How Culture is Understood in Faculty Development in the Health Professions: A Scoping Review Purpose: To examine the ways in which culture is conceptualized in faculty development (FD) in the health professions. Method: The authors searched PubMed, Web of Science, ERIC, and CINAHL, as well as the reference lists of identified publications, for articles on culture and FD published between 2006 and 2018. Based on inclusion criteria developed iteratively, they screened all articles. A total of 955 articles were identified, 100 were included in the full text screen, and 70 met the inclusion criteria. Descriptive and thematic analyses of data extracted from the included articles were conducted. Results: The articles emanated from 20 countries; primarily focused on teaching and learning, cultural competence, and career development; and frequently included multidisciplinary groups of health professionals. Only 1 article evaluated the cultural relevance of a FD program. The thematic analysis yielded 3 main themes: culture was frequently mentioned but not explicated; culture centered on issues of diversity, aiming to promote institutional change; and cultural consideration was not routinely described in international FD. Conclusions: Culture was frequently mentioned but rarely defined in the FD literature. In programs focused on cultural competence and career development, addressing culture was understood as a way of accounting for racial and socioeconomic disparities. In international FD programs, accommodations for cultural differences were infrequently described, despite authors acknowledging the importance of national norms, values, beliefs, and practices. In a time of increasing international collaboration, an awareness of, and sensitivity to, cultural contexts is needed. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A760. Acknowledgements: The authors gratefully acknowledge Ms. Naz Torabi and Ms. Andrea Quaiattini for their help with the comprehensive searches across multiple databases, Dr. Aliki Thomas for her advice regarding scoping review methodology, and Ms. Nicole Gignac for her able assistance in compiling all the data. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: Preliminary findings were presented at the 14th Asia Pacific Medical Education Conference in Singapore in January 2017. Correspondence should be addressed to Yvonne Steinert, Institute of Health Sciences Education, Faculty of Medicine, McGill University, 1110 Pine Avenue West, Montreal, Quebec, Canada H3A 1A3; email: yvonne.steinert@mcgill.ca; Twitter: @IHSE_McGill. © 2019 by the Association of American Medical Colleges

Stemming the Tide of Elder Mistreatment: A Medical School–State Agency Collaborative In 1995, the Texas Department of Family and Protective Services: Adult Protective Service Agency began a partnership with the Baylor College of Medicine geriatrics program to form the Texas Elder Abuse and Mistreatment (TEAM) Institute. The medical school–state agency partners overcame institutional and bureaucratic barriers to work collaboratively on mutually beneficial projects, including research and publications. Interprofessional students gained first-hand experience about abuse and neglect cases. As of 2019, there are 4 divisions: Clinical and Forensic Evaluation, Education and Outreach, Research and Program Evaluation, and Senior Justice. TEAM members have published numerous articles and chapters, educated members from multiple disciplines, and served thousands of mistreated older patients. In 2017, TEAM launched the first statewide telecommunication program for elder mistreatment to improve practice for the entire state. Perseverance, teamwork and dedication to the mission of the intervention and prevention of elder mistreatment has sustained this program for over 30 years. This article describes the steps to forming TEAM, the institute’s early struggles, and the subsequent community and academic contributions of this medical school–state agency collaboration. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A761. Acknowledgments: The authors wish to thank Shelby Boyer for assistance with manuscript preparation. Funding/Support: None reported. Other disclosures: J. Burnett and C.B. Dyer are funded in part by the John A. Hartford Foundation for the National Collaboratory to Address Elder Mistreatment project. Ethical approval: Reported as not applicable. Previous presentations: Some of the information presented in this article was presented at the 1st Annual International Conference on Elder Abuse, April 6, 2002, Newport Beach, CA; at the National Institute of Justice Annual Conference on Criminal Justice Research and Evaluation, July 19, 2005, Washington, DC; at the International Conference on Family Violence, September 20, 2005, San Diego, CA; at the Annual Adult Protective Services Conference, November 2, 2006, San Antonio, TX; at the National Association of Protective Service Administrators Annual Meeting, September 7, 2006, San Francisco, CA; at the American Geriatrics Society Annual Scientific Meeting, May 3 and May 5, 2007, Seattle, WA; at the 2nd Annual International Conference on Elder Abuse, February 12, 2008, Newport Beach, CA; at the American Medical Association National Advisory Council on Violence and Abuse, October 17, 2008, Chicago, IL; at the Stanford University Series Webinar, October 11, 2012; at the 29th Annual Adult Protective Services Conference, November 14, 2012, San Antonio, TX; and at the American College of Physicians Internal Medicine Meeting, April 19, 2018, New Orleans, LA. Data: Not applicable. Correspondence should be addressed to Carmel B. Dyer, Consortium on Aging, UTHealth Houston, 7000 Fannin Street, UCT 850, Houston, Texas, 77030; telephone: (713) 500-3921; email: carmel.b.dyer@uth.tmc.edu; shelby.boyer@uth.tmc.edu. © 2019 by the Association of American Medical Colleges

The Importance of Lobbying to Advance Health and Science Policy Government funding and policies are critical to academic medicine. Public funds sustain the education, research, and patient care missions of medical schools and teaching hospitals, and regulations govern the fulfillment of those missions. Consequently, both individuals and institutions often need to engage with those who develop these policies, including through lobbying. Lobbying fulfills a constitutionally protected right to petition the government for a redress of grievances, despite perceptions that it is instead only back-room dealing and insider influence. As an important part of the system of government in the United States, lobbying is subject to complex regulations, and failure to comply can result in substantial penalties, particularly for tax-exempt entities, of which almost all medical schools and teaching hospitals are. In this Invited Commentary, the author briefly summarizes these regulations to complement the article in this issue by Lynch and colleagues. He then argues that while regulatory compliance is essential, it is not the same as lobbying effectively. For individual academic researchers to do that involves a number of considerations, including whether to coordinate their efforts with those of their institution to leverage the expertise and resources of the institution, to maximize their chances for success with policymakers. Editor’s Note: This is an Invited Commentary on Fernandez Lynch H, Bateman-House A, Rivera SM. Academic advocacy: Opportunities to influence health and science policy under U.S. lobbying law. Acad Med. 2019;XX:XXX-XXX. Acknowledgments: The author wishes to thank his colleagues Heather Alarcon, JD, Karen Fisher, JD, and Atul Grover, MD, PhD, for their review of early drafts of this Invited Commentary. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Peters D. Willson, Association of American Medical Colleges, 655 K Street, NW, Suite 100, Washington, DC 20001; telephone: (202) 862-6029; email: pwillson@aamc.org. © 2019 by the Association of American Medical Colleges

Academic Advocacy: Opportunities to Influence Health and Science Policy Under U.S. Lobbying Law Medical school faculty and their colleagues in schools of nursing, public health, social work, and elsewhere often research issues of critical importance to health and science policy. When academics engage with government policymakers to advocate for change based on their research, however, they may find themselves engaged in “lobbying,” thereby entering a complex environment of legal requirements and institutional policies that they may not fully understand. To promote academic advocacy, this article explains what is and is not legally permitted when it comes to engaging with policymakers and encourages academic institutions to facilitate permissible advocacy activities. U.S. law permits academic researchers to conduct certain types of policy-focused advocacy without running afoul of legal restrictions on lobbying. Academics acting in their personal capacities and with their own resources may freely engage with policymakers in any branch of government to provide their expertise and advocate for desired outcomes. When acting in their professional capacities, academics are free to engage in most advocacy activities directed to the executive and judicial branches, and they also may advocate to influence legislation and legislators within certain limits that are particularly relevant to academic work. In all cases, academics must take care to not use restricted funds for lobbying. Academic researchers have an important role to play in advancing evidence-based health and science policy. They should familiarize themselves with legal restrictions and opportunities to influence policy based on their research, and their institutions should actively support them in doing so. Editor’s Note: An Invited Commentary by P.D. Willson appears on pages XXX–XXX. Acknowledgments: The authors wish to thank Eric Gorovitz, Joshua Greenberg, Bill Andresen, Steven Joffe, Kayte Spector-Bagdady, and Heather Pierce for helpful comments and discussions on these topics. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Holly Fernandez Lynch, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104; email: lynchhf@pennmedicine.upenn.edu; Twitter: @HollyLynchez. © 2019 by the Association of American Medical Colleges

Understanding Creative Commons No abstract available

Patient Satisfaction With Medical Student Participation in a Longitudinal Integrated Clerkship: A Controlled Trial Purpose: To determine whether longitudinal student involvement improves patient satisfaction with care. Method: The authors conducted a satisfaction survey of patients followed by 10 students enrolled in 2016-2017 in the Veterans Affairs Longitudinal Undergraduate Medical Education (VALUE) program, a longitudinal integrated clerkship (LIC) at the Minneapolis Veterans Health Care System. Students were embedded in an ambulatory practice with primary preceptors who assigned students a panel of 14 to 32 patients to follow longitudinally in inpatient and outpatient settings. Control patients, matched on disease severity, were chosen from the preceptor’s panel. Two to five months after the students completed the VALUE program, the authors conducted a phone survey of the VALUE and control patients using a validated, customized questionnaire. Results: Results are reported from 97 VALUE patients (63% response rate) and 72 controls (47% response rate) who had similar baseline characteristics. Compared to control patients, VALUE patients reported greater satisfaction with explanations provided by their health care provider, their provider’s knowledge of their personal history, and their provider’s looking out for their best interests (P < 0.05). Patients in the VALUE panel selected the top category more often than control patients for overall satisfaction with their health care (65% vs 43%, P < 0.05). Conclusions: The results of this controlled trial demonstrate that VALUE student longitudinal participation in patient care improves patient satisfaction and patient-perceived quality of health care for VALUE patients compared to controls matched by primary care provider and disease severity. These findings may have implications outside the Veterans Administration population. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A759. Acknowledgements: The authors wish to thank Dr. Mark Rosenberg, Dr. Areef Ishani, and Dr. Anne Pereira for critically reviewing this report. The authors also would like to thank Dr. Julia Langer for conducting focus groups, interns from University of Minnesota School of Public Health for conducting interviews, and Dr. Tom Rector for assisting with survey design. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: The Minneapolis VA Health Care System Institutional Review Board reviewed the study design and deemed it program evaluation and thus exempt from full review. Disclaimer: The views in the report are those of the authors and do not necessarily represent the views of the Veterans Administration or the United States government. Correspondences should be addressed to Nacide G. Ercan-Fang, One Veterans Drive, Minneapolis, MN 55417; telephone: (612) 725-2085; email: ercan001@umn.edu; alternate email: Nacide.Ercan-Fang@va.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

A Signal Through the Noise: Do Professionalism Concerns Impact the Decision-Making of Competence Committees? Purpose: To characterize how professionalism concerns influence individual reviewers’ decisions about resident progression using simulated competence committee (CC) reviews. Method: In April 2017, the authors conducted a survey of 25 Royal College of Physicians and Surgeons of Canada emergency medicine residency program directors and senior faculty who were likely to function as members of a CC (or equivalent) at their institution. Participants took a survey with 12 resident portfolios, each containing hypothetical formative and summative assessments. Six portfolios represented residents progressing as expected (PAE) and 6 represented residents not progressing as expected (NPAE). A professionalism variable (PV) was developed for each portfolio. Two counterbalanced surveys were developed in which 6 portfolios contained a PV and 6 portfolios did not (for each PV condition, 3 portfolios represented residents PAE and 3 represented residents NPAE). Participants were asked to make progression decisions based on each portfolio. Results: Without PVs, the consistency of participants giving scores of 1 or 2 (i.e., little or no need for educational intervention) to residents PAE and to those NPAE was 92% and 10%, respectively. When a PV was added, the consistency decreased by 34% for residents PAE and increased by 4% for those NPAE (P = .01). Conclusions: When reviewing a simulated resident portfolio, individual reviewer scores for residents PAE were responsive to the addition of professionalism concerns. Considering this, educators using a CC should have a system to report, collect, and document professionalism issues. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A752. Funding/Support: This study was funded (grant number: 2016-SP-22) by the Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada. Other disclosures: None reported. Ethical approval: This study (protocol number: 20170202) was approved on June 8, 2017, by the Ottawa Health Science Network Research Ethics Board. Correspondence should be addressed to Scott Odorizzi, Department of Emergency Medicine, University of Ottawa, 1053 Carling Ave., E-Main, Room EM-206, Box 227, Ottawa, Ontario, K1Y 4E9, Canada; telephone: 1-613-798-5555, ext. 19255; email: SOdorizzi@toh.ca. © 2019 by the Association of American Medical Colleges

Clinical Reasoning as a Core Competency Diagnostic error is a challenging problem; addressing it effectively will require innovation across multiple domains of health care, including medical education. Diagnostic errors often relate to problems with clinical reasoning, which involves the cognitive and relational steps up to and including establishing a diagnostic and therapeutic plan with a patient. However, despite a call from the National Academies of Sciences for medical educators to improve the teaching and assessment of clinical reasoning, the creation of explicit, theory-informed clinical reasoning curricula, faculty development resources, and assessment tools has proceeded slowly in both undergraduate and graduate medical education. To accelerate the development of this critical element of health professions education, and to promote needed research and innovation in clinical reasoning education, the Accreditation Council for Graduate Medical Education (ACGME) should revise its core competencies to include clinical reasoning. The core competencies have proven to be an effective means of expanding educational innovation across the United States and ensuring buy-in across a diverse array of institutions and disciplines. Reformulating the ACGME core competencies to include clinical reasoning would spark much-needed educational innovation and scholarship in graduate medical education, as well as collaboration across institutions in this vital aspect of physicianship, and ultimately, could contribute to a reduction of patient suffering by better preparing trainees to build individual, team-based, and system-based tools to monitor for and avoid diagnostic error. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The views expressed are those of the authors and not necessarily those of the Department of Defense, Veterans Affairs, or other federal agencies. Correspondence should be addressed to Denise M. Connor, San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA 94121; telephone: (415) 221-4810, ext. 26427; email: denise.connor@ucsf.edu; Twitter: @Denise_M_Connor. 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

Is Academic Medicine Ready for Term Limits? The use of term limits in politics and business has been proposed as a means to refresh leadership, encourage innovation, and decrease gender and racial disparities in positions of power. Many U.S. states and the executive boards of businesses have incorporated them into their constitutions and bylaws; however, studies in politics and business have shown that implementing term limits has mixed results. Specifically, research in politics has shown that terms limits have had a minimal effect on the number of women and minorities elected to office, while research in business indicates term limits do increase innovation. Additionally, term limits may have unintended negative consequences, including inhibiting individuals from developing deep expertise in a specific area of interest and destabilizing institutions that endure frequent turnover in leaders. Given this conflicting information, it is not surprising that AMCs in the United States have not widely incorporated term limits for those holding positions of power, including deans, presidents, provosts and department heads. Notably, a few academic medical centers (AMCs) have incorporated such limits for some positions, and faculty have viewed these positively for their ability to shape a more egalitarian and collaborative culture. Drawing on studies from academic medicine, politics, and business, the author examines arguments both for and against instituting term limits at AMCs. The author concludes that despite strong arguments against term limits, they deserve attention in academic medicine, especially given their potential to help address gender and racial disparities and to encourage innovation. Acknowledgments: The author wishes to thank Dr. Alex Foster and Dr. Michelle Noelck for their helpful suggestions and edits. Funding: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Correspondence should be addressed to Jared P. Austin, Mail code: CDRC, 707 SW Gaines St., Portland, Oregon 97239; telephone: (503) 494-6300; email: austinja@ohsu.edu. © 2019 by the Association of American Medical Colleges

Teaching Motivational Interviewing to Medical Students: A Systematic Review Purpose: Medical students must be prepared to work with patients with maladaptive health behaviors and chronic health conditions. Motivational interviewing (MI) is an evidence-based, patient-centered, directive communication style designed to help patients address behaviors that are detrimental to their health (e.g., substance abuse, poor diet). In this study, the authors systematically reviewed the evidence pertaining to MI curricula in medical schools. Their aims were to describe the pedagogical and content-related features of MI curricular interventions and to assess the effectiveness of the interventions and the quality of the research evidence. Method: In March 2019, the authors searched databases, seeking studies on MI in medical schools. They manually extracted descriptive information, used the Medical Education Research Study Quality Instrument (MERSQI) to assess the quality of the included studies, and synthesized the included studies’ results. Results: Sixteen studies met inclusion criteria. The majority of included studies were pre-post evaluation designs; the most rigorous were randomized controlled trials. MI curricula were heterogeneous, varying in timing, content, pedagogical approaches, and outcomes measured. Conclusions: The results of this review suggest that the implementation of MI curricula in medical schools can be feasible and effective, and that students can achieve beginning levels of proficiency. The results support the inclusion of MI in undergraduate medical education curricula and highlight next steps to advance this area of medical education research: achieving consensus around essential early MI skills that should be taught in medical schools and identifying the most effective scaffolding strategies to teach this complex mode of communication. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A754. Acknowledgments: The authors wish to thank C. Scott Dorris for his guidance in conducting the literature search and Drs. Carrie Chen and Ming-Jong Ho for their very helpful critiques of an earlier version of this report. Funding/support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Data: All data for this review were obtained from published manuscripts. Correspondence should be addressed to Dr. Stacey Kaltman, Department of Psychiatry, Georgetown University School of Medicine, 2115 Wisconsin Avenue, NW, Suite 120, Washington, DC 20007; telephone: (202) 687-6571; email: sk279@georgetown.edu. © 2019 by the Association of American Medical Colleges