Explicit Dialogue About the Purpose of Hospital Admission Is Essential: How Different Perspectives Affect Teamwork, Trust, and Patient Care Purpose: The authors previously found attending physicians conceptualize hospital admission purpose according to three perspectives: one focused dominantly on discharge, one on monitoring and managing chronic conditions, and one on optimizing overall patient health. Given implications of varying perspectives for patient care and team collaboration, this study explored how purpose of admission is negotiated and enacted within clinical teaching teams. Method: Direct observations and field interviews took place in 2 internal medicine teaching units at 2 teaching hospitals in Ontario, Canada, in summer 2017. A constructivist grounded theory approach was used to inform data collection and analysis. Results: The 54 participants included attendings, residents, and medical students. Management decisions were identified across 185 patients. Attendings and senior medical residents (second- and third-year residents) were each observed to enact one dominant perspective, while junior trainees (first-year residents and students) appeared less fixed in their perspectives. Teams were not observed discussing purpose of admission explicitly; however, differing perspectives were present and enacted. These differences became most noticeable when at the extremes (discharge-focused vs optimization-focused) or between senior medical residents and attendings. Attendings implicitly signaled and enforced their perspective, using authority to shut down and re-direct discussion. Trainees’ maneuvers for enacting their perspectives ranged from direct advocacy to covert manipulation (passive avoidance/forgetting and delaying until attending changeover). Conclusions: Failing to negotiate and explicitly label perspectives on purpose of admission may lead to attendings and senior medical residents working at cross-purposes and covert maneuvers by trainees, potentially affecting trust and professional identify development. 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 wish to thank the study participants, all of whom were invaluable to the completion of this study. The authors would also like to thank Jennifer Campi for all of her support in editing the final manuscript. The article is a better read as a result of her efforts. Funding/Support: This study was funded in part by the Ontario Medical Students’ Association (OMSA) Open Medical Student Education Research and in part by Academic Medical Organization of Southwestern Ontario (AMOSO) Innovations Grant Project R3381A06. Other disclosures: The authors have no competing interests to declare. Ethical approval: The study was approved by the University of Western Ontario Health Sciences Research Ethics Board (Project ID 6822). Previous presentations: Canadian Conference on Medical Education; April 29, 2018; Halifax, Nova Scotia, Canada. Correspondence should be addressed to Mark Goldszmidt, Centre for Education Research and Innovation, Schulich School of Medicine & Dentistry, Western University, Health Sciences Addition Room 115, London, Ontario, Canada, N6A 5C1; telephone: 519-858-5007; email: Mark.Goldszmidt@schulich.uwo.ca. © 2019 by the Association of American Medical Colleges

Toward Cultural Competency in Health Care: A Scoping Review of the Diversity and Inclusion Education Literature Purpose: To explore best practices for increasing cultural competency and reducing health disparities, the authors conducted a scoping review of the existing literature. Method: The review was guided by two questions: (1) Are health care professionals and medical students learning about implicit bias, health disparities, advocacy, and the needs of diverse patient populations? (2) What educational strategies are being used to increase student and educator cultural competency? In August 2016 and July 2018, the authors searched 10 databases (including Ovid MEDLINE, Embase, and Scopus) and MedEdPORTAL, respectively, using keywords related to multiple health professions and cultural competency or diversity and inclusion education and training. Publications from 2005 to August 2016 were included. Results were screened using a two-phase process (title and abstract review followed by full-text review) to determine if articles met the inclusion or exclusion criteria. Results: The search identified 89 articles that specifically related to cultural competency or diversity and inclusion education and training within health care. Interventions ranged from single-day workshops to a 10-year curriculum. Eleven educational strategies used to teach cultural competency and about health disparities were identified. Many studies recommended using multiple educational strategies to develop knowledge, awareness, attitudes, and skills. Less than half of the studies reported favorable outcomes. Multiple studies highlighted the difficulty of implementing curricula without trained and knowledgeable faculty. Conclusions: For the field to progress in supporting a culturally diverse patient population, comprehensive training of trainers, longitudinal evaluations of interventions, and the identification and establishment of best practices will be imperative. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A748, http://links.lww.com/ACADMED/A749, and http://links.lww.com/ACADMED/A750. Funding/Support: This study was funded by the Faculty Fellows and Emerging Scholar-Professional Grant Program, Center for Diversity and Inclusion, Washington University in Saint Louis. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: The principal investigators presented the preliminary results of this scoping literature review orally at the iTeach Symposium at Washington University in St. Louis, St. Louis, Missouri, in January 2018. Preliminary results were presented as a poster at the National Academies of Practice Annual Meeting & Forum in Atlanta, Georgia, in April 2018. Correspondence should be addressed to Douglas M. Char, Division of Emergency Medicine, Campus Box #8072, Washington University School of Medicine, 660 S. Euclid Ave., St Louis, MO 63110; telephone: (314) 362-4346; email: chard@wustl.edu. © 2019 by the Association of American Medical Colleges

A Reliability Analysis of Entrustment-Derived Workplace-Based Assessments Purpose: To examine the reliability and attributable facets of variance within an entrustment-derived workplace-based assessment system. Method: Faculty at the University of Cincinnati Medical Center internal medicine residency program assessed residents using discrete workplace-based skills called observable practice activities (OPAs) rated on an entrustment scale. Ratings from July 2012–December 2016 were analyzed using applications of generalizability theory (G-theory) and decision study framework. Given the limitations of G-theory applications with entrustment ratings (the assumption that mean ratings are stable over time), a series of time-specific G-theory analyses and an overall longitudinal G-theory analysis were conducted to detail the reliability of ratings and sources of variance. Results: During the study period, 166,686 OPA entrustment ratings were given by 395 faculty members to 253 different residents. Raters were the largest identified source of variance in both the time-specific and overall longitudinal G-theory analyses (37% and 23%, respectively). Residents were the second largest identified source of variation in the time-specific G-theory analyses (19%). Reliability was approximately 0.40 for a typical month of assessment (27 different OPAs, 2 raters, and 1–2 rotations) and 0.63 for the full sequence of ratings over 36 months. A decision study showed doubling the number of raters and assessments each month could improve the reliability over 36 months to 0.76. Conclusions: Ratings from the full 36 months of the examined program of assessment showed fair reliability. Increasing the number of raters and assessments per month could improve reliability, highlighting the need for multiple observations by multiple faculty raters. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This project was approved by the University of Cincinnati Institutional Review Board. Correspondence should be addressed to Matthew Kelleher, 231 Albert Sabin Way, Room 7559, ML 0535, Cincinnati, OH 45267-0535; email: kellehmw@ucmail.uc.edu; Twitter: @kelzj3. © 2019 by the Association of American Medical Colleges

Tensions in Assessment: The Realities of Entrustment in Internal Medicine Purpose: A key unit of assessment in competency-based medical education (CBME) is the entrustable professional activity. The variations in how entrustment is perceived and enacted across specialties are not well understood. This study aimed to develop a thorough understanding of the process, concept, and language of entrustment as it pertains to internal medicine (IM). Method: Attending supervisors of IM trainees on the clinical teaching unit were purposively sampled. Sixteen semistructured interviews were conducted and analyzed using constructivist grounded theory. The study was conducted at the University of Toronto from January to September 2018. Results: Five major themes were elucidated. First, the concepts of entrustment, trust, and competence are not easily distinguished and sometimes conflated. Second, entrustment decisions are not made by attendings, but rather are often automatic and predetermined by program or trainee level. Third, entrustment is not a discrete, point-in-time assessment due to longitudinality of tasks and supervisor relationships with trainees. Fourth, entrustment scale language does not reflect attendings’ decision making. Fifth, entrustment decisions affect the attending more than the resident. Conclusions: A tension arises between the need for a common language of CBME and the need for authentic representation of supervision within each specialty. With new assessment instruments required to operationalize the tenets of CBME, it becomes critically important to understand the nuanced and specialty-specific language of entrustment to ensure validity of assessments. Acknowledgments: The authors acknowledge Stephen Durant for assistance with interviewing and transcription and the participants for sharing their insights. Funding/Support: This study was funded by the University of Toronto Department of Medicine Challenge Grant. L. 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: This study was approved by the University of Toronto Health Sciences Research Ethics Board. Previous presentations: Peer-reviewed oral abstracts were presented at the International Conference on Residency Education, Halifax, Ontario, Canada, October 2018, and the Canadian Conference on Medical Education, Niagara Falls, Ontario, Canada, April 2019. Correspondence should be addressed to Lindsay Melvin, Toronto Western Hospital, 399 Bathurst St., 8E-425, Toronto, ON M5T 2S8 Canada; email: lindsay.melvin@uhn.ca; Twitter: @LMelvinMD. © 2019 by the Association of American Medical Colleges

Open Office Space: The Wave of the Future for Academic Health Centers? Facing space constraints similar to those experienced by many urban campuses, the University of California, San Francisco (UCSF) looked to innovative office workplace design to curb growing facilities expenditures. Mission Hall, a new office building primarily for desktop and clinical researchers and staff, was designed as an activity-based workplace (ABW), a type of open-space design. ABW was simultaneously being proposed as the template for future UCSF desktop research workspaces. ABWs can be less costly to construct than other designs and their mix of shared and open workspaces is intended to improve efficiency and interaction. Evaluations of ABWs in corporate settings have yielded mixed results. Examples of ABW buildings for faculty in academic health centers (AHCs) are rare. The Mission Hall experience provided a unique opportunity to understand the impact of an ABW design on faculty satisfaction, work effectiveness, well-being, and engagement. In a 2016 survey of faculty, one year after occupancy, respondents reported adverse changes in all four areas. The most common complaints involved noise exposure and lack of visual and auditory privacy. In response to these issues, faculty reported working at home or elsewhere more frequently, making collaboration more difficult. In 2018, UCSF retrofitted the building to create some private offices and adjusted its overall program to balance private office and open workspaces in future projects. Lessons drawn from this experience can inform workplace solutions at other AHCs. Most critical are the needs to assess functional requirements of work and align design, change management, and technologies to support those requirements. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A747. Acknowledgments: The authors are grateful for the data analysis provided by Joo Young Ro, formerly of Perkins + Will, and Dr. Yongha Hwang of University of Michigan and for the administration of the survey by Dr. Lindsay Graham of the Center for the Built Environment at the University of California, Berkeley. Funding/Support: Funding for this research was provided by the University of California Capital Programs Office. Other disclosures: None reported. Ethical approval: The University of California, San Francisco institutional review board approved the study as minimal risk. Correspondence should be addressed to Nancy Adler, 3333 California Street, Suite 465, San Francisco, California 94118; telephone: 415-476-7759; email: Nancy.adler@ucsf.edu. © 2019 by the Association of American Medical Colleges

Understanding Debriefing: A Qualitative Study of Event Reconstruction at an Academic Medical Center Purpose: This qualitative study sought to characterize the role of debriefing after real critical events among anesthesia residents at the Hospital of the University of Pennsylvania. Method: During October 2016-June 2017 and February-April 2018, the authors conducted 25 semistructured interviews with 24 anesthesia residents after they were involved in 25 unique critical events. Interviews focused on the experience of the event and the interactions that occurred thereafter. A codebook was generated through annotation, then used by 3 researchers in an iterative process to code interview transcripts. An explanatory model was developed using an abductive approach. Results: In the aftermath of events, residents underwent a multistage process by which the nature of critical events and the role of residents in them were continuously reconstructed. Debriefing—if it occurred—was one stage in this process, which also included stages of internal dialogue, event documentation, and lessons learned. Negotiated in each stage were residents' culpability, reputation, and the appropriateness of their affective response to events. Conclusions: Debriefing is one of several stages of interaction that occur after a critical event; all stages play a role in shaping how the event is interpreted and remembered. Because of its dynamic role in constituting the nature of events and residents' role in them, debriefing can be a high-stakes interaction for residents, which can contribute to their reluctance to engage in it. The function and quality of debriefing can be assessed in more insightful fashion by understanding its relation to the other stages of event reconstruction. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A751. Acknowledgments: The authors thank the residents who took time from their busy schedules to so generously relate their experiences. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was reviewed by the University of Pennsylvania institutional review board and approved on October 4, 2016 (protocol 825918). Correspondence should be addressed to Justin T. Clapp, Silverstein Building, Floor 5, Office 035, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St., Philadelphia, PA 19104; telephone: (914) 356-5435; email: Justin.Clapp@pennmedicine.upenn.edu. © 2019 by the Association of American Medical Colleges

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