Implementing a clinical-educator curriculum to enhance internal medicine residents’ teaching and professional presence

Background Physicians-in-training (residents) are typically the primary educators for medical students (MS) during clinical clerkships. However, residents are not formally trained to teach or to assess their teaching. The aim of this study was to assess the implementation of a clinical educator rotation aimed at developing residents’ competencies related to clinical teaching and professional growth. Methods A mixed-methods approach was used to develop and assess the clinical educator rotation at a teaching community hospital. Internal medicine residents who participated in the rotation and consented to the research were assigned to the clinical educator trainee group (CET), the remaining residents were assigned to the control group. Osteopathic MS rotating in the medicine service line were invited to participate. Five key assessment tools were developed and used to measure four constructs: Communication, Professional-Based Learning, Professional Engagement and System-based learning. The study used descriptive and qualitative analyses to measure primary and secondary outcomes. Results The primary outcome measure showed a positive change in resident knowledge, skills and behaviors in communication, reection, feedback, precepting, and facilitation. MS perceptions of resident teaching skills conrmed the observed changes in CETs. Some CETs continued to practice and build their capacity for teaching after completing the rotation. Qualitatively, we categorized the described codes under four pre-identied themes; communication, professional engagement, professional-based learning, and systemic-based practice. Conclusion Resident teaching and professional capacity is enriched after completing the clinical educator rotation. Other benets included: enhanced patient communication and education, increased resident condence, personal satisfaction with training, work life-balance and enhanced career satisfaction. Future research should focus on curricular content, faculty development and delivery assessment. Also, research efforts should identify appropriate emerging technologies to include in the curriculum for enhancing teaching capacity. we aimed to assess if the clinical educator rotation met its objectives from the perspective of students, residents, and faculty. Faculty and study participants observed signicant behavioral changes in the CET group after the completion of the rotation.

promote positive resident educational experiences leading to successful future clinical careers. [7][8][9][10] One method to do so is to institute a clinical-educator track geared towards a resident audience. [11][12][13] In ful lling this approach, we developed and initiated a "clinical-educator" rotation for post-graduate-year two (PGY-2) and three (PGY-3) residents in Internal Medicine (IM) to take on a leading teaching role towards junior residents and MS. The rotation introduces learning theory mixed with pragmatic skill development aided by the use of digital technologies to leverage residents' teaching capacity within our institution [14]. The primary objective of this study was to assess the impact of the clinical-educator rotation on residents' competencies related to clinical teaching and professional growth. Secondary objectives were to determine MS perceptions in reference to observed changes in residents' teaching as measured by communication, professional-based learning (PBL), professional engagement, and systemsbased learning (SBL).

Methods
A prospective, exploratory descriptive study was conducted with a concurrent triangulation design to collect both qualitative and quantitative data from three stakeholder groups: MS, residents and clinical faculty. This study was approved by the Edward Via College of Osteopathic Medicine, Institutional Review Board.

Study Population
A purposeful sampling technique was employed to recruit residents at a community teaching hospital in Orange Park, Florida. All PGY-2 and PGY-3 IM residents (n=30) were invited to participate in the study after an introductory presentation. Those residents who opted to participate in the clinical educator rotation, were consented and assigned to the test group, clinical-educator trainees (CET). All residents who chose not to participate as a CET, along with PGY-1 residents, were invited to serve as controls. Using a similar purposive sampling approach, all third year osteopathic medical students currently rotating with the residents (n=20) were invited to participate in the study. All participant residents and students in the study were required to sign written consent prior to enrollment.

Clinical Educator Rotation
The curriculum was drawn from the contemporary clinical-educator and faculty development literature. [11,15] In addition to including traditional topics such as precepting, feedback, learning theories, lecturing, and small group facilitation, we added contemporary topics to supplement the traditional offerings: modules for change management, patient-centered medical care, electronic health records (EHR), complexity, learning healthcare systems, and digital technologies. These modules were further tailored based on learners' needs identi ed prior to beginning the module in collaboration with the faculty.
[16] Using this model for developing a just-in-time curriculum, our hybrid model was built on a two to four-week rotation with an emphasis on communication and PBL delivered in the rst two weeks in eight modules. For the remaining one to two weeks, residents selected up to two additional modules per week. These latter modules exposed the residents to the domains of professional engagement, and SBL ( Table   1).
The CET and control groups were involved in the daily teaching activities of the residency program by leading daily morning huddles, morning topic discussions, precepting, evaluating clinical notes, providing feedback, and facilitation during various topic presentations. In addition, the CETs also participated in weekly bedside teaching sessions with the MS. We limited the control participation in bedside teaching, because of potential unfairness to residents who may be put on the spot in the presence of patients and students without proper orientation. Instead, for the bedside teaching experience, we elected to identify differences at the beginning and end of rotation for each CET. Prior to bedside teaching, each CET was oriented to the objectives and format of the bedside teaching session with emphasis on pre-session student orientation to clarify objectives and respond to students' questions. After the bedside session, the group met to debrief their re ections-on-learning.

Data Collection
A total of ve key assessments, designed in-house, were utilized to answer the research questions listed in Table 2. Four of the key assessments, communication, SBL, professional engagement, and PBL, aligned with the basic constructs that framed the study. Both the control and the CET groups completed these assessments. The fth assessment was a summative pre/post assessment, open-ended questionnaire, to help identify if the program met the objectives. All MS and residents completed the preassessment; whereas the post-assessment was completed by the CET group only. Towards the end of the study, we conducted a focus group discussion for the MS, residents, and faculty. Table 3 demonstrates the matrix of the assessment methods. The key constructs and assessments are described below: Communication: This construct targets verbal, written, and digital communication standards with the purpose of facilitating effective communication behaviors/patterns between all stakeholders. The stakeholders included students, residents, faculty, staff, patients/families. Communication was assessed using the morning huddle survey, an eight questions likert scale ranging from strongly disagree to strongly agree, during the morning huddle where trainees brie y review their scheduled patients. In addition, we used different strategies to assess resident communication during the rotation using observation, video, re ection and review of electronic health record notes.
PBL-The purpose of engaging residents in re ective practice was to develop residents' capacity for lifelong learning. The second assessment was therefore, re ective journaling. Each resident practiced daily journaling using Mezirows' re ective levels [17] for transformative learning to frame their re ective discussions followed by one-on-one sessions with a faculty member to anchor their skills in re ection. In addition, weekly journal narratives were assessed via a rubric by three faculty members. The re ection rubric consisted of 4-point likert scale ranging from below expectations to outstanding to assess two components, content and personal growth.
Professional Engagement-This construct targets the domain of professionalism practiced by the resident during interactions with stakeholders in the context of cultural diversity and transnational competence during presentations. The CET participants were given two choices of presentations: prepare a 15-20 minute presentation around Evidence-Based Physical Examination and deliver the presentation in a small group meeting or facilitate a small group teaching session, (60-75 minute), on an inpatient clinical case. The third assessment was presentation skills that measured if the CET demonstrated mastery of professional competencies such as the practice of empathy, cultural humility in a culturally diverse context, mastery of knowledge content, role modeling, and appropriately (voice, tone, body language, etc.) responding to learner or patient di cult interactions. Presentation rubric, 4-point likert scale, was used to assess trainees presentations from below expectations to outstanding.
SBL-This construct targets documentation processes in the EHR as a surrogate for SBL, using QNOTE, [18] a validated electronic evaluation tool used to assess clinical notes for quality by generating a quantitative score for clinical notes quality. Both resident groups completed multiple QNOTE evaluations for the same peers and provided peer-to-peer feedback regarding gaps in documentation and opportunities for improvement. Also, QNOTE enabled the CET group to identify the progression of residents and categorize them using the RIME (reporter, interpreter, manager, educator) model.
Program evaluation: A 7-item pre-and an 8-item post semi-structured questionnaire was designed inhouse to determine if the program met its objectives. In addition to collecting data from the control and CET groups, this study aimed to triangulate its ndings by capturing MS perceptions of the clinical educator rotation as measured by communication, PBL, professional engagement, and SBL. Towards the end of the study period we conducted two focus groups, one for the students and the other for the CETs to assess program outcomes.

Data analysis
Data from questionnaires, surveys, audio, and video were collected, summarized, and aggregated per group, CET vs. control, using descriptive statistics and qualitative content analysis. Two investigators transcribed and coded data and ensured appropriate assignment of codes. These codes were reviewed independently by two other faculty members experienced in qualitative analysis to ensure intercoder agreement. We identi ed recurrent and/or emerging themes from responses in an attempt to further our understanding of how the curriculum was meeting its objectives. MAXQDA 2018.2 was used for the qualitative analysis of the data. Inferential statistics were not appropriate in this study because of the limited sample size and the descriptive nature of the study. Assessments completed by faculty members were quanti ed in order to establish inter-rater reliability and validity. Moreover, quantitative data were analyzed descriptively in order to establish patterns in responses. We used various strategies to strengthen the rigor of the study by assessing the credibility, dependability, con rmability, and transferability of the outcomes [19].

Results
There was an overall improvement in CET's knowledge, skills, attitude, and behavior in relation to the domains of communication, PBL, professional engagement, and SBL. Although we enrolled 10 CET, data saturation was reached by the sixth trainee. Persistence of changes, post CET rotation, were less pronounced for PGY-2 CETs. We observed consistent use of new behaviors and skills in 4/8 CETs. The primary outcome demonstrated a behavioral change towards embracing and repetitively demonstrating use of the theoretical frameworks in support of a learner-centered approach to teaching. MS perception con rmed the observed behavioral and skill changes described in the CET group.
The most frequent three codes prior to the initiation of the CET rotation were "practice of teaching" (11.8%), "critical thinking" (9.7%), "re ective practice" (8.1%) in the CET group; "practice of teaching" (14.9%), "re ective practice" (10.2%), "challenges to teaching" (8.4%) in the control group. In contrast, the MS groups' top three codes were "re ective practice" (22.1%), "practice of teaching" (7.2%) and "education" (7.1%). Refer to Table 4, for examples of codes and correlating quotes. To identify relationships between the codes, a network map, based on the pre/post-survey and focus group interviews, showed a robust increase in post-rotation interconnectivity and proximity of codes to the practice of re ection. In both pre and post assessments, mentoring showed similar connectivity and proximity to re ective practice, see Figure 1.

Study Population
Eight (27%) IM residents enrolled as CETs and the remaining, 22 (73%) residents participated as controls. The CET group included 2 PGY-2 and 6 PGY-3 residents. A total of 17/20 (85%) of the MS enrolled in the study. The eight CETs (100%) completed at least two weeks clinical-educator rotation with three residents completing three weeks. Among the residents who elected to rotate for three weeks, one resident completed the population health module and another the patient-centered medical home (PCMH) module. The deliverables for these modules included a Grand Rounds presented by the resident on the topic, the second resident delivered a detailed document describing implementation requirements for a PCMH practice in the resident outpatient clinic.

Communication
The most common identi ed codes were 'clear and concise communication' followed by 'feedback', and 'coaching', see Table 4.
Faculty comments: From the focus group discussion, faculty stated that the CETs developed new understanding in relation to professionalism, patient care, teaching process and planning. Communication between CET and stakeholders, including patients, MS, staff, and faculty, was noted to be clear and organized when compared to the control group. CETs made use of verbal and non-verbal cues. They learned how to communicate effectively with all stakeholders to plan educational sessions.
"During the [morning discussion] article there was more discussion compared to before." " So he is now involving the residents to be part of the conversation rather than him just talking so he will ask more questions and listen to them." Evaluation tools: Using the morning huddle survey, the mean values for all questions combined were similar in both the CET and control groups with a mean of 4 correlating to 'agree' on the 5-point likert scale indicating a similar improvement in both groups.
Residents: From post-survey and focus group discussion, the residents reported that CETs showed consistency in ensuring knowledge transfer to learners.
"Facilitating the morning group and feeling/sensing that I was listening and being listened to. I felt effective and that the whole group participated." The CET group also used their communication skills to provide constructive feedback, coach learners, and ask questions at different levels of the Bloom taxonomy [20]. At the beginning of the clinicaleducator rotation, CETs anticipated communication skills as a major challenge which was not the case after the rotation.
"Communication skills were challenging, now I know how to effectively communicate our thought process." "I feel empowered as an educator and feel I am able to conduct more thought-provoking questions." "...I think I am better at giving feedback now that I have practiced multiple times and have received feedback on my feedback. I feel more comfortable with it." Students: From focus group discussion, the MS also indicated an agreement with the CETs' improvement of communication between stakeholders. In comparison, the controls were much less likely to communicate with learners through pre-planning or clarifying learning objectives when leading an educational activity. "...it is interesting when he rst started teaching us he was kind of timid and disorganized when we rst started. I gained a lot from the cases working with him but he made a lot of improvement just from the second time he was with us as a CET. Toward the end he was very pro cient very organized in teaching us."

Professional-based learning
The most common identi ed codes were 're ective practice', 'objective oriented', and 'e ciency'. See table

4.
Faculty comments: From focus group discussion, the faculty stated that the CET group demonstrated effective use of re ective skills and providing feedback to learners. Their questioning styles changed based on Bloom's taxonomy of questions and teaching was more learner-oriented. Although CETs practiced verbal and written re ection, they struggled to align their re ections according to Mezirow's hierarchies for re ective practice.
"So before he started the rotation he was more of a talker where he would share the knowledge he knows and he will keep going on regarding what he knows but after doing the rotation and during it he learned the skills and abilities of how can he get most out of the learners where he is now adapted the roll of a teacher and not just somebody that gives a lecture." Evaluation tools: Based on the Re ective Journaling Rubric, most re ective practices ranged between affective through judgmental re ectivity according to Mezirow's levels. Occasionally, a CET practiced re ection at the conceptual, psychic, or theoretical levels. The content and personal growth based on the Re ective Journaling Rubric were rated as 9% "basic", 50% "pro cient", and 41% "outstanding", in the CET group.
Residents: From post-survey, the CETs found re ective practice to be an effective tool to help them understand their role as an educator and enhance their professional-based learning.
"Re ective practice helped me recognize the caveats and gaps in my practice and interactions and taught me how to nd remedies by self-re ection" "One big part of the clinical-educator, there is actually a big mindfulness component to it so there is daily journaling and re ection in that aspect." Students: From focus group discussion, MS stated that re ection practice demonstrated by the CETs was consistent with the residents and faculty's ndings and noted deeper sense of re ection. "...to be a teacher you have to lead by example, and I think it is one of the aspects that I want to improve on," "Re ection is a sort of personal feedback for me where I can sit back and gure out where I could have been better and next time, I will try to implement that and that is what [the CET] successfully did"

Professional engagement
The most common identi ed codes were 'practice of teaching', 'patient care', and 'precepting'. See Table  4.
Faculty comments: From focus group discussion, the faculty stated that the participants in the CET group had improved their professional interactions with their patients, colleagues, and MS. This was evident through deliberately addressing patients and learners by name, actively organizing and planning teaching activities, and providing feedback in a facilitative and non-judgmental manner.
"[Another clinical-educator] gave me feedback after I gave a lecture. She video taped it, as an attending you never get this opportunity where you get feedback from peers or from other attendings or from anybody. So that was helpful because by doing this rotation she developed the skills on how to give feedback without hesitation no matter if its a peer, attending, or student." "It is di cult to evaluate somebody and be able to add to that picture unless you are paying good attention and you are following them along as now I am able to look at the picture and see what I can bring more to the table as my perception changes you are not there to be in the room or be a part of it and say yes to what has been but your job is to make sure that how this process is taking place and where it is going and if we are going together or not." Students: From focus group discussion, the MS stated that CETs demonstrated a higher level of professionalism when interacting with learners. There were noticeable changes in behavior that the MS were able to recognize as a different professional behavior when compared to the controls. "[Clinical-educators] let me be a reporter and take charge and when I present the patient to the attending, they didn't interrupt me and let me do my job as a reporter" "[Clinical-educators] were very professional, they called me by name, rather than 'medical student,' everyone calls me medical student, but they used my name. They were attentive, listen to us, and keep eye contact."

System-based learning
The most common identi ed codes were 'knowledge/education', 'critical thinking', 'technology use in teaching'. See Table 4. Evaluation tools: CETs were able to demonstrate pro ciency in SBL through the use of QNOTE. CETs were more inclined to identify gaps in notes with an average QNOTE score of 80.6, while controls were more inclined to give a higher score to the same clinical notes with an average score of 91.2, indicating a lack in identifying gaps in EHR note quality.
Residents: From post-survey and focus group discussion, the CETs were able to use their newly acquired skills in different clinical settings including precepting in the outpatient clinic and bedside coaching in the inpatient service. CETs engaged different systems by working as a team leader and facilitating the use of resources available in the hospital to engage the learners.
"Implementation of a variety of teaching strategies appropriate to learners, engage in critical thinking and create opportunities to do so, using information technology to support the learning process, role model." "...my opportunity to look at myself from a different point of view. Looking forward to discover what are the challenges that a teacher faces while trying to meet the needs of different people who may be very different from each other in the way they learn, yet have the same objective." CETs were also able to master the use of QNOTE to assist learners in identifying their gaps in clinical notes.
" I also had another CET and she went over my notes using QNOTE and I noticed a lot of errors so now I am looking at everything deeper." Students: From focus group discussion, MS stated that CETs' behavior change was evident through the bedside teaching where their actions manifested in a patient and learner-centered approach. Patients were enthusiastic to participate in the teaching session as it provided them with a deeper insight about their case and the MS had a unique opportunity to reciprocate their theoretical knowledge into practice.
"When going through review of systems and physical exam, systems-based learning allows the student to compartmentalize the teaching and ensuring all aspects of patient care/differential diagnosis are addressed. At the same time, providing a method to draw from to develop a "bigger picture" mentality with patient care." In addition to collecting data on these four constructs, we aimed to assess if the clinical educator rotation met its objectives from the perspective of students, residents, and faculty. Faculty and study participants observed signi cant behavioral changes in the CET group after the completion of the rotation.
"In my opinion I think that this was a really good effort. I have seen signi cant changes, and these changes are lifelong. It's like you developed the muscles and you keep working and those that learn and retain it if they practice it." The most noticeable behavioral changes included the ability to conduct well-structured, concise, and focused feedback to learners. For example, when precepting or leading small groups, CETs used a mix of higher order questions that engaged the learners in analysis and evaluation rather than the predominant use of low order questions such as knowledge or comprehension based. CETs provided learners with space to work through problem solving and focus on their clinical reasoning skills.
"One thing about CE he has always been very like inquisitive and always ask good questions he is always thinking deeper and thinking well what would you do in this scenario and always think that he was a person that showed that if he wanted to share something with you then he asks what do you think about this" "... what I want for both of us to critically think and then I try to direct the question in a way where it is learner-centered so if they are struggling to provide me with the answer I stop and reframe my mode of questioning in a way that it may bene t the learner to kind of see where I am trying to lead them, because sometimes what we try to do as a teacher is to give all my knowledge but don't have time to answer everything." Other behavioral changes that were acquired and used by CETs included: facilitating skills, concise and clear communication while coaching, improved patient communication, and the overall novel approach to teaching. "With CET they were very clear and able to tell me what they wanted and communicate with me how they wanted me to do something and what the expectations were." In contrast, the control group asked more knowledge-based questions and usually provided the answer to the questions without providing the opportunity for the learner to process the question and respond.
"...some other [control residents] were a little more all over the place. You wouldn't know what the expectations from day-to-day or what you are going to get or how things are going to go. If they assign you a topic, you don't know if you are going to discuss it that day, ve days later, or never. So that was something I knew with CET I knew if they assign me something to read, they will ask me the next day and need to prepare for it so we always had that discussion. I knew what my expectations were…" "In regard to other residents, the experience is not the same it depends on the senior, I had four different seniors, and each was very different some took the role on. I didn't know who is my go-to to teach me. Sometimes the interns teach more, sometime the senior. I Don't know the hierarchy, but I think the seniors have more free time to teach us and go over our notes." Through direct and indirect assessments, the most impactful observed change was the strength of association between concepts related to clinical education, especially re ective practice, feedback, mentoring, precepting, and teaching ( Figure 1).
We also assessed the progression of the CET group through focused group discussion with the MS. In comparison to the control group, MS reported that CETs were clear and concise in communicating teaching objectives for teaching activities, and professionally conducted the bedside teaching sessions.
All MS concurred that the CET group conducted teaching in a standardized fashion, while some residents in the control group demonstrated similar organization in their teaching, they were not consistent with signi cant variability between residents. "It has created structure in how to approach bedside teaching and improve my knowledge of various forms of bedside teaching, how to effectively give feedback, and how to re ect with more organization." "Last week I feel you weren't as prepared as far what you wanted us to do but this week you had it laid out what you wanted us to do, how you wanted the structure to go, and that was better. This week you came in with a game plan before we saw the patient." "[A control resident] particularly spent extra time with us to help teach us, I think it kinda came natural to him, without going through this process he is good at teaching....it varies, depends on characters. Some teach spontaneously and others need to develop the skills."

Discussion
Historically, training programs have relied on residents to teach MS without equipping the residents with the knowledge and skills to be an effective educator [21]. In this study, the emphasis on communication and professionalism was purposeful. Although limited in time to two to three weeks, by the end of the rotation, CETs had successfully achieved the objectives of the rotation. The assessment tools demonstrated that CETs developed a mindful stance and actively practiced re ection, feedback, process observation, precepting and effective questioning techniques.
"Implementation of a variety of teaching strategies appropriate to learners, engage in critical thinking and create opportunities to do so, using information technology to support the learning process, role model." Through triangulation of data sources such as the direct and indirect methods to collect data from multiple stakeholders improved the robustness of the study. Furthermore, the CET group demonstrated enduring behavioral changes related to communication, professional engagement, professional-based learning, and system-based learning.
Becoming an effective clinical educator is a challenging process that requires time and deliberate effort [22]. Hence, a transformative approach to medical education is needed to innovate an integrated pedagogical strategy. , outlined some of the gaps in the competencies and curricular domains needed to reform medical education. Their viewpoint is a paradigm shift in how faculty and academic centers should approach healthcare education compared to current practices [16].
In addition, Gonzalo et al, provided a roadmap to transform medical education emphasizing informatics, teamwork, leadership, population health, socio-ecological health from a systems science perspective [23].
Given the rapid changes in healthcare systems, it is imperative for graduate medical education to adapt to the dynamically complex healthcare system and restructure the curriculum to help learners develop the skills needed to become effective educators and leaders [24]. These studies are in line with our research initiative to develop clinical educators and help residents become resilient in this dynamically complex healthcare system.
Several studies have demonstrated the bene ts of developing a clinical educator program [11,13,25,26].
Reported outcomes from these studies were positive for improvement in the level of skills [11], impact on career choices [11,12], development as a clinical educator [12] , increasing opportunities to teach [25] and improved feedback skills [26]. Our study identi es similar bene ts and further expands on the outcomes of clinical educator programs to include improvement in communication, professional-based learning, engagement and system-based learning.
Interestingly, the bene ts gained from the CET rotation were not con ned to the CETs; we observed active transfer of skills from the CETs to other learners, such as morning huddle presentation skill and leading small group activities. Bene ts were also noted in the assessments of presentations and huddle by learners, where both the CET and control group showed improvement. We believe this is secondary to reactivity of measurement where participant controls bene t from CETs by being in proximity and observing them during their training [27]. This is a favorable outcome where further dissemination of knowledge and skills occurs among all participants.

Limitations
The overarching challenges in this study were primarily related to faculty time and the broad faculty expertise required to manage all the modules coupled with a short rotation schedule. Another challenge was occasional patient reluctance to participate in bedside teaching sessions. We also noticed some discrepancy in individualized learning challenges stemming from workload and family balance issues.
This led to a variability in ability to complete the required reading during the rotation. Another limitation is potential bias by the main faculty member who facilitated the modules in the rst two weeks covering communication and professional-based learning. However, we sought input from all faculty regarding observed changes in resident behaviors and progress which con rmed our ndings. There may be limitations to the generalizability and transferability of the results of this study because the study was conducted at one clinical setting. Participant comments at the end of the study, expressed their desire to see the rotation expand and include all residents.

Conclusion
This mixed methods approach used in the study indicates that residents can bene t from attending a time-limited rotation that builds on the foundations of teaching and professional growth. This study suggests that to build residents' teaching and professional skills, exposing them to the theory and practice of topics on practical contemporary education theory, facilitation, and communication skills is an effective strategy. Other bene ts besides improving delivery of medical student education may include enhanced patient communication and education, increased resident con dence, personal satisfaction with training, work life-balance and enhanced career satisfaction. Challenges that may limit such experiences are primarily resource driven especially time and availability of experienced faculty. Future research should focus on curricular content, faculty development and delivery assessment. Also, research efforts should identify appropriate emerging technologies to include in the curriculum for enhancing teaching capacity. Written consent prior to enrollment was required by the IRB for resident and student participation in the study.
Consent for publication: Consent for publication was granted by PubClear of Orange Park Medical Center, a facility of HCA. This research was supported by HCA and/or an HCA a liated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the o cial views of HCA or any of its a liated entities.
Availability of data and material: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing interests Funding: Supported by grant (1208135-2) from the Edward Via College of Osteopathic Medicine. The funder reviewed the study protocol and provided funding for the study.
Authors' contributions: YH collected, analyzed, and interpreted the data, he also wrote the rst draft of the manuscript. AS helped in interpreting the data and was a major contributor to writing the manuscript. CT helped in developing the protocol and assisted in writing the manuscript. SB is the principal investigator who was instrumental in developing the curriculum and methodology of the research project and its protocol, he was also a major contributor to the writing of the manuscript. All authors read and approved the nal manuscript.  To determine medical students' perceptions about the Clinical Educator rotation as measured by communication, progressional-based learning, professional engagement, and systems-based learning.
1. How do clinical educator trainees use and apply communication, practice-based learning, professional engagement, and system-based learning?
CET-clinical educator trainee.   Practice of teaching "the trainee did a great job keeping us focused on one subject/system/topic at a time and seemed to guide us when needed" Precepting "when went to see patients he actually came with me and assessed how I did my HP. He observed me directly and when we nished the encounter he gave me feedback which was very helpful to have and kind of mentoring one-on-one" Professionalism "Trainees engage in professional engagement by speaking to students properly" Responsibility for education "[She] is also good at assigning patients that are good learning patients if you have seen like 3 MIs in a week, she assigns me a patient with gastritis so it's always something new so you are not constantly seeing the same patients" based Critical thinking "Residents innately use their own personal strategies to go about decision making" Evidence-based medicine "Residents innately use their own personal strategies to go about decision making" Information retrieval "We can use resources like images that was helpful and labs which was nice" Knowledge/ education "Helps de ne reading for you that really high-yield" Organizational "very organized in teaching us and for sure he was a great teacher in those three sessions" Technology use "video readings helped identify areas in which I did not realize that I was appearing a certain way, and gave me concrete evidence of what I need to change"