Academic Medicine最新文献

The escalating pressure on medical students to produce research to gain a relative advantage during residency selection-described as a "research arms race"-has created unintended consequences for medical trainees and the broader academic community. Driven by the scarcity of residency positions and accelerated by changes in grading systems and honor societies, applicants increasingly pursue high volumes of publications and presentations, sometimes at the expense of research quality and potentially amplifying inequities. To address these concerns, the authors propose 5 actionable measures to shift the incentives driving the research arms race in residency selection with the goal of promoting a fairer and more authentic residency application process: (1) limit the number of research entries allowed in the Electronic Residency Application Service (ERAS) application to emphasize quality over quantity; (2) revise research publication categories in the ERAS application to prevent double-counting and improve transparency; (3) revise the National Resident Matching Program Charting Outcomes tool to disaggregate types of research and report more comprehensive descriptive statistics; (4) encourage residency programs to transparently share their core values by clearly communicating the traits and experiences they most value; and (5) provide medical students with diverse opportunities to demonstrate their abilities and obtain mentorship and meaningful letters of recommendation. These changes could de-escalate the rising research productivity pressure and promote fairness and holistic review in the residency application process. Broad stakeholder engagement, buy-in, and collaboration-among program directors, medical schools, specialty organizations, and medical education organizations-will be critical to successfully implement these recommendations. Without seeking to de-escalate the rising research productivity pressure, there is a risk of amplifying a destructive trend toward homogeneity, stifling the creativity and diverse interests of future physicians, and fundamentally undermining holistic review.

Problem: California faces a physician workforce crisis: an aging physician population that lacks representation from socioeconomically disadvantaged and underrepresented racial and ethnic communities. Given physician practice patterns, this discrepancy severely impacts millions of Californians. In response, the California Future Health Workforce Commission issued recommendations to enhance workforce diversity, emphasizing the importance of expanding access to educational pathways in order to build a workforce more representative of the state and its needs.

Approach: In 2021, Senate Bill 40, proposed by Sen. Melissa Hurtado, D-14, paved the way for the establishment of the California Medicine Scholars Program (CMSP). CMSP takes a pioneering approach by focusing on community colleges as critical entry points for aspiring medical professionals. This strategic initiative involves forming Regional Hubs of Healthcare Opportunity (RHHO) that connect medical schools, community colleges, 4-year universities, and health systems to facilitate student mentorship, academic advising, and early exposure to health care environments. The program aims to create a scalable, systematic pathway for community college students, leveraging their unique educational experiences to better serve California's diverse populations.

Outcomes: Initial outcomes indicate promising engagement and interest, with 399 scholars enrolled across 4 RHHO regions since the 2022-2023 academic year, including significant representation from underrepresented groups and first-generation college students. As of the 2023-2024 academic year, 150 scholars have successfully been admitted to a 4-year university-the first major academic milestone on the pathway to medical school. However, challenges remain, such as limited partnerships with community colleges and funding to expand to additional regions.

Next steps: Future steps include targeted outreach to additional community colleges and ongoing evaluations of educational outcomes and student experiences to refine and enhance program effectiveness. By addressing these gaps, CMSP aims to create a more equitable pathway into medicine that aligns with California's health care needs and workforce diversity goals.

Mission-aligned selection and retention (formerly holistic review) offers an approach to selection that considers applicants' academic metrics, attributes, and experiences to assess job-related competencies and mission-aligned characteristics. Despite residency programs' interest in mission-aligned review, the current application context presents barriers. Designed when applicants submitted more manageable numbers of applications, the Electronic Residency Application Service (ERAS) application was not designed to support mission-aligned review amid high application volumes. It lacked sufficient structure to guide applicants to provide relevant, valuable information, leaving programs to over-rely on academic metrics rather than broader evaluations of applicants' qualifications. It also did not provide a formal process for applicants to indicate genuine interest in a program or location, unintentionally leading programs to draw inferences and rely on informal communications, introducing inequities into the application process. To address these challenges, in 2021, the Association of American Medical Colleges (AAMC) sought to streamline and restructure the ERAS application to guide applicants to provide meaningful content and support programs' mission-aligned review. The AAMC also leveraged the application to provide a formal, standardized process for applicants to indicate genuine interest and for programs to identify applicants interested in their programs and communities. The AAMC updated the experiences section (limited experiences to 10 and added structured experience information), added an optional impactful experiences essay question, and added geographic preferences and program signaling. Evaluation results from the 2022-2023 and 2023-2024 cycles show these changes may improve programs' ability to conduct effective and efficient mission-aligned review and may improve fairness in the selection process. This article discusses how changes to the ERAS application seek to promote mission-aligned review and fairness in residency selection, helping programs identify capable, mission-aligned applicants. It also discusses opportunities for further research and calls for ongoing evaluation of the ERAS application by the AAMC to support continuous improvement.

Purpose: Researchers extensively studied burnout in the medical profession; however, findings on gender differences have remained inconsistent. Understanding well-being disparities between male and female resident physicians is essential for providing appropriate support and fostering a sustainable medical workforce. This study examined gender differences in burnout, depression, job stress, and job satisfaction among Japanese resident physicians in their first and second postgraduate years.

Method: The authors conducted a nationwide, cross-sectional study using data from the 2022 General Medicine In-Training Examination (GM-ITE). The analysis included resident physicians who completed the GM-ITE; it assessed burnout, job stress, and job satisfaction using single items from the Mini-Z 2.0 on a five-point Likert scale, and measured depression using the Japanese version of the Patient Health Questionnaire-2. This study categorized gender as male or female and estimated prevalence ratios (PRs) for well-being outcomes using clustered log-linear modified Poisson regression models.

Results: The final analysis included 5812 residents, of whom 31.8% were female. Compared with male residents, female residents were younger, less likely to pursue high-workload specialties, and reported fewer working hours, emergency duties, and self-study time. Well-being outcomes revealed that 17.9% experienced burnout, 29.5% reported depressive symptoms, 39.0% experienced high job stress, and 66.6% reported job satisfaction. Multivariable analysis indicated that female residents were significantly less likely to experience burnout (PR = 0.74; 95% CI, 0.65-0.84) and more likely to report job satisfaction (PR = 1.10; 95% CI, 1.05-1.13). Gender differences in depressive symptoms and high job stress were not significant.

Conclusions: Female residents in Japan experienced lower burnout rates and higher job satisfaction than their male counterparts. These findings challenged assumptions that female gender universally correlates with poor occupational well-being outcomes in the medical field and underscored the need for gender-sensitive support strategies.

Problem: Professional and graduate students face unique challenges predisposing them to food insecurity, which impacts health and wellness. Lack of research and data on the barriers to food accessibility, availability, utilization, and stability impedes developing and implementing effective initiatives addressing student food insecurity.

Approach: A medical student champion at the Perelman School of Medicine, University of Pennsylvania, partnered with a community organization in Philadelphia to run 18 weekly produce pop-ups in the 2023 to 2024 academic year to target student food insecurity. The weekly events decreased food waste and repurposed surplus food to increase the availability of fresh fruits and vegetables to students. This medical student-driven initiative depended on student volunteers to advertise the events, pick up the produce, and set up and clean up the produce pop-ups. Produce pop-up attendees completed an anonymous survey containing discrete and open-ended questions, with more than 1000 survey responses. The student champion worked with faculty to evaluate the questionnaire responses and analyze the feedback on the events to understand the challenges students may face.

Outcomes: Analysis of 1080 responses revealed that professional and graduate students attending produce pop-ups face significant barriers to food accessibility, availability, utilization, and stability. Produce pop-ups increase access to fresh fruits and vegetables, improve student physical and mental health, and decrease food waste. By offering fresh fruits and vegetables to students, produce pop-ups facilitated at-home cooking and healthy eating, empowered students to try new and varied recipes, and increased sharing and socialization. Students reported tangible improvements in wellness from attending produce pop-ups.

Next steps: Produce pop-ups offer an innovative solution to provide fresh food to students and improve student health and wellness. Academic institutions should consider tracking the prevalence of food insecurity among their students and partnering with community organizations to repurpose excess produce to combat food insecurity.

Problem: Substance use disorders (SUDs) are widespread, yet few individuals receive treatment. Internal medicine (IM) residents need clinical training on how to provide SUD treatment.

Approach: In 2023, the authors used a structured approach to develop an addiction clinic integrated into the University of Cincinnati IM resident primary care practice to provide SUD treatment. A formative logic model with output measures to evaluate the short-term outcome of the first 15 weeks of clinic was used. Output measures included no-show rates, number of patient visits, and primary SUD diagnosis. Short-term outcomes of residents' experiences were evaluated using a retrospective pre-post survey and the McNemar paired test to assess their confidence in performing addiction-related clinical tasks before vs after their rotation.

Outcomes: Eighteen learners were sent a survey from December 2023 to March 2024, with 11 responding (61%). Short-term outcomes included resident-reported confidence as moderate, quite, or extremely confident in the listed tasks before vs after their clinic experiences: making an SUD diagnosis (4 [36%] vs. 10 [91%], P = .03), interpreting urine drug screen results (4 [36%] vs. 10 [91%], P = .03), starting buprenorphine for opioid use disorder (OUD) (1 [9%] vs. 8 [73%], P = .02), titrating buprenorphine for OUD (0 [0%] vs. 8 [73%], P = .01), starting medications for alcohol use disorder (4 [36%] vs. 7 [64%], P = .36), and harm reduction counseling (4 [36%] vs. 9 [82%], P = .06). In the first 15 weeks of this clinic, there were 73 patient visits. Primary SUD diagnoses were OUD (37 [51%]), alcohol use disorder (18 [25%]), other (7 [9%]), stimulant use disorder (6 [8%]), and nicotine (5 [7%]).

Next steps: Next steps include further evaluation of the clinic rotation's impact on resident clinical behaviors, attitudes on SUD, and patient SUD outcomes.

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.