Academic Health Centers and the Quintuple Aim of Health Care.

The Quintuple Aim of health care adds health equity to the existing Quadruple Aim of improving the individual experience of care for patients, improving the health of populations, reducing the per capita cost of care, and improving the experience of health care professionals. Health equity has previously been subsumed within the other 4 aims. Elevating health equity to the status of a distinct aim is necessary to address persistent health inequities that disproportionately affect underrepresented and minoritized groups. Academic health centers (AHCs) bear a unique responsibility to advance health equity due to the societal importance of their 4 missions: patient care, education, research, and community collaboration. Interprofessional education and practice provide natural connection points that enable AHCs to prepare both health professions students and practicing health care professionals to address all 5 aims. AHCs are well positioned to assess health outcomes related to health equity, develop a health care workforce that is representative of their communities, develop innovative research questions regarding health equity, and engage and invest in the communities they serve.

The Slow Creep Back: Threats and Opportunities for IPE Posed by COVID-19.

Interprofessional education (IPE) prepares current and future health care professionals for interprofessional collaborative practice (IPCP). IPCP results in increased quality of care demanded by patients and reimbursed in value-based care models when appropriately operationalized. The COVID-19 pandemic forced rapid and unprecedented changes in higher education and healthcare, although the impact on IPE delivery in the U.S. is unknown. Analyses of qualitative survey data collected from U.S. IPE leaders (n = 21) identified the impact and challenges of the pandemic on IPE programs. Three primary themes emerged: transition to a virtual environment, uncertainties and fears regarding finance and program sustainability, and opportunities for improvements in programming, delivery, instructional design, experiential learning, and assessment. Programs faced existential pandemic-related challenges. Concurrently, the pandemic accelerated innovation in IPE curricula, illuminated opportunities for IPE to improve the work life of healthcare providers, and raised awareness of the need to extend the Quadruple Aim to eliminate health inequities.

Public Humiliation in the Surgical Clerkship: Qualitative Analysis of Responses to the Association of American Medical Colleges Graduation Questionnaire.

BACKGROUND: Nearly 1 in 5 medical students reports at least 1 incident of mistreatment, with many occurring in the perioperative environment. We aimed to further define the types of mistreatment occurring perioperatively in a national data set by using a mixed-methods approach. STUDY DESIGN: A sample of 2,224 responses to the general public humiliation free-text question on the 2015 Association of American Medical College's Graduation Questionnaire were analyzed. Using grounded theory methodology, 4 raters independently created and refined the coding schema. Final coding was determined by majority rating. Descriptive statistics, interrater reliability, and chi-square analysis were performed where appropriate. RESULTS: Among responses, 2,411 events were identified. Interrater reliability was moderate (>0.41) on 94% of variables. Events occurring in a specific setting implicated the surgery clerkship and the operating room 53.2% and 21.8% of the time, respectively. Perioperative events accounted for nearly one-third of verbal abuse reports (30.5%, 324/1059), and almost half of events described yelling (47.0%, 178/379). Mistreatment involving physical contact was significantly more likely to occur in the operating room (59% vs 41%, p < 0.001). Events coded as possibly routine education (n = 379) were significantly less common perioperatively than nonsurgical settings (20.5% vs 79.4%, p = 0.007). CONCLUSIONS: A significant proportion of medical student mistreatment events occur in the context of surgery. Surgeons and trainees must play active roles in leading and instituting needed changes to improve the learning environment to support medical students and recruit a sufficient future surgical workforce.

Peer review: a tool to enhance clinical teaching.

BACKGROUND: The system used by academic health centres to evaluate teaching must be valued by the large number of faculty staff that teach in clinical settings. Peer review can be used to evaluate and enhance clinical teaching. The objective of this study was to determine the perceptions of clinical faculty about the effects of participating in peer review. METHODS: Faculty members were observed teaching in a clinical setting by trained peer observers. Feedback was provided using a checklist of behaviours and descriptive comments. Afterwards, semi-structured interviews were conducted to assess the faculty member's perception about the process. Notes from the interviews were analysed using a grounded theory approach. The study was approved by the institutional review boards of all the institutions involved. RESULTS: Three themes emerged from the interviews with faculty members: (1) they found the process to be valuable - they received information that affirmed "good" teaching behaviours, and were prompted to be more focused on their teaching; (2) they were motivated to enhance their teaching by being more deliberate, interactive and learner-centred; and (3) they were inspired to explore other opportunities to improve their teaching skills. DISCUSSION: Peer review is a process that promotes the open discussion and exchange of ideas. This conversation advances clinical teaching skills and allows high-quality teaching behaviours to be strengthened.

Academic and professional career outcomes of medical school graduates who failed USMLE Step 1 on the first attempt.

This study sought to determine the academic and professional outcomes of medical school graduates who failed the United States Licensing Examination Step 1 on the first attempt. This retrospective cohort study was based on pooled data from 2,003 graduates of six Midwestern medical schools in the classes of 1997-2002. Demographic, academic, and career characteristics of graduates who failed Step 1 on the first attempt were compared to graduates who initially passed. Fifty medical school graduates (2.5 %) initially failed Step 1. Compared to graduates who initially passed Step 1, a higher proportion of graduates who initially failed Step 1 became primary care physicians (26/49 [53 %] vs. 766/1,870 [40.9 %]), were more likely at graduation to report intent to practice in underserved areas (28/50 [56 %] vs. 419/1,939 [ 21.6 %]), and more likely to take 5 or more years to graduate (11/50 [22.0 %] vs. 79/1,953 [4.0 %]). The relative risk of first attempt Step 1 failure for medical school graduates was 13.4 for African Americans, 7.4 for Latinos, 3.6 for matriculants >22 years of age, 3.2 for women, and 2.3 for first generation college graduates. The relative risk of not being specialty board certified for those graduates who initially failed Step 1 was 2.2. Our observations regarding characteristics of graduates in our study cohort who initially failed Step 1 can inform efforts by medical schools to identify and assist students who are at particular risk of failing Step 1.

Variables associated with full-time faculty appointment among contemporary U.S. Medical school graduates: implications for academic medicine workforce diversity.

PURPOSE: The authors sought to identify variables independently associated with full-time faculty appointment among recent medical graduates. METHOD: With institutional review board approval, the authors developed a database of individualized records for six midwestern medical schools' 1997-2002 graduates. Using multivariate logistic regression, they identified variables independently associated with full-time faculty appointment from among demographic, medical-school-related, and career-intention variables. They report adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Of 1,965 graduates in the sample, 263 (13.4%) held full-time faculty appointments in 2007-2008, including 14.4% (123/853) of women graduates and 8.6% (17/198) of underrepresented minority (URM) graduates. Women (OR: 1.386; 95% CI: 1.023-1.878), MD/PhD program graduates (OR: 2.331; 95% CI: 1.160-4.683), and graduates who reported a career-setting preference for "full-time university faculty" on the Association of American Medical Colleges' Graduation Questionnaire (OR: 3.164; 95% CI: 2.231-4.486) were more likely to have a full-time faculty appointment. Graduates who chose family medicine (OR: 0.433; 95% CI: 0.231-0.811) and surgical specialties (OR: 0.497; 95% CI: 0.249-0.994) were less likely to have a full-time faculty appointment. URM race/ethnicity was not independently associated with full-time faculty appointment (OR: 0.788; 95% CI: 0.452-1.375). CONCLUSIONS: Efforts to increase representation of women graduates in academic medicine seem to have met with greater success than efforts to increase representation of URM graduates. Greater participation of URM students in MD/PhD programs and in interventions during medical school that promote interest in academic medicine careers may increase URM graduates' representation in academic medicine.

Attrition during graduate medical education: medical school perspective.

OBJECTIVE: To identify predictors of attrition during graduate medical education (GME) in a single medical school cohort of contemporary US medical school graduates. DESIGN: Retrospective cohort study. SETTING: Single medical institution. PARTICIPANTS: Recent US allopathic medical school graduates. MAIN OUTCOME MEASURE: Attrition from initial GME program. RESULTS: Forty-seven of 795 graduates (6%) did not complete the GME in their initial specialty of choice. At bivariate analysis, attrition was associated with election to the Alpha Omega Alpha Honor Medical Society, being an MD-PhD degree holder, and specialty choice (all P < .05). Attrition was not associated with graduation year (P = .91), sex (P = .67), or age (P = .12). In a multivariate logistic regression model, MD-PhD degree holder (odds ratio, 3.43; 95% confidence interval, 1.27-9.26; P = .02), election to Alpha Omega Alpha (2.19; 1.04-4.66; P = .04), choice of general surgery for GME (5.32; 1.98-14.27; P < .001), and choice of 5-year surgical specialty including those surgical specialties with a GME training requirement of 5 years or longer (2.74; 1.16-6.44; P = .02) each independently predicted greater likelihood of attrition. CONCLUSION: Academically highly qualified graduates and graduates who chose training in general surgery or in a 5-year surgical specialty were at increased risk of attrition during GME.

Reaping what we sow: the emerging academic medicine workforce.

National efforts to increase diversity of academic medicine faculty led us to study the evolution of medical graduates' academic medicine career intentions. We conducted a retrospective cohort study of 1997-2004 U.S. allopathic medical graduates who completed both the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire, categorizing the evolution of academic medicine career intentions (sustained, emerging, diminished and no intent) by similarities/differences in graduates' responses to the career choice question on both questionnaires. Multivariable logistic regression models identified independent predictors of sustained and emerging intent (compared with no intent) and diminished intent (compared with sustained intent). Of 87,763 graduates, 67% indicated no intent, 20% emerging intent, 8% sustained intent and 5% diminished intent to pursue an academic medicine career. Asians were more likely and underrepresented minorities less likely to have sustained and emerging intent. Women were more likely to have emerging intent. Graduates planning more extensive career involvement in research at matriculation and reporting greater satisfaction with the quality of their medical education, higher clinical clerkship ratings, and lower debt were more likely to have sustained and emerging intent and less likely to have diminished intent. Graduates planning to practice in underserved areas and choosing family medicine were less likely to have sustained and emerging intent and more likely to have diminished intent (all p < 0.05). Findings can inform efforts to develop an academic medicine workforce that can meet our nation's healthcare needs and more equitably reflect the diversity of our society and medical student population.

The changing paradigm of contemporary U.S. allopathic medical school graduates' career paths: analysis of the 1997-2004 national AAMC Graduation Questionnaire database.

PURPOSE: During the last 15 years, the proportion of U.S. allopathic medical graduates planning to pursue alternative careers (other than full-time clinical practice) has been increasing. The authors sought to identify factors associated with contemporary medical graduates' career-setting plans. METHOD: The authors obtained anonymous data from the 108,408 U.S. allopathic medical graduates who completed the 1997-2004 national Association of American Medical Colleges Graduation Questionnaire (GQ). Using multinomial logistic regression, responses to eight GQ items regarding graduates' demographics, medical school characteristics, and specialty choice were tested in association with three career-setting plans (full-time university faculty; other, including government agencies, non-university-based research, or medical or health care administration; or undecided) compared with full-time (nonacademic) clinical practice. RESULTS: The sample included 94,101 (86.8% of 108,408) GQ respondents with complete data. From 1997 to 2004, the proportions of graduates planning full-time clinical practice careers decreased from 51.3% to 46.5%; the proportions selecting primary care and obstetrics-gynecology specialties also decreased. Graduates reporting Hispanic race/ethnicity or no response to race/ethnicity, lower debt, dual advanced degrees at graduation, and psychiatric-specialty choice were consistently more likely to plan to pursue alternative careers. Graduates selecting an obstetrics-gynecology specialty/ subspecialty were consistently less likely to plan to pursue alternative careers. Being female, Asian/Pacific Islander, Black or Native American/Alaskan, and selecting non-primary-care specialties were variably associated with alternative career plans. CONCLUSIONS: As the medical student population becomes more demographically diverse, as graduates increasingly select non-primary-care specialties, and as dual-degree-program graduates and alternative career opportunities for physicians expand, the proportion of U.S. graduates planning full-time clinical practice careers likely will continue to decline.

Which U.S. medical graduates plan to become specialty-board certified? Analysis of the 1997-2004 national association of American Medical Colleges Graduation Questionnaire database.

BACKGROUND: Predictors of U.S. allopathic medical-school graduates' board-certification plans have not been characterized. METHOD: Using multivariable logistic regression, graduates' responses to 11 questions on the 1997-2004 Association of American Medical Colleges Graduation Questionnaire were analyzed to identify independent predictors of plans for specialty-board certification. RESULTS: The proportion of 108,408 graduates planning specialty-board certification decreased from 97.3% in 1997 to 88.4% in 2004. Among 101,805 (93.9%) graduates with complete data, graduates who were Hispanic, rated their clinical clerkships, quality of medical education, and confidence in clinical skills more highly, had any debt, and planned "University-faculty" careers were more likely to plan becoming board certified. Females, Asians/Pacific Islanders, and graduates who planned to practice in underserved areas, planned "other" nonclinical-practice careers, and graduated with MD/other (non-PhD) degrees were less likely to plan becoming board certified. CONCLUSION: Specialty-board certification does not appear to be among the professional goals for a growing proportion of U.S. medical graduates.

What predicts USMLE Step 3 performance?

BACKGROUND: Academic and other student-specific variables associated with United States Medical Licensing Examination (USMLE) Step 3 performance have not been fully defined. METHOD: We analyzed Step 3 scores in association with medical school academic-performance measures, gender, residency specialty, and first postgraduate year (PGY-l) of training program-director performance evaluations. RESULTS: There were significant first-order associations between Step 3 scores and each of USMLE Step 1 and Step 2 scores, third-year clerkships' grade point average (GPA), Alpha Omega Alpha election, Medical Scientist Training Program graduation, broad-based specialty residency training, and PGY-l performance evaluation score. In a multiple linear regression model accounting for over 50% of the total variance in Step 3 scores, Step 2 scores, broad-based-specialty residency training, and GPA independently predicted Step 3 scores. CONCLUSIONS: Individualized Step 3 scores provide medical schools with additional means to externally validate their educational programs and to enhance the scope of outcomes assessments for their graduates.