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Prior studies have shown a correlation between the grades students receive and how they rate their teacher in the classroom. In this study, the authors probe this association on clinical rotations and explore potential mechanisms. All In-Training Evaluation Reports (ITERs) for students on mandatory clerkship rotations from April 1, 2013 to January 31, 2015 were matched with the corresponding student's rating of their teacher (SRT). The date and time that ITERs and SRTs were submitted was used to divide SRTs into those submitted before versus after the corresponding ITER was submitted. Multilevel, mixed effects linear regression was used to examine the association between SRT, ITER rating, and whether the ITER was submitted before or after SRT. Of 2373 paired evaluations, 1098 (46.3%) SRT were submitted before the teacher had submitted the ITER. There was a significant interaction between explanatory variables: when ITER ratings had not yet been submitted, the regression coefficient for this association was 0.25 (95% confidence interval [0.17, 0.33], p < 0.001), whereas the regression coefficient was significantly higher when ITER ratings were submitted prior to SRT (0.40 [0.31, 0.49], p < 0.001). Finding an association between SRT and ITER when students do not know their ITER ratings suggests that SRTs can capture attributes of effective teaching, but the effect modification when students have access to their ITER rating supports grade satisfaction bias. Further studies are needed to explain the mechanism of grade satisfaction and to identify other biases that may impact the validity of SRT.

Despite the fact that the length of medical school training has remained stable for many years, the expectations of graduating medical students (and the schools that train them) continue to increase. In this Reflection, the authors discuss motives for educational inflation and suggest that these are likely innocent, well-intentioned, and subconscious-and include both a propensity to increase expectations of ourselves and others over time, and a reluctance to reduce training content and expectations. They then discuss potential risks of educational inflation, including reduced emphasis on core knowledge and clinical skills, and adverse effects on the emotional, psychological, and financial wellbeing of students. While acknowledging the need to change curricula to improve learning and clinical outcomes, the authors proffer that it is naïve to assume that we can inflate educational expectations at no additional cost. They suggest that before implementing and/or mandating change, we should consider of all the costs that medical schools and students might incur, including opportunity costs and the impact on the emotional and financial wellbeing of students. They propose a cost-effectiveness framework for medical education and advocate prioritization of interventions that improve learning outcomes with no additional costs or are cost-saving without adversely impacting learning outcomes. When there is an additional cost for improved learning outcomes or a decline in learning outcomes as a result of cost saving interventions, they suggest careful consideration and justification of this trade-off. And when there are neither improved learning outcomes nor cost savings they recommend resisting the urge to change.

There is an inherent conflict within clinician educators as we balance the roles of healthcare provider to patients in need of care with that of educator of learners in need of teaching. In this essay we use Beauchamp and Childress' principles of biomedical ethics as a framework to compare the relationship that clinician educators have with their patients and their learners, and suggest that while we typically apply ethical principles when addressing the needs of our patients, these principles are frequently lacking in our interactions with learners. This dichotomy reflects a person-by-situation interaction that may be partly explained by the expectations of the regulatory bodies that define how clinicians should interact with patients and how educators should interact with learners. The result is that we may fall short in applying respect for autonomy, beneficence/nonmaleficence, and justice when addressing the needs of our learners. Fortunately there are ways in which we can incorporate these ethical principles into our interactions with learners while still adhering to accreditation standards and institutional policy. These include flipped classrooms and simulated learning experiences, incorporating aspects of instructional design that have been shown to improve learning outcomes, providing additional resources to learners with greater needs, and organizing training curricula around entrustable professional activities. Although the consistent application of ethical principles with all learners during all learning experiences is likely unachievable, we can, and should, move towards more ethical treatment of our learners.