Academic Medicine最新文献

Health care organizations often face challenges in managing risks, inefficiencies, fragmented processes, and duplicated efforts. In academic medicine, stakeholder engagement is also a pain point because lack of understanding or poor communication between departments and service providers creates friction. This article discusses why and how a school of medicine in a large academic medical center (AMC) implemented a shared services model and addressed key challenges. In the 6 years since its creation in 2019, the shared services model has promoted economies of scale, efficiencies, and high quality of work performed around the administrative functions of human resources, finance, research administration for preaward support services, communications, and facilities. In an AMC, this model ensures that units are consistently well supported in these functions and can focus their energies on the central mission areas of research, patient care, and education. This is especially relevant in the current climate, with the focus falling even more pointedly on efficiency and resource management in institutions that receive federal funding. Additionally, the model created an ecosystem of continuous information sharing and professional development. Importantly, it achieved these benefits without compromising individual units' autonomy and unique strengths, balancing centralized support with unit independence. The AMCs that adopt a shared services model often report benefits such as consistency, structure, collaboration, and flexibility. This combination leads to smoother operations, a more engaged workforce, and greater overall efficiency, creating a supportive environment that benefits faculty, staff, and the institution as a whole. The shared services model discussed in this article is generalizable and translatable to other AMCs as well as to large, complex organizations in both the private and public sectors that seek to improve efficiencies in administrative productivity and processes.

Purpose: Management reasoning, the process of making decisions about patient treatment, testing, and resource allocation, remains inadequately addressed in medical education. This qualitative study explored how graduate medical trainees develop management reasoning during medical school and residency.

Method: Between February and June 2024, focus groups were conducted with residents representing postgraduate years 2 to 4 from internal medicine, pediatrics, family medicine, and medicine-pediatrics at 2 US academic institutions. Using dual process theory and situated cognition theory as sensitizing concepts, focus groups explored trainees' experiences and perceptions of management reasoning learning and factors that shape their development. Reflexive thematic analysis was used to identify themes.

Results: Four focus groups with 28 residents yielded 4 themes characterizing the development of management reasoning: learning formats, factors supportive of learning, barriers to learning, and developmental trajectories. Residents developed management reasoning through experiential learning activities, such as actively managing patients, observing management practices by senior trainees and faculty clinicians, and interacting with patients, consultants, and peers. In contrast, structured educational activities typically emphasized diagnostic reasoning. Supportive factors contributing to management reasoning included verbalization of reasoning processes, opportunities for ownership, case repetition and variability within the clinical learning environment, individual learner characteristics such as preexisting knowledge base, and practices such as vulnerability and reflection. Barriers included minimized responsibility, lack of patient continuity or follow-up, hierarchy, and extrinsic cognitive load. Trainees described progression from rigid, guideline-dependent approaches toward more nuanced, patient-centered reasoning.

Conclusions: This study provides empirical evidence on how graduate medical trainees develop management reasoning along with actionable recommendations for educators to support this development. Findings highlight the need to intentionally design clinical environments to promote graduated autonomy and verbalization of reasoning by senior clinicians. Addressing identified barriers and maximizing supportive factors will help ensure that future clinicians can navigate the complexities of patient-centered management decisions.

Problem: Undergraduate medical education (UME) often lacks detailed data on student learning in the clinical learning environment, instead relying on self-reported and observational assessments of student involvement in patient care. This reliance on subjective data can lead to inconsistencies and gaps in understanding student experiences during clinical encounters. The electronic health record (EHR) contains a wealth of data that could address these limitations but is underused in UME, limiting objective analysis of student encounters and hindering the ability to monitor and ensure consistent experiences across different clinical sites.

Approach: In 2020, a multidisciplinary team at the Kaiser Permanente Bernard J. Tyson School of Medicine used business intelligence software to develop dashboards that enhance analysis of student experiences in the clinical learning environment. Student encounters were identified using a unique EHR profile that enabled the capture of encounter-level data, which were then exported to a centralized dataset, facilitating creation of dashboards for comprehensive visualization and analysis of student experiences.

Outcomes: By 2024, 17 dashboards were created that included visit- and patient-specific data. The EHR-linked dashboards featured encounter-specific details (specialty, preceptor, visit type and specialty, chief concern, diagnoses) and patient-specific details (age, race, sex, language, interpreter use). This allowed the capture of student experiences and facilitated analysis of student quality and patient-reported experience metrics. The dashboards also served as feedback tools to ensure comparability between students and cohorts across clinical sites.

Next steps: The dissemination of individualized student dashboards enables insights into clinical experiences and identifies student contributions to patient care. By sharing rich data, students can pinpoint learning opportunities and faculty can better support curricular goals, advancing precision medical education strategies. This approach can serve as a model for empirical studies on how clinical learning environments shape student development and marks a necessary step toward personalized learning systems in UME.

Purpose: Shared decision-making (SDM) is a vital component of patient-centered care. This study aims to identify key themes relevant to medical student experience with an SDM curriculum, as well as their depth of engagement with the patient perspective.

Method: Beginning in 2022, medical students at the University of Colorado participated in an SDM curriculum incorporated into a longitudinal integrated clerkship, including a written reflection about their experience with a patient SDM clinical encounter. Reflection pieces were evaluated with both thematic and narrative analysis methods. Written works were coded using interpretive phenomenological analysis to evaluate for emergent qualitative themes surrounding the participants' learned experiences during exposure to the curriculum. Separately, structural narrative analysis of the reflection pieces examined engagement, depth, and meaning making.

Results: Fifty-one students completed this SDM curriculum between 2022 and 2024. Thematic analysis of their written reflections revealed 4 primary themes: Communication and Comprehension, Patient Autonomy, Empathy, and Professional Identity Formation. Students emphasized clear communication, respect for patient values, and the emotional dimensions of SDM as elements they observed. Narrative analysis showed significant variations in dimensions of the written reflections including the richness of contextual details, specificity of witnessing, and exploration of multiple perspectives. Reflective pieces also demonstrated variable degrees of critical reflection on personal growth and future-oriented professional insights. Certain elements were notably shared between narrative elements present in deep reflections and skills important for SDM, including framing the situation, attention to details and nonverbal cues, exploration of multiple perspectives, and personal reflection.

Conclusions: SDM is a complex process that involves clear communication, empathy, and respect for autonomy. Narrative elements that create engaging written works are also important to SDM performance, including patient perspective-taking. As medical students undergo professional identity formation, an SDM curriculum engaging the patient perspective may promote a humanistic approach to clinical practice.

Problem: Teaser: An experiential learning intervention to train medical educators to effectively engage generative AI for instructional design is described.Theory-informed and evidence-based educational offerings promote student learning and equity but are time-consuming and require health professions educators to have content expertise in inclusive instructional design. While -generative AI (GAI) offers the potential to overcome these barriers, educators must learn to effectively leverage GAI tools for evidence-based instructional design. In this work, the authors piloted and evaluated a 2-part experiential learning activity to equip educators to effectively engage with GAI for instructional design purposes.

Approach: The authors implemented the GAI innovation in the graduate-level "Teaching 100" course (enrollment n = 27) at Harvard Medical School September-November 2023. Educators used GAI to annotate their lesson plans to identify application of, and opportunities to incorporate, evidence-based principles of teaching and learning. The 2-part assignment provided scaffolded instruction on prompt engineering and engaged learners in metacognitive reflection on AI-generated content. The authors evaluated the effectiveness of the GAI innovation according to the Kirkpatrick Model: descriptive analysis of self--reflections evaluated educators' subjective experience (Level 1) and planned behavioral changes (Level 3), while quantification of prompt quality pre-/post-instruction measured educators' learning (Level 2).

Outcomes: Among educators who completed the 2-part assignment (n = 17/27, 62% completion rate), the quality of -educator-generated AI prompts improved following instruction in prompt engineering: pre-instruction 1.4 (1.2) (mean [SD]) vs post-instruction 4.0 (0.8). The difference in means (2.6 points) was statistically significant (P < .0001, 95% CI [1.9, 3.3]). Metacognitive reflections revealed specific actions educators planned to pursue to implement GAI feedback to improve their instructional design. Educators reported that AI-based assignments enhanced their learning.

Next steps: The authors are developing a stand-alone, interactive GAI tool to be broadly deployed as a faculty development instructional design resource. This future work will yield a scalable solution to the challenge of developing AI literacy among health professions educators to leverage GAI for theory-informed and evidence-based instructional design.

Problem: Increasing emphasis on research productivity for residency applications has intensified pressures on medical students in recent years. Students, although eager to participate in research early on in medical school, may struggle to independently design research projects. This can result in an overreliance on faculty mentors and departmental support, as well as academic dishonesty in research and publishing.

Approach: The structured research group was initiated in August 2019 to foster student-led projects while supporting faculty mentorship. The framework includes an onboarding process to guide project formulation, regular group meetings for collaboration, and leadership roles to empower students. This adaptable model prioritizes fostering research innovation, mentorship, and ethical collaboration.

Outcomes: Since the group's inception through September 2025, faculty-supported, student-led projects have increased, fostering a collaborative environment among faculty, residents, and medical students. Alumni have highlighted the group's structure as a unique strength, contributing to the department's research culture without significantly adding to faculty workload. Other institutions have expressed interest in implementing similar models within their own programs.

Next steps: Future efforts will focus on monitoring research output, mentorship dynamics, and student engagement to guide iterative improvements. The group also aims to support broader adoption of this model while fostering inclusion across varying levels of research experience.

Purpose: Medical education has embraced Dweck's theory of a growth mindset because it reflects a commitment to developmental progression. The benefits of a growth mindset can be difficult to realize within medicine's professional culture, which may constrain its adoption and expression. To date, strategies to nurture a growth mindset have been directed toward changing the behavior of individual learners, which is insufficient. Preceptor behaviors shape the learning culture, but their influence on learner attitudes toward the learning process is unexplored.

Method: The authors conducted a qualitative study using constructivist grounded theory methodology. Seventeen learners from Western University were interviewed in 2023. An iterative process was employed whereby data collection and analysis took place concurrently. Dweck's theory of mindset was used as a sensitizing concept. Open coding was followed by more focused coding, and ideas both within and across categories were compared to inform generation of theory. A reflexivity lens was applied throughout.

Results: Learners are constantly interpreting signals and using them to form impressions about their preceptors' value systems. These signals are conveyed in a preceptor's behavior, and learners often adapt their learning behaviors accordingly. When a preceptor is perceived primarily to value learner growth, learners will adopt behaviors in line with a growth mindset. When a preceptor is perceived primarily to value displays of competence over growth, learners may adopt behaviors in line with a fixed mindset. Furthermore, in the absence of growth-valuing signals, learners tend to default to impression management and may exhibit behaviors in keeping with a fixed mindset.

Conclusions: This study offers an important new dimension to our understanding of the dynamic nature of mindsets: that learner mindsets may be preceptor-responsive, shifting in response to perceptions about preceptors' values. These new insights can inform future efforts to foster a growth mindset within medicine's professional culture.Teaser text: This study explores how learners' mindsets are influenced by preceptor attitudes and behaviors relevant to the learning process and offers an important new dimension to our understanding of the dynamic nature of mindsets: that learner mindsets may be preceptor-responsive, shifting in response to perceptions about preceptors' values.

Purpose: Early career attrition, defined as attrition within the first 10 years of a physician's practice, is a significant concern for health care professionals and policymakers because it contributes to the growing physician shortage. Previous studies examined attrition within single specialties or institutions, but comparisons between surgical and nonsurgical fields remain limited. This study aims to determine early-career attrition rates among the 5 surgical and nonsurgical specialties with the largest physician population and investigate predictors influencing departure from clinical practice.

Method: This study analyzed the Centers for Medicare and Medicaid Services' Physician Compare National Downloadable Files from 2014 through 2023 to identify physicians in the first 10 years of their career in 2014 who left practice between the third quarters of 2014 and 2015 and did not return. Those who remained absent in subsequent years, excluding clinically active physicians who opted out of Medicare, were considered early attrition cases. The study population included physicians from the 5 most common surgical and nonsurgical specialties based on practicing physician count. Logistic regression models evaluated attrition rates while adjusting for surgical status, gender, region, Area Deprivation Index, and Rural-Urban Commuting Area codes.

Results: Among 94,638 early-career physicians across 10 specialties, 1164 (1.2%) experienced early career attrition. After adjusting for physician demographic variables, psychiatrists had significantly higher adjusted odds of early career attrition than all other nonsurgical specialties and obstetricians/gynecologists had significantly higher adjusted odds of early career attrition than all surgical specialties except for general surgery. Among all early career physicians, females, surgical specialists, and those practicing in areas with lower Area Deprivation Index had significantly greater adjusted odds of experiencing early career attrition.

Conclusions: These findings highlight the need to determine reasons behind specialty-specific differences and implement targeted interventions aimed at improving physician retention to ensure current physicians do not contribute to the growing physician shortage.

Purpose: Morning report (MR), a tradition in internal medicine residency programs, is widely used across the United States and increasingly used by other specialties. However, limited data exist regarding learner-level-specific considerations. The authors conducted a scoping review to characterize current knowledge regarding learner-level MR content, structure, gaps, and outcomes.

Method: The authors searched 3 databases on June 17, 2025, for English-language peer-reviewed articles that described MR in graduate medical education. Included studies featured case-based educational activities that enhanced trainees' clinical skills from history-taking to management, targeted resident learners, and mentioned the participants' composition (ie, interns or first-year residents only or senior residents [second year and beyond] only). Data were extracted and analyzed using content analysis.

Results: Of 2,287 articles identified, 36 met the inclusion criteria. Twenty-three articles (64%) addressed first-year-related sessions, whereas 32 (89%) covered senior resident-related sessions. Common study objectives included intern (7 [19%]) or senior (11 [31%]) perception or attitudes toward MR. Structural themes included intern (11 [31%]) or senior (13 [36%]) session time limits. Few studies evaluated outcomes incorporating theoretical models or validated tools. Literature differed where intern sessions gravitated toward fundamental history-gathering, differential diagnosis generation, and adapting to the rapidly changing responsibilities of intern year, whereas senior-only sessions focused on more advanced cases and evidence-based medicine. Key gaps included limited incorporation of adult learning theory, minimal facilitator development, ways to evaluate sessions, and content or structural redesign.

Conclusions: Despite its fundamental and widespread use, MR's educational design has remained largely unchanged during the past 3 decades and remains poorly aligned with adult learning theory or rigorous evaluation. This review highlights the need for more studies to reevaluate MR through learner-specific design, incorporation of modern learning theories, and validated outcomes to ensure it continues to meet the evolving needs of trainees.