A Study of the Validity of the New MCAT Exam Purpose: To conduct a study of the validity of the new Medical College Admission Test (MCAT). Method: De-identified data for first- and second-year medical students (185 women, 54.3%; 156 men, 45.7%) who matriculated in 2016 and 2017 to the University of Minnesota Medical School – Twin Cities were included. Of those students, 220 (64.5%) had taken the new MCAT exam and 182 (53.4%) had taken the old MCAT exam (61 [17.9%] had taken both). The authors calculated descriptive statistics and Pearson product moment correlations (r) between new and old MCAT section scores. They conducted a regression analysis of MCAT section scores with Step 1 scores and with preclerkship course performance. They also conducted an exploratory factor analysis (principal component analysis with varimax rotation) of MCAT scores, undergraduate grade point average, Step 1 scores, and course performance. Results: The new MCAT exam section mean score percentiles ranged from 72 to 78 (mean composite score percentile of 80). The old MCAT exam section mean score percentiles ranged from 84 to 88 (mean composite score percentile of 83). The pattern of correlations among and between new and old MCAT exam section scores (range of r: 0.03 to 0.67, P < .01) provided evidence of both divergent and convergent validity. Backwards multiple regression of new MCAT exam section scores and Step 1 scores resulted in a multiple R of .440; the same analysis with Human Behavior course performance as the dependent variable provided a similar solution with the expected sections of the new MCAT exam (multiple R = .502). The factor analysis resulted in 4 cohesive, theoretically meaningful factors: biomedical knowledge, basic science concepts, cognitive reasoning, and general achievement. Conclusions: This study provided empirical evidence of multiple types of validity for the new MCAT exam. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This research received ethical approval from the institutional review board at the University of Minnesota Medical School – Twin Cities. Correspondence should be addressed to Claudio Violato, University of Minnesota Medical School – Twin Cities, MMC #293, 420 Delaware St. SE, Minneapolis, MN 55455; telephone: (612) 625-6382; email: cviolato@umn.edu. © 2019 by the Association of American Medical Colleges

Teaching Health Advocacy: A Systematic Review of Educational Interventions for Postgraduate Medical Trainees Purpose: A systematic review was undertaken to characterize the training approaches that are currently being implemented in postgraduate medical education to teach residents advocacy skills. Method: An initial search was conducted in MEDLINE, PubMed, Embase, ERIC, and PsycINFO in November 2016 (updated in December 2017) for articles discussing postgraduate medical education interventions covering advocacy. Articles published between 1995 and 2017 were included. Two authors independently reviewed titles and abstracts (and, if needed, the full text) for inclusion; disagreements were resolved by consensus. Data were extracted from studies to characterize the content and pedagogy of the interventions by mapping them to the CanMEDS health advocate core competencies and key concepts. Results: A total of 3,027 unique abstracts were retrieved; 2,864 were excluded upon title and abstract review, and another 85 were excluded upon full-text review. Seventy-eight total articles were included. More studies involved residents from pediatrics, psychiatry, primary care or preventative medicine, or internal medicine than from emergency medicine, surgery, obstetrics and gynecology, or neurology. Published interventions varied widely by pedagogical approach and assessment method. Conclusions: Using the CanMEDS framework, this review maps the breadth and nature of postgraduate medical education interventions in health advocacy, with applicability to community organizations, program directors, educators, and administrators working to develop advocacy training interventions. Areas of focus included adapting practice to respond to the needs of or advocacy in partnership with patients, communities, or populations served; determinants of health; health promotion; mobilizing resources as needed; and social accountability. Acknowledgments: The authors wish to thank Ms. Melanie Anderson, information specialist, Library and Information Services, University Health Network, for her helpful advice and assistance constructing the database search strategies used in this review. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. Data sharing: Additional (raw) data is available upon request from the corresponding author. Correspondence should be addressed to Lisa Richardson, Toronto General Hospital, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada; telephone: (416) 340-4800, ext. 8164; email: lisa.richardson@uhn.ca. © 2019 by the Association of American Medical Colleges

Five Principles for Using Educational Theory: Strategies for Advancing Health Professions Education Research Health professions education (HPE) research often involves examining complex phenomena. Theory provides a means for better understanding the mechanics of these phenomena and guiding health professions researchers and educators as they navigate the practical implications for teaching, learning, and research. Engaging with educational theory is, therefore, critical to facilitating this understanding. However, this engagement presents a key challenge for HPE researchers and educators without a background in social science. This article outlines 5 key principles of engaging with theory and offers integration strategies to assist HPE researchers and educators who wish to apply theory to their HPE scholarship and practice. The article concludes with a practical example of how these principles were applied to an HPE research project, demonstrating the value of theory in enhancing research quality. Existing theories can facilitate opportunities for individual researchers to better understand complex phenomena while simultaneously moving forward the field of HPE. Funding/Support: None. Other disclosures: None reported. Ethical approval: Not applicable. Disclaimers: The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense. Correspondence should be addressed to Anita Samuel, Uniformed Services University, Department of Medicine, Graduate Programs in Health Professions Education, 4301 Jones Bridge Road, Bethesda, MD 20814; telephone: 414-678-8847; email: anita.samuel.ctr@usuhs.edu. 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

Accreditation of Canadian Undergraduate Medical Education Programs: A Study of Measures of Effectiveness Purpose: Undergraduate medical education (UME) programs participate in accreditation with the belief that it contributes to improving UME quality and ultimately patient care. Linkages between accreditation and UME quality are incomplete. Previous studies focused on student performance on national examinations, medical school processes, medical school’s organizational culture types, and degree of implementation of quality improvement (QI) activities as markers of the effectiveness of accreditation. The current study sought to identify new indicators of accreditation effectiveness, in order to better understand the value and impact of accreditation. Method: This qualitative study used an expert-oriented evaluation approach to identify novel markers of accreditation effectiveness. From March 2015 to March 2016, leaders and teachers at 16 of the 17 Canadian UME programs were invited to participate in interviews and focus group discussions aimed at identifying measures of accreditation effectiveness. Themes were extracted using the method of constant comparative analysis. Results: Sixty-three individuals from 13 (81%) medical schools participated. Eight themes were formulated: Student/graduate performance, UME program processes, quality assurance and continuous quality improvement, stakeholder satisfaction, stakeholder expectations, engagement, research, and UME program quality. The latter 5 themes have not been previously studied as measures of accreditation effectiveness. All themes appear applicable to accreditation of graduate medical education as well. A framework is proposed to guide future research on the impact of accreditation. Conclusions: Eight themes were generated, representing direct and indirect indicators of the impact of accreditation. The themes are integrated into a framework proposed to guide future research on the value of accreditation along the continuum of medical education. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A771. Funding/Support: None reported. Ethical approval: • Queen’s University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board – Delegated Review (February 11, 205, #EMED-200-15 • University of Illinois at Chicago, Office for the Protection of Research Subjects (Exemption granted, March 19, 2015, #2015-0291) • Dalhousie University, Research Ethics (no additional approval required, May 27, 2015) • Memorial University of Newfoundland, Interdisciplinary Committee on Ethics in Human Research (May 28, 2015, #20160258-EX) • University of Saskatchewan, Behavioural Research Ethics (August 13, 2015, BEH #15-229) • University of Calgary, Conjoint Health Research Ethics Board (September 10, 2015, REB15-1761) • University of Alberta, Research Ethics Board (August 5, 2015, Pro00057997) • University of Manitoba, Research Ethics Boards (no additional approval required, May 28, 2015) • University of British Columbia, Behavioural Research Ethics Board (June 2, 2015, H15-01421) • Lakehead University, Research Ethics Board (August 12, 2015, #045 15-16/Romeo File No 1464642) • University of Toronto, Research Ethics Board (July 16, 2015, #31845) • Western University, Office of Research Ethics Western (no additional Ethics approval required, June1, 2015) • Université de Montréal, Comité plurifacultaire d’éthique de la recherche (August 19, 2015, CEPR-15-086-D) • Université de Sherbrooke, Comité d’éthique de la recherché en santé chez l’humain (no additional approval required, July 9, 2015, CER 2016-1140) Other disclosures: None. Previous presentations: Partial results were presented at the World Federation for Medical Education conference on accreditation, April 7–10, 2019, in Seoul, Republic of Korea. Correspondence should be addressed to Danielle Blouin, Kingston General Hospital, 76 Stuart St., Kingston, Ontario, Canada, K7L 2V7; telephone: (613) 549-6666 ext. 3977; email: blouind@queensu.ca; Twitter: @QueensUHealth. © 2019 by the Association of American Medical Colleges

A Framework for Inclusive Graduate Medical Education Recruitment Strategies: Meeting the ACGME Standard for a Diverse and Inclusive Workforce To help address health care disparities and promote higher quality, culturally sensitive care in the United States, the Accreditation Council for Graduate Medical Education and other governing bodies propose cultivating a more diverse physician workforce. In addition, improved training and patient outcomes have been demonstrated for diverse care teams. However, prioritizing graduate medical education (GME) diversity and inclusion efforts can be challenging and unidimensional diversity initiatives typically result in failure. Little literature exists regarding actionable steps to promote diversity in GME. Building on existing literature and the authors’ experiences at different institutions, the authors propose a 5-point inclusive recruitment framework for diversifying GME training programs. This article details each of the 5 steps of the framework, which begins with strong institutional support by setting diversity as a priority. Forming a cycle, the other four steps are seeking out candidates, implementing inclusive recruitment practices, investing in trainee success, and building the pipeline. Practical strategies for each step and recommendations for measurable outcomes for continued support for this work are provided. The proposed framework may better equip colleagues and leaders in academic medicine to prioritize and effectively promote diversity and inclusion in GME at their respective institutions. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable Correspondence should be addressed to Alda Maria R. Gonzaga, 200 Lothrop Street, Suite 933W MUH, Pittsburgh, PA 15217; email: gonzagaa@upmc.edu. © 2019 by the Association of American Medical Colleges

How Do Attending Physicians Prepare Residents to Deliver High-Value, Cost-Conscious Care? Purpose: An estimated 20% of health care expenditures are wasteful. Educational interventions aimed at reducing waste by delivering high-value, cost-conscious care (HV3C) often focus on the role of the physician. This study sought to understand how attending physicians, who have a central role in the workplace, prepare residents to provide HV3C. Method: Researchers from Maastricht University in Maastricht, the Netherlands, conducted semistructured interviews between September 2016 and August 2017 with 12 attending physicians who supervise residents in the workplace. Participants were purposefully sampled from 5 institutions throughout the Netherlands to include surgical and nonsurgical attending physicians and hospital- and nonhospital-based physicians. Data collection and analysis were iterative, using principles of grounded theory. Results: The attending physician’s approach to providing HV3C was an important factor in preparing residents in the workplace. Three differences became apparent: priority of HV3C training, feedback on HV3C, and obstacles to HV3C delivery. Results indicate that attending physicians use 3 teaching methods to teach HV3C delivery: Socratic questioning, role modeling, and setting limits. Training was often implicit and ad hoc. Conclusions: How attending physicians deal with HV3C themselves influences how they prepare residents in the workplace. To optimize resident training, it may be important to create a supportive environment for HV3C delivery and training. Delivery could be supported by making HV3C a shared goal for attending physicians and residents, thereby providing insight into clinical practice behavior and minimizing the influence of obstacles. Training could be optimized by supporting a variety of teaching methods suitable for daily teaching to stimulate continuous learning in residents. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A766. Acknowledgments: The authors thank the 6 program directors and 12 attending physicians for their time and input in this study. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was approved by the ethical review board associated with the Netherlands Association for Medical Education on June 18, 2015, under file number 547. Correspondence should be addressed to Lorette Stammen, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands; telephone: +31 43 388 5741; email: l.stammen@maastrichtuniversity.nl. 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

We Must Graduate Physicians, Not Doctors Today, medical schools graduate doctors, not physicians. Thousands of doctors who are U.S. citizens and graduates of U.S. and international medical schools will never become physicians because they do not obtain a residency position. Doctors need at least one year of residency to become a licensed physician. However, 4,099 applicants in 2018 and 4,170 in 2019 failed to get a position through the National Resident Matching Program Main Match; about 1,000 students get positions after the Main Match each year. The personal and societal cost is enormous: each year, approximately 3,000 non-physician doctors cannot use 12,000 education years and three-quarters of a billion dollars they invested in medical education, and cannot mitigate the shortfall of 112,000 physicians expected in 2030. To ameliorate this problem, medical schools could guarantee one year of residency. This is affordable: despite federally funded slots being capped, residency positions have increased for 17 consecutive years (20,602 in 2002 to 32,194 in 2019) because residents are cost-effective additions to the workforce. Alternatively, a 3-year curriculum plus required fourth-year primary care residency is another option. The salary during the residency year could equal other first-year residents’, or there could be a token amount for this “internship.” Both models decrease the cost of medical education; the second financially unburdens the hospital. Since the Flexner Report (when there was no formal postgraduate training), the endpoint of medical education has moved from readiness for independent medical practice (physician) to readiness for postgraduate training (doctor). To benefit individuals and society, medical education must take steps to ensure that all graduates are physicians, not just doctors. Funding/Support: None reported. Other disclosures: M. Dewan receives royalties from American Psychiatric Publishing, Inc. Ethical approval: Reported as not applicable. Data: The authors have reported 2018 and 2019 National Resident Matching Program (NRMP) Match data with permission from NRMP. Correspondence should be addressed to Mantosh J. Dewan, Office of the President, Upstate Medical University, 750 E. Adams Street, Syracuse, NY 13210; telephone: 315-464-4513; email: dewanm@upstate.edu. © 2019 by the Association of American Medical Colleges

The Effective Use of Videos in Medical Education No abstract available

Developing Health Care Organizations That Pursue Learning and Exploration of Diagnostic Excellence: An Action Plan Reducing errors in diagnosis is the next big challenge for patient safety. Diagnostic safety improvement efforts should become a priority for health care organizations, payers, and accrediting bodies; however, external incentives, policies, and practical guidance to develop these efforts are largely absent. In this Perspective, the authors highlight ways in which health care organizations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organization at Geisinger, the authors propose a 5-point action plan and corresponding policy levers to support development of LEDE organizations. These recommendations, which are applicable to many health care organizations, include (1) implementing a virtual hub to coordinate organizational activities for improving diagnosis, such as identifying risks among competing priorities, prioritizing interventions that cross intra-institutional silos, and promoting a culture of learning and safety; (2) participating in novel scientific initiatives to generate and translate evidence, given the rapidly evolving “basic science” of diagnostic excellence; (3) avoiding the “tyranny of metrics” by focusing on measurement for improvement rather than using measures to reward or punish; (4) engaging clinicians in activities for improving diagnosis and framing missed opportunities positively as learning opportunities rather than negatively as errors; and (5) developing an accountable culture of engaging and learning from patients, who are often underexplored sources of information. The authors also outline specific policy actions to support organizations in implementing these recommendations. They suggest this action plan can stimulate scientific, practice, and policy progress needed for achieving diagnostic excellence and reducing preventable patient harm. Acknowledgments: The authors would like to thank the members of Geisinger’s Committee to Improve Clinical Diagnosis for their support, their work in learning from diagnostic opportunities, and making diagnosis an organizational priority. Funding/Support: H. Singh’s research that informs this work was funded by the Veterans Affairs (VA) Health Services Research and Development Service (HSR&D) (CRE-12-033 and the Presidential Early Career Award for Scientists and Engineers USA 14-274), the Agency for Healthcare Research and Quality (R01HS27363, R01HS022087 and R18HS017820), the VA National Center for Patient Safety, the Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413), and the Gordon and Betty Moore Foundation. Diagnosis improvement activities at Geisinger are partially supported by the Safer Dx Learning Lab, funded by the Gordon and Betty Moore Foundation. These funding sources had no role in preparation, review, or approval of the manuscript. Other disclosures: None reported. Ethical approval: Reported as not applicable. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Department of Veterans Affairs or the United States government. Correspondence should be addressed to Hardeep Singh, Michael E. DeBakey Veterans Affairs Medical Center, Center for Innovations in Quality, Effectiveness and Safety (152), 2002 Holcombe Boulevard 152, Houston, TX 77030; telephone: 713-794-8515; email: hardeeps@bcm.edu. 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

Honoring Medicine’s Social Contract: A Scoping Review of Critical Consciousness in Medical Education Purpose: To explore how the construct of critical consciousness has been conceptualized within the medical education literature and identify the main elements of critical consciousness in medical education so as to inform educational strategies to foster socially conscious physicians. Method: In March 2019, the authors conducted a literature search of four databases and Google Scholar, seeking articles discussing critical consciousness in medical education published any time after 1970. Three of the authors screened articles for eligibility. Two transcribed data using a data extraction form and identified preliminary emerging themes, which were then discussed by the whole research team to ensure agreement. Results: Of the initial 317 articles identified, 20 met study inclusion criteria. The publication of academic articles around critical consciousness in medical education has expanded substantially since 2017. Critical consciousness has been conceptualized in the medical education literature through four overlapping themes: (1) social awareness, (2) cultural awareness, (3) political awareness, and (4) awareness of educational dynamics. Conclusions: Critical consciousness has been conceptualized in medical education as an intellectual construct to foster a reflexive awareness of professional power in health care, to unearth the values and biases legitimizing medicine as currently practiced, and to foster transformation and social accountability. Scholars highlighted its potential to improve socio-cultural responsibility and to foster compassion in doctors. Adopting a critical pedagogy approach in medical education can help uphold its social accountability through an intrinsic orientation to action, but any enterprise working towards embedding critical pedagogy within curricula must acknowledge and challenge the current structure and culture of medical education itself. Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A770. Acknowledgments: The authors wish to thank Professor Tim Dornan for the invaluable advice and discussions, Mr. Richard Fallis for his help in performing the literature search, and Dr. Ayelet Kuper for her help in revising the report. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable Previous presentations: The results of this scoping review were presented at the Irish Network of Medical Educators (INMED) 2019 Annual Scientific Meeting in February 2019. Correspondence should be addressed to Annalisa Manca, Centre for Medical Education, Queen’s University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, BT9 7BL; telephone +44 (0)289 0972 462; email: amanca01@qub.ac.uk; Twitter: @annalisamanca. © 2019 by the Association of American Medical Colleges