The Decline in Community Preceptor Teaching Activity: Exploring the Perspectives of Pediatricians Who No Longer Teach Medical Students Purpose: Difficulty in recruiting and retaining community preceptors for medical student education has been described in the literature. Yet little if any information is known about community outpatient preceptors who have stopped or decreased teaching time with students. This study aimed to examine these preceptors’ perspectives about this phenomenon. Method: Using a phenomenology framework, this multi-institutional qualitative study used semistructured interviews with community pediatric preceptors who had stopped or reduced teaching time with medical students. Interviews were conducted between October 2017 and January 2018 and transcribed verbatim. Interviews explored factors for engaging in teaching, or decreasing or ceasing teaching, that would enable future teaching. An initial code book was developed and refined as data were analyzed to generate themes. Results: Twenty-seven community pediatricians affiliated with 10 institutions participated. Thirty-seven codes resulted in four organizing themes: evolution of health care, personal barriers, educational system, and ideal situations to recruit and retain preceptors; each with subthemes. Conclusions: From the viewpoints of physicians who had decreased or stopped teaching students, this study more deeply explored previously described reasons contributing to the decline of community preceptors, adds newly described barriers, and offers strategies to help counter this phenomenon based on preceptors’ perceptions. These findings appear to be manifestations of deeper issues including the professional identify of clinical educators. Understanding the barriers and strategies and how they relate to preceptors themselves should better inform education leaders to more effectively halt the decline of community precepting and enhance the clinical precepting environment for medical students. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A736. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Ethical approval was granted for our study by the University of Nebraska Medical Center Institutional Review Board. Approval was assigned number 366-17-EX on June 13, 2017. Subsequently, each participating site obtained approval from their institutional review boards. Previous presentations: Poster presentation, Council on Medical Student Education in Pediatrics Annual Meeting, St. Louis, Missouri, April 12, 2018. Correspondence should be addressed to Caroline R. Paul, Department of Pediatrics, University of Wisconsin School of Medicine, Madison, WI 53593; telephone: (608) 265-7740; email: crpaul@wisc.edu. © 2019 by the Association of American Medical Colleges

It Is Time to Prioritize Education and Well-Being Over Workforce Needs in Residency Training Residents inhabit an ambiguous world. They are no longer medical students, but are still learners. They are not yet attendings, but are still paid employees. This ambiguity leads to a misalignment of departmental incentives and trainee expectations. Trainees expect their learning and well-being to be prioritized while departments are under pressure to meet staffing needs and cut costs. This sets up a fundamental disconnect between the “formal” Accreditation Council for Graduate Medical Education (ACGME) message of well-being and the dominant “hidden” workplace forces that pull in the opposite direction, possibly contributing to the epidemic of burnout in trainees. It is critical that all parties—health systems, graduate medical education (GME) programs, the ACGME, and residents—recognize this disconnect and collaborate to meaningfully implement current ACGME requirements to decompress work intensity and address well-being. Real change will require more than general directives. The ACGME will likely need to take the lead, and consider taking a design thinking approach to structuring regulations governing how and when residents work and how they are supported. It would also be worthwhile to revisit the Institute of Medicine (IOM) recommendations on GME from 2014 related to funds flow and transformation initiatives. Taking a more comprehensive approach to residents as people, workers, and vital health care professionals is the right thing to do and may well improve retention, reduce burnout, decrease medical errors, and improve care. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Jed T. Wolpaw, 1800 Orleans Street, Zayed 6222, Baltimore, MD, 21287; telephone: 410-955-9942; email: jwolpaw@jhmi.edu. © 2019 by the Association of American Medical Colleges

Investigating Group Differences in Examinees’ Preparation for and Performance on the New MCAT Exam In 2015, the Medical College Admission Test (MCAT) was redesigned to better assess the concepts and reasoning skills students need to be ready for the medical school curriculum. During the new exam’s design and rollout, careful attention was paid to the opportunities examinees had to learn the new content and their access to free and low-cost preparation resources. The design committee aimed to mitigate possible unintended effects of the redesign, specifically increasing historical mean group differences in MCAT scores for examinees from lower-socioeconomic status (SES) backgrounds and races/ethnicities underrepresented in medicine compared to those from higher-SES backgrounds and races/ethnicities not underrepresented in medicine. In this article, the authors describe the characteristics and scores of examinees who took the new MCAT exam in 2017 and compare those trends to historical ones from 2013, presenting evidence that the diversity and performance of examinees has remained stable even with the exam’s redesign. They also describe the use of free and low-cost MCAT preparation resources and MCAT preparation courses for examinees from higher- and lower-SES backgrounds and who are enrolled in undergraduate institutions with more and fewer resources, showing that examinees from lower-SES backgrounds and who attend institutions with fewer resources use many free and low-cost test preparation resources at lower rates than their peers. The authors conclude with a description of the next phase of this research: to gather qualitative and quantitative data about the preparation strategies, barriers, and needs of all examinees, but especially those from lower-SES and underrepresented racial/ethnic backgrounds. Acknowledgments: The authors would like to thank their colleagues on the Research on Diversity, Group Differences, and Academic Preparation working group of the Association of American Medical Colleges (AAMC) Medical College Admission Test (MCAT) Validity Committee (MVC) for their contributions to this work: Liesel Copeland, Francie Cuffney, William Gilliland, Doug Taylor, and Robert Witzburg. The authors would also like to thank the full MVC for their dedication and tireless efforts to evaluate the new MCAT exam: Ngozi Anachebe, Barbara Beckman, Ruth Bingham, Kevin Busche, Deborah Castellano, Francie Cuffney, Julie Chanatry, Hallen Chung, Daniel Clinchot, Liesel Copeland, Martha Elks, William Gilliland, Jorge Girotti, Kristen Goodell, Joshua Hanson, Loretta Jackson-Williams, David Jones, Catherine Lucey, R. Stephen Manuel, Janet McHugh, Stephanie McClure, Cindy Morris, Wanda Parsons, Tanisha Price-Johnson, Boyd Richards, Aaron Saguil, Aubrie Swan Sein, Stuart Slavin, Doug Taylor, Carol Terregino, Ian Walker, Robert Witzburg, David Wofsy, and Mike Woodson. The authors would like to thank Sandy Koch for her contributions to this article. In addition, they would like to thank the following AAMC personnel for reviewing earlier drafts of this article: Heather Alarcon, Gabrielle Campbell, Karen Fisher, Karen Mitchell, Norma Poll, Elisa Siegel, and Geoffrey Young. Funding/Support: None reported. Other disclosures: The Medical College Admission Test (MCAT) is a program of the Association of American Medical Colleges (AAMC). Related trademarks owned by the AAMC include Medical College Admission Test and MCAT. Ethical approval: This study was approved by the institutional review board of the American Institutes for Research as part of the Association of American Medical Colleges’ Medical College Admission Test (MCAT) Validity Research Study protocol. Previous presentations: Some of the data presented in this article were presented at the 2017 Association of American Medical Colleges (AAMC) Learn Serve Lead annual meeting in November 2017, in Boston, Massachusetts, and at the 2018 Continuum Connections: A Joint Meeting of the Group on Student Affairs (GSA), Group on Resident Affairs (GRA), Organization of Student Representatives (OSR), and Organization of Resident Representatives (ORR) in April 2018, in Orlando, Florida. Correspondence should be addressed to Cynthia A. Searcy, Association of American Medical Colleges, 655 K Street NW Suite 100, Washington, DC 20001; telephone: (202) 862-6105; email: csearcy@aamc.org. © 2019 by the Association of American Medical Colleges

The Consequences of Structural Racism on MCAT Scores and Medical School Admissions: The Past is Prologue Those in medical education have a responsibility to prepare a physician workforce that can serve increasingly diverse communities, encourage healthy changes in patients, and advocate for the social changes needed to advance the health of all. The authors of this Perspective discuss many of the likely causes of the observed differences in mean Medical College Admission Test (MCAT) scores between students from groups well-represented in medicine and those from groups underrepresented in medicine. The lower mean MCAT scores of underrepresented groups can present challenges to diversifying the physician workforce if medical schools only admit those applicants with the highest MCAT scores. The authors review the psychometric literature, which showed no evidence of bias in the exam, and note that the differences in mean MCAT scores between racial and ethnic groups are similar to those in other measures of academic achievement and performance on high-stakes tests. The authors then describe the ways in which structural racism in the United States has contributed to differences in achievement for underrepresented students compared to well-represented students. These differences are not due to differences in aptitude but to differences in opportunities. The authors describe the widespread consequences of structural racism on economic success, educational opportunity, and bias in the educational environment. They close with 3 recommendations for medical schools that may mitigate the consequences of structural racism while maintaining academic standards and admitting students likely to succeed. Adopting these recommendations may help the medical profession build the diverse physician workforce needed to serve communities today. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A734. Acknowledgments: The authors acknowledge the dedication and contributions of the Medical College Admission Test Validity Committee and the following Association of American Medical Colleges staff: Cynthia Searcy, Karen Mitchell, Lesley Ward, and Jordan Yee Prendez (psychometric intern). They thank University of California, San Francisco, School of Medicine students Jazzmin Williams and Laeesha Corneo for publicizing the maps of San Francisco that illustrate the persistent impact of structural racism on educational quality. In addition, they acknowledge the tremendous efforts of all medical school leaders, faculty, and administrators who are working to diversify the physician workforce. Funding/Support: None reported. Other disclosures: The authors co-chair the Association of American Medical Colleges Medical College Admission Test Validity Committee. They receive no compensation for this work. Ethical approval: Reported as not applicable. Disclaimer: The views expressed in this article do not necessarily reflect the views of the Uniformed Services University, the US Army, or the Department of Defense. Correspondence should be addressed to Catherine Reinis Lucey, University of California, San Francisco, School of Medicine, 533 Parnassus Ave, Suite U-80, San Francisco, CA 94143; telephone: (415) 815-1633; email: catherine.lucey@ucsf.edu. © 2019 by the Association of American Medical Colleges

I Thought I Knew Commentary on “I Thought I Knew” No abstract available

The Diversity and Success of Medical School Applicants with Scores in the Middle Third of the MCAT Score Scale Admissions officers assemble classes of medical students with different backgrounds and experiences who can contribute to their institutions’ service, leadership, and research goals. While schools’ local interests vary, they share a common goal: meeting the health needs of an increasingly diverse population. Despite the well-known benefits of diversity, the physician workforce does not yet reflect the nation’s diversity by socioeconomic status, race/ethnicity, or other background characteristics. The authors reviewed the Medical College Admission Test (MCAT) scores and backgrounds of 2017 applicants, accepted applicants, and matriculants to U.S. MD-granting schools to explore avenues for increasing medical school class diversity. They found that schools that accepted more applicants with mid-range MCAT scores had more diverse matriculating classes. Many schools admitting the most applicants with scores in the middle of the MCAT score scale were public, community-based, and primary care-focused institutions; those admitting the fewest of these applicants tended to be research-focused institutions and to report pressure to accept applicants with high MCAT scores to maintain or improve their national rankings. The authors argue that reexamining the use of MCAT scores in admissions provides an opportunity to diversify the physician workforce. Despite evidence that most students with mid-range MCAT scores succeed in medical school, there is a tendency to overlook these applicants in favor of those with higher scores. To improve the health of all, the authors call for admitting more students with mid-range MCAT scores and studying the learning environments that enable students with a wide range of MCAT scores to thrive. Acknowledgments: The authors would like to thank their colleagues on the Research on Admissions Decision Making working group of the Association of American Medical Colleges (AAMC) Medical College Admission Test (MCAT) Validity Committee (MVC) for their contributions to this research: Hallen Chung, Janet McHugh, Cindy Morris, and Mike Woodson. The authors would also like to thank the full MVC for their dedication and tireless efforts to evaluate the new MCAT exam: Ngozi Anachebe, Barbara Beckman, Ruth Bingham, Kevin Busche, Deborah Castellano, Francie Cuffney, Julie Chanatry, Hallen Chung, Daniel Clinchot, Liesel Copeland, Martha Elks, William Gilliland, Jorge Girotti, Kristen Goodell, Joshua Hanson, Loretta Jackson-Williams, David Jones, Catherine Lucey, R. Stephen Manuel, Janet McHugh, Stephanie McClure, Cindy Morris, Wanda Parsons, Tanisha Price-Johnson, Boyd Richards, Aaron Saguil, Aubrie Swan Sein, Stuart Slavin, Doug Taylor, Carol Terregino, Ian Walker, Robert Witzburg, David Wofsy, and Mike Woodson. The authors would also like to thank the following AAMC staff: Cynthia Searcy, Karen Mitchell, and Lesley Ward. Funding/Support: None reported. Other disclosures: The Medical College Admission Test (MCAT) is a program of the Association of American Medical Colleges (AAMC). Related trademarks owned by the AAMC include Medical College Admission Test and MCAT. Ethical approval: Reported as not applicable. Disclaimer: The views expressed in this article do not necessarily reflect the views of the Uniformed Services University, the US Army, or the Department of Defense. Previous presentations: Some of the data presented in this article were presented at the Association of American Medical Colleges Learn Serve Lead annual meeting in November 2017, in Boston, Massachusetts. Correspondence should be addressed to Carol A. Terregino, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane West, Piscataway, NJ 08854; telephone: (732) 235-4577; email: terregca@rwjms.rutgers.edu. © 2019 by the Association of American Medical Colleges

Parenthood During Graduate Medical Education: A Scoping Review Purpose: To conduct a scoping review of the literature on parenthood during graduate medical education (GME) and to develop a conceptual framework to inform policy and guide research. Method: The authors searched PubMed and Embase for articles published from January 1993 through August 7, 2017, using a query framework that combined the concepts of “person” (e.g., “trainee”) and “parenthood” (e.g., “breastfeeding”). They included studies describing parenthood or pregnancy of trainees in U.S. GME training programs. Two authors independently screened citations and abstracts and performed kappa coefficient tests to evaluate inter-reviewer reliability. Two authors performed a full-text review of and extracted data from each included article, and four authors coded data for all articles. The authors used descriptive statistics and qualitative synthesis to analyze data. Results: Ninety articles met inclusion criteria, and nearly half (43/90; 48%) were published between 2010 and 2017. The authors developed six themes that surround resident parenthood: wellbeing, maternal health, others’ perceptions, relationships, program preparation, and policy. They mapped these themes by relationship of stakeholders (infant and family, institutions) to the resident-parent to create a conceptual framework describing parenthood during GME. Conclusions: The findings from this scoping review have implications for policy and research. Those authoring parental leave policies could collaborate with national board leaders to develop consistent standards and include nontraditional families. Gaps in the literature include the effect of resident parenthood on patient care, postpartum health, and policy execution. Research in these areas would advance the literature on parenthood during residency. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A737 and http://links.lww.com/ACADMED/A738. Acknowledgements: The authors gratefully acknowledge Amy Oxentenko, MD, professor of medicine, Mayo Medical School, and Jennifer Takagishi, MD, professor of pediatrics, University of South Florida, for their work as content experts who vetted their literature search. The authors would also like to acknowledge Valeria Balashova who created the graphic design in Figure 3. Funding/Support: This project was made possible with a Mapping the Landscape, Journeying Together grant from the Arnold P. Gold Foundation Research Institute. This project was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR002319. Other disclosures: Dr Stack and Dr Best were also supported by the 2016 American Medical Association Foundation Joan F. Giambalvo Fund for the Advancement of Women. Ethical approval: Reported as not applicable. Previous presentations: This work was presented at the Arnold P. Gold Foundation Research Institute’s Mapping the Landscape, Journeying Together (MTL) Symposium, Chicago, Illinois, May 20, 2018. Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the Arnold P. Gold Foundation, or the American Medical Association. Correspondence should be addressed to Shobha W. Stack, Department of Medicine, University of Washington, 1959 NE Pacific Street, Box 356429, Seattle, WA; email: shobhaws@uw.edu; Twitter: @shobhastack. © 2019 by the Association of American Medical Colleges

Learning Challenges, Teaching Strategies, and Cognitive Load: Insights From the Experience of Seasoned Endoscopy Teachers Purpose: Learners of medical procedures must develop, refine, and apply schemas for both cognitive and psychomotor constructs, which may strain working memory capacity. Procedures with limitations in visual and tactile information may add risk of cognitive overload. The authors sought to elucidate how experienced procedural teachers perceived learners’ challenges and their own teaching strategies in the exemplar setting of gastrointestinal endoscopy. Method: The authors interviewed 22 experienced endoscopy teachers in the United States, Canada, and the Netherlands between May 2016 and March 2019 and performed thematic analysis using template analysis method. Interviews addressed learner challenges and teaching strategies from the teacher participants’ perspectives. Cognitive load theory informed data interpretation and analysis. Results: Participants described taking steps to “diagnose” trainee ability and identify struggling trainees. They described learning challenges related to trainees (performance over mastery goal orientation, low self-efficacy, lack of awareness), tasks (psychomotor challenges, mental model development, tactile understanding), teachers (teacher–trainee relationship, inadequate teaching, teaching variability), and settings (internal/external distractions, systems issues). Participants described employing strategies that could match intrinsic load to learners’ levels (teaching along developmental continuum, motor instruction, technical assistance/takeover), minimize extraneous load (optimize environment, systems solutions, emotional support, define expectations), and optimize germane load (promote mastery, teach schemas, stop and focus). Conclusions: Participants provided insight into possible challenges while learning complex medical procedures with limitations in sensory channels, as well as teaching strategies that may address these challenges at individual and systems levels. Using cognitive load theory, the authors provide recommendations for procedural teachers. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A735. Acknowledgments: The authors thank Dr. Bas Oldenburg for helping to identify study participants in the Netherlands. The authors thank the participants who generously contributed their time to participate in the study interviews. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The Institutional Review Board of the University of California San Francisco reviewed the study protocol and granted it exempt status as an educational research study with minimal risk (IRB # 16-18891). It was also reviewed and approved by the Netherlands Association for Medical Education Ethical Review Board. Disclaimers: None. Previous presentations: Presented at the American Educational Research Association 2019 Annual Meeting, April 2, 2019, Toronto, Ontario, Canada; and at Digestive Disease Week 2019, May 21, 2019, San Diego, California, United States. Correspondence should be addressed to Justin L. Sewell, University of California San Francisco, San Francisco General Hospital, 1001 Potrero Avenue, Unit 3D, San Francisco, CA 94110; telephone: (415) 206-4575; email: justin.sewell@ucsf.edu. © 2019 by the Association of American Medical Colleges

The Validity of Scores from the New MCAT Exam in Predicting Student Performance: Results from a Multisite Study Purpose: The new Medical College Admission Test (MCAT) was introduced in April 2015. This report presents findings from the first study of the validity of scores from the new MCAT exam in predicting student performance in the first year of medical school (M1). Method: The authors analyzed data from the national population of 2016 matriculants with scores from the new MCAT exam (N = 7,970) and the sample of 2016 matriculants (N = 955) from 16 medical schools who volunteered to participate in the validity research. They examined correlations of students’ MCAT total scores and total undergraduate grade point averages (UGPAs), alone and together, with their summative performance in M1, and the success rate of students with different MCAT scores in their on-time progression to the second year of medical school (M2). They assessed whether MCAT scores provided comparable prediction of performance in M1 by students’ race/ethnicity, socioeconomic background, and gender. Results: Correlations of MCAT scores with summative performance in M1 ranged from medium to large. Although MCAT scores and UGPAs provided similar prediction of performance in M1, using both metrics provided better prediction than either alone. Additionally, students with a wide range of MCAT scores progressed to M2 on time. Finally, MCAT scores provided comparable prediction of performance in M1 for students from different sociodemographic backgrounds. Conclusions: This study provides early evidence that scores from the new MCAT exam predict student performance in M1. Future research will examine the validity of MCAT scores in predicting performance in later years. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A731. Acknowledgements: The authors would like to thank the members of the Association of American Medical Colleges (AAMC) Medical College Admission Test (MCAT) Validity Committee for their dedication and tireless efforts to evaluate the new MCAT exam: Ngozi Anachebe, Barbara Beckman, Ruth Bingham, Kevin Busche, Deborah Castellano, Francie Cuffney, Julie Chanatry, Hallen Chung, Daniel Clinchot, Liesel Copeland, Martha Elks, William Gilliland, Jorge Girotti, Kristen Goodell, Joshua Hanson, Loretta Jackson-Williams, David Jones, Catherine Lucey, R. Stephen Manuel, Janet McHugh, Stephanie McClure, Cindy Morris, Wanda Parsons, Tanisha Price-Johnson, Boyd Richards, Aaron Saguil, Aubrie Swan Sein, Stuart Slavin, Doug Taylor, Carol Terregino, Ian Walker, Robert Witzburg, David Wofsy, and Mike Woodson. The authors would also like to thank the following AAMC personnel for reviewing earlier drafts of this manuscript: Heather Alarcon, Gabrielle Campbell, Karen Fisher, Marc Kroopnick, Karen Mitchell, Norma Poll, Elisa Siegel, and Geoffrey Young. In addition, they would like to thank Cynthia Searcy, Andrea Carpentieri, Melissa Lee, and Rob Santos for their contributions to this article. Funding/Support: None reported. Other disclosures: The Medical College Admission Test (MCAT) is a program of the Association of American Medical Colleges (AAMC). Related trademarks owned by the AAMC include Medical College Admission Test and MCAT. Ethical approval: This study was approved by the institutional review board of the American Institutes for Research as part of two different protocols: (1) the Association of American Medical Colleges’ (AAMC’s) Medical College Admission Test (MCAT) Validity Research Study protocol and (2) the participating medical schools’ MCAT Validity Study protocol. Course-based outcome data for the validity sample used in this report came from 16 medical schools that partner with the AAMC on MCAT validity research. All validity schools granted permission to the AAMC to use the data in MCAT validity research and publications. Representatives from the validity schools were also provided the opportunity to review the manuscript prior to its submission for publication. Previous presentations: Some of the data presented in this report were presented at the 2017 Association of American Medical Colleges Learn Serve Lead annual meeting in November 2017, in Boston, Massachusetts; and the 2018 Continuum Connections: A Joint Meeting of the Group on Student Affairs (GSA), Group on Resident Affairs (GRA), Organization of Student Representatives (OSR), and Organization of Resident Representatives (ORR) in April 2018, in Orlando, Florida. Correspondence should be addressed to Kun Yuan, Association of American Medical Colleges, 655 K Street NW Suite 100, Washington, DC 20001-2399; telephone: (202) 909-2080; email: kyuan@aamc.org. © 2019 by the Association of American Medical Colleges

The Covenant Burnout among doctors appears to be at epidemic proportions these days, with concomitant gushing prescriptions for wellness and resilience. But in reality, most doctors are not burned out, in the traditional sense of the word: most love taking care of patients and want nothing more than to be able to do just that. The source of the agony is the profession—or rather the corporatization of the profession—that has so impinged upon the doctors’ ability to practice medicine. Doctors placed their trust in the medical profession, but that trust has been roundly trounced. So, rather than prescribe Pilates classes for overstressed doctors, it is time for the medical profession—and the health care industry that has subsumed it—to get a check-up. To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s web site (https://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=65) follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s announcement of the current topic in the December 2018 issue for submission instructions and for more information about this feature). Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on trust in health care and health professions education Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable Correspondence should be addressed to Danielle Ofri, Bellevue Hospital, 462 First Ave., Suite 2C, New York, NY; e-mail: danielle.ofri@nyumc.org; Twitter: @danielleofri. © 2019 by the Association of American Medical Colleges