To the Editor: International students in U.S. medical schools face unique challenges. After enrolling in medical school, international students must strategically prepare for matching into residency programs that sponsor visas while engaging with meaningful extracurricular opportunities within the restrictions set forth by their student visas. As citizens of Nicaragua and Canada, respectively, who have encountered difficulties when finding answers to questions specific to our international status in undergraduate and postgraduate medical training, we suggest medical schools facilitate peer mentorship initiatives intended for international medical students. An important reason for this difficulty is the low number of enrolled international medical students in the United States. For example, of the 2020–2021 matriculating students to allopathic medical schools in the United States, only 131 out of 22,329 matriculants had a legal residence abroad. 1 In turn, medical schools may be relatively limited in providing nuanced, experience-based career guidance and support to their international students. Navigating the limited and different visa options for postgraduate training—in addition to identifying residency programs that even consider international applicants—can be challenging. This compounds the many challenges medical students face in general, including the uncertainty of matching to a residency program and the impact of the COVID-19 pandemic on each application cycle, setting up international medical students for a more complex journey in medical education than their U.S. peers. Given the few international U.S. medical graduates, and the limitations in career counseling for this population, there is a need for well-informed mentorship and guidance. Peer mentorship initiatives that connect international medical students with each other remain largely underused by medical schools. Although medical schools often offer peer mentorship programs in which more senior students provide academic advice and support to newer students, this approach is insufficient for international students who require guidance in the context of their specific situation. Instead, medical schools should proactively connect international medical students to each other across class years and, just as importantly, to their international alumni. Individuals who have navigated the many barriers present for international medical students in the United States are more likely to provide focused, experience-based support. Facilitating these relationships early in medical school may result in other benefits, including involvement with scholarship and research activities. Ultimately, international medical students in the United States have left their home countries and families to serve the U.S. people. Medical schools that admit international students should place value in using every possible tool to propel them to a successful career in medicine. Acknowledgments: The authors would like to thank the deans of the Warren Alpert Medical School of Brown University for supporting their medical training in the United States.

Aspects of medical education and clinical practice continue to reflect the antiquated notion that race is a biologically valid distinction among individuals rather than a social construct. The authors analyzed the use of race and ethnicity in a popular pediatrics textbook to determine if these concepts were being used consistently and correctly. In May 2021, using the search function on the American Academy of Pediatrics (AAP) eBooks platform, the authors searched for 29 race- or ethnicity-related terms (e.g., African, Asian, Black, race) in the AAP Textbook of Pediatric Care, 2nd Edition , which was published in 2016. One researcher extracted direct quotes containing at least one of these search terms. Three researchers independently coded each quote as problematic or nonproblematic with respect to the use of the search terms, excluding examples in which the terms were used in irrelevant contexts (e.g., black box warning). The researchers then identified themes based on the quotes that used race and ethnicity problematically. The search produced 2,167 total results across the search terms, 806 of which were relevant to race or ethnicity and were analyzed. Problematic quotes: (1) used race or ethnicity as a surrogate for social variables, (2) conflated terminology (e.g., conflated socially defined race with genetic ancestry), (3) overgeneralized or made claims based on limited data, (4) lacked clinical relevance, (5) lacked inclusivity, (6) promoted racial stereotypes, or (7) made contradicting claims about race. The use of race and ethnicity in the AAP Textbook of Pediatric Care, 2nd Edition was not always appropriate, as demonstrated by examples that reified race as a biological fact and thereby promoted structural racism. Critical evaluation of the use of race and ethnicity in all current medical textbooks and future revisions is warranted.

To the Editor: Xierali and colleagues 1 observed that family medicine has the lowest rate of promotion among clinical faculty from assistant to associate professor. This confirms previous findings that clinically-focused faculty have lower rates of promotion. 2 As family medicine faculty at a large public university, we constantly see colleagues struggling to create the body of academic work expected by the parent institution while maintaining clinical productivity. Xierali and colleagues 1 propose mentoring and promotion assistance as a remedy. We agree that these steps have merit, but it is also important to reexamine the criteria by which schools promote predominantly clinical faculty. Promotion criteria for clinical faculty should better reflect their roles and value clinical excellence and special contributions. New faculty with significant prior clinical experience should start at the rank of associate professor regardless of prior research and publications. Teaching at the bedside and in the clinic should be carefully measured, rewarding both high-quantity and high-quality clinical teaching. Aligning promotion criteria with job duties can also promote physician retention. When academic salaries are tied to rank, difficulty achieving promotion can hold faculty members at lower salaries, despite years of service—time that private practices reward with higher salaries. If we are to recruit and retain the best minds in clinical medicine, we need to be sensitive to this trend. Better alignment would also have positive economic implications for the academic center since losing a single faculty member can cost as much as $300,000 when lost revenue is included. 3 Academic medical centers depend on the contributions of clinical faculty, yet much of the vital work done by these faculty does not align with the academic model of promotion. Medical schools should take innovative steps to reward and retain the clinician–educator who prioritizes clinical work in advancing the patient care component of the triumvirate mission. They deserve to be recognized for the tremendous value they bring through excellence in patient care and bedside teaching.

To the Editor: In medical education literature, recommendations on teaching skills include a set of behaviors that concern mannerisms, speech patterns, and interactions with students. Using humor, being enthusiastic, and encouraging student participation are examples of such behaviors. Though widely recognized as desirable teacher qualities, they are referred to by various terms in medical education literature. In the field of instructional communication, they are called “teacher immediacy” behaviors, defined as the teacher’s verbal and nonverbal behaviors that decrease the perceived psychological distance between teacher and students. 1 We propose that medical teachers and medical education researchers adopt the established term “teacher immediacy” as a crisp narrative/phrase for these behaviors. Detailed descriptions and measuring tools of teacher immediacy behaviors are found in the literature. In the works of Andersen 2 and Gorham, 3 examples of verbal teacher immediacy behaviors include addressing individual students by name, asking students questions, giving feedback and praise, encouraging students to talk, and basing discussion on something a student brings up. Examples of nonverbal immediacy behaviors include smiling, gesturing, vocal expressiveness, movement about the classroom, and looking at the class while talking. Decades of empirical studies have established that teacher immediacy behaviors are positively associated with student motivation, participation, learning outcomes, and satisfaction with the instructor, instruction, and course content. 4–8 A recent systematic review 7 of studies examining the association of teacher immediacy with learner motivation found that the studies were conducted in courses of various fields, mostly science, engineering, communication, business, and general education. Thus, teacher immediacy is an important contributor to effective teaching. Adopting the established term “teacher immediacy” in medical education will give the field a common language to talk about the same set of teacher characteristics, so the phenomenon will be more likely propagated and studied for its impact. Teachers can learn and use immediacy behaviors to increase their instructional effectiveness, and researchers can investigate the construct of teacher immediacy to understand its roles in various learning contexts.

1Chief resident in pediatrics, Boston Combined Residency Program, Boston Children’s Hospital and Boston Medical Center, Boston, Massachusetts; email: [email protected]; Twitter: @Z_Winthrop; ORCID: https://orcid.org/0000-0001-8494-7266. 2Fellow, Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, Massachusetts; ORCID: https://orcid.org/0000-0002-7852-8329. Acknowledgments: The authors wish to acknowledge their mentor and coauthor, Dr. Ariel Winn, for her guidance and support of their work. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.

1Medical student, New York University Grossman School of Medicine, New York, New York; email: [email protected]; ORCID: https://orcid.org/0000-0001-5470-4810. Acknowledgements: The author thanks Michael LoCurcio, Pooja Gala, and Carolyn Drake for their guidance. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: Reported as not applicable.

“But I only received the placebo,” commented a research participant sitting next to me during our trial update and appreciation event. During an evening when the positive results of the active intervention arms were being celebrated and research participants were ecstatically sharing their trial experiences, his disappointment caught me off guard, giving me pause. When it was my turn to take the stage and present the trial update to the group, I took a detour and first asked for a show of hands to demonstrate which arm they believed was most important in the study—the active intervention arm(s) or the placebo arm. The vast majority raised their hands for the active interventions. And that is when I shared the enlightenment inspired by our brief interaction—that those in the placebo arm represent, for patients around the world, the very best care that we have in the present, while those in the active intervention arm are testing our hopes and the unknown. It is only with both, equally, that we can map our collective path forward toward a better future. My introduction to clinical trials began with the most generous mentors, who openly shared their world and provided the freedom to explore with the hope of seeing a spark ignite. I found myself gravitating toward the collaborative spirit embraced in clinical trials. I did not realize that when patients accepted the invitation to become research participants, we would learn as much from them—their individual stories, past struggles, and future hopes—as from their data. It has been transforming to experience the dedication of our research participants, to realize that it is our mutual commitment to each other that enables us to learn the full truth of what we set out to answer. Once we, both investigators and participants, commit to the journey of a clinical trial, there is a certain element of being all in, of committing to learning the answers together, whatever they may be—whether we uncover exciting advances in therapy or come across an unanticipated safety issue that we need to investigate. While research participants represent future patients, as an investigator, I have come to appreciate that I too represent physicians who face the decisional dilemma studied in each trial. Ironically, while our research teams worked ardently to retain our participants, subtly, our participants have reciprocally retained our research teams on this broader journey in clinical research. Acting as an investigator on clinical trials also taught me that careers in clinical research are not a straight path. Each study lands us at a different vantage point from the one where we began, feeding our continual curiosity and learning. Each new therapy and trial has contributed one more piece to an ever-expanding puzzle. Each advance we have collectively been a part of brings greater hope that the best is still yet to come and is within the grasp of our lifetimes, moving us forward with a renewed sense of optimism and confidence. Having served as an investigator on over 100 trials now, I can say this: It changes you. It has changed who I am as a person and how I approach so many other people in my life, including patients, colleagues, trainees, and yes, even my own children. Whereas before I placed a greater emphasis on knowing and demonstrating knowledge of the “best” paths and the “right” answers, I find that now my approach in life is largely inspired by the shared investigator–participant journey, one recognizing the value of nonjudgmental equipoise and unconditional partnership imbued with passion and commitment. To the participant who caught me off guard that evening—thank you. This one, brief moment opened me up to the greatest sense of appreciation; regardless of the treatment arm, role, or results, it is the journey we embark on together, side by side with our participants, teams, and peers, that will contribute to our greater collective knowledge, advances in care, and a better future. And that, is pure joy. Acknowledgments: The author wishes to extend deep personal gratitude to her lifelong clinical research mentors, Robert R. Henry, MD, and Robert E. Ratner, MD; adviser, Jason G. Umans, MD, PhD; John B. Buse, MD, PhD, for encouragement in sharing this personal narrative; and to all the research participants who selflessly share of themselves to better our collective future.

Learner-centered feedback models encourage educators to ask learners to self-assess at the start of feedback conversations. This study examines how learners perceive and respond to self-assessment prompts during feedback conversations and assesses medical students' perceptions of and approach to self-assessment used as the basis for these conversations. All rising second-, third-, and fourth-year medical students at a midwestern U.S. medical school were invited to participate in this study. Students participated in 1-on-1 interviews between June and August 2019 during which they were asked open-ended questions about their experiences with self-assessment and feedback during medical school. The interviews were audio recorded and transcribed, and comments related to self-assessment in feedback conversations were extracted. Thematic analysis was used to identify recurrent ideas and patterns within the transcripts, and all excerpts were reviewed and coded to ensure that the identified themes adequately captured the range of student responses. A total of 25 students participated in the study. Although some students noted improvement in their self-assessment abilities with increasing experience, no consistent gender, race, or training-level differences were found in reported attitudes or preferences. Students identified many benefits of self-assessment and generally appreciated being asked to self-assess before receiving feedback. Students had varied responses to specific self-assessment prompts, with no clear preferences for any particular self-assessment questions. Students described weighing multiple factors, such as image concerns and worries about impact on subsequent evaluations, when deciding how to respond to self-assessment prompts. The process by which learners formulate and share self-assessments in feedback conversations is not straightforward. Although educators should continue to elicit self-assessments in feedback discussions, they should recognize the limitations of these self-assessments and strive to create a safe environment in which learners feel empowered to share their true impressions.

Post-standardized patient (SP) encounter patient notes used to assess students' clinical reasoning represent a significant time burden for faculty who traditionally score them. To reduce this burden, the authors previously reported a complex faculty-developed scoring method to assess patient notes rated by nonclinicians. The current study explored whether a simplified scoring procedure for nonclinician raters could further optimize patient note assessments by reducing time, cost, and creating additional opportunities for formative feedback. Ten nonclinician raters scored patient notes of 141 students across 5 SP cases by identifying case-specific patient note checklist items. The authors identified the bottom quintile of students using the proportion of correct items identified in the note (percent-scores) and case-specific faculty-generated scoring formulas (formula-scores). Five faculty raters scored a subset of notes from low, borderline, and high-performing students (n = 30 students) using a global rating scale. The authors performed analyses to gather validity evidence for percent-scores (i.e., relationship to other variables), investigate its reliability (i.e., generalizability study), and evaluate its costs (i.e., faculty time). Nonclinician percent- and formula-scores were highly correlated ( r = .88) and identified similar lists of low-performing students. Both methods demonstrated good agreement for pass-fail determinations with each other (Kappa = .68) and with faculty global ratings (Kappa percent =.61; Kappa formula =.66). The G-coefficient of percent-scores was .52, with 38% of variability attributed to checklist items nested in cases. Using percent-scores saved an estimated $746 per SP case (including 6 hours of faculty time) in development costs over formula-scores. Nonclinician percent-scores reliably identified low-performing students without the need for complex faculty-developed scoring formulas. Combining nonclinician analytic and faculty holistic ratings can reduce the time and cost of patient note scoring and afford faculty more time to coach at-risk students and provide targeted assessment input for high-stakes summative exams.