PurposeThe role of the medical educator has evolved from being simply an educator of a learner apprentice to many different roles, such as mentor, assessor, and role model. This study examines how the conceptualization of the role of medical educators in graduate medical education (GME) has evolved over time.MethodThe authors conducted a state-of-the-art literature review to explore (1) the current conceptualization of the roles of medical educators in GME, (2) how this conceptualization came to be, and (3) how we might revise this conceptualization to advance future work. The authors searched Scopus in May 2023 and selected sentinel articles broadly adopted in the medical education literature (24 journals) and then cross-checked the search strategy in Web of Science. The search was updated in both databases in March 2025. No time limits were imposed on the searches. The authors screened 4,468 articles from Scopus, 2,571 from Web of Science, and 82 from hand search.ResultsFrom 1972 to March 2025, 30 roles appeared across the 55-article corpus. The germinal years showed educators as learner-centered role models. Transition points included (1) 1990s (broadening of educator roles relevant to professional development), (2) early 2000s (roles focused on society at large), and (3) 2010s (multiple tensions for the expanding roles of today’s educator).ConclusionsThe conceptualization of GME educators has expanded greatly over time. Reconciling, supporting, and anticipating roles will be important as GME educators continue to adapt to society’s evolving needs, with implications for essential faculty development initiatives.

PurposeAugmented reality (AR) can generate realistic holograms overlaid on the real-word environment to provide an interactive learning experience. However, further research is needed to assess the impact of such technologies on knowledge acquisition. This study aims to evaluate the efficacy of an AR learning application in anatomy education.MethodTEACHANATOMY, a controlled, randomized trial, was conducted from September 14–October 24, 2022, at the University of Zurich and the Swiss Federal Institute of Technology. It included first- and second-year medical students with no prior anatomy education and compared learning with an interactive hologram-based AR learning module—incorporating adaptive learning and gamification elements—with traditional learning (TL) methods including textbooks, videos, and online resources. Forty-eight participants were randomly allocated to the AR or TL group. The primary outcome consisted of the scores on the theoretical and practical knowledge tests. Secondary outcomes included adverse health symptoms and user experience.ResultsThe AR group performed significantly better on both theoretical (median [IQR] scores: AR: 18.8 [16.6–20.0]; TL: 9.4 [7.7–11.3]; P < .001) and practical (AR: 14.0 [12.3–14.7]; TL: 5.0 [4.0–6.0]; P < .001) knowledge tests. The most common adverse health symptoms were headache, reported by 13/24 (54.2%) TL participants and 9/24 (37.5%) AR participants, and fatigue, and experienced by 13/24 (54.2%) TL participants and 2/24 (8.3%) AR participants. All participants evaluated learning with TEACHANATOMY as a positive experience, rating it as efficient and easy to understand. All participants agreed learning with AR can be beneficial in learning anatomy, with 89.6% (43/48) and 100% (48/48) expressing willingness to use AR as a learning tool for theoretical and practical anatomy learning, respectively.ConclusionsFindings show a short-term learning benefit with the use of the TEACHANATOMY learning application, thus supporting the implementation of interactive hologram-based AR technologies to improve knowledge in anatomy education.

To the Editor: We appreciate the study done by Kraakevik and colleagues, which emphasizes a novel way to administer end-of-clerkship National Board of Medical Examiner (NBME) subject (“shelf”) examinations in the third year of medical school. The findings of their research suggest that offering flexible timing for standardized medical knowledge examinations may actually enhance shelf exam scores, as opposed to negatively impacting student performance.1 We believe that the outcomes obtained from this study carry significant implications, not only for medical education but also for the residency match process and beyond. With the recent transition of the United States Medical Licensing Exam (USMLE) Step 1 to a pass/fail scoring system, residency program directors face the challenge of devising new methods to differentiate between students. One likely approach is to shift the focus toward USMLE Step 2 scores, but an alternative suggestion has emerged that advocates for the more consistent utilization and reporting of NBME subject exams.2 This proposal would potentially increase stress associated with each individual test.2 Currently, the duration of clerkships varies across medical schools, resulting in discrepancies in the timing of shelf exams—ranging from after 4 weeks to after 6 or 8 weeks.1 Consequently, these scores should not be used as a standardized metric by residency programs. Instead of assigned timing, permitting all students to take shelf exams at their own pace could afford them greater control, similar to the flexibility currently available for taking Step 2. Moreover, it would provide residency programs with a means to incorporate shelf exams as a uniform evaluation tool. By allowing for student-selected exam timing, there exists the potential for improved scores, as evidenced by Kraakevik and colleagues’ findings, which could have a ripple effect on the competitiveness of students during the residency match. Moreover, the findings of the authors’ study align with the evolving shift toward competency-based medical education (CBME). Competency-based frameworks emphasize the development of specific skills and abilities over time-based requirements. Allowing students to choose their examination timing aligns with the principles of CBME, granting them the opportunity to demonstrate competence when they feel adequately prepared. As medical schools continue to embrace this approach, it becomes essential to explore aligned strategies that empower students and enhance their learning experience. Kraakevik and colleagues have sparked the possibility of a groundbreaking approach to tackling the match process in the Step 1 pass/fail era. By investigating the impact of flexible shelf exam scheduling and finding a positive shift in student scores, this study has perhaps unveiled a new paradigm to reshape medical education, residency match outcomes, and ultimately, the quality of health care delivery by future physicians. Shivam KhatriThird-year medical student, City University of NewYork School of Medicine, New York, New York; email: [email protected]; X (formerly Twitter):@ShivamKhatri99Alan P. SamsonovThird-year medical student, City University ofNew York School of Medicine, New York,New York

Competency-based medical education is increasingly regarded as a preferred framework for physician training, but implementation is limited. U.S. residency programs remain largely time based, with variable assessments and limited opportunities for individualization. Gaps in graduates' readiness for unsupervised care have been noted across specialties. Logistical barriers and regulatory requirements constrain movement toward competency-based, time-variable (CBTV) graduate medical education (GME), despite its theoretical benefits. The authors describe a vision for CBTV-GME and an implementation model that can be applied across specialties. Termed "Promotion in Place" (PIP), the model relies on enhanced assessment, clear criteria for advancement, and flexibility to adjust individuals' responsibilities and time in training based on demonstrated competence. PIP allows a resident's graduation to be advanced or delayed accordingly. Residents deemed competent for early graduation can transition to attending physician status within their training institution and benefit from a period of "sheltered independence" until the standard graduation date. Residents who need extended time to achieve competency have graduation delayed to incorporate additional targeted education. A proposal to pilot the PIP model of CBTV-GME received funding through the American Medical Association's "Reimagining Residency" initiative in 2019. Ten of 46 residency programs in a multihospital system expressed interest and pursued initial planning. Seven programs withdrew for reasons including program director transitions, uncertainty about resident reactions, and the COVID-19 pandemic. Three programs petitioned their specialty boards for exemptions from time-based training. One program was granted the needed exemption and launched a PIP pilot, now in year 4, demonstrating the feasibility of implementing this model. Implementation tools and templates are described. Larger-scale implementation with longer-term assessment is needed to evaluate the impact and generalizability of this CBTV-GME model.

Systems-based practice (SBP) was introduced as 1 of 6 core competencies in 1999 because of its recognized importance in the quality and safety of health care provided to patients. Nearly 25 years later, faculty and learners continue to struggle with understanding and implementing this essential competency, thus hindering the medical education community's ability to most effectively teach and learn this important competency.Milestones were first introduced in 2013 as one effort to support implementation of the general competencies. However, each specialty developed its milestones independently, leading to substantial heterogeneity in the narrative descriptions of competencies including SBP. The process to create Milestones 2.0, and more specifically, the Harmonized Milestones, took this experience into account and endeavored to create a shared language for SBP across all specialties and subspecialties. The 3 subcompetencies in SBP are now patient safety and quality improvement, systems-navigation for patient-centered care (coordination of care, transitions of care, local population health), and physician's role in health care systems (components of the system, costs and resources, transitions to practice). Milestones 2.0 are also now supported by new supplemental guides that provide specific real-world examples to help learners and faculty put SBP into the context of the complex health care environment.While substantially more resources and tools are now available to aid faculty and to serve as a guide for residents and fellows, much work to effectively implement SBP remains. This commentary will explore the evolutionary history of SBP, the challenges facing implementation, and suggestions for how programs can use the new milestone resources for SBP. The academic medicine community must work together to advance this competency as an essential part of professional development.

J.R. Lewy is a medical student at University of Michigan Medical School, Ann Arbor, Michigan; email: [email protected]; Twitter: @JxLewy; ORCID: https://orcid.org/0000-0003-0418-9309. See facing page for Standing Figure by Alberto Giacometti. Commentary first published online August 30, 2022.

Narrative assessments are commonly incorporated into competency-based medical education programs. However, efforts to share competency-based medical education assessment data among programs to support the evaluation and improvement of assessment systems have been limited in part because of security concerns. Deidentifying assessment data mitigates these concerns, but deidentifying narrative assessments is time-consuming, resource intensive, and error prone. The authors developed and tested a tool to automate the deidentification of narrative assessments and facilitate their review. The authors met throughout 2021 and 2022 to iteratively design, test, and refine the deidentification algorithm and data review interface. Preliminary testing of the prototype deidentification algorithm was performed using narrative assessments from the University of Saskatchewan emergency medicine program. The algorithm's accuracy was assessed by the authors using the review interface designed for this purpose. Formal testing included 2 rounds of deidentification and review by members of the authorship team. Both the algorithm and data review interface were refined during the testing process. Authors from 3 institutions, including 3 emergency medicine programs, an anesthesia program, and a surgical program, participated in formal testing. In the final round of review, 99.4% of the narrative assessments were fully deidentified (names, nicknames, and pronouns removed). The results were comparable for each institution and specialty. The data review interface was improved with feedback obtained after each round of review and found to be intuitive. This innovation has demonstrated viability evidence of an algorithmic approach to the deidentification of assessment narratives while reinforcing that a small number of errors are likely to persist. Future steps include the refinement of both the algorithm to improve its accuracy and the data review interface to support additional data set formats.

Procedural training for nonsurgical fields, such as internal medicine, is an important component of medical education. However, recent changes to accreditation guidelines have resulted in less formal guidance on procedural competency, not only leading to opportunities for individualizing training but also creating potential problems for trainees and training programs. In this article, the authors use internal medicine as an exemplar to review current strategies for procedural education in nonsurgical fields, including procedural simulation, dedicated procedural rotations, and advanced subspecialty training, and highlight an emerging need for learner-specific terminal milestones in procedural training. Individualized learning plans (ILPs), collections of trainee-specific objectives for learning, are arguably a useful strategy for organizing procedural training. The role of ILPs as a framework to support setting learner-specific terminal milestones, guide skill acquisition, and allocate procedural learning opportunities based on trainees' anticipated career plans is subsequently explored, and how an ILP-based approach might be implemented within the complex educational milieu of a clinical training program is examined. The limitations and pitfalls of an ILP-based approach, including the need for development of coaching programs, are considered. The authors conclude that, despite the limitations of ILPs, when combined with other current strategies for building trainees' procedural competence, these plans may help trainees maximize the educational benefits of their training period and can encourage effective, safer, and equitable allocation of procedural practice opportunities.

A central goal of precision education (PE) is efficiently delivering the right educational intervention to the right learner at the right time. This can be achieved through a PE cycle that involves gathering inputs, using analytics to generate insights, planning and implementing interventions, learning and assessing outcomes, and then using lessons learned to inform modifications to the cycle. In this paper, the authors describe 3 PE initiatives utilizing this cycle. The Graduate Medical Education Laboratory (GEL) uses longitudinal data on graduate trainee behavior, clinical skills, and wellness to improve clinical performance and professional fulfillment. The Transition to Residency Advantage (TRA) program uses learner data from medical school coupled with individualized coaching to improve the transition to residency. The Anesthesia Research Group for Educational Technology (TARGET) is developing an automated tool to deliver individualized education to anesthesia residents based on a longitudinal digital representation of the learner. The authors discuss strengths of the PE cycle and transferrable learnings for future PE innovations. Common challenges are identified, including related to data (e.g., volume, variety, sharing across institutions, using the electronic health record), analytics (e.g., validating augmented intelligence models), and interventions (e.g., scaling up learner assessments with limited resources). PE developers need to share their experiences in order to overcome these challenges, develop best practices, and ensure ethical development of future systems. Adapting a common framework to develop and assess PE initiatives will lead to a clearer understanding of their impact, help to mitigate potential risks, and allow deployment of successful practices on a larger scale.

To describe how the characteristics of the hospitals and communities they serve vary across the 4 hospital graduate medical education (GME) expense categories (according to Section 131 of the Consolidated Appropriations Act of 2021) and identify the rurally located never claimer hospitals that are most similar to teaching hospitals, signaling that they might be good candidates for new rural GME programs. Hospital categories and characteristics were gathered from the March 2022 Medicare Cost Reports; 2022 County Health Rankings & Roadmaps data were used for community characteristics. Each acute hospital was classified into 1 of the following 4 mutually exclusive hospital categories: category A, category B, established teaching hospital (ETH), and never claimer. Multinomial logistic regressions were conducted to estimate the adjusted associations of hospital characteristics with hospital categories and to identify the never claimer hospitals in rural locations that have characteristics similar to teaching hospitals (category A, category B, and ETHs). Out of 3,590 hospitals, 2,075 (57.8%) were never claimer hospitals. After adjusting for multiple characteristics, rural hospitals had a similar probability of being in each hospital category to that of urban hospitals. Never claimer hospitals served an older population and were located in communities with more uninsured adults and children and less availability of primary care physicians, dentists, and mental health professionals. This study demonstrated that most hospitals in every category, but especially teaching hospitals (i.e., category A hospitals, category B hospitals, and ETHs), were concentrated in urban areas. Larger hospitals (measured by net patient revenue) were more likely to report GME expenses (i.e., be a category A hospital, a category B hospital, or an ETH). The study suggests that there are roughly 145 rural never claimer hospitals that might be strong candidates for initiating new residency programs.