American Medical Colleges Graduation Questionnaire Research Articles

Racial and Ethnic Discrimination and Medical Students’ Identity Formation

Investigating racial and ethnic discrimination in medical education is crucial for addressing disparities and fostering an inclusive environment. To assess how racial and ethnic discrimination in medical school is associated with personal and professional identity formation (PPIF) by race and ethnicity. This retrospective cross-sectional study used deidentified data on 37 610 medical students who matriculated in 2014 or 2015 and took the Association of American Medical Colleges Graduation Questionnaire (GQ) between 2016 and 2020. Statistical analysis was performed from September 1 to November 20, 2023. Experiences of racial and ethnic discrimination were assessed through responses to 3 GQ questions about denial of opportunities, offensive remarks or names, and lower evaluations or grades due to race or ethnicity. Personal and professional development were measured as 2 separate outcomes using 2 GQ statements rated on a 5-point Likert scale (where 1 indicated strongly disagree and 5 indicated strongly agree): "My medical school has done a good job fostering and nurturing my development as a person" and "My medical school has done a good job fostering and nurturing my development as a physician." Variables of personal and professional development were both dichotomized. Of 37 610 medical students, 18 200 (48.4%) were female, and 19 410 (51.6%) were male; 2458 (6.5%) were African American or Black, 7801 (20.7%) were Asian, 2430 (6.5%) were Hispanic, 21 380 (56.9%) were White, 2404 (6.4%) were multiracial, and 1137 (3%) were other race or ethnicity. Most respondents attested that their medical school fostered their personal (27 272 [72.5%]) and professional (34 560 [91.9%]) development. African American or Black students reported the lowest rates of personal (1603 of 2458 [65.2%]) and professional (2182 of 2458 [88.8%]) development, and experienced lower likelihoods of personal (adjusted risk ratio [ARR], 0.89 [95% CI, 0.86-0.93]) and professional (ARR, 0.95 [95% CI, 0.94-0.97]) development than White students. Racial discrimination was inversely associated with development, with the highest PPIF rates among those never experiencing discrimination (personal, 25 089 of 33 508 [74.9%]; and professional, 31 257 of 33 508 [93.3%]). Those experiencing isolated discrimination (personal: ARR, 0.83 [95% CI, 0.80-0.87]; professional: ARR, 0.92 [95% CI, 0.91-0.95]) and recurrent discrimination (personal: ARR, 0.63 [95% CI, 0.60-0.66]; professional: ARR, 0.82 [95% CI, 0.80-0.84]) had relatively lower likelihoods of PPIF. African American or Black students experienced the highest rate of recurrent discrimination (543 of 2458 [22.1%]). No significant PPIF risk differences were found for other racial and ethnic groups underrepresented in medicine without discrimination compared with White students without discrimination, but all groups with recurrent discrimination had relatively lower PPIF risk. In this cross-sectional study of US medical students, racial and ethnic discrimination was associated with lower PPIF across all racial and ethnic groups compared with White students without such experiences. African American or Black students disproportionately faced this discrimination. Systemic changes in medical education are needed to combat discrimination and ensure equity in holistic student development.

Development and Implementation of an Experiential Longitudinal Health Systems Science Thread Into an Existing Medical School Curriculum.

Medical school graduates enter a complex health care delivery system involving interprofessional teamwork and multifaceted value-based patient care decisions. However, current curricula on health systems science (HSS) are piecemeal, lecture based, and confined to preclinical training. The VISTA program is a longitudinal, immersive learning curriculum integrated into the University of Chicago Pritzker School of Medicine curriculum between 2016 and 2018. Key components include a unit-based nursing interprofessional team experience, a discharge objective structured clinical examination (OSCE), a patient safety simulation, and the implementation of a Choosing Wisely SmartPhrase. Graduates before 2016-2017 and after 2018-2020 VISTA implementation completed a Likert-style survey assessing attitudes, knowledge, and behaviors on HSS topics. A free response question solicited improvement areas. The Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) was also examined. The overall VISTA survey response rate was 59%, with 126 fourth-year medical student respondents before VISTA and 120 after VISTA. Compared with pre-VISTA graduates, post-VISTA graduates reported a significantly higher rate of competence on the HSS questions, with the greatest increases seen in effective communication at discharge (n = 73/126 [57.9%] to 116/120 [96.7%], P < .001), knowledge on safety event reporting (n = 53/126 [42.1%] to 96/120 [79.8%], P < .001), and considering costs in making health care decisions (n = 76/126 [60.3%] to 117/120 [97.5%], P < .001). All were directly addressed through experiential learning interventions, and 2 were intended practice behaviors. VISTA graduate responses to free-text questions demonstrated a more nuanced understanding of HSS compared with pre-VISTA responses. The AAMC GQ data showed increased agreement with an item that mapped to HSS understanding. The VISTA program provides a model for institutions to enhance HSS education between curricular overhauls. Next steps include implementing value-added roles and additional immersive learning exercises.

Core Entrustable Professional Activities for Entering Residency: A National Survey of Graduating Medical Students' Self-Assessed Skills by Specialty.

The Association of American Medical Colleges described 13 Core Entrustable Professional Activities (EPAs) that graduating students should be prepared to perform under indirect supervision on day one of residency. Surgery program directors recently recommended entrustability in these Core EPAs for incoming surgery interns. We sought to determine if graduating students intending to enter surgery agreed they had the skills to perform these Core EPAs. Using de-identified, individual-level data collected from and about 2019 Association of American Medical Colleges Graduation Questionnaire respondents, latent profile analysis was used to group respondents based on their self-assessed Core EPAs skills' response patterns. Associations between intended specialty, among other variables, and latent profile analysis group were assessed using independent sample t -tests and chi-square tests and multivariable logistic regression methods. Among 12,308 Graduation Questionnaire respondents, latent profile analysis identified 2 respondent groups: 7,863 (63.9%) in a high skill acquisition agreement (SAA) group and 4,445 (36.1%) in a moderate SAA group. Specialty was associated with SAA group membership (p < 0.001), with general surgery, orthopaedic surgery, and emergency medicine respondents (among others) overrepresented in the high SAA group. In the multivariable logistic regression models, each of anesthesiology, ophthalmology, pediatrics, psychiatry, and radiology (vs general surgery) specialty intention was associated with a lower odds of high SAA group membership. Graduating students' self-assessed Core EPAs skills were higher for those intending general surgery than for those intending some other specialties. Our findings can inform collaborative efforts to ensure graduates' acquisition of the skills expected of them at the start of residency.

Professional Identity Formation Among Diverse U.S. Medical Students: A Quantitative Analysis of the Impact of Socioeconomic Status.

Purpose: Professional identity formation (PIF) is described as “a multifactorial phenomenon, shaped by ways that clinical and non-clinical experiences, expectations and environmental factors merge with individual values, beliefs and obligations.” 1 Data suggest that students’ personal characteristics factor in the PIF process. 2,3 This study examined how socioeconomic status (SES) (measured by generation college status [first-generation college graduate (FCG) vs continuing-generation college graduate (CCG)] and household income [high vs low]) might influence PIF among a national cohort of U.S. medical students. Method: We analyzed cohort data from an existing dataset of deidentified records from the Association of American Medical Colleges Graduation Questionnaire (GQ). 4 The GQ asks 2 questions related to PIF: (1) “My medical school has done a good job of fostering and nurturing my development as a future physician” and (2) “My medical school has done a good job of fostering and nurturing my development as a person.” We used GQ data from academic years 2014–2015 and 2015–2016. Multivariate regression models explored relationships between 4 categories of students’ SES with measures of PIF, controlling for covariates such as sex and race/ethnicity. CCG status was defined as having at least 1 parent/guardian with a bachelor’s degree. FCG status was defined as students with no parent with a bachelor’s degree. Household income was determined using 2 self-reported measures of income status: receipt of state or federal financial assistance, and parental income reported on the Matriculating Student Questionnaire. 5 Students were considered low-income if they indicated that their families were recipient of state/federal financial assistance programs (e.g., Supplemental Nutrition Assistance Program) or if their self-reported parental income was within the lowest 2 quintiles nationally (less than $41,187 for 2014–2015 cohort, and less than $43,512 for 2015–2016 cohort). A 4-level variable SES variable was created to reflect SES: continuing-generation college graduate/high income (CCG/HI), continuing-generation college graduate/low income (CCG/LI), first-generation college graduate/high income (FCG/HI), and first-generation college graduate/low income (FCG/LI). Statistical analyses were performed using STATA16.1. Results: Of the 24,796 students in our sample, 64.4%, 20.9%, 4.2%, and 10.5% identified as CCG/HI, CCG/LI, FCG/HI, and FCG/LI, respectively. CCG/LI respondents were less likely than CCG/HI peers to report that their medical school had done a good job of fostering and nurturing their development as a person (aOR: .79, 95% CI: .74, .85) and that their medical school had done a good job of fostering and nurturing their development as a future physician (aOR: .71, 95% CI: .63, .80). Similarly, FCG/LI respondents were less likely than FCG/HI peers to report that their medical school had done a good job of fostering and nurturing their development as a person (aOR: .85, 95% CI: .78, .94) and that their medical school had done a good job of fostering and nurturing their development as a future physician (aOR: .72, 95% CI: .62, .84). No significant differences were observed between FCG/HI and CCG/HI respondents on either aspect of PIF. Discussion: Our study illuminates nuances in PIF and provides new knowledge that, regardless of college graduate generation status, students who self-identified as being from low-income backgrounds were less likely than their high-income peers to report that their medical schools were doing a good job fostering personal and professional identity formation. Significance: These results reinforce that understanding the PIF experiences of diverse groups of medical trainees is critical to advance equity. More attention must be paid to the experiences of low-income students to ensure that they are and feel supported in their professional development and leave medical school equipped to thrive in their subsequent careers.

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

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. 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. 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). 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.

Perceptions on Burnout and the Medical School Learning Environment of Medical Students Who Are Underrepresented in Medicine

Burnout is a highly prevalent issue among medical trainees, but there has been limited research characterizing burnout specifically among medical students from groups who are underrepresented in medicine (URIM). To assess the association between components of the medical school learning environment and burnout among medical students who are URIM vs those who are not. This retrospective cross-sectional survey study evaluated responses of allopathic medical students graduating from all US allopathic medical schools in 2016 and 2017 to the American Medical Colleges Graduation Questionnaire. Analysis was completed between December 1, 2019, and July 1, 2020. Self-identification as a medical student who is URIM. Self-reported measures of medical student overall, disengagement, and exhaustion-related burnout using the Oldenburg Burnout Inventory for Medical Students. The American Medical Colleges Graduation Questionnaire had an 81% response rate, yielding 26 567 complete participant responses that were included the analysis. A total of 13 645 individuals (51.4%) were male, and 3947 (14.9%) identified as URIM (ie, Alaska Native, Black, Hispanic/Latinx, Native American, and/or Pacific Islander). Medical students who are URIM reported modestly higher levels of exhaustion-related burnout (mean [SD], 11.84 [3.62] vs 11.48 [3.61]; P < .001) and modestly lower mean burnout scores associated with disengagement (mean [SD], 9.24 [3.56] vs 9.36 [3.58]; P = .047). Medical students who are URIM also reported marginally less favorable student-faculty interactions in the learning environment (mean [SD], 14.09 [3.45] vs 14.29 [3.35]; P < .001). Medical students who are URIM were more likely to be in the top quartile of those who experienced exhaustion-related burnout (odds ratio, 1.19 [95% CI, 1.09-1.29]) but less likely to be in the top quartile for disengagement (odds ratio, 0.87 [95% CI, 0.80-0.94]). Regardless of URIM status, those who reported learning environment scores in the bottom quartile were more likely to experience higher rates of burnout as were those who experienced at least 1 episode of discrimination. This survey study found that medical students who are URIM had a higher risk for exhaustion-related burnout. This burnout is likely multifactorial and could represent a resiliency or survival bias, the burden of increased responsibility, and/or recurrent discrimination. The learning environment can play a key role in mitigating burnout in both medical students who are URIM and those who are not and is deserving of further research.

Association of Demographic Factors and Medical School Experiences With Students’ Intention to Pursue a Surgical Specialty and Practice in Underserved Areas

The surgical workforce shortage is a threat to promoting health equity in medically underserved areas. Although the Health Resources and Services Administration and the American College of Surgeons have called to increase the surgical pipeline for trainees to mitigate this shortage, the demographic factors associated with students' intention to practice in underserved areas is unknown. To evaluate the association between students' demographics and medical school experiences with intention to pursue surgery and practice in underserved areas. This cross-sectional study surveyed graduating US allopathic medical students who matriculated between 2007-2008 and 2011-2012. Analysis began June 2020 and ended December 2020. Intention to pursue surgery and practice in underserved areas were retrieved from the Association of American Medical Colleges graduation questionnaire. Logistic regression models were constructed to evaluate (1) the association between demographic factors and medical students' intention to pursue surgical specialties vs medical specialties and (2) the association between demographic factors and medical school electives with intention to practice in underserved areas. Among 57 307 students who completed the graduation questionnaire, 48 096 (83.9%) had complete demographic data and were included in the study cohort. The mean (SD) age at matriculation was 23.4 (2.5) years. Compared with students who reported intent to pursue nonsurgical careers, a lower proportion of students who reported intent to pursue a surgical specialty identified as female (3264 [32.4%] vs 19 731 [51.9%]; χ2 P < .001). Multiracial Black and White students (adjusted odds ratio [aOR], 1.72; 95% CI, 1.11-2.65) were more likely to report an intent for surgery compared with White students. Among students who reported an intention to pursue surgery, Black/African American students (aOR, 3.24; 95% CI, 2.49-4.22), Hispanic students (aOR, 2.00; 95% CI, 1.61-2.47), multiracial Black and White students (aOR, 2.27; 95% CI, 1.03-5.01), and Indian/Pakistani students (aOR, 1.31; 95% CI, 1.02-1.69) were more likely than White students to report an intent to practice in underserved areas. Students who reported participating in community health (aOR, 1.61; 95% CI, 1.42-1.83) or global health (aOR, 1.83; 95% CI, 1.61-2.07) experiences were more likely to report an intention to practice in underserved areas. This study suggests that diversifying the surgical training pipeline and incorporating health disparity and community health in undergraduate or graduate medical education may promote students' motivation to practice in underserved areas.

National Survey of Wellness Programs in U.S. and Canadian Medical Schools.

To describe the prevalence and scope of wellness programs at U.S. and Canadian medical schools. In July 2019, the authors surveyed 159 U.S. and Canadian medical schools regarding the prevalence, structure, and scope of their wellness programs. They inquired about the scope of programming, mental health initiatives, and evaluation strategies. Of the 159 schools, 104 responded (65%). Ninety schools (93%, 90/97) had a formal wellness program, and across 75 schools, the mean full-time equivalent (FTE) support for leadership was 0.77 (standard deviation [SD] 0.76). The wellness budget did not correlate with school type or size (respectively, P = .24 and P = .88). Most schools reported adequate preventative programming (62%, 53/85), reactive programming (86%, 73/85), and cultural programming (52%, 44/85), but most reported too little focus on structural programming (56%, 48/85). The most commonly reported barrier was lack of financial support (52%, 45/86), followed by lack of administrative support (35%, 30/86). Most schools (65%, 55/84) reported in-house mental health professionals with dedicated time to see medical students; across 43 schools, overall mean FTE for mental health professions was 1.62 (SD 1.41) and mean FTE per student enrolled was 0.0024 (SD 0.0019). Most schools (62%, 52/84) evaluated their wellness programs; they used the Association of American Medical Colleges Graduation Questionnaire (83%, 43/52) and/or annual student surveys (62%, 32/52). The most commonly reported barrier to evaluation was lack of time (54%, 45/84), followed by lack of administrative support (43%, 36/84). Wellness programs are widely established at U.S. and Canadian medical schools, and most focus on preventative and reactive programming, as opposed to structural programming. Rigorous evaluation of the effectiveness of programs on student well-being is needed to inform resource allocation and program development. Schools should ensure adequate financial and administrative support to promote students' well-being and success.

Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation

Previous studies have shown that medical student mistreatment is common. However, few data exist to date describing how the prevalence of medical student mistreatment varies by student sex, race/ethnicity, and sexual orientation. To examine the association between mistreatment and medical student sex, race/ethnicity, and sexual orientation. This cohort study analyzed data from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The questionnaire annually surveys graduating students at all 140 accredited allopathic US medical schools. Participants were graduates from allopathic US medical schools in 2016 and 2017. Data were analyzed between April 1 and December 31, 2019. Prevalence of self-reported medical student mistreatment by sex, race/ethnicity, and sexual orientation. A total of 27 504 unique student surveys were analyzed, representing 72.1% of graduating US medical students in 2016 and 2017. The sample included the following: 13 351 female respondents (48.5%), 16 521 white (60.1%), 5641 Asian (20.5%), 2433 underrepresented minority (URM) (8.8%), and 2376 multiracial respondents (8.6%); and 25 763 heterosexual (93.7%) and 1463 lesbian, gay, or bisexual (LGB) respondents (5.3%). At least 1 episode of mistreatment was reported by a greater proportion of female students compared with male students (40.9% vs 25.2%, P < .001); Asian, URM, and multiracial students compared with white students (31.9%, 38.0%, 32.9%, and 24.0%, respectively; P < .001); and LGB students compared with heterosexual students (43.5% vs 23.6%, P < .001). A higher percentage of female students compared with male students reported discrimination based on gender (28.2% vs 9.4%, P < .001); a greater proportion of Asian, URM, and multiracial students compared with white students reported discrimination based on race/ethnicity (15.7%, 23.3%, 11.8%, and 3.8%, respectively; P < .001), and LGB students reported a higher prevalence of discrimination based on sexual orientation than heterosexual students (23.1% vs 1.0%, P < .001). Moreover, higher proportions of female (17.8% vs 7.0%), URM, Asian, and multiracial (4.9% white, 10.7% Asian, 16.3% URM, and 11.3% multiracial), and LGB (16.4% vs 3.6%) students reported 2 or more types of mistreatment compared with their male, white, and heterosexual counterparts (P < .001). Female, URM, Asian, multiracial, and LGB students seem to bear a disproportionate burden of the mistreatment reported in medical schools. It appears that addressing the disparate mistreatment reported will be an important step to promote diversity, equity, and inclusion in medical education.

Defining Rural: The Predictive Value of Medical School Applicants' Rural Characteristics on Intent to Practice in a Rural Community.

To understand the predictive value of medical student application characteristics on rural practice intent. The authors constructed a linked database of 2012-2017 medical school matriculants from American Medical College Application Service applications and Association of American Medical Colleges Matriculating Student Questionnaire (MSQ, 2012-2017) and Graduation Questionnaire (GQ, 2016-2018). Using logistic regression, they compared application variables (birth, high school, childhood county, and self-declared geographical origin) to students' MSQ and GQ intent to practice rurally. Rural practice intent from matriculation to graduation was compared using the McNemar test for paired nominal data. The number of students meeting inclusion criteria was 115,027. More students self-declared rural origin (18,662; 16.4%) than were identified using geographically coded variables (6,097-8,784; 6.1%-8.1%). Geographically coded rural variables were all strongly and similarly associated with rural practice intent, with rural high school being the most predictive on both MSQ (odds ratio [OR], 6.51; CI, 6.1-7.0) and GQ (OR, 5.4; CI, 4.9-6.0). Self-declared geographical origin was associated with a similar rural practice intent on both MSQ (OR, 6.93; CI, 6.5-7.3) and GQ (OR, 5.69; CI, 5.2-6.2). Rural practice intent declined for all groups from matriculation to graduation. Considering students who self-declare as rural identifies a larger group of rural medical school applicants than more "objective" geographic variables, without negatively impacting students' predicted interest in eventual rural practice. Further research should track actual practice location and explore strategies to mitigate declining rural career interest.

See No Evil, Hear No Evil, Stop No Evil: Institutional-Level Tracking to Combat Mistreatment of Residents and Fellows.

Mistreatment of trainees, including discrimination and harassment, is a problem in graduate medical education. Current tools to assess the prevalence of mistreatment often are not administered institutionally and may not account for multiple sources of mistreatment, limiting an institution's ability to respond and intervene. We describe the utility of a brief questionnaire, embedded within longer institutional program evaluations, measuring the prevalence of different types of trainee mistreatment from multiple sources, including supervisors, team members, colleagues, and patients. In 2018, we administered a modified version of the mistreatment questions in the Association of American Medical Colleges Graduation Questionnaire to investigate the prevalence and sources of mistreatment in graduating residents and fellows. We conducted analyses to determine the prevalence, types, and sources of mistreatment of trainees at the institutional level across graduate medical education programs. A total of 234 graduating trainees (77%) from the University of Minnesota-Twin Cities completed the questions. Patients were cited as the primary source of mistreatment in 5 of 6 categories, including both direct and indirect offensive remarks, microaggressions, sexual harassment, and physical threats (paired t test comparisons from t = 3.92 to t = 9.71, all P < .001). The only category of mistreatment in which patients were not the most significant source was humiliation and shaming. Six questions concerning types and sources of trainee mistreatment, embedded within an institutional survey, generated new information for institutional-, departmental- and program-based future interventions. Patients were the greatest source for all types of mistreatment except humiliation and shaming.

Characteristics of graduating US allopathic medical students pursuing a career in neurology.

To identify factors associated with medical students becoming neurologists because, despite the increasing burden of neurologic disorders, there is a growing neurologist shortage. Deidentified data from the Association of American Medical Colleges Matriculating Student Questionnaire (MSQ) and Graduation Questionnaire (GQ) were obtained for the graduation years 2013 to 2014 through 2016 to 2017. Logistic regression was used to assess demographic characteristics and responses to training and career-related questions in association with specialty choice (intent to enter neurology). Of the 51,816 students with complete data, 1,456 (2.8%) indicated an intent to enter a neurology residency. Factors associated with an increased likelihood of entering neurology were a student's rating of excellent for their basic neuroscience course and neurology clerkship, participation in an MD/PhD program, majoring in neuroscience or psychology as an undergraduate, a selection response of "content of the specialty was a strong influence on career choice," and indicating interest in neurology on the MSQ. Factors associated with a decreased likelihood of entering neurology were a higher-priority response on the GQ for salary, work/life balance, and personal fit of the specialty. Data from surveys at the entry into and graduation from medical school suggest several approaches to increase the number of medical students entering neurology, including a focus on the student-reported quality of the basic neuroscience course and neurology clerkships, targeted engagement with MD/PhD students, and mentoring programs for students interested in neurology. Efforts to improve salaries for neurologists, to reduce medical school debt, and to improve work/life balance may also help to attract more students.

Benchmarking the Physical Therapist Academic Environment to Understand the Student Experience.

Identifying excellence in physical therapist academic environments is complicated by the lack of nationally available benchmarking data. The objective of this study was to compare a physical therapist academic environment to another health care profession (medicine) academic environment using the Association of American Medical Colleges Graduation Questionnaire (GQ) survey. The design consisted of longitudinal benchmarking. Between 2009 and 2017, the GQ was administered to graduates of a physical therapist education program (Department of Physical Therapy and Rehabilitation Science, Carver College of Medicine, The University of Iowa [PTRS]). Their ratings of the educational environment were compared to nationwide data for a peer health care profession (medicine) educational environment. Benchmarking to the GQ capitalizes on a large, psychometrically validated database of academic domains that may be broadly applicable to health care education. The GQ captures critical information about the student experience (eg, faculty professionalism, burnout, student mistreatment) that can be used to characterize the educational environment. This study hypothesized that the ratings provided by 9 consecutive cohorts of PTRS students (n = 316) would reveal educational environment differences from academic medical education. PTRS students reported significantly higher ratings of the educational emotional climate and student-faculty interactions than medical students. PTRS and medical students did not differ on ratings of empathy and tolerance for ambiguity. PTRS students reported significantly lower ratings of burnout than medical students. PTRS students descriptively reported observing greater faculty professionalism and experiencing less mistreatment than medical students. The generalizability of these findings to other physical therapist education environments has not been established. Selected elements of the GQ survey revealed differences in the educational environments experienced by physical therapist students and medical students. All physical therapist academic programs should adopt a universal method to benchmark the educational environment to understand the student experience.

Using a Modified A3 Lean Framework to Identify Ways to Increase Students' Reporting of Mistreatment Behaviors.

The proportion of students who experience mistreatment is significantly higher than the proportion of students who report mistreatment. Identifying ways to improve students' reporting of these incidents is one strategy for increasing opportunities to achieve resolution and prevent future occurrences. The authors applied a modified A3 Lean framework to examine medical student reporting of mistreatment behaviors at the University of Michigan Medical School (UMMS) in 2013-2016. The A3 Lean framework is a stepwise approach that involves outlining the background to establish the context of the problem, describing the current condition, identifying the goal or desired outcome, analyzing causes of the problem, providing proposed countermeasures for improvement, and creating follow-up plans. The authors identified three reasons for the difference between students' experiences and reporting of mistreatment and developed five countermeasures/action plan items to address this difference. The proportion of students reporting mistreatment at UMMS increased 21.4% between 2013 and 2016. Compared with 2013, more students in 2016 indicated not reporting because the incident did not seem important enough or because they resolved the issue on their own. The authors have enlisted the support of the health system's human resources department and presented the inaugural grand rounds on improving the learning environment in 2016. Among other things, they are also partnering with this team to add questions about student mistreatment and civility to the annual employee engagement survey distributed to all 20,000 employees.

Restorative Justice as the Rx for Mistreatment in Academic Medicine: Applications to Consider for Learners, Faculty, and Staff.

The mistreatment of learners is an ongoing issue at U.S. medical schools. According to responses to the 2017 Association of American Medical Colleges Graduation Questionnaire, 39.3% of medical students nationally reported being mistreated. Many articles have been published on the topic of mistreatment at medical schools over the last 20 years. These articles have focused primarily on the definition of mistreatment, the impact of mistreatment, and initiatives put into place to help mitigate the problem. To date, very little attention has been paid to repairing the harm caused by mistreatment and rebuilding community trust. Academic medicine is in need of new forums of interaction to achieve more positive learning and workplace environments.The authors discuss restorative justice practices and the potential applications that they may have in academic medicine learning and workplace environments to serve vulnerable students, faculty, and staff who are targets of mistreatment. Restorative justice practices are used to convene groups of people to engage in substantive dialogue about consequential issues that impede community functioning. This process can help a group identify and gain mutual understanding of the personal and collective harm that has occurred, create the conditions that incentivize offenders to admit responsibility rather than deny or minimize the harm, and explore and define a set of problem-solving steps to address the harm and rebuild community trust.

A Career Exploration Program: An Effective Alternative to the Traditional Use of Faculty Advisors.

Providing medical students with resources to make effective career choices is challenging for medical schools as career options outnumber the formal clinical rotations students can experience during their undergraduate education. In 2009, the authors introduced the Career Exploration (CE) courses into the required curriculum at the Quillen College of Medicine. This three-course sequence includes large-group sessions addressing broad issues related to career choices, small-group specialty interest groups, individual student self-assessments, assignments through which students receive individualized feedback, and individual student advising sessions. The overall objective of the course sequence is to involve all students in career planning from the beginning of medical school so as to help them make more informed career decisions. The authors used improvement in student satisfaction with career planning activities as a surrogate measure for the outcome of helping students make more informed career choices. Students evaluated the CE courses positively, and overall satisfaction scores averaged 4 (1 = poor to 5 = excellent). Scores on Association of American Medical Colleges Graduation Questionnaire items related to career planning showed improved student satisfaction from 2010 to 2015. Succession planning for the first- and second-year career advisor is vital-as is faculty development for all clinical advisors to ensure that they have current information regarding both the curriculum and Match process, especially as residency selection becomes increasingly competitive. Enhancing the role of fourth-year students who serve as CE III mentors has the potential to prepare these students to be better teachers as residents.

Forgiven but not Relieved: US Physician Workforce Consequences of Changes to Public Service Loan Forgiveness.

Public Service Loan Forgiveness (PSLF) was established in 2007 for public sector and nonprofit enterprise employees to pursue educational loan forgiveness. Under PSLF, graduates are offered complete loan forgiveness after 120 qualifying monthly payments while employed at public or nonprofit institutions, including payments made during residency for physicians. In response to concerns that PSLF will heavily subsidize lawyers, doctors, and other professionals, the President's 2017 budget proposes limiting maximum forgiveness. Using data from the Association of American Medical Colleges Graduation Questionnaire (n = 55,905; response rate of 80%), we found that intended participation in PSLF among medical school graduates grew 20% per year since 2010. Future primary care physicians intend to use PSLF more than programs that were historically designed to promote primary care, such as the National Health Service Corp (NHSC). The federal government's projected cost of PSLF will reach over $316 million for 2014 graduates (net present value), approximately seven times the annual contributions from the NHSC. The proposed cap will reduce the total anticipated forgiveness by nearly two-thirds and substantially reduce subsidies for physicians. More targeted measures of loan forgiveness could be considered, such as making forgiveness contingent on pursuing specialties that society needs or practicing in shortage areas.

Implementation of a Mini-CEX Requirement Across All Third-Year Clerkships

ABSTRACTProblem: Direct observation of medical students performing clinical tasks, such as eliciting a patient history or examining a patient, and the provision of feedback, are foundational to student improvement but have been reported to occur infrequently. The mini clinical evaluation exercise (mini-CEX) is a tool that can facilitate direct observation and feedback. This study assessed the impact of a mini-CEX requirement across all 3rd-year clerkships on student report of direct observation by faculty and objectively measured clinical skills. Intervention: A mini-CEX requirement across all 3rd-year clerkships was implemented in the 2012–2013 academic year. The impact of the mini-CEX requirement on student report of direct observation was assessed by end-of-clerkship surveys and Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) items on direct observation. The impact on students' clinical skills was assessed by a summative Objective Structured Clinical Examination (OSCE). Pre/post comparisons were assessed with chi-square and Fisher's exact tests. Context: A mini-CEX requirement had been in place for the internal medicine clerkship, and student reports of direct observation were historically higher for the internal medicine clerkship than for other clerkships. Faculty, residents, and students at each of the clinical sites across all 6 clerkships were oriented to the use of the mini-CEX; the feasibility of its use during usual patient interaction settings and the importance of direct observation and feedback for student improvement were emphasized during these sessions. Outcome: Adherence to the mini-CEX requirement was high: 92% of required forms were completed, and 78% of completed forms indicated that specific feedback was given. The proportion of students reporting direct observation of physical examination significantly increased in all clerkships, with the largest relative increase occurring in surgery (from 49% to 87%), χ2(1, N = 225) = 37.70, p < .0001. Significant increases were seen in faculty observation of history taking in pediatrics, surgery, and psychiatry. Direct observation rates also increased on the AAMC GQ items for history taking and physical exam for all clerkships. Failures on the summative OSCE decreased from 12% preintervention to 2% postintervention (p = .0046). Lessons Learned: Institution of a mini-CEX requirement was feasible across all 3rd-year clerkships and was associated with a significant increase in student report of direct observation by faculty and a decrease in summative OSCE failure rates.

Factors Influencing Medical School Graduates Toward a Career in Psychiatry: Analysis from the 2011-2013 Association of American Medical Colleges Graduation Questionnaire.

Various factors influence choice of medical specialty. Previous research grouped specialties into controllable lifestyle, primary care, and surgical. This study compared factors influencing individuals to choose psychiatry versus other specialties. Data came from the 2011-2013 Association of American Medical Colleges Graduation Questionnaire. The authors grouped responses, ranging from no influence to minor, moderate, and strong influence, into psychiatry and controllable lifestyle, primary care, and surgical specialties and analyzed the data using one-way analysis of variance. The analyses included 29,227 students, of which 1329 (4.5%) elected psychiatry; 10,998 (37.6%), controllable lifestyle specialties; 12,320 (42.2%), primary care specialties; and 4580 (15.7%), surgical specialties. Students choosing psychiatry reported less influence of competitiveness, student debt, and salary expectations than those choosing controllable lifestyle and surgical specialties (p < 0.0001) and more influence of work/life balance than those choosing primary care and surgical specialties (p < 0.0001). They reported less influence of family expectations than those choosing controllable lifestyle specialties (p < 0.0001). They reported more influence of fit with personality than controllable lifestyle, primary care, and surgical specialties (p < 0.004). Students entering psychiatry do not fit the traditional categories of controllable lifestyle, primary care, and surgical profiles, but fall between controllable lifestyle and primary care specialties. Recruitment efforts may need to address this different pattern of influences.

The office of student wellness: innovating to improve student mental health.

Despite increasing mental health needs among medical students, few models for effective preventive student wellness programs exist. This paper describes a novel approach developed at the University of California (UC) Davis School of Medicine: the Office of Student Wellness (OSW). Improved access and mental health service utilization have been documented, with over half of all students receiving support and clinical care. UC Davis student satisfaction mean scores on the Association of American Medical Colleges Graduation Questionnaire wellness questions have reached or exceeded national average over the last 4 years, since the OSW was founded. This program may serve as a blueprint for other medical schools in developing effective student wellness programs.