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Julia J Chang,1 Adam Hain,2 Chrysoula Dosiou,1,* Neil Gesundheit1,* 1Division of Endocrinology, Metabolism, and Gerontology, Department of Medicine, Stanford School of Medicine, Stanford, California; 2Office of Medical Education, Stanford School of Medicine, Stanford, California*These authors contributed equally to this workCorrespondence: Julia J Chang, Stanford School of Medicine, 300 Pasteur Dr., Room S025, Stanford, CA, 94305, Tel +1 650-724-2474, Fax +1 (248) 720-4461, Email jchang89@stanford.eduBackground: The COVID-19 pandemic and a movement away from traditional lecture-based learning have increased the use of online flipped classroom (FC) and active learning models in medical education. The Community of Inquiry (CoI) framework for online learning may be used to evaluate the effectiveness and strengths of the online FC model compared with other learning formats.Methods: An observational survey study was conducted to measure medical student and facilitator perceptions of an online FC endocrinology tutorial compared with online lecture experiences. For the tutorial, students were instructed to watch short, pre-recorded lecture videos on thyroid pathophysiology prior to class. During class, small groups of students were paired with a faculty facilitator in online Zoom rooms for case discussion. Students were surveyed using the CoI framework to assess elements of cognitive, social, and teaching presence between the two online learning modalities. Facilitators were also surveyed. Survey questions were rated on a 5-point Likert scale.Results: Fifty-three out of 92 students (58% response rate) and seven out of eight facilitators (88% response rate) completed surveys. In general, students felt that online FC learning improved cognitive, teaching, and social presence compared with online lecture. Areas of cognitive presence (mean score 3.9 ± 1.0 SD), such as stimulating curiosity and applying concepts, were highly rated. Certain elements of social presence (3.6 ± 0.9) and teaching presence (3.7 ± 0.9), such as expression of emotion and communication of expectations, garnered lower ratings. All surveyed facilitators felt that online FC was more effective and enjoyable to teach than online lectures but did not feel it was superior to in-person instruction.Conclusion: Medical students and facilitators viewed an online FC tutorial in endocrinology positively. Most, but not all, areas of the CoI framework were enhanced with the online FC tutorial compared with online lecture-based learning.Keywords: flipped classroom, online learning, community of inquiry, small group learning

Hamsika Chandrasekar,1 Neil Gesundheit,2 Andrew B Nevins,3 Peter Pompei,4 Janine Bruce,5 Sylvia Bereknyei Merrell6 1Department of Pediatrics, Boston Children’s Hospital, Boston, MA, USA; 2Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA; 3Department of Medicine, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, CA, USA; 4Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA; 5Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA; 6Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA Background: It is a common educational practice for medical students to engage in case-based learning (CBL) exercises by working through clinical cases that have been developed by faculty. While such faculty-developed exercises have educational strengths, there are at least two major drawbacks to learning by this method: the number and diversity of cases is often limited; and students decrease their engagement with CBL cases as they grow accustomed to the teaching method. We sought to explore whether student case creation can address both of these limitations. We also compared student case creation to traditional clinical reasoning sessions in regard to tutorial group effectiveness, perceived gains in clinical reasoning, and quality of student–faculty interaction. Methods: Ten first-year medical students participated in a feasibility study wherein they worked in small groups to develop their own patient case around a preassigned diagnosis. Faculty provided feedback on case quality afterwards. Students completed pre- and post-self-assessment surveys. Students and faculty also participated in separate focus groups to compare their case creation experience to traditional CBL sessions. Results: Students reported high levels of team engagement and peer learning, as well as increased ownership over case content and understanding of clinical reasoning nuances. However, students also reported decreases in student–faculty interaction and the use of visual aids (P < 0.05). Conclusion: The results of our feasibility study suggest that student-generated cases can be a valuable adjunct to traditional clinical reasoning instruction by increasing content ownership, encouraging student-directed learning, and providing opportunities to explore clinical nuances. However, these gains may reduce student–faculty interaction. Future studies may be able to identify an improved model of faculty participation, the ideal timing for incorporation of this method in a medical curriculum, and a more rigorous assessment of the impact of student case creation on the development of clinical reasoning skills. Keywords: case-based learning, undergraduate medical education, student case creation

Objective: To increase lean body mass and improve health status in patients with wasting associated with the acquired immunodeficiency syndrome (AIDS) by treatment with recombinant human growth hormone (rhGH), recombinant human insulin-like growth factor 1 (rhIGF-1), or both.Design: Randomized, double-blind, placebo-controlled clinical trial.Setting: University of New Mexico Clinical Research Center and University of Texas Southwestern Medical Center.Patients: 60 patients with AIDS and wasting as defined by the Centers for Disease Control and Prevention. Patients were divided into four groups of 15 patients each.Intervention: Group 1 received 1.4 mg of rhGH once daily plus placebo twice daily; group 2 received 5 mg of rhIGF-1 twice daily plus placebo once daily; group 3 received 5 mg of rhIGF-1 twice daily plus 1.4 mg of rhGH once daily; and group 4 received placebo three times daily.Measurements: Body weight, body composition, muscle strength, protein catabolism, quality of life, and immune status were assessed at baseline, and changes in these variables were measured at 6 and 12 weeks.Results: At 6 weeks, lean body mass had increased and total fat mass had decreased in the groups receiving rhGH, rhIGF-1, or both. Group 3 had the greatest changes in lean body mass (mean +/- SE, 3.2 +/- 0.59 kg; P < 0.001); only in this group were changes in body mass maintained at 12 weeks. Only patients in group 1 had improvement in muscular strength of the knees and upper body (P = 0.04) and quality of life (P = 0.01). Immunologic function did not improve in any group.Conclusions: Growth factor therapy had significantly increased lean body mass and decreased fat mass by 6 weeks, but these improvements persisted for 12 weeks only in group 3. Growth factor therapy at the dosages used in this study is not recommended because the magnitude of weight gain was modest and improvements in quality-of-life measures varied. [ABSTRACT FROM AUTHOR]

Study Objective: To evaluate the clinical and biochemical features of patients with TSH (thyroid-stimulating hormone, thyrotropin)-secreting pituitary tumors; to measure the biologic activity in vitro of circulating TSH from selected patients before and after pituitary surgery.Design: Case series.Setting: Patients in an endocrinology unit.Patients: Nine patients with TSH-secreting pituitary tumors.Measurements and Main Results: All patients had hyperthyroidism, elevated free thyroxine and triiodothyronine levels, and detected levels of TSH. The free alpha subunit, a tumor marker for neoplasms of gonadotropic or thyrotropic cell origin, was elevated in all nine patients. Seven of the nine patients had been treated with thionamides, radioactive iodine, or thyroidectomy for presumed primary hyperthyroidism. The delay from the initial treatment of hyperthyroidism to the correct diagnosis of a pituitary neoplasm was 6.2 +/- 4.8 (mean +/- SD) years. Two of the seven patients with macroadenomas died in the perioperative period (one at NIH, one at a referring hospital). Of the remaining five patients with macroadenomas, four have residual tumor and inappropriate TSH secretion, despite surgery and radiation therapy, at follow-up from 3.5 to 6 years. In contrast, the two patients with microadenomas are clinically cured 2.5 and 4 years after transsphenoidal adenomectomy. The biologic to immunologic (B/I) ratio of serum TSH, determined preoperatively in five patients with TSH-secreting tumors, was elevated compared with euthyroid subjects. In three patients the B/I ratio of serum TSH was also measured after pituitary surgery; in two the elevated B/I ratio returned to normal after successful pituitary adenomectomy, while in the third this ratio remained elevated after incomplete adenoma resection.Conclusions: With the routine availability of ultrasensitive TSH assays and their increasing use to confirm thyrotoxicosis from all causes, we expect that TSH-secreting pituitary tumors will be diagnosed earlier, before inappropriate antithyroid therapy, permitting an improved outcome. [ABSTRACT FROM AUTHOR]

Purpose: Faculty development in learning-centred medical education aims to help faculty mature into facilitators of student learning, but it is often ineffective. It is unclear how to support educators' maturation sustainably. We explored how and why medical educators working in learning-centred education, more commonly referred to as student-centred education, mature over time., Methods: We performed a qualitative follow-up study and interviewed 21 senior physician-educators at two times, ten years apart. A hierarchical model, distinguishing four educator phenotypes, was employed to deductively examine educators' awareness of the workplace context, their educational competencies, identity, and 'mission,' i.e. their source of personal inspiration. Those educators who grew in awareness, as measured by advancing in educator phenotype, were re-interviewed to inductively explore factors they perceived to have guided their maturation., Results: A minority of the medical educators grew in awareness of their educational qualities over the 10-year study period. Regression in awareness did not occur. Maturation as an educator was perceived to be linked to maturation as a physician and to engaging in primarily informal learning opportunities., Conclusions: Maturation of medical educators can take place, but is not guaranteed, and appears to proceed through a growth in awareness of, successively, educational competencies, identity, and mission. At all stages, maturation is motivated by the task, identity, and mission as a physician.

Background: The educational beliefs of medical educators influence their teaching practices. Insight into these beliefs is important for medical schools to improve the quality of education they provide students and to guide faculty development. Several studies in the field of higher education have explored the educational beliefs of educators, resulting in classifications that provide a structural basis for diverse beliefs. However, few classification studies have been conducted in the field of medical education. We propose a framework that describes faculty beliefs about teaching, learning, and knowledge which is specifically adapted to the medical education context. The proposed framework describes a matrix in which educational beliefs are organised two dimensionally into belief orientations and belief dimensions. The belief orientations range from teaching-centred to learning-centred; the belief dimensions represent qualitatively distinct aspects of beliefs, such as 'desired learning outcomes' and 'students' motivation'., Methods: We conducted in-depth semi-structured interviews with 26 faculty members, all of whom were deeply involved in teaching, from two prominent medical schools. We used the original framework of Samuelowicz and Bain as a starting point for context-specific adaptation. The qualitative analysis consisted of relating relevant interview fragments to the Samuelowicz and Bain framework, while remaining open to potentially new beliefs identified during the interviews. A range of strategies were employed to ensure the quality of the results., Results: We identified a new belief dimension and adapted or refined other dimensions to apply in the context of medical education. The belief orientations that have counterparts in the original Samuelowicz and Bain framework are described more precisely in the new framework. The new framework sharpens the boundary between teaching-centred and learning-centred belief orientations., Conclusions: Our findings confirm the relevance of the structure of the original Samuelowicz and Bain beliefs framework. However, multiple adaptations and refinements were necessary to align the framework to the context of medical education. The refined belief dimensions and belief orientations enable a comprehensive description of the educational beliefs of medical educators. With these adaptations, the new framework provides a contemporary instrument to improve medical education and potentially assist in faculty development of medical educators.

This Invited Commentary is an independent opinion piece and companion to the Perspective by Carmody and Rajasekaran that appears in this issue of Academic Medicine. The National Board of Medical Examiners (NBME), a 501(c)(3) nonprofit, is a powerful gatekeeper to the medical profession in the United States. According to publicly available tax data, the NBME, which has increased its number of income-enhancing products, had revenues of $153.9 million (M) and net assets of $177.6M in 2017, earnings (revenue less expenses) of $39.7M in 2013-2017, and a highly compensated management team. Medical students are ultimately the source of nearly all the NBME's revenue, and the NBME has contributed to the growth of medical student debt. The NBME has operated as a monopoly since its agreement in the early 1990s with the Federation of State Medical Boards to cosponsor the United States Medical Licensing Examination (USMLE). Although the NBME has developed valuable products and is ostensibly governed by a capable board, the NBME has inherent financial conflicts of interest and may be benefiting from the current "Step 1 mania" undermining undergraduate medical education. Here, the author makes 4 recommendations to reestablish the trust of the U.S. medical education community in the NBME: (1) the NBME should recuse itself from current discussions and policy-making decisions related to changes in the score reporting of the USMLE Step 1 exam; (2) the NBME should disclose and be transparent about all aspects of its finances; (3) new NBME products, changes in pricing, and changes to pass thresholds should be approved by an oversight committee, independent of the NBME; and (4) the NBME (and USMLE) should not charge students or residents for retaking any of its licensing examinations.

Background: The educational beliefs of medical academics influence how they act in class and thus influence student learning. One component of these are beliefs academics hold about the qualities of teachers themselves. These teacher qualities range from behaviours and competencies to more personal attributes such as the teacher's identity and mission. However, it is unclear what medical academics believe to be key teacher qualities. Therefore, this study explored the variety of medical academics' beliefs about 'teacher qualities', aiming to identify and characterise profiles of academics with similar beliefs., Methods: We interviewed 26 expert academics from two medical schools to explore their beliefs about teacher qualities. A concentric onion-model focusing on teacher qualities was used to analyse and categorise the data deductively. Within each theme we developed subthemes inductively. To gain insight into the variety of beliefs we then clustered the participants into teacher profiles according to the themes. To better understand each of the profiles we carried out a quantitative study of the differences between profiles regarding subthemes, contextual and personal factors, and analysed statistical significance using Fisher's exact- and Student's t-tests for categorical and continuous data, respectively., Results: Four profiles of medical academics were identified, corresponding to the most central theme that each participant had reflected on: the 'Inspirer', 'Role-model', 'Practitioner', and 'Critic'. The focus of the profiles varied from external constraining factors within the 'Critic' profile to affective personal qualities within the 'Role-model' and 'Inspirer' profiles. The profiles could be regarded as hierarchically ordered by inclusiveness. Educational institute was the only significant factor related to the profiles., Conclusions: Besides the relevance of affective teacher qualities, the 'Inspirer' profile demonstrates the importance of developing a clear mission as a teaching academic, centred around student learning and professional development. In our view, academics who inspire their students continue to be inspired themselves. The practical implications are described for faculty development programmes, and for the potential value of using these profiles within medical schools. In the discourse on educational beliefs, the authors argue that more attention should be paid to affective qualities, in particular to explicating the educational mission of academics.

Problem: Undergraduate (i.e., baccalaureate) premedical students have limited exposure to clinical practice before applying to medical school-a shortcoming, given the personal and financial resources required to complete medical training., Approach: The Stanford Immersion in Medicine Series (SIMS) is a program that streamlines the completion of regulatory requirements for premedical students and allows them to develop one-on-one mentor-mentee relationships with practicing physicians. The program, offered quarterly since 2007, is an elective available for Stanford University sophomores, juniors, and seniors. Participants apply to the program and, if accepted, receive patient rights and professionalism training. Students shadow the physician they are paired with at least four times and submit a reflective essay about their experience.SIMS program coordinators administered surveys before and after shadowing to assess changes in students' perceptions and understanding of medical careers., Outcomes: The authors observed, in the 61 Stanford premedical students who participated in SIMS between March and June 2010 and completed both pre- and postprogram questionnaires, significant increases in familiarity with physician responsibilities and in understanding physician-patient interactions. The authors detected no significant changes in student commitment to pursuing medicine. Student perceptions of the value of shadowing-high both pre- and post shadowing-did not change., Next Steps: Physician shadowing by premedical baccalaureate students appears to promote an understanding of physician roles and workplace challenges. Future studies should identify the ideal timing, format, and duration of shadowing to optimize the experience and allow students to make informed decisions about whether to pursue a medical career.

Objectives: The development of patient-centred attitudes by health care providers is critical to improving health care quality. A prior study showed that medical students with more patient-centred attitudes scored higher in communication skills as judged by standardised patients (SPs) than students with less patient-centred attitudes. We designed this multicentre study to examine the relationships among students' demographic characteristics, patient-centredness and communication scores on an SP examination., Methods: Early Year 4 medical students at three US schools completed a 12-item survey during an SP examination. Survey items addressed demographics (gender, ethnicity, primary childhood language) and patient-centredness. Factor analysis on the patient-centredness items defined specific patient-centred attitudes. We used multiple regression analysis incorporating demographic characteristics, school and patient-centredness items and examined the effect of these variables on the outcome variable of communication score., Results: A total of 351 students took the SP examination and 329 (94%) completed the patient-centredness questionnaire. Responses indicated generally high patient-centredness. Student ethnicity and medical school were significantly associated with communication scores; gender and primary childhood language were not. Two attitudinal factors were identified: patient perspective and impersonal attitude. Multiple regression analysis revealed that school and scores on the impersonal factor were associated with communication scores. The effect size was modest., Conclusions: In a medical student SP examination, modest differences in communication scores based on ethnicity were observed and can be partially explained by student attitudes regarding patient-centredness. Curricular interventions to enhance clinical experiences, teaching and feedback are needed to address key elements of a patient-centred approach to care.

Medical schools continually evolve their curricula to keep students abreast of advances in basic, translational, and clinical sciences. To provide feedback to educators, critical evaluation of the effectiveness of these curricular changes is necessary. This article describes a method of curriculum evaluation, called "empowerment evaluation," that is new to medical education. It mirrors the increasingly collaborative culture of medical education and offers tools to enhance the faculty's teaching experience and students' learning environments. Empowerment evaluation provides a method for gathering, analyzing, and sharing data about a program and its outcomes and encourages faculty, students, and support personnel to actively participate in system changes. It assumes that the more closely stakeholders are involved in reflecting on evaluation findings, the more likely they are to take ownership of the results and to guide curricular decision making and reform. The steps of empowerment evaluation include collecting evaluation data, designating a "critical friend" to communicate areas of potential improvement, establishing a culture of evidence, encouraging a cycle of reflection and action, cultivating a community of learners, and developing reflective educational practitioners. This article illustrates how stakeholders used the principles of empowerment evaluation to facilitate yearly cycles of improvement at the Stanford University School of Medicine, which implemented a major curriculum reform in 2003-2004. The use of empowerment evaluation concepts and tools fostered greater institutional self-reflection, led to an evidence-based model of decision making, and expanded opportunities for students, faculty, and support staff to work collaboratively to improve and refine the medical school's curriculum.

For more than 40 years, the faculties of Duke University School of Medicine (SOM) and Stanford University SOM have encouraged or required students to engage in scholarship as a way to broaden their education and attract them to careers in academic medicine. A dedicated period of research was first integrated into the Duke curriculum in 1959 to provide an opportunity for students to develop into physician leaders through a rigorous scholarly experience in biomedically related research. Originally designed to foster experience in laboratory-based basic research, the third-year program has evolved in response to the changing landscape of medicine and shifting needs and career interests of the medical student population. Stanford University SOM also has a long-standing commitment to biomedical research and currently requires each student to complete an in-depth, mentored "scholarly concentration." In contrast to Duke, where most of the scholarly research experiences take place in an immersive third year, the Stanford program encourages a longitudinal, multiyear exposure over all four (or five) years of medical school. Although the enduring effects of embedding a rigorous research program are not yet fully known, preliminary data suggest that these experiences instill an appreciation for research, impart research rigor and methodologies, and may motivate students to pursue careers in academic medicine. The authors discuss the histories, evolution, logistics, and ongoing challenges of the research programs at Duke University SOM and Stanford University SOM.

Abraham Flexner's 1910 report is credited with promoting critical reforms in medical education. Because Flexner advocated scientific rigor and standardization in medical education, his report has been perceived to place little emphasis on the importance of public health in clinical education and training. However, a review of the report reveals that Flexner presciently identified at least three public-health-oriented principles that contributed to his arguments for medical education reform: (1) The training, quality, and quantity of physicians should meet the health needs of the public, (2) physicians have societal obligations to prevent disease and promote health, and medical training should include the breadth of knowledge necessary to meet these obligations, and (3) collaborations between the academic medicine and public health communities result in benefits to both parties. In this article, commemorating the Flexner Centenary, the authors review the progress of U.S. and Canadian medical schools in addressing these principles in the context of contemporary societal health needs, provide an update on recent efforts to address what has long been perceived as a deficit in medical education (inadequate grounding of medical students in public health), and provide new recommendations on how to create important linkages between medical education and public health. Contemporary health challenges that require a public health approach in addition to one-on-one clinical skills include containing epidemics of preventable chronic diseases, reforming the health care system to provide equitable high-quality care to populations, and responding to potential disasters in an increasingly interconnected world. The quantitative skills and contextual knowledge that will prepare physicians to address these and other population health problems constitute the basics of public health and should be included throughout the continuum of medical education.