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

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

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

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

Foucault on the Wards: Rediscovering Reflection as a Social Pediatrician in Training The author states that as a second-year medical student with a liberal arts degree, it is often difficult for him to reconcile his former education with the current demands of his training. Although the medical curriculum acknowledges the importance of a biopsychosocial model, the prioritization of knowledge remains the same: know your biological, pharmacological, and anatomical facts. However, the author’s experience with a social pediatrics research summer studentship moved him beyond this basic sciences mindset and provided a practical framework for the application of his liberal arts training. The experience was twofold: he worked on a research project while simultaneously shadowing a pediatrician twice a week. His project applied a Foucauldian critical discourse analysis to an archive of texts that sought to better characterize the term social pediatrics. The author concludes that the thought-changing reflection, mentorship, and concrete clinical experiences made possible by the summer studentship expanded his worldview. Acknowledgments: The author would like to thank Tina Martimianakis, PhD, Robert Paul, PhD, and Rabia Khan of the Wilson Centre at the University of Toronto, and also thank Brett Schrewe, MDCM, at the University of British Columbia for their guidance. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Not applicable. Previous presentations: This work was presented in part at the Richard K. Reznick Wilson Centre Research Day; October 12, 2018; Toronto, Ontario, Canada; and at the Canadian Paediatric Society Annual Conference; June 7, 2019; Toronto, Ontario, Canada. Correspondence should be addressed to Kevin Maynard, 853 Brigadoon Drive, Hamilton, Ontario, Canada L9C 7P2; telephone: 289-808-7539; e-mail: kevin.maynard@mail.utoronto.ca. © 2019 by the Association of American Medical Colleges

Perceptions of Pressures to Alter or Misrepresent Time Allocation Among Clinician-Researchers with NIH Career Development Awards Purpose: National Institutes of Health (NIH) career development (i.e., K) awards mandate specific allocations of effort to research and training. The authors sought to understand pressures perceived by award recipients to change or misrepresent effort, and whether these perceptions differed by gender. Method: In 2010-2011 and 2014, the authors surveyed K08 and K23 award recipients. Questions evaluated perceived pressure to change or misrepresent time allocation. Multivariable logistic regression modeling of pressure to misrepresent effort evaluated associations with individual and basic job characteristics. Results: Of the 1,719 faculty surveyed, 493 women and 573 (1,066 [62%]) responded at both time points. Most respondents reported feeling pressure to increase time spent on professional activities other than their K award-related research or career development or to decrease time on their K award-related research. The likelihood of perceiving pressure differed significantly by gender: 68% of women vs 55% of men (P < 0.001). A minority reported perceiving pressure to misrepresent professional time (women, 29%, vs men, 27%, P = 0.52). Multivariable analysis revealed that pressure to misrepresent professional time was less likely among respondents at institutions with the most extramural funding (P = 0.02). A significant pairwise interaction between gender and K award type suggested that female K08 awardees had higher odds than male peers to perceive pressure to misrepresent time. Conclusions: Most K award recipients reported feeling pressure to do more non-K award-related activities. More than a quarter reported feeling pressure to misrepresent effort. Additional research is needed to evaluate the proportion of academic medical faculty who actually misrepresent professional effort. Acknowledgments: The authors wish to thank the K award recipients who took the time to participate in the study described in this report. Funding/Support: This work was supported by Grant 5 R01 HL101997-04 from the National Institutes of Health to Dr. Jagsi. The funding body played 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 report. Other disclosures: Outside the current work, Dr. Jagsi also reports funding from the National Institutes of Health (NIH), the Greenwall Foundation, the Susan Komen Foundation, the Doris Duke Foundation, Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium; personal fees from Amgen and Vizient; and stock options in Equity Quotient. Dr. Moniz has received support from the Agency for Healthcare Research and Quality (AHRQ) under award number K08 HS025465 outside the current work. Dr. Mangurian reports funding from the Doris Duke Foundation and NIH outside the current work. Ethical approval: This study was approved by the University of Michigan Institutional Review Board (HUM00025530). Correspondence should be addressed to R. Jagsi, Department of Radiation Oncology, University of Michigan; UHB2C490, SPC 5010; 1500 East Medical Center Drive; Ann Arbor, MI 48109-5010; telephone (734) 936-8700; email: rjagsi@med.umich.edu; Twitter: @reshmajagsi. © 2019 by the Association of American Medical Colleges

Continuity with Patients, Preceptors, and Peers Improves Primary Care Training: A Randomized Medical Education Trial Purpose: Infusing continuity of care into medical student clerkships may accelerate professional development, preserve patient-centered attitudes, and improve primary care training. However, prospective, randomized studies of longitudinal curricula are lacking. Method: All entering Northwestern University Feinberg School of Medicine students in 2015 and 2016 were randomized to the Education Centered Medical Home (ECMH), a 4-year, team-based primary care clerkship; or a mentored Individual Preceptorship (IP) for two years followed by a traditional 4-week primary care clerkship. Students were surveyed four times (baseline, M1, M2, and M3 year [through 2018]); surveys included the Maslach Burnout Inventory (MBI); the Communication, Curriculum, and Culture (C3) survey assessing the hidden curriculum; and the Attitudes Toward Health Care Teams (ATHCT) scale. The authors analyzed results using an intent-to-treat approach. Results: 329 students were randomized; 316 (96%) participated in surveys. 70.1% of all respondents would recommend the ECMH to incoming first-year students. ECMH students reported a more positive learning environment (overall quality, 4.4 ECMH vs. 4.0 IP, P < .001), greater team-centered attitudes (ATHCT scale, 3.2 vs. 3.0, P = .007), less exposure to negative aspects of the hidden curriculum (C3 scale, 4.6 vs. 4.3, P < .001), and comparable medical knowledge acquisition. ECMH students established more continuity relationships with patients (2.2 vs. 0.3, P < .001) and reported significantly higher professional efficacy (MBI-PE, 4.1 vs. 3.9, P = .02). Conclusions: In this randomized medical education trial, the ECMH provided superior primary care training across multiple outcomes compared to a traditional clerkship-based model, including improved professional efficacy. Acknowledgments: The authors thank Raymond Curry, MD, John X. Thomas, PhD, and Marianne Green, MD, for their support for the ECMH and assistance in project implementation. The authors also thank the organizations that have served as ECMH sites, including PCC Community Wellness Center, Erie Family Health Center, Community Health Clinic of Chicago, Near North Health Service Corporation, and Northwestern Medical Group. Funding/Support: Predominant funding for the ECMH was provided by the Augusta Webster Office of Medical Education at Northwestern University Feinberg School of Medicine. Additional contributions funding ECMH clinics were provided by Northwestern University’s Global Health Initiative, and Northwestern Memorial Hospital. Additional grant support specific for educational research and dissemination was provided to support authors B.L. Henschen, D.T. Liss, K.A. Cameron, E.R. Ryan, L.A. Gard, and D.B. Evans by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP29963, Academic Units for Primary Care Training and Enhancement. The information, content and conclusions expressed in this manuscript are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. REDCap is supported at FSM by the Northwestern University Clinical and Translational Science (NUCATS) Institute, Research reported in this publication was supported, in part, by the National Institutes of Health’s National Center for Advancing Translational Sciences, Grant Number UL1TR001422. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Other disclosures: None reported. Ethical approval: Ethical approval has been granted for this study by the Northwestern University Institutional Review Board. Correspondence should be addressed to Dr. Daniel B. Evans, 675 N. St. Clair St, Galter Pavilion, Suite 18-200, Chicago, IL 60611; telephone, (312) 695-8630; e-mail: daevans@nm.org; Twitter: @devans_at_NUmed. © 2019 by the Association of American Medical Colleges

Comparison of Continuing Medical Education at U.S. Medical Schools and Other Accredited Organizations: A 20-Year Analysis Purpose: To describe a long-term overview of accredited continuing medical education (CME) at M.D.-granting medical schools in the United States. Method: Self-reported data about type, duration, and numbers of learner participants of accredited CME activities and income for CME units from each medical school were compiled annually by the Accreditation Council for Continuing Medical Education (ACCME) between 1998 and 2017. Comparisons were made with data from all other ACCME-accredited organizations. Results: Between 1998 and 2017, medical schools represented 18%–19% of all ACCME-accredited organizations. CME activities, hours of instruction, learner participants, and income increased gradually until reaching the highest levels between 2008 and 2011 before remaining constant. In 2017, each school generated a median of 132 activities [interquartile range (IQR) 66–266], of which 44% were courses and 31% were regularly scheduled series (RSSs), and a median of 29,824 learner interactions (IQR: 8,464–46,255). Total income rose gradually until 2010 before declining. In 2017, each school reported a median annual income of $1.0M (IQR: $0.2M–$2.9M) from CME activities, comprising 44% from registration fees, 39% from commercial support, and 14% from advertising and exhibits. Compared to other accredited organization types, medical schools generally developed more RSS activities and proportionally fewer interprofessional and online activities. Conclusions: While medical schools represent less than 20% of all ACCME-accredited organizations their role is pivotal and their influence far-reaching. For medical schools to fulfill their responsibility as education leaders, they need to prioritize support for CME offices and faculty development and implement new approaches to teaching and learning. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A764. Acknowledgments: The authors wish to thank Tamar Hosansky for editorial support. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: As this study did not involve human subjects and was an educational research study, it was exempt from ethical review at all associated organizations. Previous presentations: This research was not presented elsewhere at any medical or educational societies. Data: All data are from the ACCME and are used with permission. Additional data can be accessed at http://www.accme.org/publications/annual-data-reports. Correspondence should be addressed to Graham McMahon, Accreditation Council for CME, 401 N. Michigan Avenue, Suite 1850, Chicago, Illinois, 60611; email: gmcmahon@accme.org; Twitter: @accreditedCME. © 2019 by the Association of American Medical Colleges

An Investigation of the Relationship Between COMLEX-USA Licensure Examination Performance and State Licensing Board Disciplinary Actions Purpose: Passing the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) serves as a licensing requirement, yet there is limited understanding between this high-states exam and performance outcomes. This study examined the relationship between COMLEX-USA scores and disciplinary actions received by osteopathic physicians. Method: Data for osteopathic physicians (N = 26,383) who graduated from medical school from 2004–2013 were analyzed using multinomial logistic regression to assess the relationship between COMLEX-USA scores and placement into one of 3 disciplinary action categories relative to no action received, controlling for years in practice and gender. Results: Less than 1% of physicians in this study (n = 187) had a disciplinary action(s). Controlling for all COMLEX-USA levels, years in practice, and gender, higher Level 3 scores were associated with significant decreased odds for all action categories: revoked licensed (odds ratio [OR] = 0.51, 95% confidence interval [CI] 0.36, 0.72; P < .001), imposed limitations to practice (OR = 0.59, 95% CI 0.41, 0.84; P < .01), and other action imposed (OR = 0.48, 95% CI 0.33, 0.69; P < .001), relative to not receiving an action. In these same models, higher Level 2 Performance Evaluation Biomedical/Biomechanical Domain scores decreased the odds for an action that revoked a license (OR = 0.75, 95% CI 0.58, 0.98, P < .05) and imposed limitations to practice (OR = 0.64, 95% CI 0.49, 0.84, P < .001). Conclusions: These findings provide evidence that the COMLEX-USA delivers useful information regarding the likelihood of a practitioner receiving state board disciplinary actions. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: On July 31, 2018, the Center for the Advancement of Healthcare Education and Delivery Institutional Review Board (IRB) approved this study being exempt from IRB review because of minimal risk to study participants. Data: Not applicable. Correspondence should be addressed to William L. Roberts, National Board of Osteopathic Medical Examiners, Inc., 101 West Elm Street, Suite 150, Conshohocken, PA 19428-2004; telephone: (610) 825-6551; email: broberts@nbome.org. © 2019 by the Association of American Medical Colleges

How Culture is Understood in Faculty Development in the Health Professions: A Scoping Review Purpose: To examine the ways in which culture is conceptualized in faculty development (FD) in the health professions. Method: The authors searched PubMed, Web of Science, ERIC, and CINAHL, as well as the reference lists of identified publications, for articles on culture and FD published between 2006 and 2018. Based on inclusion criteria developed iteratively, they screened all articles. A total of 955 articles were identified, 100 were included in the full text screen, and 70 met the inclusion criteria. Descriptive and thematic analyses of data extracted from the included articles were conducted. Results: The articles emanated from 20 countries; primarily focused on teaching and learning, cultural competence, and career development; and frequently included multidisciplinary groups of health professionals. Only 1 article evaluated the cultural relevance of a FD program. The thematic analysis yielded 3 main themes: culture was frequently mentioned but not explicated; culture centered on issues of diversity, aiming to promote institutional change; and cultural consideration was not routinely described in international FD. Conclusions: Culture was frequently mentioned but rarely defined in the FD literature. In programs focused on cultural competence and career development, addressing culture was understood as a way of accounting for racial and socioeconomic disparities. In international FD programs, accommodations for cultural differences were infrequently described, despite authors acknowledging the importance of national norms, values, beliefs, and practices. In a time of increasing international collaboration, an awareness of, and sensitivity to, cultural contexts is needed. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A760. Acknowledgements: The authors gratefully acknowledge Ms. Naz Torabi and Ms. Andrea Quaiattini for their help with the comprehensive searches across multiple databases, Dr. Aliki Thomas for her advice regarding scoping review methodology, and Ms. Nicole Gignac for her able assistance in compiling all the data. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: Preliminary findings were presented at the 14th Asia Pacific Medical Education Conference in Singapore in January 2017. Correspondence should be addressed to Yvonne Steinert, Institute of Health Sciences Education, Faculty of Medicine, McGill University, 1110 Pine Avenue West, Montreal, Quebec, Canada H3A 1A3; email: yvonne.steinert@mcgill.ca; Twitter: @IHSE_McGill. © 2019 by the Association of American Medical Colleges