The Hahnemann University Hospital Closure and What Matters: A Department Chair’s Perspective The closure of Hahnemann University Hospital (HUH), which was announced on June 26, 2019, resulted in the most significant graduate medical education displacement in history, sending 570 residents to new institutions within a month of the announcement. Over 2,000 physicians, nurses, and staff lost their jobs. While seemingly predictable in retrospect, the closure came as a cataclysmic event to all involved. In this Invited Commentary, a Department Chair reflects on the lessons learned from these unprecedented circumstances. These lessons cover areas that are not a typical concern for faculty who are focused on teaching their trainees, but are worthy of their attention. Corporate and organizational structure, leadership, and financing of the hospital were critical determining characteristics of the failure. The role that the Accreditation Council for Graduate Medical Education and the Centers for Medicare and Medicaid Services played in this event were key stabilizers. However, their role in future events offer opportunities to play a more active role and alter how the next massive displacement unfolds, possibly preserving teaching programs. Highly competitive health systems should rethink non-collaborative strategies before allowing struggling institutions to succumb to market forces. Finally, a commitment by a hospital to the mission of academic medicine is a sacred trust with the faculty, trainees, and patients that it serves. It should not be undertaken by any enterprise that is not well resourced and equipped with the knowledge and expertise to meet this most serious of commitments. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Richard J. Hamilton, Drexel University College of Medicine, 245 North 15th Street, Mailstop 1011, Philadelphia, PA 19102; email: rh35@drexel.edu; Twitter: @rjhamiltonmd. © 2019 by the Association of American Medical Colleges

Critical Theory: Broadening our Thinking to Explore the Structural Factors at Play in Health Professions Education As part of the Philosophy of Science series of Invited Commentaries, this article on critical theory describes the origins of this research paradigm and its key concepts and orientations (ontology, epistemology, axiology, methodology, and rigor). The authors frame critical theory as an umbrella term for different theories, including feminism, anti-racism, and anti-colonialism. They emphasize the structural analysis that critical scholars conduct to uncover and sometimes address the role that social, political, cultural, economic, ethnic, and gender factors play in health professions education. They note the importance of acknowledging one’s social location when doing critical research, and highlight the core values of democracy and egalitarianism that underpin critical research. Methodologically, the authors stress how critical scholars reject singular truths in favor of more nuanced portraits of concepts and events, mobilize inductive approaches over deductive ones, and use critical theory to develop their projects and analyze their data. Following upon this elucidation of critical theory, the authors apply this paradigm to analyze the sample case of Lee, a medical resident who was involved in a medication error. The authors conclude that research conducted in the critical tradition has the potential to transcend individualistic accounts by revealing underlying structural forces that constrain or support individual agency. Editor’s note: This article is part of a collection of Invited Commentaries exploring the Philosophy of Science. Acknowledgments: The authors wish to thank two anonymous reviewers for high-quality feedback, as well as Emily Harvey, Anna McLeod, and Lara Varpio for coordinating the Philosophy of Science series of Invited Commentaries. Funding/Support: E. Paradis’ research is funded by the Canada Research Chairs program. L. Nimmon’s research is funded by a Social Sciences and Humanities Research Council (SSHRC) Insight Development Grant 430-2018-0409. C. Whitehead’s research is funded by the BMO Financial Group Chair in Health Professions Research, University Health Network. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Elise Paradis, Leslie Dan Faculty of Pharmacy, 144 College St, Toronto, ON, M4S 3M2 Canada; telephone: 415-792-7549; email: elise.paradis@utoronto.ca; Twitter: @ep_qc. © 2019 by the Association of American Medical Colleges

Internal Medicine Resident Professionalism Assessments: Exploring the Association With Patients’ Overall Satisfaction With Their Hospital Stay Purpose: Successful training of internal medicine (IM) residents requires accurate assessments. Patients could assess IM residents in a hospital setting, but medical educators must understand how contextual factors may affect assessments. The objective was to investigate relationships between patient, resident, and hospital-encounter characteristics and the results of patient assessments of IM resident professionalism. Method: The authors performed a prospective cohort study of postgraduate year 1 (PGY-1) IM residents and their patients at 4 general medicine inpatient teaching services at Mayo Clinic Hospital, Saint Mary’s Campus in Rochester, Minnesota, from July 1, 2015, through June 30, 2016. Patient assessments of resident professionalism were adapted from validated instruments. Multivariable modeling with generalized estimating equations was used to determine associations between patient assessment scores and demographic characteristics of residents, residents’ clinical performance and evaluations (including professionalism assessments in other settings), patients, and hospital encounters and to account for repeated assessments of residents. Results: A total of 409 patients assessed 72 PGY-1 residents (mean [SD], 5.7 [3.0] patient assessments per resident). In the multivariable model, only the highest rating out of 5 levels for overall satisfaction with hospital stay was significantly associated with patient assessment scores of resident professionalism (β [SE], 0.80 [0.08]; P < .001). Hospitalized patients’ assessment scores of resident professionalism were not significantly correlated with assessment scores of resident professionalism in other clinical settings. Conclusions: Hospitalized patients’ assessment scores of in-hospital resident professionalism were strongly correlated with overall patient satisfaction with hospital stay but were not correlated with resident professionalism in other settings. The limitations of patient evaluations should be considered before incorporating these evaluations into programs of assessment. Acknowledgments: This study was supported, in part, by staff assistance from the Mayo Clinic Internal Medicine Residency Office of Educational Innovations as part of the Accreditation Council for Graduate Medical Education Educational Innovations Project. The authors thank Donna K. Lawson, CCRP, for her support with patient enrollment, obtaining patient consent, and data collection. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was approved by the Mayo Clinic Institutional Review Board (No. 15-003003) on June 25, 2015. Correspondence should be addressed to John T. Ratelle, Division of Hospital Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905; email: ratelle.john@mayo.edu. © 2019 by the Association of American Medical Colleges

Re-visioning Academic Medicine Through a Constructionist Lens Constructionism in academic medicine matters. It encourages educators and researchers to question taken-for-granted assumptions, paying close attention to socially and historically-contingent meanings. In this Invited Commentary, the authors explain what constructionism is; examine its ontological, epistemological, and axiological underpinnings; and outline its common methodologies and methods. Although constructivism favors the individual; constructionism privileges the social as the controlling force behind the construction of meaning. Where micro-constructionism attends to the minutiae of language, macro-constructionism focuses on broader discourses reproduced through material and social practices and structures. While social constructionists might situate themselves at any point on the relativist-realist continuum, many constructionists focus on constructionism as epistemology (the nature of knowledge) rather than ontology (the nature of reality). From an epistemological standpoint, constructionism asserts that how we come to know the world is constructed through social interaction. Constructionism thus values language, dialogue, and context, in addition to internal coherence between epistemology, methodology, and methods. Constructionism similarly values the concepts of dependability, authenticity, credibility, confirmability, reflexivity, and transferability. It also embraces the researcher-researched relationship. Given the privileging of language, qualitative methodologies and methods are key in constructionism, with constructionist-type questions focusing on how people speak. Here, the authors encourage the reader to develop an understanding of constructionism in order to re-vision academic medicine through a constructionist lens. Editor’s note: This article is part of a collection of Invited Commentaries exploring the Philosophy of Science. Acknowledgements: The authors would like to thank the editors of, and other contributors to, this Philosophy of Science series of Invited Commentaries for their helpful developmental feedback on earlier drafts of this manuscript. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimers: This Invited Commentary represents the views of the authors based on the cited literature. Correspondence should be addressed to Charlotte Rees, College of Science, Health, Engineering and Education, Murdoch University, Building 245, Room 2.018, 90 South Street, Murdoch, WA 6150, Australia; email: charlotte.rees-sidhu@murdoch.edu.au; Twitter: @charlreessidhu © 2019 by the Association of American Medical Colleges

Redesigning the Learning Environment to Promote Learner Well-Being and Professional Development There is a high prevalence of burnout and depression among medical students and residents (or learners), which can negatively impact them personally, their professional development, and the patients to whom they provide care. Educators have a responsibility for the system-level factors that influence learners’ well-being. In this Perspective, the authors outline strategies institutions and affiliated training sites responsible for educating learners can take to pursue the recommended goal related to learners, their well-being, and the learning environment in the National Academies of Sciences, Engineering, and Medicine consensus study report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A777. Acknowledgments: The authors thank members of the National Academies of Sciences, Engineering, and Medicine consensus study System Approaches to Improve Patient Care by Supporting Clinician Well-Being who collaboratively worked together to write the report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Liselotte N. Dyrbye, 200 First St. SW, Rochester, MN 55905; telephone: (507) 284-2511; e-mail: dyrbye.liselotte@mayo.edu; Twitter: @dyrbye. © 2019 by the Association of American Medical Colleges

The Positivism Paradigm of Research Research paradigms guide scientific discoveries through their assumptions and principles. Understanding paradigm-specific assumptions helps illuminate the quality of findings that support scientific studies and identify gaps in generating sound evidence. This article focuses on the research paradigm of positivism, examining its definition, history, and assumptions (ontology, epistemology, axiology, methodology, and rigor). Positivism is aligned with the hypothetico-deductive model of science that builds on verifying a priori hypotheses and experimentation by operationalizing variables and measures; results from hypothesis testing are used to inform and advance science. Studies aligned with positivism generally focus on identifying explanatory associations or causal relationships through quantitative approaches, where empirically based findings from large sample sizes are favored—in this regard, generalizable inferences, replication of findings, and controlled experimentation have been principles guiding positivist science. Criteria for evaluating the quality of positivist research are discussed. An example from health professions education is provided to guide positivist thinking in study design and implementation. Editor’s note: This article is part of a collection of Invited Commentaries exploring the Philosophy of Science. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. 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. 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

Commentary on "After the Diagnosis" No abstract available

14 Years Later: A Follow-Up Case-Study Analysis of 8 Health Professions Education Scholarship Units Purpose: Internationally, health professions education scholarship units (HPESUs) are often developed to promote engagement in educational scholarship, yet little is known about how HPESUs change over time or what factors support their longevity. In hopes of helping HPESUs thrive, this study explored factors that shaped the evolution of 8 HPESUs over the past 14 years. Method: This study involved retrospective case-study analysis of the 8 American, Canadian, and Dutch HPESUs profiled in a 2004 publication. First, the research team summarized key elements of HPESUs from the 2004 articles, then conducted semi-structured interviews with the current unit directors. In the first set of questions, directors were asked to reflect on how the unit had changed over time, what successes the unit enjoyed, what enabled these successes, what challenges the unit encountered, and how these challenges were managed. In the second set of questions, questions were tailored to each unit, following up on unique elements from the original article. The team used Braun and Clarke’s 6-phase approach to thematic analysis to identify, analyze, and report themes. Results: The histories of the units varied widely—some had grown by following their original mandates, some had significant mission shifts, and others had nearly disappeared. Current HPESU directors identified 3 key factors that shaped their HPESU’s longitudinal development: the people working within and overseeing the HPESU (the need for a critical mass of scholars, a pipeline for developing scholars, and effective leadership); institutional structures (issues of centralization, unit priorities, and clear messaging); and funding (the need for multiple funding sources). Conclusions: Study findings offer insights that may help current HPESU directors to strategically plan for their unit’s continued development. Tactically harnessing the factors identified could help directors ensure their HPESU’s growth and contend with the challenges that threaten the unit’s success. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A778. Acknowledgments: The authors wish to thank all the directors who volunteered to be interviewed, and research assistant support from the Research Support Unit of the Department of Innovation in Medical Education (DIME), University of Ottawa. Funding/Support: Funding for this project was received from the Department of Medicine, University of Ottawa. Other disclosures: None reported. Ethical approval: Ethical approval was granted by the Ottawa Health Science Network Research Ethics Board, protocol number 20150210-01H. Disclaimer: The opinions expressed in this publication are those of the authors and do not necessarily reflect those of the Uniformed Services University of the Health Sciences, the Department of Defense, or any other U.S. federal agency. Correspondence should be addressed to Susan Humphrey-Murto, The Riverside Hospital, 1967 Riverside Drive Box 6-27, Ottawa, Ontario, Canada, K1H 7W9; telephone: (613) 737-8899, ext. 81851; email: shumphrey@toh.on.ca. 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

Revealing Novel IDEAS: A Fiduciary Framework for Team-Based Prescribing The importance of safe, effective, and cost-effective prescribing habits can hardly be overstated in the current pay-for-value environment. The prescribing process taught in most medical curricula focuses primarily on accurate medical indications. While this may be of utmost importance from the clinician’s perspective, it falls short of addressing the other key elements of highly effective prescribing. These other elements are often paramount in the minds of patients. A patient-centric framework that associates and incorporates the necessary components of optimal prescribing is overdue. Building this framework into medical curricula will foster increased teamwork among providers and enhance shared decision making between patients and clinicians. In addition to establishing accurate medical indications, prescribing teams need to assure every prescribed medication is desired, effective, affordable, and safe for patients who receive them. Prescription writing is an honorable prerogative and doing so safely, effectively, and cost-effectively requires both teamwork and technology. Highly effective prescribing teams can implement the IDEAS (Indicated, Desired, Effective, Affordable, Safe) framework through appropriate and deliberate delegation. By empowering members of the care team to support and educate patients, this framework will allow physicians to focus on ensuring appropriate indications and real-world effectiveness. This novel IDEAS framework serves as an important mental model for medical trainees and reinforces sound prescribing habits among seasoned clinicians. High-touch and high-tech partnerships have the potential to maximize the triple aim (i.e., improving the patient’s experience of care, improving the health of populations, and reducing the per capita cost of health care). In an era when costs overwhelm quality, providing a fiduciary framework to instill responsibility for optimal prescribing, especially among young physician–leaders, is invaluable. Acknowledgments: The authors wish to thank the faculty, mentors, and advisors at Stanford University’s Clinical Excellence Research Center Fellowship, specifically Dr. Arnie Milstein, Dr. Terry Platchek, Dr. Craig Lindquist, Dr. Bob Kaplan, Dr. Kevin Schulman, Dr. David Sobel, Dr. Niteesh Choudhry, and Dr. Sachin Jain. The authors would also like to thank the dedicated care teams, leadership, and clinicians at Desert Oasis Healthcare, CareMore, Kaiser Permanente, and PHARMAC (New Zealand government’s Pharmaceutical Management Agency). Funding/Support: B.M. Brady was supported by a Clinical and Translational Science Award from the National Center for Advancing Translational Sciences, National Institutes of Health (UL1 TR-001085). Other disclosures: Since completion of this research, R.S. Plowman has become senior medical director at Proteus Digital Health. L.G. Osterberg has consulted for Proteus Digital Health, but that work did not coincide with the period of this research. Ethical approval: Reported as not applicable. Disclaimers: The opinions and assertions are those of the authors and do not necessarily reflect the official policy or position of the Department of Veterans Affairs. Correspondence should be addressed to R. Scooter Plowman, 2600 Bridge Parkway, Redwood City, CA 94065; telephone: (913) 787-2603; email address: scooter.plowman@gmail.com. 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

Shining a Light Into the Black Box of Group Learning: Medical Students’ Experiences and Perceptions of Small Groups Purpose: Group work is seen as serving multiple positive purposes in health professions education, such as providing an opportunity for students to master course content, transfer knowledge into clinical practice, and develop collaborative/teamwork skills. However, there have been relatively few studies exploring medical students’ experiences of the small-group learning context or what they learn in and from that context. Method: Between January 2018 and January 2019, the authors used grounded theory methods to conduct semistructured interviews with 9 medical students to explore their perceptions of the value of the group as a mechanism for learning both content and teamwork skills. Sessions were audiorecorded and transcribed verbatim. One author coded the transcripts and identified codes, which the team then discussed, refined, and used to develop themes. Results: Students were able to express all the expected goals for small-group learning, such as retaining course materials, mimicking future health care team interactions, and creating a collaborative environment. However, when their experiences were further explored, students seemed to have perceived that the value of group learning was as a mechanism for reviewing rather than for deepening their learning. Further, students frequently expressed the opinion that the tutor was the primary factor in the success of a group, and when group function was suboptimal, students described giving up on the group or relying on the tutor to address the problem. Conclusions: Formal, small-group, tutor-led learning sessions, at least in the context of single-term groups, may not be accomplishing what educators might hope. Although students understand the intent of small-group learning, it cannot be assumed that such groups are deepening learning or solving the teamwork problems in health professions education. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A779. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was approved by the University of British Columbia Behavioral Research Ethics Board on January 16, 2018 (ID: H17-034015). Previous presentations: A peer-reviewed oral abstract presentation was given at the 2019 Canadian Conference on Medical Education, April 15, 2019, Niagara Falls, Ontario, Canada. Correspondence should be addressed to Glenn Regehr, Centre for Health Education Scholarship, Suite 429, 2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3 Canada; email: glenn.regehr@ubc.ca. © 2019 by the Association of American Medical Colleges