Post-Positivism in Health Professions Education Scholarship An understanding of the diversity of perspectives within the research paradigms of health professions education (HPE) is essential for rigorous research design and more purposeful engagement with the contributions of others. In this article the authors explicitly discuss the underlying assumptions, notions of good scholarship, and shortcomings of the post-positivism research paradigm. While post-positivism is likely one of the more familiar paradigms within HPE research, it is rarely formally or explicitly described. Drawing on key literature and contemporary examples, the authors describe the ontology, epistemology, methodologies, axiology, signs of rigor, and common critiques of post-positivism. A case study provides the focus for a practical illustration of how a post-positivist approach to education research could be applied. Suggestions for further reading are provided for those who are keen to delve deeper into the history and key tenants of the post-positivist stance. Editor’s note: This article is part of a collection of Invited Commentaries exploring the Philosophy of Science. Funding/Support: This work was partially supported by a Salary Award provided to M. Young by the Fondation de Recherche du Québec – Sante. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Meredith E. Young, Faculty of Medicine, McGill University, 1110 Pine Avenue West, Montreal, QC H1A 1A3; telephone: 514-398-4059; email: Meredith.young@mcgill.ca; Twitter: @meredithyoung1. © 2019 by the Association of American Medical Colleges

Alpha Omega Alpha Honor Medical Society: A Commitment to Inclusion, Diversity, Equity, and Service in the Profession of Medicine With a motto of “Be Worthy to Serve the Suffering,” Alpha Omega Alpha Honor Medical Society (AΩA) supports the importance, inclusion, and development of a culturally and ethnically diverse medical profession with equitable access for all. The underrepresentation of minorities in medical schools and medicine continues to be a challenge for the medical profession, medical education, and AΩA. AΩA has worked, and continues to work, to ensure the development of diverse leaders fostering within them the objectivity and equity to be inclusive servant leaders who understand and embrace diversity in all its forms. Inclusion of talented individuals from different backgrounds benefits patient care, population health, education, and scientific discovery. AΩA values an inclusive, diverse, fair, and equitable work and learning environment for all, and supports the medical profession in its work to achieve a welcoming, inclusive environment in teaching, learning, caring for patients, and collaboration. The diversity of medical schools is changing and will continue to change. AΩA is committed to continuing to work with its members, medical school deans, and AΩA chapters to assure that AΩA elections are unbiased and based on the values of AΩA and the profession of medicine in service to patients and the profession. Progress toward diversity, inclusion, and equity is more than simply checking off a box or responding to criticism—it is about being and developing diverse excellent physicians. AΩA and all those in the medical profession must continue to guide medicine to be unbiased, open, accepting, inclusive, and culturally aware in order to “Be Worthy to Serve the Suffering.” Editor’s note: This is an Invited Commentary on Lynch G, Hollaway T, Muller D, Palermo A-G. Suspending Student Selections to Alpha Omega Alpha Honor Medical Society: How One School Is Navigating the Intersection of Equity and Wellness. Acad Med. 2019;94:XXX-XXX. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable Correspondence should be addressed to Richard Byyny, 12635 E. Montview Blvd., Suite 270, Aurora, CO 80045; email: r.byyny@alphaomegaalpha.org; Twitter: @AOA_society. © 2019 by the Association of American Medical Colleges

Suspending Student Selections to Alpha Omega Alpha Honor Medical Society: How One School Is Navigating the Intersection of Equity and Wellness Medical education must provide students with a delicate balance of academic rigor, equity, and wellness. While the medical education community espouses all these values, the authors believe the way medical students are evaluated and rewarded undermines equity and wellness. Alpha Omega Alpha Honor Medical Society (AΩA) membership is arguably the highest honor that a medical student can achieve. In the short term it opens doors to the most selective training opportunities, and in the long term ushers students into an elite group of future physician leaders. Yet recent data have demonstrated that AΩA is disproportionately awarded to white students. At Icahn School of Medicine at Mount Sinai (ISMMS), the authors observed that students underrepresented in science and medicine were persistently underrepresented among those selected for AΩA. They describe efforts at ISMMS to reduce bias in the selection process and the ultimate decision to suspend medical student selection for AΩA altogether. The authors argue that selection to AΩA reinforces the structural biases and social privilege that are embedded in medical education, and undermines the ability to deliver an educational experience that has as its core tenets equity and wellness. Suspending participation in student selection for AΩA is an important step toward recognizing that medical school learning environments continue to privilege white students over students who are underrepresented in medicine. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable Editor’s note: A commentary by R.L. Byyny, D. Martinez, L. Cleary, et al, will appear in the same issue as this article. Correspondence should be addressed to David Muller, MD, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1255, New York, New York, 10029; telephone: (212) 241-8716; email: David.muller@mssm.edu. © 2019 by the Association of American Medical Colleges

The Birth, Death, and Renaissance (?) of Dissection: A Critique of Anatomy Teaching With—or Without—the Human Body A riveting debate regarding the fate of dissection, the classical method of anatomy, is sweeping through medical academia, as imaging tools gain a greater foothold in anatomy teaching programs. This Perspective does not aim to grapple with the question of “how should anatomy be taught” but rather to explain why the transformation of anatomical education is taking place by situating these developments in the broader philosophical context of modern medicine, offered by Michel Foucault’s The Birth of the Clinic: An Archaeology of Medical Perception. Emphasizing the body’s crucial role in the epistemological change in medical practice in the early 19th century, Foucault coined the term “medical gaze” to denote the doctor’s observation of the patient’s body in search of signs of disease. Within this new systematic perception of disease, which brought about the anatomo-clinical method, the clinical gaze thus embraced the study of the body via dissection. The author contends that the introduction of medical imaging into the diagnostic process has resulted in a shift in the focus of the clinical gaze from the body to its medical image, and that this process is mirrored in anatomy by its discarding of the cadaver. Given the fundamental differences between the phenomenology of the body and its medical image, the author suggests that when using medical images in medical schools and teaching hospitals, one teaches, at the very least, a new kind of anatomy. Foucault’s analysis of the painting The Treachery of Images by Réne Magritte lends some support to the ideas presented here. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A775. Acknowledgments: The author is greatly indebted to Prof. Brian Hodges (The Wilson Centre, University of Toronto) for his invaluable comments on an early draft of the article. The author also thanks Prof. Hagi Kenaan (Department of Philosophy, Tel Aviv University) and Mr. Dan Largman (Buchmann Faculty of Law, Tel Aviv University) for their insight comments during the preparation of the article, Prof. Shmuel Reis (Hebrew University of Jerusalem) for some thoughtful discussions on the article, and Mr. Aviad Sajevitch for producing the homage to Magritte (Figure 1). Additionally, the author is grateful to two anonymous reviewers for their careful reading of the manuscript and their insightful comments, which substantially improved the article. Lastly, the author thanks Dr. Spencer B. Gay, Department of Radiology and Medical Imaging, University of Virginia School of Medicine, and the Société des Auteurs dans les Arts Graphiques et Plastiques (ADAGP) in Paris, France, for granting permission to use the photos featured in the supplemental digital content, as well as Mr. Aviad Sajevitch, who created and granted permission for the use of the digital painting featured in print and online. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Assaf Marom, The Ruth and Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, 1 Efron St., Haifa 31096, Israel; email: assafma@technion.ac.il. © 2019 by the Association of American Medical Colleges

Can Better Selection Tools Help Us Achieve Our Diversity Goals in Postgraduate Medical Education? Comparing Use of USLME Step 1 Scores and Situational Judgment Tests at 7 Surgical Residencies Purpose: Use of the United States Medical Licensing Examination (USMLE) for residency selection has been criticized for its inability to predict clinical performance and potential bias against underrepresented minorities (URMs). This study explored the impact of altering traditional USMLE cutoffs and adopting more evidence-based applicant screening tools on inclusion of URMs in the surgical residency selection process. Method: Multi-method job analyses were conducted at 7 U.S. general surgical residency programs during the 2018–2019 application cycle to gather validity evidence for developing selection assessments. Unique situational judgment tests (SJTs) and scoring algorithms were created to assess applicant competencies and fit. Programs lowered their traditional USMLE Step 1 cutoffs and invited candidates to take their unique SJT. URM status (woman, racial/ethnic minority) of candidates who would have been considered for interview using traditional USMLE Step 1 cutoffs was compared to the candidate pool considered based on SJT performance. Results: A total of 2,742 general surgery applicants were invited to take an online SJT by at least 1 of the 7 programs. Approximately 35% of applicants who were invited to take the SJT would not have met traditional USMLE Step 1 cutoffs. Comparison of USMLE-driven versus SJT-driven assessment results demonstrated statistically different percentages of URMs recommended; including the SJT allowed an average of 8% more URMs offered an interview invitation (P < .01). Conclusions: Reliance on USMLE Step 1 as a primary screening tool precludes URMs from being considered for residency positions at higher rate than non-URMs. Developing screening tools to measure a wider array of candidate competencies can help create a more equitable surgical workforce. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A776. Acknowledgments: None. Funding/Support: None reported. Ethical approval: This study was deemed quality improvement through the University of Texas Institutional Review Board, and thus no IRB approval was required. Other disclosures: A.K. Gardner, K.J. Cavanaugh, R.E. Willis, and B.J. Dunkin all provide advice on selection and assessment to training programs and organizations through SurgWise Consulting. Previous presentations: These data were presented at the International Association for Medical Education (AMEE) Conference, August 27, 2019, Austria, Vienna; and at the Association of American Medical Colleges Workforce Research conference, May 2, 2019, Alexandria, Virginia. Correspondence should be addressed to Aimee K. Gardner, School of Health Professions, Baylor College of Medicine, MS: BCM115, DeBakey Building, M108K, One Baylor Plaza, Houston, TX 77030; telephone: (713) 798-4613; email: aimee.gardner@bcm.edu; Twitter: @AimeeGthePHD. © 2019 by the Association of American Medical Colleges

Leveraging the Medical School Admissions Process to Foster a Smart, Humanistic, and Diverse Physician Workforce An excellent physician has a range of talents, including the knowledge and critical thinking abilities to work with the rapidly changing biomedical and social science content of the profession as well as the interpersonal and communication skills to build meaningful relationships with patients and families. The Medical College Admission Test (MCAT) was revised in 2015 to focus more on analytical reasoning skills and behavioral and social sciences knowledge to ensure that future physicians have the capabilities needed to care for patients in the 21st century and to allow admissions committees to identify applicants who have demonstrated proficiency in these areas. With these changes, scores continue to be predictive of student performance in the preclerkship curriculum. In this Invited Commentary, the author argues that, as educators struggle to define the characteristics of the “right” candidates for medical school and design processes to identify and admit those applicants, it is important to consider the message being sent by calls for the MCAT exam to play a reduced role in admissions decisions. Educators must avoid diminishing the importance of intellectual rigor and, while pursuing goals for a more diverse physician workforce, maintain standards that ensure medicine’s commitment to patients. The author concludes with suggestions for how educators can work with under-resourced colleges and premedical programs to help disadvantaged students get the preparation they need to succeed in medical school and throughout their careers. Taking these steps will allow educators to support students, prepare them for practice, and fulfill their obligation to the public to produce excellent physicians. Editor’s Note: This is an Invited Commentary on Lucey CR, Saguil A. The consequences of structural racism on MCAT scores and medical school admissions: The past is prologue. Acad Med. 2020;95:XX-XX; Terregino CA, Saguil A, Price-Johnson T, Anachebe NF, Goodell K. The diversity and success of medical school applicants with scores in the middle third of the MCAT score scale. Acad Med. 2020;95:XX-XX; Girotti JA, Chanatry JA, Clinchot DM, et al. Investigating group differences in examinees’ preparation for and performance on the new MCAT exam. Acad Med. 2020;95:XX-XX; and Busche K, Elks ML, Hanson JT, et al. The validity of scores from the new MCAT exam in predicting student performance: Results from a multi-site study. Acad Med. 2020;95:XX-XX. Acknowledgements: The author thanks David Roberts, MD, and Steven Weinberger, MD, for their review of an earlier draft of this article. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Richard M. Schwartzstein, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; telephone: (617) 667-5494; email: rschwart@bidmc.harvard.edu. © 2019 by the Association of American Medical Colleges

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