The stakes of getting clinical reasoning right are not academic. The National Academies of Sciences, Engineering, and Medicine estimated in its 2015 report Improving Diagnosis in Health Care that most people will experience at least one diagnostic error in their lifetime, a finding that has driven a decade of effort to strengthen reasoning instruction. Subsequent studies have documented the persistence of the problem: research on hospitalized patients under investigation for COVID-19, published in 2023, catalogued the prevalence and causes of diagnostic errors on the wards, and a 2024 analysis in JAMA Internal Medicine found diagnostic errors among hospitalized adults who died or were transferred to intensive care. Cognitive pitfalls—availability bias, premature closure, anchoring on an early hypothesis—are well characterized, and reflective reasoning practices can measurably improve diagnostic accuracy among trainees. The question has never been whether clinical reasoning matters, but how to teach it at scale.

That question is harder than it sounds. National surveys of internal medicine clerkship directors and of clinical skills course directors in the United States have repeatedly shown that clinical reasoning education is uneven, under-resourced, and fragmented across the curriculum. A 2022 cross-disciplinary needs assessment published in PLoS One confirmed persistent gaps in clerkship-year reasoning education, and a 2023 scoping review in Academic Medicine found that preclinical curricula vary widely in content and rigor. A multicenter interview study of European educators published in BMC Medical Education in 2021 asked directly why longitudinal clinical reasoning curricula are so difficult to implement and catalogued the barriers: faculty time, competing curricular demands, and the sheer intensity of the individualized feedback that good reasoning instruction requires. Teaching a student to notice the moment their thinking slips from hypothesis generation to premature commitment demands small groups, careful observation, and conversation—precisely the formats that consume the most instructor hours.

Enter the Associate Course Educator. The program, developed at a private, not-for-profit U.S. medical school, selects senior medical students who have completed their core clerkships and appoints them to a twelve-month term, renewable for eligible students. ACEs are not ad hoc teaching volunteers; they occupy a formal leadership position within the longitudinal clinical reasoning course. Each ACE commits to delivering at least twenty hours of teaching annually, receives close mentorship and explicit instruction in the pedagogy of clinical reasoning, leads educational projects, contributes to scholarship, and participates in curricular review. In other words, the role is designed as a mentored apprenticeship in medical education, not merely an staffing convenience. The Yale Institutional Review Board reviewed the program and determined it did not constitute human subjects research, and all participants engaged voluntarily with consent.

The results, measured across six recruitment cycles, are striking. Eighty-four students applied to the program and forty-four were selected, an acceptance rate of 52.4 percent, indicating substantial demand among students for formal teaching roles. More importantly for the curriculum, the number of annual clinical reasoning sessions grew from eight to twenty-two over the program’s run. Just as telling was the shift in format: sessions migrated from large-group lectures to predominantly small-group and one-on-one teaching—the exact instructor-intensive formats that faculty constraints had made difficult to sustain. By expanding the pool of trained educators, the program changed not just the quantity of reasoning instruction but its fundamental shape, moving it toward the interactive, feedback-rich modalities that education research considers most effective for developing diagnostic skill.

The theoretical foundation for this approach is peer-assisted learning, a well-studied phenomenon in medical education. A 2022 systematic review and meta-analysis in Medical Education examined peer-assisted learning across medical curricula, and a 2025 study in Academic Medicine compared practical skills teaching delivered by near-peers against faculty instruction. Classic work by Olle ten Cate and Steven Durning laid out the psychology of peer teaching, arguing that near-peers occupy a privileged cognitive and social position: they remember recently what it felt like not to know, they speak the learner’s language, and the social distance between teacher and learner is small enough that students ask questions they might hesitate to raise with faculty. Teaching itself also consolidates the teacher’s knowledge—a principle long recognized in students-as-teachers programs, which a 2010 national survey in Academic Medicine found had proliferated across U.S. medical schools even before programs like ACE formalized them into leadership roles.

What distinguishes the ACE model from a conventional teaching assistantship is its explicit pairing of peer teaching with leadership and scholarship. ACEs did not simply staff existing sessions; they generated educational innovations that the authors report contributed to the institutional curriculum, and they disseminated their work at regional and national academic venues. The program’s appendix catalogs notable projects in undergraduate medical education produced by ACEs during their terms. This design reflects a growing conviction in medical education research that future clinician-educators need early, structured exposure to the craft of teaching. Studies of clinician educator tracks during internal medicine residency have found that longitudinal education curricula shape participants’ trajectories and skills, and a 2025 modified Delphi study in Academic Medicine reached consensus on the most important teaching skills for residents in clinician educator tracks—skills that programs like ACE begin cultivating years earlier.

The timing of this innovation is significant for another reason. Clinical reasoning is increasingly framed not as an implicit byproduct of clinical exposure but as a core competency in its own right, with published consensus statements defining the content of undergraduate reasoning curricula and interprofessional frameworks specifying the competencies needed to improve diagnosis. Educators have developed a toolkit of teaching and assessment methods—script concordance testing, serial concept maps, the clinical integrative puzzle, the Assessment of Reasoning Tool—each designed to make the invisible process of diagnostic thinking visible and gradable. Recent work has extended the framework beyond diagnosis to management reasoning. Yet all of these methods share a common requirement: trained facilitators who can model reasoning aloud, probe a learner’s differential diagnosis, and deliver calibrated feedback. A program that multiplies the number of such facilitators, at modest cost, addresses the central constraint on every one of these methods.

There are, of course, open questions. The published report is a program description and evaluation rather than a controlled trial, and the authors themselves sit within a broader conversation—reflected in a 2026 JAMA Internal Medicine commentary—calling for more experimental studies in medical education. Whether ACE-taught students show measurable gains in diagnostic accuracy compared with traditionally taught peers remains to be tested, as does the durability of benefits for the ACEs themselves as they progress to residency. But the program’s six-year track record demonstrates proof of concept: a formal, longitudinal, leadership role for senior students can expand instructional capacity nearly threefold, sustain the small-group formats that reasoning education demands, and simultaneously build a pipeline of future clinician-educators. At a moment when diagnostic error remains a leading patient safety concern and faculty teaching resources are stretched thin, the idea that the most scalable new educators in academic medicine might be the students one year ahead is an audacious one—and one that other institutions are likely to watch closely.

The deeper lesson of the ACE experiment may be institutional rather than cognitive. Medical schools have long treated teaching as something faculty do and students receive, with students-as-teachers programs occupying a peripheral, often extracurricular niche. By converting peer teaching into a structured leadership position with mentorship, curricular authority, and scholarly expectations, the ACE role argues that learners can be genuine partners in building the curriculum—especially for a skill like clinical reasoning, where the recent learner’s perspective is itself a teaching asset. With forty-four selected educators, twenty-two annual sessions, and scholarship reaching national audiences, the program offers a template that requires no new faculty hires, no expensive simulation equipment, and no curricular revolution—only a willingness to reconceive who, exactly, is qualified to teach the art of thinking like a doctor.

Subject of Research: A peer-assisted learning program using senior medical students as formal educators to strengthen clinical reasoning instruction

Article Title: The ACEs of Clinical Reasoning: a Formal, Longitudinal, Leadership Role for Medical Students to Augment Clinical Reasoning Education

Article References: Tang, Z., Swallow, M. A., Bahar, R. C., Gaeta Gazzola, M., & Wijesekera, T. P. (2026). The ACEs of Clinical Reasoning: a Formal, Longitudinal, Leadership Role for Medical Students to Augment Clinical Reasoning Education. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10904-7

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10904-7

Keywords: clinical reasoning, medical education, peer-assisted learning, near-peer teaching, diagnostic error, medical students, curriculum design, clinician educators, feedback, Yale School of Medicine, Journal of General Internal Medicine, ACEs

The scale of the findings is difficult to overstate. Adverse childhood experiences, commonly abbreviated as ACEs, are potentially traumatic events that occur before the age of 18, ranging from abuse and neglect to household dysfunction and community-level violence. Decades of research, beginning with the landmark 1998 Felitti and Anda investigation in the United States, have established that ACEs are not isolated misfortunes but tend to co-occur, and that their cumulative burden produces dose-dependent increases in disease risk, mental illness, and early mortality. The new Turkish data extend this epidemiological logic to a population of emerging adults navigating the transition to university life, a developmental window in which health behaviors often crystallize into lifelong patterns.

The study relied on a web-based cross-sectional survey administered between April and June 2024. Participants completed a structured self-report questionnaire assessing exposure to ACEs, including child maltreatment and household dysfunction, alongside a battery of health-risk behaviors in young adulthood. Web-based surveys of this kind allow rapid recruitment across a dispersed student population, though the authors acknowledge that self-report instruments inherently depend on participants’ willingness and ability to recall sensitive childhood events. Ethical approval was granted by the Ethics Committee of Giresun University, and informed consent was obtained from all participants in accordance with the Declaration of Helsinki.

What the questionnaire revealed is a hierarchy of adversity that few observers would have predicted at the top. The most frequently reported ACE was community violence, experienced by 81.1 percent of respondents, a striking figure that suggests violence exposure beyond the household is the dominant adversity shaping this cohort. Emotional neglect followed at 74.0 percent, then emotional abuse at 49.9 percent, witnessing violence against household members at 39.2 percent, bullying at 33.2 percent, and physical abuse at 27.9 percent. The prominence of emotional neglect and emotional abuse, forms of maltreatment that leave no bruises yet corrode a child’s sense of worth and security, underscores the argument of trauma researchers that psychological adversity can be as consequential as physical harm.

The analytical heart of the study lies in the association between cumulative ACE scores and adult health-risk behaviors. The researchers found that a higher number of ACEs was significantly linked to tobacco use, alcohol consumption, sedentary behavior, overweight and obesity, suicidal ideation, suicide attempts, interpersonal violence, and early sexual initiation, defined as sexual activity before the age of 16. This constellation of outcomes is consistent with the well-documented dose-response relationship observed internationally, from studies of college students in Zambia, Vietnam, Uganda, and Brazil to systematic reviews such as the 2017 Hughes and Bellis meta-analysis in The Lancet Public Health, which concluded that individuals with four or more ACEs face substantially elevated risks across mental and physical health domains.

Several mechanistic frameworks help explain why childhood adversity casts such a long shadow. The toxic stress model proposes that chronic activation of the hypothalamic-pituitary-adrenal axis during sensitive developmental periods alters stress regulation, immune function, and neural circuitry in ways that persist into adulthood. Behavioral theories add that health-risk behaviors often serve as coping strategies, with nicotine, alcohol, and other forms of self-regulation providing short-term relief from emotional pain that originated in childhood. Social learning perspectives further note that children raised in violent or neglectful environments may internalize interpersonal violence as normative, a pathway that could help account for the observed association between ACE burden and subsequent involvement in interpersonal violence.

The near-universal prevalence of at least one ACE in this sample, 97.7 percent, is notably higher than in many comparable studies and invites careful interpretation. Broader ACE inventories that include community violence and bullying, as this one does, inevitably capture more of the population than the original ten-category frameworks focused narrowly on household dysfunction. Still, the finding that nearly half the sample carried four or more ACEs signals a substantial public health burden within Turkish higher education, one that likely reflects the cumulative effect of economic precarity, exposure to regional conflict and earthquake trauma, and gaps in child protection infrastructure. Prior Turkish research, including a 2016 comparison of parent and child reports of maltreatment published in the Central European Journal of Public Health, has suggested that official figures substantially undercount the true prevalence of child maltreatment in the country.

The suicide-related findings deserve particular emphasis. Both suicidal ideation and suicide attempts were significantly associated with higher ACE counts, echoing results from Ugandan university students and American college populations. Young adulthood is already a peak period for the onset of suicidal behavior, and the intersection of unprocessed childhood trauma with the academic, financial, and social pressures of university life appears to create a particularly volatile combination. University counseling services, the authors’ findings suggest, should routinely screen for childhood adversity rather than treating presenting symptoms in isolation, because the developmental roots of distress may lie far beneath the surface.

Çam and Ustuner Top conclude that their results highlight the need for trauma-informed public health strategies aimed at preventing ACEs and promoting resilience. Trauma-informed care, in this framework, means redesigning educational, health, and social systems to recognize the prevalence of trauma, avoid re-traumatization, and build protective factors such as stable adult relationships and community support. The authors received no external funding for the work and declared no competing interests. Because the data are sensitive, they are not openly available but can be requested from the corresponding author for reasonable research purposes.

Limitations remain, as they do in all cross-sectional self-report research. Temporal ordering between ACEs and adult behaviors cannot be definitively established, recall bias may shape reported adversity, and a web-based convenience sample of university students may not generalize to young adults who never enter higher education, a group often at even greater risk. Yet the convergence of this Turkish dataset with findings from across five continents suggests a robust biological and social reality: the wounds of childhood do not stay in childhood. Every percentage point of ACE prevalence that public health systems can reduce, researchers argue, translates downstream into fewer cancers, addictions, suicide attempts, and violent injuries, making early prevention one of the highest-leverage interventions available to any society.

Subject of Research: Adverse childhood experiences and their association with health-risk behaviors among Turkish university students

Article Title: Adverse Childhood Experiences and Associated Health-Risk Behaviors Among University Students in Turkey: A Cross-Sectional Analysis

Article References: Adverse Childhood Experiences and Associated Health-Risk Behaviors Among University Students in Turkey: A Cross-Sectional Analysis. (n.d.). https://doi.org/10.1007/s40653-026-00979-z

Image Credits: AI Generated

DOI: 10.1007/s40653-026-00979-z

Keywords: adverse childhood experiences, ACEs, university students, Turkey, health-risk behaviors, child maltreatment, emotional neglect, community violence, suicidal ideation, trauma-informed care, public health, cross-sectional study