Academic Medicine

Collaborative Solutions to Antibiotic Stewardship in Small Community and Critical Access Hospitals The overuse and misuse of antibiotics affects patients in many ways, including by driving antibiotic resistance, a serious public health threat in the United States and around the world. To improve patient safety and address rising rates of resistance, an increasing number of health care facilities have created antibiotic stewardship programs (ASPs). ASPs have been successful in slowing the emergence of resistance and improving patient outcomes. However, there are serious geographic and resource barriers to ASP adoption in small community hospitals and critical access hospitals. Fortunately, many barriers can be overcome by using collaborative models to bring together key stakeholders, including large hospitals and health systems and academic medical centers; hospital associations; federal, state, and local public health organizations; and federal and state offices of rural health. These stakeholders are ideally positioned to assist with stewardship efforts in small community and critical access hospitals and, in doing so, can improve patient safety while stemming the spread of resistant bacteria. Acknowledgments: The authors acknowledge Elisa Arespacochaga for her support of the initiative. Funding/Support: None reported. 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 American Hospital Association, University of Illinois College of Law, the Centers for Disease Control and Prevention, the Federal Office of Rural Health Policy, or The Pew Charitable Trusts. Correspondence should be addressed to Jay Bhatt, 155 North Wacker Drive, Suite 400 Chicago, IL 60606; @bhangrajay: email: jbhatt@aha.org. 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

Professionalism as the Bedrock of High-Value Care “High-value care” has become a popular mantra and a call to action among health system leaders, policy makers, and educators who are advocating widespread practice changes to reduce costs, minimize overuse, and optimize outcomes in the United States. Regrettably, current research does not demonstrate significant progress in improving high-value care. Many investigators have looked to payment models, benefit design, and policy changes as the main levers to reduce low-value care delivery; thus, the prevailing approach to ensuring high-value care has been to identify and limit low-value services. This approach has a clear limitation: the number of identified low-value services has become too numerous for individual physicians to track. Using professionalism as a key driver of practice change presents an important opportunity to shift from a deficit-based reactive model to one that is proactive and uses the concepts of intrinsic motivation and medical stewardship to effect high-value care. Transforming aspirational values such as professionalism into actions that engage all physician stakeholders regardless of their position or influence, and regardless of system agility or payment structure, has the potential for bringing about real change. These concepts can be integrated into medical education, introduced early in training, and modeled by educators to drive long-term sustainable change. Physicians can, and should, embrace professionalism as the motivation for redesigning care. Payment reform incentives that align with their professional values should follow and encourage these efforts; that is, payment reform should not be the impetus for redesigning care. Funding/Support: None reported. Other disclosures: Christopher Moriates reports receiving royalties from McGraw-Hill for the textbook Understanding Value-Based Healthcare. Ethical approval: Reported as not applicable. Correspondence should be addressed to Leah M. Marcotte, Department of Medicine, University of Washington, 1107 NE 45th Street, Suite 355, Seattle, WA 98105; telephone: (206) 543-3163; email: leahmar@uw.edu; Twitter: @marcottl. © 2019 by the Association of American Medical Colleges

A Comparison of Costs: How California Teaching Hospitals Achieved Slower Growth Than Nonteaching Hospitals in Operating Room Costs From 2005 to 2014 Purpose: Historically, teaching hospitals have had higher costs than their nonteaching counterparts, introducing potential financial risk in value-based payment models. This study compared risk-adjusted operating room (OR) costs between teaching and nonteaching hospitals in California. Method: Using 2,992 financial statements from fiscal years (FYs) 2005–2014, the authors extracted data for OR total costs, components of direct costs, and indirect costs. Cross-sectional and longitudinal models estimated OR costs per minute of surgery by teaching status, ownership, case mix index, and geographic area. Results: The risk-adjusted cost was $9.44 per minute less in teaching than nonteaching hospitals in FY2014 (95% CI 3.03, 15.85, P = .004). Between FY2005 and FY2014, OR costs grew more slowly at teaching hospitals due to slower wage growth and indirect costs per minute (respectively, -$0.13 and -$0.77 per minute per year, P = .005 and P < .001). Hourly pay rose more at teaching hospitals ($0.26 per hour per year, P = .008), but was more than offset by slower full-time equivalents growth (-0.002 per 10,000 OR minutes per year, P = .001). Between FY2005 and FY2014, operative volume increased at teaching hospitals and decreased at nonteaching hospitals. Conclusions: By 2014, California teaching hospitals had lower OR costs per minute than nonteaching hospitals due to relative labor productivity gains and slower indirect cost growth. The latter likely resulted from a shift of volume from nonteaching to teaching facilities. These trends will help teaching hospitals compete under value-based models. Implications for patients and nonteaching hospitals warrant evaluation. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A702. Funding/Support: Christopher Childers is funded by AHRQ#F32HS025079. AHRQ had no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, approval of the manuscript; or decision to submit for publication. Other disclosures: None reported. Ethical approval: The UCLA Institutional Review Board determined that the study was not human subjects research. Previous presentations: This work was presented at the American College of Surgeons 104th Annual Clinical Congress, Scientific Forum, Boston, MA, October 22, 2018. Correspondence should be addressed to Christopher P. Childers, Department of Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., CHS 72-247, Los Angeles, CA 90095; email: cchilders@mednet.ucla.edu; Twitter: @cchildersmd. © 2019 by the Association of American Medical Colleges

Describing the Evidence Base for Accreditation in Undergraduate Medical Education Internationally: A Scoping Review Purpose: To summarize the state of evidence related to undergraduate medical education (UME) accreditation internationally, describe from whom and where the evidence has come, and identify opportunities for further investigation. Method: The authors searched Embase, ERIC, PubMed, and Scopus from inception through January 31, 2018, without language restrictions to identify peer-reviewed articles on UME accreditation. Articles were classified as scholarship if all Glassick’s criteria were met and non-scholarship if not all were met. Author, accrediting agency, and study characteristics were analyzed. Results: Database searching identified 1,379 non-duplicate citations, resulting in 203 unique, accessible articles for full text review. Of these and with articles from hand searching added, 36 articles were classified as scholarship (30 as research) and 85 as non-scholarship. Of the 36 scholarship and 85 non-scholarship articles, respectively, 21 (58%) and 44 (52%) had an author from the United States or Canada, 8 (22%) and 11 (13%) had an author from a low- or middle-income country, and 16 (44%) and 43 (51%) had an author affiliated with a regulatory authority. Agencies from high-income countries were featured most often (scholarship: 28/60, 47%; non-scholarship: 70/101, 69%). Six (17%) scholarship articles reported receiving funding. All 30 research studies were cross-sectional or retrospective, 12 (40%) reported only analysis of accreditation documents, and 5 (17%) attempted to link accreditation with educational outcomes. Conclusions: Limited evidence exists to support current UME accreditation practices or guide accreditation system creation or enhancement. More research is required to optimize UME accreditation systems’ value for students, programs, and society. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A707. Acknowledgments: The authors gratefully acknowledge Dr. Carolyn Park, who provided translations of the Korean-language articles, and Dr. John Boulet, who reviewed our list of references. Funding/Support: None reported. Other disclosures: M. van Zanten participated in the development of the World Federation for Medical Education (WFME) Recognition Programme and serves as an ad-hoc recognition team member. Ethical approval: Reported as not applicable. Previous presentations: Aspects of this work were presented as an abstract at the Accreditation in Health Professions Summit on August 29–30, 2018, in Basel, Switzerland. Correspondence should be addressed to Sean Tackett, 5200 Eastern Ave., Mason F Lord Building, Suite 2300, Baltimore, MD, 21224; email: stacket1@jhmi.edu. © 2019 by the Association of American Medical Colleges

“Yes, I’m the Doctor”: One Department’s Approach to Assessing and Addressing Gender-Based Discrimination in the Modern Medical Training Era While gender-based bias and discrimination (GBD) is known to exist in medical training, there is limited guidance for training programs on how to understand and combat this issue locally. The Massachusetts General Hospital Department of Surgery established the Gender Equity Task Force (GETF) to address GBD in the local training environment. In 2017, members of the GETF surveyed residents in surgery, anesthesia, and internal medicine at two academic hospitals to better understand perceived sources, frequency, forms, and effects of GBD. Overall, 371 residents completed the survey (60% response rate, 197 women). Women trainees were more likely to endorse personal experience of GBD and sexual harassment than men (P < .0001) with no effect of specialty on rates of GBD or sexual harassment. Patients and nursing staff were the most frequently identified groups as sources of GBD. While an overwhelming majority of both men (86%) and women (96%) respondents either experienced or observed GBD in the training environment, less than 5% of respondents formally reported such experiences, most frequently citing a belief that nothing would happen. Survey results served as the basis for a variety of interventions addressing nursing staff and patients as sources of GBD, low confidence in formal reporting mechanisms, and the pervasiveness of GBD, including sexual harassment, across specialties. These results reproduce other studies’ findings that GBD and sexual harassment disproportionately affect women trainees while demonstrating how individual training programs can incorporate local GBD data when planning interventions to address GBD. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A703. Acknowledgments: The authors would like to acknowledge the Partners Center of Expertise, the Massachusetts General Hospital Departments of Anesthesia, Medicine, and Surgery, and the Brigham and Women’s Hospital Departments of Anesthesia, Medicine, and Surgery for their support of and participation in this study. The authors also acknowledge the contributions of the additional members and collaborators of the MGH Gender Equity Task Force: Taylor Coe, MD, Mara Kenger, MD, Robert Lekowski, MD, MPH, Casey Luckhurst, MD, Winta Mehtsun, MD, MPH, Philicia Moonsamy, MD, Emily Naoum, MD, Alaska Pendleton, MD, Gregory Snyder, MD, Kristin Sonderman, MD, Mariah Tanious, MD, and Nneka Ufere, MD. Funding/Support: Funding for participant incentives was provided by the Partners Center of Expertise in Medical Education and the Massachusetts General Hospital Department of Surgery. Other disclosures: None reported. Ethical approval: The survey protocol was approved by the Institutional Review Board of Partners Healthcare Protocol number 2017P001789. Previous presentations: Portions of this data were presented at the annual meeting of the Massachusetts Chapter of the American College of Surgeons, Boston, December 1, 2018 (local meeting). Correspondence should be addressed to Sophia K. McKinley, Massachusetts General Hospital, 55 Fruit St., GRB 425, Boston, MA 02114; telephone: (617) 832-5899; email: skmckinley@partners.org. © 2019 by the Association of American Medical Colleges

“Getting Out of That Siloed Mentality Early”: A Qualitative Study of Interprofessional Learning in a Longitudinal Placement for Early Medical Students Purpose: Although descriptions of interprofessional education often focus on interactions among students from multiple professions, embedding students from 1 profession in clinical settings may also provide rich opportunities for interprofessional learning (IPL). This study examines affordances and barriers to medical students’ interactions with and opportunities to learn from health care professionals while learning health systems science in clinical workplaces. Method: In May 2017, 14 first-year medical students at the University of California, San Francisco participated in a semistructured interview about IPL experiences during a 17-month, weekly half-day clinical microsystem placement focused on systems improvement (SI) projects and clinical skills. Communities of practice and workplace learning frameworks informed the interview guide. The authors analyzed interview transcripts using conventional qualitative content analysis. Results: The authors found much variation among the 14 students’ interprofessional interactions and experiences in 12 placement sites (7 outpatient, 4 inpatient, 1 emergency department). Factors influencing the depth of interprofessional interactions included the nature of the SI project, clinical workflow, student and staff schedules, workplace culture, and faculty coach facilitation of interprofessional interactions. Although all students endorsed the value of learning about and from diverse health care professionals, they were reluctant to engage with, or “burden,” them. Conclusions: There are significant IPL opportunities for early medical students in longitudinal placements focused on SI and clinical skills. Formal curricular activities, SI projects conducive to interprofessional interactions, and faculty development can enhance the quality of workplace-based IPL. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A706. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Ethical approval was obtained from the University of California, San Francisco Committee on Human Research (reference #189270, April 21, 2017). Previous presentations: This study was presented at the spring conference of the Western Group on Educational Affairs, Association of American Medical Colleges, March 25, 2018, Denver, Colorado. Correspondence should be addressed to Josette Rivera, University of California, San Francisco, 3333 California St, Suite 380, San Francisco, CA 94143; email: josette.rivera@ucsf.edu. © 2019 by the Association of American Medical Colleges

Strategic Planning in Health Professions Education: Scholarship or Management? Strategic planning, in its various forms, is an evaluation practice that is ubiquitous in academic medicine. However, published reports of strategic planning at academic health centers usually ignore theory. In a 2017 strategic planning exercise at the Wilson Centre, a scholarly model evolved using a theoretical framework and a research approach rather than a conventional management model, which typically identifies outcomes and how to achieve them. After completing this exercise, the authors considered the larger questions of the assumptions underpinning different models of strategic planning and strategic planning’s value to academic medicine. To elaborate on these questions, the authors examine relevant literature and set out the Wilson Centre’s emergent scholarly model. They describe the main features of the scholarly model, including ways it differs from a management approach and from the typical approach to strategic planning in the authors’ experience and in the field of health professions education research. The authors also share lessons learned as a means to encourage consideration by other academic organizations. Acknowledgments: The authors acknowledge the involvement of Dr Shiphra Ginsburg in the strategic planning process, the very helpful comments on the manuscript by Dr Robert Paul, the assistance of Carrie Cartmill with manuscript preparation, and the editorial contributions of Jennifer Campi. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Editor’s Note: An Invited Commentary by W.T. Mallon appears on pages XX–XX. Correspondence should be addressed to Cynthia Whitehead, The Wilson Centre, 200 Elizabeth Street 1ES559, Toronto, Ontario, Canada M5G 2C4; telephone: 416-340-3646; e-mail: cynthia.whitehead@utoronto.ca © 2019 by the Association of American Medical Colleges

Treating the “Not-Invented-Here Syndrome” in Medical Leadership: Learning From the Insights of Outside Disciplines Physicians are being increasingly called upon to engage in leadership at all levels of modern health organizations, leading many to call for greater research and training interventions regarding physician leadership development. Yet, within these calls to action, the authors note a troubling trend toward siloed, medicine-specific approaches to leadership development, and a broad failure to learn from the evidence and insight of other relevant disciplines, such as the organizational sciences. The authors describe how this trend reflects what has been called the “Not-Invented-Here Syndrome” (NIHS)—a commonly observed reluctance to adopt and integrate insights from outside disciplines—and highlight the pitfalls of NIHS for effective physician leadership development. Failing to learn from research and interventions in the organizational sciences inhibits physician leadership development efforts, leading to redundant rediscoveries of known insights and reinventions of existing best practices. The authors call for physician leaders to embrace ideas that are “proudly developed elsewhere” and work with colleagues in outside disciplines to conduct collaborative research and develop integrated training interventions to best develop physician leaders who are prepared for the complex, dynamic challenges of modern health care. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Christopher G. Myers, Johns Hopkins Carey Business School, 100 International Drive, Baltimore, MD 21202; telephone: 410-234-9391; email: cmyers@jhu.edu; Twitter: @ChrisGMyers. © 2019 by the Association of American Medical Colleges

A Matter of Trust Trust is a fundamental tenet of the patient-physician relationship, and is central to providing person-centered care. Because trust is profoundly relational and social, building trust requires navigation around issues of power, perceptions of competence, and the pervasive influence of unconscious bias—processes that are inherently complex and challenging for learners, even under the best of circumstances. The authors examine several of these challenges related to building trust in the patient-physician relationship. They also explore trust in the student-teacher relationship. In an era of competency-based medical education, a learner has the additional duty to be perceived as “entrustable” to two parties: the patient and the preceptor. Dialogue, a relational form of communication, can provide a framework for the development of trust. By engaging people as individuals in understanding each other’s perspectives, values, and goals, dialogue ultimately strengthens the patient-physician relationship. Through promoting a sense of agency in the learner, dialogue strengthens the student-teacher relationship as well by fostering trust in oneself through development of a voice of one’s own. To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s web site (https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=65) follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the December 2018 issue for submission instructions and for more information about this feature). Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on trust in health care and health professions education. Acknowledgments: The authors would like to thank the Department of Medicine Group on Dialogical Teaching and Person-Centered Care for inspiring discussions. Funding/Support: A.K. Kumagai would also like to acknowledge the FM Hill Foundation for generous support. Other disclosures: None reported. 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

An Interprofessional Substance Use Disorder Course to Improve Students’ Educational Outcomes and Patients’ Treatment Decisions Purpose: Substance use is a public health concern. Health professions organizations recommend improvements in substance use disorder (SUD) education. Mezirow’s Transformative Learning Theory was used as the educational framework to develop a course that would provide students with opportunities to improve their understanding of SUDs; to assess, challenge, and reflect on their attitudes toward patients with SUDs; to receive direct observation, assessment, and feedback on behavior change counseling; and to engage in interprofessional education. The study’s purpose was to evaluate the impact of an interprofessional SUD course on students’ educational outcomes and their attitudes toward interprofessionalism. Method: Students from several health professions—medicine, pharmacy, physician assistant, nursing, and social work—attended a monthly interprofessional education SUD course starting in spring 2018. The course, taught by an interprofessional faculty, consisted of four interactive classes focused on empathy and recognizing personal bias; behavioral change counseling; and recognition, screening, and treatment of SUDs. Students attended a 12-step recovery meeting and had an optional opportunity to counsel a patient using behavioral change counseling. Results: Seventy-eight students completed the course. Students demonstrated significant improvements in their attitudes toward patients with SUDs and toward interprofessionalism, as measured by the Substance Abuse Attitudinal Scale and the Student Perceptions of Interprofessional Clinical Education survey. Nearly 70% of students counseled a patient with an SUD and 93% of counseled patients agreed to follow-up care. Conclusions: The course (1) enriched students’ understanding, attitudes, and behaviors toward patients with SUDs and toward interprofessional collaboration and (2) positively influenced patients’ treatment decisions. Funding/Support: The study was supported by an innovations grant from the Duke Area Health Education Center, Duke University, and by the Josiah Charles Trent Memorial Foundation Endowment Fund, Duke University, Duke University Division of Addiction Medicine. Other disclosures: None reported. Ethical approval: This study was approved as exempt by the Duke University IRB (IRB protocol number Pro00086678). Correspondence should be addressed to Andrew J. 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