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

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

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

Same but Different: Exploring Mechanisms of Learning in a Longitudinal Integrated Clerkship Purpose: Longitudinal integrated clerkships (LICs) are a widely used method of delivering clerkship curricula. Although there is evidence that LICs work and core components of LIC training have been identified, there is insufficient understanding of which components are integral to why they work. To address this question, this research explored how students experienced the first year of an LIC program. The aim was to use participants’ understanding of their learning experiences to identify potential mechanisms of the LIC curriculum model. Method: Thirty-two interviews were conducted with 13 University of Toronto students, 7 LIC and 6 block rotation students from the same site, October 2014–September 2015. A thematic analysis was performed iteratively to explore participants’ understanding of their key learning experiences and outcomes. Results: Participants in both cohorts described their key learning outcome as integration and application of knowledge during patient care. Experiences supporting this outcome were articulated as longitudinal variable practice and continuity of relationships with preceptors and patients. Critically, these experiences manifested differently for the 2 cohorts. For block students, these learning experiences appeared to reflect the informal curriculum, whereas for LIC students, learning experiences were better supported by the LIC formal curriculum. Conclusions: The results illustrate the importance of learning experiences that support longitudinality and continuity. By also emphasizing variability and knowledge integration, they align with literature on expert development. Notably, many of the learning experiences identified resulted from informal learning and thus support going beyond the formal curriculum when evaluating the effectiveness of curricula. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A739. Acknowledgments: The authors thank the longitudinal integrated clerkship research subcommittee at the University of Toronto. Funding/Support: This study was funded by the Education Development Fund and the Department of Family and Community Medicine at the University of Toronto. M. Mylopoulos is supported in part by the Medical Psychiatry Alliance, a collaborative health partnership of the University of Toronto, the Centre for Addiction and Mental Health, the Hospital for Sick Children, Trillium Health Partners, the Ontario Ministry of Health and Long-Term Care, and an anonymous donor. Other disclosures: None reported. Ethical approval: This study was approved by the institutional review board of the University of Toronto. Correspondence should be addressed to Maria Mylopoulos, the Wilson Centre, 200 Elizabeth St., ES 1-565, Toronto, ON M5G 2C4 Canada; telephone: (416) 340-3615; email: maria.mylopoulos@utoronto.ca. © 2019 by the Association of American Medical Colleges

On Marriage [Excerpt from The Prophet] Commentary on an excerpt from “On Marriage” No abstract available

The Decline in Community Preceptor Teaching Activity: Exploring the Perspectives of Pediatricians Who No Longer Teach Medical Students Purpose: Difficulty in recruiting and retaining community preceptors for medical student education has been described in the literature. Yet little if any information is known about community outpatient preceptors who have stopped or decreased teaching time with students. This study aimed to examine these preceptors’ perspectives about this phenomenon. Method: Using a phenomenology framework, this multi-institutional qualitative study used semistructured interviews with community pediatric preceptors who had stopped or reduced teaching time with medical students. Interviews were conducted between October 2017 and January 2018 and transcribed verbatim. Interviews explored factors for engaging in teaching, or decreasing or ceasing teaching, that would enable future teaching. An initial code book was developed and refined as data were analyzed to generate themes. Results: Twenty-seven community pediatricians affiliated with 10 institutions participated. Thirty-seven codes resulted in four organizing themes: evolution of health care, personal barriers, educational system, and ideal situations to recruit and retain preceptors; each with subthemes. Conclusions: From the viewpoints of physicians who had decreased or stopped teaching students, this study more deeply explored previously described reasons contributing to the decline of community preceptors, adds newly described barriers, and offers strategies to help counter this phenomenon based on preceptors’ perceptions. These findings appear to be manifestations of deeper issues including the professional identify of clinical educators. Understanding the barriers and strategies and how they relate to preceptors themselves should better inform education leaders to more effectively halt the decline of community precepting and enhance the clinical precepting environment for medical students. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A736. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Ethical approval was granted for our study by the University of Nebraska Medical Center Institutional Review Board. Approval was assigned number 366-17-EX on June 13, 2017. Subsequently, each participating site obtained approval from their institutional review boards. Previous presentations: Poster presentation, Council on Medical Student Education in Pediatrics Annual Meeting, St. Louis, Missouri, April 12, 2018. Correspondence should be addressed to Caroline R. Paul, Department of Pediatrics, University of Wisconsin School of Medicine, Madison, WI 53593; telephone: (608) 265-7740; email: crpaul@wisc.edu. © 2019 by the Association of American Medical Colleges

It Is Time to Prioritize Education and Well-Being Over Workforce Needs in Residency Training Residents inhabit an ambiguous world. They are no longer medical students, but are still learners. They are not yet attendings, but are still paid employees. This ambiguity leads to a misalignment of departmental incentives and trainee expectations. Trainees expect their learning and well-being to be prioritized while departments are under pressure to meet staffing needs and cut costs. This sets up a fundamental disconnect between the “formal” Accreditation Council for Graduate Medical Education (ACGME) message of well-being and the dominant “hidden” workplace forces that pull in the opposite direction, possibly contributing to the epidemic of burnout in trainees. It is critical that all parties—health systems, graduate medical education (GME) programs, the ACGME, and residents—recognize this disconnect and collaborate to meaningfully implement current ACGME requirements to decompress work intensity and address well-being. Real change will require more than general directives. The ACGME will likely need to take the lead, and consider taking a design thinking approach to structuring regulations governing how and when residents work and how they are supported. It would also be worthwhile to revisit the Institute of Medicine (IOM) recommendations on GME from 2014 related to funds flow and transformation initiatives. Taking a more comprehensive approach to residents as people, workers, and vital health care professionals is the right thing to do and may well improve retention, reduce burnout, decrease medical errors, and improve care. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Jed T. Wolpaw, 1800 Orleans Street, Zayed 6222, Baltimore, MD, 21287; telephone: 410-955-9942; email: jwolpaw@jhmi.edu. © 2019 by the Association of American Medical Colleges

Investigating Group Differences in Examinees’ Preparation for and Performance on the New MCAT Exam In 2015, the Medical College Admission Test (MCAT) was redesigned to better assess the concepts and reasoning skills students need to be ready for the medical school curriculum. During the new exam’s design and rollout, careful attention was paid to the opportunities examinees had to learn the new content and their access to free and low-cost preparation resources. The design committee aimed to mitigate possible unintended effects of the redesign, specifically increasing historical mean group differences in MCAT scores for examinees from lower-socioeconomic status (SES) backgrounds and races/ethnicities underrepresented in medicine compared to those from higher-SES backgrounds and races/ethnicities not underrepresented in medicine. In this article, the authors describe the characteristics and scores of examinees who took the new MCAT exam in 2017 and compare those trends to historical ones from 2013, presenting evidence that the diversity and performance of examinees has remained stable even with the exam’s redesign. They also describe the use of free and low-cost MCAT preparation resources and MCAT preparation courses for examinees from higher- and lower-SES backgrounds and who are enrolled in undergraduate institutions with more and fewer resources, showing that examinees from lower-SES backgrounds and who attend institutions with fewer resources use many free and low-cost test preparation resources at lower rates than their peers. The authors conclude with a description of the next phase of this research: to gather qualitative and quantitative data about the preparation strategies, barriers, and needs of all examinees, but especially those from lower-SES and underrepresented racial/ethnic backgrounds. Acknowledgments: The authors would like to thank their colleagues on the Research on Diversity, Group Differences, and Academic Preparation working group of the Association of American Medical Colleges (AAMC) Medical College Admission Test (MCAT) Validity Committee (MVC) for their contributions to this work: Liesel Copeland, Francie Cuffney, William Gilliland, Doug Taylor, and Robert Witzburg. The authors would also like to thank the full MVC for their dedication and tireless efforts to evaluate the new MCAT exam: Ngozi Anachebe, Barbara Beckman, Ruth Bingham, Kevin Busche, Deborah Castellano, Francie Cuffney, Julie Chanatry, Hallen Chung, Daniel Clinchot, Liesel Copeland, Martha Elks, William Gilliland, Jorge Girotti, Kristen Goodell, Joshua Hanson, Loretta Jackson-Williams, David Jones, Catherine Lucey, R. Stephen Manuel, Janet McHugh, Stephanie McClure, Cindy Morris, Wanda Parsons, Tanisha Price-Johnson, Boyd Richards, Aaron Saguil, Aubrie Swan Sein, Stuart Slavin, Doug Taylor, Carol Terregino, Ian Walker, Robert Witzburg, David Wofsy, and Mike Woodson. The authors would like to thank Sandy Koch for her contributions to this article. In addition, they would like to thank the following AAMC personnel for reviewing earlier drafts of this article: Heather Alarcon, Gabrielle Campbell, Karen Fisher, Karen Mitchell, Norma Poll, Elisa Siegel, and Geoffrey Young. Funding/Support: None reported. Other disclosures: The Medical College Admission Test (MCAT) is a program of the Association of American Medical Colleges (AAMC). Related trademarks owned by the AAMC include Medical College Admission Test and MCAT. Ethical approval: This study was approved by the institutional review board of the American Institutes for Research as part of the Association of American Medical Colleges’ Medical College Admission Test (MCAT) Validity Research Study protocol. Previous presentations: Some of the data presented in this article were presented at the 2017 Association of American Medical Colleges (AAMC) Learn Serve Lead annual meeting in November 2017, in Boston, Massachusetts, and at the 2018 Continuum Connections: A Joint Meeting of the Group on Student Affairs (GSA), Group on Resident Affairs (GRA), Organization of Student Representatives (OSR), and Organization of Resident Representatives (ORR) in April 2018, in Orlando, Florida. Correspondence should be addressed to Cynthia A. Searcy, Association of American Medical Colleges, 655 K Street NW Suite 100, Washington, DC 20001; telephone: (202) 862-6105; email: csearcy@aamc.org. © 2019 by the Association of American Medical Colleges

The Consequences of Structural Racism on MCAT Scores and Medical School Admissions: The Past is Prologue Those in medical education have a responsibility to prepare a physician workforce that can serve increasingly diverse communities, encourage healthy changes in patients, and advocate for the social changes needed to advance the health of all. The authors of this Perspective discuss many of the likely causes of the observed differences in mean Medical College Admission Test (MCAT) scores between students from groups well-represented in medicine and those from groups underrepresented in medicine. The lower mean MCAT scores of underrepresented groups can present challenges to diversifying the physician workforce if medical schools only admit those applicants with the highest MCAT scores. The authors review the psychometric literature, which showed no evidence of bias in the exam, and note that the differences in mean MCAT scores between racial and ethnic groups are similar to those in other measures of academic achievement and performance on high-stakes tests. The authors then describe the ways in which structural racism in the United States has contributed to differences in achievement for underrepresented students compared to well-represented students. These differences are not due to differences in aptitude but to differences in opportunities. The authors describe the widespread consequences of structural racism on economic success, educational opportunity, and bias in the educational environment. They close with 3 recommendations for medical schools that may mitigate the consequences of structural racism while maintaining academic standards and admitting students likely to succeed. Adopting these recommendations may help the medical profession build the diverse physician workforce needed to serve communities today. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A734. Acknowledgments: The authors acknowledge the dedication and contributions of the Medical College Admission Test Validity Committee and the following Association of American Medical Colleges staff: Cynthia Searcy, Karen Mitchell, Lesley Ward, and Jordan Yee Prendez (psychometric intern). They thank University of California, San Francisco, School of Medicine students Jazzmin Williams and Laeesha Corneo for publicizing the maps of San Francisco that illustrate the persistent impact of structural racism on educational quality. In addition, they acknowledge the tremendous efforts of all medical school leaders, faculty, and administrators who are working to diversify the physician workforce. Funding/Support: None reported. Other disclosures: The authors co-chair the Association of American Medical Colleges Medical College Admission Test Validity Committee. They receive no compensation for this work. Ethical approval: Reported as not applicable. Disclaimer: The views expressed in this article do not necessarily reflect the views of the Uniformed Services University, the US Army, or the Department of Defense. Correspondence should be addressed to Catherine Reinis Lucey, University of California, San Francisco, School of Medicine, 533 Parnassus Ave, Suite U-80, San Francisco, CA 94143; telephone: (415) 815-1633; email: catherine.lucey@ucsf.edu. © 2019 by the Association of American Medical Colleges

I Thought I Knew Commentary on “I Thought I Knew” No abstract available