How Do Attending Physicians Prepare Residents to Deliver High-Value, Cost-Conscious Care? Purpose: An estimated 20% of health care expenditures are wasteful. Educational interventions aimed at reducing waste by delivering high-value, cost-conscious care (HV3C) often focus on the role of the physician. This study sought to understand how attending physicians, who have a central role in the workplace, prepare residents to provide HV3C. Method: Researchers from Maastricht University in Maastricht, the Netherlands, conducted semistructured interviews between September 2016 and August 2017 with 12 attending physicians who supervise residents in the workplace. Participants were purposefully sampled from 5 institutions throughout the Netherlands to include surgical and nonsurgical attending physicians and hospital- and nonhospital-based physicians. Data collection and analysis were iterative, using principles of grounded theory. Results: The attending physician’s approach to providing HV3C was an important factor in preparing residents in the workplace. Three differences became apparent: priority of HV3C training, feedback on HV3C, and obstacles to HV3C delivery. Results indicate that attending physicians use 3 teaching methods to teach HV3C delivery: Socratic questioning, role modeling, and setting limits. Training was often implicit and ad hoc. Conclusions: How attending physicians deal with HV3C themselves influences how they prepare residents in the workplace. To optimize resident training, it may be important to create a supportive environment for HV3C delivery and training. Delivery could be supported by making HV3C a shared goal for attending physicians and residents, thereby providing insight into clinical practice behavior and minimizing the influence of obstacles. Training could be optimized by supporting a variety of teaching methods suitable for daily teaching to stimulate continuous learning in residents. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A766. Acknowledgments: The authors thank the 6 program directors and 12 attending physicians for their time and input in this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was approved by the ethical review board associated with the Netherlands Association for Medical Education on June 18, 2015, under file number 547. Correspondence should be addressed to Lorette Stammen, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands; telephone: +31 43 388 5741; email: l.stammen@maastrichtuniversity.nl. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by the Association of American Medical Colleges

We Must Graduate Physicians, Not Doctors Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 non-physician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education, and cannot mitigate the shortfall of 112,000 physicians expected in 2030. To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents’, or there could be a token amount for this “internship.” Both models decrease the cost of medical education; the second financially unburdens the hospital. Since the Flexner Report (when there was no formal postgraduate training), the endpoint of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors. Funding/Support: None reported. Other disclosures: M. Dewan receives royalties from American Psychiatric Publishing, Inc. Ethical approval: Reported as not applicable. Data: The authors have reported 2018 and 2019 National Resident Matching Program (NRMP) Match data with permission from NRMP. Correspondence should be addressed to Mantosh J. Dewan, Office of the President, Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210; telephone: 315-464-4513; email: dewanm@upstate.edu. © 2019 by the Association of American Medical Colleges

The Effective Use of Videos in Medical Education No abstract available

Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Plan Reducing errors in diagnosis is the next big challenge for patient safety. Diagnostic safety improvement efforts should become a priority for health care organizations, payers, and accrediting bodies; however, external incentives, policies, and practical guidance to develop these efforts are largely absent. In this Perspective, the authors highlight ways in which health care organizations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organization at Geisinger, the authors propose a 5-point action plan and corresponding policy levers to support development of LEDE organizations. These recommendations, which are applicable to many health care organizations, include (1) implementing a virtual hub to coordinate organizational activities for improving diagnosis, such as identifying risks among competing priorities, prioritizing interventions that cross intra-institutional silos, and promoting a culture of learning and safety; (2) participating in novel scientific initiatives to generate and translate evidence, given the rapidly evolving “basic science” of diagnostic excellence; (3) avoiding the “tyranny of metrics” by focusing on measurement for improvement rather than using measures to reward or punish; (4) engaging clinicians in activities for improving diagnosis and framing missed opportunities positively as learning opportunities rather than negatively as errors; and (5) developing an accountable culture of engaging and learning from patients, who are often underexplored sources of information. The authors also outline specific policy actions to support organizations in implementing these recommendations. They suggest this action plan can stimulate scientific, practice, and policy progress needed for achieving diagnostic excellence and reducing preventable patient harm. Acknowledgments: The authors would like to thank the members of Geisinger’s Committee to Improve Clinical Diagnosis for their support, their work in learning from diagnostic opportunities, and making diagnosis an organizational priority. Funding/Support: H. Singh’s research that informs this work was funded by the Veterans Affairs (VA) Health Services Research and Development Service (HSR&D) (CRE-12-033 and the Presidential Early Career Award for Scientists and Engineers USA 14-274), the Agency for Healthcare Research and Quality (R01HS27363, R01HS022087 and R18HS017820), the VA National Center for Patient Safety, the Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413), and the Gordon and Betty Moore Foundation. Diagnosis improvement activities at Geisinger are partially supported by the Safer Dx Learning Lab, funded by the Gordon and Betty Moore Foundation. These funding sources had no role in preparation, review, or approval of the manuscript. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Department of Veterans Affairs or the United States government. Correspondence should be addressed to Hardeep Singh, Michael E. DeBakey Veterans Affairs Medical Center, Center for Innovations in Quality, Effectiveness and Safety (152), 2002 Holcombe Boulevard 152, Houston, TX 77030; telephone: 713-794-8515; email: hardeeps@bcm.edu. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by the Association of American Medical Colleges

Honoring Medicine’s Social Contract: A Scoping Review of Critical Consciousness in Medical Education Purpose: To explore how the construct of critical consciousness has been conceptualized within the medical education literature and identify the main elements of critical consciousness in medical education so as to inform educational strategies to foster socially conscious physicians. Method: In March 2019, the authors conducted a literature search of four databases and Google Scholar, seeking articles discussing critical consciousness in medical education published any time after 1970. Three of the authors screened articles for eligibility. Two transcribed data using a data extraction form and identified preliminary emerging themes, which were then discussed by the whole research team to ensure agreement. Results: Of the initial 317 articles identified, 20 met study inclusion criteria. The publication of academic articles around critical consciousness in medical education has expanded substantially since 2017. Critical consciousness has been conceptualized in the medical education literature through four overlapping themes: (1) social awareness, (2) cultural awareness, (3) political awareness, and (4) awareness of educational dynamics. Conclusions: Critical consciousness has been conceptualized in medical education as an intellectual construct to foster a reflexive awareness of professional power in health care, to unearth the values and biases legitimizing medicine as currently practiced, and to foster transformation and social accountability. Scholars highlighted its potential to improve socio-cultural responsibility and to foster compassion in doctors. Adopting a critical pedagogy approach in medical education can help uphold its social accountability through an intrinsic orientation to action, but any enterprise working towards embedding critical pedagogy within curricula must acknowledge and challenge the current structure and culture of medical education itself. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A770. Acknowledgments: The authors wish to thank Professor Tim Dornan for the invaluable advice and discussions, Mr. Richard Fallis for his help in performing the literature search, and Dr. Ayelet Kuper for her help in revising the report. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable Previous presentations: The results of this scoping review were presented at the Irish Network of Medical Educators (INMED) 2019 Annual Scientific Meeting in February 2019. Correspondence should be addressed to Annalisa Manca, Centre for Medical Education, Queen’s University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, BT9 7BL; telephone +44 (0)289 0972 462; email: amanca01@qub.ac.uk; Twitter: @annalisamanca. © 2019 by the Association of American Medical Colleges

The Effectiveness of Teaching Clinical Empathy to Medical Students: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Purpose: Clinical empathy is a necessary trait to provide effective patient care, despite differences in how it is defined and constructed. The aim of this study was to examine whether empathy interventions in medical students are effective and how confounding factors potentially moderate this effect. Method: The authors performed a systematic review and meta-analysis. They searched the literature published between 1948 and 2018 for randomized controlled trials that examined empathy interventions in medical students. The search (database searching, citation tracking, hand-searching relevant journals) yielded 380 studies, which they culled to 16 that met the inclusion criteria. For the meta-analysis, they used a random effects model to produce a pooled estimate of the standardized mean difference (SMD) then completed subgroup analyses. Results: The authors found evidence of the possibility of response and reporting bias. The pooled SMD was 0.68 (95% confidence interval 0.43, 0.93) indicating a moderately positive effect of students developing empathy after an intervention compared to those in the control groups. There was no evidence of publication bias, but heterogeneity was significantly high (I2 = 88.5%, P < .01). Subgroup analyses indicated that significant moderating factors for developing empathy were age, country, scope of empathy measurement, type of empathy intervention, and presence of rehearsal. Moderating factors with limited evidence were sex, study quality, journal impact factor, and intervention characteristics. Conclusions: Despite heterogeneity and biases, empathy interventions in medical students are effective. These findings reinforce arguments in the literature and add considerable rigor from the meta-analysis. The authors propose a conceptual model for educators to follow when designing empathy interventions in medical students. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A769. Acknowledgements: The authors thank Dr. Asta Medisauskaite and Dr. Shah-Jalal Sarker for providing constructive feedback during the writing of this article. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: This work was completed as part of K.C. Fragkos’s master’s in clinical education at the University College London Medical School. Data: All data generated or analyzed during this study are included in Supplemental Digital Appendix 3 available at http://links.lww.com/ACADMED/A769. Correspondence should be addressed to Konstantinos C. Fragkos, University College London Hospitals, NHS Foundation Trust, 250 Euston Road, London, UK NW1 2PG; email: constantinos.frangos.09@ucl.ac.uk; telephone: +44 (0)7960 340489; Twitter: @KCFragkos. © 2019 by the Association of American Medical Colleges

Common Types of Gender-Based Microaggressions in Medicine Purpose: Microaggressions are subtle verbal or nonverbal everyday behaviors that arise from unconscious bias, covert prejudice, or hostility. They may contribute to the persistent disparities faced by women in medicine. In this study, the authors sought to identify common microaggressions experienced by women faculty in medicine and to determine if specific demographic characteristics affect the reported frequencies of these microaggressions. Method: The authors used chain referral sampling to collect real-life anecdotes about microaggressions from women faculty across the nation. Thirty-four unique experiences from those reported were identified and scripted then reenacted using professional actors to create 34 videos of the real-life microaggressions and 34 corresponding fictional “control” versions of the same situations. The videos, presented in a random order, were evaluated by faculty from 4 academic medical centers from 2016-2018. Results: A total of 124 faculty (79 women, 45 men) participated. Women reported higher frequencies of microaggressions than men in 33 of the 34 videos depicting microaggressions (P value range: < .001 to .042, area under the curve [AUC] range: 0.60 to 0.69). No such differences were seen with the control videos. Women identified 21 microaggressions as occurring frequently. No significant differences were found with respect to participants’ age, race/ethnicity, academic rank, or years in medicine. Post hoc analyses showed that the microaggressions fell into 6 themes: encountering sexism, encountering pregnancy and child care related bias, having abilities underestimated, encountering sexually inappropriate comments, being relegated to mundane tasks, and feeling excluded/marginalized. Conclusions: Privilege is often invisible to those who have it, whereas bias and discrimination are readily apparent to those who experience it. Knowledge of common microaggressions will allow for targeted individual, interpersonal, and institutional solutions to mitigate disparities in medicine. [footnote] *The videos used in this project and some of the verbatim comments from the study participants are available to individuals through the Project Respect portal (https://respect.stanford.edu) and through an app called “Stanford Project Respect” available in the Apple App Store. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was reviewed and approved by the Stanford University institutional review board on May 12, 2015 and subsequently by the institutional review boards at the University of Rochester School of Medicine, Harvard Medical School, and the Medical University of South Carolina. Previous presentations: Presented by Vyjeyanthi S. Periyakoil as an opening plenary at the Association of American Medical Colleges Council of Faculty and Academic Societies Spring Meeting, April 2019, in Atlanta, Georgia. Correspondence should be addressed to Vyjeyanthi S. Periyakoil, Stanford University School of Medicine, 1701 Page Mill Rd, 2nd Floor Room 222, Palo Alto, CA 94304; email: periyakoil@stanford.edu; Twitter: @palliator. © 2019 by the Association of American Medical Colleges

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