Academic Medicine最新文献

Like a patient with a serious medical crisis arriving in an emergency department, an article submitted to a journal has a story to tell. Just as a doctor must develop trust with a patient to provide the opportunity for a story to unfold and allow for unexpected twists and turns, an editor of a journal must develop trust to communicate effectively with authors and help them tell their stories. The vital heartbeats of a journal are the ideas that become stories told by authors and are nurtured by reviewers, editors, and staff. As Academic Medicine celebrates its 100-year anniversary, the important stories told by previous authors will continue to resonate like the continued beating of a heart and provide relevance for the current articles that will influence future authors, students, and the health professions education community.

The residency selection process remains a significant barrier to the actualization of competency-based education across the continuum of medical education in North America. Current residency selection practices emphasize a narrow set of comparative achievements-standardized test performance, publication counts, and honor society memberships-within a norm-referenced system, which can divert attention from developing criterion-referenced competencies that indicate readiness to provide safe, high-quality care on day one of residency. In this manuscript, the authors argue that the residency selection process must change in order to facilitate a growth-oriented, competency-based undergraduate medical experience that ensures preparedness for residency training across all applicants to graduate medical education programs. The authors explore current issues in residency selection, particularly the use of current measures that are nonpredictive of future success, biased, and incentivize an achievement-oriented mindset. These measures focus students away from competency toward attaining a checklist of achievements such as honors society membership, research publications, and other merit badges that are far less relevant to patient care and residency preparedness, which is antithetical to a competency-based approach. The authors propose supplanting the current application review process with a modified lottery among students deemed on track to be qualified by their medical schools to begin residency based on competency-based criterion rather than normative measures. This lottery would be for interview positions and focus on aligning students geographically and from a shared interest perspective with programs where they would ideally thrive. These students would subsequently interview with residency programs as they normally would and enter the Match. The authors detail how a modified lottery would function including allowance for student choices, enhanced equality, and attention to special circumstances such as couples matching and international medical graduates as well as presenting pitfalls to this approach.

Purpose: In 2024, homelessness in the United States reached a historic peak. Homelessness creates challenges for affected individuals and health care professionals. Although research suggests that health professions education (HPE) students and trainees and homeless patients can benefit from educational and training programs in health care for homeless individuals (homeless health care), how many programs exist or are effective is unknown. This scoping review identifies programs, synthesizes outcomes, summarizes gaps, and provides recommendations to advance practice.

Method: In May 2023, the authors used keywords including homelessness and medical education to search for peer-reviewed and gray literature published from January 2000 to December 2024 about homeless health care programs for students and trainees in clinical psychology, dentistry, medicine, nursing, occupational and physical therapy, pharmacy, physician assistant, public health, and social work. The latest peer-reviewed literature searches were completed in August 2025 using Ovid MEDLINE, Embase, CINAHL, and ERIC, and the latest gray literature was drawn in September 2025 from HPE institutional websites in 20 cities with large homeless populations.

Results: The authors identified 167 HPE homeless health care programs, most commonly in medicine (123 [73.7%]), nursing (57 [34.1%]), and social work (40 [24.0%]). Student-run clinics (67 [40.1%]) and street medicine programs (55 [32.9%]) were the most prevalent program types. Only 27 (16.2%) evaluated student, trainee, or patient outcomes, and only 24 (14.4%) described a program curriculum.

Conclusions: Many HPE institutions lack homeless health care programming, and certain professions and regions are underrepresented. Programs are often student-led and challenging to sustain. However, evaluations have demonstrated significant potential benefits for students, trainees, and homeless patients. Educators have described effective practices, curricula, and tools to create, sustain, and evaluate homeless health care programs. The authors recommend incorporating effective practices, creating programs for underrepresented professions and regions, and developing interprofessional competencies for homeless health care.

The dual goals of medical training are to ensure that trainees can demonstrate the performance required to move on to the next phase of their training while, at the same time, shaping "non-ability" outcomes that should support lifelong learning and improve performance over time. Yet, the data on performance after completion of training suggests that we are not consistently meeting our second goal. Here, the authors consider non-ability outcomes as a composite of three overlapping attributes: mindset; motivation; and grit, and use the term "growth attributes" to describe this composite outcome. Since learning experiences typically involve at least one teacher, they view the impact of learning experiences on outcomes as a person x person x context (P x P x C) interaction. They review relevant literatures on the impact of growth attributes on future learning and use the P x C x C framework to discuss potential strategies to enhance one or more growth attributes in medical trainees. The authors predict that changes to the learning context that promote educational safety and trainee autonomy should support growth attributes. Similarly, the interaction between trainee and teacher is likely to cultivate growth attributes when the teacher balances support of the trainee with an appropriate level of challenge, provides growth-promoting feedback, and models growth attributes. In addition to potentially improving life-long learning and future clinical performance, growth attributes may bring additional benefits to trainees and physicians in the form of enhanced well-being and reduced risk of burnout. Consequently, growth attributes can be viewed as a surrogate for important long-term outcomes. The authors end by proposing future steps for exploring the role of growth attributes in medical training, starting with a validity evaluation of tools to assess growth attributes followed by studies to evaluate strategies to nurture growth attributes in medical trainees.

Purpose: Current clinical reasoning assessments rely mostly on outcome-based rather than process-based indicators, which fails to account for early reasoning processes that impact overall diagnostic accuracy. Between 2022 and 2024, the National Board of Medical Examiners collaborated with medical school faculty members to develop a formative objective structured clinical examination for clinical reasoning (OSCE-CR), which used standardized patient encounters to assess observed student behaviors in 3 clinical reasoning process subdomains. This study evaluates the psychometric properties of scores from a large-scale pilot study to inform the utility of OSCE-CR as a formative assessment in undergraduate medical education.

Method: The large-scale pilot study was conducted in fall 2023 and included 76 clerkship students across 4 different U.S. medical schools. All students completed 4 different standardized patient cases, and 2 trained faculty raters scored videos of each case-student combination on the 3 clinical reasoning process subdomains. Multivariate generalizability theory (G-theory) was used to evaluate score reliabilities (at the subdomain and composite levels), and generalized linear mixed modeling (GLMM) was used to evaluate the predictive utility of the subdomain scores on diagnostic accuracy.

Results: The multivariate G-theory results demonstrated acceptable subdomain (mean Φ coefficient = 0.466) and composite reliability estimates (mean Φ coefficient = 0.738). Reliability estimates were most influenced by number of cases, with the addition of more cases to the assessment yielding substantially higher reliability estimates, particularly at the subdomain level. The GLMM results indicated composite scores were a significant positive predictor of diagnostic accuracy (0.605; 95% CI, 0.053-1.157; P = .03).

Conclusions: The results provide initial psychometric evidence for use of OSCE-CR to measure and provide feedback on relevant clinical reasoning processes linked to diagnostic accuracy. By moving beyond outcome-based indicators, OSCE-CR enables students to practice these process-related behaviors to improve their clinical reasoning and reduce future diagnostic errors.

Purpose: Becoming a physician requires navigating a deliberately rigorous pathway designed to ensure the development of competent physicians. Although most trainees complete training without difficulty, 2% to 30% require remediation. Remediation is a resource-intensive and emotionally charged process that often falls outside graduate medical education's (GME's) cultural norms, leading to negative personal and societal implications. This scoping review examines reviews on remediation in medical education with a focus on GME.

Method: The authors searched Ovid MEDLINE, Embase, PsycINFO, and Web of Science for knowledge syntheses published from database inception to October 2025 discussing remediation in medical education, with a GME focus. The searches were initially run in December 2023 and updated in May and October 2025. Search terms included remediation, underperforming student, struggling learner, medical education, and review. Narrative and perspective reviews were excluded. A 7-stage remediation framework was used to organize the findings.

Results: Fourteen reviews were analyzed, with most being systematic (7 [50.0%]) or scoping (4 [28.6%]) reviews. Included reviews were published between 2009 and 2025, with most (78.5%) published between 2020 and 2025. Definitions of struggling learner and remediation varied across the literature or were undefined, illustrating an absence of shared clarity in their meanings. Reviews commonly reported on the identification and diagnosis of competency deficiencies and interventions to address them but did not discuss how to communicate and involve learners in remediation planning or on high-impact outcomes to evaluate remediation efficacy.

Conclusions: Clear definitions of remediation in medical education have yet to be agreed on. Furthermore, gaps still exist in our collective knowledge surrounding learner involvement with remediation efforts and in determining impactful outcomes that measure the success of remediation, the struggling learner's reintegration into the health profession after remediation, and, ultimately, improvements in patient care.

Medical education increasingly values coproduction-the collaborative design and execution of educational services by faculty and learners. At the same time, institutions often fall short of genuine coproduction, engaging with learners through superficial feedback processes such as satisfaction surveys. The Liaison Committee on Medical Education emphasizes these surveys in its accreditation review process. As Artino and colleagues discuss, learner satisfaction surveys suffer from weak validity evidence. Further, reliance on these surveys can exacerbate dysfunctional learner-faculty dynamics and detract from the shared educational goals of improving teaching, learning, and patient care. Medical education's overreliance on satisfaction surveys exemplifies the phenomenon of codestruction, where efforts at collaboration create unintended burdens, inefficiencies, and conflicts that undermine educational value. This commentary, coauthored by a medical student and a medical educator, explores the tension between coproduction's ideals and the prevailing satisfaction-based approach to engaging learners in medical education design. The challenge of coproduction is epistemic: it concerns what can be known and by whom. Learners are not experts in education and, consistent with metacognitive theories and research, may inaccurately rate their educational knowledge. Faculty may suffer from the "curse of knowledge," failing to recognize how nonexpert learners experience education. By examining what learners and educators are well-positioned to know, medical education can better harness these groups' complementary expertise. The goal is not to abandon educational coproduction-services like education are always coproduced-but instead to undertake it more effectively. Drawing on educational frameworks for learner engagement, the authors propose core principles to guide fit-for-purpose coproduction in medical education: clearly defined engagement goals and a plan aligned with these goals, constructive interaction emphasizing collective problem-solving, mutual learning to address role-specific knowledge gaps, and accountable decision-making processes. This approach moves beyond satisfaction surveys, offering a path to truly collaborative education that benefits learners, educators, and-ultimately-patients.