontario M5G 1X5, Canada; telephone: (416) 586-8671; fax: (416) 586-8864; email: shiphra.ginsburg@utoronto.ca; Twitter: @sginsburg1. © 2019 by the Association of American Medical Colleges

Finding Greater Value in the Fourth Year of Medical School: Accelerating the Transition to Residency The recent focus on competency-based medical education has heralded a true change in U.S. medical education. Accelerating the transition from medical school to residency may reduce student debt, encourage competency-based educational advancement, and produce residency graduates better prepared for the independent and unsupervised practice of medicine. With some purposeful design considerations, innovative time-variable programs or fixed-time accelerated tracks can be implemented within current regulatory parameters and without major alteration of existing institutional regulatory guidelines, state licensing requirements, or specialty certification requirements. Conferring an MD degree in less than 4 full academic years provides opportunities to customize and find greater value in the fourth year of medical school as well as to redeploy time from undergraduate medical education to graduate medical education; this could shorten the overall time to completion of training and/or provide for customization of training in the final years of residency. In this article, the authors discuss the regulatory requirements for successful implementation, consider issues related to “off-cycle” graduates advancing to residency training outside of the Match, and share examples of three innovative accelerated programs in pediatrics, family medicine, and orthopaedics that have yielded advantages to individual learners, including reduced educational debt, as well as to the health care system. Acknowledgments: The authors acknowledge Donna H. Kern, MD, senior associate dean for medical education and associate professor, Department of Family Medicine, Medical University of South Carolina College of Medicine, for her support of the program, participation in the panel session at the AAMC’s Learn, Serve, Lead 2017, and assistance in technical editing of the manuscript. Funding/Support: No extramural funding was received in support of this work. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: This material was originally presented at Learn, Serve, Lead 2017: The AAMC Annual Meeting; November 5, 2017; Boston, Massachusetts. Correspondence should be addressed to Vincent D. Pellegrini Jr, Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, One Medical Center Drive, Lebanon, NH 03756; telephone: 603-653-6090; e-mail: Vincent.D.Pellegrini.Jr@hitchcock.org. © 2019 by the Association of American Medical Colleges

The Development of New MD-Granting Medical Schools in the United States in the 21st Century No new MD-granting medical schools were established during the 1980s and 1990s due to concerns that existed within the academic and policymaking communities that the United States was going to experience a major oversupply of physicians in the coming decades due to the increase that had occurred in medical school enrollment in the 1960s and 1970s. However, the results of studies conducted in the 1990s suggested that the country was actually going to experience a major shortage of physicians in the coming decades. As a result, new medical schools began to be established in the country after the turn of the 21st century. Since then, 29 new MD-granting medical schools have been established in the United States. This Invited Commentary examines some of the characteristics of the new schools and provides an overview of various factors that contributed to their development, including financial resources and geographic location. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Michael E. Whitcomb, email: whitcombmesr@hotmail.com. © 2019 by the Association of American Medical Colleges

Interprofessional Substance Use Disorder Education in Health Professions Education Programs: A Scoping Review Purpose: The authors conducted this scoping review to (1) provide a comprehensive evaluation and summation of published literature reporting on interprofessional substance use disorder (SUD) education for students in health professions education programs and (2) appraise the research quality and outcomes of interprofessional SUD education studies. Their goals were to inform health professions educators of interventions that may be useful to consider as they create their own interprofessional SUD courses and to identify areas of improvement for education and research. Method: The authors searched 3 Ovid MEDLINE databases (MEDLINE, In-Process & Other Non-Indexed Citations, and Epub Ahead of Print), Embase.com, ERIC via FirstSearch, and Clarivate Analytics Web of Science from inception through December 7, 2018. The authors used the Medical Education Research Study Quality Instrument (MERSQI) to assess the included studies’ quality. Results: The authors screened 1,402 unique articles, and 14 met inclusion criteria. Publications dated from 2014-2018. Ten (71%) included students from at least 3 health professions education programs. The mean MERSQI score was 10.64 (SD = 1.73) (range 7.5–15). Interventions varied by study, and topics included general substance use (n = 4, 29%), tobacco (n = 4, 29%), alcohol (n = 3, 21%), and opioids (n = 3, 21%). Two studies (14%) used a nonrandomized 2-group design. Four (29%) included patients in a clinical setting or panel discussion. Ten (72%) used an assessment tool with validity evidence. Studies reported interventions improved students’ educational outcomes related to SUDs and/or interprofessionalism. Conclusions: Interprofessional SUD educational interventions improved health professions students’ knowledge, skills, and attitudes toward SUDs and interprofessional collaboration. Future SUD curriculum design should emphasize assessment and measure changes in students’ behaviors and patient or health care outcomes. Interprofessional SUD education can be instrumental in preparing the future workforce to manage this pressing and complex public health threat. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A767. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Andrew Muzyk, P.O. Box 3089–Pharmacy, Durham, NC 27710; telephone: 919-681-3438; e-mail: Andrew.Muzyk@duke.edu. © 2019 by the Association of American Medical Colleges

Outcomes Associated With Insertion of Indwelling Urinary Catheters by Medical Students in the Operating Room Following Implementation of a Simulation-Based Curriculum Purpose: Catheter associated urinary tract infection (CAUTI) is a priority quality metric for hospitals. The impact of placement of indwelling urinary catheter (IUC) by medical students on CAUTI rates is not well known. This study examined the impact of a simulation-based medical student education curriculum on CAUTI rates at an academic medical center. Method: Patient characteristics, procedural data, and outcome data from all operating room IUC insertions from June 2011 through December 2016 at the Northwestern University Feinberg School of Medicine were analyzed using a multivariable model to evaluate associations between CAUTI and inserting provider. Infection data before and after implementation of a simulation-based IUC competency course for medical students were compared. Results: A total of 57,328 IUC insertions were recorded during the study period. Medical students inserted 12.6% (7,239) of IUCs. Medical students had the lowest overall rate of CAUTI among all providers during the study period (medical students: 0.05%, resident/fellows: 0.2%, attending physicians: 0.3%, advanced practice clinicians: 0.1%, nurses: 0.2%; P = 003). Further, medical student IUC placement was not associated with increased odds of CAUTI in multivariable analysis (odds ratio 0.411, 95% confidence interval 0.122, 1.382, P = .15). Implementation of a simulation-based curriculum for IUC insertion resulted in complete elimination of CAUTI in patients catheterized by medical students (0 in 3,471). Conclusions: IUC insertion can be safely performed by medical students in the operating room. Simulation-based skills curricula for medical students can be effectively implemented and achieve clinically relevant improvements in patient outcomes. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A768. Acknowledgments: None. Funding/Support: None reported. Other Disclosures: None reported. Ethical approval: Data were collected as part of a chartered institutional quality improvement project and were accordingly exempt from institutional review board review. Disclaimers: None. Previous presentations: This study was presented as a poster presentation at an internal institutional research conference where it won first place in the Medical Education category. Data: The authors do not have permission to distribute these data publicly. Correspondence should be addressed to David D. Odell, Northwestern University Feinberg School of Medicine, Suite 650, 676 North Saint Clair, Chicago, Illinois, 60611; email: dodell@nm.org. © 2019 by the Association of American Medical Colleges

Reflections on Learning to Heal, Time to Heal, and Let Me Heal In this Invited Commentary, the author reflects on the contributions, influence, and continued relevance of his three books on American medical education: Learning to Heal, Time to Heal, and Let Me Heal. Collectively, the books provide a panoramic view of U.S. medical education spanning two centuries, and they cover virtually every topic and consideration pertinent to the enterprise. They are works of education as well as works of history, and as such, they identify the timeless principles and values—maintaining rigorous academic standards and serving as a public trust—that need to be protected at all costs if medical education in the United States is to retain its tradition of excellence and leadership. Learning to Heal describes the creation and maturation of the U.S. system of medical education, focusing on its cultural as well as its scientific roots; the book also defined the educational meaning and significance of these changes. Time to Heal introduced the term “learning environment” into the lexicon of medical education; it also inspired a number of notable experiments in undergraduate and graduate medical education. Let Me Heal provided the intellectual foundation for the 2017 version of Section VI of the Common Program Requirements of the Accreditation Council for Graduate Medical Education. However, the most notable contribution of these books is their analysis of medical education’s ongoing challenges and opportunities; thus, they provide a framework for improving medical education and health care delivery in the United States today. Acknowledgements: The author thanks W. Brownell Anderson, Jordan J. Cohen, Reneée C. Fox, and David B. Hellmann for their comments and sage advice. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to K.M. Ludmerer, Washington University in Saint Louis School of Medicine, 660 South Euclid Ave, Box 8066, St Louis, MO 63110, telephone: (314) 362-8073; email: KLUDMERE@WUSTL.EDU. © 2019 by the Association of American Medical Colleges

Women’s Representation Among Members and Leaders of National Medical Specialty Societies Purpose: National medical specialty societies speak for their respective fields in policy debates, influence research, affect trainees’ specialization decisions, provide career development opportunities, and confer awards and recognitions. This study provides a comprehensive overview of the gender demographics of society members and leaders. Method: In 2016, the Group on Women in Medicine and Science (of the Association of American Medical Colleges) sought to characterize the gender of members and leaders of specialty societies from 2000-2015. This report provides descriptive data, including how many of the responding societies (representing each of 30 major medical specialties) had substantial (> 10%) increases in women’s representation among leadership between the first and second halves of the study period. Results: The average proportion of female full members in responding societies was 25.4% in 2005; 29.3% in 2015. The proportion of women serving as the highest-ranking elected leader between 2000-2015 in each specialty ranged from 0 to 37.5% (mean 15.8%). The mean proportion of women on governing boards ranged from 0 to 37.3% (mean of means, 18.8%) in 2000-07 and from 0 to 47.6% (mean of means, 25.2%) in 2008-2015. In 9 specialties, the mean percentage of women serving on governing boards increased by > 10% from the first to second half of the study period. Conclusions: Although many women are full members of specialty societies, women still constitute a minority of leaders. This report establishes a baseline from which to evaluate the effect of societies’ efforts to improve diversity, equity, and inclusion. Acknowledgements: The authors gratefully acknowledge the contributions of Barbara Fivush, Rebecca Ganetzsky, Marin Gillis, Martha Gulati, and other members of the Association of American Medical Colleges (AAMC) Group on Women in Medicine and Science (GWIMS) Steering Committee for their assistance in data collection, which they provided without compensation, along with the staff supporting the AAMC’s GWIMS and Council of Faculty and Academic Societies. Funding/Support: None reported. Other disclosures: Ms. Lautenberger is a paid employee of the Association of American Medical Colleges (AAMC), and all other authors have served on the steering committee of the AAMC’s Group on Women in Medicine and Science. Dr. Jagsi reports unrelated grants from the National Institutes of Health, the Doris Duke Charitable Foundation, the Susan Komen Foundation, and the Greenwall Foundation; consulting fees from Amgen and Vizient; and stock options for serving as an advisor to Equity Quotient. Dr. Flotte reports unrelated consulting fees for serving as an advisor to Beam Therapeutics. Ethical approval: This work was considered research on organizations (not human subjects research requiring institutional review board [IRB] approval) and no individual-level or private data were obtained; therefore, no IRB approval was needed or sought. Data: Each society providing data granted the authors permission to use the information provided for this analysis. The authors provided each society with a summary of the data pertinent to that society only for review prior to submitting this manuscript to Academic Medicine. The authors rounded all data to the tenth place—except, in an effort to maintain maximum fidelity to the information provided, where the data were rounded to the ones place by the submitting organization. Correspondence should be addressed to Dr. Reshma Jagsi, Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5010; telephone (734) 936-7810; e-mail: rjagsi@med.umich.edu; Twitter: @reshmajagsi. © 2019 by the Association of American Medical Colleges

It’s a Marathon, Not a Sprint: Rapid Evaluation of CBME Program Implementation Purpose: Despite the broad endorsement of competency-based medical education (CBME), myriad difficulties have arisen in program implementation. The authors sought to evaluate the fidelity of implementation and identify early outcomes of CBME implementation using Rapid Evaluation to facilitate transformative change. Method: Case-study methodology was used to explore the lived experience of implementing CBME in the emergency medicine postgraduate program at Queen’s University, Canada, using iterative cycles of Rapid Evaluation in 2017–2018. After the intended implementation was explicitly described, stakeholder focus groups and interviews were conducted at 3 and 9 months post-implementation to evaluate the fidelity of implementation and early outcomes. Analyses were abductive, using the CBME core components framework and data-driven approaches to understand stakeholders’ experiences. Results: In comparing planned with enacted implementation, important themes emerged with resultant opportunities for adaption. For example, lack of a shared mental model resulted in frontline difficulty with assessment and feedback, and a concern that the granularity of competency-focused assessment may result in “missing the forest for the trees,” prompting the return of global assessment. Resident engagement in personal learning plans was not uniformly adopted and learning experiences tailored to residents’ needs were slow to follow. Conclusions: Rapid Evaluation provided critical insights into the successes and challenges of operationalization of CBME. Implementing the practical components of CBME was perceived as a sprint, while realizing the principles of CBME and changing culture in postgraduate training is a marathon requiring sustained effort in the form of frequent evaluation and continuous faculty and resident development. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A762. Acknowledgments: The authors would like to thank all of the faculty and residents at Queen’s University Emergency Medicine for their willingness to participate in interview and focus groups. Funding/Support: This study was funded by a Southeastern Ontario Academic Medical Organization (SEAMO) Endowed Scholarship and Education Fund grant. Other disclosures: None reported. Ethical approval: This study received approval from the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board (Emed-262-17). Disclaimers: None reported. Previous presentations: Limited preliminary findings from this study were presented as a poster at the 2018 Canadian Association of Emergency Physicians annual conference, May 28, 2018, Calgary, Alberta, Canada; and as a Technical Report submitted to the Royal College Emergency Medicine Specialty Committee, November 21, 2017. More complete findings were presented as an oral presentation at the 2018 World Summit on Competency-Based Medical Education (CBME), Basel, Switzerland, August 24, 2018; and as an oral presentation at the 2018 International Conference on Residence Residency Education, October 20, 2018, Halifax, NS, Canada. Correspondence should be addressed to Andrew K. Hall, Department of Emergency Medicine, Queen’s University, Victory 3, Kingston General Hospital, 76 Stuart Street, Kingston, ON, Canada, K7L 2V7; telephone: (613) 548-2368; email: andrew.hall@queensu.ca; Twitter: @AKHallMD. © 2019 by the Association of American Medical Colleges

Characteristics of Paid Malpractice Claims Among Resident Physicians From 2001–2015 in the United States Purpose: Limited information exists about medical malpractice claims against physicians-in-training. Data on residents’ involvement in malpractice actions may inform perceptions about medicolegal liability and influence clinical decision-making at a formative stage. This study aimed to characterize rates and payment amounts of paid malpractice claims on behalf of resident physicians in the United States. Method: Using data from the National Practitioner Data Bank, 1,248 paid malpractice claims against resident physicians (interns, residents and fellows) 2001–2015, representing 1,632,471 residents-years, were analyzed. Temporal trends in overall and specialty-specific paid claim rates, payment amounts, catastrophic (> $1 million) and small (< $100,000) payments, and other claim characteristics were assessed. Payment amounts were compared to attending physicians during the same time period. Results: The overall paid malpractice claim rate was 0.76 per 1,000 resident-years from 2001–2015. Among 1,194 unique residents with paid claims, 95.7% had exactly one claim, while 4.3% had 2 to 4 claims during training. Specialty-specific paid claim rates ranged from 0.12 per 1,000 resident-years (pathology) to 2.96 (obstetrics/gynecology). Overall paid claim rates decreased by 52% from 2001–2005 to 2011–2015 (95% CI: 0.45, 0.59). Median inflation-adjusted payment amount was $199,024 (2015 dollars); not significantly different from payments made on behalf of attending physicians during the same period. Proportions of catastrophic (11.2%) and small (33.1%) claims did not significantly change over the study period. Conclusions: From 2001–2015, paid malpractice claim rates on behalf of resident physicians decreased by 52%, while median payment amounts were stable. Resident paid claim rates were lower than attending physicians, while payment amounts were similar. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A763. Acknowledgments: The authors wish to thank Susan Loomis, Radiology Educational Media Services at Massachusetts General Hospital. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to McKinley Glover, Massachusetts General Hospital, 55 Fruit St, GBR 273A, Boston, Massachusetts 02114; telephone: (617) 726-8323; email: McKinley.Glover@mgh.harvard.edu. © 2019 by the Association of American Medical Colleges

Clinical Reasoning and Diagnostic Error: A Call to Merge Two Worlds to Improve Patient Care Numerous and substantial challenges exist in the provision of safe, cost-effective, and efficient health care. The prevalence and consequences of diagnostic error, one of these challenges, have been established by the literature; however, these errors persist, and the pace of improvement has been slow. One potential reason for the lack of needed progress is that addressing delayed and wrong diagnoses will require contributions from two currently distinct worlds: clinical reasoning and diagnostic error. In this Invited Commentary, the authors argue for merging the diagnostic error and clinical reasoning fields as the perspectives, frameworks, and methodologies of these two fields could be leveraged to yield a more aligned approach to understanding and subsequently to mitigating diagnostic error. The authors focus on the problem of diagnostic labeling (a categorization task where one has to choose the correct label or diagnosis). The authors also elaborate on why this alignment could also help guide health care improvement efforts, using the vexing problem of context specificity that leads to unwanted variance in health care as an example. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The views expressed herein are those of the authors and not necessarily those of the Department of Defense or other federal agencies. Correspondence should be addressed to Steven J. Durning, Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814; email: steven.durning@usuhs.edu. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2019 by the Association of American Medical Colleges