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Purpose: Medical education initiatives incorporate arts and humanities (AHs) to foster physician competence and professionalism. However, the full potential of these initiatives is unclear. A recent conceptual framework attempts to clarify this potential but was constructed primarily from undergraduate medical education studies. To explore AH instruction in graduate medical education (GME), the authors asked: What is the potential of a longitudinal curriculum incorporating AHs for the personal and professional development of internal medicine interns throughout the intern year?, Method: From September 2021 to June 2022, 14 internal medicine interns at a large internal medical residency program participated in a longitudinal qualitative study, recording longitudinal audio-diaries (LADs) and participating in semistructured interviews. The LAD response rate was 91%, and the interview completion rate was 96%. The authors identified 3 themes that reflected shared meaning on the transformative potential of AHs: reclaiming personal sense of self, building community, and surfacing empathy. They constructed stories from 2 interns whose trajectories resonated most with AH instruction's potential for personal and professional development., Results: Interns valued the abstract over the concrete benefits of AHs. Interns detailed valuable abstract benefits, with reclaiming sense of self, building community, and surfacing empathy apparent across time, pointing to long-term effects of AH interventions. The intern stories revealed a steady appreciation for AHs and difficulty with the practical utility of AHs midyear before a return to recognition of its value by year's end., Conclusions: Despite varying AHs experience levels, interns consistently appreciated AH instruction. These findings extend a prior conceptual model to a GME population by highlighting AH instruction's potential for reclaiming interns' senses of self, building community, and surfacing empathy. Future curricula can leverage this ability to create meaningful connections with one's purpose, peers, and patients to maximize the potential of AH instruction for GME learners., (Copyright © 2024 the Association of American Medical Colleges.)

Purpose: Medical education journal editors work to improve scholarly rigor and expand access to scholarship. How editors conceptualize these dual roles is unknown and holds implications for the kinds of scholarship that are valued and made visible through publication. The authors applied the concept of capacity building to examine how medical education journal editors conceptualize and operationalize capacity building and to identify the contextual factors that support or constrain these efforts., Method: Using a reflexive thematic approach, the authors interviewed 13 editors of 11 medical education journals between February 2022 and March 2023. Data collection and analyses were performed iteratively. Interview transcripts were coded by 2 authors to generate initial codes, which were then refined by the research team until final themes were created., Results: Editors viewed capacity building "making space" for people and perspectives. Making space for people included efforts to support editors and reviewers, offer feedback to authors, and engage with readers. Making space for perspectives included efforts to promote discussion on diversity and inclusion and to introduce ideas perceived to advance the field. How editors made space was shaped by a journal's ecosystem, including local features unique to each journal (e.g., aims, scope, readership) and system-level factors that influenced all journals (e.g., English as the language of science, academic promotion and tenure)., Conclusions: Although medical education journal editors' capacity-building work will inevitably guide future scholars and scholarship, their work should be considered in the context of a larger ecosystem, including such features as institutional academies for scholarship and promotion and tenure policies. Improving rigor and expanding access will require clarifying how editors' approach and understand capacity building to advance as a field. Future work should clarify how individual journals' capacity-building efforts can be facilitated and how journals can collectively reimagine spaces for knowledge-building conversations., (Copyright © 2024 the Association of American Medical Colleges.)

Problem: Program evaluation approaches that center the achievement of specific, measurable, achievable, realistic, and time-bound goals are common in health professions education (HPE) but can be challenging to articulate when evaluating emergent programs. Principles-focused evaluation is an alternative approach to program evaluation that centers on adherence to guiding principles, not achievement of goals. The authors describe their innovative application of principles-focused evaluation to an emergent HPE program., Approach: The authors applied principles-focused evaluation to the Children's Hospital of Philadelphia Medical Education Collaboratory, a works-in-progress program for HPE scholarship. In September 2019, the authors drafted 3 guiding principles. In May 2021, they used feedback from Collaboratory attendees to revise the guiding principles: Advance Excellence , Build Bridges , and Cultivate Learning ., Outcomes: In July 2021, the authors queried participants about the extent to which their experience with the Collaboratory adhered to the revised guiding principles. Twenty of the 38 Collaboratory participants (53%) responded to the survey. Regarding the guiding principle Advance Excellence , 9 respondents (45%) reported that the Collaboratory facilitated engagement in scholarly conversation only by a small extent, and 8 (40%) reported it facilitated professional growth only by a small extent. Although some respondents expressed positive regard for the high degree of rigor promoted by the Collaboratory, others felt discouraged because this degree of rigor seemed unachievable. Regarding the guiding principle Build Bridges , 19 (95%) reported the Collaboratory welcomed perspectives within the group. Regarding the guiding principle Cultivate Learning , 19 (95%) indicated the Collaboratory welcomed perspectives within the group and across disciplines, and garnered collaboration., Next Steps: Next steps include improving adherence to the principle of Advancing Excellence , fostering a shared mental model of the Collaboratory's guiding principles, and applying a principles-focused approach to the evaluation of multi-site HPE programs., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Association of American Medical Colleges.)

Meaningful Equity, Diversity, and Inclusion (EDI) efforts may be stymied by concerns about whether proposed initiatives are performative or tokenistic. The purpose of this project was to analyze discussions by the Research in Medical Education (RIME) Program Planning committee about how best to recognize and support underrepresented in medicine (URiM) researchers in medical education to generate lessons learned that might inform local, national, and international actions to implement meaningful EDI initiatives. Ten RIME Program Planning Committee members and administrative staff participated in a focus group held virtually in August 2021. Focus group questions elicited opinions about "if and how" to establish a URiM research award. The focus group was recorded, transcribed, and thematically analyzed. Recognition of privilege, including who has it and who doesn't, underpinned the focus group discussion, which revolved around 2 themes: (1) tensions between optics and semantics, and (2) potential unintended consequences of trying to level the medical education playing field. The overarching storyline threaded throughout the focus group discussion was intentionality. Focus group participants sought to avoid performativity by creating an award that would be meaningful to recipients and to career gatekeepers such as department chairs and promotion and tenure committees. Ultimately, participants decided to create an award that focused on exemplary Equity, Diversity, and Inclusion (EDI) scholarship, which was eventually named the "RIME URiM Research Award." Difficult but productive conversations about EDI initiatives are necessary to advance underrepresented in medicine (URiM) scholarship. This transparent commentary may trigger further critical conversations., (Copyright © 2022 by the Association of American Medical Colleges.)

This year marks the 60th anniversary (1961-2021) of Research in Medical Education (RIME). Over the past 6 decades, RIME has selected medical education research to be presented each year at the Association of American Medical Colleges Annual Meeting: Learn Serve Lead and published in a supplement of Academic Medicine. In this article, the authors surveyed RIME chairs from the past 20 years to identify ways that RIME has advanced medical education research and to generate ideas for future directions. RIME chairs described advancements in the rigor and impact of RIME research and the timeliness of the topics, often serving as a driver for cutting-edge research. They highlighted RIME's role in promoting qualitative research, introducing new epistemologies, and encouraging networking as a means of career advancement. Going forward, RIME chairs suggested (1) strengthening collaborations with formal advanced MEd and PhD degree programs, (2) creating formal mentorship channels for junior and minority faculty, and (3) promoting research related to knowledge translation., (Copyright © 2021 by the Association of American Medical Colleges.)

Purpose: Research on how entrustment decisions are made identifies 5 influential factors (supervisor, trainee, supervisor-trainee relationship, context, task). However, this literature primarily represents the perspective of supervisors in graduate medical education and is conducted outside of an assessment framework where entrustment decisions have consequences for trainees and for patients. To complement the literature, the authors explored how medical students in a pilot program that used an entrustable professional activity (EPA) assessment framework perceived factors influencing entrustment decisions., Method: The authors conducted a secondary analysis of qualitative data from program evaluation of a pilot project using an EPA assessment framework to advance students through their curriculum and into residency. Data were derived from 8 focus groups conducted over 4 years (2015-2018) with 27 students who shared their experience of learning and supervision in the project. Sensitized by the entrustment literature, the authors coded and analyzed focus group transcripts according to principles of thematic analysis., Results: Components of the trainee and supervisor-trainee relationship factors predominated students' perceptions of entrustment decisions. Students directed their own learning by asking for feedback, seeking opportunities to engage in learning, sharing limitations of their knowledge with supervisors, and pushing supervisors to recalibrate assessments when appropriate. Students' agentic actions were facilitated by longitudinal supervisor-trainee relationships wherein they felt comfortable asking for help and built confidence in patient care. Students mentioned components of other factors that influenced entrustment decisions (supervisor, clinical task, clinical context), but did so less frequently and from a nonagentic vantage point., Conclusions: Students' perspectives on entrustment decisions can be derived from their views on learning and supervision in an EPA assessment framework. Their perspectives complement the literature by highlighting students' agentic actions to influence entrustment decisions and promotion of agentic action through practices incorporating longitudinal supervisor-trainee relationships., (Copyright © 2020 by the Association of American Medical Colleges.)

Purpose: To investigate students' experience (over time) with meta-reflection writing exercises, called Signature Reflections. These exercises were used to strengthen reflective capacity, as part of a 4-year reflective writing portfolio curriculum that builds on a recognized strategy for reflection (narrative medicine) and employs longitudinal faculty-mentors., Method: In 2018, the authors conducted 5 focus groups with 18 third-year students from the Columbia University Vagelos College of Physicians and Surgeons class of 2019 to examine students' experience with Signature Reflections. Using an iterative, thematic approach, they developed codes to reflect common patterns in the transcripts, distilled conceptually similar codes, and assembled the code categories into themes., Results: Three core themes (safe space, narrative experience, mirror of self) and 1 overarching theme (moving through time) were identified. Students frequently experienced relief at having a safe reflective space that promoted grappling with their fears or vulnerabilities and highlighted contextual factors (e.g., trusted faculty-mentors, protected time) that fostered a safe space for reflection and exploration. They often emphasized the value of tangible documentation of their medical school journey (narrative experience) and reported using Signature Reflections to examine their emerging identity (mirror of self). Overlapping with the core themes was a deep appreciation for the temporal perspective facilitated by the Signature Reflections (moving through time)., Conclusions: A longitudinal narrative medicine-based portfolio curriculum with pauses for meta-reflection allowed students, with faculty support, to observe their trajectory through medical school, explore fears and vulnerabilities, and narrate their own growth. Findings suggest that narrative medicine curricula should be required and sufficiently longitudinal to facilitate opportunities to practice the skill of writing for insight, foster relationships with faculty, and strengthen students' temporal perspectives of their development., (Copyright © 2020 by the Association of American Medical Colleges.)

To establish a research and development agenda for Entrustable Professional Activities (EPAs) for the coming decade, the authors, all active in this area of investigation, reviewed recent research papers, seeking recommendations for future research. They pooled their knowledge and experience to identify 3 levels of potential research and development: the micro level of learning and teaching; the meso level of institutions, programs, and specialty domains; and the macro level of regional, national, and international dynamics. Within these levels, the authors categorized their recommendations for research and development. The authors identified 14 discrete themes, each including multiple questions or issues for potential exploration, that range from foundational and conceptual to practical. Much research to date has focused on a variety of issues regarding development and early implementation of EPAs. Future research should focus on large-scale implementation of EPAs to support competency-based medical education (CBME) and on its consequences at the 3 levels. In addition, emerging from the implementation phase, the authors call for rigorous studies focusing on conceptual issues. These issues include the nature of entrustment decisions and their relationship with education and learner progress and the use of EPAs across boundaries of training phases, disciplines and professions, including continuing professional development. International studies evaluating the value of EPAs across countries are another important consideration. Future studies should also remain alert for unintended consequences of the use of EPAs. EPAs were conceptualized to support CBME in its endeavor to improve outcomes of education and patient care, prompting creation of this agenda., (Copyright © 2021 by the Association of American Medical Colleges.)

Purpose: It takes many years for trainees to become physicians-so long that their individual journeys through medical school and residency are seldom systematically studied and thus not well understood. Lack of understanding hinders effective support of future physicians' development across traditional time-bound phases of medical education. The authors initiated a longitudinal qualitative study, tracing a cohort of 6 trainees through the same medical school and 6 different residencies. They asked, how do stability and change characterize the lived experience of trainees through time?, Method: From 2010 to 2019, the authors conducted in-depth interviews every 6 to 12 months with 6 trainees, using reflective prompts about formative events and prior interviews. Data were inductively coded and analyzed in an iterative fashion. By scrutinizing data via time-ordered displays of codes, the authors identified 3 patterns of stability and change, particularly related to constructing careers in medicine. The study originated at a private medical school in New York, New York., Results: Patterns in the balance between stability and change were shaped by trainees' career interests. Trainees motivated by stable clinical interests perceived their journey as a "series of stepping-stones." Trainees motivated by evolving clinical interests described disruptive change or "upsets"; however, they were still accommodated by medical education. In contrast, trainees motivated by stable nonclinical (i.e., social science) interests perceived their journey as a "struggle" in residency because of the clinically heavy nature of that phase of training., Conclusions: Based on this descriptive, 9-year study of a small number of trainees, medical education seems to accommodate trainees whose journeys are motivated by clinical interests, even if those clinical interests change through time. Medical education could consider alternatives to time-bound frames of reference and focus on the right time for trainees to integrate clinical and social sciences in medical training., (Copyright © 2020 by the Association of American Medical Colleges.)

Purpose: To evaluate response process validity evidence for clinical competency committee (CCC) assessments of first-year residents on a subset of General Pediatrics Entrustable Professional Activities (EPAs) and milestones in the context of a national pilot of competency-based, time-variable (CBTV) advancement from undergraduate to graduate medical education., Method: Assessments of 2 EPAs and 8 milestones made by the trainees' actual CCCs and 2 different blinded "virtual" CCCs for 48 first-year pediatrics residents at 4 residency programs between 2016 and 2018 were compared. Residents had 3 different training paths from medical school to residency: time-variable graduation at the same institution as their residency, time-fixed graduation at the same institution, or time-fixed graduation from a different institution. Assessments were compared using ordinal mixed-effects models., Results: Actual CCCs assigned residents higher scores than virtual CCCs on milestones and one EPA's supervision levels. Residents who graduated from a different institution than their residency received lower milestone ratings than either group from the same institution; CBTV residents received higher ratings on one milestone (ICS4) and similar ratings on all others compared with non-CBTV residents who completed medical school at the same institution., Conclusions: First-year residents who graduated from CBTV medical school programs were assessed as having the same level of competence as residents who graduated from traditional medical school programs, but response process evidence suggests that members of CCCs may also draw on undocumented personal knowledge of the learner to draw conclusions about resident competence.

Research and scholarship in health professions education has been shaped by intended audience (i.e., producers vs users) and the purpose of research questions (i.e., curiosity driven or service oriented), but these archetypal dichotomies do not represent the breadth of scholarship in the field. Akin to an array of lenses required by scientists to capture images of a black hole, the authors propose the analogy of lenses with different focal lengths to consider how different kinds of research questions can offer insight into health professions research-a microscope, a magnifying glass, binoculars, and telescopes allow us to ask and answer different kinds of research questions. They argue for the relevance of all of the different kinds of research questions (or focal lengths); each provides important insight into a particular phenomenon and contributes to understanding that phenomenon in a different way. The authors propose that research questions can move fluidly across focal lengths. For example, a theoretical question can be made more pragmatic through asking "how" questions ("How can we observe and measure a phenomenon?"), whereas a pragmatic question can be made more theoretic by asking a series of "why" questions ("Why are these findings relevant to larger issues?"). In summary, only through the combination of lenses with different focal lengths, brought to bear through interdisciplinary work, can we fully comprehend important phenomena in health professions education and scholarship-the same way scientists managed to image a black hole.

Purpose: Despite academic medicine's endorsement of professional development and mentoring, little is known about what junior faculty learn about mentoring in implicit curricula of professional development programs, and how their mentor identity evolves in this context. The authors explored what faculty-participants in the Educational Scholars Program implicitly learned about mentoring and how the implicit curriculum affected mentor identity transformation., Method: Semistructured interviews with 19 of 36 former faculty-participants were conducted in 2016. Consistent with constructivist grounded theory, data collection and analysis overlapped. The authors created initial codes informed by Ibarra's model for identity transformation, iteratively revised codes based on incoming data patterns, and created visual representations of relationships amongst codes to gain a holistic, shared understanding of the data., Results: In the implicit curriculum, faculty-participants learned the importance of having multiple mentors, the value of peer mentors, and the incremental process of becoming a mentor. The authors used Ibarra's model to understand how the implicit curriculum worked to transform mentor identity: Faculty-participants reported observing mentors, experimenting with different ways to mentor and to be a mentor, and evaluating themselves as mentors., Conclusions: The Educational Scholars Program's implicit curriculum facilitated faculty-participants taking on mentor identity via opportunities it afforded to watch mentors, experiment with mentoring, and evaluate self as mentor, key ingredients for identity construction. Leaders of professional development programs can develop faculty as mentors by capitalizing on what faculty-participants learn in the implicit curriculum and deliberately structuring postgraduation mentoring opportunities.

The day-to-day rigors of medical education often preclude learners from gaining a longitudinal perspective on who they are becoming. Furthermore, the current focus on competencies, coupled with concerning rates of trainee burnout and a decline in empathy, have fueled the search for pedagogic tools to foster students' reflective capacity. In response, many scholars have looked to the tradition of narrative medicine to foster "reflective spaces" wherein holistic professional identity construction can be supported. This article focuses on the rationale, content, and early analysis of the reflective space created by the narrative medicine-centered portfolio at the Columbia University Vagelos College of Physicians and Surgeons. In January 2015, the authors investigated learning outcomes derived from students' "Signature Reflections," end-of-semester meta-reflections on their previous portfolio work. The authors analyzed the Signature Reflections of 97 (of 132) first-year medical students using a constant comparative process. This iterative approach allowed researchers to identify themes within students' writings and interpret the data. The authors identified two overarching interpretive themes-recognition and grappling-and six subthemes. Recognition included comments about self-awareness and empathy. Grappling encompassed the subthemes of internal change, dichotomies, wonder and questioning, and anxiety. Based on the authors' analyses, the Signature Reflection seems to provide a structured framework that encourages students' reflective capacity and the construction of holistic professional identity. Other medical educators may adopt meta-reflection, within the reflective space of a writing portfolio, to encourage students' acquisition of a longitudinal perspective on who they are becoming and how they are constructing their professional identity.

The authors argue that Nel Noddings' philosophy, "an ethic of caring," may illuminate how students learn to be caring physicians from their experience of being in a caring, reciprocal relationship with teaching faculty. In her philosophy, Noddings acknowledges two important contextual continuities: duration and space, which the authors speculate exist within longitudinal integrated clerkships. In this Perspective, the authors highlight core features of Noddings' philosophy and explore its applicability to medical education. They apply Noddings' philosophy to a subset of data from a previously published longitudinal case study to explore its "goodness of fit" with the experience of eight students in the 2012 cohort of the Columbia-Bassett longitudinal integrated clerkship. In line with Noddings' philosophy, the authors' supplementary analysis suggests that students (1) recognized caring when they talked about "being known" by teaching faculty who "cared for" and "trusted" them; (2) responded to caring by demonstrating enthusiasm, action, and responsibility toward patients; and (3) acknowledged that duration and space facilitated caring relations with teaching faculty. The authors discuss how Noddings' philosophy provides a useful conceptual framework to apply to medical education design and to future research on caring-oriented clinical training, such as longitudinal integrated clerkships.

As an early and important experience in medical education, dissection in the gross anatomy lab is a locus of professional formation. Because students often think of their professional development in evolving, narrative terms, the authors propose that close attention to these narratives might add to understanding of professional formation in progress. They solicited written reflections from students, to explore ways that both the content and form of written reflections might illuminate themes relevant to professional formation, and to describe some elements of professional formation in the context of one institution (Baylor College of Medicine, Houston, Texas). Seventeen students participated in writing sessions and wrote in response to an oral interview transcript and to a poem. Using a reading approach that grew out of the narrative medicine movement, the authors collaboratively engaged the content and form of these written reflections.Students' collection of written reflections was a rich source of information about their experiences in the anatomy lab. Through both content (e.g., expressions of gratitude, transitions, self-awareness) and form (e.g., from less detailed writing to literary playfulness), their writings gave a glimpse into the tensions, disappointments, and satisfactions of the practice of gross anatomy.This project models one way that educators can read and respond to the reflective writing that students generate. The authors go on to propose ways that interactions around reflective writing can be part of a broader goal of forming narrative-minded physicians, who become increasingly self- and other-aware as they progress in their education and practice.

Purpose: This exploratory multisite study investigated relative proportions of residents' perceived learning across the explicit, implicit (typically called hidden or informal), and extra-curricula for six Clinical Learning Environment Review (CLER) focus areas-patient safety, health care quality, care transitions, supervision, fatigue management, and professionalism-using qualitative and numeric data., Method: In April through June 2013, the authors recruited and interviewed third-year categorical pediatric residents from three sites. For each CLER focus area, the authors asked residents to think aloud while they assigned a total of 60 points to the explicit, implicit, and extra-curricula, according to where they perceived their learning occurred. All interviews were audio taped and transcribed verbatim. The authors coded qualitative data from interviews using the constant comparative method, scrutinized qualitative data for themes, and reviewed qualitative and numeric data., Results: A total of 28/79 (35%) residents participated. Residents perceived learning to occur most often in the implicit curriculum for five of the six CLER focus areas; the one exception being health care quality, which predominantly took place in the explicit curriculum. In the implicit curriculum, role modeling and "learning by doing" were frequently reported modes of learning. The explicit curriculum was perceived as an important baseline for understanding clinical areas. Relatively less learning was perceived to occur in the extra-curriculum., Conclusions: The authors believe that recognizing learning in "other-than-explicit" curricula could broaden the medical education community's understanding of the purview of the medical education curriculum and help educators tap into underused educational opportunities for important clinical topics.

Purpose: Current focus in medical education on competencies and curricular objectives draws attention to boundaries rather than the openness inherent in the learning process. This qualitative study explored the tension between boundedness (mandated curricular objectives) and openness (variability in learning experience as students traverse the explicit, implicit, and extracurriculum) in the curriculum., Method: Following the revision and implementation of 10 curricular objectives for Columbia University College of Physicians and Surgeons, the authors interviewed 18 fourth-year medical students in spring 2011. For each objective, students indicated the relative influence of the explicit curriculum, implicit curriculum, and extracurriculum on their learning. Students were asked to think aloud and assign points as they made these judgments. Quantitative and qualitative data were analyzed to understand students' perceptions of learning across curricula and for each curricular objective., Results: There was marked variability in students' learning experience. For two objectives, students perceived that learning occurred mainly in the explicit curriculum and consumed a disproportionate amount of study time. For two other objectives, students perceived that learning occurred mainly in the extracurriculum because opportunities to learn these objectives in the implicit and explicit curricula were sparse. For six objectives, students perceived that learning occurred mostly in the implicit curriculum, often through "watching" or interacting with peers., Conclusions: The findings can inform discussions about how to balance the boundedness of curricular mandates with the inherent openness of students' learning experiences.

Purpose: In 2003, the advisory dean program at Columbia University College of Physicians and Surgeons was created to better connect students and faculty by supporting student academic progress and improving career advising. With the program in its eighth year, the authors were interested in identifying key factors in maintaining ongoing vitality and effectiveness., Method: In 2011, the authors conducted a reflective analysis to study the program, using available information from dean interviews, student surveys, meeting agendas, and program leader reflections, aided by the Bolman and Deal four-part framework for organizational functioning (structural, human resource, political, and symbolic)., Results: Structural factors included reframing program goals to match program activities, situating the program within broader academic advising and counseling resources, and increasing face time between entering students and their deans. Human resource factors included managing higher-than-expected turnover of deans with dean selection and orientation strategies that balance diversity and consistency, and providing ongoing training to promote continual professional growth. Political factors included balancing resources (e.g., money, administrative support) from the school and departments to help the deans protect and manage their time. Symbolic factors were related to leveraging the deans as symbols of institutional values and commitment to education (e.g., participation in the white coat ceremony), and being aware of "hidden meanings" associated with decisions within other frames (e.g., student-to-dean ratio)., Conclusions: A variety of strategies across frames were used to maintain the program. This report can serve as a guide to program maintenance for other institutions.