Physician Fertility: A Call to Action Infertility is more prevalent in female physicians than in the U.S. general population. While pregnancy and its potential medical and career development consequences among physicians have been explored in the literature, infertility and its consequences remain understudied and unaddressed. Fertility issues are important for all physicians hoping to start families, including male physicians, transgender physicians, single physicians, and physicians with same-sex partners. Infertility has numerous physical, emotional, and financial consequences and may have a negative impact on physician well-being. Options to preserve fertility (such as egg, embryo, and sperm cryopreservation) are available, yet physicians may not be aware of or have the financial ability to make use of such resources. Physician reproductive health, including the ability to build a family if and when a physician chooses, is a vital aspect of well-being. The risks and consequences of infertility and the management of fertility should be studied and addressed from policy and advocacy standpoints. The authors, who have experienced and sought treatment for infertility, bring attention to the challenges around both physician infertility and preservation of fertility. They propose three strategies to address physician infertility: increasing fertility education and awareness starting at the undergraduate medical education level and continuing throughout training and practice; providing insurance coverage for and access to fertility assessment and management; and offering support for those undergoing fertility treatments. The authors believe that implementing these suggestions would make a significant positive impact on trainees and practicing physicians and help build a health care workforce that is healthy and well physically, emotionally, and financially. Acknowledgments: The authors wish to acknowledge the helpful review and commentary from two colleagues, Dr. Emily Jungheim (associate professor, Reproductive Endocrinology and Infertility, Washington University in St. Louis) and Dr. Asima K. Ahmad (Fertility Centers of Illinois). Neither was paid for their assistance. Funding/support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Ariela L. Marshall, Mayo Clinic, Division of Hematology, Mayo Building 10th floor, 10-90E, 200 First Street SW, Rochester, MN 55905; telephone: 507-284-8634; email: marshall.ariela@mayo.edu. © 2019 by the Association of American Medical Colleges

Learning After the Simulation Is Over: The Role of Simulation in Supporting Ongoing Self-Regulated Learning in Practice The complex and dynamic nature of the clinical environment often requires health professionals to assess their own performance, manage their learning, and modify their practices based on self-monitored progress. Self-regulated learning studies suggests that while learners may be capable of such in situ learning, they often need guidance to enact it effectively. In this Perspective, the authors argue that simulation training may be an ideal venue to prepare learners for self-regulated learning in the clinical setting but may not currently be optimally fostering self-regulated learning practices. They point out that current simulation debriefing models emphasize the need to synthesize a set of identified goals for practice change (what behaviors might be modified) but do not address how learners might self-monitor the success of their implementation efforts and modify their learning plans based on this monitoring when back in the clinical setting. The authors describe the current models of simulation-based learning implied in the simulation literature and suggest potential targets in the simulation training process, which might be optimized to allow medical educators to take full advantage of the opportunity simulation provides to support and promote ongoing self-regulated learning in practice. Acknowledgments: The authors wish to thank the Vancouver General Hospital Trauma Services’ team for their collaboration in this project. Funding/Support: This study was supported by the Robert Maudsley Fellowship for Studies in Medical Education from the Royal College of Physicians and Surgeons of Canada. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Farhana Shariff, Center for Health Education Scholarship, University of British Columbia, P. A. Woodward Instructional Resources Centre, 429 – 2194 Health Sciences Mall, Vancouver, BC Canada V6T 1Z3; telephone: 604-822-8970; email: Farhana.shariff@mail.mcgill.ca. © 2019 by the Association of American Medical Colleges

Seeking Inclusion Excellence: Understanding Racial Microaggressions as Experienced by Underrepresented Medical and Nursing Students Purpose: To describe how racial microaggressions may affect optimal learning for underrepresented health professions students. Method: The authors conducted focus groups and individual interviews from November 2017 to June 2018 with 37 students at University of California, Davis and Yale University who self-identified as underrepresented in medicine or nursing. Questions explored incidence, response to, and effects of racial microaggressions, as well as students’ suggestions for change. Data were organized and coded then thematic analysis was used to identify themes and subthemes. Results: The data showed consistent examples of microaggressions across both health professions and schools, with peers, faculty, preceptors, and structural elements of the curricula all contributing to microaggressive behavior. The 3 major themes were: students felt devalued by microaggressions; students identified how microaggressions affected their learning, academic performance, and personal wellness; and students had suggestions for promoting inclusion. Conclusions: The data indicated that students perceived that their daily experiences were affected by racial microaggressions. Participants reported strong emotions while experiencing racial microaggressions including feeling stressed, frustrated, and angered by these interactions. Further, students believed microaggressions negatively affected their learning, academic performance, and overall well-being. This study shows the need for leadership and faculty of health professions schools to implement policies, practices, and instructional strategies that support and leverage diversity so that innovative problem-solving can emerge to better serve underserved communities and reduce health disparities. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A772. Acknowledgments: The authors would like to thank the students who bravely shared their insights and perspectives. Additionally, the authors thank the expert colleagues who reviewed the themes: Dr. Jann Murray-Garcia, Dr. Jorge Garcia, Dr. Ruth Shim, Dr. Rachel Robitz, Dr. Fawn Cothran, Dr. Poh Choo How, and Dr. Swati Rao. Further, the authors acknowledge the contributions of Dr. Tonya Fancher and University of California Davis Center for a Diverse Health Care Workforce. Funding/Support: This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3,791,026 with 0 percent financed with non-governmental sources. Disclosures: None reported. Ethical approval: Institutional review board approval was obtained from the University of California Davis Office of Research, May 4, 2017, ID#: 1059626-1 and Yale University ID#:1512016959, December 7, 2017. Disclaimers: The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the United States government. Previous presentations: This content was presented at the National Conference on Race and Ethnicity in Higher Education, May 31, 2019, Portland, Oregon. Data: None. Correspondence should be addressed to Kupiri Ackerman-Barger, University of California, Davis, Betty Irene Moore School of Nursing, 2450 48th Street, Suite 2600, Sacramento, CA 95817; email: packerman@ucdavis.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

The Effect of Foregrounding Intended Use on Observers’ Ratings and Comments in the Assessment of Clinical Competence Purpose: Some educational programs have adopted the premise that the same assessment can serve both formative and summative goals; however, how observers understand and integrate the intended uses of assessment may affect the way they execute the assessment task. The objective of this study was to explore the effect of foregrounding a different intended use (formative vs. summative learner assessment) on observer contributions (ratings and comments). Method: In this randomized, experimental, between-groups, mixed-methods study (May—September 2017), participants observed three pre-recorded clinical performances under formative or summative assessment conditions. Participants rated performances using a global rating tool and provided comments. Participants were then asked to reconsider their ratings from the alternative perspective (from which they were originally blinded). They received the opportunity to alter their ratings and comments and to provide rationales for their decision to change or preserve their original ratings and comments. Outcomes included participant-observers’ comments, ratings, changes to each, and stated rationales for changing or preserving contributions. Results: Foregrounding different intended uses of assessment data for participant-observers did not result in differences in ratings, number or type of comments (both emphasized evaluative over constructive statements), or the ability to differentiate among performances. After adopting the alternative perspective, participant-observers made only small changes in ratings or comments. Participant-observers reported that they engage in the process in an evaluative manner despite different intended uses. Conclusions: Foregrounding different intended uses for assessments did not result in significant systematic differences in the assessment data generated. Observers provided more evaluative than constructive statements overall, regardless of the intended use of the assessment. Future research is needed to explore whether these results hold in social/workplace-based contexts and how they might affect learners. Acknowledgements: The authors would like to thank Tobi Lam for her technical support, the organizations that supported recruitment, and the observers who participated in the study reported here. Funding/Support: The authors would like to thank the Medical Council of Canada for generously supporting the study reported here (MCC-14/1617). other disclosures: None reported. Ethical approval: The University of Toronto Research Ethics Board approved this study on October 28, 2016 (Ref. # 33537). Previous presentations: Canadian Conference for Medical Education; April 2019; Niagara Falls, Ontario and International Conference on Residency Education; September 2019; Ottawa, Ontario. Correspondence should be addressed to: Walter Tavares, Wilson Centre, 200 Elizabeth St., 1ES-565, Toronto, Ontario, Canada M5G 2C4; telephone: (416) 340-3646 / (416) 340-3079; e-mail: walter.tavares@utoronto.ca; Twitter: @WalterTava. © 2019 by the Association of American Medical Colleges

The Distinctions Between Theory, Theoretical Framework, and Conceptual Framework Health professions education (HPE) researchers are regularly asked to articulate their use of theory, theoretical frameworks, and conceptual frameworks in their research. However, all too often, these words are used interchangeably or without a clear understanding of the differences between these concepts. Further problematizing this situation is the fact that theory, theoretical framework, and conceptual framework are terms that are used in different ways in different research approaches. In this article, the authors set out to clarify the meaning of these terms and to describe how they are used in two approaches to research commonly used in HPE: the objectivist deductive approach (from theory to data) and the subjectivist inductive approach (from data to theory). In addition to this, given that within subjectivist inductive research theory, theoretical framework, and conceptual framework can be used in different ways, they describe 3 uses that HPE researchers frequently rely on: fully inductive theory development, fully theory-informed inductive, and theory-informing inductive data analysis. Editor’s note: This article is part of a collection of Invited Commentaries exploring the Philosophy of Science. 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 do not necessarily reflect those of the Uniformed Services University of the Health Sciences, the United States Department of Defense or other federal agencies. Correspondence should be addressed to Lara Varpio, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814; email: lara.varpio@usuhs.edu; Twitter: @LaraVarpio. 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

Internal Medicine Residency Program Directors’ Screening Practices and Perceptions About Recruitment Challenges Purpose: To examine internal medicine residency program directors’ (PDs’) screening practices and perceptions about current recruitment challenges. Method: In March–May 2017, the Association of Program Directors in Internal Medicine Survey Committee sent a survey to 373 Alliance for Academic Internal Medicine member residency programs. PDs rated the importance of 23 inclusion and 11 exclusion criteria for interview invitation decision-making, provided United States Medical Licensing Examination (USMLE) cutoff scores for U.S. medical school and international medical graduates, and indicated changes in recruitment practices due to application inflation, including their ability to conduct holistic review, and interest in potential solutions to address application inflation. Exploratory factor analysis was used to identify and confirm the factors (or groups of criteria) that were most important to interview invitation decision-making. Results: The response rate for eligible programs was 64% (233/363). USMLE Step 2 Clinical Knowledge scores were the criteria most frequently reported to be “very important” (131/233, 57%). Among respondents who reported any criteria as “very important,” 155/222 (70%) identified a single most important (SMI) criterion. Non-USMLE criteria were frequently reported as a SMI criterion (68%). Concerning exclusion criteria, 157/231 (68%) reported they “absolutely would not invite” applicants with hints of unprofessional behavior. Of the 214/232 (92%) who reported an increase in applications, 138 (64%) adjusted recruitment practices. Respondents were most interested in limiting the number of applications per applicant (163/231, 71%), allowing applicants to indicate high interest in a subset of programs (151/229, 66%), and creating a national database of qualities of matched applicants for each program (121/228, 53%). Conclusions: PDs rely heavily on USMLE scores when making interview invitation decisions. However, collectively, non-USMLE criteria were more frequently reported as SMI criteria. Most programs adjusted recruitment practices to respond to application volume. Several potential solutions to address application inflation garnered wide support. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A773. Acknowledgments: The authors thank the members of the Alliance for Academic Internal Medicine Medical Student to Resident Interface Committee and the National Resident Matching Program for their thoughtful input on this article. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study protocol was deemed exempt by the Mayo Clinic Institutional Review Board (IRB no. 08-007125) in 2008. Previous presentations: This work was previously presented as an oral abstract, Factors program directors value most in prospective candidates: A national survey of internal medicine directors, Association of American Medical Colleges Annual Meeting 2018, Austin, Texas, November 4, 2018. Correspondence should be addressed to Steven V. Angus, University of Connecticut School of Medicine, 263 Farmington Ave., Farmington, CT 06030; email: angus@uchc.edu. © 2019 by the Association of American Medical Colleges

Teaching Evidence-Based Medicine to Medical Students Using Wikipedia as a Platform Problem: While ideal curricular structures for effective teaching of evidence-based medicine (EBM) have not been definitively determined, optimal strategies ensure that EBM teaching is interactive and clinically based, aligns with major trends in education and health care, and uses longitudinally integrated, whole-task activities. Approach: The authors developed a longitudinal, semester-long project, embedded in a first-year medicine course, through which they taught EBM using Wikipedia as a platform. Students worked individually and in small groups to choose a medicine-related Wikipedia article, identify information gaps, search for high-quality resources, appraise the sources, and incorporate the new information into the article (i.e., by editing Wikipedia). Students also applied their new appraisal skills to critique a second article. The authors used an online tool to track and record student editing, and they obtained qualitative data on student perceptions of the project via survey. Duplicate marking of a sample of assignments was performed using the Valid Assessment of Learning in Undergraduate Education (VALUE) critical thinking rubric developed by Finley and Rhodes. Outcomes: In fall 2017, 101 students made over 1,000 unique edits to 16 online Wikipedia articles, adding over 10,000 words. Through thematic analysis of qualitative data, the authors highlighted several aspects of the project that students appreciated, as well as barriers related to completing their projects. Correlation of the 17 consenting students’ final assignments with the critical thinking rubric supports the assignment structure as a tool for assessing critical thinking. Next Steps: This authentic task adheres to the principles of high-quality EBM instruction and could be implemented by a variety of health care educational programs. Modifications to the delivery model are underway to address challenges identified. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A774. Acknowledgements: The authors would like to acknowledge the members of the WikiEdu Foundation and WikiProject Medicine for their online support and guidance, especially for their student editors. Funding/Support: This project received funding from the Queen’s University Centre for Teaching and Learning as part of the institutional Cognitive Assessment Redesign (CAR) project. This institutional project is funded by the Higher Education Quality Council of Ontario, through a grant from their Centre for Learning Outcomes Assessment to a consortium of universities and colleges in Ontario, Canada. Other disclosures: None reported. Ethical approval: Queen’s University General Ethics Board approval March 5, 2018; Certificate # GACAD-009-17. Learning Outcomes Assessment Consortium 2 - Cognitive Assessment Redesign (CAR); TRAQ 6021334. Disclaimers: The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. Previous presentations: This project and the evaluation data was presented at the Evidence Live 2018 conference at the Oxford Centre for Evidence-Based Medicine, Oxford, England, June 2018. Correspondence should be addressed to Heather Murray, Department of Emergency Medicine, Queen’s University, c/o Kingston Health Sciences Centre, 76 Stuart St, Kingston, Ontario, Canada, K7L 2V7; email: heather.murray@queensu.ca; Twitter: @HeatherM211. 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

Approaches to Measuring Trends in Interdisciplinary Research Publications at One Academic Medical Center Purpose: To determine if publications from interdisciplinary collaborations involving at least 1 Johns Hopkins University author increased between 2005 and 2015 and to compare different methods for determining the disciplinarity of research articles. Method: In 2017–2018, 100 peer-reviewed biomedical science articles were randomly selected from years 2005, 2010, and 2015 and classified as unidisciplinary or interdisciplinary based on Scopus author affiliation data (method 1). The corresponding authors of the 2010 and 2015 articles were sent a survey asking them to describe the disciplines involved in their research (method 2) and to define their research as unidisciplinary or interdisciplinary based on provided definitions (method 3). Results: There was a statistically significant increase in the proportion of interdisciplinary articles in 2015 compared with both 2005 and 2010 (P = .02). Comparison of the three methods indicated that 45% of the articles were classified as interdisciplinary based on author affiliation data (method 1), 40% based on the corresponding author’s description of the disciplines involved in their research (method 2), and 71% based on the corresponding author’s definition of their article’s disciplinarity (method 3). There was a statistically significant difference in the proportion of articles classified as interdisciplinary between method 1 and 3 (P < .001) and between method 2 and 3 (P < .001). Conclusions: This study found that interdisciplinary research increased at Johns Hopkins University over the past decade and highlights the difference between corresponding authors’ views of their own research and other methods for determining interdisciplinarity. Funding/Support: This publication was made possible by the Johns Hopkins Institute for Clinical and Translational Research (ICTR), which is funded in part by Grant Number UL1 TR001079 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Ethical approval: The Johns Hopkins School of Medicine’s institutional review board approved this study. Other disclosures: None reported. Disclaimers: The contents of this article are solely the responsibility of the authors and do not necessarily represent the official view of the Johns Hopkins ICTR, NCATS, or the NIH. Correspondence should be addressed to Christine M. Weston, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 North Broadway, Baltimore, MD 21205; telephone: (443) 287-8039; email: cweston1@jhu.edu. © 2019 by the Association of American Medical Colleges

On Time and Tea Bags: Chronos: ,: Kairos: , and Teaching for Humanistic Practice In these days of overwhelming clinical work, decreased resources, and increased educational demands, time has become a priceless commodity. Competency-based medical education attempts to address this challenge by increasing educational efficiency and decreasing the “steeping” of learners in clinical activities for set durations of time. However, in this environment, how does one teach for compassionate, humanistic practice? The answer arguably lies in clinician teachers’ recognition and engagement in a different type of time, that of kairos. Ancient Greek thought held that there were two interrelated types of time: chronological, linear, quantitative time—chronos—and qualitative, opportune time—kairos. Unlike chronos, kairos involves a sense of the “right time,” the “critical moment,” the proportionate amount. Developing a sense of kairos involves learning to apply general principles to unique situations lacking certainty and acting proportionally to need and context. Educationally, it implies intervening at the critical moment—the moment in which a thoughtful question, comment, or personal expression of perplexity, awe, or wonder can trigger reflection, dialogue, and an opening up of perspectives on the human dimensions of illness and medical care. A sensibility to kairos involves an awareness of what makes a moment “teachable,” an understanding of chance, opportunity, and potential for transformation. Above all, inviting kairos means grasping an opportunity to immerse oneself and one’s learners—even momentarily—into an exploration of patients and their stories, perspectives, challenges, and lives. Acknowledgments: For support of their work, A.K. Kumagai acknowledges the F.M. Hill Foundation of Women’s College Hospital, and T. Naidu and A.K. Kumagai acknowledge the Wilson Centre. Funding/Support: None reported. Other disclosures: A.K. Kumagai is supported by the F.M. Hill Foundation of Women’s College Hospital. Ethical approval: Reported as not applicable. Correspondence should be addressed to Arno K. Kumagai, Department of Medicine, Women’s College Hospital, 76 Grenville Ave., Toronto, ON M5S 1B2, Canada; email: arno.kumagai@utoronto.ca. © 2019 by the Association of American Medical Colleges

A Study of the Validity of the New MCAT Exam Purpose: To conduct a study of the validity of the new Medical College Admission Test (MCAT). Method: De-identified data for first- and second-year medical students (185 women, 54.3%; 156 men, 45.7%) who matriculated in 2016 and 2017 to the University of Minnesota Medical School – Twin Cities were included. Of those students, 220 (64.5%) had taken the new MCAT exam and 182 (53.4%) had taken the old MCAT exam (61 [17.9%] had taken both). The authors calculated descriptive statistics and Pearson product moment correlations (r) between new and old MCAT section scores. They conducted a regression analysis of MCAT section scores with Step 1 scores and with preclerkship course performance. They also conducted an exploratory factor analysis (principal component analysis with varimax rotation) of MCAT scores, undergraduate grade point average, Step 1 scores, and course performance. Results: The new MCAT exam section mean score percentiles ranged from 72 to 78 (mean composite score percentile of 80). The old MCAT exam section mean score percentiles ranged from 84 to 88 (mean composite score percentile of 83). The pattern of correlations among and between new and old MCAT exam section scores (range of r: 0.03 to 0.67, P < .01) provided evidence of both divergent and convergent validity. Backwards multiple regression of new MCAT exam section scores and Step 1 scores resulted in a multiple R of .440; the same analysis with Human Behavior course performance as the dependent variable provided a similar solution with the expected sections of the new MCAT exam (multiple R = .502). The factor analysis resulted in 4 cohesive, theoretically meaningful factors: biomedical knowledge, basic science concepts, cognitive reasoning, and general achievement. Conclusions: This study provided empirical evidence of multiple types of validity for the new MCAT exam. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This research received ethical approval from the institutional review board at the University of Minnesota Medical School – Twin Cities. Correspondence should be addressed to Claudio Violato, University of Minnesota Medical School – Twin Cities, MMC #293, 420 Delaware St. SE, Minneapolis, MN 55455; telephone: (612) 625-6382; email: cviolato@umn.edu. © 2019 by the Association of American Medical Colleges