Academic Medicine最新文献

Purpose: Teaser: This study examines perceptions of systems leaders about the value of stude nt education illuminating non-financial motivators for investing in UME.Medical schools prioritize education as central to their mission; however, most exist within complex academic medical centers and health care systems where prioritization of education, clinical, and research missions varies. Support for medical student education has diminished in many settings. This study aimed to understand how leaders broadly consider the value of medical student education programs and consequently make choices to invest resources in undergraduate medical education (UME).

Method: Value measurement methodology (VMM) was used to develop a semistructured interview guide to assess value across 5 domains: individual, operational, financial, social and societal, and strategic and political. Hospital executives, department chairs, and deans from 4 health care systems affiliated with the University of Colorado School of Medicine participated in interviews from November 2023 to March 2024. A hybrid thematic analysis was performed using the VMM framework.

Results: Twenty-nine leaders across systems and departments were interviewed. Leaders consider the value of UME aligned with their strategic priorities. Leaders ascribed both tactical and symbolic value to investments in student education and considered student impact on their current and future workforce as well as their mission. Student education is perceived as a connecting force between academic missions, attracting talented faculty, and encouraging reciprocity of learning in clinical settings. Leaders voiced responsibility to train the next generation and influence how the future workforce is trained.

Conclusions: The strongest reason leaders invest in student education is return on investment: education is an upfront cost, but value manifests in anticipated mission and workforce outcomes. Understanding how leaders consider the value of UME is paramount as medical educators propose collaborative efforts to enhance investment in clinician educators and curricular efforts.

Purpose: Clinician burnout is a health care crisis, especially for medical trainees, with few evidence-based curricula on durable resiliency skills. The researchers hypothesize that a curriculum fostering uncertainty tolerance, self-compassion, and adaptive thinking can enhance medical students' resilience. Applied improvisation, derived from the principles of unscripted, collaborative theater, has been used to strengthen clinicians' interpersonal and communication skills. This study investigates the potential impact of improvisation-based training on medical students' capacity to tolerate uncertainty, cultivate self-awareness, and build resilience.

Method: All first-year medical students at The University of Arizona College of Medicine-Phoenix attended four 3-hour mandatory applied improvisation training sessions during 15 months (2022-2024). A mixed-methods approach was used to expand knowledge of the educational process, content, and impacts. Quantitative data included 3 validated scales: Intolerance of Uncertainty Scale 12 (IUS-12), Self-Compassion Scale (SCS), and the Connor-Davidson Resilience Scale (CD-RISC). Qualitative data included brief text responses to a set of question prompts, anonymous feedback collected in the live postsession debrief, and a reflective writing assignment analyzed for key themes and various aspects of the improvisational training.

Results: Of the 118 students, 108 (92%) consented to participate in this study, and 84 (76%) completed all quantitative and qualitative instruments. The quantitative data showed statistically significant improvement in the SCS over time (mean [95% CI] change in score from session 1: -0.01 [-0.11 to 0.09] for session 2, 0.05 [-0.05 to 0.15] for session 3, and 0.12 [0.02-0.22] for session 4; P = .04), with no significant improvement on the IUS-12 or CD-RISC. The qualitative data indicated that most participants experienced an overall positive impact, with a few reporting disliking the content and nature of improvisation training.

Conclusions: These findings carry potential implications for curricular design in filling a crucial gap of teaching uncertainty tolerance, self-compassion, and resiliency to medical students.

Numerous studies have shown that medical learners experience poorer wellbeing than their counterparts in the general population. Over the last decade, medical learner wellbeing has become front-of-mind for educators and administrators, which has helped drive systematic improvements in learning and working environments. However, as awareness has grown on the importance of learner wellbeing, a parallel narrative has emerged that questions whether these initiatives are impacting the development of medical competency. In this article, the authors argue that the false dichotomy of wellbeing vs competency stems from a historical medical culture that prized self-sacrifice and "toughness" as markers of competence. There is no doubt that professional growth in medicine requires elements of discomfort and uncertainty. However, the line between productive stress and harm has historically been blurred and pushed by medical training. This culture of "toughness" consequently reinforces a harmful hidden curriculum that dissuades learners from raising appropriate concerns about excessive workloads and mistreatment. However, the evidence is clear that enhanced learner wellbeing promotes competency and patient safety, rather than detracts from it. The authors, therefore, propose a set of actionable steps to support both the personal health and professional development of learners. This includes distinguishing between necessary and unnecessary discomfort, integrating wellbeing into continuous quality improvement, fostering open and safe dialogue between learners and faculty, as well as committing to a cultural shift in medical education that embeds wellbeing into structural systems and policies. Through recognizing wellbeing as an integral part of competency, learners can be supported to become highly skilled, resilient, and compassionate members of the health workforce. Teaser: Medical learner wellbeing is no longer a fringe concern-it is central to how we train competent, safe physicians. Yet as wellbeing initiatives have expanded, a worry has emerged: are we coddling learners at the expense of rigor? This article challenges that framing by arguing that the perceived trade-off between wellbeing and competency is a false dichotomy rooted in a culture that equates self-sacrifice and "toughness" with excellence. While growth in medicine inevitably involves discomfort and uncertainty, the boundary between productive challenge and preventable harm has historically been blurred, fueling a hidden curriculum that normalizes excessive workloads, silences learners, and undermines safety. Drawing on growing evidence, the authors show that supporting learner wellbeing strengthens-not weakens-competency and patient care. They propose concrete, actionable strategies to align wellbeing with professional development. Reframing wellbeing as foundational to competency is essential to developing skilled, resilient, and compassionate clinicians.

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.

Competency-based medical education (CBME) aims to modernize postgraduate training through developmental, learner--centered assessment. However, many residents still experience the process as procedural and detached from meaningful growth. Using self-determination theory, the authors examine how current CBME practices often undermine residents' needs for autonomy, competence, and relatedness, producing superficial compliance rather than internalization and authentic commitment. Beyond structural critique, they highlight agentic engagement-residents' proactive efforts to "pull" autonomy support and shape feedback-as an underused but essential lever for revitalizing CBME. Field notes and entrustable professional activities can serve as coaching tools rather than bureaucratic artifacts but only if situated within autonomy-supportive dialogue, trusting relationships, and competence-oriented feedback. Drawing from self-determination theory research, the authors outline evidence-based, need-supportive strategies for embedding CBME practices into routine workflows. Collectively, the recommendations offer educators a pragmatic guide for aligning assessment culture with resident motivation, professional identity formation, and well-being. Without motivational alignment, CBME risks remaining an exercise in form over substance.

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.