Choosing Words Wisely: Residents’ Use of Rhetorical Appeals in Conversations About Unnecessary Tests Purpose: To characterize how residents employ rhetorical appeals (i.e., the strategic use of communication to achieve specifiable goals) when discussing unnecessary diagnostic tests with patients. Method: In 2015, senior hematology residents from 10 Canadian universities participating in a national formative objective structured clinical examination (OSCE) completed a resource stewardship communication station. In this communication scenario, a standardized patient (SP) portrayed a patient requesting unnecessary thrombophilia testing following early pregnancy loss. The authors performed a thematic analysis of audio transcripts using a qualitative description approach to identify residents’ rhetorical appeals to logic (rational appeals), credibility, and emotion. Results: For persuasive communication, residents (n = 27) relied primarily on rational appeals that fit into three categories (with themes) focused on medical evidence (poor utility, professional guidelines and recommendations), avoidance of harm (insurance implications, unnecessary or potentially harmful interventions, patient anxiety), and reassurance to patient (normalizing, clinical pretest probability, criteria for reconsidering testing). Appeals to credibility and emotion were rarely used. Conclusions: In an OSCE setting, residents relied predominantly on rational appeals when engaging SPs in conversations about unnecessary tests. These observations yield insights into how recent emphasis within residency education on appropriate test utilization may manifest when residents put recommendations into practice in conversations with patients. This study’s framework of rational appeals may be helpful in designing communication curricula about unnecessary testing. Future studies should explore rhetoric about unnecessary testing in the clinical environment, strategies to teach and coach residents leading these conversations, and patients’ preferences and responses to different appeals. Acknowledgments: The authors would like to acknowledge Lisa St. Amant for research coordination, Nina Chana for logistical support, Michelle Geddes (Hematology Program director, University of Calgary), and Martina Trinkaus (Hematology Program director, University of Toronto) for supporting this project. Funding/Support: Funding for this project was provided by the Hematology Trainee Education Award for Canadian Hematology trainees. L.S. Stroud is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. Other disclosures: None reported. Ethical approval: Research ethics approval was obtained from the Health Sciences Research Ethics Board at the University of Toronto, Protocol Reference #31651. Previous presentations: The data were previously presented at the Canadian Conference on Medical Education on April 30, 2017, in Winnipeg, Manitoba, Canada. Correspondence should be addressed to Eric K. Tseng, Division of Hematology/Oncology, St. Michael’s Hospital Department of Medicine, University of Toronto, 30 Bond Street, Room 2-084 Donnelly Wing, Toronto, ON, Canada M5B 1W8; telephone: 416-864-5128; e-mail: eric.tseng@mail.utoronto.ca; Twitter: @tsengeric. © 2019 by the Association of American Medical Colleges

The Impact of Title VII Dental Workforce Programs on Dentists’ Practice Location: A Difference-in-Differences Analysis Purpose: To examine the potential impact of Health Resources and Services Administration (HRSA) funding (predoctoral [PD] and postdoctoral [PDD] programs) on dentists’ practice location in the United States. Method: The authors linked 2011-2015 data from HRSA’s Electronic Handbooks to 2015 data from the American Dental Association Masterfile, dental health professional shortage areas, and rural-urban commuting area codes. They examined the associations between PD and PDD funding and dentists’ practice location between 2004 and 2015 using a difference-in-differences analysis and multiple logistic regressions, adjusting for covariates. Results: From 2004 to 2015, 21.2% (1,588/7,506) of dentists graduated from institutions receiving PD funding and 26.8% (2,014/7,506) graduated from institutions receiving PDD funding. Among dentists graduating from institutions receiving PDD funding, after adjusting for covariates, those graduating between 2011 and 2015 were more likely to practice in a rural area than those graduating between 2004 and 2010 (odds ratio [OR] = 1.98; 95% confidence interval [CI] = 1.04 - 3.76). Te difference-in-differences approach showed that PD and PDD funding significantly increased the odds that a dentist would practice in a rural area (respectively, OR = 2.70; 95% CI = 1.31 - 5.79 / OR = 2.84; 95% CI = 1.40 - 5.77). Conclusions: HRSA oral health training program funding had a positive effect on dentists choosing to practice in a rural area. By increasing the number of dentists practicing in rural communities, HRSA is improving access to, and the delivery of, oral health care services to underserved and vulnerable rural populations. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A744. Acknowledgments: The authors thank Drs. Arpita Chattopadhyay and George Zangaro for their valuable guidance in helping to conceptualize and frame the initial analyses. They also thank Dr. Renée Joskow, chief dental officer, and Dr. Carolyn Robbins, public health analyst, both of the Health Services and Resources Administration, for their valuable input and careful review of both the analyses and the article. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was exempt from ethical review because the data used were public use data. Disclaimer: At the time this work was completed, all authors were fulltime employees of the Health Resources and Services Administration (HRSA), an operating division of the United States Department of Health and Human Services (HHS). The findings, analyses, and conclusions reported here are those of the authors and should not be construed as the official position or policy of HRSA, HHS, or the U.S. Government. Correspondence should be addressed to Chiu-Fang Chou, National Center for Health Workforce Analysis, Bureau of Health Workforce, Health Resources and Services Administration, 5600 Fishers Lane, 11N-66C, Rockville, MD 20852; telephone: (301) 443-1474; email: cchou@hrsa.gov. Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government. © 2019 by the Association of American Medical Colleges

Independent and Interwoven: A Qualitative Exploration of Residents’ Experiences with Educational Podcasts Purpose: Educational podcasts are an increasingly popular platform for teaching and learning in health professions education. Yet it remains unclear why residents are drawn to podcasts for educational purposes, how they integrate podcasts into their broader learning experiences, and what challenges they face when using podcasts to learn. Method: The authors used a constructivist grounded theory approach to explore residents’ motivations and listening behaviors. They conducted 16 semi-structured interviews with residents from 2 US and 1 Canadian institution from March 2016 to August 2017. Interviews were recorded and transcribed. The transcripts were analyzed using constant comparison and themes were identified iteratively, working toward an explanatory framework that illuminated relationships among themes. Results: Participants described podcasts as easy to use and engaging, enabling both broad exposure to content and targeted learning. They reported often listening to podcasts while doing other activities, being motivated by an ever-present desire to use their time productively; this practice led to challenges retaining and applying the content they learned from the podcasts to their clinical work. Listening to podcasts also fostered participants’ sense of connection to their peers, supervisors, and the larger professional community, yet it created tensions in their local relationships. Conclusions: Despite the challenges of distracted, contextually-constrained listening and difficulties translating their learning into clinical practice, residents found podcasts to be an accessible and engaging learning platform that offered them broad exposure to core content and personalized learning, concurrently fostering their sense of connection to local and national professional communities. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A745. Acknowledgements: The authors wish to thank Rachel Howard for designing Figure 1 and Joshua Jauregui, MD, for his support. Funding/Support: This work was funded by a grant from the University of Washington Center for Leadership & Innovation in Medical Education. Other disclosures: None reported. Ethical approval: This study was reviewed and deemed to be exempt by the University of Washington Human Subjects Division (January 19, 2016; HSD #51120) and the University of California, San Francisco Human Research Protection Program Institutional Review Board (February 7, 2016; IRB# 16-18612). The Hamilton Integrated Research Ethics Board (September 2, 2016; 2016-1430-GRA) approved this study. Correspondence should be addressed to Jeffrey Riddell, Department of Emergency Medicine, Keck School of Medicine of USC, 1200 N. State Street, Room 1011, Los Angeles, CA 90033; telephone: (323) 409-6667; email: jriddell@usc.edu; Twitter: @jeff__riddell. © 2019 by the Association of American Medical Colleges

Establishing Trust When Assessing Learners: Barriers and Opportunities Trust plays a critical role in the assessment of learners in the clinical setting. In an ideal system, learners can be vulnerable and share their limitations and areas for improvement while faculty possess the time and skill to provide specific feedback that enables learners to achieve competency in clinical skills. For medical students, a number of threats to the establishment of trust in the learning environment exist, including the interplay between feedback and grades, the existence of bias, and competing demands for faculty time. However, several strategies can help institutions to overcome these threats and foster a culture of trust related to assessment and assessment systems: provide ungraded environments where learners are able to be vulnerable; co-create assessments and assessment systems with faculty and learners; acknowledge and address bias; and provide faculty with adequate time and resources to employ best practices in assessment. By intentionally employing these strategies, our institutions can support trust in assessment systems and further learner growth and achievement. 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. Acknowledgments: The authors would like to acknowledge and thank the ABIM Foundation for initiating a series of discussions on trust and the role it plays in health professions education and patient care. Funding/Support: None reported. Other disclosures: B.M. Dolan and J. Arnold have no disclosures. M.M. Green is chair of the board of directors for the American Board of Internal Medicine. Ethical approval: Reported as not applicable. Correspondence should be addressed to Marianne M. Green, Feinberg School of Medicine, Northwestern University, 303 E. Chicago Avenue, Ward Building, Chicago, IL 60611-3008; e-mail: m_green@northwestern.edu; Twitter: @mariannegreen63. © 2019 by the Association of American Medical Colleges

Taking Students as They Should Be: Restoring Trust in Undergraduate Medical Education A recently published editorial focused on trust in the relationship between teacher and learner; in this Invited Commentary, the authors examine trust between administrators, course directors, curriculum committees, and medical students, exploring the ways that a lack of trust may be manifest, how this impacts students, and how trust can be built in undergraduate medical education (UME). The hierarchical and paternalistic culture in medical education can skew curricular and policy decisions in the direction of distrust of students, leading to overscheduling and overprograming of students through much of UME and to inflexible policies and procedures. Students may feel unheard or disrespected by some administrators and course directors when asking for changes, particularly when advocating for reductions in workload or increased flexibility. The collective impact of this lack of trust appears substantial, leaving many students with feelings of frustration, resentment, and cynicism. Trust can be built and efforts to do so have little associated cost. Administrators and course directors need to demonstrate respect, compassion, flexibility, and trust in students. Trust is built on relationships, and administrators should avoid isolation and engage meaningfully with students. Efforts should be made to reduce overscheduling of students so that they have more opportunity to pursue activities in which they can find meaning. Flexibility in scheduling of mandatory sessions and exams should be introduced wherever possible. If we take these collective steps, students will be more likely to find a path to becoming the doctors they are capable of becoming. 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. Acknowledgements: The authors thank David Sklar for selecting trust as the topic for this New Conversations series, as it opened our eyes to looking at medical education culture in a way we had not previously. The authors would also like to thank Chantal Young, Natasha Slavin, Noriko Gamblin, and Claire Brady for their input. Importantly, the authors thank Philip Alderson, dean of the medical school, who placed his trust in them. Finally, the authors thank the many students who contributed to the mutual trust that they felt at Saint Louis University. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Stuart Slavin, 401 N. Michigan Ave., Suite 2000, Chicago, IL 60611; email: sslavin@acgme.org. © 2019 by the Association of American Medical Colleges

How Consistent Is Competent? Examining Variance in Psychomotor Skills Assessment Purpose: Direct assessment of trainee performance across time is a core tenant of competency-based medical education. Unlike variability of psychomotor skills across levels of expertise, performance variability exhibited by a particular trainee across time remains unexplored. The goal of this study was to document the consistency of individual surgeons’ technical skill performance. Method: A secondary analysis of assessment data (collected 2010–2012, originally published 2015) generated by a prospective cohort of participants at Montreal Children’s Hospital with differing levels of expertise was conducted in 2017. Trained raters scored blinded recordings of a myringotomy and tube insertion performed 4 times by junior and senior residents and attending surgeons over a 6-month period using a previously reported assessment tool. Descriptive exploratory analyses and univariate comparison of standard deviations (SDs) were conducted to document variability within individuals across time and across training levels. Results: Thirty-six assessments from 9 participants were analyzed. The SD of scores for junior residents was highly variable (5.8 out of a scale of 30 compared to 1.8 for both senior residents and attendings [F(2,19) = 5.68, P < 0.05]). For a given individual, the range of scores was twice as large for junior residents than for senior residents and attendings. Conclusions: Surgical residents may display highly variable performances across time, and individual variability appears to decrease with increasing expertise. Operative skill variability could be underrepresented in direct-observation assessment; emphasis on an adequate amount of repetitive evaluations for junior residents may be needed to support judgments of competence or entrustment. Acknowledgments: The authors wish to acknowledge J. Schwartz, A. Costescu, S. Agrawal, and K. Roth for their contribution to the study “Objective Assessment of Myringotomy and Tympanostomy Tube Insertion: A prospective Single-Blinded Validation Study,”12 which laid the foundations for this study. The authors would also like to acknowledge Jing Xiao from the Centre for Medical Education at McGill University for his help with graphing. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Ethical approval was provided by the Montreal’s Children Hospital Ethics Review Board (IRB Study no. A09-E75-09B) for the initial study as described in Schwartz et al.12 No additional ethical approval was necessary for this secondary analysis. Previous presentations: Labbé M, Mascarella M, Young M, Doyle P, Husein M, Nguyen L. How Consistent is Competent: Examining Variance in Technical Skills Examination. Podium presentation at the Canadian Conference on Medical Education, Halifax, Nova Scotia, Canada; April 30, 2018. Data: Data used in this manuscript were collected at the Montreal Children’s Hospital from 2010 to 2012 by L.H.P.Nguyen (principal investigator of both studies), and initial publication of the entire dataset can be found in Schwartz et al.12 Correspondence should be addressed to Lily H.P. Nguyen, Department of Otolaryngology–Head and Neck Surgery, Montreal Children’s Hospital, McGill University, 1001 boul. Decarie, A02.3015, H4A 3J1, Montreal, Quebec, Canada; telephone (514) 412-4400, ext. 25302; email: phan.nguyen@mcgill.ca. © 2019 by the Association of American Medical Colleges

Health Care in the United States: Individual Right or Government Duty? The authors discuss the notion of health care as a governmental duty rather than a right of individuals. The notion of individual rights was proposed by political philosophers of the 17th and 18th century, who posited that people existed in a state of nature before coming together to form communities. Members of communities relinquish certain freedoms in exchange for services provided by government, including protection of the natural rights of “life, liberty, and the pursuit of happiness.” In this tradition, there are natural rights that exist prior to government and must be protected from government infringement. The U.S. Constitution almost exclusively enshrines negative rights, which protect natural rights from government interference. Rights belong to individuals, whereas the government has duties to provide services, such as basic education, that society deems to be important. The discussion of health care as a positive right, one requiring government to provide citizens with services, runs counter to this tradition of natural rights. The authors propose that reframing the discussion to see universal access to health care as an obligation of government, rather than a right of individuals, will center the discussion more accurately within U.S. political tradition. This may drain the emotional charge associated with claims to “rights” from public debate and allow for productive negotiations over the extent of health care appropriate for government to provide, within the context of the other obligations that form the social contract between the citizenry and its government. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Jessica N. Holtzman, University of California San Francisco, 505 Parnassus Ave, San Francisco, CA 94143; email: jessica.holtzman@ucsf.edu; twitter: @jholtzman3. © 2019 by the Association of American Medical Colleges

Teaching Professionalism in Postgraduate Medical Education: A Systematic Review Purpose: This systematic review sought to summarize published professionalism curricula in postgraduate medical education (PGME) and identify best practices for teaching professionalism. Method: Three databases (MEDLINE, Embase, ERIC) were searched for articles published from 1980 through September 7, 2017. English-language articles were included if they (1) described an educational intervention addressing professionalism; (2) included postgraduate medical trainees; and (3) evaluated professionalism outcomes. Results: Of 3,383 articles identified, 50 were included in the review. The majority evaluated pre- and posttests for a single group (24, 48%). Three (6%) were randomized controlled trials. The most common teaching modality was small-group discussions (28, 56%); other methods included didactics, reflection, and simulations. Half (25, 50%) used multiple modalities. The professionalism topics most commonly addressed were professional values/behavior (42, 84%) and physician well-being (23, 46%). Most studies measured self-reported outcomes (attitude and behavior change) (27, 54%). Eight (16%) evaluated observed behavior and 3 (6%) evaluated patient outcomes. Of 35 studies that evaluated statistical significance, 20 (57%) reported statistically significant positive effects. Interventions targeting improvements in knowledge were most often effective (8/12, 67%). Curriculum duration was not associated with effectiveness. The 45 quantitative studies were of moderate quality (Medical Education Research Study Quality Instrument [MERSQI] mean score = 10.3). Conclusions: Many published curricula addressing professionalism in PGME are effective. Significant heterogeneity in the outcomes assessed and teaching modalities made it difficult to synthesize results to identify best practices. Future work should build upon these curricula to improve the quality and validity of professionalism teaching tools. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A746. Funding/Support: The authors express sincere gratitude to the Savlov/Schmidt Scholars Program in Geriatrics at the Sinai Health System and University Health Network, Toronto, Ontario, Canada, for supporting S.B. and W.A. as summer research students for this project. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: Poster presentation at the 2018 Canadian Conference on Medical Education, Halifax, Nova Scotia, April 29, 2018. Correspondence should be addressed to Arielle S. Berger, Toronto Rehabilitation Institute, 550 University Ave, Suite 5-105-3, Toronto, Ontario, Canada, M5G 2A2; telephone: 416-597-3422, ext. 3027; email: Arielle.Berger@UHN.ca. © 2019 by the Association of American Medical Colleges

Comparison of Male and Female Resident Milestone Assessments During Emergency Medicine Residency Training: A National Study Purpose: A previous study found that milestone ratings at the end of training were higher for male than female residents in emergency medicine (EM). However, that study was restricted to a sample of 8 EM residency programs, and used individual faculty ratings from milestone reporting forms that were designed for use by the program’s Clinical Competency Committee (CCC). The objective of this study was to investigate whether similar results would be found when examining the entire national cohort of EM milestone ratings reported by programs after CCC consensus review. Method: This study examined longitudinal milestone ratings for all EM residents (n = 1,363; 125 programs) reported to the Accreditation Council for Graduate Medical Education every 6 months from 2014–2017. A multilevel linear regression model was used to estimate differences in slope for all subcompetencies, and predicted marginal means between genders were compared at time of graduation. Results: There were small but statistically significant differences between males’ and females’ increase in ratings from initial rating to graduation on 6 of the 22 subcompetencies. Marginal mean comparisons at time of graduation demonstrated gender effects for 4 patient care subcompetencies. For these subcompetencies, males were rated as performing better than females; differences rnaged from 0.048 to 0.074 milestone ratings. Conclusions: In this national dataset of EM resident milestone assessments by CCCs, males and females were rated similarly at the end of their training for the majority of subcompetencies. Statistically significant but small absolute differences were noted in 4 patient care subcompetencies. Acknowledgments: None. Funding/Support: None reported. Ethical approval: This study was deemed exempt by the Institutional Review Board of the American Institutes for Research (AIR EX00382). Other disclosures: Virginia Commonwealth University receives funding for Dr. Santen outside of this work from the American Medical Association Accelerating Change in Medical Education grant for program evaluation. Other authors do not have relevant financial interests. Previous presentations: Portions of this work have been previously presented at the Accreditation Council for Graduate Medical Education Annual Education Conference, Orlando, FL, March 3, 2018; the annual meeting of the Association for Medical Education in Europe, Basel, Switzerland, August 30, 2018; and the Association of American Medical Colleges Medical Education Meeting, Austin, TX, November 2, 2018 Data: The authors had permission from the Accreditation Council for Graduate Medical Education to use the data for research purposes. Correspondence should be addressed to Sally A Santen, Virginia Commonwealth University School of Medicine, P.O. Box 980565, Richmond, VA 232980-565; telephone: (804) 219-9827; email: sally.santen@vcuhealth.org. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. © 2019 by the Association of American Medical Colleges

The Illness of Pierrot Commentary on The Illness of Pierrot No abstract available