Purpose: We developed a pilot elective to enhance the critical care training experience for medical students through integration of didactic, simulation, and experiential learning with the goal to increase student confidence in caring for patients with critical illness and advance knowledge and competencies within core critical care topics. Approach: We created and piloted a 4-week critical care elective for fourth-year medical students pairing clinical experience with didactic and simulation-based training. Students completed two 2-week intensive care unit (ICU) rotations in both medical and surgical ICUs. Students received 6 half-days of didactics focusing on: respiratory failure, ventilator management, shock, acid/base, and discussions at the end of life. Didactic sessions were coupled with simulation-based training to reinforce content through application and provide opportunity to build procedural skills. Medical knowledge was assessed via multiple-choice questions delivered before and after course completion. Course grades were determined through clinical evaluations by faculty/residents, written examination, and simulation assessment. Pre- and postknowledge assessment performance was compared between students enrolled in the pilot and traditional curricula. The traditional curriculum involved clinical experience without formal didactics or simulation opportunities, and course grades were determined by evaluations only. Outcomes: No students received passing scores of 70% on the precourse medical assessment in either curriculum group. The mean score on the postcourse knowledge assessment for the novel-curriculum students (N = 13) was 21.8/30 (72.8%), compared with the 17/30 (56%) for the students in the traditional curriculum (N = 6). No students in the traditional curriculum received a passing score on the postcourse assessment. Before the course, few students felt “comfortable” or “very comfortable” managing common ICU conditions (acute respiratory distress syndrome, 0%; undifferentiated shock, acute hypercarbic respiratory failure, and identifying need for mechanical ventilation, 33%; acute hypoxemic respiratory failure and cardiogenic shock, 50%; septic and hypovolemic shock, 83%). At completion, there was an improvement in the reported level of comfort; 100% of students reported feeling “comfortable” or “very comfortable” with all topics, save for cardiogenic shock at 83%. Comfortability levels remained high on subsequent evaluation 12 months post-course (6 months into trainee’s intern year). Discussion: A limitation of traditional critical care curricula is that it lacks structure designed to ensure exposure to core critical care topics. It relies on the randomness of patient’s disease states present during a given rotation. Incorporating scheduled didactics ensures consistent exposure to these topics regardless of the patient cases on service. A limitation of this study is the small sample size of both the novel-curriculum group and the percentage of traditional curriculum students undergoing written assessment. Despite the small sample size (N = 13), this pilot demonstrates feasibility of consistent delivery of core content via didactics and simulation coupled with experiential learning. Our results may suggest benefit in this multimodal approach compared with experiential learning alone; however, further research is needed. Traditional assessment relies solely on clinical impression which is biased and often fails to capture an actionable level of detail. Lack of objective measures of assessment impedes identification of areas for improvement at the trainee level as well as within a curriculum. The use of multiple methods of assessment allows for mitigation of bias and overcomes some of the limitations of a single method alone. 1 Simulation assessment allows for greater practical assessment of procedural competency than written assessment. Significance: With this novel pilot curriculum incorporating multiple educational strategies, students improved their confidence and knowledge in core critical care topics. By harnessing didactic and simulation training to complement the clinical experience, consistent delivery of core content is assured. Furthermore, evaluation is strengthened through use of knowledge assessment questions and simulation-based assessment as compared with traditional evaluations which are largely subjective. More research is needed to understand the impact when scaled to a larger group.

Purpose: Patients with disabilities comprise 12% to 20% of the U.S. population and suffer from lack of access to adequate and equitable health care. 1 These disparities are aggravated by the fact that health care providers receive little training to prepare them to care for this population and lack knowledge of common forms of disability, such as cerebral palsy and learning disabilities. 2,3 The purpose of this study was to evaluate whether integrating disability-focused educational content into existing preclinical curricula resulted in improved medical student knowledge and comfort in providing care for patients with disabilities. Approach: A total of 6 novel curricular components were added for first- and second-year medical students, weaved throughout existing longitudinal and organ-system-based courses to highlight developmental, cognitive, and physical disabilities. We modified existing clinical reasoning and problem-based learning cases to promote small group discussion on clinical decision making for patients with disabilities. Topics covered in these cases included appendicitis in a patient with Trisomy 21, birth complications following pregnancy, caring for patients with Alzheimer’s dementia, and small bowel obstruction in a patient with cerebral palsy. Relevant clinical and physical exam skills content were added to our school’s clinical skills course materials, including specific history-taking questions and videos demonstrating physical exam maneuvers in patients with restricted mobility. Two patient panels facilitated by faculty, focusing on Trisomy 21 and neurologic disabilities, were added within organ system courses, in addition to a student-led documentary screening and accessibility workshop. Each class year experienced a total of 6 new curricular sessions. Outcomes: Forty-six percent of first-year and 38% of second-year medical students who experienced novel curricular components completed both pre- and postsurveys. 4 At the end of the academic year, there was a statistically significant increase in comfort working with people with disabilities in a clinical setting reported among first-year medical students (P < .05). Among the 6 interventions, both class years reported that any patient panels, the documentary screening, and accessibility workshop had the greatest impact in increasing their knowledge of health challenges faced by patients with disabilities and their readiness in caring for this population in the future. Students commented that the Trisomy 21 patient panel helped them understand the lived experience of these patients and their families, and specifically appreciated “learning from the way faculty interacted with them” and how it encouraged them to “think about their own biases.” Compared with a 14% satisfaction in disability educational content before curricular implementation, 67% of first-year and 56% of second-year medical students reported satisfaction with the new curriculum (P < .001). Significance: Specific educational content on caring for patients with disabilities was successfully integrated into several preclinical longitudinal and organ system courses in a manner that promoted active student discussion and reflection. Most students were satisfied with the curricular changes. Limitations include variability in exposure to the curriculum as some program components were optional, lack of a comparison group, and other simultaneous curricular changes that may have influenced student perceptions. Based on constructive student feedback, future improvements to the curriculum will involve simulation sessions to practice applying concepts and skills as well as more reflection opportunities to share experiences caring for patients with disabilities during clinical rotations. Integrating disability-related training into existing preclinical curricula is a feasible and effective method to supplement medical student knowledge, skills, and comfort in caring for patients with disabilities. Specific educational materials and sessions are easily transferable to other medical schools and do not require subject matter expertise. Medical students benefit from early exposure and training in caring for diverse patient populations.

Purpose: Medical school includes an abrupt transition in learning environments as students move from the classroom to the hospital. Learning “on the wards” is a constantly changing, unfamiliar environment with less structure and more hierarchy within the teams. This can lead to students feeling uncomfortable or being unaware of mistreatment reporting protocols or appropriateness of speaking up. The Association of American Medical Colleges annual questionnaire reported that 40% of students nationally report experiencing mistreatment at least once during medical school. 1 Multiple medical schools have implemented interventions to decrease the rate and impact of student mistreatment. This includes a safe reporting mechanism with prompt response, videos to help faculty identify and understand the impact of mistreatment, and curriculum focused on intervening when mistreatment is identified. 1,2 Approach: Vanderbilt University School of Medicine established the Learning Environment Assessment and Feedback (LEAF) Committee to better coordinate efforts and build a mechanism for collaboration and accountability. 3 It is based on the principle that improving the clinical learning environments for educators and learners can be driven by generating a shared vision and a framework for tracking progress. The LEAF Committee is designed to be interprofessional and interorganizational, with medical students serving as an integral part. They help to define and track indicators, set priorities, communicate findings, and recommend action steps. They have also initiated and led multiple interventions to address mistreatment. 4 The LEAF Committee includes deans, educators, administrative staff, students, and residents from the School of Medicine as well as representatives from the School of Nursing and the Medical Center. Each year the committee reviews selected performance metrics from multiple data streams and generates an Interprofessional Clinical Learning Environment Report Card. 5 The report highlights key recommendations and action steps. The top priority has been to reduce the mistreatment of medical students including experiences of public humiliation and bias. Three priority student-led initiatives have been recently implemented based on identified learning environment needs—RISE (Reporting Issues in Striving for Excellence) reporting system for medical students (2018), antihumiliation workshops (2019), and bystander intervention (2020). Outcomes: Student knowledge of school procedures to report mistreatment increased by almost 15 percentage points from 2019 to 2021, compared with a 3 percentage point increase nationally. The percentage of respondents experiencing any negative behaviors decreased by 9% locally and did not decrease nationally in the same time period. The percentage of respondents experiencing public embarrassment decreased by 3 percentage points locally and only 1 percentage point nationally. In both mistreatment indicators, Vanderbilt student responses moved from above the national average in negative experiences to below the national average between 2019 and 2021. This data reporting period was influenced by active collaboration across student and faculty leaders to address mistreatment reporting systems, public humiliation, and bystander intervention skill development. Discussion: Student-led initiatives to improve clinical learning environments can be very effective. Providing an institutional support structure such as the LEAF Committee allows students to carry projects across cohorts, learn from data, share knowledge and interpretations, and participate in the types of coordination necessary for change. The 3 interventions implemented by medical students contributed to improvements in knowledge about reporting processes and the rate of medical student reported mistreatment including public humiliation. Significance: Medical students can play a significant role in improving clinical learning environments. While many medical schools support student curriculum committees or medical education research/quality improvement efforts, we show the importance of having a committee solely dedicated to the learning environment. This committee should include educators and learners of all levels. The LEAF Committee provides a dedicated space for deans, faculty/staff, residents, and students to work toward a common goal of improving the experience of learners in the clinical realm.

Purpose: Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but TIC education for clinicians has not been well examined. To remedy this, the authors conducted a multidisciplinary, scoping literature review to discern best practices for design, implementation, and evaluation of TIC curricula for health care professionals. Method: The research team searched Ovid Medline, Cochrane Library, Elsevier’s Scopus, Elsevier’s Embase, Web of Science, and the Published International Literature on Traumatic Stress database. Two independent reviewers screened 1,824 abstracts and excluded 1,697. After assessing 127 full-text articles, they excluded 76 based on predefined exclusion criteria; subsequently, they identified 4 additional articles through hand searching. Results: Fifty-five studies met inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma, responding to disclosures, defining trauma, and understanding trauma’s impact on health. Forty-seven of the studies included curricular evaluations, most commonly pre- and postsurveys. A minority used only postsurveys or a retrospective pre–post survey. The most common survey items included confidence in TIC skills, training content knowledge, participant demographics, and attitudes regarding the importance of TIC. Discussion: Future curricula should include applying a foundational lens of cultural humility, understanding the impacts of marginalization and oppression on individual and collective experiences of trauma, interprofessional collaboration, and incorporating survivors’ voices in education. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care providers. Significance: Although medical school curricula are increasingly including TIC education, best practices in TIC curricula have not been developed. This scoping review lays the groundwork for evidence-based strategies for the design, implementation, and evaluation of TIC curricula in the health professions.

1Fourth-year medical student, Virginia Commonwealth University School of Medicine, Richmond, Virginia; email: [email protected]; Twitter: @mattvalexander; ORCID: https://orcid.org/0000-0002-8157-3745. 2Third-year medical student, University of Michigan Medical School, Ann Arbor, Michigan; ORCID: https://orcid.org/0000-0002-6677-221X. 3Third-year medical student, University of Michigan Medical School, Ann Arbor, Michigan. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable. First published online.

Purpose: Primary care (PC) career choice has been declining among U.S. medical graduates and residents since the 1990s. 1,2 By 2034, an estimated shortage of 17,800–48,000 PC physicians is expected. 2 Some medical schools have developed programs to increase students’ interest in PC specialties and practice in underserved areas. 3,4 To our knowledge, the durability of early PC-specialty preference for long-term PC practice has not been reported. Method: The Association of American Medical Colleges provided linked, deidentified data for a national cohort of 48,533 U.S. MD-granting medical school matriculants from 1998–1999 through 2000–2001. Data from the Student Records System (sex, race/ethnicity, and graduation year), Matriculating Student Questionnaire (MSQ; specialty board certification plans and attitudinal variables: importance of prestige and social responsibility in choosing a medical career), Graduation Questionnaire (GQ; total debt, plans to practice in underserved areas, and student ratings [excellent vs not excellent] of PC and non-PC clerkship experiences), and American Medical Association (AMA) Physician Masterfile practice data through May 2020 were used. The outcome was office-based practice in a specialty from the AMA Physician Masterfile, categorized as follows: (1) general-PC (i.e., internal medicine, pediatrics, family practice, general practice, internal medicine/pediatrics, or internal medicine/family practice as primary specialty, with another general-PC or unspecified secondary specialty), (2) PC-subspecialty (i.e., general-PC primary and PC-subspecialty secondary specialty, or PC-subspecialty as primary specialty), and (3) non-PC specialties (i.e., non-PC primary specialty). Multivariable logistic regression models identified variables independently associated with general-PC vs each of PC-subspecialty and non-PC-specialty practice. Results: Of 46,698 graduates in 2002–2013, 30,435 (65.2%) had complete data for analysis (7,700 [25.3%] general-PC physicians, 5,327 [17.5%] PC subspecialists, and 17,408 [57.2%] non-PC specialists). Female (vs male) students, and students with plans to practice in underserved areas (vs no plans) were more likely to report general-PC (vs PC-subspecialty) practice. Underrepresented racial/ethnic minorities in medicine (URiM), Asian/Pacific Islander (Asian/PI) students (each vs White), and students planning to pursue non-PC specialties or no board certification (each vs PC board certification plans) on the MSQ were each less likely to report general-PC (vs PC-subspecialty) practice. In the second model, female students and students reporting plans to practice in underserved areas (vs no plans), endorsing higher importance of social responsibility, or rating only PC clerkships excellent (vs rating both PC and non-PC clerkships excellent) were each more likely to report general-PC (vs non-PC-specialty) practice. URiM, Asian/PI students, students planning to pursue non-PC or no board certification, and students endorsing higher importance of prestige were each less likely to report general-PC (vs non-PC-specialty) practice. Discussion: Several factors were associated with future PC practice. The greater likelihood of women and lower likelihood of URiM graduating students to choose PC specialties on the GQ has been reported. 1 We extend this work, finding lower likelihood of URiM and A/PI physicians to be in general-PC practice. Importantly, early preference for PC specialties was positively associated with general-PC practice in both models. This may reassure medical schools considering early specialty preferences for admissions or entry into early, PC-pathway programs. Although clerkship experiences might influence students to change specialty interests, 5 to our knowledge, associations between clerkship experiences and PC practice have not been examined. We observed that students reporting excellent PC-clerkship experiences were more likely to report general-PC (vs non-PC) practice. Greater importance of social responsibility in choosing medicine also was positively associated with general-PC (vs non-PC) practice. Significance: Medical school experiences that are amenable to intervention were associated with greater odds of general-PC practice. Admitting students with early interest in PC specialties or who highly value social responsibility, fostering students’ plans to practice in underserved areas, 3,4 and improving PC-clerkship experiences may help mitigate the PC-physician shortage. Acknowledgments: The authors thank Hershel Alexander, PhD, Marie Caulfield, PhD (retired), David Matthew, PhD, and Lindsay Roskovensky, at the Association of American Medical Colleges (AAMC), for their efforts to obtain and prepare the deidentified datasets from various sources and their assistance with data coding; the National Board of Medical Examiners (NBME) Office for Research Strategy for permission to use Step 1 licensing examination data; Kristy Vanderplow at MMS, Inc., for provision of the American Medical Association (AMA) Physician Masterfile data; and Maria Pérez, MA, at Washington University School of Medicine, for data management and preparation of the data for analysis.

1Fourth-year medical student, Sidney Kimmel Medical College, Philadelphia, Pennsylvania; email: [email protected]. Funding/Support: None reported. Other disclosure: None reported. Ethical approval: Reported as not applicable.

Coaching programs have been implemented in medical education to improve skill development and feedback for trainees. As more faculty take on coaching roles, it is critical to understand how being a coach affects faculty as well as trainees. This study examined the effects of coaching residents on faculty members' relationships, learning, and professional identity formation (PIF), as they move through intersecting communities across landscapes of practice. From July 2020 to January 2021, the authors conducted a mixed-methods study of current and former coaches at 2 institutions with longitudinal pediatric resident coaching programs. They used a concurrent triangulation design in which qualitative and quantitative data were collected simultaneously and integrated during data analysis. A survey explored the impact of coaching on faculty members' learning, relationships, and PIF, and semistructured interviews further examined coaches' experiences. The interview transcripts were analyzed inductively guided by the sensitizing principles of PIF and landscapes of practice. Of 43 eligible coaches, 32 (74%) completed the survey, and 18 completed interviews. Four themes emerged from the interviews. (1) Coaches' relationships supported belonging in multiple communities. (2) Coaching enabled multidimensional learning. (3) Relationships served as mechanisms of learning for coaches. (4) Coaches' relationships and learning catalyzed PIF. Furthermore, there was a significant difference in the effects of coaching on career growth by faculty rank ( P = .02). Coaches' strengthened PIF increased a sense of purpose, meaning, and professional fulfillment, and inspired new career directions. Survey data further supported these findings. Being a coach deepened faculty members' professional identities through their varied relationships, multidimensional learning, and sense of belonging in intersecting communities. This study introduces a framework to understand the factors mediating coaches' PIF and highlights how investing in coaching leads to important benefits for coaches.

1Fourth-year medical student, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire; email: [email protected]; ORCID: https://orcid.org/0000-0002-9876-2657. Acknowledgements: The author thanks Julia Frew, MD, for her input on borderline personality disorder stigma and guidance in writing this letter. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.

Medical educators recognize that partnering actively with health system leaders closes significant health care experience, quality, and outcomes gaps. Medical schools have explored innovations training physicians to care for both individual patients and populations while improving systems of care. Yet, early medical student education fails to include systems improvement as foundational skills. When health systems science is taught, it is often separated from core clinical skills. The Clinical Microsystems Clerkship at the University of California, San Francisco School of Medicine, launched in 2016, integrates clinical skills training with health systems improvement from the start of medical school. Guided by communities of practice and workplace learning principles, it embeds first-year and second-year students in longitudinal clinical microsystems with physician coaches and interprofessional clinicians one day per week. Students learn medical history, physical examination, patient communication, interprofessional teamwork, and health systems improvement. Assessments include standardized patient examinations and improvement project reports. Program outcome measures include student satisfaction and attitudes, clinical skills performance, and evidence of systems improvement learning, including dissemination and scholarship. Students reported high satisfaction (first-year, 4.10; second-year, 4.29, on a scale of 1-5) and value (4.14) in their development as physicians. Clinical skills assessment accuracy was high (70%-96%). Guided by interprofessional clinicians across 15 departments, students completed 258 improvement projects in 3 health systems (academic, safety net, Veterans Affairs). Sample projects reduced disparities in hypertension, improved opiate safety, and decreased readmissions. Graduating students reported both clinical skills and health systems knowledge as important to physician success, patient experience, and clinical outcomes (4.73). Most graduates discussed their projects in residency applications (85%) and disseminated related papers and presentations (54%). Integrating systems improvement, interprofessional teamwork, and clinical skills training can redefine early medical student education. Health system perspectives, long-term outcomes, and sustainability merit further exploration.