Residency program directors use clerkship grades for high-stakes selection decisions despite substantial variability in grading systems and distributions. The authors apply clustering techniques from data science to identify groups of schools for which grading distributions were statistically similar in the internal medicine clerkship. Grading systems (e.g., honors/pass/fail) and distributions (i.e., percent of students in each grade tier) were tabulated for the internal medicine clerkship at U.S. MD-granting medical schools by manually reviewing Medical Student Performance Evaluations (MSPEs) in the 2019 and 2020 residency application cycles. Grading distributions were analyzed using k-means cluster analysis, with the optimal number of clusters selected using model fit indices. Among the 145 medical schools with available MSPE data, 64 distinct grading systems were reported. Among the 135 schools reporting a grading distribution, the median percent of students receiving the highest and lowest tier grade was 32% (range: 2%-66%) and 2% (range: 0%-91%), respectively. Four clusters was the most optimal solution (η 2 = 0.8): cluster 1 (45% [highest grade tier]-45% [middle tier]-10% [lowest tier], n = 64 [47%] schools), cluster 2 (25%-30%-45%, n = 40 [30%] schools), cluster 3 (20%-75%-5%, n = 25 [19%] schools), and cluster 4 (15%-25%-25%-25%-10%, n = 6 [4%] schools). The findings suggest internal medicine clerkship grading systems may be more comparable across institutions than previously thought. The authors will prospectively review reported clerkship grading approaches across additional specialties and are conducting a mixed-methods analysis, incorporating a sequential explanatory model, to interview stakeholder groups on the use of the patterns identified.

Health care inequities persist, and it is difficult to teach health professions students effectively about implicit bias, structural inequities, and caring for patients from underrepresented or minoritized backgrounds. Improvisational theater (improv), where performers create everything in a spontaneous and unplanned manner, may help teach health professions trainees about advancing health equity. Core improv skills, discussion, and self-reflection can help improve communication; build trustworthy relationships with patients; and address bias, racism, oppressive systems, and structural inequities. Authors integrated a 90-minute virtual improv workshop using basic exercises into a required course for first-year medical students at University of Chicago in 2020. Sixty randomly chosen students took the workshop and 37 (62%) responded to Likert-scale and open-ended questions about strengths, impact, and areas for improvement. Eleven students participated in structured interviews about their experience. Twenty-eight (76%) of 37 students rated the workshop as very good or excellent, and 31 (84%) would recommend it to others. Over 80% of students perceived their listening and observation skills improved, and that the workshop would help them take better care of patients with experiences different than their own. Six (16%) students experienced stress during the workshop but 36 (97%) felt safe. Eleven (30%) students agreed there were meaningful discussions about systemic inequities. Qualitative interview analysis showed that students thought the workshop helped develop interpersonal skills (communication, relationship building, empathy); helped personal growth (insights into perception of self and others, ability to adapt to unexpected situations); and felt safe. Students noted the workshop helped them to be in the moment with patients and respond to the unexpected in ways more traditional communication curricula have not. The authors developed a conceptual model relating improv skills and equity teaching methods to advancing health equity. Improv theater exercises can complement traditional communication curricula to advance health equity.

There is a persistent rural physician shortage in the United States. Policies to scale up the health workforce in response to this shortage must include measures to draw and maintain existing and newly trained health care workers to rural regions. Prior studies have found that experience in community medicine in rural practice settings increases the likelihood of medical graduates practicing in those regions but have not accounted for selection bias. This study examined the impact of a community-based clinical immersion program on medical graduates' decision to work in rural regions, adjusting for covariates to control for selection bias. Data on sociodemographic characteristics and career interests and preferences for all 1,172 University of Washington School of Medicine graduates between 2009 and 2014 were collected. A logistic model (model 1) was used to evaluate the impact of Rural Underserved Opportunities Program (RUOP) participation on the probability of physicians working in a rural region. Another model (model 2) included the propensity score as a covariate in the regression to control for possible confounding based on differences among those who did and did not participate in the RUOP. Of the 994 students included in the analysis, 570 (57.3%) participated in RUOP training, and 111 (11.2%) were currently working in rural communities after their training. Regression analysis results showed that the odds of working in a rural region were 1.83 times higher for graduates who participated in RUOP in model 1 ( P = .03) and 1.77 times higher in model 2 ( P = .04). The findings of this study emphasize that educational programs and policies are crucial public health interventions that can promote health equity through proper distribution of health care workers across rural regions of the United States.

When June 23rd rolls around each year, I remember the very first day of my residency. It was a great, immensely significant—and wholly terrifying—moment in my life. Despite being very well prepared, I, of course, did not feel ready at all. I did not feel ready for the responsibilities of caring for so many patients. I did not feel ready for the new hospital systems and staff. I was ready for a paycheck but not for the mountain of paperwork from Human Resources and the new dual role as learner–employee. And I certainly did not feel ready for all that I would see and experience in that crucial, formative year. I survived, of course, and I learned something very important. Day 1 of one’s internship is, in fact, not nearly as frightening as Day 1 of the second year of residency, when you are responsible for your team’s brand-new interns facing their first day, not feeling quite ready. In this issue of our journal, we have several articles 1–5 on the transition from undergraduate medical education (UME) to graduate medical education (GME). These articles have been written by and for stakeholders in health professions education, including learners, teachers, and leaders in academic medicine and health systems. According to Hauer et al 1 of the Coalition for Physician Accountability (CoPA), the transition from UME to GME is, in its ideal state, a system to support a continuum of professional development and learning, thus serving learners, educators, and the public, and engendering trust among them. It also supports the well-being of learners and educators, promotes diversity, and minimizes bias. Challenges to attaining this ideal state in the undergraduate-to-graduate transition, noted by Swails et al 2 (also of CoPA) in their root cause analysis, include bias, limited resources and cost, a competitive culture, poorly functioning systems, a lack of adequate standards, and lack of sufficient alignment across systems and stakeholders, all of which generate an “ineffective” transition. This analysis overlaps with 3 persistent issues, identified by Hauer et al, 1 that require greater ongoing attention and management. First, present approaches to assessment are not suited to ranking and sorting candidates for GME placement. A second issue is the inherent tension in the role of resident as a health professions learner and a health system worker. And a third concern is that the current Match process may position the interests and needs of individual physicians-in-training at odds with the interests and needs of the health care workforce and public. Financial burdens carried by medical students and residents are an additional concern, raised in a commentary by Lin et al 3: We are acutely aware of the high and growing costs of away rotations, application fees…, and in-person interviews and second looks—on top of increasing median education debt, now greater than $200,000. The authors, who are former trainee representatives of CoPA, advocate that undergraduate and graduate medical learners be collaborative partners and agents of change in the current system. Lin et al 3 also highlight 2 key recommendations from a final report of CoPA: forming a national committee to manage quality improvement of the UME–GME transition and having pilot interventions to reduce the growing number of residency applications. The idea of reducing residency application numbers through application “limits” was the most popular possible solution endorsed in a qualitative study performed by Dacre et al. 4 In this project, authors used semistructured interviews to ask 30 participants from 9 medical specialties about 5 residency application reform proposals. The proposals were (1) using a match process to obtain interviews, (2) having preference signaling during the application process, (3) introducing application limits, (4) disclosing geographic preference(s), and (5) eliminating the Match. None of the proposals was embraced by all participants. Interestingly, only 3 of 25 participants agreed with dismantling the Match, and a number of participants expressed concern that such a step would hurt students’ interests. Almost all participants felt that system change was nevertheless warranted, particularly with respect to problems of equity, complexity, or poor outcomes. The benefits of virtual residency interviews over traditional in-person interviews are outlined by Hampshire et al, 5 who note that the use of virtual interviews reduces the carbon footprint of the field of medicine and fosters greater equity by reducing the cost burden for applicants. Other recommendations offered by our colleagues are related to developing a common competency framework with aligned assessments, introducing workforce diversity evaluations and equitable recruitment practices, and increasing attention to data-driven studies to improve the UME–GME transition. The authors of several articles 1–4 in this cluster emphasize the need for greater transparency at institutional and national levels and the need for pilot studies of novel programs that could improve matching with preferred programs and, at the same time, produce a more even distribution of physicians and a strengthened medical workforce in the United States. Taken together, this guidance resonates with past scholarship appearing in Academic Medicine in which Morgan et al 6 emphasized the importance of a responsible educational handover at the UME–GME juncture. The ideal educational handover is one that is learner driven; oriented toward continuous, individualized learning; supported by accurate performance data and appropriate institutional infrastructure; and genuinely helps students actually be prepared for the care of patients. Past work appearing in the journal has similarly reinforced the importance of greater emphasis on competency-based assessments (such as discussed by Murray et al 7), and better preparation in the last year of medical school. 8 “An ideal state cannot be achieved quickly or without compromise,” caution Hauer et al, 1 who also invite our field to seek change, celebrate “early wins,” and show “ongoing flexibility and adaptation.” The experiences of the past few years suggest that we are capable of constructive change, as the example of virtual residency interviews, born out of necessity during the pandemic, illustrates. 5 First days will always be difficult, but we in the field of academic medicine can care for future physicians and their patients by making the transition from UME to GME as seamless and supported as possible. The well-being of our learners, educators, and, most importantly, their patients and the public is at stake.

Intraoperative teaching is a critical component of surgery residents' education. Although prior studies have investigated best practices from the viewpoint of the expert educator, the perspective of the learner has been less explored. This study examined the ideal faculty teaching behaviors that optimize intraoperative teaching from the surgical residents' perspective. Using a grounded theory method, this study explored perspectives on intraoperative faculty teaching qualities of 5 focus groups of categorical clinical general surgical residents of the same postgraduate year from June to August 2021. Focus group discussions were recorded, transcribed, and coded. Emerging themes were identified, along with their corresponding subthemes. Thirty-nine general surgery residents participated in the focus groups. Overall, 6 themes emerged regarding resident priorities of intraoperative teaching, with 10 subthemes. Themes included the following: (1) character, with subthemes of caring, respect for resident, and self-control; (2) intraoperative skill, with subthemes of clinical and operative skill and modeling leadership in the operating room; (3) instructional approach; (4) feedback, with subthemes of content of feedback and debriefing; (5) discernment of resident needs, with subthemes of managing expectations, individualizing instruction, and autonomy; and (6) variety of teachers. Certain tangible strategies, such as demonstrating genuine care for the learner, using clear directional words, and giving actionable feedback, were considered vital by residents. In the development of great surgical educators, the emphasis should not be on conformity to a single idealized teaching style but should celebrate and encourage diversity of personas and teaching styles within a department or program.

To the Editor: The COVID-19 pandemic permanently changed the residency application process, leading programs to create innovative recruitment strategies and leaving applicants searching for answers about the process. Typically, resources and guidance about the Match are provided through shared experiences of peers and medical school administrators, but with virtual interviews, recruitment seasons are more unique. To address this shift, in September 2020, with one $48 microphone and 2 trainee voices, we launched Inside the Match. The goal was simple: to create a platform to provide free, equitable opportunities and transparency about the residency Match process. The Inside the Match podcast features interviews with residents and leaders in medical education about navigating the Match process, which has been resonating with listeners. As of October 2022, there have been more than 173,000 listens of 124 episodes, over 21,000 followers on our Instagram account (@Inside_TheMatch), over 47,000 followers on our Twitter account (@Inside_TheMatch), and 20.816 million impressions of the #InsideTheMatch hashtag in August 2022 per Symplur Signals. In addition, since our website (insidethematch.com) launched in October 2021, we have had over 276,000 website visits and 240 blog posts written by trainees nationwide to support other trainees in navigating the Match process. For Match 2022, we reviewed 258 personal statements for applicants underrepresented in medicine and guided unmatched applicants. Based on hundreds of requests from Match applicants, we curated content on topics that ranged from writing personal statements, preparing for interviews, and creating rank lists. Trainees are recruited through social media to write blog content and provide podcast interviews. Allowing trainees to provide content creation ensures the information is tailored to their Match experience. This rapid growth and uptake of a volunteer-driven free platform showcase the clear need for and impact of trainee voices to assist applicants through this stressful journey to residency. As the Match process continues to be mired in a web of complexity, one thing remains clear: the average number of residency applications from medical students has increased. 1 While this rise was seen prepandemic, COVID-19 has hastened and complicated the process. Due to concerns about being unmatched, applicants are applying to more programs, leading to an increase in application costs. Although this issue is multifactorial, providing a free resource to all applicants can help create an equitable playing field and may even help mitigate this alarming application trend. Going forward, Inside the Match will remain free of commercial interest, and we hope this free platform helps demystify the Match process and provides a supportive network for Match applicants. Acknowledgments: The authors would like to acknowledge members of the Inside The Match collaborative for their continued mentorship: Kemi Babagbemi, MD, Katherine C. Chretien, MD, Jessica A. Gold, MD, MS, William N. Levine, MD, Kamran M. Mirza, MD, PhD, Travis Reece-Nguyen, MD, MPH, Erica A. Schuyler, MD, and Travis Smith, DO.

Her name meant I leave in Sesotho, a language that lives deep in my heart after 2 years as a Peace Corps volunteer in Lesotho, a country in southern Africa where 31% of the population had human immunodeficiency virus (HIV) during my time there from 2003 to 2005. Lesotho is where I decided to become a pediatrician. Eight years later, a world away in Colorado, I stood in front of a baby girl, Tsamaea (suh-MY-ah), who I met 2 minutes before she stopped breathing and lost pulses in the emergency department (ED). Before I made the connection to Lesotho, I kept thinking—why does her name sound so familiar? I was 36 weeks pregnant and beginning a night shift in the ED. While I was feeling all the symptoms of pregnancy—fatigue, ravenous appetite, and swollen feet—it was my hyperdynamic circulation that was most notable in that moment. “Can you check for a pulse?” my co-resident asked. I could only feel my own. I thought, “This cannot be. It must be my hyperdynamics.” Our 10-month-old patient had been observed for hours and was receiving a fluid bolus on her way upstairs for hospital admission. Moments after starting fluids, bubbles started coming out of her mouth, and I could auscultate only gurgling sounds in her lungs. After multiple rounds of chest compressions and medications, she left us. She died. I remember faculty in medical school saying there are patients who will stick with you your whole life. You will learn from them as they are your greatest teachers. Tsamaea taught me the things that can masquerade behind respiratory distress in a wintry sea of bronchiolitis. During debriefing, I learned that her autopsy revealed myocarditis, which is why she had cardiovascular collapse with a fluid bolus. What appeared as dehydration and respiratory distress due to bronchiolitis was actually cardiogenic shock due to myocarditis. Still today, when I see patient after patient during the waves of bronchiolitis, I think twice about an alternate diagnosis in disguise. Since 2020, learning to treat patients with COVID-19 reminds me that we remain humble learners of medicine. All our resources have been stretched—rooms, staff, equipment, compassion—and yet our patients are plentiful and continue to provide us with ample learning opportunities. In October of last year, our hospital pediatric team was called to a rapid consult. Our patient was Shawn, a 13-year-old who was admitted with COVID-19, abdominal pain, and fever. We were called to evaluate newly developing hypotension and tachycardia. While he was calmly sitting in bed, answering questions slowly, I noticed that he had a quiet precordium and normal pulses. We decided to give him a fluid bolus, draw labs, and check on him in an hour. Upon returning, he was completing his fluids and suddenly began to have decreased responsiveness and thready pulses. While he improved with treatment and was telling me about his favorite anime show on the way to the intensive care unit, I felt shaken. It was more than I expected, and it was not until hours later that I recognized the connections between Shawn and Tsamaea. At debriefing, we discussed that Shawn likely had multisystem inflammatory syndrome in children which can present with signs of both septic and cardiogenic shock. I reflected on Shawn’s quiet precordium and normal pulses despite fever. I strung that clinical pearl with Tsamaea’s. Shawn and Tsamaea remind me that learning from our difficult cases honors them and improves our abilities as healers. I grieved Tsamaea again in 2021 and celebrated Shawn’s good outcome. I also treasure my now 9-year-old son, who has accompanied me on this journey of being a pediatrician and always, always learning.

A better understanding of how communication skills education impacts trainees' communication skills is important for continual improvement in graduate medical education (GME). Guided by the Kirkpatrick Model, this review focused on studies that measured communication skills in either simulated or clinical settings. The aim of this systematic review was to examine the effect of experiential communication skills education on GME trainees' communication behaviors. Five databases were searched for studies published between 2001 and 2021 using terms representing the concepts of medical trainees, communication, training, and skills and/or behaviors. Included studies had an intervention design, focused only on GME trainees as learners, used experiential methods, and had an outcome measure of communication skills behavior that was assessed by a simulated or standardized patient (SP), patient, family member, or outside observer. Studies were examined for differences in outcomes based on study design; simulated versus clinical evaluation setting; outside observer versus SP, patient, or family member evaluator; and length of training. Seventy-seven studies were ultimately included. Overall, 54 (70%) studies reported some positive findings (i.e., change in behavior). There were 44 (57%) single-group pre-post studies, 13 (17%) nonrandomized control studies, and 20 (26%) randomized control studies. Positive findings were frequent in single-group designs (80%) and were likely in nonrandomized (62%) and randomized (55%) control trials. Positive findings were likely in studies evaluating communication behavior in simulated (67%) and clinical (78%) settings as well as in studies with outside observer (63%) and SP, patient, and family member (64%) evaluators. This review demonstrates strong support that experiential communication skills education can impact GME trainees' communication behaviors. Marked heterogeneity in communication trainings and evaluation measures, even among subgroups, did not allow for meta-analysis or comparative efficacy evaluation of different studies. Future studies would benefit from homogeneity in curricular and evaluation measures.