Academic Medicine最新文献

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.

Problem: Medical residents perform bedside procedures that impact patient outcomes. However, no national standard exists to determine when residents can perform procedures without direct supervision. The utility and feasibility of various procedural competency assessment methods remain unclear.

Approach: A multidimensional clinical competency assessment tool (CAT) was developed to evaluate procedural performance using a checklist, global skills assessment (GSA), and Entrustment Score (ES). Residents had to meet cutoffs for all three components to pass. Checklist cutoffs were set using the Angoff method. The CAT assessed internal medicine interns performing large-volume paracentesis (LVP) and central venous catheter insertion (CVC) across three hospital systems from July 2022 to June 2023. Inter-rater reliability was assessed using two simultaneous assessments.

Outcomes: The CAT was completed in 29.7% (174) of LVP and CVC procedures performed by PGY-1s. The checklist passing cutoffs were < 9 mistakes for LVP and < 6 for CVC. Among 23 LVP dual-assessments, 3 (13%) achieved passing scores with no disagreement (Cohen's kappa = 1.0). While 85% of LVPs met the checklist cutoff, only 20% met the GSA cutoff and 15% for ES. Out of 14 CVC dual assessments, none achieved passing agreement, and two had disagreement, a percent agreement of 87%. Seventy-five percent of CVCs met the checklist cutoff, 14% of GSA, and 7% of ES.

Next steps: This study demonstrates the feasibility and reliability of implementing a multi-dimensional clinical CAT. Checklists alone did not accurately assess competency; however, combined with holistic scores, they yielded strong overall inter-rater agreement and more appropriate pass rates for this cohort. These findings support using multiple complementary assessment methods to better identify competent performances. Future steps include refining checklists to focus on critical steps, evaluating bias in holistic scoring, and assessing the CAT over an extended period with a cohort spanning a broader range of expertise.

Purpose: Residency selection processes have become increasingly time intensive and complex. This study examined current processes and barriers to the creation and composition of internal medicine clerkship narrative assessments to inform potential improvement opportunities.

Method: Internal medicine clerkship directors (CDs) at US Liaison Committee on Medical Education-accredited medical schools with membership in an academic medicine professional association completed a multithemed annual survey between September 7 and December 6, 2022. The survey explored faculty development for composing narrative assessments, translation of assessments to the Medical Student Performance Evaluation (MSPE) narrative, and practices for editing MSPE evaluations.

Results: Of the 140 CDs sent the survey, 112 responded (response rate, 80.0%). Two CDs who did not complete the entire survey completed this study's section (section response rate, 81.4%). The frameworks reported to assess clinical performance included Accreditation Council for Graduate Medical Education core competencies (84 [73.7%]), Reporter-Interpreter-Manager-Educator (51 [44.7%]), and Entrustable Professional Activities (49 [43.0%]). Fifty-seven CDs (50.0%) review and interpret preceptor comments, 65 (57.1%) select portions of faculty assessments or representative comments, and 24 (21.1%) copy and paste all faculty narrative comments. Most respondents reported that narrative comments described clinical skills to a moderate (60 [52.6%]) or great (52 [45.6%]) extent. Clerkship directors identified assessments that primarily describe teamwork and personal attributes or use code words and global adjectives instead of providing descriptions of observable clinical skills. No associations with school size or grading scheme were identified in a subgroup analysis.

Conclusions: Although responsibility for the end-of-clerkship narrative evaluation belongs mostly to CDs, the processes for creating range from synthesis to administrative copy-paste. Although largely reliant on faculty narrative assessments, CDs reconfirmed inconsistent quality and continued to perceive barriers to faculty development for improvement. Understanding these process similarities, differences, and stressors will help identify opportunities and needs for future improvement efforts.

Purpose: This study explores the relationship between medical students' sense of belonging and perceived learning climate in clerkships, how these perceptions vary across clinical departments, and how students describe the interplay between belonging and learning climate.

Method: A mixed-methods approach with an explanatory sequential design was used among medical students at Maastricht University. Quantitative data from 6,434 program evaluation questionnaires completed between December 2014 and January 2020 were retrospectively analyzed to assess the relationship between belongingness and learning climate. Thematic analysis of narrative questionnaire responses and one focus group provided further insights into students' experiences. Data were integrated at the analytic and interpretation stages toward a conceptual model.

Results: The mean (SD) belongingness score was 3.90 (1.13). The mean (SD) learning climate score was 7.62 (1.72). A positive correlation between belongingness and learning climate was found (r = 0.693, P < .001). Significant differences were observed among clinical departments, with the family medicine department scoring highest on both measures. Having a meaningful role enabled by various stakeholders, such as residents, nurses, and consultants, was identified as key to enhancing both belongingness and learning climate. Students conceptualized a meaningful role as being allowed active participation in patient care and having genuine interest shown in them.

Conclusions: Students' sense of belonging and perceived learning climate are closely intertwined and shaped by the degree to which students are given meaningful roles in clinical practice. This underscores the importance of intentional engagement strategies by the broader health care team and educational administrators to foster an inclusive educational environment and promote active student participation. Roster planning can support this by scheduling learning opportunities. Faculty development should focus on supporting student learning, fostering personal engagement and open dialogue, and providing meaningful feedback. Students themselves are encouraged to actively seek meaningful ways to contribute in clinical settings.

The success of early-career faculty at R1 research-intensive institutions depends on institutions' ability to establish an independent, grant-funded research program in a highly competitive funding environment in which only 2,174 of 11,463 National Institutes of Health (NIH) applications (19%) submitted by early-stage investigators were funded in 2023. This report summarizes outcomes of early-career faculty enrolled in the University of California San Diego Health Sciences Grant Writing Course (GWC), which provided a structured, step-by-step, multicomponent experience focused on preparing a competitive grant proposal. The program evaluation includes effects on grant submission and funding rates and grant-writing self-efficacy after 2 years of follow-up. Eighty-five early-career faculty members were enrolled in the GWC from 2017 to 2021, including 48 (56%) MD and MD-PhD physicians, 37 (44%) PhD faculty, 45 (53%) women, and 15 (18%) self-identifying as being from underrepresented racial or ethnic backgrounds. Data from 82 participants (98%) at 12 or 24 months were used for grant outcomes, and 75 participants (88%) with 12- and 24-month data were used in the self-efficacy analysis. Seventy-one participants (87%) submitted their course proposal, and 79 (96%) submitted at least one grant application by the 2-year follow-up. Thirty-three GWC proposals (40%) were funded, and 65 participants (79%) received at least one grant as principal investigator or multiple principal investigator since taking the course. Success rates were equal for men (26 [79%]) and women (34 [79%]) and highest (12 [86%]) for underrepresented faculty. Of the funded proposals, 49 (30%) were NIH R01, R01-equivalent, or R21 awards. Underrepresented participants had the highest (19 [48%]) success rate. Participants' confidence in the 19 grant-writing skills inventory increased overall. The GWC is a highly effective and innovative program for improving grant-writing success of early-career, women, and underrepresented faculty in academic medicine.

Purpose: Scholarship on psychological safety (PS) in medicine has focused on improving patient safety on interprofessional teams. In medical education, PS literature has focused on the role of PS in simulation and on undergraduate medical education learners. However, less is written about the role of PS in shaping the learning of graduate medical education (GME) trainees. As a step toward better understanding the relationship between PS and the GME clinical learning environment (CLE), the authors conducted a scoping review exploring the phenomenon of PS in the CLE for GME learners.

Method: The authors used Arksey and O'Malley's 5-step framework: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing, and reporting results. The authors included Levac's sixth step-consulting with key informants. The authors searched PubMed, Scopus, Web of Science, Embase, and PsychInfo in November 2022 and again in February 2025 for peer-reviewed English-language articles published from database inception to the search date using broad search terms designed to include all works discussing PS in the CLE. They developed an extraction tool to catalog search results and used thematic analysis to code and thematically cluster findings.

Results: After screening 1,234 articles, 44 articles published from 2014 to 2025 met criteria for inclusion, of which 28 were original research. Findings clustered around 3 roles for PS: (1) a foundational component of trainee well-being and learning, (2) a proxy for residents' satisfaction with their CLE, and (3) a hallmark of successful teaching or supervisory behaviors.

Conclusions: Works in this review correlate the presence of PS with trainee well-being, resident learning, and supervisory behaviors; however, significant gaps remain in the literature regarding the specifics of how PS can and should be created for GME trainees, particularly for marginalized individuals.

Purpose: Knowledge about death, dying, loss, grief, and end-of-life care is an essential skill for physicians. However, end-of-life education is often incorporated into medical school curricula in the United States as electives. This scoping review explores the current empirical literature on how death and dying is taught in U.S. medical schools to identify evidence-based teaching practices and areas of opportunities to enhance death and dying education for future physicians.

Method: The authors conducted a systematic scoping review in PubMed and EMBASE, using PRISMA-ScR guidelines, of articles focused on death and dying education conducted in a U.S. MD-granting medical school setting between January 2010 and April 2025. Successive reviews of the titles, abstracts, and full texts were performed, as well as forward and backward citation searches. The initial search yielded 4,959 records; ultimately, the analytic sample for this review was 43 articles.

Results: Overall, the 43 included articles described significant variation in how death and dying is taught in medical schools. Twenty-one studies used quantitative methodologies, 13 used qualitative methodologies, and 9 used mixed or multiple methods. In line with competency-based medical education standards, the authors organize the findings around the knowledge, skills, and abilities model. Over half of the articles (n = 25) emphasized knowledge acquisition, 22 integrated skills-based components, and 28 addressed the assessment of abilities. Simulation training was common within skills-based interventions.

Conclusions: There remains a sizeable gap in evidence-based medical education related to knowledge, skills, and abilities pertaining to end-of-life care. The authors offer next steps for developing, implementing, and measuring evidence-based interventions to improve end-of-life care competency. The authors advocate for continued implementation of evidence-based educational interventions, regardless of anticipated specialty area, throughout all preclinical and clinical years.