The article, published on 31 August 2026 in the Healing Arts section of the journal, is not a trial or a systematic review. It is a narrative reflection, a genre that general internal medicine has long used to examine the human texture of doctoring. Yet its central claim is empirically grounded in decades of communication research: the small, seemingly non-clinical gestures that clinicians make are not distractions from care but components of it. The popsicle is Herba’s emblem for a class of interactions that cost almost nothing, take seconds, and can change the trajectory of an encounter, a hospitalization, or a career.

The technical framing matters because the piece arrives at a time when clinical encounters are increasingly measured, timed, and documented. Electronic health records, relative value units, and productivity metrics quantify what can be counted: orders placed, notes closed, patients seen per hour. What they cannot capture is the quality of the interpersonal exchange, even though that quality is measurably tied to outcomes. Studies of patient-clinician communication have repeatedly shown that the first moments of an encounter shape disclosure, that interruptions in the opening minute correlate with missed concerns, and that empathic statements, even brief ones, are associated with better adherence and lower malpractice claims. Popsicle moments sit precisely in the territory that metrics miss.

Herba’s reflection draws its power from the specificity of the clinical scene. A popsicle given before an uncomfortable procedure is not merely a kindness; it is a physiological intervention of sorts. Cold oral stimulation can soothe, distract, and in some contexts reduce distress in pediatric patients, and the act of pausing to offer one forces the clinician to slow down at exactly the moment when workflow pressure pushes toward speed. The gesture also reframes the relationship: the clinician is no longer only the person about to do something painful but the person who noticed the child as a child. In communication terms, the popsicle performs alliance-building that no scripted patient-satisfaction module replicates.

The broader literature gives this emblem technical substance. Research on the so-called golden minute of the clinical encounter shows that if clinicians allow patients to complete their opening statement without interruption, the visit rarely runs longer, yet the yield of undisclosed concerns rises substantially. Work on nonverbal behavior demonstrates that seating position, eye contact, and even the physical act of turning away from the screen alter what patients volunteer. Studies of procedural care in pediatrics show that distraction and comfort measures reduce perceived pain and the need for pharmacologic sedation in some settings. Each of these findings describes a mechanism by which a popsicle moment operates: it buys time, it shifts attention, and it changes the emotional register of the encounter.

What makes the reflection timely is the structural squeeze on such moments. Documentation burden in the United States consumes a substantial share of clinician time, with studies estimating that physicians spend roughly two hours on administrative and clerical work for every hour of direct patient contact. Under that arithmetic, the seconds spent fetching a popsicle or sitting down to listen compete directly with the inbox and the note. Herba’s piece implicitly argues that the cost-benefit calculation is wrong: the popsicle moment is not overhead but care, and systems that price it as overhead will systematically extinguish it. The reflection joins a growing genre of medical humanities writing that treats these micro-behaviors as legitimate subjects of scholarship rather than sentimental asides.

There is also a training dimension. Medical education increasingly emphasizes competency milestones, standardized patient encounters, and communication checklists, which are valuable but can reduce interpersonal skill to a scored script. A checklist can verify that the clinician introduced himself and asked about concerns; it cannot verify that he noticed the child’s fear and responded with a frozen treat. Herba’s narrative suggests that the most formative lessons in clinical empathy are transmitted informally, through observation of senior clinicians who model small gestures, and that these lessons are at risk when clinical education is compressed and attendings are pulled toward productivity. The popsicle moment, in this reading, is a unit of tacit knowledge, learned by imitation rather than instruction.

The piece also speaks to burnout, the dominant occupational crisis of modern medicine. Burnout research has identified meaning and connection as protective factors: clinicians who report frequent experiences of deep connection with patients show lower rates of emotional exhaustion. Popsicle moments are, by definition, experiences of connection, and they are among the few elements of clinical work that clinicians themselves can initiate without permission, budget, or institutional approval. A reflection like Herba’s functions partly as a reminder to colleagues that these moments are available every day, and that reclaiming them is a form of professional self-care that requires no wellness module. The irony that such moments must be defended in a medical journal is itself part of the diagnosis.

Readers outside medicine may find the piece resonant for a different reason: it describes a universal principle of service and care work. In nursing, teaching, hospice care, and emergency response, the small unprompted gestures, the extra minute, the offered comfort, are repeatedly identified by practitioners as the moments that sustain them and by recipients as the moments they remember. Herba’s popsicle is a case study in how care is actually experienced, not as a bundle of billable interventions but as a sequence of noticed details. The reflection’s viral potential lies in that universality, wrapped in a concrete image that anyone can picture instantly.

Published in the Healing Arts section of the Journal of General Internal Medicine, the article joins a tradition in which general internists examine the craft of doctoring with the same seriousness applied to therapeutics. Its evidence is narrative rather than statistical, but its claims align with a robust empirical literature on communication, empathy, and clinician well-being. The popsicle moment is small, cheap, and easily overlooked, which is exactly why it needs naming. Once named, it becomes something clinicians can seek, educators can teach, and systems can protect, rather than a private memory that fades with each inbox hour. Herba’s contribution is to give the moment a handle, so that it can be picked up and passed on.

Subject of Research: Medical humanities and clinical communication

Article Title: Popsicle Moments

Article References: Herba, J. (2026). Popsicle Moments. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10762-3

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10762-3

Keywords: medical humanities, clinical communication, physician well-being, patient care, internal medicine, burnout, medical education, Popsicle, Moments, scientific research

The study, led by Ryan Nall of the University of Florida College of Medicine with colleagues from institutions across the country and the Alliance for Academic Internal Medicine, surveyed clerkship directors at U.S. medical schools who hold membership in Clerkship Directors in Internal Medicine, the national organization that represents the faculty responsible for running the core rotation. Of 141 clerkship directors invited to participate, 114 completed the survey, an exceptionally strong response rate of 80.9 percent that lends considerable weight to the results. The cross-sectional instrument collected descriptive data on the fundamental architecture of the clerkship: how long it lasts, which educational models it employs, what students experience on inpatient wards and in outpatient clinics, and how all of this has shifted relative to the period before the pandemic. Because the survey captured a nationally representative sample, the findings can reasonably be generalized to the vast majority of MD-granting schools in the United States.

The headline structural finding is one of continuity. Nearly nine in ten clerkships, 87.7 percent, still use the traditional block model, in which students are immersed in internal medicine for a concentrated period rather than weaving the specialty through an entire academic year as in longitudinal integrated clerkships. The median clerkship length stands at eight weeks, a figure that has remained remarkably consistent across successive national surveys. This persistence is notable given that longitudinal models have attracted substantial enthusiasm in the education literature for more than a decade. Studies of longitudinal integrated clerkships have documented benefits for continuity of relationships between students, preceptors, and patients, and prior surveys of clerkship directors explored the diffusion of these innovations. Yet the block model endures as the dominant format, likely reflecting institutional inertia, scheduling complexity, faculty capacity, and the logistical costs of restructuring an entire clinical curriculum around a minority model.

Beneath that stability, however, the survey documented measurable post-pandemic compression. Compared with the pre-pandemic period, 34.2 percent of clerkships reported an increase in the number of students assigned per rotation, while 19.3 percent reported a decrease in overall clerkship length. These two trends point in the same direction: more learners passing through less protected time. The authors characterize this as clerkship directors navigating increasing complexity in the learning environment, alongside structural, institutional, and system-level challenges. Rising student density on teaching services has been a recurring concern in the hospital medicine literature, where studies of direct-care teaching services have examined how many learners can be accommodated without diluting the educational experience or compromising patient care. A clerkship that simultaneously absorbs more students per rotation and shortens its duration faces a compounding challenge to the apprenticeship model at its core.

Ambulatory training emerged as one of the most striking weak points in the current landscape. Only 49.6 percent of clerkships require an internal medicine-specific ambulatory experience, meaning that roughly half of American medical students complete the core internal medicine rotation without a mandatory outpatient component in the discipline. This is a paradoxical finding for a specialty that defines itself around comprehensive, longitudinal care of adults, and it echoes longstanding critiques that undergraduate medical education underweights chronic disease and outpatient management relative to acute hospital care. The ambulatory half of internal medicine, where hypertension, diabetes, and preventive care are actually managed, remains an optional experience for a substantial share of students. As physician workforce projections raise alarms about the adequacy of the future physician supply and the distribution of generalist physicians, the marginal status of outpatient training within the flagship generalist clerkship is a detail with potentially outsized consequences.

The pandemic’s imprint on teaching methods is also visible in the data, though in a way that suggests partial reversal rather than permanent transformation. A full 92.0 percent of clerkships have returned to in-person didactics since the pandemic, indicating that the wholesale shift to remote learning that defined 2020 and 2021 has largely been unwound for the core rotation’s classroom teaching. This finding aligns with systematic reviews comparing blended and traditional learning in medical education, which have shown that digital formats can match traditional instruction on some outcomes but rarely replicate the tacit learning of the clinical workplace. The rapid return to in-person teaching suggests that clerkship directors, having experimented with virtual didactics under duress, judged face-to-face instruction essential to the clerkship’s mission even as many institutions retain hybrid elements elsewhere in their curricula.

Perhaps the most sobering results concern the challenges clerkship directors themselves identify as most pressing. The most common difficulties reported were ensuring that students receive formative feedback, recruiting enough faculty preceptors, and delivering faculty development. Each of these points to a structural vulnerability in clinical education. Formative feedback, the low-stakes coaching that allows students to correct errors before high-stakes assessment, depends on preceptors having time and skill to observe and critique performance. Preceptor recruitment is strained by the same workforce pressures documented in recent analyses of the physician pipeline, as clinical productivity demands compete with teaching obligations. Faculty development, meanwhile, requires institutional investment in clinicians as educators, an investment that is easy to defer when clinical volumes surge. That these three challenges top the list suggests the clerkship’s most serious problems are not curricular but human: too few trained teachers, with too little time, for a growing cohort of learners.

The survey arrives at a moment of unusual flux in how clinical performance is measured. The transition of USMLE Step 1 to pass/fail scoring has shifted weight toward clerkship evaluations and away from a single numerical score, intensifying scrutiny of assessment practices within rotations. Commentators have described a shadow economy of effort emerging around pass/fail grading, with unintended consequences for how students engage with clinical work, and others have called for rebuilding clerkship assessment around objectivity and equity. Against this backdrop, the survey’s finding that clerkship directors struggle to guarantee formative feedback takes on added significance: if national licensing examinations no longer differentiate students numerically, the quality of day-to-day feedback and evaluation within the clerkship becomes the load-bearing element of the assessment system, and it is precisely that element directors report as most fragile.

There is also a genuinely reassuring thread running through the data. Despite the pressures of increased student numbers, shortened rotations, and strained preceptor pools, the authors report that clerkship directors have maintained stable learner density on rotations and preserved ambulatory training within the clerkship overall. The median eight-week duration and the dominant block structure have held. In other words, the system has bent without breaking. The pandemic prompted clerkship directors to reevaluate their curricula and educational strategies, and the resilience they demonstrated, restoring in-person teaching and holding core structures in place, represents a quiet institutional achievement that rarely makes headlines but directly shapes the competence of every graduating physician who passes through an internal medicine ward.

What the survey ultimately provides is a baseline for the decisions ahead. Medical schools continue to multiply, with recent counts documenting steady growth in MD-granting institutions and enrollment, which will only intensify the competition for teaching patients, teaching beds, and teaching faculty. Workforce analyses published in leading journals warn of mounting challenges to sustaining a robust physician pipeline, making the internal medicine clerkship, the specialty’s principal recruitment and training vehicle, a strategic asset rather than a curricular formality. Whether the field responds by protecting clerkship length, capping learner density, mandating ambulatory experiences, and investing in preceptor development will determine whether the next national survey documents recovery or continued erosion. For now, the picture is clear: the traditional clerkship endures, but the margins are thinning, and the educators who run it know exactly where the strain is greatest.

Subject of Research: National survey of the structure of the internal medicine clerkship in U.S. medical schools

Article Title: Current Landscape of the Internal Medicine Clerkship: A National Survey

Article References: Nall, R., Pincavage, A., Ratcliffe, T. A., Williams, W., Mullick, D. T., Duca, N. S., Kisielewski, M., Eadie, E., Weinstein, A. R., & Lai, C. J. (2026). Current Landscape of the Internal Medicine Clerkship: A National Survey. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10718-7

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10718-7

Keywords: internal medicine, clerkship, medical education, clerkship directors, COVID-19, ambulatory training, block rotation, formative feedback, preceptors, undergraduate medical education, national survey, Journal of General Internal Medicine

Academic General Internal Medicine, or GIM, sits at the crossroads of patient care, education, research, and systems improvement. For those who aspire to lead, the skills cultivated through a generalist perspective provide a strong foundation for navigating volatility, uncertainty, complexity, and ambiguity, the conditions collectively known as VUCA. From this vantage point, GIM leaders integrate evidence across domains, translate it for different audiences, and keep teams moving when answers are incomplete. They frame problems, set shared aims, and adapt as contexts shift. In unpredictable environments, the ability to manage uncertainty, utilize practical judgment, foster inclusion, and integrate systems thinking enables GIM leaders to deliver high-value care, effective education, and impactful research and policy.

Examining leadership in healthcare generally, and academic medicine specifically, through generalist and specialist lenses highlights how generalist leadership provides the integrative capacity to align, translate, and apply specialist expertise in complex systems. The generalist–specialist contrast clarifies why breadth supports leadership in medicine: specialists excel in niches and with precision, while generalists remain agile for a wide variety of occurrences and are arguably the best approach with an unknown future. Many of the most complex challenges in healthcare—managing multimorbidity, addressing care gaps, reducing health inequities, and implementing new technologies—are fundamentally systemic. Generalists synthesize recommendations, balance risks, elicit patient preferences, and unite multidisciplinary teams. When the path is uncertain, leadership is not about superseding experts but about integrating expertise to develop patient-, learner-, and population-centered plans. Any academic leader, specialists included, can possess these skills; however, they should be identified as a generalist leadership skill set.

In volatile settings, generalist leaders often frame issues and integrate data, while specialist leaders optimize and articulate a path forward. Generalist leaders in medicine operate within these realities daily while anticipating future directions. They already navigate shifting technologies, fiscal pressures, expanding patient access to artificial intelligence, and evolving learner needs, requiring problem-solving and action in settings defined by uncertainty. Generalist leadership skills are embedded in the daily work of medicine. Integrative clinical judgment requires balancing conflicting guidelines, navigating transitions across settings, and aligning care plans with what matters most to patients. Cross-disciplinary communication connects patient priorities with colleagues, care teams, payers, and community partners to coordinate action around shared goals. Networked execution depends on understanding how systems function, mobilizing the right people and resources, and translating observations into meaningful action. Emotional regulation and inclusion foster psychologically safe environments for learners, staff, and patients, particularly during difficult conversations and periods of change. Finally, comprehensivists, including general internists, pediatricians, and family physicians, bring a whole-person perspective that integrates competing priorities, navigates complexity, and connects diverse viewpoints in service of patients, teams, and communities.

Generalists are adept at identifying and diagnosing situational challenges and selecting appropriate responses. The VUCA framework offers one practical tool for understanding what is driving a situation. Is the challenge being driven by volatility, uncertainty, complexity, or ambiguity? Once the underlying context is identified, leaders can align actions with the demands of the situation. In volatile environments, generalist leaders build in flexibility through adaptable timelines and diversified approaches. In uncertain situations, they create information through disciplined experiments and small pilots, much as clinicians gather additional data when confronted with diagnostic uncertainty. When faced with complexity, they standardize and simplify processes, clarify roles, and map workflows and handoffs to better understand the interdependencies that shape clinical and learning environments. In ambiguous situations, they create pilots and prototypes to clarify the path forward.

The central generalist leadership inquiry is: which problem are we solving, for whom, and how will we know? A VUCA lens for a rapidly changing environment would ask, for volatility, how do we ride this change; for uncertainty, what would reduce the unknowns; for complexity, where and what are the relationships that matter most; and for ambiguity, what is really the problem we are trying to solve? This diagnostic habit matters because misreading the driver of a crisis leads to misaligned responses. Treating an ambiguous problem as if it were merely volatile, for example, produces frantic activity rather than genuine clarification. Naming the condition first converts diffuse anxiety into a targeted leadership question, and that question then disciplines the choice of experiments, timelines, and stakeholder conversations that follow.

In clinical settings, generalist leadership involves serving as the primary interpreter for patients and care systems. Generalists take on the first and often hardest work: making sense of undifferentiated presentations, stitching together discordant data, and leading shared decisions when certainty is not on the table. They are the managers of algorithmic and guideline outputs, applying probabilistic reasoning, guiding patients through complex findings, and participating in co-produced, shared decision-making, which fosters inclusion, trust, and actionable choices. They also design the team, clinical or research, on purpose: generalists frame and communicate the uncertainty and keep watch for context shifts, reframing hypotheses and diagnoses as signals change. This approach also role models transparent uncertainty management for learners and team members, showing that admitting incomplete knowledge is a professional strength rather than a liability.

Learners are stepping into clinics and classrooms where numeracy, probabilistic reasoning, the ability to spot algorithmic bias, and true cross-disciplinary collaboration are baseline rather than bonus skills. In class and on rounds, GIM leaders make it safe to disagree and to say I do not know. Differing points of view help improve diagnosis, enhance cooperation, and strengthen team resilience. Generalist leaders often take an asset-based approach, which reframes learners and colleagues as reservoirs of capacity rather than deficits to be fixed. The GIM educator can recognize and reward synthesis, such as reconciling conflicting guidelines and aligning plans with social context, rather than focusing solely on medical knowledge as fact-based. These leaders can foster metacognitive skills and resilience by acknowledging the cognitive and emotional demands of the profession. Educational leaders should measure success by what and how learners adapt to uncertainty, not only by what is taught.

GIM research is inherently integrative, spanning clinical epidemiology, patient safety, health services research, implementation science, health equity, informatics, and community-engaged initiatives. It includes bringing in collaborators who emphasize shared purpose and respect in research and system design. It may mean inviting patients, community partners, and frontline staff to help define questions, test ideas, and judge what success looks like. Today’s scientific challenges rarely fit neatly within a single discipline. In an era of increasing funding pressures and team-based research, GIM research leaders connect experts across fields, bridge research and practice, and help ensure that scientific advances improve the health of patients and communities. Generalists thrive by taking undifferentiated problems, reconciling discordant data and guidelines, aligning questions with context, and engaging stakeholders. The GIM leader uses LEAD: learn, elevate, adapt, drive. They learn broadly, elevate others through sponsorship, adapt through disciplined experiments and pilots, and drive change with a clear vision.

Comprehensivists, whether general internists, pediatricians, or family physicians, frame context, define the questions that guide action, and communicate uncertainty honestly. These shared ways of working create a foundation for collaboration and leadership across generalist specialties, for example advocating for high-value primary care. In a period of significant change in healthcare and academic medicine, the comprehensivist approach brings together whole-person thinking and the ability to move forward amid volatility, uncertainty, complexity, and ambiguity. Generalist leadership is the discipline of building iterative connections while working through uncertainty. Both GIM and generalist leadership build a habit of mind that turns ambiguity into coordinated, meaningful action in clinics, classrooms, and research. When leaders name the kind of VUCA they are facing and LEAD, they help their teams move with clarity and courage, even when certainty is not on the table.

Subject of Research: Generalist leadership and VUCA in internal medicine

Article Title: A Heuristic for Generalist Leadership in Times of Volatility, Uncertainty, Complexity, and Ambiguity (VUCA)

Article References: Lypson, M. L. (2026). A Heuristic for Generalist Leadership in Times of Volatility, Uncertainty, Complexity, and Ambiguity (VUCA). Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10772-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10772-1

Keywords: VUCA, generalist leadership, internal medicine, healthcare leadership, complexity science, medical education, health services research, clinical decision-making, systems thinking, academic medicine, Heuristic, Generalist

Researchers at the University of Pittsburgh School of Medicine recruited 44 internal medicine teaching faculty from a single large academic medical center and asked them to review four clinical vignettes, each describing a patient scenario with a management decision to be made. For every case, the participants read a piece of electronic consultation advice, or e-consultation, generated by OpenEvidence, a medically specialized generative AI system that has rapidly become one of the most widely used clinical AI platforms among physicians. Before and after reading the advice, the physicians answered multiple-choice questions about how they would manage the patient, allowing the investigators to measure whether the AI’s recommendations actually changed their decisions.

The study’s central twist was a randomization scheme. Half of the participants were told the advice had been written by a specialist attending physician, while the other half were told it came from a medically specialized artificial intelligence system. In reality, all of the advice was AI-generated. The design allowed the researchers to isolate whether the label alone, the perceived source of the advice, influenced how physicians judged its quality or whether they adopted its recommendations.

The results were striking in their uniformity. Across six domains of perceived quality, completeness, actionability, clarity, appropriateness, trustworthiness, and use of evidence-based practice, the physicians gave the advice high marks, with overall mean ratings ranging from 4.2 to 4.7 on a 5-point scale. Critically, there were no statistically significant differences between the group that believed the advice came from a human specialist and the group that knew it came from an AI system. The label, in other words, did not matter.

The adoption data were even more dramatic. Before reading the e-consultation advice, only 37.5 percent of participants chose the management option that the AI would later recommend. After reading it, that figure jumped to 81.8 percent, an odds ratio of 8.43 with a 95 percent confidence interval of 5.00 to 14.28 and a p-value below 0.001. Whether the physicians thought they were reading the words of a human colleague or a machine made no measurable difference in this shift, with an odds ratio of 1.18 for the labeling effect and a confidence interval spanning 0.51 to 2.75.

These findings arrive at a moment when generative AI tools are being integrated into clinical workflows at unprecedented speed. OpenEvidence, the platform used in the study, has been described by its own developers as the fastest-growing application for physicians in history, following a funding round that valued the company at 3.5 billion dollars. Prior research has shown that large language models can perform at expert level on complex diagnostic challenges, and earlier studies have documented that clinicians’ diagnostic reasoning can be swayed by AI input, sometimes for better and sometimes for worse. What this new study adds is direct evidence that experienced teaching faculty, the physicians responsible for training the next generation, rate AI-generated consultation advice as highly as they would rate human specialist advice, and change their management decisions accordingly.

The context of e-consultation matters here. Electronic consultations, in which a primary care clinician submits a question to a specialist asynchronously rather than referring the patient for an in-person visit, have expanded rapidly as a means of improving access to specialty expertise. Systematic reviews have documented their benefits for connecting primary care to hospital-level expertise, but studies have also identified suboptimal e-consult requests and variable adherence to specialist recommendations. The Pittsburgh study suggests that when the consultant is an algorithm rather than a human specialist, physicians may be just as receptive, and just as likely to act on what they read.

That receptiveness cuts both ways. On one hand, if AI-generated advice is accurate, well-referenced, and genuinely useful, high adoption rates could accelerate the dissemination of best practices and reduce variation in care. Prior work has shown that management changes following multidisciplinary team discussions are associated with improved survival outcomes for cancer patients, and that second opinions in general internal medicine frequently alter diagnoses and management plans. If an AI system can approximate the value of a specialist consultation, the implications for access and efficiency are enormous, particularly in underserved areas where specialist availability is limited.

On the other hand, the study’s authors and the broader literature caution that susceptibility to AI recommendations is not inherently benign. Research on clinical decision support has shown that clinicians can be overly compliant with algorithmic advice, a phenomenon sometimes called automation bias, and recent work has demonstrated that the correctness of AI recommendations directly affects diagnostic accuracy in clinical decision-making. If physicians adopt AI-generated advice at rates approaching 82 percent regardless of its source, the quality assurance burden shifts from the individual clinician to the system itself. The study did not evaluate whether the AI’s recommendations were objectively correct for each vignette, only whether physicians found them persuasive and acted on them.

The researchers also note that their participants were teaching faculty at a single academic medical center, a group that may be more familiar with AI tools than the average clinician, and that the vignettes were hypothetical rather than live patient cases. Whether the same patterns hold in real clinical settings, with real patients and real time pressures, remains an open question. The authors call for future studies to explore what factors influence the adoption of AI-generated recommendations and how curricula for faculty and trainees can shape consultation utilization. As generative AI becomes embedded in the daily workflow of medicine, understanding not just what these systems say but how physicians respond to them may prove as important as the underlying technology itself.

Subject of Research: Physician perceptions and adoption of AI-generated e-consultation advice in clinical decision-making

Article Title: Physician Ratings and Adoption of AI-Generated e-Consultation Advice: A Randomized Clinical Vignette Study

Article References: Desjardins, G., Jain, V., Simonson, M. G., & McQuade, C. N. (2026). Physician Ratings and Adoption of AI-Generated e-Consultation Advice: A Randomized Clinical Vignette Study. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10777-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10777-w

Keywords: generative artificial intelligence, e-consultation, clinical decision-making, internal medicine, OpenEvidence, randomized vignette study, physician perceptions, medical education, automation bias, clinical reasoning, Journal of General Internal Medicine, healthcare AI

The authors ground their analysis in the historical legacy of hysteria, a diagnosis popularised in the early twentieth century that attributed physical symptoms to emotional distress primarily among women. They argue that this diagnostic framework provides essential context for contemporary patterns of dismissal and pathologisation, particularly towards marginalised populations. The term medical gaslighting itself did not appear in the academic literature until 2020, emerging in an account of a woman with long COVID who reported repeated dismissal prior to diagnosis. Since then, the concept has gained recognition in literature on chronic or contested illnesses, yet it still lacks a clear, consistent, and theoretically grounded definition that could guide research, clinical practice, and public understanding.

To construct their definition, the researchers draw on the origins of gaslighting in Patrick Hamilton’s 1938 play Gas Light, which depicts a husband manipulating his wife into doubting her sanity by dimming the gaslights in their home. The term entered academic literature through case studies of involuntary hospitalisation as psychological abuse and has since come to describe a form of psychological abuse in which an individual is manipulated into questioning their own perception of reality. The authors highlight sociologist Paige Sweet’s interviews with forty-three survivors of domestic violence, which demonstrated that gaslighting becomes especially abusive when embedded within social inequities and power dynamics, particularly those related to gender. Sweet conceptualises gaslighting as repeated efforts to construct a surreal environment in which victims are made to feel or appear crazy, thereby undermining their sense of reality, identity, autonomy, and mobility.

Building on this foundation, the researchers examine how medical gaslighting operates within Western medicine’s structural constraints. They cite a qualitative analysis of 334 online survey responses in which respondents with long COVID used the language of medical gaslighting to make sense of their experiences seeking care. Participants described repeated dismissal by medical professionals who were unable or reluctant to recognise their symptoms as real, with physicians invoking biomedical objectivity, including negative diagnostic test results, to discount patients’ subjective symptoms. The authors of that study suggest that medical gaslighting can be understood as a rhetoric of ontological politics, echoing Annemarie Mol’s argument that what counts as real in medicine is inherently political. This framing positions medical gaslighting not merely as an interpersonal failure but as a systemic condition embedded within the epistemology of Western medicine itself.

The researchers emphasise that Western medicine has historically been constructed around a normative body: wealthy, White, able-bodied, heterosexual, cisgender, and endosex male. Although medical gaslighting is not exclusive to marginalised communities, this structural bias systemically disadvantages those outside the norm. They cite interviews with twelve gynaecologists and general practitioners in which women with endometriosis were characterised as hysterical and labelled crazy when they failed to respond to diagnosis or treatment as expected. Miranda Fricker’s concept of epistemic injustice, which describes harm done to someone in their capacity as a knower due to prejudice or limited interpretive resources, provides a useful framework for understanding how implicit biases and power dynamics produce such harm. The authors also highlight the role of intersectionality, noting that while Black women may experience compounded marginalisation within healthcare, White women benefit from racial privilege while still experiencing gender-based disadvantage.

The perspective piece engages critically with alternative framings that have emerged in recent medical literature. Emergency physician Robert Jedick has argued that the term medical gaslighting overlooks physicians’ perspectives and frames patient-provider relationships in conflict, proposing miscommunication as an alternative that better acknowledges the organisational pressures facing medical professionals. The Australian researchers counter that characterising such encounters as miscommunication risks reframing structurally embedded power dynamics as interpersonal misunderstandings, shifting responsibility towards patients seeking recognition of their symptoms. They argue that this reframing may invalidate the lived experiences of those harmed by medical gaslighting, and that the language of medical gaslighting can function as a form of self-advocacy, enabling patients to make sense of their experiences within a medical system that has failed to recognise their legitimacy.

The researchers also address the question of intent, which has divided scholars in the field. Some have distinguished manipulative gaslighting from epistemic gaslighting on the basis of intent, while others have proposed medical invalidation to describe gaslighting-like behaviours that occur without manipulative intent, including those arising from well-meaning clinical practice. The authors argue that patients cannot reasonably be expected to discern the intent of medical professionals, and that introducing additional terminology is unlikely to resolve underlying epistemic tensions when the meaning of the existing term remains contested. They contend that the outcomes of both manipulative and unintentional dismissal are often similar, leading individuals to question or doubt the legitimacy of their concerns, and that a definition of medical gaslighting must recognise that it occurs regardless of intent.

Having surveyed the conceptual landscape, the researchers advance their own definition, which they present as a framework for empirical and clinical inquiry. They define medical gaslighting as a complex phenomenon, understood through psychological and sociological frameworks, in which individuals experience the repeated dismissal and invalidation of their health concerns by medical professionals, healthcare organisations, or the broader medical system, an experience that leads them to question or doubt the legitimacy of their concerns. Influenced by systemic inequities and power dynamics, it occurs regardless of intent and often in the absence of evidence-based care. The authors stress that this definition should continue to evolve as the field progresses, and that it establishes a foundation for academics and medical professionals to identify and address systemic inequities within Western medicine while reinforcing accountability within the medical system.

The researchers argue that such accountability can inform training that prioritises patient-centred care and transparent communication in clinical decision-making, strengthening patient-provider relationships, particularly in the management of chronic or contested illnesses within internal medicine. They distinguish their framing from legal claims of medical negligence, which typically focus on isolated incidents or individual providers, noting that medical gaslighting is more accurately understood as a psychological and institutional process that normalises the devaluation of individuals lacking testimonial power within the medical system. Over time, repeated encounters may generate a documented history of misdiagnoses and ineffective treatments, leading to patients being labelled as psychosomatic or manipulative, with clinical records potentially reflecting the implicit biases of previous providers and leaving patients with limited authority to challenge such assumptions.

Ultimately, the authors call for Western medicine to turn its diagnostic gaze towards medical gaslighting and work to extinguish the systemic inequities that sustain it. They contend that sensationalisation of the term has limited meaningful engagement, leaving insufficient empirical and clinical work to guide practice, and that there is an urgent need to identify and address medical gaslighting within Western medicine to prevent further dismissal and invalidation. By advancing a clear, theoretically grounded definition that affirms the lived experiences of those harmed while establishing a framework for research and clinical inquiry, the researchers aim to ensure that the phenomenon is consistently understood across public, academic, and clinical contexts, transforming a viral term into a rigorous instrument for structural change.

Subject of Research: Medical Gaslighting

Article Title: Defining Medical Gaslighting—To Extinguish It

Article References: Janiszewski, C. M. S., Mosterd, D., Emerson, C., Mikocka-Walus, A., & Grech, L. B. (2026). Defining Medical Gaslighting—To Extinguish It. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10787-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10787-8

Keywords: medical gaslighting, patient dismissal, chronic illness, epistemic injustice, healthcare inequities, long COVID, patient-provider communication, systemic bias, internal medicine, medical sociology, Defining, Medical

The research team, led by Deena M. Hamza of the University of Alberta alongside colleagues from Queen’s University, McMaster University, the University of Ottawa, the University of British Columbia, and the Royal College itself, conducted a rapid evaluation study across four Canadian internal medicine residency programs. Rather than waiting years for outcome data, the team used a utilization-focused evaluation approach, gathering data through interviews and focus groups with residents, faculty, and program administrators at each site. Their qualitative thematic analysis was guided by the Core Components Framework for evaluating competency-based medical education implementation, a tool designed to compare what programs intended to do against what they actually did, and to identify the adaptations programs made along the way.

The framework allowed the researchers to systematically examine five key elements of Competence by Design: outcome competencies, sequenced progression, tailored learning experiences, competency-focused instruction, and programmatic assessment. By comparing stated intentions with reported experiences, the team could identify where implementation was faithful to the design and where programs had drifted or adapted. This distinction matters enormously for a national reform initiative. If programs are quietly reshaping the model to fit local constraints, that adaptation may be reasonable, or it may signal a gap between theory and practice that needs addressing before the reform’s benefits can be realized.

On the positive side, the findings were striking. Programs reported more frequent feedback and more direct observation of trainees than under the previous system. This is a fundamental shift. Under time-based training, feedback often arrived sporadically, sometimes only at the end of a rotation, when the opportunity to act on it had already passed. Competence by Design was designed to change that by embedding assessment into daily clinical work, and the study suggests it is working. Residents and faculty described enhanced coaching relationships, with faculty taking on roles closer to mentors and guides than examiners. Programs also engaged in proactive curricular review, actively realigning their training activities with the outcome competencies that define success in the new model.

These successes are not trivial. Direct observation of trainees is one of the most powerful tools in medical education, allowing faculty to see what residents can actually do rather than relying on secondhand reports or end-of-rotation impressions. Frequent feedback, delivered close to the moment of performance, gives residents the chance to adjust in real time. Coaching relationships, in which faculty invest in a resident’s development over time rather than simply judging them, have been shown to accelerate learning and improve trainee satisfaction. The fact that these elements emerged as key successes across four different programs suggests that the core design of Competence by Design is resonating with the people who use it daily.

But the study also surfaced prominent challenges that the reform’s architects will need to confront. The most significant was confusion about expectations. Residents and faculty reported unclear expectations regarding what performance was required at different training stages. This reflects a gap in shared understanding of sequenced progression, one of the five core components of the model. In theory, sequenced progression means residents advance through defined stages, each with its own expectations, and faculty know what to look for at each stage. In practice, the study found that this shared understanding had not fully taken hold. Faculty were uncertain what to expect from a resident in one stage versus another, and residents were uncertain what was expected of them. This ambiguity undermines the precision that competency-based education is supposed to deliver.

The second major challenge was technological. The electronic assessment systems that programs relied on to track resident progress had significant limitations. These platforms were not designed to efficiently capture and display the granular data that competency-based education generates, making it difficult for faculty and program administrators to use assessment data for tracking progress. The result was a system that generated data but did not make it actionable. This is a familiar problem in health information technology: platforms built for one purpose often struggle to serve the needs of a new paradigm. The study suggests that without better technological support, the data-rich promise of competency-based education will remain partially unrealized.

The third challenge was the sheer volume of assessment. Competence by Design increases the frequency of assessment, which is central to its design, but this frequency comes at a cost. Faculty described increased assessment burden and assessor fatigue, a phenomenon that has been documented in other competency-based education implementations. When faculty are asked to complete more assessments more often, the risk is that assessments become perfunctory, completed to satisfy a requirement rather than to genuinely evaluate performance. This drift toward bureaucratic box-ticking has been noted in the literature as a misalignment between curriculum theory and clinical reality, and the study’s findings suggest it is a real risk in internal medicine programs.

The researchers conclude that early evaluation of Competence by Design in internal medicine has yielded notable improvements in feedback culture, direct observation, and curriculum alignment, but that significant cultural and logistical challenges persist. They call for ongoing program refinements, faculty development, and technological support to realize the full potential of the model. Faculty development is particularly important, because the success of competency-based education depends on faculty understanding the new expectations and being equipped to assess against them. Without sustained investment in developing faculty, the confusion about expectations documented in this study is likely to persist.

What makes this study valuable is its honesty. Rather than presenting Competence by Design as either a triumph or a failure, the team documented both the genuine gains and the persistent difficulties. The findings suggest that the reform is neither a revolution completed nor a promise broken, but a work in progress. The feedback culture is improving. Direct observation is increasing. Curricula are being realigned. But the shared understanding of what competency means at each stage, the technology to track it, and the assessment workload to sustain it remain unresolved. For a national reform initiative now several years into implementation, this kind of rapid, honest evaluation is exactly what is needed to guide the next phase of refinement. The study offers a roadmap for what programs, faculty, and the Royal College should prioritize as Competence by Design matures: clarify expectations, invest in faculty development, fix the technology, and manage the assessment burden. Those four priorities may determine whether the reform ultimately delivers on its promise to produce better-trained physicians.

Subject of Research: Exploring the Intentions, Experiences, and Adaptations of Postgraduate Internal Medicine Programs in the Implementation of Competence by Design

Article Title: Exploring the Intentions, Experiences, and Adaptations of Postgraduate Internal Medicine Programs in the Implementation of Competence by Design

Article References: Hamza, D. M., Ladak, Z., McGuire, N., Oswald, A., Katz, S., Martin, L., Vegas, D. B., Gilchrist, T., Yelle, D., van Melle, E., Frank, J. R., Cheung, W. J., Derby, B., Dalseg, T. R., Cooke, L., & Hall, A. K. (2026). Exploring the Intentions, Experiences, and Adaptations of Postgraduate Internal Medicine Programs in the Implementation of Competence by Design. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10795-8

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10795-8

Keywords: medical education, competency-based education, residency training, internal medicine, postgraduate training, assessment, Canada, health professions education, Exploring, Intentions, Experiences, Adaptations

The authors’ argument rests on a distinction that is easy to state but has been largely ignored by regulators. Commercial trials sponsored by pharmaceutical companies exist to establish the efficacy and safety of new drugs for market authorization. Academic treatment optimization studies, or TOS, ask a fundamentally different question: how should treatments already available in the clinic be dosed, sequenced, combined, intensified, or de-escalated? These questions carry limited commercial incentive, yet they determine whether a new agent actually improves survival in routine care. Without academic trials systematically comparing treatment strategies against established standards, the field loses its capacity to translate scientific advances into better outcomes for patients.

The historical record shows what is at stake. In pediatric oncology, successive generations of randomized optimization trials conducted by cooperative study groups helped raise event-free survival for major childhood malignancies from below 20 percent in the 1950s to more than 60 percent, and for some diseases approximately 90 percent, by the early 2000s. Similar investigator-initiated randomized research established adjuvant chemotherapy for node-positive breast cancer and shaped multimodal treatment across leukemia, lymphoma, germ-cell tumors, colorectal cancer, and lung cancer. Comparable optimization questions have driven progress in cardiology and nephrology, where trials clarified how combinations of established therapies should be sequenced and intensified. These achievements were not the product of a single breakthrough drug but of iterative, comparative, and often unglamorous clinical experimentation.

The regulatory turning point came with the EU Clinical Trials Directive 2001/20, which introduced harmonized requirements for trial authorization, sponsor responsibilities, monitoring, safety reporting, and documentation. For industry-sponsored programs with dedicated infrastructure, the burden was absorbable. For investigator-initiated studies run on limited academic funding, it proved crushing. Berdel and colleagues illustrate the shift with data from the German Society for Paediatric Oncology and Haematology: the number of open treatment optimization studies fell from 33 in 2002 to just 2 in 2017. Over the same period, drug trials conducted under the directive increased and disease-oriented registries multiplied from 1 to 28. Registries can document real-world care and support quality improvement, but they cannot generate the randomized comparative evidence needed to establish which treatment strategy is superior.

The financial and temporal dimensions of the burden are documented in striking detail. Drawing on the personal experience of one author, the authors report that a monocenter Phase I trial that once took roughly one month from protocol to first patient visit now takes more than a year and a half, and more than four years from protocol to publication. A multicenter Phase II or III study that previously required three months to open now takes more than two years. Costs tell a similar story: a Phase I monocenter study that cost approximately 30,000 euros now exceeds 200,000 euros, while a Phase II/III multicenter trial has risen from under 50,000 euros to roughly 500,000 euros. Documentation has ballooned from around 100 pages to more than 3,000 pages for a single-center Phase I study, and from about 200 pages to over 3,000 pages for multicenter trials. The authors emphasize these are illustrative approximations rather than a systematic regulatory audit, but the magnitude of change is difficult to dismiss.

Data from beyond oncology reinforce the pattern. Between 2006 and 2012, the Ethics Committee of Westphalia-Lippe in Germany recorded a decline in investigator-initiated academic drug trials from 6 to 2, while commercial drug trials fell only modestly from 38 to 29 and registries increased from 1 to 11. The concurrent rise of registry-based activity and fall of interventional academic studies is consistent with a shift toward observational approaches as regulatory requirements intensified, a trend also reported from other EU member states. The authors acknowledge that such descriptive data cannot establish simple causality, and that growing collaboration between academia and industry complicates the interpretation of trial counts, but the structural shift in who initiates interventional research is difficult to ignore.

The Clinical Trials Regulation 536/2014, which replaced the directive and became mandatory for all EU and EEA trials since 31 January 2025, brought genuine improvements: a harmonized framework, a single submission portal through the Clinical Trials Information System, coordinated assessment, and increased transparency. Yet the authors argue that harmonization does not automatically produce risk-proportionality. Investigator-initiated multicenter studies still face substantial administrative hurdles, particularly when they involve complex treatment strategies, multiple interventions, or off-label use of authorized medicines. The relevant provisions are fragmented across the regulation’s text and difficult for investigators to navigate. Recent analyses continue to identify challenges for academic and pragmatic trials, and European policy documents, including the Draghi report on competitiveness, have raised concerns about the EU’s attractiveness as a location for clinical research.

The core of the authors’ proposal is a conceptual reframing: regulatory burden should be calibrated not to the marketing authorization status of a medicine but to the incremental risk and burden a specific research intervention introduces relative to established clinical care. The OECD classification distinguishes trials involving authorized medicines used within the label (category A), off-label use supported by published evidence or established practice (B1), off-label use without such support (B2), and non-authorized products (C). Many academic optimization studies fall into categories B1 and B2. An evidence-supported change in dose, duration, sequence, or combination of established treatments may carry little additional risk compared with routine care, even when technically off-label. Conversely, an intervention formally within a label may still introduce meaningful risk in a substantially different treatment context. The authors propose that OECD category A and B1 studies with minimal incremental risk should be eligible for a proportionate regulatory pathway, with selected B2 studies considered where additional evidence and expert assessment support a similarly low-risk classification.

Under this framework, such trials would still be registered through the Clinical Trials Information System to preserve transparency and harmonization, but would be assessed by ethics committees rather than necessarily by national competent authorities. Ethics committees, drawing on physicians experienced in the relevant disease area, would evaluate incremental risk on a trial-specific basis using predefined criteria. The definition of established clinical care would not rest with individual investigators but with medical societies, such as the European Society for Medical Oncology, which maintain regularly updated evidence-based guidelines across most cancer types. Monitoring, adverse-event reporting, and oversight would be risk-adapted, drawing on guidance developed by the Danish Medicines Agency, with every monitoring and reporting requirement justified prospectively in the protocol. The authors stress this does not mean less protection for participants; it means resources are directed toward risks that actually matter to participants and data integrity.

The proposal arrives at a politically opportune moment. In December 2025, the European Commission presented a draft European Biotech Act that includes measures to simplify clinical-trial procedures, reduce administrative burden, and accelerate authorization, including amendments to the Clinical Trials Regulation and further risk-based differentiation, with a new minimal-intervention category for OECD category A trials. The authors argue this movement should be extended to explicitly cover evidence-supported academic optimization studies, including OECD B1 and selected B2 trials. They acknowledge real challenges: definitions of established care may differ between countries, professional guidelines may lag behind rapidly evolving evidence, and ethics committees may initially apply different thresholds for minimal risk. These difficulties, they contend, argue for transparent criteria and shared guidance rather than abandoning risk-adapted assessment. The objective, as the authors and a broader coalition of European medical societies have emphasized, is not deregulation of academic clinical research but risk-proportionate regulation that preserves participant protection while restoring the capacity of independent investigators to answer the questions that industry has no incentive to ask.

Subject of Research: Academic treatment optimization studies in oncology and internal medicine: a risk- and burden-adapted regulatory framework for the European Union

Article Title: Academic treatment optimization studies in oncology and internal medicine: a risk- and burden-adapted regulatory framework for the European Union

Article References: Berdel, W. E., Dreyling, M., Schrappe, M., Wanner, C., & Schmidt, G. (2026). Academic treatment optimization studies in oncology and internal medicine: a risk- and burden-adapted regulatory framework for the European Union. The Lancet Regional Health – Europe, 71, Article 101888. https://doi.org/10.1016/j.lanepe.2026.101888

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101888

Keywords: clinical trials, EU regulation, oncology, pediatric oncology, treatment optimization, investigator-initiated trials, Clinical Trials Regulation, risk-proportionate oversight, medical societies, health policy, internal medicine, European Biotech Act

The research, published in the journal Advances in Drug and Alcohol Research, drew on a prospective sample of 2,872 acutely hospitalized internal medicine patients recruited at Lovisenberg Diaconal Hospital in Oslo between November 2016 and December 2017. During the original study, patients self-reported their drinking using the four-item Alcohol Use Disorder Identification Test, known as AUDIT-4, and provided blood samples analyzed with liquid chromatography-mass spectrometry, or LC-MS, to detect illicit drugs such as tetrahydrocannabinol, amphetamine, methamphetamine, cocaine, MDMA, and heroin. Crucially, none of this information was ever shared with the hospital staff treating those patients. That design choice transformed the study data into a gold-standard benchmark against which the physicians’ own documentation could be measured.

From the original cohort, the researchers identified 688 patients whose drinking exceeded low-risk guidelines, defined as AUDIT-4 scores of at least 5 for women and 7 for men, and/or who tested positive for one or more illicit drugs. Electronic records were available for 653 of them, comprising 548 alcohol-positive patients and 157 illicit drug-positive patients, with 48 individuals appearing in both groups. The team then combed through admission records and discharge summaries, scoring an alcohol assessment as complete only if it described both the quantity and frequency of consumption, for example units of alcohol per week, and a drug assessment as complete only if it named the substance and described how often it was used. Vague phrases such as “drinks moderately” or “recreational drug use” were classified as incomplete.

The findings were sobering. Among the 548 patients with study-verified drinking above low-risk thresholds, physicians documented quantity and frequency in only 43.2 percent of records, equivalent to 237 patients. An alcohol-related intervention, whether counseling, planned follow-up with a family physician, or referral to a treatment institution, was recorded in just 22.0 percent, or 121 patients. Perhaps most telling, only 9.1 percent of alcohol-positive patients received an alcohol-related ICD-10 diagnosis code at discharge, and even among those with scores indicating harmful drinking or possible dependence, coding rose to just 20.7 percent. For illicit drug users, the picture was similar: a complete assessment appeared in 34.4 percent of records and an intervention in 26.0 percent.

The timing of documentation mattered as much as its presence. In admission records of alcohol-positive patients, 41.8 percent contained complete quantity and frequency assessments and 15.2 percent contained no mention of alcohol at all. By discharge, the situation had deteriorated sharply: only 18.6 percent of discharge summaries included a complete assessment, and 56.9 percent made no reference to alcohol whatsoever. A parallel pattern emerged for drug-positive patients, with complete assessments falling from 31.2 percent at admission to 28.5 percent at discharge, while 44.6 percent of discharge records omitted illicit drug use entirely. Because discharge summaries are the primary channel of information to the general practitioners who manage post-hospital care, this attrition represents a systematic loss of clinically vital information at exactly the moment it matters most for continuity of treatment.

Statistical modeling revealed which patients were most likely to receive thorough attention. Complete quantity and frequency assessments of alcohol use were independently associated with harmful drinking levels, with each additional year of age, and were significantly less likely during outpatient emergency department evaluations compared with ward admissions. Interventions were strongly linked to harmful drinking, with an adjusted odds ratio of 4.87, and to the presence of a complete quantity and frequency assessment itself, which tripled the odds of an intervention at an adjusted odds ratio of 3.66. Psychological distress, measured by the Symptom Checklist-5, and unemployment also independently predicted intervention. The relationship between assessment and intervention is the study’s central mechanistic insight: physicians cannot counsel patients about drinking patterns they have never quantified, making documentation the gateway through which all subsequent preventive action must pass.

Why does this gap between verified substance use and recorded substance use persist? The authors point to the unforgiving tempo of emergency care, where time pressure and crowding squeeze the space available for detailed history taking, a hypothesis supported by the lower documentation rates among outpatients evaluated and discharged within hours. But the stakes of omission are high even at consumption levels well below overtly harmful thresholds. Recent population-level analyses have demonstrated a dose-response relationship between alcohol intake and all-cause mortality beginning around 100 grams per week, and at-risk drinking worsens outcomes across a remarkable range of common hospital conditions: it increases recurrence of atrial fibrillation, raises the risk of heart failure readmission, undermines glycemic control in diabetes, contributes to falls in older adults, reduces medication adherence, complicates anticoagulant therapy, and interacts dangerously with psychoactive prescriptions. Unrecognized heavy drinking also leaves patients vulnerable to withdrawal syndromes, whose most severe manifestation, delirium, can be fatal.

The study’s authors argue that the tools to close this gap already exist and are neither burdensome nor experimental. AUDIT-4 takes minutes to administer and can be simplified further to just the quantity and frequency questions, and patients in the study readily disclosed both at-risk and harmful drinking when asked. Brief interventions delivered in emergency departments have been shown to reduce at-risk drinking in the short term, and alcohol interventions in primary care produce measurable reductions in harmful drinking at twelve months. The most promising structural solution may be technological: embedding screening questions directly into electronic triage forms has achieved screening rates approaching 97 percent in prior research, whereas physician-directed training alone has yielded more modest results. The authors also suggest that clinicians could make fuller use of ICD-10 codes that denote alcohol use without implying harm, since more consistent coding would improve the registries used to estimate the true scale of alcohol-related harm in hospital populations.

Limitations remain, and the authors acknowledge them candidly. The data come from a single mid-sized urban hospital, so local documentation practices may not generalize everywhere; self-reported alcohol consumption is subject to recall bias, though typically in the direction of under-reporting, which would make the true prevalence of at-risk use even higher; and some counseling may have occurred without ever being written down. The illicit drug analyses were under-powered for regression modeling, and laboratory detection of a drug says nothing about dosage or frequency. Yet the core conclusion stands with unusual clarity. Hospital admission is one of the few moments when a person with risky drinking or drug use is guaranteed contact with the health system, and this study shows that in most cases that moment slips past unused. Treating substance use documentation with the same rigor as tobacco status, allergy lists, and medication records, and verifying that discharge summaries carry it forward, would convert a routine hospital stay from a missed opportunity into a genuine public health intervention delivered at scale.

Subject of Research: Documentation and management of at-risk alcohol and illicit drug use among acutely hospitalized internal medicine patients

Article Title: Missed opportunities: the detection and management of at-risk drinking and illicit drug use in acutely hospitalized patients

Article References: Gamboa, D., Kabashi, S., Jørgenrud, B., Lerdal, A., Nordby, G., & Bogstrand, S. T. (2025). Missed opportunities: the detection and management of at-risk drinking and illicit drug use in acutely hospitalized patients. Advances in Drug and Alcohol Research, 5, Article 14149. https://doi.org/10.3389/adar.2025.14149

Image Credits: AI Generated

DOI: 10.3389/adar.2025.14149

Keywords: alcohol screening, illicit drug use, emergency department, electronic health records, AUDIT-4, LC-MS, brief intervention, internal medicine, discharge summaries, ICD-10 coding, substance use assessment, hospital care

The scale of the evaluation is what sets the work apart. Rather than piloting a course at a single enthusiastic campus, the team surveyed learners across all eight schools, collecting pre-intervention responses from 1,829 students, roughly 60 percent of those invited, and post-intervention responses from 1,187 students, about 39 percent. Each student rated themselves on 32 distinct obesity medicine competencies and completed measures of their beliefs, attitudes, and knowledge about obesity both before and after the curriculum. This learner-perspective design matters because, as the authors note, no prior studies had evaluated competency-based obesity education interventions from the point of view of the students actually experiencing them.

The results were consistent and statistically robust. After the intervention, students reported significantly higher self-ratings across all 32 competencies, with mean scores rising from 2.79 to 3.15 on the study’s rating scale, a difference the authors report as significant at p less than 0.001. Self-assessed knowledge about obesity also improved, moving from a mean of 2.92 to 3.00. Perhaps most strikingly, the curriculum appeared to shift the emotional and attitudinal dimensions of obesity care: negative beliefs about patients with obesity dropped from a mean of 2.82 to 2.08, while positive attitudes toward patients with obesity rose dramatically, from 1.53 to 3.55. In a field where weight bias among clinicians is well documented and can degrade the quality of care patients receive, that attitudinal shift may be as consequential as any gain in technical knowledge.

The architecture of the intervention reflects two well-established ideas from education science. The curriculum was grounded in social constructivist learning theory, the view that learners build understanding through dialogue and shared practice rather than passively absorbing information, and it was guided by a logic model framework, a planning tool that links program activities to expected outcomes so that implementation and evaluation proceed together. In practice, this meant that dialogue within school-based teams was supported by an expert steering committee that provided scaffolding and expertise. Each participating institution retained local control over curricular content, with faculty champions deciding how to adapt shared materials, combine them with other evidence-based resources, or develop original educational interventions of their own.

That balance between national coordination and local autonomy was deliberate, and it speaks to a persistent tension in medical education reform. A one-size-fits-all obesity curriculum risks ignoring the realities of individual schools, their patient populations, their faculty strengths, and their existing course structures. But leaving each school to improvise alone reproduces the very fragmentation that created the education gap in the first place. The collaborative framework tested here, in which a shared set of 32 competencies anchors the effort while content decisions stay local, offers a template that other under-taught areas of medicine might copy. The competency framework itself was not invented for this study; it draws on the Obesity Medicine Education Collaborative’s competencies for medical education, published in 2019, which gave the project an externally developed, nationally recognized benchmark.

The stakes of this curricular gap are not abstract. Obesity contributes to many of the chronic diseases that internists manage daily, and recent reviews in JAMA Internal Medicine have emphasized that primary care clinicians are increasingly expected to initiate and manage obesity treatment, including newer pharmacotherapies, without having received systematic training in them. Surveys of primary care residents have documented gaps in both knowledge and practice, and the American Heart Association issued a scientific statement in 2024 calling for better implementation of obesity science into clinical practice. The American Medical Association has formally recognized the obesity crisis, and the Association of American Medical Colleges has flagged the need for action. Against that backdrop, the finding that a structured, competency-based intervention can move student self-ratings across an entire multi-school network is a meaningful proof of concept.

The study’s methods deserve scrutiny, as self-reported outcomes always do. Students rated their own competence, knowledge, and attitudes rather than being tested through objective examinations or observed clinical encounters, so the results capture perceived readiness rather than demonstrated skill. Self-assessment in medical education is known to be imperfect, and learners can overestimate or underestimate their abilities. The response rate also fell between the pre- and post-intervention surveys, from 60 percent to 39 percent, raising the possibility that the students who completed both were systematically different from those who did not. The authors frame the work as a pilot and as a quality improvement initiative, approved by the Northwestern University Institutional Review Board as such, and the emphasis is on feasibility and scalability rather than definitive causal proof.

Funding and conflict-of-interest disclosures are also part of the story, and the authors are unusually explicit about the safeguards employed. The study was funded by an unrestricted educational grant awarded to The Obesity Society by Novo Nordisk, but the funder had no role in study design, selection or delivery of curricular content, data collection, management, analysis, or interpretation. The externally developed national competency framework, local determination of content by faculty champions, the participation of eight institutions, and the freedom of those champions to ignore shared materials altogether were all designed to insulate the educational intervention from commercial influence. Several individual authors disclosed research or consultant funding from Novo Nordisk, and two serve on its advisory board, disclosures the journal publishes alongside the article.

What emerges from the eight-school experiment is less a finished curriculum than a working model of collaborative curricular change. The FORWARD initiative, as the program is known, demonstrates that a network of medical schools can align around a shared competency framework, implement locally tailored interventions, and measure movement in learner-reported competence, knowledge, and attitudes at a scale that single-campus studies cannot match. The authors argue that this large, multi-institutional approach demonstrates the feasibility and scalability of a collaborative framework for addressing the curricular gap in obesity medicine education, and the data they present, spanning nearly 3,000 survey responses across diverse institutions, lend that claim considerable weight.

The broader implications extend well beyond obesity. Medical curricula everywhere lag behind clinical science in areas that evolve quickly, from obesity pharmacotherapy to genomics to climate-related health risks, and the traditional mechanism for catching up, waiting for textbook publishers and national boards to incorporate new material, moves too slowly. The model tested here suggests an alternative: define competencies nationally, let local faculty champions construct the teaching, support them with expert scaffolding, and evaluate the result through the learners themselves. If the attitudinal gains reported in this study prove durable as these students enter residency and practice, the payoff could be measured not just in test scores but in the quality and compassion of care delivered to the growing number of patients living with obesity.

Subject of Research: A multi-institutional competency-based obesity medicine education intervention for US medical students

Article Title: Self-Reported Obesity Medicine Competence, Knowledge, and Attitudes Among US Medical Students: An Eight-School Pre- vs. Post-Intervention Study

Article References: Pasarica, M., Kushner, R. F., Leary, A. V., Mirando, A., Correa, R., Agarwal, M., Grunvald, E., Velasquez, S. T., Uhley, V., Purnell, J. Q., Carpenter, D.-A., Velazquez, A., Smolarz, G., the FORWARDQI group, Croniger, C., Johnson, M. S., Loza, J., Mock, A., & Pfotenhauer, K. (2026). Self-Reported Obesity Medicine Competence, Knowledge, and Attitudes Among US Medical Students: An Eight-School Pre- vs. Post-Intervention Study. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10913-6

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10913-6

Keywords: obesity medicine, medical education, competency-based education, medical students, curriculum intervention, weight bias, internal medicine, social constructivist learning, logic model, multi-institutional collaboration, Journal of General Internal Medicine, physician training

The project was carried out by the National HIV Residency Pathway Consortium, or NHRPC, a steering committee of six national HIV leaders formed in February 2021. The group, which included two family medicine and four internal medicine experts representing five institutions and states, brought together decades of experience in HIV clinical care, training, and education. From the outset, the committee defined five goals: to establish a collaboration mechanism for HIV residency pathway leaders nationwide, to share best practices and resources, to help programs establish new pathways, to develop methods for evaluating program efficacy, and to identify solutions for the conspicuous deficit of pathway programs in the regions of the country where HIV is most prevalent.

HIV residency pathways are not a new idea. Since the first such track was established in 2006, more than 25 have appeared in family medicine and internal medicine residencies across the country, and more than 225 residents have graduated from them. Roughly 40 percent of those graduates now provide both primary and HIV care to people with HIV. But the geography of this educational effort has been strikingly mismatched with the epidemiology of the disease. Most existing pathways, and most of their graduates, are concentrated far from the areas of greatest need, particularly the Southern United States, where HIV prevalence is highest. The consortium’s central insight was that expanding the workforce would require deliberately seeding new pathways in those underserved, high-prevalence regions.

To test that idea, the steering committee implemented a one-year pilot project in 2023, funded by the Health Resources and Services Administration. From July 1, 2023, through June 30, 2024, the New England AIDS Education and Training Center, one of eight regional centers operating under Part F of the Ryan White HIV/AIDS Program, worked with the committee to recruit new or developing family medicine and internal medicine HIV pathways from high-prevalence areas. Interested programs submitted proposals that included a work plan, a budget justification, and a sustainability and evaluation plan. The committee judged applications on feasibility, on need as measured by local HIV prevalence, and on the experience and commitment of pathway directors and faculty in HIV care and education.

Six programs were selected, and each received 68,000 dollars in seed funding to start or expand its pathway. The money mattered more than its modest size might suggest. Across the six sites, 77.6 percent of the funds supported personnel costs, including protected time for faculty leadership, curriculum development, resident mentorship, and administrative coordination. The remainder went toward travel and conference attendance, recruitment and program development, and resident educational resources. All six awardees reported that securing this funding was essential to their pathway’s success, and four of the six said ongoing funding would be necessary to sustain their programs beyond the pilot year. The other two indicated that, while continued support would be beneficial, they could maintain some version of the pathway without it.

Beyond money, the project invested heavily in structured mentorship and peer support. Pathway faculty received monthly support through meetings that alternated among small-group sessions with steering committee mentors, larger sessions with the committee and all funded site directors, and consortium-wide gatherings. Over the project year, the steering committee held 21 mentoring meetings with individual pathway directors, averaging 3.5 per site, plus quarterly meetings with the six funded directors. The full consortium, which by then included 31 programs, met quarterly as well, drawing representation from 22 programs and an average of 13.6 participants per meeting. Topics ranged from clinical requirements and resident recruitment to evaluation and curricular resources. The organizers drew on the de Carvalho-Filho framework for building a community of practice for faculty development, and used Microsoft Teams for meetings, file sharing, and communication across the network.

A key deliverable of the pilot was the HIV Residency Pathway Toolkit, developed by the steering committee during the project year and refined through iterative feedback from HRSA and pathway directors. Launched in May 2024 on the website of the National AETC Support Center, the toolkit offers step-by-step guidance on nearly every operational question a new pathway faces: assessing local need and resources, creating a budget, designing a training model and didactics, establishing minimum clinic requirements, supporting faculty, and planning for sustainability. It also includes a comprehensive assessment schema built on previously published HIV-specific entrustable professional activities, mapped to the Accreditation Council for Graduate Medical Education’s milestones, along with faculty development in competency-based assessment. Pathway directors highlighted that seeing different options for structuring pathways, building schedules, and creating budgets was particularly helpful in organizing their own programs into coherent wholes.

The results of the pilot year were encouraging. Across the six sites, 24 residents matriculated into HIV pathways, six in family medicine and 18 in internal medicine. Recruitment was left entirely to the participating programs, and at the time of the report no participants had yet graduated. Evaluation combined process metrics with end-of-year survey responses from faculty and residents, with narrative comments coded thematically. Residents consistently reported developing a passion for integrated HIV and primary care, recognizing the impact of Ryan White funding and multidisciplinary care teams, and appreciating the complexities of caring for people with HIV. They reported greater confidence and strengthened clinical skills, and faculty independently observed the same growth. Many residents said the pathway influenced or reinforced their HIV-related career goals, with some describing newfound interest in outpatient medicine, in caring for people with HIV and other underserved populations, or in working at Ryan White-funded clinics.

Curriculum resources also proved their value. Every site used the publicly accessible, HRSA-funded National HIV Curriculum to track resident progress, and directors singled out its mini-lectures and podcasts as especially useful. Use of the HIV-specific entrustable professional activities was encouraged but not mandated; one pathway adopted 11 of the 12 during the pilot year, and four others planned to begin using them the following year. Directors also identified areas for improvement, including deeper collaboration with residency program leadership, more intentional modification of resident schedules to balance volume, breadth, and depth of patient contact, and earlier planning for conference attendance, since schedules are built months in advance. All pathways expressed the hope of continuing after the pilot year, pending institutional support.

The authors are candid about the limitations of their work. The short funding window and limited budget precluded a standardized pathway selection process, and the deliberate design of locally adaptable pathways may limit generalizability on a national scale. The findings reflect only the first year of implementation, without data on program growth, changes in resident confidence, patient satisfaction, or the long-term outcomes that matter most, such as workforce retention and career selection. Several programs reported that a single year of funding was disruptive, and the team’s experience suggests that at least two to three years are needed to launch sustainable pathways. Still, the pilot achieved its primary goal: catalyzing six new HIV training pathways in high-prevalence regions where few or none previously existed, and training 24 new residents in the process. The authors argue that novel, multi-year funding mechanisms should be developed to support and evaluate such pathways, and that the model could be adapted for other disciplines. As people with HIV continue to live longer and the clinician shortage deepens, this quietly pragmatic experiment offers a template for growing the HIV workforce exactly where it is needed most.

Subject of Research: Expansion of HIV residency training pathways to address the HIV clinician workforce shortage in high-prevalence regions of the United States

Article Title: Expanding the HIV Workforce Through Residency HIV Pathways

Article References: Budak, J. Z., Bositis, C., Day, P. G., Carson-Sasso, V., Hebert, S., Simpson, E. H., Chastain, C., Spach, D., Barakat, L., & Bolduc, P. (2026). Expanding the HIV Workforce Through Residency HIV Pathways. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10809-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10809-5

Keywords: HIV, residency training pathways, clinician workforce, graduate medical education, family medicine, internal medicine, Ryan White HIV/AIDS Program, mentorship, community of practice, health workforce shortage, primary care, HRSA