PURPOSE: The concept of "distance traveled" (DT), which contextualizes applicants' achievements within their lived experiences, has emerged as a key component of holistic medical school admissions. However, little is kno...PURPOSE: The concept of "distance traveled" (DT), which contextualizes applicants' achievements within their lived experiences, has emerged as a key component of holistic medical school admissions. However, little is known about how applicants interpret and navigate disclosing DT within application materials. This study explores medical students' experiences with sharing DT and offers actionable recommendations for incorporating DT into equitable and holistic medical school selection processes. METHOD: The authors conducted semistructured interviews with medical students from US medical schools. Participants were recruited through purposive sampling to ensure demographic and geographic diversity. The Social Ecological Model guided interviews to explore students' understanding of DT, disclosure decisions, and admissions process reflections. Interviews were conducted between October and December 2021. Transcribed interviews were qualitatively analyzed using interpretive description. RESULTS: In total, 31 medical students from 7 US medical schools were included in the study. Three major themes emerged: (1) navigating unclear expectations-students experienced confusion about what aspects of their DT to share, how much detail to include, and how their narratives would be received; (2) balancing vulnerability and perception-students feared being judged negatively or perceived as seeking pity, leading some to omit significant experiences; and (3) the burden of personal disclosure-students described discomfort with recounting personal hardships in a professional context, especially when unsure who would read or interpret their stories. CONCLUSIONS: Although DT disclosures can enrich holistic review, applicants face emotional, strategic, and informational barriers to sharing their lived experiences. Medical school admissions processes are encouraged to provide more precise guidance on DT, promote culturally responsive review practices, and support applicants through thoughtful design and implementation of narrative components. These changes can help ensure DT is equitably and meaningfully incorporated into applicant evaluations.
In 2005, Weill Cornell Medicine revised the Hippocratic Oath. Since then, this revised oath has been administered to graduating medical students and become part of the curriculum during first-year orientation. In a flipp...In 2005, Weill Cornell Medicine revised the Hippocratic Oath. Since then, this revised oath has been administered to graduating medical students and become part of the curriculum during first-year orientation. In a flipped classroom exercise, one of the students questioned the Hippocratic injunction, "That I seek the counsel of others when they are more expert." The student wondered whether a physician should step aside in favor of artificial intelligence (AI). Should physicians defer to its expertise? In this commentary, the author responds to this query, balancing the ethical mandate to use this emerging technology to provide the best evidence-based medicine to those entrusted to one's care against the risk of delegating responsibility to an entity that can neither worry about the provision of care nor provide the therapeutic balm of the patient-physician relationship. The author questions how AI might affect professional formation and medical education, alter the development of a caring ethos, and foster a misplaced confidence in the extent of our medical knowledge. Delegation of writing and thinking to AI could similarly undermine opportunities for learning and human discernment, which can be the font for discovery. The author notes the irony that AI, as an all-knowing and all-seeing muse, might replace Apollo, to which the oath pledges fealty. The author asks if medicine wants to replace one mythology with another and cede the most humanistic of disciplines to a machine. If machines are allowed to think for us, physicians will lose an essential element of practice, forsaking the requisite self-knowledge to have agency and responsibility for their actions, thus ending medicine as it has been known.
O'Connor MM, Hobday PM, Long M
… +23 more, Soep J, Schwartz A, Balmer DF, Borman-Shoap E, Herman BE, Hanson JL, Lane JL, Andrews JS, Bale JF, Buckelew SM, Chen HC, Cullen MJ, Glasgow T, Good BP, Henry D, Murray KE, Richards BF, Rosenberg A, Carraccio C, West DC, Englander R, Powell DE, Education in Pediatrics Across the Continuum (EPAC) Study Group1
PURPOSE: Despite the movement toward competency-based medical education (CBME), most training programs in the United States still advance learners based on time-in-training rather than achievement of competency standards...PURPOSE: Despite the movement toward competency-based medical education (CBME), most training programs in the United States still advance learners based on time-in-training rather than achievement of competency standards. The Education in Pediatrics Across the Continuum (EPAC) project sought to answer whether it is possible to make time-variable, competency-based advancement decisions by creating a program that spans undergraduate (UME) to graduate medical education (GME) to fellowship/practice. This article reports the outcomes of the EPAC project. METHOD: Each participating site (Universities of California-San Francisco, Colorado, Minnesota, and Utah) selected 4 consecutive cohorts and prospectively followed them from July 2013 to June 2023. Implementation allowed for site-variability but adhered to common design principles. The Core Entrustable Professional Activities (EPAs) for Entering Residency and the General Pediatrics EPAs were the competency frameworks. Each site convened a clinical competency committee every three to six months to determine readiness for learner transition from UME to GME and GME to practice/fellowship based on demonstrated competence. RESULTS: Fifty-six learners enrolled in EPAC and forty-four (79%) completed the program as designed. The time required for each learner to demonstrate readiness for transition from UME to GME (mean 20.2 four-week blocks [SD 2.76], range 14.5-26) and GME to practice/fellowship (mean 5.8 six-month blocks, [SD 0.34], range 4.9-6.1) varied. EPAC participants' educational outcomes were comparable to non-EPAC graduates at the same site, including Milestones ratings (B = 0.30, P = .21), first time pass rates for the American Board of Pediatrics initial certifying exam (93%, 95% CI 81%-98%), and attainment of fellowship or job placements after graduation. CONCLUSIONS: The outcomes of the EPAC project demonstrated the ability to make competency-based readiness-to-transition decisions for individual learners and is the first CBME program to span the UME/GME medical education continuum in the US. Lessons learned from the EPAC project have the potential to contribute to advancement efforts for CBME.
PROBLEM: Diagnostic reasoning, the cognitive process of interpreting clinical information to arrive at a diagnosis, is a critical competency in medical education, and has been taught using authentic methods such as stand...PROBLEM: Diagnostic reasoning, the cognitive process of interpreting clinical information to arrive at a diagnosis, is a critical competency in medical education, and has been taught using authentic methods such as standardized patients and peer role-playing that simulate real clinical encounters. Although effective, these approaches require substantial time, space, and cost. APPROACH: To address the limitations of traditional approaches, artificial intelligence-powered virtual patient chatbots were developed between April 21-28, 2025, with a chatbot builder that incorporates natural language processing. The design was guided by 2 core cognitive models of diagnostic reasoning-the dual process model and the memory model. The chatbots simulated authentic physician-patient interactions across 3 clinical scenarios: fatigue, stomach ache, and memory loss. Students can perform differential diagnoses based on various clinical data and received immediate feedback on diagnostic accuracy. OUTCOMES: The patient chatbots were evaluated through surveys and interviews with faculty (May 2025) and students (November 2025). Findings consistently indicated that the chatbots functioned as an effective (4.50/5) and usable tool (4.46/5) for diagnostic reasoning practice. Participants perceived that the chatbots supported "core cognitive processes of diagnostic reasoning" by prompting active hypothetico-deductive reasoning, whereas repeated exposure to different cases was viewed as facilitating pattern recognition. Faculty highlighted the chatbots' cost-efficiency and scalability within curricula, whereas students emphasized authentic "from-zero" clinical reasoning and the value of reviewing dialogue logs for reflection. Overall, the results demonstrate that the chatbots can provide a feasible and educationally meaningful environment for practicing diagnostic reasoning in medical education. NEXT STEPS: Future work should refine artificial intelligence-powered virtual patient chatbots by incorporating tiered case complexity, patient-centered language, and equity-oriented design. Effective use will require systematic instructional design and learner preparation for emotionally challenging scenarios. Larger empirical studies using both outcome and interaction data are needed to evaluate educational impact and guide integration into clinical training.
The initial encounter between clinician and patient represents a critical yet often undervalued moment in healthcare delivery. This commentary emphasizes that first impressions are not merely social pleasantries but foun...The initial encounter between clinician and patient represents a critical yet often undervalued moment in healthcare delivery. This commentary emphasizes that first impressions are not merely social pleasantries but foundational determinants of therapeutic alliance and patient outcomes. The quality of initial human connection-characterized by authentic presence, genuine attention, and visible respect for patient humanity-establishes the scaffolding upon which therapeutic relationships are constructed. Research demonstrates that patients who perceive themselves as genuinely seen and heard in opening moments exhibit greater satisfaction, improved treatment adherence, and measurably better health outcomes.
PURPOSE: Accurate and complete order entry is an essential skill for all medical graduates. However, medical students report limited confidence in performing this task. This study examined stakeholder perspectives on ord...PURPOSE: Accurate and complete order entry is an essential skill for all medical graduates. However, medical students report limited confidence in performing this task. This study examined stakeholder perspectives on order entry to identify educational gaps and inform curriculum development. METHOD: This phenomenological, qualitative study was performed from November 2024 to May 2025 with semistructured interviews of interprofessional stakeholders at the University of Nebraska Medical Center regarding their perceptions of common and high-consequence errors in order entry by new physicians and suggestions for needed education. Stakeholders included inpatient nurses, inpatient pharmacists, interns, and supervising physicians. Analysis was performed using open inductive coding. RESULTS: Eight themes emerged from qualitative analysis of 17 stakeholder interviews. Education and training highlighted the need for both formal and informal instruction on order entry, medication management, and institutional protocols. Contextual awareness emphasized the importance of critically evaluating order appropriateness and identifying inconsistencies. Collaboration in care underscored the role of interprofessional teamwork and communication in reducing errors. Oversight and accountability revealed that early trainees often rely on pharmacists and nurses to catch mistakes, highlighting the need for structured supervision and personal responsibility. Optimizing order systems addressed how electronic health record design, including order sets, prepopulated fields, and decision support, affects accuracy and efficiency. Special populations and vulnerable moments identified increased risk of errors in pediatric, renal, and transitional care scenarios. Informed decision-making reflected gaps in clinical knowledge related to medication selection, dosing, and interactions. Precision in practice stressed the importance of paying attention to detail, verifying accuracy, and balancing speed with thoroughness in order entry. CONCLUSIONS: New physicians face multifaceted challenges in mastering order entry, underscoring the need for integrated, longitudinal, and interprofessional educational approaches. Although targeted interventions can improve confidence and competence, sustained practice, reflective learning, and supportive system design are essential for developing durable proficiency.
PROBLEM: Graduate medical education requires learners to acquire broad clinical exposures to meet core competencies for unsupervised practice, but variability in clinical learning environments and reliance on resource-in...PROBLEM: Graduate medical education requires learners to acquire broad clinical exposures to meet core competencies for unsupervised practice, but variability in clinical learning environments and reliance on resource-intensive assessments hinder precise assessment of trainees' clinical experiences. Electronic health records hold promise for precision medical education, yet manual mapping of International Classification of Diseases, Tenth Revision (ICD-10) codes to specialty-specific clinical practice domains limits scalability. APPROACH: The authors leveraged electronic health record data and artificial intelligence (AI) to map residents' encounter diagnoses to the American Board of Emergency Medicine's Model of the Clinical Practice of Emergency Medicine (MCPEM). Resident encounters across 3 sites at a single academic system (January 1-October 31, 2023) were analyzed with an AI model, mapped to MCPEM categories with ICD-10 descriptors, and quantified with vectors to match to the closest MCPEM category. Faculty raters validated the most common mappings iteratively, which were subsequently integrated into interactive learner dashboards. OUTCOMES: Among 119,320 encounters, 5960 unique ICD-10 descriptors (1126 stem codes) were identified. For the 650 most common diagnoses, 507 (78.0%) of emergency department diagnosis text descriptors were determined as valid mappings to an MCPEM subcategory. In mappings where faculty were discordant with the lowest distance mapping, 171 of 305 alternative subcategory mappings (56.0%) achieved agreement, increasing the concordance between reviewers to 515 of 650 (79.2%) overall. Interactive dashboards displayed resident-level case mix mapped to MCPEM categories, with anonymized peer comparisons and program-level aggregates, enabling identification of patterns and gaps by domain. NEXT STEPS: Planned work includes iterating AI-automated mappings by expanding inputs beyond diagnoses, engaging wider stakeholder review of mapping validations, and assessing generalizability to other specialties' content outlines to produce a scalable and reproducible model to increase the precision of feedback loops to inform graduate medical education, the clinical learning environment, and training design.
This Scholarly Perspective frames workplace-based training in medical education as a succession concept and explores how the benefits of the traditional apprenticeship model can integrate with modern competency-based med...This Scholarly Perspective frames workplace-based training in medical education as a succession concept and explores how the benefits of the traditional apprenticeship model can integrate with modern competency-based medical education. In 2024, the author broadened the construct of medical competence into 3 semihierarchical layers: canonical, contextual, and personalized. Canonical competence (the canon that all professionals should know) relates to knowledge and skills that meet generalized, context-independent standards, assessed with methods of high psychometric quality. Personalized competence has a focus on the individual pursuit of excellence. The focus of this article is on contextual competence (the ability to work in a patient care context). Contextual competence requires workplace-based assessment and judgments by professionals with relevant expertise and experience. Central is the notion of entrustment. The aim of workplace-based training and assessment is bringing learners to a level of readiness to be entrusted with health care tasks, beyond the standards for canonical competence. Entrustment with units of practice (entrustable professional activities [EPAs]) implies providing autonomy to learners, which requires a prospective focus (Is the learner ready for patient care?) rather than a retrospective focus (Has the learner completed all tasks as assigned?). Autonomy, relevant for identity formation, can be modulated by providing a deliberate decrease of supervision and by starting with small part-tasks (nested EPAs), later subsumed in broader EPAs. An apprenticeship model of workplace-based training and assessment with a prospective aim requires, along with supervisory effort, a rotational structure that allows for sufficient acquaintance with the trainees to enable entrustment with patient care. When entrustment is taken seriously, pivotal points arise when learners start to contribute to care and thus take over the work of their supervisors. Not only is this a return on investment, but it also can enhance learner motivation and supervisor satisfaction; however, it requires a curricular transformation.
PURPOSE: Licensure and certification examinations have traditionally served to ensure physicians possess the knowledge and skills required for independent practice. However, with the growing emphasis on workplace-based a...PURPOSE: Licensure and certification examinations have traditionally served to ensure physicians possess the knowledge and skills required for independent practice. However, with the growing emphasis on workplace-based assessment (WBA), the role and relevance of these point-in-time examinations are increasingly debated. This systematic review aimed to explore the association between physician performance on national licensing and certification examinations and subsequent measures of quality of care in practice. METHOD: The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Six databases were searched through to November 2025. Original research studies were included if they examined the relationship between performance on medical licensing or certification examinations and physician performance in independent practice, including patient outcomes and fitness to practice. Data were extracted and analyzed using content analysis to identify patterns and trends across studies. RESULTS: A total of 44 studies involving 1,021,187 physicians were included. The findings demonstrated that examination performance was consistently associated with quality of patient care and fitness-to-practice concerns. Better examination performance was linked to improved adherence to mammography screening recommendations, appropriate prescribing practices, improved care of patients with diabetes, lower patient morbidity and mortality, fewer complaints to regulatory bodies, and lower malpractice payments. The association was observed across examination formats and medical specialties. CONCLUSIONS: The results suggest that national licensing and certification examinations are valuable predictors of future clinical performance. They provide a uniform benchmark to ensure physicians meet rigorously defined criteria. The findings support continued use of these examinations as part of a comprehensive assessment program to promote high-quality patient care and physician competence. This is critical in an era of increased physician mobility, where many physicians have trained in jurisdictions with widely varying curricula and assessment practices. National examinations help ensure that all licensed physicians meet a consistent standard for clinical competence.